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Hip: M. Parry, V. Wylde, and A. W. Blom Ninety-day mortality after elective total hip replacement: 1549 PATIENTS USING ASPIRIN AS A THROMBOPROPHYLACTIC AGENT J Bone Joint Surg Br 2008; 90-B: 306-307 [Abstract] [Full text] [PDF]

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Ninety-day mortality after elective total hip replacement: role of post-operative mobilisation

KC Kong, King George Hospital, IG3 8YB   (12 June 2008)

More detail needed

Shyan Lii Goh   (14 March 2008)

Controversy surrounding thromboprophylaxis

Rohit Gupta   (6 March 2008)

Ninety-day mortality after elective total hip replacement: role of post-operative mobilisation 12 June 2008
KC Kong, Consultant Orthopaedic Surgeon Ilford, Essex, United Kingdom, King George Hospital, IG3 8YB Send letter to journal: Re: Ninety-day mortality after elective total hip replacement: role of post-operative mobilisation kck{at}doctors.org.uk KC Kong, et al.	Sir, I read this article with interest. The authors have raised an important point in the remarkable change in mortality following total joint arthroplasty. This change has not been taken into account by NICE nor by the ACCP in their published guidance. There is evidence for a tremendous reduction of thromboembolism following total knee replacement1 which may have a higher rate of thromboembolism than total hip replacement. Now this may still be attributed to use of low molecular weight heparin but their doppler rate of deep vein thrombosis has shown a 30-fold reduction in incidence with its use and with early mobilisation. Very early mobilisation has only been given a C grade for evidence by the American Association of Orthopaedic Surgeons.2 The authors did not report on their post-operative mobilisation regime in their 2003 to 2006 cohort and whether it differed from their previous reported cohort of 1993 to 1996.3 K.C. Kong, Consultant Orthopaedic Surgeon, King George Hospital, Ilford, Essex, UK. 1. Pearse EO, Caldwell BF, Lockwood RJ, Hollard J. Early mobilisation after conventional knee replacement may reduce the risk of postoperative venous thromboembolism. J Bone Joint Surg [Br] 2007;89-B:316-22. 2. American Academy of Orthopaedic Surgeons Clinical Guideline on Prevention of Symptomatic Pulmonary Embolism in Patients Undergoing Total Hip or Knee Arthroplasty. May 2008. http://www.aaos.org/research/guidelines/PE_summary.pdf (accessed 13/06/2008). 3. Blom A, Pattison G, Whitehouse S, Taylor A, Bannister G. Early death following primary total hip arthroplasty: 1,727 procedures with mechanical thrombo-prophylaxis. Acta Orthop 2006;77:347–50.
More detail needed 14 March 2008
Shyan Lii Goh, Advanced Trainee, Orthopaedics Royal North Shore Hospital, St Leonard, NSW, Australia Send letter to journal: Re: More detail needed sgoh{at}hotmail.com Shyan Lii Goh	Sir, I thank Parry et al for their article which seeks to re-examine the role of chemical prophylaxis in elective total hip replacement (THR), particularly the use of aspirin and anti-thromboembolic stockings. While the article is succinct, and suggested the role of low-dose aspirin as beneficial against early death post-THR, I find it difficult to reconcile the lack of information provided and the conclusion with confidence. Several queries come to mind: 1. Mortality is not the sole complication from the development of a thromboembolic event, although between 15% and 25% of patients with pulmonary embolism die within 90 days. To attribute the thromboprophylactic property of aspirin in the role of protection of early THR death underplays the incidence and morbidity of post-THR thromboembolism and falsely reduces the effect of aspirin to thromboprophylaxis only. How can one use only death as the determinant of clinical effectiveness of thromboprophylaxis? 2. Spinal anaesthesia with or without general anaesthesia, and the use of a mechanical foot pump peri-operatively has shown effective reduction of symptomatic deep venous thrombosis. It is uncertain if these techniques contribute to the excellent current results obtained at Avon, although there are suggestions of their use in an earlier study.1 3. Without doubt the profile of patients undergoing THR over the last 20 years has changed dramatically, involving much younger patients with less morbidity. I believe demographic data will be helpful to readers in determining if the proposed conclusion is applicable to their own centres. Parry et al may have stumbled onto some panacea at Avon to reduce thromboembolic events in THR patients, however, the lack of details makes it difficult for me to share their enthusiasm that aspirin is the main reason for the result. S.L. Goh, Advanced Trainee, Orthopaedics, Royal North Shore Hospital, St Leonard, NSW, Australia. 1. Blom A, Pattison G, Whitehouse S, Taylor A, Bannister G. Early death following primary total hip arthroplasty: 1,727 procedures with mechanical thrombo-prophylaxis. Acta Orthop 2006;77:347-50.
Controversy surrounding thromboprophylaxis 6 March 2008
Rohit Gupta, ST2 Trauma and Orthopaedics Wythenshawe Hospital, Manchester, UK. Send letter to journal: Re: Controversy surrounding thromboprophylaxis rohitgupta0109{at}doctors.org.uk Rohit Gupta	Sir, I read this article with interest and I would like to draw your attention to the statement made towards the end, "although the NICE guidelines suggest the use of heparin thromboprophylaxis, this study found that routine aspirin administration was beneficial in protecting against early death after THR". I feel that the study in itself is unable to give strong evidence of the beneficial effect of aspirin. The "Prevention of pulmonary embolism" study1 which was used by the author as evidence that aspirin is effective in preventing DVT and pulmonary embolism after orthopaedic surgery had controversially concluded that aspirin should be used for a wide range of surgical conditions even though the data within that study showed that aspirin made no difference in the 4000 hip and knee arthroplasty patients for whom this intervention was examined in a randomised manner.2 Many surgeons searching for evidence to use chemical thromboprophylaxis may be influenced by evidence which has not been subjected to robust analysis. The SIGN guidelines3 from Scotland, for example, recommend aspirin without any rational explanation, whereas other guidelines (ACCP, ICS)4,5 specifically advise against it. In the current climate of controversy surrounding thromboprophylaxis in joint replacement I feel we need strong evidence to support a surgeon’s justification for the chosen method of thromboprophylaxis. R. Gupta, ST2 Trauma and Orthopaedics, Wythenshawe Hospital, Manchester, UK. 1. No authors listed. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet 2000;355:1295-302. 2. Warwick D, Dahl OE, Fisher WD. Orthopaedic thromboprophylaxis: limitations of current guidelines. J Bone Joint Surg [Br] 2008;90-B:127-32. 3. SIGN 2002. Prophylaxis of venous thromboembolism. SIGN Guideline No. 62. http://www.sign.ac.uk/guidelines/fulltext/62/index.html (last accessed 11/12/2007). 4. Cardiovascular Disease Educational and Research Trust, et al. Prevention and treatment of venous thromboembolism. International Consensus Statement (guidelines according to scientific evidence). Int Angiol 2006;25:101-61. 5. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(3 Suppl):338S-400S.