Introduction Venous thromboembolic disease is a serious complication of total hip replacement (THR). Use of low-molecular-weight heparin (LMWH) has been shown to reduce the occurrence of deep-vein thrombosis (DVT) significantly, but side effects such as bleeding and thrombocytopenia are frequent. Pneumatic compression with foot-pumps seems to provide the best balance of effectiveness and safety. However, a recent meta-analysis showed that the overall number of patients investigated in randomised clinical trials is too small to draw evidence-based conclusions regarding mechanical prophylaxis of DVT. This trial is a contribution in comparing the effectiveness and safety of mechanical versus chemical prophylaxis of DVT in patients managed with THR. Methods Inclusion criteria were hip osteoarthritis, age less than 80 years, and uninterrupted use of a foot-pump. Exclusion criteria were a history of thromboembolic disease, heart disease, malignancy and bleeding diatheses. Two hundred and sixteen consecutive patients were considered for inclusion in the trial and were randomized either for management with (LMWH) (Fraxiparin, Sanofi -Synthelabo, France) or with the A-V Impulse foot-pump (Orthofix Vascular Novamedix, UK). All patients started mobilisation on crutches with partial weight-bearing on day two using compression stockings. The foot-pump was applied on both feet in the recovery room and was used until patient discharge. Management with the foot-pump was interrupted only during physiotherapy and toileting. A reverse Trendelenburg position (head-high, feet-low) was applied at rest to enhance the pneumatic effect of the pumps. Patients were monitored for DVT using serial duplex sonography (Sonoline Elegra, Siemens, Germany) at day three, 10 and 45 after surgery. Results DVT was detected in three of 100 patients managed with the foot-pump compared with six of 100 patients who received chemical prophylaxis. Sixteen patients did not tolerate continuous use of the foot-pump and were excluded from the study. The average post-operative drainage was 259 ml in the foot-pump group and 328 ml in the control group (p=0.05). Patients with foot-pump had less swelling of the thigh (10 mm compared with 15 mm) (p=0.05). One patient developed heparin-induced thrombocytopenia. Conclusions This study confirms the effectiveness and safety of mechanical prophylaxis of DVT in THR, confirming the outcomes of previous randomized clinical trials. Some patients cannot tolerate the foot-pump, mostly because of sleep disturbance. In relation to the conduct of this study, one or more of the authors is in receipt of a research grant from a non-commercial source

Routine prophylaxis for venous thromboembolic disease after total hip replacement (THR) is recommended. Pneumatic compression with foot pumps seems to provide an alternative to chemical agents. However, the overall number of patients investigated in randomised clinical trials has been too small to draw evidence-based conclusions. This randomised clinical trial was carried out to compare the effectiveness and safety of mechanical versus chemical prophylaxis of DVT in patients after THR. Inclusion criteria were osteoarthritis of the hip and age less than 80 years. Exclusion criteria included a history of thromboembolic disease, heart disease, and bleeding diatheses. There were 216 consecutive patients considered for inclusion in the trial who were randomised either for management with the A-V Impulse System foot pump. We excluded 16 patients who did not tolerate continuous use of the foot pump or with low-molecular-weight heparin (LMWH). Patients were monitored for DVT using serial duplex sonography at 3, 10 and 45 days after surgery. DVT was detected in three of 100 patients in the foot-pump group and with six of 100 patients in the LMWH group (p < 0.05). The mean post-operative drainage was 259 ml in the foot-pump group and 328 ml in the LMWH group (p < 0.05). Patients in the foot-pump group had less swelling of the thigh (10 mm compared with 15 mm; p < 0.05). One patient developed heparin-induced thrombocytopenia. This study confirms the effectiveness and safety of mechanical prophylaxis of DVT in THR. Some patients cannot tolerate the foot pump

Objectives

We aimed to examine the characteristics of deep venous flow in the leg in a cast and the effects of a wearable neuromuscular stimulator (geko; FirstKind Ltd) and also to explore the participants’ tolerance of the stimulator.

Prophylaxis against venous thromboembolism after elective total hip replacement is routinely recommended. Our preference has been to use mechanical prophylaxis without anticoagulant drugs. A randomised controlled trial was performed to evaluate whether the incidence of post-operative venous thromboembolism was reduced by using pharmacological anticoagulation with either fondaparinux or enoxaparin in addition to our prophylactic mechanical regimen. A total of 255 Japanese patients who underwent primary unilateral cementless total hip replacement were randomly assigned to one of three postoperative regimens, namely injection of placebo (saline), fondaparinux or enoxaparin. There were 85 patients in each group. All also received the same mechanical prophylaxis during and after the operation, regardless of their assigned group. The primary measurement of efficacy was the presence of a venous thromboembolic event by day 11, defined as deep-vein thrombosis detected by ultrasonography, documented symptomatic deep-vein thrombosis or documented symptomatic pulmonary embolism. The duration of follow-up was 12 weeks. The rate of venous thromboembolism was 7.2% with the placebo, 7.1% with fondaparinux and 6.0% with enoxaparin (p = 0.95 for the comparison of all three groups). Our study confirmed the effectiveness and safety of mechanical thromboprophylaxis without the use of anticoagulant drugs after total hip replacement in Japanese patients

This study was undertaken to evaluate the safety and efficacy of retrievable inferior vena cava filters in high-risk orthopaedic patients. A total of 58 patients had a retrievable inferior vena cava filter placed as an adjunct to chemical and mechanical prophylaxis, most commonly for a history of previous deep-vein thrombosis or pulmonary embolism, polytrauma, or expected prolonged immobilisation. In total 56 patients (96.6%) had an uncomplicated post-operative course. Two patients (3.4%) died in the peri-operative period for unrelated reasons. Of the 56 surviving patients, 50 (89%) were available for follow-up. A total of 32 filters (64%) were removed without complication at a mean of 37.8 days (4 to 238) after placement. There were four filters (8%) which were retained because of thrombosis at the filter site, and four (8%) were retained because of incorporation of the filter into the wall of the inferior vena cava. In ten cases (20%) the retrievable filter was left in place to continue as primary prophylaxis. No patient had post-removal thromboembolic complications. A retrievable inferior vena cava filter, as an adjunct to chemical and mechanical prophylaxis, was a safe and effective means of reducing the acute risk of pulmonary embolism in this high-risk group of patients. Although most filters were removed without complications, thereby avoiding the long-term complications that have plagued permanent indwelling filters, a relatively high percentage of filters had to be left in situ

Introduction A prospective cohort study was conducted to assess the incidence of venous thromboembolism (VTE) in 300 patients undergoing elective spinal surgery. Although this subject has been extensively studied in patients undergoing joint replacement surgery, the true incidence of VTE related to spinal surgery remains unknown. We also sought to assess the efficacy of various forms of VTE prophylaxis, another area which has not been adequately studied. Methods Bilateral lower extremity venous duplex scans were performed pre-operatively, within one week postoperatively and at 4 to 6 weeks post-operatively. Information was collected regarding age, gender, body mass index, type and duration of surgical procedure, intra-operative blood loss and blood transfusion, pre- and post-operative mobility and other risk factors for VTE. All patients received vigorous mechanical prophylaxis with 56% of patients receiving pharmacological prophylaxis (unfractionated or low molecular weight heparin) according to surgeon preference. Results The overall incidence of post-operative deep vein thrombosis (DVT) was 3.4%. The incidence in those receiving pharmacological prophylaxis was 1.2% versus 6.3% in those who received mechanical prophylaxis alone (p< 0.05). Just under half of the post-operative DVTs (1.4%) occurred after hospital discharge with none of these patients receiving heparin. There were two cases of pulmonary embolism (0.7%), both occurring during hospitalization, and there were no deaths. There was no difference in blood loss or transfusion rates between patients receiving or not receiving pharmacological prophylaxis and there were no serious complications related to blood loss. There was a surprisingly high incidence of abnormalities detected on pre-operative scanning, with DVT occurring in 3.0% and superficial thrombophlebitis in 24.8%. Discussion The incidence of DVT in patients after spinal surgery was 3.4% and was significantly lower (1.2 %) in patients who received pharmacological prophylaxis. Given that the rates of bleeding-related complications were not different between the two groups, we conclude that it is both efficacious and safe to use pharmacological prophylaxis in combination with mechanical prophylaxis routinely in patients undergoing spinal surgery. A 27.8% incidence of pre-operative venous abnormalities may reflect pre-operative immobility due to pain in this group of patients, and justifies the use of ultrasound scanning as an important pre-operative screening tool. In addition, the high incidence of late-onset DVT justifies the need for follow-up scanning several weeks after discharge. This study is the amongst the largest of its type to date, however a larger, randomized and controlled trial is now necessary to confirm these results and allow the formulation of unambiguous guidelines for spinal surgery and VTE prophylaxis

Aims. To evaluate the incidence of primary venous thromboembolism (VTE), epidural haematoma, surgical site infection (SSI), and 90-day mortality after elective spinal surgery, and the effect of two protocols for prophylaxis. Patients and Methods. A total of 2181 adults underwent 2366 elective spinal procedures between January 2007 and January 2012. All patients wore anti-embolic stockings, mobilised early and were kept adequately hydrated. In addition, 29% (689) of these were given low molecular weight heparin (LMWH) while in hospital. SSI surveillance was undertaken using the Centers for Disease Control and Prevention criteria. Results. In patients who only received mechanical prophylaxis, the incidence of VTE was 0.59% and that of SSI 2.1%. In patients who were additionally given LMWH, the incidence of VTE was 0% and that of SSI 0.7%. The unadjusted p-value was 0.04 for VTE and 0.01 for SSI. There were no cases of epidural haematoma or 90-day mortality in either group. When adjusted for case-mix, LMWH remained a significant factor (p = 0.006) for VTE, but not for SSI. Conclusion. A peri-operative protocol involving mechanical anti-embolism stockings, adequate hydration, and early post-operative mobilisation is effective in significantly reducing the incidence of VTE. The addition of LMWH is safe in patients at higher risk of developing VTE. Cite this article: Bone Joint J 2017;99-B:1204–9

Venous Thromboembolism (VTE) is the most common complication following major joint surgery. While attention has focused on VTE following joint arthroplasty their exists a gap in the literature examining the incidence of VTE in spinal surgery; with a shortage of epidemiological data, guidelines for optimal prophylaxis are limited. This survey, undertaken at the 2009 BASS Annual Meeting, sought to examine prevailing trends in VTE thromboprophylaxis in spinal surgery and to compare selections made by Orthopaedic and Neurosurgeons. We developed a questionnaire based around eight clinical scenarios. Participants were asked to supply details on their speciality (orthopaedics or neurosurgery) and level of training (grade) and to select which method(s) of thromboprophylaxis they would employ for each scenario. Thirty-nine participants provided responses to the eight scenarios; complete details, including speciality and grade of those surveyed, were complied for 27 of the 39 questionnaires completed. LMWH was the preferred pharmacological method of thromboprophylaixs selected 31% and 72% of the time by orthopaedic and neurosurgeons respectively. For each of the eight clinical scenarios LMWH and BK TEDS were selected more frequently by neurosurgeons than orthopaedic surgeons who elected to employ early mobilisation and mechanical prophylaxis. Neurosurgeons were more likely to employ more than method of thromboprophylaxis. Thromboprophylactic selections differed between the two groups; Neurosurgeons preferred LMWH and BK TEDS whilst Early Mobilisation and Mechanical prophylaxis were the preferred methods of thromboprophylaxis amongst orthopaedic surgeons. Based on the results of this survey neurosurgeons more closely adhered to guidelines outlined by NICE/BASS

Introduction. Reported incidence of DVT after spinal surgery ranges from 0-15% and PE 0.5-2.7%. Theoretically, manipulation of the vessels and venous stasis caused by retraction during anterior lumbar inter-body fusion may increase the propensity for thrombosis. The reported incidence of DVT and PE following major abdominal and pelvic surgery are high (up to 23%) and all these patients routinely receive chemical prophylaxis. Aim. Should patients undergoing ALIF surgery receive chemical prophylaxis routinely?. Materials and Methods. Retrospective review of ALIF procedures done between Jan 2007- Jan 2010. Review of case notes, radiology reports and telephone call to the patients to exclude DVT. Total of 76 patients underwent ALIF during this period. Forty six were female(60.5%) and 36 were 2 level fusions(47%). L5-S1 being commonly fused (76%) followed by L4-L5 (23%). Average surgical time from theatre records is 115 minutes(31-369 minutes). All patients received mechanical prophylaxis in the form of thigh length TED stockings. None of the patients were on treatment for DVT prior to surgery. Results. Three patients (3.9%) had Doppler proved DVT which required anticoagulation treatment. There was no reported incidence of PE. Discussion. There is no definite evidence in the literature to suggest ALIF surgery has higher incidence of thromboembolic complications, though theoretical possibility of increased risk. Current study suggests that incidence is 3.9% with mechanical prophylaxis alone which is very small when compared to incidence after major abdominal, pelvic or gynaecological procedures. Our small study sample suggests routine use of chemical prophylaxis to reduce the risk of DVT for anterior lumbar inter-body fusion is not justified

Purpose of Study. To investigate current practice of thromboprophylaxis in major UK spinal centres for both trauma and elective surgery, and to asses compliance with NICE guidelines. Methods. A telephonic survey was carried out which comprised of questions relating to current practice of thromboprophylaxis in major spinal units across the UK. Questions probed practice with regard to trauma versus elective surgery, agents used, timing of prophylaxis, length of treatment and whether practice has changed since the introduction of NICE guidelines. Results. Thirty specialised centres were contacted. Twenty eight centres followed NICE recommendations, with 2 centres using their own protocol. Four centres made changes to their existing protocols after the emergence of NICE guidelines. GCS (Graduated compression stockings) were uniformly used by all, with most centres using flowtron boots and/or foot in addition. The practices are differing within centres for elective versus trauma surgery. Of note, in patients with an acute cord injury, 20 centres used combined pre operative prophylaxis whereas 10 centres used only mechanical prophylaxis. Three units (10 %) describe a noticeable rise in complications related to chemoprophylaxis, whilst only one unit has reported a PE death within the last year. Discussion. Our survey assesses compliance to the NICE guidelines by the UK's spinal units. Mechanical prophylaxis appears to be the most common mode of prophylaxis understandably due to predictable safety profile. Use of chemo-prophylaxis varies amongst different surgeons and centres. Rather than a result of evidence based practice, the decision appears to be related to the previous experiences of that unit. Although the NICE guidelines provide a reasonable platform to the practice of thromboprophylaxis, more studies are required to evaluate the risks of thrombosis and bleeding events in spinal surgery

Introduction. Guidelines from the North American Spine Society (2009 and 2013) are the best evidence-based instructions on venous thromboembolism (VTE) and antibiotic prophylaxis in spinal surgery. NICE guidelines exist for VTE prophylaxis but do not specifically address spinal surgery. In addition, the ruling of the UK Supreme Court in 2015 resulted in new guidance on consent being published by the Royal College of Surgeons of England (RCSEng). This study assesses our compliance in antibiotic, VTE prophylaxis and consent in spinal surgery against both US and UK standards. Methods. Retrospective review of spinal operations performed between August and December 2016. Case notes, consent forms and operation notes were analysed for consent, peri-operative antibiotic prescribing and post-operative VTE instructions. Results. Four Spinal surgeons performed 45 operations during this period. 31 patients (69%) received a copy of the signed consent with this process being formally documented in 22 (71%) of those cases. All patients were consented by a competent surgeon. 82% of cases consented prior to the date of procedure were countersigned on the day of operation. There was a mean time of 25.3 days between initial consent and operation (Range: 0–170). 37 (82%) cases had clear instructions for VTE and antibiotic prophylaxis. All prescribed post-operative antibiotics were administered. Discussion. The North American Guidelines state that prophylactic antibiotic is appropriate in all spinal surgery with prolonged cases requiring intraoperative re-dosing and only complex cases needing a postoperative regimen. Eight patients underwent a complex procedure and 7 appropriately received postoperative antibiotics. Of the 29 patients that underwent a simple procedure, 12 did not receive post-operative regimen, in line with the guidelines. However, the remainder 17 were over treated. The US Guidelines recommend mechanical VTE prophylaxis only in elective spinal surgery except in high risk patients. All our patients received VTE mechanical prophylaxis. RCSEng guidelines require consent being taken prior to procedure by a competent surgeon and confirmed on day of procedure. All patients in our cohort were consented prior to the date of operation allowing time for considering options and independent research. 82% of patients had consent confirmed on day of operation. Conclusion. This study demonstrates that we met guideline advice for all patients with regards VTE prophylaxis. We have a tendency to over treat with post-operative antibiotics and not all patients had their consent confirmed on day of procedure but was consented well before day of operation. North America still lead the way with guidelines on spinal surgery to which we should adhere, with NICE guidelines providing limited instructions. New consenting guidelines from RCSEng may not be currently widely known and thus should be a source of education for all surgeons

In response to the recent publication in April 2007 of NICE guidelines on venous thromboembolism, we report our practice and experience of VTE in adult hip and knee arthroplasty. It is generally agreed that the 2 major complications of VTE are sudden death as a result of pulmonary embolism and post thrombotic syndrome. NICE guidelines make 2 assumptions:. That chemical and mechanical prophylaxis can reduce these complications. That Orthopaedic surgery, in particular elective Primary Joint Replacements are particularly high risk procedures with respect to these 2 complications. We have studied a large cohort of patients who had Aspirin only as chemical prophylaxis to determine the incidence of clinical thromboembolism before and after discharge and the mortality from PE at 90 days. We performed a prospective analysis of consecutive patients undergoing primary total knee and hip replacement from November 2002 to November 2007. In total 2050 patients had total knee replacement and 2203 patients had total hip replacement. All patients were treated at one specialist centre under the care of one surgeon. Data was complete and accurate for all patients at 90 days post-operatively. Standard practice was the use of 150mg Aspirin from Day 1 post-operatively for a total of six weeks combined with spinal anaesthesia and early mobilisation. The overall rate for Fatal Pulmonary embolism 0.07% (3/4253), overall death rate 0.3%(13/4253), for treated non-fatal PE 0.66% (28/4253) and for treated above knee DVT was 0.33%(14/4253). Our data suggests that fatal pulmonary embolism is not common and does not account for most deaths following total hip and knee arthroplasty. We suggest there is no evidence that chemical/mechanical prophylaxis reduces the risk of sudden death from PE following elective primary joint replacement and with modern surgical practice elective hip and knee replacement should no longer be considered high risk procedures

In response to the recent publication in April 2007 of NICE guidelines on venous thromboembolism, we report our practice and experience of VTE in adult hip and knee arthroplasty. It is generally agreed that the 2 major complications of VTE are sudden death as a result of pulmonary embolism and post thrombotic syndrome. NICE guidelines make 2 assumptions:. That chemical and mechanical prophylaxis can reduce these complications. That Orthopaedic surgery, in particular elective Primary Joint Replacements are particularly high risk procedures with respect to these 2 complications. We have studied a large cohort of patients who had Aspirin only as chemical prophylaxis to determine the incidence of clinical thromboembolism before and after discharge and the mortality from PE at 90 days. We performed a retrospective analysis of consecutive patients undergoing primary total knee and hip replacement from November 2002 to November 2007. In total 2050 patients had total knee replacement and 2203 patients had total hip replacement. All patients were treated at one specialist centre under the care of one surgeon. Data was complete and accurate for all patients at 90 days post-operatively. Standard practice was the use of 150mg Aspirin from Day 1 post-operatively for a total of six weeks combined with spinal anaesthesia and early mobilisation. The overall rate for Fatal Pulmonary embolism 0.07% (3/4253), overall death rate 0.31%(13/4253), for treated non-fatal PE 0.66% (28/4253) and for treated above knee DVT was 0.33%(14/4253). Our data suggests that fatal pulmonary embolism is not common and does not account for most deaths following total hip and knee arthroplasty. We suggest there is no evidence that chemical/mechanical prophylaxis reduces the risk of sudden death from PE following elective primary joint replacement and with modern surgical practice elective hip and knee replacement should no longer be considered high risk procedures

The optimal characteristics of pneumatic compression for mechanical prophylaxis of thromboembolism after total knee arthroplasty (TKA) are not known. Our study compared two methods of calf compression, with the hypothesis that the device which provided a larger increase in peak venous velocity would produce a lower rate of thromboembolism. We performed a prospective, randomised study on 423 patients (472 knees). Duplex ultrasonography was carried out by experienced technicians who were blinded to the device used. Overall, 206 patients (232 knees) used a rapid inflation, asymmetrical compression (RIAC) device and 217 (240 knees) a sequential circumferential compression device (SCD). The rate of venous thromboembolism was 6.9% with the RIAC device compared with 15% for the SCD device (p = 0.007). The incidence of thrombi with unilateral primary TKA was 8.4% for the RIAC compared with 16.8% for the SCD device (p = 0.03). In 47 patients with a bilateral TKA, the incidence of thrombi was 4% for the RIAC compared with 22.7% for the SCD device (p = 0.05 per knee). There was a low rate of mortality and pulmonary embolism when using mechanical prophylaxis for thromboembolism after TKA. Our findings show that the use of rapid inflation, asymmetrical calf compression gave a significantly lower rate of thromboembolism

Recently, the International Consensus Statement Group reported that mechanical prophylaxis with foot-pumps should be considered “Grade A” recommendation for prevention of deep-vein thrombosis after total hip replacement. Mechanical prophylaxis with foot-pumps provides an interesting alternative to chemical agents in the prevention of thomboembolic disease following major orthopaedic surgery procedures. Recent duplex ultrasound studies have suggested that simultaneous use of graduated compression stockings (GCS) may hinder the pneumatic compression effect of foot pumps. The hypothesis of this prospective study was that the use of foot-pumps without GCS does not affect the efficacy of DVT prophylaxis, and improves patient compliance. 846 consecutive patients admitted at a single institution undergoing total hip (THR) or knee replacement (TKR) were included in the study. The A-V Impulse System® foot-pump units (Orthofix Vascular Novame-dix, Andover, UK) was used in all patients. Forty-six patients discontinued the use of foot-pumps, leaving 400 patients who received foot-pumps in combination with GCS and 400 patients with foot pumps alone. Eleven patients of the stocking group (2.7%) and 9 patients of the no-stockings group (2.3%) developed postoperative symptomatic DVT (p=0.07). DVT was more frequent in TKR (10 of 364; 2.7%) than in THR (10 of 436; 2.3%). Non-fatal pulmonary embolism occurred in 4 patients out of 20 with symptomatic DVT, 2 each of the stockings and no stockings groups. The foot pump discontinuation rate of patients treated with stockings was 7%, versus 4% of patients treated without stockings (p< 0.05). In conclusion, management of patients with foot-pumps without GCS does not reduce efficacy of DVT prophylaxis after THR and TKR, and improves patient compliance

The optimal regime of antithrombotic prophylaxis for patients undergoing total knee arthroplasty (TKA) has not been established. Many surgeons employ intermittent pneumatic compression while others use low-molecular-weight heparins (LMWH) which were primarily developed for total hip arthroplasty. We compared the efficacy and safety of these two techniques in a randomised study with blinded assessment of the endpoint by phlebography. We randomised 130 patients, scheduled for elective TKA, to receive one daily subcutaneous injection of nadroparin calcium (dosage adapted to body-weight) or continuous intermittent pneumatic compression of the foot by means of the arteriovenous impulse system. A total of 108 patients (60 in the LMWH group and 48 in the mechanical prophylaxis group) had phlebography eight to 12 days after surgery. Of the 47 with deep-vein thrombosis, 16 had received LMWH (26.7%, 95% CI 16.1 to 39.7) and 31, mechanical prophylaxis (64.6%, 95% CI 49.5 to 77.8). The difference between the two groups was highly significant (p < 0.001). Only one patient in the LMWH group had severe bleeding. We conclude that one daily subcutaneous injection of calcium nadroparin in a fixed, weight-adjusted dosage scheme is superior to intermittent pneumatic compression of the foot for thromboprophylaxis after TKA. The LMWH scheme was also safe

Following the recent publication in April 2007 of NICE guidelines on venous thromboembolism, we report our practice and experience of VTE in adult hip and knee arthroplasty. It is generally agreed that the 2 major complications of VTE are sudden death as a result of pulmonary embolism and post thrombotic syndrome. NICE guide-lines make 2 assumptions:. That chemical and mechanical prophylaxis can reduce these complications. That Orthopaedic surgery, in particular elective Primary Joint Replacements are particularly high risk procedures with respect to these 2 complications. Methods and Results: We have studied a large cohort of patients who had Aspirin only as chemical prophylaxis to determine the incidence of clinical thromboembolism before and after discharge and the mortality from PE at 90 days. We performed a retrospective analysis of consecutive patients undergoing primary total knee and hip replacement from November 2002 to November 2007. In total 2050 patients had total knee replacement and 2203 patients had total hip replacement. All patients were treated at one specialist centre under the care of one surgeon. Data was complete and accurate for all patients at 90 days post-operatively. Standard practice was the use of 150mg Aspirin from Day 1 post-operatively for a total of six weeks combined with spinal anaesthesia and early mobilisation. The overall rate for Fatal Pulmonary embolism 0.07% (3/4253), overall death rate 0.31%(13/4253), for treated non-fatal PE 0.66% (28/4253) and for treated above knee DVT was 0.33%(14/4253). Conclusion: Our data suggests that fatal pulmonary embolism is not common and does not account for most deaths following total hip and knee arthroplasty. We suggest there is no evidence that chemical/mechanical prophylaxis reduces the risk of sudden death from PE following elective primary joint replacement and with modern surgical practice elective hip and knee replacement should no longer be considered high risk procedures

Venous Thromboembolism is a common complication following a hip replacement. Recently the pulmonary embolism prevention study was published. It reported that aspirin decreased the fatal pulmonary embolism rate in patients admitted with a fracture neck of femur. In addition new products (synthetic factor X inhibitor -Fondaparinux, and a direct thrombin inhibiter-Desirudin) have been reported to be more effective than low molecular weight heparin in preventing asymptomatic deep vein thrombosis. We felt it was important to repeat a survey, done in 1997, on the use thromboembolism prophylaxis among British Orthopaedic Surgeons. A single page questionnaire was sent out to all 1308 consultants Orthopaedic surgeons who were members of the British Orthopaedic Association. Those who did not respond were sent a reminder letter. We achieved a 72% response rate. All surgeons use some form of prophylaxis. Eighty five percent of surgeons use pharmacological prophylaxis. Low molecular weight heparin is used by 55% of surgeons. Twenty percent of surgeons use aspirin as their only form of pharmacological prophylaxis. Less than 1% (5 consultants) use early mobilisation alone and nearly 2% (13 consultants) use graded stockings and early mobilisation as their only form of prophylaxis. Seventy four percent of surgeons have a unit policy. Thirty percent have changed their regime in the last 3 years. The majority of British Orthopaedic surgeons still use pharmacological thromboprophylaxis. There has been a significant increase in the use of Aspirin from 5% to 30%. Aspirin is often combined with a mechanical prophylaxis. This has led to an increase in the use of intermittent calf compression (3% to 22%), and foot pumps (12% to 19%). Low molecular weight heparin use has fallen by 10%. The majority of British Orthopaedic surgeons still use pharmacological thromboprophylaxis. There has been a significant increase in the use of Aspirin from 5% to 30%. Aspirin is often combined with a mechanical prophylaxis. This has led to an increase in the use of intermittent calf compression (3% to 22%), and foot pumps (12% to 19%). Low molecular weight heparin use has fallen by 10%

Although patients with a history of venous thromboembolism (VTE) who undergo lower limb joint replacement are thought to be at high risk of further VTE, the actual rate of recurrence has not been reported. The purpose of this study was to identify the recurrence rate of VTE in patients who had undergone lower limb joint replacement, and to compare it with that of patients who had undergone a joint replacement without a history of VTE. . From a pool of 6646 arthroplasty procedures (3344 TKR, 2907 THR, 243 revision THR, 152 revision TKR) in 5967 patients (68% female, mean age 67.7; 21 to 96) carried out between 2009 and 2011, we retrospectively identified 118 consecutive treatment episodes in 106 patients (65% female, mean age 70; 51 to 88,) who had suffered a previous VTE. Despite mechanical prophylaxis and anticoagulation with warfarin, we had four recurrences by three months (3.4% of 118) and six by one year (5.1% of 118). In comparison, in all our other joint replacements the rate of VTE was 0.54% (35/6528). The relative risk of a VTE by 90 days in patients who had undergone a joint replacement with a history of VTE compared with those with a joint replacement and no history of VTE was 6.3 (95% confidence interval, 2.3 to 17.5). There were five complications in the previous VTE group related to bleeding or over-anticoagulation. Cite this article: Bone Joint J 2014;96-B:1515–19

Aims. This phase II safety study aimed to investigate the bleeding side effect profile in patients treated with Rivaroxaban as a new agent for venous thromboembolism (VTE) prophylaxis following hip or knee arthroplasty. Methods. A retrospective study of complications was conducted in 88 consecutive patients undergoing hip and knee arthroplasty at one centre. Patients received chemical and/or mechanical VTE prophylaxis according to local guidelines. Data was collected from notes and evaluated using Fisher's exact test and t-Test. Significance was determined if p< =0.05. The primary end-point was local wound site oozing or bleeding. Secondary end-points were drop in haemoglobin, drain output and infection. Results. 55 patients were treated with Rivaroxaban, 18 with mechanical prophylaxis only, 10 with Enoxaparin and 5 with aspirin, clopidogrel or warfarin. The Rivaroxaban cohort demonstrated a statistically significant amount of increased major bleeding (24% vs. 0% p=0.03) and wound oozing (27% vs. 0% p=0.02) when compared to patients treated with Enoxaparin. Compared to those treated with other methods of VTE prophylaxis, Rivaroxaban also significantly increased major bleeding (24% vs. 6% p=0.01) and wound oozing (27% vs. 12% p=0.03). The Rivaroxaban cohort demonstrated a significantly larger drop in haemoglobin compared to the combined non-Rivaroxaban group (3.0 vs. 2.4 g/dL p=0.04). There was no significant difference in drain volume or rate of infection between groups. Conclusions. Rivaroxaban appears to cause increased wound site bleeding in comparison to Enoxaparin and other methods of thromboembolism prophylaxis. Further use of Rivaroxaban at this centre was therefore discontinued; however, the small group sizes and retrospective non-randomised design of this study introduce bias and limit the reliability of its findings. Prospective randomised controlled trial focused on wound complications is required to eliminate selection and reporter biases