NICE guidelines state that patients undergoing hip or knee arthroplasty should start as an in-patient and then continue pharmacological VTE prophylaxis for 28–35 days. Retrospective review of all elective hip and knee arthroplasties during one calendar month gave a baseline measurement of how many patients had VTE prophylaxis prescribed on their discharge summary. A new, electronically completed, bespoke Trauma and Orthopaedic discharge summary was created with a discreet area clearly marked for VTE prophylaxis, to serve as a reminder to prescribe it. In March 2012, 93 patients underwent hip/knee arthroplasty. 76% (71/93) were prescribed VTE prophylaxis to take home, there was no clinical reason explaining the failure to prescribe prophylaxis in the remaining 24%. In July 2013, after implementation of the change, 117 patients underwent hip/knee arthroplasty. 99% (116/117) were prescribed VTE prophylaxis to take home. Repeat audit in October 2013 showed that 103 patients underwent hip/knee arthroplasty and 100% were prescribed VTE prophylaxis. A simple but clear change to paperwork, brought about a rapid and seemingly lasting change in the prescription of out-patient VTE prophylaxis. The improvement was seen before and after a change of the Junior Doctor workforce suggesting the change in documentation was the main influencing factor

Venous Thromboembolism (VTE) prophylaxis is an essential part of orthopaedic surgeries in preventing life-threatening thromboembolic events such as Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE). Orthopaedic surgery has the highest incidence rate of thromboembolic events as compared to any other surgical specialities, making it an essential component in managing any orthopaedic case. At Queen's Medical Centre (QMC), a major trauma centre in the United Kingdom (UK), sees up to 750 NOF fracture cases annually, making it one of the busiest trauma and orthopaedic centres in the UK. Our study aims to evaluate how VTE Prophylaxis is conducted in a UK Major Trauma Centre for NOF and pelvic fragility fractures and how human factors can improve its efficacy. The Nottingham University Hospitals (NUH) Trust has implemented new guidelines from August 2019 that patients with fragility fractures such as NOF and pelvic fractures are prescribed with 28 days VTE prophylaxis with Enoxaparin, or their own anti-coagulants if risk of thrombosis exceed the risk of bleeding. This is an adaptation from the trust to align their guidelines closer to the NICE 2018 guidelines. We will be evaluating the initial compliance of VTE Prophylaxis, identify and utilise human factors, then re-analyse the department after implementing interventions on the same batch of junior doctors working in the department. Data of 100 patients with fragility fractures were collected, 50 consecutive patients in the pre-intervention window during August 2019 and 50 in the post-intervention window during November 2019. The pre-intervention data had 43 NOF and 7 Pelvic fractures. Our study showed that 93% of NOF fracture and 100% of pelvic fracture received the correct course of VTE prophylaxis. The data was presented at the local department junior doctor academic session. Three simple human factor interventions were implemented over the course of September and October: Education to the trauma and orthopaedic department on the new guideline, extended VTE labels on drug charts for patients with fragility fractures, VTE reminder labels at doctors' stations. Another 50 consecutive patients' data were collected during November 2019. Data shows that 97.8% of NOF (p>0.05) and 60% of pelvic fracture (p>0.05) received the correct course of VTE prophylaxis. Our data has shown an increase in correct VTE prescription for NOF fracture patients, which is the main bulk of our fragility fracture patients whilst we see a drop in pelvic fracture patients. Due to the limited time frame of four months where junior doctors in the UK rotate between specialities, we are only able to collect data during the first month, implement interventions between datasets and collect data on the final month of the four-month rotation. A future bigger study might provide a more significant result on the department. We believe that the key to achieving 100% VTE prophylaxis in the T&O department is optimising human factors, educating junior doctors, who are not orthopaedic trained, with sufficient information of the guidelines, and evidence of the risk and benefits of providing prolonged VTE prophylaxis for orthopaedic patients. In conclusion, we found that QMC, a major trauma centre with high patient volume and turnover, has a high level of compliance with VTE prophylaxis for fragility fractures and it is imperative that utilising human factors will inch the department closer to its goal of 100% VTE compliance

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

Venous thromboembolism (VTE) is a preventable cause of morbidity and mortality in patients undergoing elective hip arthroplasty surgery. The balance of post-operative VTE prophylaxis and risk of post-operative haemorrhage remains at the forefront of surgeon's mind. The National Institute for Clinical Excellence (NICE) has altered their prophylaxis guidance in the setting of total hip arthroplasty (THA). The aim of this study was to present the VTE incidence in 8,890 patients who underwent total hip arthroplasty between January 1997 and March 2018 with Aspirin as the primary agent for pharmacological thromboprophylaxis. Analysis of prospective data collection from consecutive patients undergoing THA was performed with the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) occurring within 6 months of the index operation as the primary outcome measure. 90-day all-cause mortality of this cohort of patients was also analysed. 8890 patients were reviewed. This included 7235 primary, 224 complex primary and 1431 revision cases. The incidence of DVT was 0.64% after elective THA and the incidence of PE was 0.54%. There was no difference in the incidence between primary and revision cases. The 90-day all-cause mortality was 0.88%. Cardiovascular and respiratory disease were the main causes of death following surgery. Only 0.03% of deaths (n= 3) within 90 days of index surgery were due to VTE. Our results support the use of aspirin as an effective form of prophylaxis against VTE following THA. It is not associated with an increased incidence in symptomatic DVT, PE or death compared to other published studies. The fact that it is inexpensive, readily available, requires no monitoring and does not pose an increased risk of bleeding are other attractive advantages of using aspirin for VTE prophylaxis

Venous thromboembolism (VTE) remains an immediate threat to patients following total hip and knee replacement. While there is a strong consensus that steps should be taken to minimise the risk to patients by utilising some forms of prophylaxis for the vast majority of patients, the methods utilised have been extremely variable. Clinical practice guidelines (CPGs) have been published by various professional organisations for over 25 years to provide recommendations to standardise VTE prophylaxis. Historically, these recommendations have varied widely depending in underlying assumptions, goals, and methodology of the various groups. This effort has previously been exemplified by the American College of Chest Physicians (ACCP) and the American Academy of Orthopaedic Surgeons (AAOS). The former group of medical specialists targeted minimising venographically proven deep vein thrombosis (DVT) (the vast majority of which are asymptomatic) as their primary goal prior to 2012. The latter group of surgeons targeted minimising symptomatic VTE. As a result prior to 2012, the recommendations of the two groups were widely divergent. In the past year, both groups have reassessed the current literature with the principal goals of minimising symptomatic VTE events and bleeding complications. As a result, for the first time the CPGs of these two major subspecialty organisations are in close agreement

The December 2024 Arthroplasty Roundup. 360. looks at: Aspirin for hip and knee arthroplasty?; VTE prophylaxis; VTE prophylaxis part II

Rivaroxaban, an oral, direct FXa inhibitor has shown in large phase III trials to be both superior to enoxaparin a low molecular weight heparin for VTE prophylaxis in patients undergoing MOS, and to also have a good safety profile. RECORD, a pivotal clinical trial program investigating rivaroxaban for the prevention of VTE after THR and TKR surgery, consists of four multinational, randomized, double-blind, double-dummy phase III studies (RECORD1,2,3 and 4) comparing rivaroxaban 10 mg once-daily with enoxaparin 40 mg once-daily or 30 mg twice-daily. The RECORD program has consistently shown superiority of rivaroxaban to enoxaparin at preventing VTE after major orthopaedic surgery. Results from the RECORD 2 study confirmed the benefit of extended thromboprophylaxis after THR. Rivaroxaban was more effective than enoxaparin at reducing the incidence of VTE and all course mortality in patients undergoing THR, with a relative risk reduction (RRR) of 70% in total VTE (RECORD 1). In the TKR populations, rivaroxaban was superior to both once-daily (RECORD 3) and twice-daily (RECORD 4) enoxaparin, with a RRR of 49% and 31.4%, respectively. It also significantly reduced the incidence of symptomatic VTE in TKR patients (RECORD 3). Rivaroxaban groups had low and similar bleeding rates to enoxaparin across the RECORD program. Thus, with its superior efficacy and a good safety profile, oral, once-daily fixed dosing with rivaroxaban could transform the future of VTE prevention after major orthopaedic surgery and improve the quality and reliability of patients care

Aims. We investigated the efficacy and safety profile of commonly used venous thromboembolism (VTE) prophylaxis agents following hip and knee arthroplasty. Methods. A systematic search of PubMed, Embase, Cochrane Library, Web of Science, and OrthoSearch was performed. Prophylaxis agents investigated were aspirin (< 325 mg and ≥ 325 mg daily), enoxaparin, dalteparin, fondaparinux, unfractionated heparin, warfarin, rivaroxaban, apixaban, and dabigatran. The primary efficacy outcome of interest was the risk of VTE, whereas the primary safety outcomes of interest were the risk of major bleeding events (MBE) and wound complications (WC). VTE was defined as the confirmed diagnosis of any deep vein thrombosis and/or pulmonary embolism. Network meta-analysis combining direct and indirect evidence was performed. Cluster rank analysis using the surface under cumulative ranking (SUCRA) was applied to compare each intervention group, weighing safety and efficacy outcomes. Results. Of 86 studies eligible studies, cluster rank analysis showed that aspirin < 325 mg daily (SUCRA-VTE 89.3%; SUCRA-MBE 75.3%; SUCRA-WC 71.1%), enoxaparin (SUCRA-VTE 55.7%; SUCRA-MBE 49.8%; SUCRA-WC 45.2%), and dabigatran (SUCRA-VTE 44.9%; SUCRA-MBE 52.0%; SUCRA-WC 41.9%) have an overall satisfactory efficacy and safety profile. Conclusion. We recommend the use of either aspirin < 325 mg daily, enoxaparin, or dabigatran for VTE prophylaxis following hip and knee arthroplasty. Cite this article: Bone Joint J 2024;106-B(9):924–934

Patients with pelvic and acetabular fractures have a high risk of developing thromboembolic complications. Despite routine screening, the risk of PE remains high and may develop in patients with negative DVT screening. The search for a means to identify the patient ‘at risk’ has been elusive.

537 consecutive patients, referred to Royal Adelaide Hospital over a 20 year period for treatment of pelvic and acetabular fractures, were evaluated prospectively for pulmonary embolus (PE). 352 patients referred directly to the author were treated with variable dose heparin as prophylaxis to venous thromboembolic (VTE) disease. 184 patients primarily admitted under the general surgeons or to ITU, prior to referral to the author, were treated with fixed dose heparin or Enoxaparin. All patients were followed prospectively to determine the rate of pulmonary embolus. The heparin dosage requirements of those who developed pulmonary emboli were compared to those who did not. Patients were also identified for whom a clinical diagnosis of deep venous thrombosis (DVT) was made during the study and their heparin dosage requirements were determined.

7 of 352 patients treated with variable dose heparin developed PE (1.98%). 13 of 184 patients treated with fixed dose heparin, Enoxaparin, or combinations, developed PE (7.06%). An incidental finding of DVT was made in 36 patients. Of these, 10 patients (2.8%) were treated with variable dose heparin and 26 patients (14.1%) with fixed dose heparin or Enoxaparin.

The average Injury Severity Score was higher in patients treated with variable dose heparin than those treated with fixed dose regimes. Patients treated with variable dose heparin who developed PE showed a progressively increasing heparin requirement. The majority of patients who did not develop PE (72%) showed a progressively decreasing heparin requirement (suggesting reversal of a prothrombotic state). 21% showed an initial increasing heparin requirement followed by a decreasing requirement (suggesting a prothrombotic state that was reversed, e.g. a DVT successfully treated by the increasing heparin dose provided by a variable dose regime). 4% manifested a static heparin requirement (suggesting maintenance of a prothrombotic state). 8 patients treated with variable dose heparin developed DVT. 6/8 patients manifested a phase of progressively increasing heparin requirement, followed by a decreased requirement, and 2/8 patients manifested a sustained level of heparin requirement.

Patients with pelvic and acetabular fractures treated with variable dose heparin showed a rate of PE (1.98%). This is remarkably low compared with published rates of PE in such patients, and particularly compared with those patients treated only with chemoprophylaxis. The rate of PE was 3.5x higher and the rate of DVT was 5x higher in patients treated with fixed dose heparin or Enoxaparin. Patients who developed PE or DVT manifested an increasing heparin requirement. An increasing dosage of heparin may protect the ‘at risk’ patient from venous thromboembolism. Fixed dose unfractionated heparin/LMWH may be insufficient to treat the ‘at risk’ patient. An increasing heparin requirement may identify the patient ‘at risk’.

Major orthopaedic surgeries such as total hip and total knee replacements are considered a major risk factor for venous thromboembolism (VTE). Without prophylaxis, DVT occurs in 10–40% of general surgical or medical patients and 40–60% of patients following major orthopaedic surgery. There has, however, been a perception that VTE is less common in Asia than in Western countries. New evidence has emerged recently that contradicts this perception. Results from multinational epidemiological studies (SMART, AIDA, ENDORSE) clearly showed that the rate of venographic and symptomatic thrombosis after major joint replacement in Asian patients is similar to that previously reported in patients in Western countries. However, thromboprophylaxis is not routinely used in Asia, even in situations considered high risk in Western countries. The ENDORSE study reported that less than 20% of at-risk surgical patients in Asia received prophylaxis compared with over 80% in Western countries. This leaves the majority of patients at risk of developing VTE and VTE-related conditions, which continues after hospital discharge. Current guidelines recommend the use of thromboprophylaxis for at least 10 days and up to 35 days in patients undergoing total joint replacement. Available anticoagulants are effective at preventing VTE but are associated with various limitations, such as parenteral administration as in the case of UFH and LMWH. A narrow therapeutic window, unpredictable pharmacology, frequent coagulation monitoring and dose-adjustment as in the case of vitamin K antagonists (VKAs). Several new, oral anticoagulants are in advanced clinical development, including the direct thrombin inhibitor, dabigatran, and the direct Factor Xa inhibitors, rivaroxaban and apixaban.

Abstract. Introduction. Neck of femur (NOF) fracture patients are at risk of developing venous thromboembolisms (VTE). VTE risks could be reduced by adhering to the National Institute for Health and Care Excellence (NICE) recommendation for 1 month of prophylaxis with low molecular weight heparin. This audit aimed to assess and improve local compliance to national guidelines on VTE prophylaxis in NOF fracture patients following discharge. Methods. A retrospective consecutive case series of all NOF fractures treated at our institution from May – July 2021 was conducted. Those not eligible for outpatient VTE prophylaxis were excluded (anticoagulated for other indications, completed prophylactic course in hospital, inpatient death, pharmacological prophylaxis contraindicated). The agent and duration of VTE prophylaxis, and the occurrence of clinically significant VTE or bleeds were recorded. A re-audit was conducted in March 2022. Results. From May – July 2021, only 1/65 (1.5%) patient was discharged on a VTE prophylaxis regime consistent with NICE guidelines (1 enoxaparin, 56 rivaroxaban, 6 apixaban; 58 35-day course, 5 28-day course). A quick-guide document summarising the standard inpatient and outpatient VTE prophylaxis regimes for various orthopaedic indications was designed and widely disseminated. In March 2022, 30/34 (88.2%) patients were discharged with enoxaparin and 24/34 (70.6%) received a 28-day course. There were no cases of clinically significant VTE or bleeds in both cycles. Conclusion. Local compliance to national guidelines improved significantly with the implementation of a standardised VTE prophylaxis protocol. Our quick-guide document is a reproducible way of communicating consensus and ensuring consistency within a department

Introduction. Total contact casting (TCC) is one of the most commonly utilized modalities in the management of diabetic feet. We undertook a retrospective review to determine the prevalence of symptomatic VTE events in patients treated in a weight bearing TCC in our diabetic foot unit, and to formulate guidelines for VTE prophylaxis. Methods. Electronic records were reviewed to identify all patients treated in a TCC between 2014 and 2021. Data collection included patient demographics, comorbidities, period of immobilization in TCC, the incidence of VTE events, and any VTE prophylaxis prescribed during their period in TCC. Results. 549 patients were identified who had at least one episode of TCC. Mean age was 67 years (range 28 to 94 years) and the mean duration in cast was 10.2 weeks (range 0.3–46 weeks). Only 6 patients (1.1%) were prescribed chemical thrombo-prophylaxis during their period in TCC. Mean body mass index (BMI) for these patients was 32.3 (Range 18.4–58.9). Other significant comorbidities: 81% (n-444) of patients had associated cardio-vascular comorbidities; 54 % (n-296) had renal comorbidities including 22% (n-121) having had dialysis and 4.2% (n-23) with renal transplants. Eight of the 549 patients (1.5%) had suffered a VTE event of which only 2 (0.36%) were during the period of immobilization in TCC. One was a symptomatic DVT (0.18%) and the another was an asymptomatic (incidental) finding of pulmonary embolism (PE). There was no mortality related to the VTE episodes. Conclusion. NICE guidelines state that one should “Consider pharmacological VTE prophylaxis for patients with lower limb immobilization”. Our study finds that patients treated in a weight bearing TCC do not require routine pharmacological VTE prophylaxis, in spite of an extended period of lower limb immobilization and significant medical comorbidities

Due to working time restrictions a full-shift cross-covering system is commonplace. As more than one surgeon is responsible for trauma admissions in a 24-hour period a complete handover is paramount to ensure continuity of care. The purpose of this audit was to determine whether the introduction of a formal handover/admission form would improve this continuity with regards to prescription of venous thromboembolism (VTE) prophylaxis in hip fracture patients. In Stirling Royal Infirmary chemical VTE prophylaxis for hip fracture patients is 40mg enoxaparin at 6pm unless there is a contraindication. Over a 14-day period we prospectively documented the prescription of VTE prophylaxis and doses missed under the current admissions system. Following this a proforma was introduced that was to be exchanged at handover meetings. The proforma included patients' name/details, admission ward, and tasks to be completed during clerk-in, including VTE prophylaxis prescription. Tasks outstanding at handover had to be documented and completed by the subsequent doctor. Each form was signed and dated by the receiving doctor. We subsequently re-evaluated the prescription of VTE prophylaxis in hip fracture patients. Between 1/12/10-15/12/10, 23 patients were admitted with hip fracture. 12 had appropriate VTE prophylaxis, 6 missed one dose, 4 missed two, and 1 missed three all due to failure of prescription. Following the introduction of the proforma, 12 patients were admitted with hip fractures between 31/12/10-14/1/11. All were prescribed appropriate VTE prophylaxis and missed no doses. 1 patient was on warfarin and had enoxaparin prescribed but withheld until INR< 2.0. After the introduction of a handover form VTE prophylaxis prescription vastly improved. This proforma ensured that all elements of initial management were completed allowing for physician accountability, greater efficacy of handover and continuity of care

Venous thromboembolic events (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), remain one of the most common complications following total joint arthroplasty. Reported rates of symptomatic VTE following THA and TKA range from 0.83% to 15% and 2% to 10%, respectively. Thus, VTE prophylaxis should be routinely administered following total joint arthroplasty. However, while orthopaedic surgeons have considerable flexibility regarding their VTE prophylaxis regimen, it remains unclear which is optimal. Patients at low risk of VTE may receive excessive anticoagulation and unnecessarily risk further perioperative morbidity (wound complications, bleeding) following total joint arthroplasty. With an evolving health care landscape, emphasis on complications and readmissions, and shorter inpatient hospitalizations, it is imperative that a VTE prophylaxis regimen is simple, effective, easy to monitor, and has high patient compliance. Mobile pneumatic compression devices (MCDs) have been used with greater frequency following total joint arthroplasty, with multiple reports demonstrating their effectiveness in VTE prevention with or without the addition of aspirin for chemical prophylaxis. The use of MCDs allows the avoidance of more aggressive anticoagulation in the majority of patients undergoing total joint arthroplasty, decreases the incidence of wound complications, and achieves a low overall incidence of symptomatic VTE. Future investigations are necessary to determine the necessity and impact of the addition of aspirin to the use of MCDs for VTE prophylaxis

The selection of venous thromboembolism (VTE) prophylaxis after total joint arthroplasty (TJA) has been controversial. Although the aspirin controversy is presumably resolved, there is no medical evidence for the “optimal” VTE prophylaxis regime for individual patients. A risk-stratified multi-modal VTE prophylaxis protocol was developed and adopted by consensus. VTE risk factors and bleeding risk factors were categorised into six VTE/bleeding risk levels: (1) pre-operative vitamin K antagonists (VKA) use, (2) bleeding risk factors, (3) hypercoagulable state, (4) pre-operative anti-platelet therapy [clopidogrel use], (5) VTE risk factors, (6) no VTE or bleeding risk factors. The pharmacologic agents used for each risk level were: (1) resume VKA with low molecular weight heparin (LMWH) bridge, (2) pharmacologic agents contra-indicated and mechanical prophylaxis only, (3) VKA for 90 days with LMWH bridge, (4) resume anti-platelet therapy, (5) LMWH in hospital and discharge on aspirin for 90 days, (6) aspirin for 90 days (starting in hospital). In addition to pharmacologic treatment, all patients received multi-modal prophylaxis including early mobilisation, mechanical foot pumps, and neuraxial anesthesia when not contra-indicated. Prior to surgery, a VTE/bleeding risk factor checklist was completed determining the risk level. The intervention cohort included all TJA patients from January 1, 2010 to December 31, 2012. The comparison cohort included all TJA patients from the year prior to implementation of the protocol at the same community hospital. Thirty day all-cause non-elective re-admissions, 30 day same-site re-operations, 90 day VTE events, and protocol compliance were abstracted from the electronic medical record. The intervention group consisted of 2679 patients (1075 hip arthroplasty patients and 1604 knee arthroplasty patients). The comparison group consisted of 1118 patients (323 hip arthroplasty patients and 795 knee arthroplasty patients). The 30 day all cause non-elective re-admission rate was 2.72% (73/2679) in the intervention group and 4.29% (48/1118) in the comparison group (p=0.0148). The 30 day same-site re-operation rate was 1.38% (37/2679) in the intervention group and 1.25% (14/1118) in the comparison group (p=0.8773). The 90 day VTE event rate was 1.57% (42/2679) in the intervention group and 3.40% (38/1118) in the comparison group (p=0.0007). The VTE rate was higher for knee arthroplasty patients 2.00% (32/1604) than for hip arthroplasty patients 0.93% (10/1075) (p=0.0379). The rate of VTE events was higher for patients that deviated from the VTE protocol 5.03% (10/199) than for all risk groups treated per the protocol 1.29% (32/2481) (p=0.0007). The risk-stratified multi-modal VTE prophylaxis protocol simultaneously reduced 30 day all-cause non-elective re-admissions and 90 day VTE events. The possible causes for reducing 30 day re-admissions and reducing 90 day VTE events are: (1) reducing bleeding events by using aspirin for VTE prophylaxis in more than 80% of patients, (2) extending VTE prophylaxis to 90 days, and (3) using multi-modal prophylaxis. The risk-stratified multi-modal VTE prophylaxis protocol for total joint arthroplasty is consistent with 9 of the 10 recommendations in the AAOS Clinical Practice Guideline. The risk-stratification checklist provides a standardised tool to assess risks, discuss risks, and make shared decision with patients. Patient treatment that deviated from the protocol had a significantly higher VTE rate (5.03%). Protocol compliance increased each year from 91.1% in 2010 to 94.2% in 2012

Aims. Malignancy and surgery are risk factors for venous thromboembolism (VTE). We undertook a systematic review of the literature concerning the prophylactic management of VTE in orthopaedic oncology patients. Methods. MEDLINE (PubMed), EMBASE (Ovid), Cochrane, and CINAHL databases were searched focusing on VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), bleeding, or wound complication rates. Results. In all, 17 studies published from 1998 to 2018 met the inclusion criteria for the systematic review. The mean incidence of all VTE events in orthopaedic oncology patients was 10.7% (1.1% to 27.7%). The rate of PE was 2.4% (0.1% to 10.6%) while the rate of lethal PE was 0.6% (0.0% to 4.3%). The overall rate of DVT was 8.8% (1.1% to 22.3%) and the rate of symptomatic DVT was 2.9% (0.0% to 6.2%). From the studies that screened all patients prior to hospital discharge, the rate of asymptomatic DVT was 10.9% (2.0% to 20.2%). The most common risk factors identified for VTE were endoprosthetic replacements, hip and pelvic resections, presence of metastases, surgical procedures taking longer than three hours, and patients having chemotherapy. Mean incidence of VTE with and without chemical prophylaxis was 7.9% (1.1% to 21.8%) and 8.7% (2.0% to 23.4%; p = 0.11), respectively. No difference in the incidence of bleeding or wound complications between prophylaxis groups was reported. Conclusion. Current evidence is limited to guide clinicians. It is our consensus opinion, based upon logic and deduction, that all patients be considered for both mechanical and chemical VTE prophylaxis, particularly in high-risk patients (pelvic or hip resections, prosthetic reconstruction, malignant diagnosis, presence of metastases, or surgical procedures longer than three hours). Additionally, the surgeon must determine, in each patient, if the risk of haemorrhage outweighs the risk of VTE. No individual pharmacological agent has been identified as being superior in the prevention of VTE events. Cite this article: Bone Joint J 2020;102-B(12)1743:–1751

Considerable debate exists regarding which agent(s) should be preferred for venous thromboembolism (VTE) chemical prophylaxis following joint replacement. We assessed the practice of surgeons regarding VTE chemical prophylaxis for primary THR and TKR, pre and post issuing of updated NICE guidance in 2018. A survey, circulated through the British Hip Society and regional trainee networks/collaboratives, was completed by 306 UK surgeons at 187 units. VTE chemical prophylaxis prescribing patterns for surgeons carrying out primary THR (n=258) and TKR (n=253) in low-risk patients were assessed post publication of 2018 NICE recommendations. Prescribing patterns before and after the NICE publication were subsequently explored. Questions were also asked about surgeon equipoise for participation in future RCTs. Following the new guidance, 34% (n=87) used low-molecular weight heparin (LMWH) alone, 33% (n=85) aspirin (commonly preceded by LMWH), and 31% (n=81) direct oral anticoagulants (DOACs: with/without preceding LMWH) for THR. For TKR, 42% (n=105) used aspirin (usually monotherapy), 31% (n=78) LMWH alone, and 27% (n=68) DOAC (with/without preceding LMWH). NICE guidance changed the practice of 34% of hip and 41% of knee surgeons, with significantly increased use of aspirin preceded by LMWH for THR (before=25% vs. after=73%;p<0.001), and aspirin for TKR (before=18% vs. after=84%;p<0.001). Significantly more regimens were NICE guidance compliant after the 2018 update for THR (before=85.7% vs. after=92.6%;p=0.011) and TKR (before=87.0% vs. after=98.8%;p<0.001). Support from surgeons for future RCTs was dependent on the clinical question, ranging from 48% participation in trials (effectiveness of aspirin vs. a DOAC) to 79% (effectiveness of 14 days LMWH vs. 28 days LMWH). Over one-third of surveyed surgeons changed their VTE chemical prophylaxis in response to 2018 NICE recommendations, with more THR and TKR surgeons now compliant with latest NICE guidance. The major change in practice was an increased use of aspirin for VTE chemical prophylaxis. Furthermore, there is an appetite amongst UK surgeons for participating in future RCTs, with a trial comparing standard versus extended duration LMWH likely feasible in current practice

The National Institute of Clinical Excellence (NICE) published guidance for reducing the risk of venous thromboembolism (VTE) in January 2010. This guidance has had a significant impact on the management of all inpatients. It is now mandatory to risk assess every inpatient and commence appropriate treatment if indicated. The guidelines specifically exclude outpatients although NICE recognises' that lower limb cast immobilisation is a risk factor for VTE. The purpose of our study was to establish the current practice for the management of outpatients treated with lower limb casts in England. The NHS Choices website lists 166 acute hospitals in England. A telephone audit was conducted in February 2011. A member of the on call orthopaedic team was asked: 1. Are you aware of the NICE guidelines for VTE prophylaxis? 2. In your department, outpatients treated with a lower limb cast, are they risk assessed for VTE? 3. If a patient undergoes Open Reduction Internal Fixation (ORIF) for an ankle fracture and is discharged wearing a cast, are they given VTE prophylaxis? 4. If yes - for how long are they treated?. Responses were obtained from 150 eligible hospitals (1 FY1, 28 FY2, 44 ST1-ST2, 76 ST3+, 1 Consultant). 62% of responders stated that they were aware of the NICE guidance. 40% of responders stated that outpatients were routinely risk assessed for VTE. 32% of responders stated that ankle fractures treated with an ORIF and discharged wearing a cast would receive VTE prophylaxis. The duration of treatment varied from 5 days, to 6 weeks, to removal of cast. The management of patients treated with a lower limb cast is variable and inconsistent throughout England. Although there are no national guidelines for this patient group, the routine risk assessment of outpatients was higher than anticipated by the authors. We recommend that if VTE prophylaxis is commenced as an inpatient, then it should be continued until the cast is removed

Background. Venous Thrombo-Embolism is a recognized complication of lower limb immobilization. In the neuropathic patient total contact casting (TCC) is used in the management of acute charcot neuroathropathy and/or to off-load neuropathic ulcers, frequently for long time periods. To our knowledge there is no literature stating the prevalence of VTE in patients undergoing TCC. We perceive that neuropathic patients with active charcot have other risk factors for VTE which would predispose them to this condition and would mandate the use of prophylaxis. We report a retrospective case series assessing the prevalence of VTE in the patients being treated with TCCs. Methods. Patients undergoing TCC between 2006 and 2018 were identified using plaster room records. These patients subsequently had clinical letters and radiological reports assessed for details around the TCC episode, past medical history and any VTE events. Results. There were 143 TCC episodes in 104 patients. Average age at cast application was 55 years. Time in cast averaged 45 days (range 5 days – 8 months, median 35 days). 3 out of 4 patients had neuropathy as a consequence of diabetes. One TCC related VTE (0.7% of casting episodes) was documented. This was a proximal DVT confirmed on USS 9 days following cast removal. No patient received VTE prophylaxis while in TCC. Conclusion. Despite these complex patients having a multitude of co-morbidities the prevalence of VTE in the TCC setting remains similar to that of the general population. This may be due to the fact that TCCs permit weight bearing. This case series suggests that, while all patients should be individually VTE risk assessed as for any lower limb immobilization, chemical thromboprophylaxis is not routinely indicated in the context of TCCs

Introduction. ‘VTE disease is the new MRSA’, with much attention received in the media and the political world. Following the 2010 NICE guidelines all patients admitted to hospital should have VTE prophylaxis considered and a formal VTE risk assessment done with documentation and review in a 24 hour period. We carried out a completed audit cycle to identify our adherence to these guidelines and introduced a novel method to ensure compliance. Materials/Methods. An audit of 400 patients admitted to the orthopaedic department was carried out with review of case notes. Three key parameters were investigated: Firstly the compliance of carrying out a risk assessment for VTE disease with correct documentation, secondly investigating how many patients got re-assessed in 24 hours and finally if patients received appropriate VTE prophylaxis. The data was re-audited following the introduction of a new drug chart with a box section for VTE risk assessment and prophylaxis on the chart itself. Results. In the first cycle VTE risk assessments were carried out in 2.5% with 0% having a re-assessment in 24 hours and 93.5% of patients having correctly prescribed VTE prophylaxis. Following the new drug charts, the risk assessments were carried out in 79%, re-assessment in 50% and correct prescribed prophylaxis in 99% of the patients. Conclusions. We recommend all hospitals should have a section in the drug chart itself for VTE risk assessment and prophylaxis as this greatly improves compliance to the NICE guidelines. This ensures optimal patient care and protects the trust from litigations