Venous Thromboembolism

1. An Orthopod’s Perspective Venous Thromboembolism Adrian Beaumont Consultant Orthopaedic Surgeon Salisbury District Hospital

2. Size of Problem • ? 25,000 deaths per year • VTE in 40% to 60% joint replacements • Fatal PE in 0.1% to 5% • Inconsistent thromboprophylaxis • Joint registry shows increasing use of mechanical and chemical methods

5. Hugh Owen Thomas 1834 - 1891

8. Fast Track Mobilisation • No clear data on VTE risk • Intuitively beneficial

9. Rudolf Virchov 1821 - 1902

16. Nice Guidelines 2010 • Had orthopaedic input • Risk assess • Hip and knee replacements high risk • Combined methods • Oral agents (not aspirin) • Duration • ‘Opt out’ when bleeding risk

18. Evidence! Or Evidence? Cross trial comparisons • Criteria • End points • Definitions • Sponsored? • Statistics Need Expert Interpretation

21. Anti-Embolism Stockings • Often problematic for our patients • Wounds, swelling etc • Restricted movement • Large legs

24. Hip Fractures • Very common • High mortality • Immobility • Delay to theatre • Age

25. Lower Limb Casts • Evidence if risk • ? UK lags behind Europe • Risk assess or risk forgetting • Plymouth type scoring system • LMWH prescribed at discretion • Ongoing audit

29. Major Bleeding (EMEA) • Fatal Bleeding • Decrease Hb by 20 grams • Transfusion 2 units blood • Critical bleeding • Leading to discontinuation • At surgical site • Leading to reoperation

32. Deep Infection Often disastrous Usually means implant removal

34. Summary • The importance VTE recognised • We have some knowledge of efficacy • Variable but increasing prophylaxis • The adverse effects must be considered • Expert guidance needed • There will be ongoing change

35. Thank You