TARGETED THROMBOPROPHYLAXIS IN MAJOR JOINT REPLACEMENT SURGERY: THE RESULTS OF AN AUDIT OF 7,532 PATIENTS

Background Current UK NICE guidelines on the prevention of thromboembolism state that all patients undergoing elective Hip or Knee Replacement surgery should be offered combined mechanical and pharmacological VTE prophylaxis. Methods The original audit was performed between October 1999 and January 2009, totaling 7,532 patients. Updated to the full 10 years, a total of 8,140 patients underwent hip or knee replacement surgery (revision and primary) in our unit. Using a targeted thromboprophylaxis policy 83% of patients received mechanical A-V foot pumps only until mobile. High risk patients (12%) received in addition LMWH or fondaparinux, with only very high risk patients continuing on chemical prophylaxis post-discharge. All data are collected and stored on our own joint registry database with patients being assessed pre-operatively to determine their level of VTE risk. Results Overall DVT rate was 1%, PE rate 0.5% and fatal PE rate 0.06%. The rates were slightly higher in the targeted Chemical thromboprophylaxis group (DVT 1.6%, PE 0.95%, fatal PE 0.1%) as expected as these patients were identified as being high risk. 5% of patients failed to receive any prophylaxis and in these patients the rates were the lowest of all (DVT 0.8%, PE 0.3% and fatal PE 0%). All p-values were >0.05. These rates are similar to those published in recent trials involving the oral anticoagulants Dabigatran and Rivaroxaban, given to all patients, (RE-NOVATE, RECORD 1,2,3,4, RE-MOBILISE Trials) with all p values again > 0.05. Complications however were ten times less using a targeted approach. Conclusion We recommend the use of a targeted approach, only chemically treating those patients who are at high risk for thromboembolism, along with a rapid recovery programme. This has not only been shown to be safe but cuts costs and has ten times fewer complications than treating all patients with both chemical and mechanical prophylaxis as suggested by NICE.