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VTE prevention in major orthopedic surgery
Editor's Note: This letter concerns an article in a Cleveland Clinic Journal of Medicine supplement (Preventing Venous Thromboembolism Throughout the Continuum of Care) distributed to only a portion of the Journal's regular readership, owing to the terms of the grant supporting the supplement.
To the Editor: I must strongly disagree with Deitelzweig and colleagues’ recommendations against the use of aspirin for thromboprophylaxis in elective joint replacement surgery.1 The references cited2–5 are outdated. In the last few years, in patients undergoing minimally invasive hip replacement (done either posterolaterally or via an anterior approach with epidural anesthesia), early ambulation and thromboprophylaxis with compression boots and enteric-coated aspirin (or alternative antiplatelet agents in patients allergic to aspirin) has been associated with a lower incidence of deep vein thrombosis (DVT) and postoperative bleeding than either enoxaparin or fondaparinux.6–9
Our experience in Los Angeles under the direction of Dr. Lawrence Dorr, past president of the Hip Society, is also instructive: minimally invasive hip replacement performed via a posterior approach with a 2- to 3-day length of stay and with the use of multimodal thromboprophylaxis including aspirin (or an alternate antiplatelet) has resulted in a low incidence of proximal DVT and no deaths from pulmonary embolism.10 Our experience with total knee replacement is similar but has included a slightly higher rate of DVT in patients older than 75 years of age.10
The American Academy of Orthopaedic Surgeons has clearly supported the use of aspirin as an effective modality for DVT prophylaxis.11 We are patiently awaiting the newest recommendations from the American College of Chest Physicians, which I believe should incorporate aspirin in DVT prophylaxis and thus get medical physicians on the same page as orthopedic surgeons.
- Deitelzweig SB, McKean SC, Amin AN, Brotman DJ, Jaffer AK, Spyropoulos AC. Prevention of venous thromboembolism in the orthopedic surgery patient. Cleve Clin J Med 2008; 75(suppl 3):S27–S36.
- 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.
- Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous thromboembolism. Chest 2001; 119(1 suppl):132S–175S.
- Zimlich RH, Fulbright BM, Friedman RJ. Current status of anticoagulation therapy after total hip and total knee arthroplasty. J Am Acad Orthop Surg 1996; 4:54–62.
- PEP Trial Collaborative Group. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet 2000; 355:1295–1302.
- Berend KR, Lombardi AV Jr. Multimodal venous thromboembolic disease prevention for patients undergoing primary or revision total joint arthroplasty: the role of aspirin. Am J Orthop 2006; 35:24–29.
- Westrich GH, Bottner F, Windsor RE, Laskin RS, Haas SB, Sculco TP. VenaFlow plus Lovenox vs VenaFlow plus aspirin for thromboembolic disease prophylaxis in total knee arthroplasty. J Arthroplasty 2006; 21(6 suppl 2):139–143.
- Lotke PA, Lonner JH. The benefit of aspirin chemoprophylaxis for thromboembolism after total knee arthroplasty. Clin Orthop Relat Res 2006; 452:175–180.
- Callaghan JJ, Dorr LD, Engh GA, et al. Prophylaxis for thromboembolic disease: recommendations from the American College of Chest Physicians—are they appropriate for orthopaedic surgery? J Arthroplasty 2005; 20:273–274.
- Dorr LD, Gendelman V, Maheshwari AV, Boutary M, Wan Z, Long WT. Multimodal thromboprophylaxis for total hip and knee arthroplasty based on risk assessment. J Bone Joint Surg Am 2007; 89:2648–2657.
Editor's Note: This letter concerns an article in a Cleveland Clinic Journal of Medicine supplement (Preventing Venous Thromboembolism Throughout the Continuum of Care) distributed to only a portion of the Journal's regular readership, owing to the terms of the grant supporting the supplement.
To the Editor: I must strongly disagree with Deitelzweig and colleagues’ recommendations against the use of aspirin for thromboprophylaxis in elective joint replacement surgery.1 The references cited2–5 are outdated. In the last few years, in patients undergoing minimally invasive hip replacement (done either posterolaterally or via an anterior approach with epidural anesthesia), early ambulation and thromboprophylaxis with compression boots and enteric-coated aspirin (or alternative antiplatelet agents in patients allergic to aspirin) has been associated with a lower incidence of deep vein thrombosis (DVT) and postoperative bleeding than either enoxaparin or fondaparinux.6–9
Our experience in Los Angeles under the direction of Dr. Lawrence Dorr, past president of the Hip Society, is also instructive: minimally invasive hip replacement performed via a posterior approach with a 2- to 3-day length of stay and with the use of multimodal thromboprophylaxis including aspirin (or an alternate antiplatelet) has resulted in a low incidence of proximal DVT and no deaths from pulmonary embolism.10 Our experience with total knee replacement is similar but has included a slightly higher rate of DVT in patients older than 75 years of age.10
The American Academy of Orthopaedic Surgeons has clearly supported the use of aspirin as an effective modality for DVT prophylaxis.11 We are patiently awaiting the newest recommendations from the American College of Chest Physicians, which I believe should incorporate aspirin in DVT prophylaxis and thus get medical physicians on the same page as orthopedic surgeons.
Editor's Note: This letter concerns an article in a Cleveland Clinic Journal of Medicine supplement (Preventing Venous Thromboembolism Throughout the Continuum of Care) distributed to only a portion of the Journal's regular readership, owing to the terms of the grant supporting the supplement.
To the Editor: I must strongly disagree with Deitelzweig and colleagues’ recommendations against the use of aspirin for thromboprophylaxis in elective joint replacement surgery.1 The references cited2–5 are outdated. In the last few years, in patients undergoing minimally invasive hip replacement (done either posterolaterally or via an anterior approach with epidural anesthesia), early ambulation and thromboprophylaxis with compression boots and enteric-coated aspirin (or alternative antiplatelet agents in patients allergic to aspirin) has been associated with a lower incidence of deep vein thrombosis (DVT) and postoperative bleeding than either enoxaparin or fondaparinux.6–9
Our experience in Los Angeles under the direction of Dr. Lawrence Dorr, past president of the Hip Society, is also instructive: minimally invasive hip replacement performed via a posterior approach with a 2- to 3-day length of stay and with the use of multimodal thromboprophylaxis including aspirin (or an alternate antiplatelet) has resulted in a low incidence of proximal DVT and no deaths from pulmonary embolism.10 Our experience with total knee replacement is similar but has included a slightly higher rate of DVT in patients older than 75 years of age.10
The American Academy of Orthopaedic Surgeons has clearly supported the use of aspirin as an effective modality for DVT prophylaxis.11 We are patiently awaiting the newest recommendations from the American College of Chest Physicians, which I believe should incorporate aspirin in DVT prophylaxis and thus get medical physicians on the same page as orthopedic surgeons.
- Deitelzweig SB, McKean SC, Amin AN, Brotman DJ, Jaffer AK, Spyropoulos AC. Prevention of venous thromboembolism in the orthopedic surgery patient. Cleve Clin J Med 2008; 75(suppl 3):S27–S36.
- 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.
- Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous thromboembolism. Chest 2001; 119(1 suppl):132S–175S.
- Zimlich RH, Fulbright BM, Friedman RJ. Current status of anticoagulation therapy after total hip and total knee arthroplasty. J Am Acad Orthop Surg 1996; 4:54–62.
- PEP Trial Collaborative Group. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet 2000; 355:1295–1302.
- Berend KR, Lombardi AV Jr. Multimodal venous thromboembolic disease prevention for patients undergoing primary or revision total joint arthroplasty: the role of aspirin. Am J Orthop 2006; 35:24–29.
- Westrich GH, Bottner F, Windsor RE, Laskin RS, Haas SB, Sculco TP. VenaFlow plus Lovenox vs VenaFlow plus aspirin for thromboembolic disease prophylaxis in total knee arthroplasty. J Arthroplasty 2006; 21(6 suppl 2):139–143.
- Lotke PA, Lonner JH. The benefit of aspirin chemoprophylaxis for thromboembolism after total knee arthroplasty. Clin Orthop Relat Res 2006; 452:175–180.
- Callaghan JJ, Dorr LD, Engh GA, et al. Prophylaxis for thromboembolic disease: recommendations from the American College of Chest Physicians—are they appropriate for orthopaedic surgery? J Arthroplasty 2005; 20:273–274.
- Dorr LD, Gendelman V, Maheshwari AV, Boutary M, Wan Z, Long WT. Multimodal thromboprophylaxis for total hip and knee arthroplasty based on risk assessment. J Bone Joint Surg Am 2007; 89:2648–2657.
- Deitelzweig SB, McKean SC, Amin AN, Brotman DJ, Jaffer AK, Spyropoulos AC. Prevention of venous thromboembolism in the orthopedic surgery patient. Cleve Clin J Med 2008; 75(suppl 3):S27–S36.
- 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.
- Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous thromboembolism. Chest 2001; 119(1 suppl):132S–175S.
- Zimlich RH, Fulbright BM, Friedman RJ. Current status of anticoagulation therapy after total hip and total knee arthroplasty. J Am Acad Orthop Surg 1996; 4:54–62.
- PEP Trial Collaborative Group. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet 2000; 355:1295–1302.
- Berend KR, Lombardi AV Jr. Multimodal venous thromboembolic disease prevention for patients undergoing primary or revision total joint arthroplasty: the role of aspirin. Am J Orthop 2006; 35:24–29.
- Westrich GH, Bottner F, Windsor RE, Laskin RS, Haas SB, Sculco TP. VenaFlow plus Lovenox vs VenaFlow plus aspirin for thromboembolic disease prophylaxis in total knee arthroplasty. J Arthroplasty 2006; 21(6 suppl 2):139–143.
- Lotke PA, Lonner JH. The benefit of aspirin chemoprophylaxis for thromboembolism after total knee arthroplasty. Clin Orthop Relat Res 2006; 452:175–180.
- Callaghan JJ, Dorr LD, Engh GA, et al. Prophylaxis for thromboembolic disease: recommendations from the American College of Chest Physicians—are they appropriate for orthopaedic surgery? J Arthroplasty 2005; 20:273–274.
- Dorr LD, Gendelman V, Maheshwari AV, Boutary M, Wan Z, Long WT. Multimodal thromboprophylaxis for total hip and knee arthroplasty based on risk assessment. J Bone Joint Surg Am 2007; 89:2648–2657.