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Communications to the Editor |

Risk vs Benefits for Thromboembolic Disease After Total Joint Surgery FREE TO VIEW

Paul A. Lotke, MD
Author and Funding Information

Affiliations: Hospital of the University of Pennsylvania, Philadelphia, PA,  Erasme University Hospital, Brussels, Belgium

Correspondence to: Paul A. Lotke, MD, Hospital of the University of Pennsylvania, Department of Orthopedic Surgery, 3400 Spruce St, Philadelphia, PA 19104; e-mail: paul.lotke@uphs.upenn.edu



Chest. 2005;127(6):2297-2298. doi:10.1378/chest.127.6.2297-a
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Published online

To the Editor:

Surgeons and internists frequently weigh their risks and benefits on different scales. I believe this is the case with the guidelines for prophylaxis against thromboembolic disease that were recently published in CHEST (September 2004).1 The risks of bleeding weigh heavily in the surgeons’ decision making, whereas the internists see the pulmonary problems. Therefore, true evidence-based medicine must be applied carefully to derive a set of guidelines that is universally accepted by both groups.

First, recognizing that all of the recommendations in CHEST are based on the presence or absence of deep vein thrombosis (DVT), we must ask whether DVT is an accurate surrogate marker for patients who are at risk for a pulmonary embolism (PE) after undergoing total joint surgery. If they are, we should see a proportional reduction of PE with a reduction in DVT. In fact, we do not. It is well known that after total knee surgery the incidence of DVT is two to three times that of total hip surgery, but there is an equal or reduced number of PEs after total knee surgery, not a twofold to threefold increase.

While it has been well documented that DVT is an accurate marker of risk for medical and thrombophilic patients, the same risks may not apply to those undergoing total joint surgery. In those postoperative patients, up to 60% have experience a DVT, while the incidence of fatal PE is 0.1 to 0.2%.2 Postoperative clots may have been formed by local mechanical injury to the venous system at the time of surgery and may not convey the same ominous prognosis.

Second, it is unclear whether we can generalize the safety data on postoperative chemoprophylactic agents, as reported in the literature, to all of our patients. The well-controlled, prospective, randomized drug studies in the literature exclude, by protocol, patients with prior DVT or GI bleeds, and the investigators choose not to enroll elderly, frail, and noncompliant patients. Therefore, the enrollees are a selected, healthier population and may not accurately represent the true bleeding risks.

Third, we must examine carefully the postsurgical morbidity of patients who experience significant bleeding events. The more effective a chemoprophylactic agent is in reducing the incidence of DVT, it may also effectively increase the risk from bleeding. Significant bleeding events occur in 1.8 to 5.1% of patients in the healthiest selected populations, creating significant morbidity for the patient and the surgeon.

Therefore, using evidence-based medicine, we must question the data that show that DVT is an accurate marker for the patient who has undergone total joint surgery and is at risk for PE. Without this evidence, the recommendations, as published in CHEST for the orthopedic medicine community, may be exposing our patients to expensive, risky, and perhaps minimally effective regimens.

Geerts, WH, Pineo, GF, Heit, JA, et al (2004) Prevention of venous thromboembolism: the seventh ACCP conference on antithrombotic and thrombolytic therapy.Chest126(suppl),338S-400S
 
Gill, SG, Mills, D, Joshi, AB Mortality following primary total knee arthroplasty.J Bone Joint Surg Am2003;85A,432-435
 
To the Editor:

I thank the authors for these comments and agree that the potential place of hemodialysis or hemofiltration in the treatment of patients with acute renal failure is indeed an important issue, but it is still very much under debate. As the authors state, few studies are currently available, and further research is needed to assess the available techniques, the optimal dose of dialysis, and the superiority of continuous over intermittent use.


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References

Geerts, WH, Pineo, GF, Heit, JA, et al (2004) Prevention of venous thromboembolism: the seventh ACCP conference on antithrombotic and thrombolytic therapy.Chest126(suppl),338S-400S
 
Gill, SG, Mills, D, Joshi, AB Mortality following primary total knee arthroplasty.J Bone Joint Surg Am2003;85A,432-435
 
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