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Aggressive pharmacologic protocols may be associated with TJR complications
To guide orthopedists in selecting prophylaxes, AAOS has issued new recommendations.
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Orthopedic surgeons wishing to prevent or treat deep venous thrombosis or pulmonary embolism in their patients are faced with many questions about which prophylaxis methods to select, according to Robert L. Barrack, MD.
If untreated, “The prevalence of deep venous thrombosis (DVT) is really shocking,” he said.
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Still, “Not all patients need prophylaxis. We just don’t know which ones do,” Barrack said during the 8th Annual Current Concepts in Joint Replacement Spring Meeting.
Orthopedists recognize a combination approach might be optimal because no single modality works well in every total joint replacement (TJR) case, he said. “Ideally, we should have something that is effective, low-risk and cost-effective.”
Prophylaxis guidelines
Some help has arrived via new clinical guidelines issued this spring by the American Academy of Orthopaedic Surgeons (AAOS) for preventing symptomatic pulmonary embolism (PE) in patients undergoing total hip or knee replacement.
Before that, the only guidelines were those developed by the American College of Chest Physicians (ACCP). Top-level ACCP evidence-based PE/DVT prophylaxis recommendations emphasized pharmacologic prevention and international normalized ratios between 2 and 3.
By orthopedic standards, 1A recommendations are aggressive for TJR, Barrack said. Yet orthopedists should be familiar with those recommendations because hospital oversight committees and state and federal agencies are embracing them as the “de facto standard of care,” he said.
Using ACCP guidelines during TJR may result in an increased incidence of bleeding and drainage. Other complications ensued in patients treated with a 1A protocol at Barrack’s hospital, Barnes-Jewish Hospital in St. Louis. They previously used routine ultrasound screening prior to discharge and a short course (7 days) of low-dose Coumadin (warfarin sodium, Bristol-Myers Squibb), but “We switched to 10 days of Lovenox (enoxaparin sodium, Sanofi Aventis) because of the difficulty of monitoring a high number of outpatients on longer courses of Coumadin,” Barrack said.
Images: Barrack RL |
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Returns to OR
If patients developed a hematoma, they discontinued it. “We had a number of returns to the operating room … [and] a significant number of minor complications,” like prolonged drainage and/or prolonged hospitalization, he said.
A study of short-course warfarin conducted at the same center showed excellent results, no deaths and 0.1% PE rate, Barrack said. “It is hard to get lower than that and [it is] very cost effective.”
Barrack said, “Our results with the non-1A protocol were excellent. Our results with the 1A protocol were poor.”
AAOS guidelines
The AAOS guidelines will give TJR surgeons more latitude in treatment options and their duration while de-emphasizing aggressive pharmacologic treatments. Barrack expects they will put DVT prophylaxis treatment decisions back in the hands of orthopedists, producing improved efficacy and lower complication rates.
With the number of TJRs expected to increase exponentially in the future, “The stakes are high and growing higher,” Barrack said. “If we embrace one of these overly aggressive protocols, it could result in… unnecessary complications.”
See related articles on DVT/PE on pages 20 and 32 of the print issue.
For more information:
- Robert L. Barrack, MD, can be reached at Washington University School of Medicine, 660 S. Euclid, Campus Box 8233, Dept. of Orthopedics, St. Louis, MO 63110; 314-747-2562; e-mail: barrackr@wustl.edu. He teaches/speaks on behalf of Smith & Nephew Orthopaedics.
Reference:
- Barrack RL. DVT prophylaxis: Protecting patient or surgeon? Trends, truths & quality. #59. Presented at the 8th Annual Current Concepts in Joint Replacement Spring 2007 Meeting. May 20-23, 2007. Las Vegas.
- For information on the AAOS PE prophylaxis protocol go to: http://www.aaos.org.