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Hip replacement surgeons support the 2007 PE prophylaxis guidelines from AAOS
AAOS research in developing the guidelines found various PE interventions had comparable efficacy.
SAN FRANCISCO — Support for the American Academy of Orthopaedic Surgeons’ guidelines for preventing pulmonary embolus is growing among total hip arthroplasty surgeons.
Total hip arthroplasty (THA) surgeons, like Thomas P. Sculco, MD, favor pulmonary embolus (PE) guidelines from their own academy vs. those from the American College of Chest Physicians (ACCP). “I think the American Academy of Orthopaedic Surgeons (AAOS) guidelines are far more appropriate for what we do,” he said.
“The AAOS guidelines found no difference among interventions for PE, fatal PE or total death,” Paul F. Lachiewicz, MD, said at the Hip Society/American Association of Hip and Knee Surgeons Specialty Day meeting, held during the annual AAOS meeting here. He applauded the AAOS guidelines committee for its thorough review of evidence for all treatment options and addressing issues orthopedists were most concerned about.
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Lachiewicz said the AAOS-recommended approach to PE prophylaxis may eventually prove more effective due to its customized approach to PE prevention based on patient risk.
Some concerns
At the meeting, Sculco outlined the latest ACCP PE prophylaxis guidelines, which recommend using low molecular weight heparin, fondaparinux or warfarin for primary THA.
“These guidelines are overly aggressive in their treatment modalities. I think they have increased risk for morbidity and mortality,” he said.
Clinically, “hemorrhage is a problem given these guidelines,” and they make no attempt at stratification of PE prophylaxis therapies by risk, Sculco said.
Sculco cited a recent 20-study, 28,000-patient analysis that had endpoints of mortality and non-fatal PE as evidence for not adopting the AACP recommendations. When researchers grouped patients by whether they received anticoagulants, multimodal prophylaxis or warfarin, they found the lowest morality risk of 0.19% in the multimodal group.
That group also had the lowest rate of non-fatal PE, Sculco noted.
Equivalent outcomes
For the AAOS guidelines, a committee reviewed evidence-based findings including 42 of 2,700 articles reporting on nearly 15,000 THA cases that met criteria for clinical PE, Lachiewicz said. Death rates varied slightly according to PE prophylaxis used, but researchers found no differences in their results.
Lachiewicz said the most important guideline is for the orthopedic surgeon to preoperatively classify their patients’ risks for PE and bleeding as standard or elevated. “... Document that somewhere and consider the risk assessment ratio in your decision for treatment,” he said.
He noted the AAOS guidelines include opinions about using filters when usual prophylaxis is contraindicated and they encourage continuing chemoprophylaxis and mechanical prophylaxis measures postoperatively.
For more information:
- Paul F. Lachiewicz, MD, can be reached at UNC Department of Orthopedics, 242 Burnett-Womack CB #7055, Chapel Hill, NC 27599; 919-966-9073; e-mail: Paul_Lachiewicz@med.unc.edu. He has no direct financial interest in any products or companies mentioned in this article.
- Thomas P. Sculco, MD, can be reached at the Hospital for Special Surgery, 535 E. 70th St., New York, NY 10021; 212-774-2478; e-mail: tpstkr@aol.com. He has no direct financial interest in any products or companies mentioned in this article.
References:
- Lachiewicz, PF. The position of the AAOS on thromboembolism prophylaxis. Presented at the Hip Society/AAHKS Specialty Day Meeting. March 8, 2008. San Francisco.
- Sculco TP. ACCP guidelines: In opposition. Presented at the Hip Society/AAHKS Specialty Day Meeting. March 8, 2008. San Francisco.