Summer 2012


66th Annual Mtg

VOS 66th Annual Meeting
May 3-5, 2013
Mandarin Oriental Hotel
WashinGton, DC



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Clinical News

VTE Prophylaxis:
The Guideline Wars Are Over

By Tray Cui, MD

In June issue of Journal of the AAOS, a guest editorial article by Jay R. Lieberman summarizes recently published evidence-based clinical practice guidelines on the prevention of venous thromboembolic (VTE) disease in patients undergoing orthopaedic surgery by the American College of Chest Physicians (ACCP) (Table 1). The new ACCP guidelines clearly recognize that the selection of a prophylaxis regimen for patients undergoing major orthopaedic surgery demands a balance between safety and bleeding and that the goal of VTE prophylaxis is to reduce fatal and symptomatic pulmonary embolism and deep vein thrombosis. As a result, both the new ACCP guidelines (2012) and the new AAOS guidelines (2011) provide orthopaedic surgeons with flexibility regarding the use of different prophylactic regimens, although this clinical flexibility is the result of different study methodologies.

The two guidelines agree that the use of ultrasonography at hospital discharge is not appropriate. Both guidelines support combining a chemoprophylactic agent with an IPCD in most patients.

The inclusion of aspirin as an alternative to no antithrombotic prophylaxis represents a major change because aspirin had received a grade 1A recommendation against its use in the previous ACCP guidelines.

The panel recommends starting LMWH prophylaxis either 12 hours preoperatively or postoperatively rather than 4 hours before or after the procedure because of concerns about increased bleeding.

Dr. Lieberman also indicated that the Surgical Care Improvement Project (SCIP) for VTE prophylaxis guidelines are still the measure of quality in a hospital. At the present time, LMWH, warfarin, fondaparinux, and rivaroxaban are acceptable agents for both total hip and knee arthroplasty patients. Mechanical devices alone can be used for total knee arthroplasty patients. Therefore, the combination of aspirin and a mechanical device is acceptable for total knee arthroplasty patients. If this combination is selected for a total hip arthroplasty patient, one would still have to document in the chart that this regimen has been selected because of concerns regarding bleeding. Read more:

Table 1.  Highlights: Prevention of Venous Thromboembolism in Orthopaedic Surgery. American College of Chest Physicians Evidence-based Clinical Practice Guidelines, Ninth Edition


In patients undergoing THA or TKA we recommend use of one of the following for a minimum of 10 to 14 days rather than no anti-thrombotic prophylaxis: LMWH, fondaparinux, apixaban, dabigatran, rivaroxaban, LDUH, adjusted-dose VKA, aspirin (all grade 1B), or an IPCD (grade 1C)


For patients undergoing major orthopedic surgery (THA, TKA, HFS) and receiving LMWH as thromboprophylaxis, we recommend starting either 12 h or more preoperatively or 12 h or more postoperatively rather than within 4 h or less preoperatively or 4 h or less postoperatively (grade 1B)


In patients undergoing THA or TKA, irrespective of the concomitant use of an IPCD or length of treatment, we suggest the use of LMWH in preference to the other agents we have recommended as alternatives: fondaparinux, apixaban, dabigatran, rivaroxaban, LDUH (all grade 2B), adjusted-dose VKA, or aspirin (all grade 2C)


For patients undergoing major orthopedic surgery, we suggest extending thromboprophylaxis in the outpatient period for up to 35 days from the day of surgery rather than for only 10 to 14 days (grade 2B)


In patients undergoing major orthopedic surgery, we suggest using dual prophylaxis with an antithrombotic agent and an IPCD during the hospital stay (grade 2C)


In patients undergoing major orthopedic surgery and increased risk of bleeding, we suggest using an IPCD or no prophylaxis rather than pharmacologic treatment (grade 2C)


In patients undergoing major orthopedic surgery, we suggest against using IVC filter placement for primary prevention over no thromboprophylaxis in patients with an increased bleeding risk or contraindications to both pharmacologic and mechanical thromboprophylaxis (grade 2C)


For asymptomatic patients following major orthopedic surgery, we recommend against Doppler (or duplex) ultrasound screening before hospital discharge (grade 1B)

HFS = hip fracture surgery, IPCD = intermittent pneumatic compression device, IVC = inferior vena cava, LDUH = low-dose unfractionated heparin, LMWH = low-molecular-weight heparin, THA = total hip arthroplasty, TKA = total knee arthroplasty, VKA = vitamin K antagonist

2. Modern Metal-on-Metal Hip Implants-AAOS Technology Overview Summary
This AAOS Technology Overview was prepared using systematic review methodology and summarizes the findings of studies published as of July 15, 2011, on modern metal-on-metal hip implants. Analyses conducted on outcomes by two joint registries indicate that patients who receive metal-on-metal total hip arthroplasty (THA) and hip resurfacing are at greater risk for revision than are patients who receive THA using a different bearing surface combination. Data from these registries also indicate that larger femoral head components have higher revision rates and risk of revision and that older age is associated with increased revision risks of large-head metal-on-metal THA. Several studies noted a correlation between suboptimal hip implant positioning and higher wear rates, local metal debris release, and consequent local tissue reactions to metal debris. In addition, several studies reported elevated serum metal ion concentrations in patients with metal-on-metal hip articulations, although the clinical significance of these elevated ion concentrations remains unknown.
The complete overview is available at:

3. Smith & Nephew withdraws metal hip liner.
MedPage Today reports that Smith & Nephew has initiated a voluntary market withdrawal of the optional metal liner component of the company’s R3 Acetabular System. The company states that the withdrawal was implemented after a review of the product and a finding that the company was "not satisfied with the clinical results." The company says that the withdrawal does not impact other R3 System liners, and asks anyone experiencing unusual symptoms to contact his or her surgeon. The withdrawal does not change the current practice for patient follow-up care for this component.
Read more:

Read the Smith & Nephew statement:

4. Study claims rehospitalizations for SSI after arthroplasty cost as much as $65 million per year.
Data presented at the annual conference of the Association for Professionals in Infection Control and Epidemiology find that readmissions for surgical site infection (SSI) following total hip and total knee arthroplasty may cost the health care system as much as $65 million per year. The authors drew data from a large health insurance database covering between 31 million and 45 million insured individuals. They found that, of 174,425 cases with hip or knee replacement in 2007, 2,134 (1.2 percent) had a hospitalization for SSI within 1 year following surgery. Of those, 267 (12.5 percent) were subsequently readmitted during the year after the initial SSI hospitalization due to SSI-related issues (mean cost of $26,815), and 870 (40.8 percent) had at least one subsequent "all-cause" hospitalization during the year following the initial SSI hospitalization (mean cost of $31,046).

Read more: