Thromboprophylaxis after replacement arthroplastyBMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7301.1546/a (Published 23 June 2001) Cite this as: BMJ 2001;322:1546
Many surgeons prefer not to prescribe chemoprophylaxis after arthroplasty
- David A Macdonald, consultant orthopaedic surgeon ()
EDITOR—Thomas confirms that intermittent calf compression reduces the rate of pulmonary embolism to 1% after replacement arthroplasty without having the possible side effects of chemoprophylaxis.1 He goes on to state that when the efficacy of foot pumps was compared with that of anticoagulation “the results in terms of preventing deep venous thrombosis were comparable.”
The rest of the editorial is aimed at supporting the use of anticoagulation in these patients. I presume that Thomas is neither an orthopaedic surgeon nor a patient who has had a failed joint replacement; if he was he would not regard an incidence of major bleeding with anticoagulation of 1% as being an “acceptable price to pay.”
His conclusion that anticoagulation is the single most effective way of preventing these complications is not supported by the rest of his editorial. It seems incongruous that he is suggesting using a method of prophylaxis with a 1% rate of major complications to prevent a complication with the same incidence.
If this article is not retracted or a counter-argument published there is a risk that litigation lawyers will use it against the many orthopaedic surgeons who avoid chemoprophylaxis in patients undergoing arthroplasty.
- Duncan P Thomas, former head of division of haematology, National Institute for Biological Standards and Control ()
EDITOR—Macdonald seems more concerned about the hazards of chemoprophylaxis than the dangers of thromboembolism. No effective drug treatment is without some risk, and I tried not to underplay the undoubted but quite small risks of anticoagulant treatment. Thromboembolism in patients undergoing replacement arthroplasty is a well recognised hazard, and the question is, where does the balance of risk lie?
I have no quarrel with the use of foot pumps while patients are in hospital, although data concerning their effectiveness are sparse. But does Macdonald send his patients home with foot pumps? Evidence increasingly shows that the risk of thromboembolism continues well after patients have usually left hospital.
As for retracting my argument, perhaps Macdonald should be more concerned about the risk of litigation that he runs from not using effective prophylaxis. A failed joint replacement is indeed a tragedy, but I suggest that it is less so than sudden death from pulmonary embolism. A recent American-Canadian consensus statement on prevention of venous thromboembolism recommended only the use of warfarin or low molecular weight heparin as prophylaxis of choice after major joint replacement.1
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