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• W2345383514 abstract "The Bone & Joint JournalVol. 98-B, No. 5 EditorialFree AccessAspirin – have we had the answer all along?CrossMarkF. S. HaddadF. S. HaddadProfessor of Orthopaedic Surgery, Editor-in-ChiefCorrespondence should be sent to Professor F. S. Haddad; e-mail: E-mail Address: [email protected]The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET and NIHR University College London Hospitals Biomedical Research Centre, UK.Search for more papers by this authorPublished Online:1 May 2016https://doi.org/10.1302/0301-620X.98B5.38070AboutSectionsPDF/EPUB ToolsDownload CitationsTrack CitationsPermissionsAdd to Favourites ShareShare onFacebookTwitterLinked InRedditEmail All orthopaedic surgeons are occasionally faced with the spectre of complications after surgery. We are also under much closer scrutiny than our predecessors. Recognised infrequent complications of elective surgery, such as infection and pulmonary emboli, are now evaluated very critically, and can lead to complaints and litigation.Few areas have aroused as much interdisciplinary controversy as chemoprophylaxis after arthroplasty surgery. There are multiple specialties involved, and many disagreements. Whilst all recognise that there is a definite risk of thromboembolic complications after routine arthroplasty, there is little consensus on the true incidence in current practice, and on the appropriate prophylactic measures that should be in place. Moreover, it is unclear whether our primary goal should be the absolute avoidance of all events including asymptomatic deep venous thromboses (DVT), or whether our focus should be fatal pulmonary emboli or overall mortality after surgery. There has been a big drive, over the last 15 years, towards chemoprophylaxis after surgery, which has largely driven by haematologists and physicians. This has been resisted by the orthopaedic community with increasing evidence that mechanical prophylaxis and early mobilisation may be sufficient without the need to anticoagulate, which has its own attendant risks. There has also been an aspirin lobby, extolling the virtues of aspirin as an anti-thromboembolic agent – thus providing chemoprophylaxis with a perceived lower risk of local bleeding.Peter Howard et al’s paper1 provides an excellent update on the incidence of thromboembolic episodes following hip arthroplasty, and adds further support to the use aspirin after arthroplasty surgery. They confirm that the rate of pulmonary emboli after total hip arthroplasty surgery is extremely low. This study supports recent work from Cusick and Beverland, Barrack, and Parvizi et al, all of whom put forward sound evidence for the use of aspirin as an appropriate thromboprophylactic agent within a multimodal regime.2-6The difficulty lies in the fact that bodies that set guidance, such as the National Institute of Health and Care Excellence, will often only look at level one data, and may well disregard important data sets such Howard et al’s,1 and another recently published from David Beverland’s unit.3 Whilst there may be criticisms of the methodology, and there may be some selection bias within the study, there is nevertheless an important message that we should heed when considering the risk-benefit equation of DVT prophylaxis. The incidence of serious thromboembolic complications is relatively low with modern techniques and early active mobilisation. If risk stratification identifies the patients who must have full blown chemoprophylaxis, we could then avoid aggressive anticoagulation in the majority of patients undergoing joint arthroplasty. The low incidence of thromboembolic events makes robust and appropriately powered studies designed to detect differences in the instance of rare occurrences, such as pulmonary emboli, almost impossible and unaffordable. This is an area where some of the critical questions cannot be answered with level one data, and where we are reliant on case series and large databases to help us unravel important issues. Orthopaedic surgeons need to ensure that they evaluate their patients appropriately, assess risk repeatedly and carefully consider, with colleagues within their units, whether chemoprophylaxis is indeed required, and if so, whether the evidence presented makes aspirin a good candidate for the majority of their patients. There are of course still many variables that need to be considered if aspirin is used. These include the time to from surgery to start of therapy, the dose, the duration, the risk of administering non-steroidal anti-inflammatories at the same time, and potential gastric side-effects. There is also the possibility that some units may choose mixed therapy whereby patients will receive low molecular heparin as inpatients and then be discharged on aspirin. There is also the need to translate from arthroplasty surgery to other major orthopaedic surgery of the spine and lower limb.There is a great divide between those physicians who feel that thromboembolic events should never occur, favour chemoprophylaxis at high doses almost immediately after surgery, and largely ignore the risk of local bleeding complications; and the majority of the surgical community who have seen interventions evolve dramatically over the last three decades – with patients spending less time in theatre, having less pain after surgery and mobilising quickly and leaving hospital rapidly – and perceive the risk as much lower.7 These patients do not seem to suffer anywhere near as many thromboembolic complications as the previous generation and potentially should not need the same level of prophylaxis. Yet our guidelines and our management are still often based on old historical data that was collected when our operations and pathways were very different.8-11There is broad agreement that repeated risk assessment is necessary in each case, and that there are high-risk groups, particularly amongst those patients who have suffered previous thromboembolic events or who have a hereditary predisposition to thromboembolic disease (thrombophilia) or who are likely to be immobile for prolonged periods. Such patients require bespoke solutionsWe also cannot agree as to the appropriate end points to aim for. Whilst there are some down sides to symptomatic DVT, setting the bar as high as to avoid all asymptomatic venous thromboses may amount to overtreatment that is associated with a high level of local complications. There is no doubt that we would all wish to avoid altogether a pulmonary embolism, most especially one that is fatal. At the same time, we need to be mindful of the fact that whatever intervention we introduce should not increase or cause mortality as that is even more important from the patient’s perspective. There are a number of methods of chemoprophylaxis available. Traditional treatment with low dose Warfarin has largely been superseded outside of the United States by the use of low-molecular-weight heparin, and more recently, Factor 10 inhibitors. There are arguments over the doses to be used and it would appear superficially that the more the drug causes bleeding, the more likely it is to prevent thromboembolic complications and in turn, the more likely it is to lead to local haematomas, infections and the need for further surgery and result in a suboptimal outcome. The future may yet herald other interventions that can be applied pre- and intra-operatively in order to decrease the risk without increasing bleeding. Mobile compression devices show some promise as part of a multimodal regime. Chemoprophylaxis clearly has an ongoing role at present, but the agents to be used must be judged very carefully. The voice of the orthopaedic community vehemently suggests that aspirin should be added to the list of drugs that can be used in low- to moderate-risk patients undergoing arthroplasty surgery. References 1 Bayley EJ, Brown S, Bhamber N, Howard PW. Fatal pulmonary embolism following elective total hip arthroplasty: a 12-year study. Bone Joint J 2016;98-B:585–588. Link, ISI, Google Scholar2 Cusick LA, Beverland DE. The incidence of fatal pulmonary embolism after primary hip and knee replacement in a consecutive series of 4253 patients. J Bone Joint Surg [Br] 2009;91-B:645–648. Link, ISI, Google Scholar3 Ogonda L, Hill J, Doran E, et al. Aspirin for thromboprophylaxis after primary lower limb arthroplasty: early thromboembolic events and 90 day mortality in 11 459 patients. Bone Joint J 2016;98-B:341–348. Link, ISI, Google Scholar4 Barrack RL. Thromboprophylaxis for patients undergoing joint replacement. Bone Joint J 2014;96-B:3–4. Link, ISI, Google Scholar5 Tischler EH, Ponzio DY, Diaz-Ledezma C, Parvizi J. Prevention of venous thromboembolic events following femoroacetabular osteoplasty: aspirin is enough for most. Hip Int 2014;24:77–80. Crossref, Medline, ISI, Google Scholar6 Raphael IJ, Tischler EH, Huang R, et al. Aspirin: an alternative for pulmonary embolism prophylaxis after arthroplasty? Clin Orthop Relat Res 2014;472:482–488. Crossref, Medline, ISI, Google Scholar7 Huang R, Buckley PS, Scott B, Parvizi J, Purtill JJ. Administration of aspirin as a prophylaxis agent against venous thromboembolism results in lower incidence of periprosthetic joint infection. J Arthroplasty 2015;30(9 Suppl):39–41. Crossref, ISI, Google Scholar8 Nam D, Nunley RM, Johnson SR, et al. The effectiveness of a risk stratification protocol for thromboembolism prophylaxis after hip and knee arthroplasty. J Arthroplasty 2015 (Epub). Crossref, ISI, Google Scholar9 Nam D, Nunley RM, Johnson SR, et al. Thromboembolism prophylaxis in hip arthroplasty: routine and high risk patients. J Arthroplasty 2015;30:2299–2303. Crossref, Medline, ISI, Google Scholar10 Nam D, Nunley RM, Johnson SR, Keeney JA, Barrack RL. Mobile compression devices and aspirin for VTE prophylaxis following simultaneous bilateral total knee arthroplasty. J Arthroplasty 2015;30:447–450. Crossref, Medline, ISI, Google Scholar11 Parvizi J, Huang R, Raphael IJ, Arnold WV, Rothman RH. Symptomatic pulmonary embolus after joint arthroplasty: stratification of risk factors. Clin Orthop Relat Res 2014;472:903–912. Crossref, Medline, ISI, Google ScholarFiguresReferencesRelatedDetailsCited ByClinical outcomes and risk factors of thromboprophylaxis with rivaroxaban versus aspirin in patients undergoing hip arthroplasty in low‐incidence population: A nationwide study in Korea7 March 2019 | Pharmacoepidemiology and Drug Safety, Vol. 28, No. 4The Use of Aspirin for Prophylaxis Against Venous Thromboembolism Decreases Mortality Following Primary Total Joint Arthroplasty20 March 2019 | Journal of Bone and Joint Surgery, Vol. 101, No. 6Established dogma should be challengedF. S. Haddad1 November 2017 | The Bone & Joint Journal, Vol. 99-B, No. 11What is the optimal level of expectation?F. S. Haddad1 September 2017 | The Bone & Joint Journal, Vol. 99-B, No. 9Venous Thromboembolism Following Hip and Knee ArthroplastyJournal of Bone and Joint Surgery, Vol. 99, No. 11The literature evolvesone step at a timeF. S. Haddad1 August 2016 | The Bone & Joint Journal, Vol. 98-B, No. 8 Vol. 98-B, No. 5 Metrics Downloaded 186 times History Published online 1 May 2016 Published in print 1 May 2016 InformationCopyright © 2016, The British Editorial Society of Bone and Joint Surgery: All rights reservedPDF download" @default.
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