‘ Administration of aggressive anticoagulation is not necessary for the majority of patients undergoing orthopaedic procedures .’ He added that there is now plenty of evidence to show that intermittent compression devices work very well to prevent VTE but also that they provide additional benefits such as a reduction in post-surgical swelling of extremities , offer a better range of motion for the knee , and are associated with better patient satisfaction compared with the use of aggressive anticoagulation .
One overarching conclusion of the guideline , stemming from the available literature , is that low-dose aspirin is costeffective and a safe modality for prevention of VTE . Studies have shown tha the use of aspirin also reduces post-operative fever , which is a common event that worries the patients and healthcare professionals . Moreover , Dr Parvizi mentioned that the use of aspirin has also been to reduce the rate of extra bone formation in the soft tissues ( heterotopic ossification ) and stiffness after orthopaedic procedures . He explained how the guideline recommended that ‘ aspirin should preferably be given twice a day for a period of four weeks but even two weeks of aspirin appears to be enough for most of these patients .’
Overall , Dr Parvizi thinks that the new guidelines will allow clinicians to move away from the use of aggressive anticoagulants and to make greater use of intermittent compression devices and aspirin . In fact , he believes that the use of aggressive anticoagulants should now be reserved for those patients with a ‘ genetic predisposition and / or patients an extremely high risk for a VTE .’
Q How will these guidelines impact clinical practice ?
A Dr Parvizi mentioned how in the US there has been a general shift over the last few years away from the use of aggressive anticoagulation towards the use of aspirin and intermittent compression devices . In fact , he quoted data from ‘ a survey of over 3000 joint surgeons showing that over 90 % of surgeons now use compression devices and / or aspirin for prevention of VTE after joint replacement .’ While there has been an important change in practice among US surgeons , he thought that adoption of aspirin and intermittent compression devices by surgeons from other parts of the world has been slow mostly due to medico-legal concerns . A further barrier to adoption of aspirin and intermittent compression devices has been the resistance of colleagues from other specialties , such as haematology and cardiology , who might not be aware of the wealth of orthopaedic literature endorsing the use of aspirin . He hopes that the publication of the new guidelines will provide the necessary endorsement and reassurance to the medical community to embrace a change in practice .
Q Are there any remaining uncertainties that might be addressed in the future ?
A Dr Parvizi felt that one of the benefits of developing a new guideline was that while providing robust evidence to support a change in orthopaedic practice , it also highlighted gaps in the current evidence and enabled the formulation of relevant questions that should be addressed by future research . He believes that there is a need for independent studies to compare the efficacy of low-dose aspirin with other anticoagulation agents . He mentioned one current , ongoing study ( PEPPER trial ) that is comparing low-dose aspirin , coumadin and factor 10 inhibitors for VTE prevention , the results of which are eagerly awaited . He noted how more studies are required to better understand the genetic mutations that predispose individuals towards having a VTE as well as more work on the role of intermittent compression devices .
Taken together , Dr Parvizi hoped that future studies will facilitate a move away from the use of expensive anticoagulants which ultimately have a huge economic impact . For example , he described how ‘ in the US alone there are over one million joint replacement procedures undertaken per year so if 92 % of those patients are receiving aspirin , the anticipated cost savings would run into hundreds of millions .’ Furthermore , there are a whole range of additional benefits to using aspirin including a reduction in the development of haematomas , infection risk , post-operative fever and subsequent clinical , fever work-up , less need for transfusions and a lower level of post-operative anaemia . He added that ‘ the available data suggest that ‘ aspirin is actually better than coumadin for the prevention of VTE .’ Ultimately , he suggested that ‘ convenience , efficacy , safety and economic benefits of aspirin are just beyond dispute now and that , over time , there will be a shift towards the use of aspirin and intermittent compression devices instead of expensive anticoagulant medications .’
As for the next steps , Dr Parvizi says that the combination of the publication of the guideline in a prestigious orthopaedic journal ( Journal of Bone and Joint Surgery ) and future translations of the documents into numerous languages will allow effective dissemination of the work that was generated by over 500 experts . The guidelines are being discussed at various conferences and have been endorsed by a number of professional organisations , publishing the guideline on their websites . Finally , Dr Parvizi believes that it is necessary that patients who require orthopaedic procedures should no longer fear the development of a blood clot and become better informed that the changes in surgical procedures and VTE management in recent years are designed to be safer and more convenient for them .
Dr Javad Parvizi James Edward Professor of Orthopaedic Surgery at Sidney Kimmel School of Medicine and Rothman Institute in Philadelphia , US . He specialises in the management of young patients with hip disorders such as dysplasia and femoroacetabular impingement , and the management of patients with periprosthetic joint infection .
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