1. Venous Thromboembolism
An Orthopod’s Perspective
Will plan to say where we have come from and where we are now, the future??
Adrian Beaumont
Consultant Orthopaedic Surgeon
Salisbury District Hospital

2. Size of Problem ? 25,000 deaths per year
VTE in 40% to 60% joint replacements
Fatal PE in 0.1% to 5%
Inconsistent thromboprophylaxis
Joint registry shows increasing use of mechanical and chemical methods
I doubt 25,000 avoidable hospital deaths from VTE

3. Asaymptomatic underwater Symptomatric above Fatal PE at tip
Total VTE usually used but doubt abt relevance of asymptomatic distal clot (popliteal is proximal)

4. Any orthopaedic surgeons in audience? Instantly recognisable figure

5. Hugh Owen Thomas
Long Line Anglesey Bonesetters. Trained doctor. Worked in Liverpool.Operated at home. No hospital appointment. Uncle of Robert Jones who worked with him. Cap pulled down over missing eye. Fag in mouth
HOT was grandfather of modern orthopaedics. RJ was the father.

6. His classic work from 1875

7. Enforced, uninterrupted and prolonged rest

8. Fast Track Mobilisation
No clear data on VTE risk
Intuitively beneficial
150 years on....Government drive. Anaesthetic etc. Change of mindset. Cost effective

9. Going back a few years before Thomas, nearly 200Doctor, pathologist politician. German ?Rudolph Virchov did not really propose the triad.
He did propose the cell theory and Virchov (Troisier) left supraclavicular node for eg stomach cancer.
Coined the term embolism.
Rudolf Virchov

11. Tqt on, knee flexed, long procedure

12. Added common risk factor - obesity

13. All Virchovs criteria

14. Just to wake you up after a long day of clots and clotspeak
Just to wake you up after a long day of clots and clotspeak. And to say we cannot bury our heads in the sand, we should do what we can.

15. We all coherent but some more concerned about bleeding.
Why no females? Coherence is important.All to be on board. Agreement on protocols makes us more protected. NICE guidelines.
We all coherent but some more concerned about bleeding.

16. Nice Guidelines 2010 Had orthopaedic input Risk assess
Hip and knee replacements high risk
Combined methods
Oral agents (not aspirin)
Duration
‘Opt out’ when bleeding risk
Panel of 7 orthopods.. Asprin previously considered because of SIGN guidelines now being rewritten.Hip and knee replacements automatically high risk.Hip 28 to 35 days. Knee 10 to 14.
The probs of bleeding often later!

17. As yet not obligatorey – study from Basingstoke

18. Evidence! Or Evidence? Cross trial comparisons Criteria End points
Definitions
Sponsored?
Statistics
Need Expert Interpretation
Criteria eg thrombosis van be measured different methods, . Orig I125 stopped because of cross transference of disease.Venography, ultrasound.
Definition of bleed criteria not all same European Medicines Agency .I dont understand stats.

19. Is included in induction pack
Is included in induction pack. Laminated versions on relevant noticeboards.
Applies to trauma and elective.

20. Foot pumps and scuds. No real issue, some evidence that they help and though a hassle are unlikely to jeopardise outcomes

21. Anti-Embolism Stockings
Often problematic for our patients
Wounds, swelling etc
Restricted movement
Large legs
And I understand limited evidence of efficacy.
For the most part we dont care much about stockings

22. But there are exceptions! Sorry, not sure wehere that one crept in from. Not our typical pt.

23. This is more our typical patient

24. Hip Fractures Very common High mortality Immobility Delay to theatre
Age
100,000 per year in UK. Approx 25% die within a year.
Treat as per flow diagram

25. Lower Limb Casts Evidence if risk ? UK lags behind Europe
Risk assess or risk forgetting
Plymouth type scoring system
LMWH prescribed at discretion
Ongoing audit
French letters during ski season!! No clear guidance therefore why not risk asses. Seems a low risk treatment
Recent paper fro NZ 13 symptomatic VTE, 6 distal – similar to THR so similar proph recommended
Plymouth group Keenan. NICE based. Score 3 or more LMWH. Worked out at 10% of pts. Picks out pts with predictable risk
Absolute risk factors 3 pts, relative risk factors 2 or 1 point. Repeat audit due now – Sept 10

27. Male pt. Bruising right down leg. Brawny stiff, heavy
Male pt. Bruising right down leg. Brawny stiff, heavy. PP, retired army officer. Adcock. Was a worry cos inflamm markers were very high.did fine so whats the worry?...

28. Swollen stiff etc. I assisted reg to do and it was dry when closed
Swollen stiff etc. I assisted reg to do and it was dry when closed. Dressing soaked.

29. Major Bleeding (EMEA) Fatal Bleeding Decrease Hb by 20 grams
Transfusion 2 units blood
Critical bleeding
Leading to discontinuation
At surgical site
Leading to reoperation
European medicines agency (EMEA). Critical bleeding eg brain, eye ears spine. Surgical site is important. Hard to compare – different surgeon, anaes etc. We are often more worried by later bleeding leading to oozy wounds Next pics of wound
SS bleeding not included in all studies. We do not “flag up” 2 unit trnafusion!

30. MIGHT NOT BE CONSIDERED MAJOR BLEEDING
MIGHT NOT BE CONSIDERED MAJOR BLEEDING! Even before dressing removed is oozing, therefore germs can get in! The can swim but not walk (DCC). This might only come to light after a few days. ?Too late to stop anticoag.

31. For any surgeons – not be my standard incision
For any surgeons – not be my standard incision! Swollen tight bruiused oozing. Should we give antibiotics, should we keep in hospital?

32. Deep Infection Often disastrous Usually means implant removal
May lead to incapacity, amputation – crippled not killed! Thoughts of it keep us awake at night. More of a wory to orthopods than acute bleeding

33. Seven and half thousand lower limb arthroplasty, ten years, 11% only had chemical methods.

34. Summary The importance VTE recognised
We have some knowledge of efficacy
Variable but increasing prophylaxis
The adverse effects must be considered
Expert guidance needed
There will be ongoing change
Incomplete knowlege. Changes in clinical practice enormous and exponential. Clinicians must have unput but experts needed

35. Thank You