Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Lawrence D. Dorr, MD, and Lisa Chao, BS*,
The Arthritis Institute at Centinela Hospital Medical Center, Inglewood, California
Posted May 2007
This is a timely study. The orthopaedic community has been
investigating the use of treatment methods other than the chemoprophylactic use
of low-molecular-weight heparin and full-dose warfarin1,2. This
randomized study clearly shows the efficacy of mechanical prophylaxis with use
of intermittent pneumatic compression for both elective procedures and
emergency procedures for the treatment of trauma. The use of intermittent
pneumatic compression and low-molecular-weight heparin (certoparin) provided
highly significant (p = 0.007) improved protection against deep venous
thrombosis as compared to low-molecular-weight heparin alone. Although the
American College of Chest Physician guidelines for total hip replacement do not
recommend the use of intermittent pneumatic compression after total hip
replacement except in patients who are at a high risk of increased bleeding3,
the study by Eisele et al. did show a benefit because patients who had total
hip replacement and were managed with low-molecular-weight heparin and
intermittent pneumatic compression had no deep venous thrombosis.
The prevalence of deep venous thrombosis was so low with
intermittent pneumatic compression and low-molecular-weight heparin (four of
901, 0.44%) that we agree with the authors that they should compare the use of low-molecular-weight
heparin to the use of intermittent pneumatic compression alone. Hooker et al.4,
in their study of intermittent pneumatic compression and aspirin after primary
and revision total hip arthroplasty, reported a higher rate of deep venous
thrombosis (twenty-three [4.6%] of 502 hips) than the rate that was reported in
this study but also reported no deaths from pulmonary embolism. The use of
intermittent pneumatic compression along with aspirin is the foundation of the
multimodal treatments advocated for total hip replacement1,5-7 and
total knee replacement8.
These treatments differentiate patients who are at low risk and patients who
are at high risk for venous thromboembolism and reserve the use of
chemoprophylaxis with warfarin or low-molecular-weight heparin for the patients
at high risk. The results of published reports of protection against pulmonary
embolism and deep venous thrombosis with multimodal treatment are as good as or
better than the results of published reports of protection with warfarin or
low-molecular-weight heparin, with a lower rate of bleeding complications9-14.
unfortunately,
in the current study, Eisele et al. have not reported the data that are needed
by the orthopaedic community to substantiate the efficacy of the treatments
used. The reader is left to assume there is no occurrence of pulmonary embolism
because these data are never stated in the article. The reader must wonder
whether the authors measured only deep venous thrombosis. The second deficiency
is the absence of any data on clinical outcomes other than deep venous
thrombosis. The failure to report clinical outcomes is a major limitation, and a
disturbing precedent, of thromboembolic studies conducted by drug companies
investigating warfarin or low-molecular-weight heparin9-14. A
comprehensive evaluation of the efficacy of a prophylactic treatment against
thromboembolism necessitates data on overall deaths (particularly deaths from
bleeding complications), wound hematomas (and reoperations required), and wound
drainage and infection. It is the occurrence of these clinical outcomes that
has stimulated some in the orthopaedic community to seek alternative treatments
to chemical anticoagulation15. Since this study used low-molecular-weight
heparin (certoparin), and low-molecular-weight heparin (enoxaparin) has been
shown to cause the most bleeding complications10,11, we cannot
recommend the use of low-molecular-weight heparin with intermittent pneumatic
compression treatment, despite the superb protection against deep venous
thrombosis (and possibly pulmonary embolism) that this treatment affords, until
the data on clinical outcomes are provided for our review. We would also suggest
that orthopaedic journals make an editorial policy that these data be included
in all published articles on prophylactic treatment against thromboembolism.
*The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
References
1. Lachiewicz PF, Soileau ES. Multimodal prophylaxis for THA with mechanical compression. Clin Orthop Relat Res. 2006;453:225-30.
2. Lotke PA, Lonner JH. The benefit of aspirin chemoprophylaxis for thromboembolism after total knee arthroplasty. Clin Orthop Relat Res. 2006;452:175-80.
3. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG. Prevention of venous thromboembolism: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest. 2004;126(3 Suppl):338S-400S.
4. Hooker JA, Lachiewicz PF, Kelley SS. Efficacy of prophylaxis against thromboembolism with intermittent pneumatic compression after primary and revision total hip arthroplasty. J Bone Joint Surg Am. 1999;81:690-6.
5. Gonzalez Della Valle A, Serota A, Go G, Sorriaux G, Sculco TP, Sharrock NE, Salvati EA. Venous thromboembolism is rare with a multimodal prophylaxis protocol after total hip arthroplasty. Clin Orthop Relat Res. 2006;444:146-53.
6. Salvati EA, Pellegrini VD Jr, Sharrock NE, Lotke PA, Murray DW, Potter H, Westrich GH. Recent advances in venous thromboembolic prophylaxis during and after total hip replacement. J Bone Joint Surg Am. 2000;82:252-70.
7. Sculco TP, Colwell CW Jr, Pellegrini VD Jr, Westrich GH, Böttner F. Prophylaxis against venous thromboembolic disease in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am. 2002;84:466-77.
8. Larson CM, MacMillan DP, Lachiewicz PF. Thromboembolism after total knee arthroplasty: intermittent pneumatic compression and aspirin prophylaxis. J South Orthop Assoc. 2001;10:155-63.
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10. Colwell CW Jr, Collis DK, Paulson R, McCutchen JW, Bigler GT, Lutz S, Hardwick ME. Comparison of enoxaparin and warfarin for the prevention of venous thromboembolic disease after total hip arthroplasty. Evaluation during hospitalization and three months after discharge. J Bone Joint Surg Am. 1999;81:932-40.
11. Fitzgerald RH Jr, Spiro TE, Trowbridge AA, Gardiner GA Jr, Whitsett TL, O'Connell MB, Ohar JA, Young TR; Enoxaparin Clinical Trial Group. Prevention of venous thromboembolic disease following primary total knee arthroplasty. A randomized, multicenter, open-label, parallel-group comparison of enoxaparin and warfarin. J Bone Joint Surg Am. 2001;83:900-6.
12. Francis CW, Pellegrini VD Jr, Totterman S, Boyd AD Jr, Marder VJ, Liebert KM, Stulberg BN, Ayers DC, Rosenberg A, Kessler C, Johanson NA. Prevention of deep-vein thrombosis after total hip arthroplasty. Comparison of warfarin and dalteparin. J Bone Joint Surg Am. 1997;79:1365-72.
13. Lieberman JR, Wollaeger J, Dorey F, Thomas BJ, Kilgus DJ, Grecula MJ, Finerman GA, Amstutz HC. The efficacy of prophylaxis with low-dose warfarin for prevention of pulmonary embolism following total hip arthroplasty. J Bone Joint Surg Am. 1997;79:319-25.
14. Pellegrini VD Jr, Clement D, Lush-Ehmann C, Keller GS, Evarts CM. Natural history of thromboembolic disease after total hip arthroplasty. Clin Orthop Relat Res. 1996:333;27-40.
15. Callaghan JJ, Dorr LD, Engh GA, Hanssen AD, Healy WL, Lachiewicz PF, Lonner JH, Lotke PA, Ranawat CS, Ritter MA, Salvati EA, Sculco TP, Thornhill TS; American College of Chest Physicians. Prophylaxis for thromboembolic disease: recommendations from the American College of Chest Physicians--are they appropriate for orthopaedic surgery? J Arthroplasty. 2005;20:273-4.
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