CENTRE FOR EVIDENCE IN TRAUMA AND ORTHOPAEDIC SURGERY
A SY S T E M AT I C R E V I E W O F T H E
Effectiveness of thromboprophylaxis
in total hip and knee replacement
I N F O R M I N G PAT I E N T S A N D S U R G E O N S
Mark Dunbar1 Howard Kwong1 Piyush Upadhyay1 Dai Morgan1 Michael Lwin1 Devendra Damany1
Jane Hutton3 Gillian Surr2 Jennifer Marsh3 John Copas3 Damian Griffin1
[1] Warwick Medical School [2] University Hospital Coventry and Warwickshire NHS Trust [3] Department of Statistics University of Warwick
The use of thromboprophylaxis following hip and knee replacement is almost universally accepted as standard practice. [Brenkel
2003]
METHOD
A systematic review was performed of the English language
literature published from 1981 to 2002.
162 papers met our inclusion criteria consisting of 272
cohorts (more than 50 000 patients).
CLINICAL QUESTION
In patients undergoing total hip or total knee arthroplasty
which of the commonly used methods of prophylaxis is most
effective in preventing clinically important events?
FONDAPARINUX
FONDAPARINUX
WARFARIN
WARFARIN
LMWH
LMWH
ASPIRIN
ASPIRIN
MECHANICAL
MECHANICAL
STOCKINGS
STOCKINGS
REDUCED RATE OF DVT
NONE
-4
-2
0
REDUCED RATE OF FATAL PE
NONE
2
4
-0.2
-0.1
0
0.1
0.2
Estimated Absolute Risk Reduction (and 95% confidence intervals) for
Estimated Absolute Risk Reduction (and 95% confidence intervals) for
symptomatic DVT (Deep vein thrombosis) associated with common forms of
symptomatic PE (Pulmonary embolism) associated with common forms of
thromboprophylaxis
thromboprophylaxis
FATAL PE
SYMP PRX DVT
PREVENTED
PREVENTED
Stockings
Mechanical
Aspirin
LMWH
Warfarin
Fondaparinux
1
2
1
2
1
2
-10
20
20
25
20
40
MAJOR
BLEEDS
COST (_)
0
0
5
20
40
50
15k
140k
1k
75k
85k
80k
Estimatres of effects of using prophylactic strategies over 5 years in a typical
hospital performing 500 joint replacements each year
0.3
CONCLUSIONS
• No method of prophylaxis is statistically significantly more
effective than using nothing
• Chemical prophylaxis causes at least as many bleeding
complications as symptomatic DVTs prevented
• The number of PEs prevented is very small
The use of any thromboprophylaxis in hip and knee
replacement surgery can not be supported by the literature.
FURTHER WORK
A detailed statistical analysis of the likely biases in this review of non-randomised evidence is being performed.
warwick orthopaedics