1. An Orthopod’s Perspective 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

5. Hugh Owen Thomas 1834 - 1891

8. Fast Track Mobilisation  No clear data on VTE risk  Intuitively beneficial

9. Rudolf Virchov 1821 - 1902

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

18. Evidence! Or Evidence? Cross trial comparisons  Criteria  End points  Definitions  Sponsored?  Statistics Need Expert Interpretation

21. Anti-Embolism Stockings  Often problematic for our patients  Wounds, swelling etc  Restricted movement  Large legs

24. Hip Fractures  Very common  High mortality  Immobility  Delay to theatre  Age

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

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

32. Deep Infection Often disastrous Usually means implant removal

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

35. Thank You