Letters To The Editor

VTE prevention in major orthopedic surgery

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Editor's Note: This letter concerns an article in a Cleveland Clinic Journal of Medicine supplement (Preventing Venous Thromboembolism Throughout the Continuum of Care ) distributed to only a portion of the Journal's regular readership, owing to the terms of the grant supporting the supplement .

To the Editor: I must make several comments regarding the review by Deitelzweig and colleagues .1

First, all but one of the article’s six authors report having received honoraria, consulting fees, or research funding from companies that market medical products; therefore, their observations are not going to be “clean.”

Second, the most worrisome part of the article is that the authors downplay the issue of bleeding. As recently reported by surgeons from the Rothman Institute of Orthopedics at Thomas Jefferson University, there is a very clear connection in their practice between periprosthetic infection and an international normalized ratio (INR) greater than 1.5. 12 All of us in the Hip Society and the American Association of Hip and Knee Surgeons have seen cases with infection directly related to hematoma formation. This has been totally underreported and understated, and was thought not to be scientific until this recent report from the Rothman Institute. 12

Third, as an orthopedic surgeon, I have to follow the guidelines of the American Academy of Orthopaedic Surgeons. 11 To blindly follow the guidelines of the Surgical Care Improvement Project ( http://www.medqic.org) is asking for less than ideal results in orthopedic cases.

I see a very strong trend toward aspirin. A number of academics in prominent institutions are using aspirin, particularly in knee surgery.

I personally have experience with a group of 350 orthopedic surgery patients whom I have managed based on the approach recently reported by Bern et al—ie, warfarin 1 mg/day for 7 days prior to surgery, followed by variable warfarin dosing during the hospital stay to achieve a target INR of 1.5 to 2.0, followed by a maintenance warfarin dose of 1 mg daily for 30 days after discharge. 13 I am very pleased with the results of this regimen. I have not encountered any wound issues, unlike my prior experience when using warfarin dosed to an INR of 2.0 to 3.0. I have currently modified this approach so that all male patients first receive two 325-mg aspirin tablets daily for 2 weeks, then warfarin 1 mg/day for the 7 days before surgery, followed by postoperative warfarin dosed to an INR of 1.5 to 2.0 during hospitalization, and then warfarin 2 to 5 mg/day for 30 days based on the patient’s INR response during hospitalization. The postoperative warfarin dosing requires monitoring, of course.

The results have been far superior to the bleeding rates reported from the Rothman Institute. 12 It is unfortunate that an approach such as this, as well as the rationale behind it, was not discussed in your supplement.

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