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Fitzmaurice and Murray make a compelling case for implementing the guidelines on thromboprophylaxis from the National Institute for Health and Clinical Excellence (NICE).1 However, many orthopaedic surgeons would profess to a different point of view.
Firstly, there is currently no evidence from published studies that thromboprophylaxis reduces mortality in patients undergoing elective hip or knee replacements. Secondly, there is much concern regarding the attempted prevention of what the authors themselves call a “silent” disease. While orthopaedic surgeons have not traditionally been seen as the pioneers of holistic medicine, we are reticent to expose our patients to increased risks from treatment for a condition only identified by a radiological test. The NICE guidelines own statistics emphasise this point by documenting the incidence of venous thromboembolism (VTE; radiologically diagnosed deep vein thrombosis and pulmonary embolism) after hip replacement without prophylaxis as 44% and the symptomatic VTE incidence in the same group as only 0.51%.2
Thirdly, we are disappointed by the lack of appropriate secondary outcome measures in the NICE analysis. No mention is made of wound haematoma, wound discharge, or joint infection. If these are not thought to be important issues then the millions of pounds spent every year attempting to prevent infection in hip replacement are clearly ill spent.
Competing interests: None declared.