title: Fatal pulmonary embolism following elective total hip arthroplasty: a 12-year study.
abstract: OBJECTIVE
  The place of thromboprophylaxis in arthroplasty surgery remains controversial, with a challenging requirement to balance prevention of potentially fatal venous thrombo-embolism with minimising wound-related complications leading to deep infection. We compared the incidence of fatal pulmonary embolism in patients undergoing elective primary total hip arthroplasty (THA) between those receiving aspirin, warfarin and low molecular weight heparin (LMWH) for the chemical component of a multi-modal thromboprophylaxis regime.
  
  
  METHODS
  A prospective audit database was used to identify patients who had died within 42 and 90 days of surgery respectively between April 2000 and December 2012. A case note review was performed to ascertain the causes of death.
  
  
  RESULTS
  During this period 7983 THAs were performed. The rate of mortality was 0.43% and 0.58% at 42 and 90 days respectively. The groups comprised 1571 patients (19.7%) on warfarin, 1838 (23.0%) on LMWH and 4574 (57.3%) on aspirin. The 90-day mortality for these three groups was 0.38%, 1.09% and 0.43% respectively. The higher mortality rate for LMWH was significant (p < 0.05). There were six fatal pulmonary emboli (PEs) (0.08%). A total of three occurred within 42 days, all in the LMWH group. A total of three occurred between 42 and 90 days; one on warfarin, two on LMWH. The leading causes of death in all three groups were lower respiratory tract infections and myocardial infarction.
  
  
  CONCLUSIONS
  We confirmed that fatal PE following elective THA with a multi-modal prophylaxis regime is rare. We further found that LMWH conferred no benefit over aspirin in this context, and is associated with a higher all-cause rate of mortality.
  
  
  CONCLUSIONS
  This study proposes that aspirin may be an appropriate thromboprophylaxis agent when used as part of a multi-modal regimen, suggesting current guidelines should be reviewed. Cite this article: Bone Joint J 2016;98-B:585-8.
authors.affiliation: The Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK.
authors.forename: E
authors.initials: E
authors.lastname: Bayley
authors.affiliation: Royal Hallamshire Hospital, Sheffield S10 2JF, UK.
authors.forename: S
authors.initials: S
authors.lastname: Brown
authors.affiliation: St George's University Hospital NHS FoundationTrust, Blackshaw Road, Tooting London SW17 0QT, UK.
authors.forename: N S
authors.initials: NS
authors.lastname: Bhamber
authors.affiliation: Royal Derby Hospital, Derby DE22 3NE, UK.
authors.forename: P W
authors.initials: PW
authors.lastname: Howard
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use*; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects*; D001241:Aspirin / Q000627:therapeutic use; D018890:Chemoprevention; D054869:Clinical Audit; D017558:Elective Surgical Procedures / Q000009:adverse effects; D006495:Heparin, Low-Molecular-Weight / Q000627:therapeutic use; D006801:Humans; D009203:Myocardial Infarction / Q000401:mortality; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D011183:Postoperative Complications / Q000401:mortality; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000401:mortality* / Q000517:prevention & control; D012141:Respiratory Tract Infections / Q000401:mortality; D006113:United Kingdom / Q000453:epidemiology; D014859:Warfarin / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight; D010975:Platelet Aggregation Inhibitors; D014859:Warfarin; D001241:Aspirin
keywords: Aspirin; Fatal pulmonary embolism; Thromboprophylaxis; Total Hip replacement