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Comparing Australian orthopaedic surgeons' reported use of thromboprophylaxis following arthroplasty in 2012 and 2017.

ABSTRACT: BACKGROUND:It is generally accepted that all arthroplasty patients should receive venous thromboembolism (VTE) and bleeding risk assessments, and that postoperative thromboprophylaxis be routinely prescribed where appropriate. Guideline recommendations regarding what to prescribe, however, have been inconsistent over the years, particularly regarding the appropriateness of aspirin. Our aim was to explore thromboprophylaxis patterns in use following hip and knee arthroplasty in Australia, and to examine associated variables. METHODS:Orthopaedic surgeons were invited via mail to participate in two national surveys, conducted in 2012 (N?=?478) and 2017 (N?=?820), respectively. RESULTS:The final response rates were 50.0 and 65.8% for 2012 and 2017, respectively. The thromboprophylaxis prescribing routines reported by respondents were divided into four categories: anticoagulant-only (the same anticoagulant-only routine for everyone), aspirin-only (aspirin for everyone), staged-supply (an anticoagulant during the initial postoperative period, followed by aspirin, for everyone) and risk-stratification routines (differing regimens depending on patients' perceived risk of VTE). The most common approaches reported were anticoagulant-only routines; however, their popularity almost halved within the five-year period (from ~?74% to ~?41%). Conversely, staged-supply and risk-stratification protocol usage increased by more than two and nine times, respectively. In 2017, over one-half of surgeons reported prescribing aspirin in their practice. Reported concern for postoperative VTE and infections (OR 0.555 95% CI 0.396-0.779, p?=?0.001 and OR 1.455 95% CI 1.010-2.097, p?=?0.044 respectively), as well as Arthroplasty Society membership (OR 2.814 95% CI 1.367-5.790, p?=?0.005) were predictors for use of aspirin (Cox and Snell R square?=?0.072). The factor most commonly reported to shape surgeons' protocols was research literature. Factors limiting prescribing of pharmacological prophylaxis included a perception that it increases bleeding and wound infection risk, is inconvenient, and lacks evidence applicable to real-world practice. CONCLUSIONS:VTE prevention post-arthroplasty is an evolving and multi-faceted entity, influenced by a range of factors and seemingly in need of robust evidence from large clinical trials to guide practice. The data highlighted potential short-falls in practice related to aspirin over-use, which could be further explored and addressed in future studies in order to optimise patient outcomes and reduce the significant morbidity and healthcare costs associated with VTE following these increasingly common surgical procedures.

SUBMITTER: Mirkazemi C

PROVIDER: S-EPMC6368726 | biostudies-literature | 2019 Feb

REPOSITORIES: biostudies-literature

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Comparing Australian orthopaedic surgeons' reported use of thromboprophylaxis following arthroplasty in 2012 and 2017.

Mirkazemi Corinne C Bereznicki Luke R LR Peterson Gregory M GM

BMC musculoskeletal disorders 20190208 1

<h4>Background</h4>It is generally accepted that all arthroplasty patients should receive venous thromboembolism (VTE) and bleeding risk assessments, and that postoperative thromboprophylaxis be routinely prescribed where appropriate. Guideline recommendations regarding what to prescribe, however, have been inconsistent over the years, particularly regarding the appropriateness of aspirin. Our aim was to explore thromboprophylaxis patterns in use following hip and knee arthroplasty in Australia, ...[more]

PMID: 30736774

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Project description:BackgroundIn older adults facing knee arthroplasty, the ability to resume downhill skiing postoperatively is unclear. This study aimed to determine the perspectives of Alberta orthopedic surgeons and senior residents regarding downhill skiing after total knee arthroplasty (TKA) or unicompartmental knee arthroplasty (UKA).MethodsIn May 2019, a Web-based survey was sent through the Alberta Orthopaedic Society to poll orthopedic surgeons performing arthroplasty and senior orthopedic residents (postgraduate year 4 or 5) in Alberta regarding the permissibility of downhill skiing after TKA or UKA. The survey also elicited information regarding under which conditions or restrictions, if any, surgeons would allow patients to return to downhill skiing, whether these recommendations were evidence based, and whether surgeons had seen complications from downhill skiing in their patients who had undergone knee arthroplasty.ResultsOf the 41 respondents, 21 (51%) were full-time fellowship-trained orthopedic surgeons, 15 (37%) were specialists with some arthroplasty in their practice, and 5 (12%) were orthopedic residents. Ten of 40 respondents (25%) would allow unrestricted downhill skiing after TKA, and 1 (2%) would not allow any skiing at all. The remaining 29 (72%) indicated that they might allow downhill skiing under specific conditions, with the top 3 being limitations on speed and intensity (29 [71%]), return of full range of motion and strength in the operative knee (26 [63%]), and years of downhill ski experience (23 [56%]). Fourteen respondents (34%) would allow unrestricted downhill skiing after UKA, and 27 (66%) would allow skiing with the same top 3 conditions as for TKA. Thirty-two respondents (78%) reported that their decisions were not evidence based, and 35 (85%) had never seen complications from downhill skiing after TKA or UKA.ConclusionAlberta orthopedic surgeons and senior residents are cautious regarding skiing after knee arthroplasty. The majority reported that their restrictions were not evidence based, which indicates the need for further investigation to develop an approach for surgeons to consistently and safely address return to downhill skiing after TKA or UKA.

Project description:Background: Persistent wound leakage after joint arthroplasty is a scantily investigated topic, despite the claimed relation with a higher risk of periprosthetic joint infection. This results in a lack of evidence-based clinical guidelines for the diagnosis and treatment of persistent wound leakage after joint arthroplasty. Without such guideline, clinical practice in orthopaedic hospitals varies widely. In preparation of a nationwide multicenter randomized controlled trial on the optimal treatment of persistent wound leakage, we evaluated current Dutch orthopaedic care for persistent wound leakage after joint arthroplasty. Methods: We conducted a questionnaire-based online survey among all 700 members of the Netherlands Orthopaedic Association, consisting of 23 questions on the definition, classification, diagnosis and treatment of persistent wound leakage after joint arthroplasty. Results: The questionnaire was completed by 127 respondents, representing 68% of the Dutch hospitals that perform orthopaedic surgery. The results showed wide variation in the classification, definition, diagnosis and treatment of persistent wound leakage among Dutch orthopaedic surgeons. 56.7% of the respondents used a protocol for diagnosis and treatment of persistent wound leakage, but only 26.8% utilized the protocol in every patient. Most respondents (59.1%) reported a maximum period of persistent wound leakage before starting non-surgical treatment of 3 to 7 days after index surgery and 44.1% of respondents reported a maximum period of wound leakage of 10 days before converting to surgical treatment. Conclusions: The wide variety in clinical practice underscores the importance of developing an evidence-based clinical guideline for the diagnosis and treatment of persistent wound leakage after joint arthroplasty. To this end, a nationwide multicenter randomized controlled trial will be conducted in the Netherlands, which may provide evidence on this important and poorly understood topic.

Project description:BACKGROUND:Over the past decade, there has been significant growth in the awareness and understanding of fragility among orthopaedic surgeons in the context of osteoporotic fractures and with it, improvements in the recognition and management of fragility fractures. Emerging as a major clinical and research focus in aged care is the concept of frailty and its associations with fragility, sarcopenia, falls and rehabilitation. Currently, research is lacking on how orthopaedic surgeons perceive frailty and the role of frailty screening. A baseline understanding of these perceptions is needed to inform integration of frailty identification and management for patient optimization in orthopaedic practices, as well as research and education efforts of patients and healthcare professionals in orthopaedic contexts. METHODS:We used an exploratory design guided by qualitative description to conduct 15 semi-structured telephone and in-person interviews across three orthopaedic surgeon subgroups (Registrars, Junior Consultants, and Senior Consultants). Data collection and analysis occurred iteratively and was guided by thematic saturation. RESULTS:Orthopaedic surgeons have a disparate understanding of frailty. Between colleagues, frailty is often referred to non-specifically to suggest a general state of risk to the patient. Frailty screening is regarded positively but its specific utility in orthopaedic environments is questioned. Easy-to-administer frailty screening tools that are not exclusive assessments of functional status are viewed most satisfactorily. However these tools are rarely used. CONCLUSIONS:There is little understanding among orthopaedic surgeons of frailty as a phenotype. Beliefs around modifiability of frailty were dissimilar as were the impact of related risk factors, such a cognitive status, chronic disease, social isolation, and environmental influences. This in turn may significantly impact on the occurrence and treatment outcomes of fragility fracture, a common orthopaedic problem in older populations. This study highlights need for knowledge translation efforts (e.g. education) to achieve cohesive understanding of frailty among health professionals.

Project description:BackgroundSo-called "hazardous attitudes" (macho, impulsive, antiauthority, resignation, invulnerable, and confident) were identified by the Federal Aviation Administration and the Canadian Air Transport Administration as contributing to road traffic incidents among college-aged drivers and felt to be useful for the prevention of aviation accidents. The concept of hazardous attitudes may also be useful in understanding adverse events in surgery, but it has not been widely studied.Questions/purposesWe surveyed a cohort of orthopaedic surgeons to determine the following: (1) What is the prevalence of hazardous attitudes in a large cohort of orthopaedic surgeons? (2) Do practice setting and/or demographics influence variation in hazardous attitudes in our cohort of surgeons? (3) Do surgeons feel they work in a climate that promotes patient safety?MethodsWe asked the members of the Science of Variation Group-fully trained, practicing orthopaedic and trauma surgeons from around the world-to complete a questionnaire validated in college-aged drivers measuring six attitudes associated with a greater likelihood of collision and used by pilots to assess and teach aviation safety. We accepted this validation as applicable to surgeons and modified the questionnaire accordingly. We also asked them to complete the Modified Safety Climate Questionnaire, a questionnaire assessing the absence of a safety climate that is based on the patient safety cultures in healthcare organizations instrument. Three hundred sixty-four orthopaedic surgeons participated, representing a 47% response rate of those with correct email addresses who were invited.ResultsThirty-eight percent (137 of 364 surgeons) had at least one score that would have been considered dangerously high in pilots (> 20), including 102 with dangerous levels of macho (28%) and 41 with dangerous levels of self-confidence (11%). After accounting for possible confounding variables, the variables most closely associated with a macho attitude deemed hazardous in pilots were supervision of surgical trainees in the operating room (p = 0.003); location of practice in Canada (p = 0.059), Europe (p = 0.021), and the United States (p = 0.005); and being an orthopaedic trauma surgeon (p = 0.046) (when compared with general orthopaedic surgeons), but accounted for only 5.3% of the variance (p < 0.001). On average, 19% of surgeon responses to the Modified Safety Climate Questionnaire implied absence of a safety climate.ConclusionsHazardous attitudes are common among orthopaedic surgeons and relate in small part to demographics and practice setting. Future studies should further validate the measure of hazardous attitudes among surgeons and determine if they are associated with preventable adverse events. We agree with aviation safety experts that awareness of amelioration of such attitudes might improve safety in all complex, high-risk endeavors, including surgery-a line of thinking that merits additional research.

Dataset Information

Comparing Australian orthopaedic surgeons' reported use of thromboprophylaxis following arthroplasty in 2012 and 2017.

Publications

Comparing Australian orthopaedic surgeons' reported use of thromboprophylaxis following arthroplasty in 2012 and 2017.

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