ICM on VTE: A Major Step Forward in Patient Care

Current trends for venous thromboembolic prophylaxis for hip arthroscopy: a modified Delphi and nominal group technique consensus study

The overall risk of venous thromboembolism (VTE) after hip arthroscopy (HA) is reported to range from 0.2% to 9.5%, but a clear set of recommendations for VTE prophylaxis in HA patients remains scarce. The aim is to survey high-volume hip arthroscopists about their current trends regarding VTE prophylaxis use. A combination of two consensus group methods was used in this study: nominal group technique (NGT) and modified Delphi. A preliminary questionnaire was prepared, and rounds of discussion were completed between NGT members. The final version of the survey was administered to 35 high-volume hip surgeons. Delegates' mean volume of annual hip arthroscopic surgery was 109. Approximately 22% of their patients are revision HA procedures. A total of 91.4% of delegates use chemoprophylaxis, 28.6% use sequential compression devices and 91.4% believed that chemoprophylaxis is necessary for more prolonged and complex procedures (strong consensus). Aspirin was the choice for all participants, and the duration was 2-3 weeks (31.4%), 1 month (65.7%) and 2-3 months (2.9%). History of VTE, hypercoagulable status, and malignancy were considered risk factors. No consensus was achieved for the discontinuation of oral contraceptive and smoking preoperatively. However, the optimal length of VTE prophylaxis is unclear. A total of 97.1% of the experts responded that they administer aspirin between 2 and 4 weeks. High-volume arthroscopic surgeons do consider VTE prophylaxis to be important and warranted in the postoperative setting. Aspirin is the mainstay of chemoprophylaxis, although the appropriate duration is unknown.

An Evaluation of Patient-reported Outcome Measures and Minimal Clinically Important Difference Usage in Hand Surgery

Background

This study was designed to examine the current use of patient-reported outcome measures (PROMs) and minimal clinically important difference (MCID) calculations in the hand surgery literature in an effort to standardize their use for research purposes.

Methods

A systematic review of the hand surgery literature was conducted. All nonshoulder upper extremity articles utilizing PROMs were compared between different journals, different surgical indications, and differing usage. MCID values were reported, and calculation methods assessed.

Results

In total, 4677 articles were reviewed, and 410 met the inclusion criteria of containing at least one PROM. Of the 410 articles reporting PROMs, 148 also mentioned an associated MCID. Of the articles that mentioned MCIDs, 14 calculated MCID values based on their specific clinical populations, whereas the remainder referenced prior studies. An estimated 35 different PROMs were reported in the study period; 95 different MCID values were referenced from 65 unique articles.

Conclusions

There are many different PROMs currently being used in hand surgery clinical reports. The reported MCIDs from their related PROMs are from multiple different sources and calculated by different methods. The lack of standardization in the hand surgery literature makes interpretation of studies utilizing PROMs difficult. There is a need for a standardized method of calculating MCID values and applying these values to established PROMs for nonshoulder upper extremity conditions.

Direct Oral Anticoagulants: How Do These Drugs Work, How to Monitor, and What Is Their Role in Orthopaedic Surgery

Postoperative venous thromboembolism is a major adverse event associated with orthopaedic surgery. With the addition of perioperative anticoagulation and antiplatelet therapy, the rates of symptomatic venous thromboembolism have dropped to 1% to 3%, and as such, practicing orthopaedic surgeons must be familiar with these medications, including aspirin, heparin, or warfarin, and the use of direct oral anticoagulants (DOACs). DOACs are increasingly being prescribed due to their predictable pharmacokinetics and increased convenience, as they do not require routine monitoring, and 1% to 2% of the general population is currently anticoagulated. Although the introduction of DOACs has yielded additional treatment options, this has also led to confusion and uncertainty regarding treatment, specialized testing, and when and what reversal agents are appropriate. This article provides a basic overview of DOAC medications, their suggested use in the perioperative setting, effects on laboratory testing, and consideration for when and how to use reversal agents in orthopaedic patients.

Impact of Prolonged Operative Duration on Postoperative Symptomatic Venous Thromboembolic Events After Thoracolumbar Spine Surgery

OBJECTIVE

To determine the effect of operative duration on the rate of postoperative symptomatic venous thromboembolic (VTE) events in patients undergoing thoracolumbar spine fusion.

METHODS

We identified all thoracolumbar spine fusion patients between 2012 and 2021. Operative duration was defined as time from skin incision to skin closure. A 1:1 propensity match was conducted incorporating patient and surgical characteristics. Logistic regression was performed to assess predictors of postoperative symptomatic VTE events. A receiver operating characteristic curve was created to determine a cutoff time for increased likelihood of VTE.

RESULTS

We identified 101 patients with VTE and 1108 patients without VTE. Seventy-five patients with VTE were matched to 75 patients without VTE. Operative duration (339 vs. 262 minutes, P = 0.010) and length of stay (5.00 vs. 3.54 days, P = 0.008) were significantly longer in patients with a VTE event. Operative duration was an independent predictor of VTE on multivariate regression (odds ratio: 1.003, 95% confidence interval: 1.001-1.01, P = 0.021). For each additional hour of operative duration, the risk of VTE increased by 18%. A cutoff time of 218 minutes was identified (area under the curve [95% confidence interval] = 0.622 [0.533-0.712]) as an optimal predictor of increased risk for a VTE event.

CONCLUSIONS

Operative duration significantly predicted symptomatic VTE, especially after surgical time cutoff of 218 minutes. Each additional hour of operative duration was found to increase VTE risk by 18%. We also identify the impact of VTE on 90-day readmission rates, suggesting significantly higher costs and opportunity for hospital acquired conditions, in line with prior literature.