Venous Thromboembolism Prophylaxis in Orthopaedic Trauma Patients

Sagi, H. Claude; Ahn, Jaimo; Ciesla, David J.; Collinge, Cory; Molina, Cesar S.; Obremskey, William T.; Guillamondegui, Oscar D.

doi:10.1097/bot.0000000000000387

Cited by 62 publications

(36 citation statements)

References 37 publications

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“…16 The Orthopaedic Trauma Association Evidence Based Quality Value and Safety Committee highlights variability in prescribed regimens due to the poor scientific support for various regimens and emphasises the need for guidelines to improve patient care. 17 The CHEST guidelines emphasise the need for systematic reviews of patient values and…”

Section: Introductionmentioning

confidence: 99%

Patient preferences for venous thromboembolism prophylaxis after injury: a discrete choice experiment

et al. 2017

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ObjectiveLimited evidence for the optimal venous thromboembolism (VTE) prophylaxis regimen in orthopaedic trauma leads to variability in regimens. We sought to delineate patient preferences towards cost, complication profile, and administration route (oral tablet vs. subcutaneous injection).DesignDiscrete choice experiment (DCE).SettingLevel 1 trauma center in Baltimore, USA.Participants232 adult trauma patients (mean age 47.9 years) with pelvic or acetabular fractures or operative extremity fractures.Primary and secondary outcome measuresRelative preferences and trade-off estimates for a 1% reduction in complications were estimated using multinomial logit modelling. Interaction terms were added to the model to assess heterogeneity in preferences.ResultsPatients preferred oral tablets over subcutaneous injections (marginal utility, 0.16; 95% CI: 0.11 - 0.21, P<0.0001). Preferences changed in favor of subcutaneous injections with an absolute risk reduction of 6.98% in bleeding, 4.53% in wound complications requiring reoperation, 1.27% in VTE, and 0.07% in death from pulmonary embolism (PE). Patient characteristics (sex, race, type of injury, time since injury) affected patient preferences (P<0.01).ConclusionsPatients preferred oral prophylaxis and were most concerned about risk of death from PE. Furthermore, the findings estimated the trade-offs acceptable to patients and heterogeneity in preferences for VTE prophylaxis.

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Section: Introductionmentioning

confidence: 99%

Patient preferences for venous thromboembolism prophylaxis after injury: a discrete choice experiment

et al. 2017

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“…First, only members of the OTA who treat primarily fractures were surveyed. Second, the response rate of 31% was high for a survey of the OTA, in which response rates are typically 10 to 15% [23–25]. Third, surgeons were able to enter open-ended responses to some questions, enabling them to indicate that their practice patterns did not fit into the multiple-choice options.…”

Section: Discussionmentioning

confidence: 99%

Current practice of antibiotic prophylaxis for surgical fixation of closed long bone fractures: a survey of 297 members of the Orthopaedic Trauma Association

et al. 2017

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Background: The risk of postoperative surgical site infection after long bone fracture fixation can be decreased with appropriate antibiotic use. However, there is no agreement on the superiority of a single-or multiple-dose perioperative regimen of antibiotic prophylaxis. The purpose of this study is to determine the following: 1) What are the current practice patterns of orthopaedic trauma surgeons in using perioperative antibiotics for closed long bone fractures? 2) What is the current knowledge of published antibiotic prophylaxis guidelines among orthopaedic trauma surgeons? 3) Are orthopaedic surgeons willing to change their current practices? Methods: A questionnaire was distributed via email between September and December 2015 to 955 Orthopaedic Trauma Association members, of whom 297 (31%) responded. Results: Most surgeons (96%) use cefazolin as first-line infection prophylaxis. Fifty-nine percent used a multiple-dose antibiotic regimen, 39% used a single-dose regimen, and 2% varied this decision according to patient factors. Thirty-six percent said they were unfamiliar with Centers for Disease Control and Prevention (CDC) antibiotic prophylaxis guidelines; only 30% were able to select the correct CDC recommendation from a multiple-choice list. However, 44% of surgeons said they followed CDC recommendations. Fifty-six percent answered that a single-dose antibiotic prophylaxis regimen was not inferior to a multiple-dose regimen. If a level-I study comparing a single preoperative dose versus multiple perioperative antibiotic dosing regimen for treatment of closed long bone fractures were published, most respondents (64%) said they would fully follow these guidelines, and 22% said they would partially change their practice to follow these guidelines. Conclusion: There is heterogeneity in the use of single-versus multiple-dose antibiotic prophylaxis for surgical repair of closed long bone fractures. Many surgeons were unsure of current evidence-based recommendations regarding perioperative antibiotic use. Most respondents indicated they would be receptive to high-level evidence regarding the single-versus multiple-dose perioperative prophylactic antibiotics for the treatment of closed long bone fractures.

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“…Considering that orthopaedic trauma patients often have multiple injuries that may increase VTE and bleeding risks, drawing inference from the arthroplasty literature is cautioned. Based on the lack of scientific support for various regimens in this population, the Orthopaedic Trauma Association Evidence-Based Quality Value and Safety Committee recently emphasized the need for standardized VTE prevention guidelines to improve care [ 20 ].…”

Section: Introductionmentioning

confidence: 99%

Aspirin versus low-molecular-weight heparin for venous thromboembolism prophylaxis in orthopaedic trauma patients: A patient-centered randomized controlled trial

et al. 2020

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Background Emerging evidence suggests aspirin may be an effective venous thromboembolism (VTE) prophylaxis for orthopaedic trauma patients, with fewer bleeding complications. We used a patient-centered weighted composite outcome to globally evaluate aspirin versus low-molecular-weight heparin (LMWH) for VTE prevention in fracture patients. Methods We conducted an open-label randomized clinical trial of adult patients admitted to an academic trauma center with an operative extremity fracture, or a pelvis or acetabular fracture. Patients were randomized to receive LMWH (enoxaparin 30-mg) twice daily (n = 164) or aspirin 81-mg twice daily (n = 165). The primary outcome was a composite endpoint of bleeding complications, deep surgical site infection, deep vein thrombosis, pulmonary embolism, and death within 90 days of injury. A Global Rank test and weighted time to event analysis were used to determine the probability of treatment superiority for LMWH, given a 9% patient preference margin for oral administration over skin injections. Results Overall, 18 different combinations of outcomes were experienced by patients in the study. Ninety-nine patients in the aspirin group (59.9%) and 98 patients in the LMWH group (59.4%) were event-free within 90 days of injury. Using a Global Rank test, the LMWH had a 50.4% (95% CI, 47.7–53.2%, p = 0.73) probability of treatment superiority over aspirin. In the time to event analysis, LMWH had a 60.5% probability of treatment superiority over aspirin with considerable uncertainty (95% CI, 24.3–88.0%, p = 0.59). Conclusion The findings of the Global Rank test suggest no evidence of superiority between LMWH or aspirin for VTE prevention in fracture patients. LMWH demonstrated a 60.5% VTE prevention benefit in the weighted time to event analysis. However, this difference did not reach statistical significance and was similar to the elicited patient preferences for aspirin.

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Venous Thromboembolism Prophylaxis in Orthopaedic Trauma Patients

Abstract: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Cited by 62 publications

References 37 publications

Patient preferences for venous thromboembolism prophylaxis after injury: a discrete choice experiment

Patient preferences for venous thromboembolism prophylaxis after injury: a discrete choice experiment

Current practice of antibiotic prophylaxis for surgical fixation of closed long bone fractures: a survey of 297 members of the Orthopaedic Trauma Association

Aspirin versus low-molecular-weight heparin for venous thromboembolism prophylaxis in orthopaedic trauma patients: A patient-centered randomized controlled trial

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