Introduction
Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism
(PE), is a potentially fatal complication from knee arthroplasty. Its prevention can
use pharmacological and mechanical methods. These methods must be effective (that
is, avoiding fatal outcomes) and safe (that is, not causing major bleeding).[1]
[2] Despite the great importance of this topic in the daily life of orthopedists, there
is still no consensus on the best thromboprophylaxis regimen for total knee arthroplasty
(TKA), either nationally or internationally.[1]
[2]
[3]
[4]
The present study describes the preferences and current practices of a sample of Brazilian
orthopedic knee surgeons regarding thromboprophylaxis for TKA.
Materials and Methods
The present research started after approval by the Research Ethics Committee of Universidade
Federal do Pará and by the Brazilian Knee Surgery Society (SBCJ, in the Portuguese
acronym), in addition to registration on Plataforma Brasil.
The present online study collected data on perceptions and practices of knee surgeons
working in Brazil; its report follows the guidelines for writing web-based research
known as Checklist for Reporting Results of Internet E‐Surveys (CHERRIES).[5]
We sent the open-ended questionnaire ([Appendix 1], [Supplementary material], available online only) to all SBCJ members. First, it was sent by email on December
18, 2020 ([Appendix 2], [Supplementary material], available online only) to 1,612 orthopedists. On December 27, 2020, a message sent
via WhatsApp to all regional SBCJ groups ([Appendix 3], [Supplementary material], available online only) invited orthopedists to participate in the research. We
offered no reward for participation.
The answers were received until January 26, 2021. We requested the e-mail address
of the participant, but no other identification method, to avoid duplicates. If the
same participant (same e-mail address) answered the questionnaire more than once,
we considered only the last one and discarded any other. E-mail and WhatsApp messages
were saved in the Google Forms platform website for automatic storage, with access
restricted to researchers through a password. To complete the survey, all participants
had to read and agree with an informed consent form (ICF) available as a link in the
initial text ([Appendix 4], [Supplementary material], available online only).
The questionnaire consisted of 51 questions divided into 4 sections. The first section
gathered general information about the participant. The second and third sections
inquired about their perioperative routine in TKA and thromboprophylaxis preferences
and practices (pharmacological or mechanical techniques or both), respectively. A
final section was reserved for optional comments. The thromboprophylaxis methods listed
in the questionnaire were based on a literature review, on international guidelines,
and on the combined clinical experience of the authors.
In a pilot phase, we tested the online questionnaire with 6 orthopedists; the average
time for its completion was 4 minutes. Some questions have been reworded to avoid
ambiguity and improve usability/functionality.
Of the 51 questions, 35 were multiple choice (including 2 allowing more than one choice),
and 15 were discursive. Some questions linked to some answers (branching logic), so
the number of total questions to each participant could range from 17 to 51. There
was no randomization in the order of the questions. We adopted the same sequence to
maintain the line of reasoning. During the completion of the questionnaire, the participant
could go back and review their answers until the final submission. Except for the
“Final Comments” field, all other questions were mandatory. Since the platform only
captured data from fully answered questionnaires, there were no incomplete questionnaires.
For the statistical analysis, absolute and relative frequencies described the conduct
and preferences of the surgeons according to the characteristics of interest. The
Kirkwood and Sternes likelihood-ratio test verified associations. Data were tabulated
in Microsoft Excel 2003 (Microsoft Corp., Redmond, WA, USA) and analyzed with IBM
SPSS Statistics for Windows version 20.0 (IBM Corp., Armonk, NY, USA). The significance
level was set at 5%.
Results
We received 311 responses, including 65 duplicates excluded along with 1 participant
who stated not performing routine TKA. Thus, we analyzed 245 questionnaires. This
number corresponds to a response rate of 15.19% of the total SBCJ members during the
study period, even though affiliation has not been verified.
[Table 1] shows the profile of the participants and their concerns with TKA complications.
[Table 2] shows their preferences and thromboprophylaxis practices. Except for 3 participants
(1.2%), all surgeons used some form of thromboprophylaxis. Most orthopedists (76%)
preferred a combination of pharmacological and mechanical techniques. The most prescribed
drug after surgery was enoxaparin (87%). All those prescribing thromboprophylaxis
on admission also recommend their home use. Among those prescribing enoxaparin during
hospitalization, only 30% maintain it after discharge; the other 70% switch to another
oral drug. The most prescribed drug by these orthopedists was rivaroxaban (65%), mainly
(86%) starting 24 hours after the last enoxaparin dosage. Among the orthopedists prescribing
a drug other than enoxaparin during hospitalization, the majority (94%) did not change
the medication after hospital discharge.
Table 1
|
Variable
|
Description
|
|
Time since the conclusion of R4 in knee surgery
|
|
Up to 10 years
|
58 (23.6%)
|
|
11 to 20 years
|
81 (32.9%)
|
|
21 to 30 years
|
65 (26.4%)
|
|
> 30 years
|
42 (17.1%)
|
|
Brazilian Region
|
|
North
|
27 (11%)
|
|
Northeast
|
44 (17.9%)
|
|
Southeast
|
134 (54.5%)
|
|
South
|
24 (9.8%)
|
|
Central-West
|
17 (6.9%)
|
|
Which are your main knee replacement patients?
|
|
Health insurance/Private practice
|
168 (68.3%)
|
|
Brazilian Universal Healthcare System (SUS)
|
33 (13.4%)
|
|
Similar volumes from SUS/Private practice
|
45 (18.3%)
|
|
Arthroplasties performed per month
|
|
0 to 4
|
143 (58.1%)
|
|
5 to 8
|
73 (29.7%)
|
|
≥ 9
|
30 (12.2%)
|
|
Do you predominantly act as the main surgeon or the assistant surgeon?
|
|
Main surgeon
|
226 (91.9%)
|
|
Assistant surgeon
|
20 (8.1%)
|
|
How concerned are you about the following potential complications in total knee arthroplasty?
[Thromboembolism]
|
|
Not concerned
|
2 (0.8%)
|
|
Slightly concerned
|
20 (8.1%)
|
|
Moderately concerned
|
25 (10.2%)
|
|
Concerned
|
94 (38.2%)
|
|
Very concerned
|
105 (42.7%)
|
|
How concerned are you about the following potential complications in total knee arthroplasty?
[Infection]
|
|
Not concerned
|
3 (1.2%)
|
|
Slightly concerned
|
12 (4.9%)
|
|
Moderately concerned
|
7 (2.8%)
|
|
Concerned
|
50 (20.3%)
|
|
Very concerned
|
174 (70.7%)
|
|
How concerned are you about the following potential complications in total knee arthroplasty?
[Minor bleeding]
|
|
Not concerned
|
52 (21.1%)
|
|
Slightly concerned
|
70 (28.5%)
|
|
Moderately concerned
|
47 (19.1%)
|
|
Concerned
|
65 (26.4%)
|
|
Very concerned
|
12 (4.9%)
|
|
How concerned are you about the following potential complications in total knee arthroplasty?
[Major bleeding]
|
|
Not concerned
|
14 (5.7%)
|
|
Slightly concerned
|
38 (15.4%)
|
|
Moderately concerned
|
43 (17.5%)
|
|
Concerned
|
85 (34.6%)
|
|
Very concerned
|
66 (26.8%)
|
|
Which is the anesthesia protocol most used by your team for total knee replacement?
|
|
General
|
1 (0.4%)
|
|
Epidural
|
1 (0.4%)
|
|
Epidural with catheter
|
4 (1.6%)
|
|
Spinal
|
98 (39.8%)
|
|
Spinal + ultrasound-guided peripheral block
|
136 (55.3%)
|
|
Spinal + epidural
|
6 (2.4%)
|
|
Do you believe that a tourniquet may increase the incidence of thromboembolic events
in total knee replacement?
|
|
No
|
117 (47.6%)
|
|
Yes
|
129 (52.4%)
|
|
How long do you keep a patient with no complications hospitalized after a primary
knee replacement?
|
|
1 day
|
18 (7.3%)
|
|
2 days
|
138 (56.1%)
|
|
3 days
|
81 (32.9%)
|
|
> 3 days
|
9 (3.7%)
|
|
How soon after surgery do you allow the patient to resume walking?
|
|
Within 24 hours
|
93 (37.8%)
|
|
From 24 to 48 hours
|
137 (55.7%)
|
|
From 48 to 72 hours
|
13 (5.3%)
|
|
> 72 hours
|
3 (1.2%)
|
|
Do you use a tourniquet in most of your arthroplasties?
|
|
No
|
45 (18.3%)
|
|
Yes
|
201 (81.7%)
|
|
If you often use a tourniquet, for how long do you do it?
|
|
From before skin incision up to the total closure of the surgical site
|
79 (39.3%)
|
|
From before skin incision up to the cementation of the prosthesis
|
121 (60.2%)
|
|
Only during cementation
|
1 (0.5%)
|
Table 2
|
Variable
|
Description
|
|
In your routine, do you use any kind of thromboprophylaxis for total knee replacement?
|
|
No
|
3 (1.2%)
|
|
Yes
|
243 (98.8%)
|
|
Which thromboprophylaxis type(s) do you use for total knee replacement?
|
|
Pharmacological alone
|
57 (23.5%)
|
|
Mechanical alone
|
1 (0.4%)
|
|
Pharmacological + mechanical
|
185 (76.1%)
|
|
When do you start the pharmacological thromboprophylaxis?
|
|
Before surgery
|
15 (6.2%)
|
|
After surgery
|
227 (93.8%)
|
|
Which drug do you use after surgery?
|
|
Aspirin
|
5 (2.1%)
|
|
Apixaban
|
3 (1.2%)
|
|
Dabigatran
|
4 (1.7%)
|
|
Enoxaparin
|
211 (87.2%)
|
|
Rivaroxaban
|
18 (7.4%)
|
|
Another drug
|
1 (0.4%)
|
|
How long after surgery is the first dose administered?
|
|
Up to 2 hours
|
16 (6.6%)
|
|
3 to 6 hours
|
86 (35.5%)
|
|
7 to 11 hours
|
34 (14%)
|
|
12 hours
|
86 (35.5%)
|
|
≥ 24 hours
|
20 (8.3%)
|
|
What is the frequency of administration of this drug during hospitalization?
|
|
Every 12 hours
|
8 (3.3%)
|
|
Once a day
|
234 (96.7%)
|
|
For how long the patient must take this drug during hospitalization?
|
|
1 day
|
3 (1.2%)
|
|
2 days
|
29 (12%)
|
|
3 days
|
10 (4.1%)
|
|
Only while the patient cannot walk. When walking is resumed, I terminate the drug
|
2 (0.8%)
|
|
During the whole hospitalization period
|
198 (81.8%)
|
|
The options you stated above indicate your current practice. Would you prefer another
conduct if you could use other resources/drugs?
|
|
No, I am free to work as I prefer
|
189 (78.1%)
|
|
Yes, but they are not available at the hospital(s) I work
|
27 (11.2%)
|
|
Yes, but they are not financed by health insurance providers
|
26 (10.7%)
|
|
Do you prescribe pharmacological thromboprophylaxis after hospital discharge?
|
|
Yes
|
242 (100%)
|
|
Do you prescribe the same drug used during hospitalization for home treatment after
discharge?
|
|
No
|
153 (63.2%)
|
|
Yes
|
89 (36.8%)
|
|
Which new drug do you prescribe for home use?
|
|
Acetylsalicylic acid
|
18 (11.8%)
|
|
Apixaban
|
30 (19.6%)
|
|
Dabigatran
|
6 (3.9%)
|
|
Rivaroxaban
|
99 (64.7%)
|
|
For how long the patient must use this drug at home?
|
|
1 week
|
4 (1.7%)
|
|
10 days
|
68 (28.1%)
|
|
2 weeks
|
83 (34.3%)
|
|
3 weeks
|
40 (16.5%)
|
|
4 weeks
|
44 (18.2%)
|
|
> 4 weeks
|
3 (1.2%)
|
|
The options you stated above indicate your current practice. Would you prefer another
conduct if you could use other resources/drugs?
|
|
No, I am free to work as I prefer
|
203 (83.9%)
|
|
Yes, but the administration route prevents its home use
|
10 (4.1%)
|
|
Yes, but the cost would prevent its use by my patients
|
29 (12%)
|
|
Do you prescribe mechanical thromboprophylaxis after total knee replacement?
|
|
No
|
72 (29.8%)
|
|
Yes
|
170 (70.2%)
|
|
What type of mechanical prophylaxis do you use?*
|
|
Graduated compression stockings
|
140 (81.9%)
|
|
Continuous passive motion (CPM) device
|
25 (14.6%)
|
|
Fixed pneumatic compression device
|
39 (22.8%)
|
|
Portable pneumatic compression device
|
8 (4.7%)
|
|
How do you use the device?
|
|
On the operated lower extremity alone
|
20 (11.7%)
|
|
On both lower extremities
|
151 (88.3%)
|
|
When do you start the mechanical thromboprophylaxis?
|
|
Before surgery
|
11 (6.4%)
|
|
During surgery
|
18 (10.5%)
|
|
Immediately after the end of surgery
|
105 (61.4%)
|
|
A couple of hours after the end of surgery
|
37 (21.6%)
|
|
The options you stated above indicate your current practice. Would you prefer another
conduct if you could use other resources/drugs?
|
|
No, I am free to work as I prefer
|
121 (70.8%)
|
|
Yes, but they are not available at the hospital(s) I work
|
17 (9.9%)
|
|
Yes, but they are not financed by health insurance providers
|
13 (7.6%)
|
|
Yes, but the device is not available where I work
|
3 (1.8%)
|
|
Yes, but the cost would prevent its use by my patients
|
17 (9.9%)
|
|
Do you stratify your thromboprophylaxis method for knee replacement or do you use
the same routine regimen for all patients?
|
|
I stratify it
|
82 (33.7%)
|
|
I use the same method for all patients
|
161 (66.3%)
|
|
Do you follow any guideline regarding a thromboprophylaxis method?
|
|
No
|
88 (36.2%)
|
|
Yes, 2011 American Academy of Orthopaedic Surgeons (AAOS)
|
38 (15.6%)
|
|
Yes, 2012 American College of Chest Physicians (ACCP)
|
10 (4.1%)
|
|
Yes, the guidelines from the hospital I work
|
102 (42%)
|
|
Yes, 2019 National Institute for Health and Care Excellence (NICE)
|
5 (2.1%)
|
[Table 3] associates the preferences and practices of the interviewee with the time since
completing their knee specialization. There is a statistically significant association
between time since training and some practices. Surgeons with < 10 years of experience
started the pharmacological prophylaxis 12 hours after surgery (p = 0.030) and used less continuous passive motion (CPM) devices (p = 0.023) and portable pneumatic compression devices (p = 0.014); in addition, they were less likely to stratify the thromboprophylaxis method
according to the patient, meaning that they usually prescribe the same method for
all patients (p < 0.001). Orthopedists with 21 to 30 years of experience opt for graduated compression
stockings (p = 0.022) rather than for a fixed pneumatic compression device (p = 0.030).
Table 3
|
Variable
|
R4 completion
|
p-value
|
|
Up to 10 years
|
11 to 20 years
|
21 to 30 years
|
> 30 years
|
|
Which thromboprophylaxis type(s) do you use for total knee replacement?
|
|
Pharmacological alone
|
10 (17.5)
|
24 (29.6)
|
16 (25)
|
7 (17.1)
|
0.292
|
|
Mechanical alone
|
0 (0)
|
0 (0)
|
0 (0)
|
1 (2.4)
|
|
Pharmacological + mechanical
|
47 (82.5)
|
57 (70.4)
|
48 (75)
|
33 (80.5)
|
|
When do you start the pharmacological thromboprophylaxis?
|
|
Before surgery
|
1 (1.8)
|
8 (9.9)
|
5 (7.8)
|
1 (2.5)
|
0.125
|
|
After surgery
|
56 (98.2)
|
73 (90.1)
|
59 (92.2)
|
39 (97.5)
|
|
Which drug do you use after surgery?
|
|
Acetylsalicylic acid
|
0 (0)
|
0 (0)
|
3 (4.7)
|
2 (5)
|
0.058
|
|
Apixaban
|
0 (0)
|
3 (3.7)
|
0 (0)
|
0 (0)
|
|
Dabigatran
|
0 (0)
|
1 (1.2)
|
1 (1.6)
|
2 (5)
|
|
Enoxaparin
|
54 (94.7)
|
72 (88.9)
|
54 (84.4)
|
31 (77.5)
|
|
Rivaroxaban
|
3 (5.3)
|
5 (6.2)
|
6 (9.4)
|
4 (10)
|
|
Another drug
|
0 (0)
|
0 (0)
|
0 (0)
|
1 (2.5)
|
|
How long after surgery is the first dose administered?
|
|
Up to 2 hours
|
2 (3.5)
|
3 (3.7)
|
5 (7.8)
|
6 (15)
|
0.030
|
|
3 to 6 hours
|
12 (21.1)
|
29 (35.8)
|
30 (46.9)
|
15 (37.5)
|
|
7 to 11 hours
|
6 (10.5)
|
14 (17.3)
|
8 (12.5)
|
6 (15)
|
|
12 hours
|
28 (49.1)
|
30 (37)
|
18 (28.1)
|
10 (25)
|
|
≥ 24 hours
|
9 (15.8)
|
5 (6.2)
|
3 (4.7)
|
3 (7.5)
|
|
What is the frequency of administration of this drug during hospitalization?
|
|
Every 12 hours
|
2 (3.5)
|
2 (2.5)
|
0 (0)
|
4 (10)
|
0.042
|
|
Once a day
|
55 (96.5)
|
79 (97.5)
|
64 (100)
|
36 (90)
|
|
For how long the patient must take this drug during hospitalization?
|
|
1 day
|
0 (0)
|
1 (1.2)
|
2 (3.1)
|
0 (0)
|
0.002
|
|
2 days
|
1 (1.8)
|
11 (13.6)
|
10 (15.6)
|
7 (17.5)
|
|
3 days
|
2 (3.5)
|
0 (0)
|
5 (7.8)
|
3 (7.5)
|
|
Only while the patient cannot walk. When walking is resumed, I terminate the drug
|
0 (0)
|
0 (0)
|
2 (3.1)
|
0 (0)
|
|
During the whole hospitalization period
|
54 (94.7)
|
69 (85.2)
|
45 (70.3)
|
30 (75)
|
|
The options you stated above indicate your current practice. Would you prefer another
conduct if you could use other resources/drugs?
|
|
No, I am free to work as I prefer
|
41 (71.9)
|
59 (72.8)
|
55 (85.9)
|
34 (85)
|
0.104
|
|
Yes, but they are not available at the hospital(s) I work
|
8 (14)
|
13 (16)
|
2 (3.1)
|
4 (10)
|
|
Yes, but they are not financed by health insurance providers
|
8 (14)
|
9 (11.1)
|
7 (10.9)
|
2 (5)
|
|
Do you prescribe the same drug used during hospitalization for home treatment after
discharge?
|
|
No
|
40 (70.2)
|
55 (67.9)
|
39 (60.9)
|
19 (47.5)
|
0.101
|
|
Yes
|
17 (29.8)
|
26 (32.1)
|
25 (39.1)
|
21 (52.5)
|
|
Which new drug do you prescribe for home use?
|
|
Acetylsalicylic acid
|
1 (2.5)
|
8 (14.5)
|
6 (15.4)
|
3 (15.8)
|
0.560
|
|
Apixaban
|
10 (25)
|
10 (18.2)
|
8 (20.5)
|
2 (10.5)
|
|
Dabigatran
|
1 (2.5)
|
2 (3.6)
|
2 (5.1)
|
1 (5.3)
|
|
Rivaroxaban
|
28 (70)
|
35 (63.6)
|
23 (59)
|
13 (68.4)
|
|
For how long the patient must use this drug at home?
|
|
1 week
|
0 (0)
|
2 (2.5)
|
1 (1.6)
|
1 (2.5)
|
0.253
|
|
10 days
|
10 (17.5)
|
28 (34.6)
|
22 (34.4)
|
8 (20)
|
|
2 weeks
|
21 (36.8)
|
27 (33.3)
|
17 (26.6)
|
18 (45)
|
|
3 weeks
|
9 (15.8)
|
12 (14.8)
|
10 (15.6)
|
9 (22.5)
|
|
4 weeks
|
16 (28.1)
|
11 (13.6)
|
13 (20.3)
|
4 (10)
|
|
> 4 weeks
|
1 (1.8)
|
1 (1.2)
|
1 (1.6)
|
0 (0)
|
|
The options you stated above indicate your current practice. Would you prefer another
conduct if you could use other resources/drugs?
|
|
No, I am free to work as I prefer
|
42 (73.7)
|
68 (84)
|
58 (90.6)
|
35 (87.5)
|
0.061
|
|
Yes, but the administration route prevents its home use
|
1 (1.8)
|
5 (6.2)
|
2 (3.1)
|
2 (5)
|
|
Yes, but the cost would prevent its use by my patients
|
14 (24.6)
|
8 (9.9)
|
4 (6.3)
|
3 (7.5)
|
|
Do you prescribe mechanical thromboprophylaxis after total knee replacement?
|
|
No
|
14 (24.6)
|
31 (38.3)
|
18 (28.1)
|
9 (22.5)
|
0.204
|
|
Yes
|
43 (75.4)
|
50 (61.7)
|
46 (71.9)
|
31 (77.5)
|
|
Graduated compression stockings
|
|
No
|
6 (14)
|
13 (26)
|
3 (6.5)
|
9 (28.1)
|
0.022
|
|
Yes
|
37 (86)
|
37 (74)
|
43 (93.5)
|
23 (71.9)
|
|
Continuous passive motion (CPM) device
|
|
No
|
42 (97.7)
|
41 (82)
|
38 (82.6)
|
25 (78.1)
|
0.023
|
|
Yes
|
1 (2.3)
|
9 (18)
|
8 (17.4)
|
7 (21.9)
|
|
Fixed pneumatic compression device
|
|
No
|
33 (76.7)
|
35 (70)
|
42 (91.3)
|
22 (68.8)
|
0.030
|
|
Yes
|
10 (23.3)
|
15 (30)
|
4 (8.7)
|
10 (31.3)
|
|
Portable pneumatic compression device
|
|
No
|
43 (100)
|
49 (98)
|
44 (95.7)
|
27 (84.4)
|
0.014
|
|
Yes
|
0 (0)
|
1 (2)
|
2 (4.3)
|
5 (15.6)
|
|
How do you use the device?
|
|
On the operated lower extremity alone
|
5 (11.6)
|
6 (12)
|
5 (10.9)
|
4 (12.5)
|
0.997
|
|
On both lower extremities
|
38 (88.4)
|
44 (88)
|
41 (89.1)
|
28 (87.5)
|
|
When do you start the mechanical thromboprophylaxis?
|
|
Before surgery
|
3 (7)
|
4 (8)
|
3 (6.5)
|
1 (3.1)
|
0.647
|
|
During surgery
|
4 (9.3)
|
7 (14)
|
3 (6.5)
|
4 (12.5)
|
|
Immediately after the end of surgery
|
28 (65.1)
|
24 (48)
|
31 (67.4)
|
22 (68.8)
|
|
A couple of hours after the end of surgery
|
8 (18.6)
|
15 (30)
|
9 (19.6)
|
5 (15.6)
|
|
The options you stated above indicate your current practice. Would you prefer another
conduct if you could use other resources/drugs?
|
|
No, I am free to work as I prefer
|
26 (60.5)
|
30 (60)
|
35 (76.1)
|
30 (93.8)
|
0.070
|
|
Yes, but they are not available at the hospital(s) I work
|
6 (14)
|
7 (14)
|
3 (6.5)
|
1 (3.1)
|
|
Yes, but they are not financed by health insurance providers
|
3 (7)
|
5 (10)
|
4 (8.7)
|
1 (3.1)
|
|
Yes, but the device is not available where I work
|
1 (2.3)
|
1 (2)
|
1 (2.2)
|
0 (0)
|
|
Yes, but the cost would prevent its use by my patients
|
7 (16.3)
|
7 (14)
|
3 (6.5)
|
0 (0)
|
|
Do you stratify your thromboprophylaxis method for knee replacement or do you use
the same routine regimen for all patients?
|
|
I stratify it
|
6 (10.5)
|
33 (40.7)
|
27 (42.2)
|
16 (39)
|
< 0.001
|
|
I use the same method for all patients
|
51 (89.5)
|
48 (59.3)
|
37 (57.8)
|
25 (61)
|
|
Do you follow any guideline regarding a thromboprophylaxis method?
|
|
No
|
21 (36.8)
|
33 (40.7)
|
25 (39.1)
|
9 (22)
|
0.538
|
|
Yes, 2011 American Academy of Orthopaedic Surgeons (AAOS)
|
10 (17.5)
|
12 (14.8)
|
7 (10.9)
|
9 (22)
|
|
Yes, 2012 American College of Chest Physicians (ACCP)
|
1 (1.8)
|
3 (3.7)
|
3 (4.7)
|
3 (7.3)
|
|
Yes, the guidelines from the hospital I work
|
24 (42.1)
|
30 (37)
|
28 (43.8)
|
20 (48.8)
|
|
Yes, 2019 National Institute for Health and Care Excellence (NICE)
|
1 (1.8)
|
3 (3.7)
|
1 (1.6)
|
0 (0)
|
[Table 4] shows some practices and preferences associated with the Brazilian region in which
they work (p < 0.05). Surgeons from the South and Central-West regions of Brazil frequently changed
the drug after hospital discharge. The drug selected for home use also varies according
to the Brazilian region. Mechanical prophylaxis was prescribed often in the South
region, with fixed pneumatic compression standing out compared mainly with the North
and Northeast regions. Mechanical thromboprophylaxis started earlier in the North
region.
Table 4
|
Variable
|
Brazilian Region
|
p-value
|
|
North
|
Northeast
|
Southeast
|
South
|
Central-West
|
|
Which thromboprophylaxis type(s) do you use for total knee replacement?
|
|
Pharmacological alone
|
8 (29.6)
|
10 (22.7)
|
35 (26.7)
|
2 (8.3)
|
2 (11.8)
|
0.440
|
|
Mechanical alone
|
0 (0)
|
0 (0)
|
1 (0.8)
|
0 (0)
|
0 (0)
|
|
Pharmacological + mechanical
|
19 (70.4)
|
34 (77.3)
|
95 (72.5)
|
22 (91.7)
|
15 (88.2)
|
|
When do you start the pharmacological thromboprophylaxis?
|
|
Before surgery
|
4 (14.8)
|
3 (6.8)
|
7 (5.4)
|
1 (4.2)
|
0 (0)
|
0.278
|
|
After surgery
|
23 (85.2)
|
41 (93.2)
|
123 (94.6)
|
23 (95.8)
|
17 (100)
|
|
Which drug do you use after surgery?
|
|
Acetylsalicylic acid
|
0 (0)
|
0 (0)
|
4 (3.1)
|
1 (4.2)
|
0 (0)
|
0.192
|
|
Apixaban
|
0 (0)
|
0 (0)
|
3 (2.3)
|
0 (0)
|
0 (0)
|
|
Dabigatran
|
2 (7.4)
|
0 (0)
|
2 (1.5)
|
0 (0)
|
0 (0)
|
|
Enoxaparin
|
25 (92.6)
|
42 (95.5)
|
107 (82.3)
|
20 (83.3)
|
17 (100)
|
|
Rivaroxaban
|
0 (0)
|
2 (4.5)
|
13 (10)
|
3 (12.5)
|
0 (0)
|
|
Another drug
|
0 (0)
|
0 (0)
|
1 (0.8)
|
0 (0)
|
0 (0)
|
|
How long after surgery is the first dose administered?
|
|
Up to 2 hours
|
1 (3.7)
|
2 (4.5)
|
6 (4.6)
|
5 (20.8)
|
2 (11.8)
|
0.006
|
|
3 to 6 hours
|
10 (37)
|
22 (50)
|
33 (25.4)
|
10 (41.7)
|
11 (64.7)
|
|
7 to 11 hours
|
2 (7.4)
|
7 (15.9)
|
20 (15.4)
|
4 (16.7)
|
1 (5.9)
|
|
12 hours
|
11 (40.7)
|
12 (27.3)
|
57 (43.8)
|
4 (16.7)
|
2 (11.8)
|
|
≥ 24 hours
|
3 (11.1)
|
1 (2.3)
|
14 (10.8)
|
1 (4.2)
|
1 (5.9)
|
|
What is the frequency of administration of this drug during hospitalization?
|
|
Every 12 hours
|
0 (0)
|
0 (0)
|
7 (5.4)
|
1 (4.2)
|
0 (0)
|
0.114
|
|
Once a day
|
27 (100)
|
44 (100)
|
123 (94.6)
|
23 (95.8)
|
17 (100)
|
|
For how long the patient must take this drug during hospitalization?
|
|
1 day
|
1 (3.7)
|
0 (0)
|
2 (1.5)
|
0 (0)
|
0 (0)
|
0.898
|
|
2 days
|
3 (11.1)
|
5 (11.4)
|
16 (12.3)
|
3 (12.5)
|
2 (11.8)
|
|
3 days
|
0 (0)
|
1 (2.3)
|
7 (5.4)
|
1 (4.2)
|
1 (5.9)
|
|
Only while the patient cannot walk. When walking is resumed, I terminate the drug
|
1 (3.7)
|
0 (0)
|
1 (0.8)
|
0 (0)
|
0 (0)
|
|
During the whole hospitalization period
|
22 (81.5)
|
38 (86.4)
|
104 (80)
|
20 (83.3)
|
14 (82.4)
|
|
The options you stated above indicate your current practice. Would you prefer another
conduct if you could use other resources/drugs?
|
|
No, I am free to work as I prefer
|
15 (55.6)
|
35 (79.5)
|
104 (80)
|
22 (91.7)
|
13 (76.5)
|
0.078
|
|
Yes, but they are not available at the hospital(s) I work
|
5 (18.5)
|
5 (11.4)
|
15 (11.5)
|
0 (0)
|
2 (11.8)
|
|
Yes, but they are not financed by health insurance providers
|
7 (25.9)
|
4 (9.1)
|
11 (8.5)
|
2 (8.3)
|
2 (11.8)
|
|
Do you prescribe the same drug used during hospitalization for home treatment after
discharge?
|
|
No
|
14 (51.9)
|
22 (50)
|
84 (64.6)
|
20 (83.3)
|
13 (76.5)
|
0.028
|
|
Yes
|
13 (48.1)
|
22 (50)
|
46 (35.4)
|
4 (16.7)
|
4 (23.5)
|
|
Which new drug do you prescribe for home use?
|
|
Aspirin
|
1 (7.1)
|
0 (0)
|
12 (14.3)
|
3 (15)
|
2 (15.4)
|
0.007
|
|
Apixaban
|
3 (21.4)
|
3 (13.6)
|
18 (21.4)
|
0 (0)
|
6 (46.2)
|
|
Dabigatran
|
1 (7.1)
|
3 (13.6)
|
1 (1.2)
|
1 (5)
|
0 (0)
|
|
Rivaroxaban
|
9 (64.3)
|
16 (72.7)
|
53 (63.1)
|
16 (80)
|
5 (38.5)
|
|
For how long the patient must use this drug at home?
|
|
1 week
|
3 (11.1)
|
0 (0)
|
1 (0.8)
|
0 (0)
|
0 (0)
|
0.173
|
|
10 days
|
8 (29.6)
|
17 (38.6)
|
30 (23.1)
|
7 (29.2)
|
6 (35.3)
|
|
2 weeks
|
7 (25.9)
|
10 (22.7)
|
55 (42.3)
|
7 (29.2)
|
4 (23.5)
|
|
3 weeks
|
4 (14.8)
|
8 (18.2)
|
20 (15.4)
|
3 (12.5)
|
5 (29.4)
|
|
4 weeks
|
4 (14.8)
|
9 (20.5)
|
22 (16.9)
|
7 (29.2)
|
2 (11.8)
|
|
> 4 weeks
|
1 (3.7)
|
0 (0)
|
2 (1.5)
|
0 (0)
|
0 (0)
|
|
The options you stated above indicate your current practice. Would you prefer another
conduct if you could use other resources/drugs?
|
|
No, I am free to work as I prefer
|
20 (74.1)
|
37 (84.1)
|
109 (83.8)
|
22 (91.7)
|
15 (88.2)
|
0.099
|
|
Yes, but the administration route prevents its home use
|
0 (0)
|
2 (4.5)
|
5 (3.8)
|
1 (4.2)
|
2 (11.8)
|
|
Yes, but the cost would prevent its use by my patients
|
7 (25.9)
|
5 (11.4)
|
16 (12.3)
|
1 (4.2)
|
0 (0)
|
|
Do you prescribe mechanical thromboprophylaxis after total knee replacement?
|
|
No
|
11 (40.7)
|
11 (25)
|
44 (33.8)
|
2 (8.3)
|
4 (23.5)
|
0.042
|
|
Yes
|
16 (59.3)
|
33 (75)
|
86 (66.2)
|
22 (91.7)
|
13 (76.5)
|
|
Graduated compression stockings
|
|
No
|
4 (25)
|
7 (21.2)
|
13 (14.9)
|
6 (27.3)
|
1 (7.7)
|
0.467
|
|
Yes
|
12 (75)
|
26 (78.8)
|
74 (85.1)
|
16 (72.7)
|
12 (92.3)
|
|
Continuous passive motion (CPM) device
|
|
No
|
10 (62.5)
|
24 (72.7)
|
80 (92)
|
21 (95.5)
|
11 (84.6)
|
0.006
|
|
Yes
|
6 (37.5)
|
9 (27.3)
|
7 (8)
|
1 (4.5)
|
2 (15.4)
|
|
Fixed pneumatic compression device
|
|
No
|
16 (100)
|
30 (90.9)
|
62 (71.3)
|
14 (63.6)
|
10 (76.9)
|
0.003
|
|
Yes
|
0 (0)
|
3 (9.1)
|
25 (28.7)
|
8 (36.4)
|
3 (23.1)
|
|
Portable pneumatic compression device
|
|
No
|
14 (87.5)
|
32 (97)
|
84 (96.6)
|
20 (90.9)
|
13 (100)
|
0.394
|
|
Yes
|
2 (12.5)
|
1 (3)
|
3 (3.4)
|
2 (9.1)
|
0 (0)
|
|
How do you use the device?
|
|
On the operated lower extremity alone
|
4 (25)
|
6 (18.2)
|
7 (8)
|
2 (9.1)
|
1 (7.7)
|
0.292
|
|
On both lower extremities
|
12 (75)
|
27 (81.8)
|
80 (92)
|
20 (90.9)
|
12 (92.3)
|
|
When do you start the mechanical thromboprophylaxis?
|
|
Before surgery
|
3 (18.8)
|
0 (0)
|
6 (6.9)
|
2 (9.1)
|
0 (0)
|
0.013
|
|
During surgery
|
2 (12.5)
|
2 (6.1)
|
14 (16.1)
|
0 (0)
|
0 (0)
|
|
Immediately after the end of surgery
|
8 (50)
|
20 (60.6)
|
49 (56.3)
|
16 (72.7)
|
12 (92.3)
|
|
A couple of hours after the end of surgery
|
3 (18.8)
|
11 (33.3)
|
18 (20.7)
|
4 (18.2)
|
1 (7.7)
|
|
The options you stated above indicate your current practice. Would you prefer another
conduct if you could use other resources/drugs?
|
|
No, I am free to work as I prefer
|
9 (56.3)
|
25 (75.8)
|
61 (70.1)
|
17 (77.3)
|
9 (69.2)
|
0.412
|
|
Yes, but they are not available at the hospital(s) I work
|
2 (12.5)
|
4 (12.1)
|
9 (10.3)
|
1 (4.5)
|
1 (7.7)
|
|
Yes, but they are not financed by health insurance providers
|
2 (12.5)
|
1 (3)
|
4 (4.6)
|
4 (18.2)
|
2 (15.4)
|
|
Yes, but the device is not available where I work
|
0 (0)
|
1 (3)
|
2 (2.3)
|
0 (0)
|
0 (0)
|
|
Yes, but the cost would prevent its use by my patients
|
3 (18.8)
|
2 (6.1)
|
11 (12.6)
|
0 (0)
|
1 (7.7)
|
|
Do you stratify your thromboprophylaxis method for knee replacement or do you use
the same routine regimen for all patients?
|
|
I stratify it
|
4 (14.8)
|
14 (31.8)
|
47 (35.9)
|
10 (41.7)
|
7 (41.2)
|
0.173
|
|
I use the same method for all patients
|
23 (85.2)
|
30 (68.2)
|
84 (64.1)
|
14 (58.3)
|
10 (58.8)
|
|
Do you follow any guideline regarding a thromboprophylaxis method?
|
|
No
|
11 (40.7)
|
17 (38.6)
|
43 (32.8)
|
8 (33.3)
|
9 (52.9)
|
0.397
|
|
Yes, 2011 American Academy of Orthopaedic Surgeons (AAOS)
|
6 (22.2)
|
9 (20.5)
|
18 (13.7)
|
2 (8.3)
|
3 (17.6)
|
|
Yes, 2012 American College of Chest Physicians (ACCP)
|
0 (0)
|
1 (2.3)
|
6 (4.6)
|
2 (8.3)
|
1 (5.9)
|
|
Yes, the guidelines from the hospital I work
|
10 (37)
|
17 (38.6)
|
59 (45)
|
12 (50)
|
4 (23.5)
|
|
Yes, 2019 National Institute for Health and Care Excellence (NICE)
|
0 (0)
|
0 (0)
|
5 (3.8)
|
0 (0)
|
0 (0)
|
None of the preferences and practices showed a statistically significant association
with the volume of surgical procedures (p > 0.05; [Table 5]).
Table 5
|
Variable
|
Arthroplasties performed per month
|
p-value
|
|
0 to 4
|
5 to 8
|
≥ 9
|
|
Which thromboprophylaxis type(s) do you use for total knee replacement?
|
|
Pharmacological alone
|
32 (22.9)
|
17 (23.3)
|
8 (26.7)
|
0.863
|
|
Mechanical alone
|
1 (0.7)
|
0 (0)
|
0 (0)
|
|
Pharmacological + mechanical
|
107 (76.4)
|
56 (76.7)
|
22 (73.3)
|
|
When do you start the pharmacological thromboprophylaxis?
|
|
Before surgery
|
9 (6.5)
|
3 (4.1)
|
3 (10)
|
0.530
|
|
After surgery
|
130 (93.5)
|
70 (95.9)
|
27 (90)
|
|
Which drug do you use after surgery?
|
|
Aspirin
|
2 (1.4)
|
2 (2.7)
|
1 (3.3)
|
0.783
|
|
Apixaban
|
1 (0.7)
|
2 (2.7)
|
0 (0)
|
|
Dabigatran
|
2 (1.4)
|
1 (1.4)
|
1 (3.3)
|
|
Enoxaparin
|
123 (88.5)
|
63 (86.3)
|
25 (83.3)
|
|
Rivaroxaban
|
11 (7.9)
|
4 (5.5)
|
3 (10)
|
|
Another drug
|
0 (0)
|
1 (1.4)
|
0 (0)
|
|
How long after surgery is the first dose administered?
|
|
Up to 2 hours
|
10 (7.2)
|
4 (5.5)
|
2 (6.7)
|
0.119
|
|
3 to 6 hours
|
39 (28.1)
|
32 (43.8)
|
15 (50)
|
|
7 to 11 hours
|
17 (12.2)
|
12 (16.4)
|
5 (16.7)
|
|
12 hours
|
59 (42.4)
|
21 (28.8)
|
6 (20)
|
|
≥ 24 hours
|
14 (10.1)
|
4 (5.5)
|
2 (6.7)
|
|
What is the frequency of administration of this drug during hospitalization?
|
|
Every 12 hours
|
4 (2.9)
|
3 (4.1)
|
1 (3.3)
|
0.896
|
|
Once a day
|
135 (97.1)
|
70 (95.9)
|
29 (96.7)
|
|
For how long the patient must take this drug during hospitalization?
|
|
1 day
|
1 (0.7)
|
1 (1.4)
|
1 (3.3)
|
0.623
|
|
2 days
|
15 (10.8)
|
10 (13.7)
|
4 (13.3)
|
|
3 days
|
5 (3.6)
|
5 (6.8)
|
0 (0)
|
|
Only while the patient cannot walk. When walking is resumed, I terminate the drug
|
1 (0.7)
|
1 (1.4)
|
0 (0)
|
|
During the whole hospitalization period
|
117 (84.2)
|
56 (76.7)
|
25 (83.3)
|
|
The options you stated above indicate your current practice. Would you prefer another
conduct if you could use other resources/drugs?
|
|
No, I am free to work as I prefer
|
104 (74.8)
|
61 (83.6)
|
24 (80)
|
0.286
|
|
Yes, but they are not available at the hospital(s) I work
|
15 (10.8)
|
8 (11)
|
4 (13.3)
|
|
Yes, but they are not financed by health insurance providers
|
20 (14.4)
|
4 (5.5)
|
2 (6.7)
|
|
Do you prescribe the same drug used during hospitalization for home treatment after
discharge?
|
|
No
|
94 (67.6)
|
43 (58.9)
|
16 (53.3)
|
0.225
|
|
Yes
|
45 (32.4)
|
30 (41.1)
|
14 (46.7)
|
|
Which new drug do you prescribe for home use?
|
|
Aspirin
|
10 (10.6)
|
7 (16.3)
|
1 (6.3)
|
0.333
|
|
Apixaban
|
20 (21.3)
|
9 (20.9)
|
1 (6.3)
|
|
Dabigatran
|
2 (2.1)
|
2 (4.7)
|
2 (12.5)
|
|
Rivaroxaban
|
62 (66)
|
25 (58.1)
|
12 (75)
|
|
For how long the patient must use this drug at home?
|
|
1 week
|
2 (1.4)
|
2 (2.7)
|
0 (0)
|
0.094
|
|
10 days
|
36 (25.9)
|
22 (30.1)
|
10 (33.3)
|
|
2 weeks
|
40 (28.8)
|
31 (42.5)
|
12 (40)
|
|
3 weeks
|
30 (21.6)
|
8 (11)
|
2 (6.7)
|
|
4 weeks
|
30 (21.6)
|
8 (11)
|
6 (20)
|
|
> 4 weeks
|
1 (0.7)
|
2 (2.7)
|
0 (0)
|
|
The options you stated above indicate your current practice. Would you prefer another
conduct if you could use other resources/drugs?
|
|
No, I am free to work as I prefer
|
114 (82)
|
63 (86.3)
|
26 (86.7)
|
0.648
|
|
Yes, but the administration route prevents its home use
|
5 (3.6)
|
3 (4.1)
|
2 (6.7)
|
|
Yes, but the cost would prevent its use by my patients
|
20 (14.4)
|
7 (9.6)
|
2 (6.7)
|
|
Do you prescribe mechanical thromboprophylaxis after total knee replacement?
|
|
No
|
41 (29.5)
|
19 (26)
|
12 (40)
|
0.381
|
|
Yes
|
98 (70.5)
|
54 (74)
|
18 (60)
|
|
Graduated compression stockings
|
|
No
|
18 (18.2)
|
9 (16.7)
|
4 (22.2)
|
0.873
|
|
Yes
|
81 (81.8)
|
45 (83.3)
|
14 (77.8)
|
|
Continuous passive motion (CPM) device
|
|
No
|
84 (84.8)
|
46 (85.2)
|
16 (88.9)
|
0.898
|
|
Yes
|
15 (15.2)
|
8 (14.8)
|
2 (11.1)
|
|
Fixed pneumatic compression device
|
|
No
|
74 (74.7)
|
45 (83.3)
|
13 (72.2)
|
0.404
|
|
Yes
|
25 (25.3)
|
9 (16.7)
|
5 (27.8)
|
|
Portable pneumatic compression device
|
|
No
|
97 (98)
|
50 (92.6)
|
16 (88.9)
|
0.137
|
|
Yes
|
2 (2)
|
4 (7.4)
|
2 (11.1)
|
|
How do you use the device?
|
|
On the operated lower extremity alone
|
12 (12.1)
|
5 (9.3)
|
3 (16.7)
|
0.692
|
|
On both lower extremities
|
87 (87.9)
|
49 (90.7)
|
15 (83.3)
|
|
When do you start the mechanical thromboprophylaxis?
|
|
Before surgery
|
8 (8.1)
|
3 (5.6)
|
0 (0)
|
0.705
|
|
During surgery
|
9 (9.1)
|
7 (13)
|
2 (11.1)
|
|
Immediately after the end of surgery
|
59 (59.6)
|
34 (63)
|
12 (66.7)
|
|
A couple of hours after the end of surgery
|
23 (23.2)
|
10 (18.5)
|
4 (22.2)
|
|
The options you stated above indicate your current practice. Would you prefer another
conduct if you could use other resources/drugs?
|
|
No, I am free to work as I prefer
|
69 (69.7)
|
36 (66.7)
|
16 (88.9)
|
0.528
|
|
Yes, but they are not available at the hospital(s) I work
|
8 (8.1)
|
8 (14.8)
|
1 (5.6)
|
|
Yes, but they are not financed by health insurance providers
|
9 (9.1)
|
4 (7.4)
|
0 (0)
|
|
Yes, but the device is not available where I work
|
2 (2)
|
1 (1.9)
|
0 (0)
|
|
Yes, but the cost would prevent its use by my patients
|
11 (11.1)
|
5 (9.3)
|
1 (5.6)
|
|
Do you stratify your thromboprophylaxis method for knee replacement or do you use
the same routine regimen for all patients?
|
|
I stratify it
|
44 (31.4)
|
29 (39.7)
|
9 (30)
|
0.434
|
|
I use the same method for all patients
|
96 (68.6)
|
44 (60.3)
|
21 (70)
|
|
Do you follow any guideline regarding a thromboprophylaxis method?
|
|
No
|
53 (37.9)
|
27 (37)
|
8 (26.7)
|
0.401
|
|
Yes, 2011 American Academy of Orthopaedic Surgeons (AAOS)
|
17 (12.1)
|
15 (20.5)
|
6 (20)
|
|
Yes, 2012 American College of Chest Physicians (ACCP)
|
4 (2.9)
|
3 (4.1)
|
3 (10)
|
|
Yes, the guidelines from the hospital I work
|
62 (44.3)
|
27 (37)
|
13 (43.3)
|
|
Yes, 2019 National Institute for Health and Care Excellence (NICE)
|
4 (2.9)
|
1 (1.4)
|
0 (0)
|
[Table 6] shows that the use of CPM by surgeons who work predominantly in the Brazilian public
health system (SUS, in the Portuguese acronym) is statistically lower when compared
with that of surgeons from other services, such as private ones (p = 0.024). These surgeons would also opt for different thromboprophylaxis techniques
if they could (p = 0.008).
Table 6
|
Variable
|
Which are your main knee replacement patients?
|
p-value
|
|
Private Insurance
|
Brazilian Universal Healthcare System (SUS)
|
Same volume SUS/Private Insurance
|
|
Which thromboprophylaxis type(s) do you use for total knee replacement?
|
|
Pharmacological alone
|
37 (22.3)
|
10 (30.3)
|
10 (22.7)
|
0.793
|
|
Mechanical alone
|
1 (0.6)
|
0 (0)
|
0 (0)
|
|
Pharmacological + mechanical
|
128 (77.1)
|
23 (69.7)
|
34 (77.3)
|
|
When do you start the pharmacological thromboprophylaxis?
|
|
Before surgery
|
9 (5.5)
|
1 (3)
|
5 (11.4)
|
0.286
|
|
After surgery
|
156 (94.5)
|
32 (97)
|
39 (88.6)
|
|
Which drug do you use after surgery?
|
|
Acetylsalicylic acid
|
1 (0.6)
|
1 (3)
|
3 (6.8)
|
0.072
|
|
Apixaban
|
1 (0.6)
|
0 (0)
|
2 (4.5)
|
|
Dabigatran
|
1 (0.6)
|
1 (3)
|
2 (4.5)
|
|
Enoxaparin
|
150 (90.9)
|
28 (84.8)
|
33 (75)
|
|
Rivaroxaban
|
12 (7.3)
|
3 (9.1)
|
3 (6.8)
|
|
Another drug
|
0 (0)
|
0 (0)
|
1 (2.3)
|
|
How long after surgery is the first dose administered?
|
|
Up to 2 hours
|
12 (7.3)
|
1 (3)
|
3 (6.8)
|
0.104
|
|
3 to 6 hours
|
62 (37.6)
|
11 (33.3)
|
13 (29.5)
|
|
7 to 11 hours
|
23 (13.9)
|
1 (3)
|
10 (22.7)
|
|
12 hours
|
53 (32.1)
|
16 (48.5)
|
17 (38.6)
|
|
≥ 24 hours
|
15 (9.1)
|
4 (12.1)
|
1 (2.3)
|
|
What is the frequency of administration of this drug during hospitalization?
|
|
Every 12 hours
|
3 (1.8)
|
2 (6.1)
|
3 (6.8)
|
0.192
|
|
Once a day
|
162 (98.2)
|
31 (93.9)
|
41 (93.2)
|
|
For how long the patient must take this drug during hospitalization?
|
|
1 day
|
3 (1.8)
|
0 (0)
|
0 (0)
|
0.041
|
|
2 days
|
14 (8.5)
|
7 (21.2)
|
8 (18.2)
|
|
3 days
|
9 (5.5)
|
0 (0)
|
1 (2.3)
|
|
Only while the patient cannot walk. When walking is resumed, I terminate the drug
|
0 (0)
|
1 (3)
|
1 (2.3)
|
|
During the whole hospitalization period
|
139 (84.2)
|
25 (75.8)
|
34 (77.3)
|
|
The options you stated above indicate your current practice. Would you prefer another
conduct if you could use other resources/drugs?
|
|
No, I am free to work as I prefer
|
130 (78.8)
|
24 (72.7)
|
35 (79.5)
|
0.778
|
|
Yes, but they are not available at the hospital(s) I work
|
17 (10.3)
|
6 (18.2)
|
4 (9.1)
|
|
Yes, but they are not financed by health insurance providers
|
18 (10.9)
|
3 (9.1)
|
5 (11.4)
|
|
Do you prescribe the same drug used during hospitalization for home treatment after
discharge?
|
|
No
|
112 (67.9)
|
18 (54.5)
|
23 (52.3)
|
0.090
|
|
Yes
|
53 (32.1)
|
15 (45.5)
|
21 (47.7)
|
|
Which new drug do you prescribe for home use?
|
|
Aspirin
|
13 (11.6)
|
0 (0)
|
5 (21.7)
|
0.109
|
|
Apixaban
|
21 (18.8)
|
4 (22.2)
|
5 (21.7)
|
|
Dabigatran
|
6 (5.4)
|
0 (0)
|
0 (0)
|
|
Rivaroxaban
|
72 (64.3)
|
14 (77.8)
|
13 (56.5)
|
|
For how long the patient must use this drug at home?
|
|
1 week
|
3 (1.8)
|
0 (0)
|
1 (2.3)
|
0.482
|
|
10 days
|
49 (29.7)
|
8 (24.2)
|
11 (25)
|
|
2 weeks
|
50 (30.3)
|
16 (48.5)
|
17 (38.6)
|
|
3 weeks
|
31 (18.8)
|
2 (6.1)
|
7 (15.9)
|
|
4 weeks
|
30 (18.2)
|
6 (18.2)
|
8 (18.2)
|
|
> 4 weeks
|
2 (1.2)
|
1 (3)
|
0 (0)
|
|
The options you stated above indicate your current practice. Would you prefer another
conduct if you could use other resources/drugs?
|
|
No, I am free to work as I prefer
|
142 (86.1)
|
24 (72.7)
|
37 (84.1)
|
0.319
|
|
Yes, but the administration route prevents its home use
|
7 (4.2)
|
1 (3)
|
2 (4.5)
|
|
Yes, but the cost would prevent its use by my patients
|
16 (9.7)
|
8 (24.2)
|
5 (11.4)
|
|
Do you prescribe mechanical thromboprophylaxis after total knee replacement?
|
|
No
|
46 (27.9)
|
12 (36.4)
|
14 (31.8)
|
0.596
|
|
Yes
|
119 (72.1)
|
21 (63.6)
|
30 (68.2)
|
|
Graduated compression stockings
|
|
No
|
22 (18.3)
|
2 (9.5)
|
7 (23.3)
|
0.419
|
|
Yes
|
98 (81.7)
|
19 (90.5)
|
23 (76.7)
|
|
Continuous passive motion (CPM) device
|
|
No
|
99 (82.5)
|
21 (100)
|
26 (86.7)
|
0.024
|
|
Yes
|
21 (17.5)
|
0 (0)
|
4 (13.3)
|
|
Fixed pneumatic compression device
|
|
No
|
90 (75)
|
17 (81)
|
25 (83.3)
|
0.552
|
|
Yes
|
30 (25)
|
4 (19)
|
5 (16.7)
|
|
Portable pneumatic compression device
|
|
No
|
115 (95.8)
|
20 (95.2)
|
28 (93.3)
|
0.857
|
|
Yes
|
5 (4.2)
|
1 (4.8)
|
2 (6.7)
|
|
How do you use the device?
|
|
On the operated lower extremity alone
|
15 (12.5)
|
3 (14.3)
|
2 (6.7)
|
0.590
|
|
On both lower extremities
|
105 (87.5)
|
18 (85.7)
|
28 (93.3)
|
|
When do you start the mechanical thromboprophylaxis?
|
|
Before surgery
|
9 (7.5)
|
2 (9.5)
|
0 (0)
|
0.235
|
|
During surgery
|
10 (8.3)
|
3 (14.3)
|
5 (16.7)
|
|
Immediately after the end of surgery
|
73 (60.8)
|
11 (52.4)
|
21 (70)
|
|
A couple of hours after the end of surgery
|
28 (23.3)
|
5 (23.8)
|
4 (13.3)
|
|
The options you stated above indicate your current practice. Would you prefer another
conduct if you could use other resources/drugs?
|
|
No, I am free to work as I prefer
|
92 (76.7)
|
10 (47.6)
|
19 (63.3)
|
0.008
|
|
Yes, but they are not available at the hospital(s) I work
|
10 (8.3)
|
2 (9.5)
|
5 (16.7)
|
|
Yes, but they are not financed by health insurance providers
|
11 (9.2)
|
1 (4.8)
|
1 (3.3)
|
|
Yes, but the device is not available where I work
|
2 (1.7)
|
1 (4.8)
|
0 (0)
|
|
Yes, but the cost would prevent its use by my patients
|
5 (4.2)
|
7 (33.3)
|
5 (16.7)
|
|
Do you stratify your thromboprophylaxis method for knee replacement or do you use
the same routine regimen for all patients?
|
|
I stratify it
|
60 (36.1)
|
7 (21.2)
|
15 (34.1)
|
0.231
|
|
I use the same method for all patients
|
106 (63.9)
|
26 (78.8)
|
29 (65.9)
|
|
Do you follow any guideline regarding a thromboprophylaxis method?
|
|
No
|
57 (34.3)
|
12 (36.4)
|
19 (43.2)
|
0.126
|
|
Yes, 2011 American Academy of Orthopaedic Surgeons (AAOS)
|
24 (14.5)
|
6 (18.2)
|
8 (18.2)
|
|
Yes, 2012 American College of Chest Physicians (ACCP)
|
3 (1.8)
|
3 (9.1)
|
4 (9.1)
|
|
Yes, the guidelines from the hospital I work
|
78 (47)
|
12 (36.4)
|
12 (27.3)
|
|
Yes, 2019 National Institute for Health and Care Excellence (NICE)
|
4 (2.4)
|
0 (0)
|
1 (2.3)
|
Discussion
The present online survey with Brazilian knee surgeons revealed a lack of a national
clinical guideline, resulting in a wide range of thromboprophylaxis practices that
do not comply with international standards. Although the interventions employed and
preferred by orthopedists and the moment of their use vary according to the Brazilian
region, the experience time of the surgeons, and the type of hospitals, they should
be based on scientific evidence. The present study shows that this is the time to
build a rational, evidence-based national guideline to be adopted by both public and
private hospitals.
Thromboprophylaxis remains a frequent practice. Only 3 participants (1.2%) claimed
not to use any method. This percentage is consistent with the one observed in a survey
during the Brazilian Congress of Orthopedics in 2007.[6] Despite the low number of participants denying thromboprophylaxis, we need to discuss
the potential legal implications of its absence since there is international scientific
evidence of its benefit. This discussion would help build a national consensus.
A total of 76% of orthopedists selected a combination of pharmacological and mechanical
prophylaxis, regardless of other variables. As in previous studies,[6]
[7]
[8] the drug most commonly used during hospitalization was enoxaparin, cited by 87%
of the participants. This choice agrees with the American College of Chest Physicians
(ACCP) guidelines, which recommend low molecular weight heparin (LMWH) for thromboprophylaxis
in arthroplasties.[1] The American Academy of Orthopedic Surgeons (AAOS) recommends no particular agent.[2] In 2019, the National Institute for Health and Care Excellence (NICE) from the United
Kingdom recommended one of the following three options: aspirin for 14 days, LMWH
for 14 days combined with anti-embolism stockings until discharge, or rivaroxaban.[9] Therefore, Brazilian surgeons mostly follow the NICE guideline.
The moment to start LMWH is controversial both among participants and the literature.[10]
[11] The ACCP guidelines advocate that LMWH administration should not begin earlier than
12 hours after the end of the surgery and not less than 12 hours before its start.[1] In our survey, 94% of the participants started pharmacological prophylaxis after
surgery, but at different times: most (56%) did it up to 11 hours after arthroplasty,
while ∼ 36% did it 12 hours after surgery, and ∼ 8% did it ≥ 24 hours later. The earlier
onset occurred mainly among more experienced orthopedists (those who completed their
4th year of residency [R4] 21 to 30 years ago). The choice to start prophylaxis 12 hours
after the end of surgery is statistically higher among orthopedists with up to 10
years since R4 completion (knee subspecialty in Brazil), showing greater alignment
with the ACCP guidelines even though they did not declare to follow it in the same
proportion.
About 60% of the participants answered that they change their prescription for home
use, especially those who initially select enoxaparin. The cost and subcutaneous administration
of enoxaparin probably explain this switch. On the other hand, those who prescribe
oral drugs during hospitalization usually maintain them for home use. The most common
prescription for domiciliar use was rivaroxaban, selected by 54% of the participants.
However, 85% of these orthopedists prescribed enoxaparin during hospitalization, maybe
due to the guidelines of the hospital where they work, since 42% report following
them. This preference for enoxaparin and rivaroxaban is consistent with an Australian
study from 2019.[8]
The wide range in the duration of pharmacological prophylaxis in our research mirrors
the uncertainty presented in the literature. The NICE recommends 14 days.[9] The ACCP suggests at least 10 days but recommends 35 days.[1] The AAOS guidelines state that the duration of prophylaxis must be individualized
and discussed by the doctor and the patient.[2] Most participants opted for a 10- or 14-day prescription (28 and 34%, respectively),
and only one-third report stratifying the regimen according to the patient.
Few participants preferred aspirin. In other countries, however, this drug has been
increasingly used.[8]
[12] Because of its low risk of bleeding, easy oral administration, low cost, and prophylactic
action against the main cause of death after arthroplasty (ischemic heart disease)[13], we expected that the adherence to it would be much higher than the 2% observed
in our research. None of the orthopedists who claimed to operate predominantly on
SUS patients prescribes aspirin. Perhaps, the fear of possible medical and legal implications,
mentioned by some in the optional final comments section, explains the low use, although
several studies support it;[14]
[15]
[16]
[17]
[18] in addition, aspirin is accepted as pharmacological prophylaxis by the main guidelines
in the world.[1]
[2]
[9]
Early mobility is the most simple and cheap form of mechanical prophylaxis against
thrombus formation.[19] Studies relating thromboembolism with walking after TKA reveal a significantly lower
incidence of thromboembolic complications in patients walking within 24 hours in comparison
with those starting to walk on the 2nd day.[20]
[21] Improved anesthetic techniques, especially with the advent of ultrasound-guided
adductor canal block, facilitate early walk.[22]
[23] In total, 55% of the participants mentioned spinal anesthesia associated with this
block, but even so, only 38% of them claimed that their patients resume walking within
24 hours postoperatively.
The main mechanical method used by the participants was the graduated compression
stocking (GCM), cited by 82%. The literature, however, does not seem to agree on its
effectiveness.[3]
[4]
[24]
[25]
The ACCP and the AAOS recommend only intermittent pneumatic compression devices (IPCD)
for mechanical prophylaxis.[1]
[2] The ACCP recommends a portable device (which allows walking) for at least 18 hours
a day.[1] However, only 5% of the participants recommended this device, and only 2 of them
prescribed its use for > 18 hours per day. Although it is the mechanical thromboprophylaxis
device most recommended in the literature, the limited availability of these portable
devices in Brazil may partially explain its low use. In Australia, Mirkazemi et al.[8] reported a rate of portable IPCD use of 89.9%. Other guidelines also prefer them
over graduated compressive stockings.[3]
[4] The NICE suggests anti-embolism stockings, but it does not specify which ones.[9] Mechanical prophylaxis was mostly prescribed by participants from the South region,
especially fixed compression devices, which do not allow walking.
Approximately 15% of the participants used CPM devices, statistically less among younger
orthopedists. A meta-analysis conducted by He et al.[26] revealed that these devices are not effective for TKA thromboprophylaxis.
Our study reflects the controversy observed in the literature on the relationship
between tourniquet and thromboembolism in TKA. Among participants, there is no consensus
if tourniquets increase the occurrence of VTE (52 versus 48%). However, 70% of them
used it, even those considering it thrombogenic. Among those who did not believe that
tourniquet increases VTE events, 95% used it. Overall, 82% routinely used a tourniquet,
which is lower than the 93% rate observed in Australia.[8]
As for potential post-TKA complications, the participants were more concerned with
infections than with thromboembolic phenomena. This is consistent with the study of
Mirkazemi et al.[8] Surgeons may believe that the risk of infection is greater because most thromboembolic
events occur after hospital discharge and the incidence of fatal VTE is very low.
In recent years, a trend for thromboprophylaxis individualization has been observed.[8]
[27]
[28] In our research, a third of the participants reported this individualization, which
is statistically more frequent among orthopedists with > 10 years of knee subspecialization.
Further studies are required to confirm this trend.
Although 70% of the respondents said they were free to choose their method, more than
half of those working predominantly in the SUS would like to use a different technique,
but they do not do so mainly because of the cost. This fact reflects the lower financial
availability in this setting. A study from a federal public teaching hospital in Brazil
showed an adherence rate to outpatient thromboprophylaxis after TKA and total hip
arthroplasty of 73%; however, it did not investigate the cost of the drug.[29]
The fact that 42% of the participants follow the guidelines of their hospitals may
explain the wide range of thromboprophylaxis techniques cited here. In addition, 36%
of the participants do not follow any guidelines, which is in line with a study by
Carvalho Júnior et al.[30] These findings should motivate the development of national guidelines on the subject.
We emphasize that only SBCJ members participated in the present research. However,
we know that other orthopedists, not SBCJ members, also perform TKA; including them
could alter our findings. On the other hand, although we invited only SBCJ members
to participate, we cannot assure that the practices and preferences they reported
reflect an official position of the society; the present research is about individual
practices and preferences.
