American Society of Hematology 2019 guidelines for management of venous thromboembolism : prevention of venous thromboembolism in surgical hospitalized patients

Background: Venous thromboembolism (VTE) is a common source of perioperative morbidity and mortality. Objective: These evidence-based guidelines from the American Society of Hematology (ASH) intend to support decision making about preventing VTE in patients undergoing surgery. Methods: ASH formed a multidisciplinary guideline panel balanced to minimize bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline-development process, including performing systematic reviews. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. Results: The panel agreed on 30 recommendations, including for major surgery in general (n = 8), orthopedic surgery (n = 7), major general surgery (n = 3), major neurosurgical procedures (n = 2), urological surgery (n = 4), cardiac surgery and major vascular surgery (n = 2), major trauma (n = 2), and major gynecological surgery (n = 2). Conclusions: For patients undergoing major surgery in general, the panel made conditional recommendations for mechanical prophylaxis over no prophylaxis, for pneumatic compression prophylaxis over graduated compression stockings, and against inferior vena cava filters. In patients undergoing total hip or total knee arthroplasty, conditional recommendations included using either aspirin or anticoagulants, as well as for a direct oral anticoagulant over low-molecular-weight heparin (LMWH). For major general surgery, the panel suggested pharmacological prophylaxis over no prophylaxis, using LMWH or unfractionated heparin. For major neurosurgery, transurethral resection of the prostate, or radical prostatectomy, the panel suggested against pharmacological prophylaxis. For major trauma surgery or major gynecological surgery, the panel suggested pharmacological prophylaxis over no prophylaxis.Peer reviewe

2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/137753/1/acr23274.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/137753/2/acr23274_am.pd

2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/137769/1/art40149.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/137769/2/art40149_am.pd

Postoperative prophylactic antibiotics in total joint arthroplasty

The Center for Disease Control and Prevention recently released their 2017 Guideline for the Prevention of Surgical Site Infection. One of their recommendations is the ordering of a single dose of preoperative prophylactic antibiotics with no subsequent postoperative dosing; this recommendation includes perioperative antibiotics for patients undergoing total joint arthroplasty. At this time, the American Association of Hip and Knee Surgeons (AAHKS) does not agree with this recommendation vis-a-vis total joint arthroplasty because it contradicts current international standards of care with limited evidence and study. AAHKS still recommends postoperative antibiotics and recommends further research. Both the Board of Counselors and Board of Specialty Societies of the American Academy of Orthopaedic Surgeons have endorsed this AAHKS recommendation through an advisory opinion; the American Academy of Orthopaedic Surgeons Board of Directors adopted that advisory opinion in June 2017. A 2017 Foundation for Arthroplasty Research and Education prospective, randomized study is being undertaken to provide level I evidence for or against single-dose vs 24-hour antibiotic prophylaxis in primary total knee arthroplasty. Keywords: Total joint arthroplasty, Antibiotics, Prophylaxis, Surgery, Infectio

Measuring the attitudes and impact of the eighty-hour workweek rules on orthopaedic surgery residents.

BACKGROUND: The literature on graduate medical education contains anecdotal reports of some effects of the new eighty-hour workweek on the attitudes and performance of residents. However, there are relatively few studies detailing the attitudes of large numbers of residents in a particular surgical specialty toward the new requirements. METHODS: Between July and November 2004, a survey created by the Academic Advocacy Committee of the American Academy of Orthopaedic Surgeons was distributed by mail, fax, and e-mail to a total of 4207 orthopaedic residents at the postgraduate year-1 through year-6 levels of training. The survey responses were tabulated electronically, and the results were recorded. RESULTS: The survey response rate was 13.2% (554 residents). Sixty-eight percent (337) of the 495 respondents whose postgraduate-year level was known were at the postgraduate year-4 level or higher. Attitudes concerning the duty rules were mixed. Twenty-three percent of the 554 respondents thought that eighty hours constituted an appropriate number of duty hours per week; 41% believed that eighty hours were too many, and 34% thought that eighty hours were not sufficient. Thirty-three percent of the respondents had worked greater than eighty hours during at least a single one-week period since the new rules were implemented; this occurred more commonly among the postgraduate year-3 and more junior residents. Orthopaedic trauma residents had the most difficulty adhering to the new duty-hour restrictions. Eighty-two percent of the respondents indicated that their residency programs have been forced to make changes to their call schedules or to hire ancillary staff to address the rules. The use of physician assistants, night-float systems, and so-called home-call assignments were the most common strategies used to achieve compliance. CONCLUSION: Resident attitudes toward the work rules are mixed. The rules have forced residency programs to restructure. Junior residents have more favorable attitudes toward the new standards than do senior residents. Self-reporting of duty hours is the most common method of monitoring in orthopaedic training programs. Such systems allow ample opportunity for inaccuracies in the measurement of hours worked. Although residents report an improved quality of life as a result of these new rules, the attitude that the quality of training is diminished persists

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective.

OBJECTIVE: To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS: We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS: The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION: This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations