The International Consensus Meeting for orthopedic infections is a rigorous effort that unites global experts to debate and vote on statements that will form the basis for new or enhanced clinical guidelines.
Becker's Healthcare recently spoke with Javad Parvizi, MD, James Edward Professor of Orthopedic Surgery at Sidney Kimmel School of Medicine and Rothman Institute in Philadelphia, about a new consensus statement related to blood clot prevention intended to improve patient outcomes and reduce healthcare costs.
Note: Responses have been edited for length and clarity.
Question: Many guidelines for blood clot prevention exist. What's the significance of this new ICM consensus statement?
Dr. Javad Parvizi: Numerous organizations worldwide have created guidelines related to the issue of venous thromboembolism in orthopedics. Given the imperfect data available on VTE, it's not surprising that the medical community has criticized these guidelines on some grounds.
Many guidelines limit their scope to specific surgical procedures like total hip and knee replacements. Others fail to recognize the importance of variations in geographic and racial predisposition to VTE. Almost all attempt to create recommendations by relying either preferentially or exclusively on high-level studies. The latter strategy has resulted in inclusion of studies conducted by pharmaceutical companies to satisfy regulatory requirements for approval of new chemoprophylaxis agents for clinical use. These studies often evaluate the difference in the incidence of distal deep veinous thrombosis as detected by venography, rather than clinically important VTE or the now rare fatal pulmonary embolus which is the real concern for the medical community and patients alike. Other guidelines overlook the complications that can arise as a result of administering some of these agents. Many of these complications result in immense expense and can lead to fatality.
The International Consensus Meeting recognized the limitations of the current guidelines and the need for unbiased randomized trials with clinically important endpoints. In response, a group of experts convened to generate guidelines or recommendations that address the real-world issues.
Q: There are numerous outcomes from the consensus statement work. What are the top few findings you would highlight?
JP: This initiative produced a compendium that encompasses 200 questions and topics related to all surgical subspecialties in orthopedics, not just joint replacement. Each question offers important clinical information to improve patient care. There are several important highlights. The first is that for the majority of surgical procedures, aspirin and intermittent pneumatic compression devices (IPCs) may be adequate. In addition, it's become clear that genetic and racial predispositions influence VTE. Recognizing genetic factors may help us tailor VTE prophylaxis accordingly. It's also become apparent that no validated or appropriate risk stratification systems exist for VTE or bleeding.
Q: What did you and the team leading the consensus statement learn in the process of developing it?
JP: To develop the consensus statement, delegates from 135 international societies, 68 countries and various specialties including anesthesia, cardiology, hematology, internal medicine and orthopedics combed through the literature in a systematic review format. They created practical recommendations related to all the subspecialties in orthopedics that would also have global applications. Nearly 600 experts followed the strict Delphi process, as in prior ICM activities, to generate this monumental document. Over one year, the group reviewed all published work related to VTE and orthopedics to generate responses and recommendations to the nearly 200 issues collated from the field.
We learned little to no evidence exists related to VTE after most orthopedic procedures. We also discovered that surgical procedures have changed over the years, with emphasis on early mobilization of patients and less invasive surgical and anesthesia techniques.
Q: What have you heard from the experts about the work you're doing?
JP: The reception from the medical community in general and orthopedic surgeons in particular has been amazing. All 135 societies are interested in disseminating the document through their websites and annual meetings. In addition, delegates want to translate the document into 18 languages.
Q: What do you think will be the result of the consensus statement work? What do you hope will change for the better?
JP: The new guidelines are applicable to patients worldwide undergoing every orthopedic procedure. We believe the recommendations will reduce mortality, complications and the costs associated with subsequent episodes of care. With patients undergoing joint replacement, for example, the administration of aspirin and IPC, instead of aggressive anticoagulation, has been shown to reduce mortality, readmission, reoperation, postoperative fever, loosening of implants, stiffness, wound discharge, periprosthetic joint infection and more. The implementation of the global guidelines and recommendations will result in enormous cost savings for the healthcare sector.