Current Trends Regarding Perioperative Pharmacological Anticoagulation in Lower Limb Surgeries among Orthopedic Surgeons of Pakistan -An Audit

Abstract:Perioperative anticoagulation has been recommended by AAOS, AACP, and ASH during orthopedic procedures of the lower limb. Guidelines show a difference of opinion regarding the optimum duration and drug of choice giving a way to use different methods of anticoagulation. This audit assessed the preferences for pharmacological anticoagulation in lower limb surgeries among orthopedic surgeons of Pakistan. Materials and Methods: An online questionnaire-based cross-sectional study was started from June-September 2021 in Dr Ruth K.M. Pfau Civil Hospital Karachi where Orthopedic surgeons (n=632) were invited to fill those questionnaires. A total of 85 orthopedic surgeons responded completely. An electronic eight-question survey was designed which included questions about demographics of surgeons, the drug of choice, perioperative duration, preferred surgeries, and average incidence of thromboembolism per year. Results: 12.9% surgeons use anticoagulation for all surgeries while 82.3% of orthopedic surgeons use anticoagulants in selective surgeries. LMWH (94.1%) and Rivaroxaban (17.6%) were the drug of choice for most surgeons. 70.6% of respondents never used anticoagulation preoperatively. 17.7% used it three days preoperatively. 28.24% of surgeons prescribed anticoagulation for 3 days postoperatively while 17.7% of surgeons prescribed anticoagulation for 2 weeks postoperatively. 10.6% of surgeons never used anticoagulation postoperatively. Arthroplasty (71.7%), trauma (55.3%), and pelvis and acetabulum (54.1%) were the subspecialties with routine anticoagulation. 81.2% and 17.7% of surgeons reported less than 1% and 1% to 3% incidence of thromboembolism, respectively. No surgeon reported any incidence of thromboembolism above 5%. Conclusion: Use of anticoagulation is prevalent among orthopedic surgeons in Pakistan. However, significant differences are observed regarding the perioperative duration. The surgeons need to prescribe DOAC such as Rivaroxaban and Dabigatran as agents of choice while extended postoperative pharmacological anticoagulation of 28-35 days needs to be adopted.