Asia-Pacific venous thromboembolism consensus in knee and hip arthroplasty and hip fracture surgery: Part 1. Diagnosis and risk factors

Postoperative venous thromboembolism (VTE) is a significant cause of morbidity and mortality in patients undergoing knee and hip arthroplasty and hip fracture surgery; however, VTE is considered potentially preventable with several modalities of prophylactic management [ 1 , 2 ]. The VTE prevention guidelines by the American Academy of Orthopaedic Surgeons (AAOS) or the American College of Chest Physicians (ACCP) have been implemented in most countries in Asia [ 3 , 4 , 5 ]. However, according to these guidelines, there are some concerning issues and complications related to VTE prophylaxis in major joint replacement and hip fracture surgeries because of differences in the healthcare systems and cultural aspects [ 6 , 7 ]. Among orthopedic surgeons who practice in the Asia-Pacific (AP) Region, some alternative options for VTE prevention in knee and hip arthroplasty and hip fracture surgery are somewhat necessary. These Asian-specific guideline/consensus statements are expected to provide better patient outcomes and compliances. Therefore, in a one-year period, we have obtained an AP consensus agreement on VTE prophylaxis in knee and hip arthroplasty and hip fracture surgery in Asian patients among AP orthopedic experts. According to the results of the consensus statements, some accepted methods of VTE prophylaxis are different from those published in international guidelines regarding the details of diagnosis and risk factors and methods of prophylaxis. We hope that this AP VTE consensus will provide orthopedic surgeons who practice in the AP Region appropriate options for VTE diagnosis and prevention methods that benefit their patients with fewer complications. The consensus was instructed using the modified Delphi method for agreement [ 8 , 9 ]. The working team used a real-time Delphi multiround online software ( https://calibrum.com ), responding anonymously [ 10 ]. After receiving agreement of 93 AP orthopedic experts to join the group, all experts were divided into three groups, including group 1: diagnosis and risk factors; group 2: mechanical VTE prophylaxis; and group 3: pharmacological VTE prophylaxis (Fig. 1 ). Demonstration of method and procedures for formation of AP venous thromboembolism consensus The first-round real-time online survey was begun on 18 October 2019. There were four rounds of the survey and an additional round for consensus voting. The consensus was successfully finished on 11 September 2020. In each round, experts could repeatedly view and comment on documents via the Internet until the end of the survey time. Based on evidence-based medicine and experts opinions, the five-round survey has optimized AP experts’ agreement on debatable issues in VTE prophylaxis in knee and hip arthroplasty and hip fracture surgery before consensus voting, in terms of statements, recommendations, justifications, and references. Given the approximately one-month period of each round, all experts could have several opportunities to access the survey for the online response. All statements in the survey were accompanied by a text box allowing comments in qualitative responses to be made anonymously. Besides open comments, experts were requested to rate their agreement on each statement according to a Likert scale of 1–9, (1 = strongly disagree, 9 = strongly agree) [ 11 ]. After closing of the survey in each round, the working team and assistants read the responses for all statements, including comments or suggestions, and also searched out more evidence-based medicine data-related commented issues. For agreement evaluation, all statements were assessed into three categories: (1) Agreement: Likert 7, 8, and 9; (2) Neutral: Likert 4, 5, and 6; and (3) Disagreement: Likert 1, 2, and 3. All passed statements needed to have ≥75% agreement from voters [ 9 ]. Any statements having < 75% agreement were to be reviewed, revised, and resubmitted in the next round of the survey. Again, all AP experts were asked for agreements and comments until the final round (Fig. 2 ) [ 9 ]. After four rounds of surveys, all passed statements were finally sent for online voting [ 9 ]. The criteria of voting for consensus were as follows: (1) Unanimous consensus: 100% agreement; (2) Strong consensus: ≥ 75% agreement; (3) Weak consensus: > 50%, < 75% agreement [ 9 ]. Algorithm demonstrating four-round consensus survey using modified Delphi method and the final voting for consensus