Sports Med DOI 10.1007/s40279-013-0121-2

REVIEW ARTICLE

Venous Thromboembolism Following Arthroscopic Knee Surgery: A Current Concepts Review of Incidence, Prophylaxis, and Preoperative Risk Assessment William C. Graham • David C. Flanigan

Ó Springer International Publishing Switzerland 2013

Abstract The purpose of this review was to compile existing knowledge regarding venous thromboembolism (VTE) after arthroscopic knee surgery (AKS). We reviewed the reported incidence, published prophylaxis guidelines, randomized controlled trials (RCT) of prophylaxis, and current prophylaxis practice patterns. In this context we then considered the most appropriate VTE risk assessment model for patients undergoing knee arthroscopy. The existing body of literature regarding VTE and AKS reports a wide range of incidence, often utilizing primary outcome measures with unclear clinical significance: asymptomatic and distal deep vein thrombosis (DVT). Published prophylaxis guidelines provide limited practical guidance and it is unclear how to translate the results of RCTs to clinical practice, as many of the VTE prevented by routine prophylaxis are asymptomatic or distal DVT. Literature regarding actual implementation of pharmacologic prophylaxis following AKS suggests that no consensus exists. Patients undergoing knee arthroscopy would be best managed with the individual model of VTE risk assessment rather than the group model that is applied to hip and knee arthroplasty patients.

1 Introduction A 1992 review of complications after arthroscopic knee surgery (AKS) reported that venous thromboembolism (VTE) was the most common cause of perioperative

W. C. Graham  D. C. Flanigan (&) Department of Orthopaedics, OSU Sports Medicine Center, The Ohio State University, 2050 Kenny Road, Suite 3100, Columbus, OH 43221-3502, USA e-mail: [email protected]

mortality following knee arthroscopy [1]. Numerous reports of pulmonary embolism (PE) after AKS have been published [2–22], ten of which describe at least one mortality [4, 6, 8–12, 15, 16, 19]. VTE accounts for 7–30 % of all complications following AKS [6, 23]. Despite the relatively low overall complication rate for AKS, estimated to be 1–2 % by surgeon recall [23, 24] and 5–8.2 % as determined by retrospective review [6, 25], the millions of knee arthroscopies performed annually [8, 26, 27] ensure that the total number of thromboembolic complications after AKS is not insignificant. A 2011 study by Nguyen et al. identified more than 3,500 patients with a thromboembolic complication following AKS in the United States over a 3-year period [28]. This report likely understates the problem as it was isolated to patients 65 years and older, and only investigated patients undergoing arthroscopic meniscectomy. The purpose of this review was to examine and compile the existing literature describing VTE after AKS and to use the available information to consider the best VTE risk assessment model for use in preoperative evaluation of patients undergoing knee arthroscopy. Studies reporting an incidence of VTE, PE, or deep vein thrombosis (DVT) following AKS have been summarized. Published national and international guidelines for the use of pharmacologic thromboprophylaxis after AKS are reviewed, as well as randomized controlled trials (RCT) of prophylaxis after AKS. Published descriptions of actual practice patterns are included. Literature regarding the clinical significance of distal and asymptomatic DVT and different VTE risk assessment models was also evaluated. Of note, the majority of the literature describing VTE and AKS focuses on DVT rather than PE or all VTE. A comprehensive review was performed to compile the existing literature regarding VTE and AKS. The PubMed

W. C. Graham, D. C. Flanigan

and MEDLINE databases were searched on June 4, 2012, and again on June 5, 2012, to ensure accuracy, with the key terms ‘venous thromboembolism,’ ‘VTE,’ ‘deep vein thrombosis,’ ‘DVT,’ ‘pulmonary embolism,’ ‘PE,’ ‘arthroscopic knee surgery,’ and ‘knee arthroscopy.’ This search strategy produced 114 hits. First stage screening of titles and abstracts to exclude unrelated articles yielded 61 articles for full text review. Bibliographies of these articles were manually searched for additional studies not identified by the initial search strategy and 17 additional articles were found. The following inclusion criteria were applied to the 82 articles reviewed in full: reports of PE after AKS, studies reporting an incidence of VTE, PE, or DVT after AKS, and articles or studies attempting to define the role of pharmacologic thromboprophylaxis after AKS. Commentary and opinion were excluded. Three case reports of VTE after AKS in patients with known heritable thrombophilias were excluded, and two case series of patients receiving pharmacologic thromboprophylaxis after AKS without control groups were excluded. This algorithm, detailed in Fig. 1, identified 56 articles which were used to construct this review. Literature regarding the clinical significance of Fig. 1 Diagram of the research methodology. AKS arthroscopic knee surgery, LMWH lowmolecular-weight heparin, VTE venous thromboembolism

distal DVT and asymptomatic DVT was also reviewed, as well as literature regarding VTE risk assessment.

2 The Incidence of Venous Thromboembolism After Knee Arthroscopy Literature describing the incidence of VTE after AKS can be divided into two categories: large retrospective studies reporting only symptomatic events and small prospective investigations identifying both symptomatic and asymptomatic thromboembolic events. Retrospective reviews by design inherently use only symptomatic DVT and symptomatic PE as primary outcome measures. In contrast, the prospective studies employ routine screening of all included patients with ultrasonography, phlebography, or magnetic resonance venography, thus reporting all DVT, both symptomatic and asymptomatic, as the primary outcome measure. Tables 1, 2, 3 summarize 26 studies reporting an incidence of VTE, PE, or DVT after AKS. Including asymptomatic DVT has a notable effect when considering the relationship between VTE and AKS.

VTE Following Knee Arthroscopy Table 1 Retrospective reviews reporting the incidence of VTE after arthroscopic knee surgery References

n

Savarese et al. [32]

790

Hoppener et al. [31]

Arthroscopic procedures

DVT incidence (symptomatic) (%)

Not documented

1.2

PE incidence (symptomatic) (%)

82

Not documented

3.7

Morgan et al. [29]

12,595

Not documented

0.30

0.06

Nguyen et al. [28]

314,578

Meniscectomy

0.8

0.3

Jameson et al. [11]

301,701

Meniscal repair

0.12

0.08

VTE incidence (symptomatic) (%)

0.19

Meniscectomy Chondroplasty Ligament reconstruction Loose body removal Abrasion arthroplasty Other Hetsroni et al. [10]

418,323

0.03

Meniscal repair Meniscectomy ACL reconstruction Chrondroplasty Synovectomy Debridement

Maletis et al. [15]

20,770

Meniscal repair

0.25

0.17

0.4

0.3

0.18

0.44

Meniscectomy Synovectomy Debridement Ligament reconstruction Lateral release Jameson et al. [30]

13,941

ACL reconstruction

ACL anterior cruciate ligament, DVT deep vein thrombosis, PE pulmonary embolism, VTE venous thromboembolism

Table 2 Prospective cohorts included in analysis References

n

Stringer et al. [35] Williams et al. [33]

48 85

Roth et al. [37]a

61

Cullison et al. [45] Durica et al. [42] Demers et al. [44]

67 190 184

Schippinger et al. [36]

101

Jaureguito et al. [41]

239

Arthroscopic procedures Not documented Included ligament reconstruction Other procedures not specified Meniscectomy Chondroplasty Synovectomy Loose body removal ACL reconstruction Not documented Diagnostic arthroscopy Ligament reconstruction Meniscectomy Chondroplasty Other Excluded ligament reconstruction Included procedures not specified Included ligament reconstruction Included osteotomies Other procedures not specified

DVT incidence (all) (%)

PE incidence (all) (%)

4.2 3.5

PE incidence (symptomatic) (%)

VTE incidence (all) (%)

0.0 0.0

8.2

1.5 3.2 17.9

7.9 2.9

0.0 0.0

8.9

1.0 0.0

11.8

W. C. Graham, D. C. Flanigan Table 2 continued References

n

Arthroscopic procedures

Delis et al. [43]

102

Wirth et al. [34]a

122

Michot et al. [39]a

64

Canata and Chiey [47]a Ng et al. [38]

18 84

Lavage Meniscectomy Plica removal Lateral release Chondroplasty Cyst decompression Meniscectomy Chondroplasty Debridement Loose body removal Diagnostic arthroscopy Meniscectomy Chondroplasty Loose body removal Other ACL reconstruction Meniscectomy Chondroplasty Meniscal repair Ligament reconstruction Other Excluded ligament reconstruction Included procedures not specified Not documented ACL reconstruction Meniscectomy Chondroplasty Debridement Ligament reconstruction

Hoppener et al. [31]

335

Ettema et al. [25] Marlovits et al. [40]a Camporese et al. [46]a

69 68 660

DVT incidence (all) (%)

PE incidence (all) (%)

PE incidence (symptomatic) (%)

VTE incidence (all) (%)

7.84

4.1

0.0

15.6

0.0

0 1.1

5.7

0.3

4.4 41.2 4.4

1.4 0.0 0.3

a

Represents DVT incidence in control groups of studies evaluating the effect of pharmacologic thromboprophylaxis on the incidence of DVT following AKS. ACL anterior cruciate ligament, AKS arthroscopic knee surgery, DVT deep vein thrombosis, PE pulmonary embolism, VTE venous thromboembolism

Table 3 Meta-analysis included in review of literature References

n

Arthroscopic procedures

DVT incidence (%)

Ilahi et al. [49]

684

Excluded ligament reconstruction

9.9

Analysis included Williams et al. [33], Durica et al. [42], Demers et al. [44], Delis et al. 43], Wirth et al. [34], and Michot et al. [39]. DVT deep vein thrombosis

Six large retrospective reviews of VTE after AKS have been published, all placing the incidence of symptomatic DVT or PE after AKS at less than 1 % [10, 11, 15, 28–30]. These studies, reporting on 12,595–418,323 patients, found the incidence of symptomatic DVT to be 0.12–0.8 % and the incidence of symptomatic PE to be 0.03–0.3 %. Two smaller retrospective studies describing VTE after AKS have also been published. These studies, powered comparably to the prospective studies of VTE and AKS, report on 82 patients [31] and 790 patients [32] and found a symptomatic DVT rate of 3.7 and 1.2 %, respectively.

Prospective evaluations of the relationship between VTE and AKS have yielded markedly different results. Seventeen prospective studies have been published, reporting an incidence of DVT after AKS of 0–41.2 % [25, 33–47]. These are all smaller studies (n = 18–660) which employed routine screening of all patients for DVT, thus detecting both symptomatic and asymptomatic thrombi. Marlovits et al. [40] found a 41.2 % incidence of DVT after anterior cruciate ligament (ACL) reconstruction using routine magnetic resonance venography (MRV), a screening method associated with a higher rate of false positives

VTE Following Knee Arthroscopy

than ultrasound or phlebography [48]. Treating the results of Marlovits et al. as an outlier, the range of DVT reported by the prospective cohorts becomes 0–17.9 %. Heterogeneous patient populations, different inclusion and exclusion criteria, and different diagnostic methodology precluded some of these prospective cohorts from inclusion in a 2005 meta-analysis of DVT after AKS [49]. However Ilahi et al. [49] were able to include 684 patients and found a 9.9 % incidence of all DVT, both symptomatic and asymptomatic, following AKS. The potential consequences of DVT include discomfort from symptomatic DVT, post-thrombotic syndrome (PTS), and PE [50]. The relationship between symptomatic and proximal DVT and these morbidities is well defined; however, the clinical significance of asymptomatic DVT and distal DVT is debatable. Looking more closely at the characteristics of the individual DVT reported in this body of literature finds that, in prospective studies of DVT after AKS, a majority of the thrombi are asymptomatic, and a majority are distal. Twelve of the 17 prospective cohorts reported the specific location of the DVT detected [25, 33– 35, 38, 39, 41–44, 46]. There were 126 DVT detected in these 12 studies and 79 % (100/126) were distal. In contrast, retrospective reviews only report symptomatic events, and the majority of DVT identified are proximal. Maletis et al. [15] retrospectively reported on 51 DVT after AKS, with 88 % being proximal and only 12 % distal. Ten of the prospective studies specifically reported whether patients with thrombi were symptomatic [25, 33, 34, 36, 39, 41, 43, 44, 46]. Of the 125 DVT reported in these 10 studies, only 39 % (49/125) were symptomatic. The clinical ambiguity surrounding asymptomatic DVT is highlighted by close examination of the 9th edition of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines for Antithrombotic Therapy and Prevention of Thrombosis (AT9). Across all areas of medicine, not just with respect to orthopaedic-associated VTE, AT9 contains more changes from the preceding edition (AT8) than between any two previous iterations of the guidelines [51]. Underlying many of these changes is a new focus by the authors of AT9 to emphasize whether existing VTE literature uses only symptomatic DVT or both asymptomatic and symptomatic DVT as the primary outcome measure [51]. In considering the quality and value of available evidence regarding VTE treatment and prophylaxis, AT9 defined symptomatic DVT as a ‘‘patientimportant’’ event [51]. Asymptomatic DVT is defined as a ‘‘fundamentally unsatisfactory’’ outcome on which to base VTE treatment and prophylaxis recommendations due to ‘‘lack of knowledge about the consequences of asymptomatic thrombi’’ [51]. Yet, while AT9 highlights the distinction between asymptomatic and symptomatic DVT, AT9 also proceeds to recommend the same treatment for an

incidentally discovered asymptomatic DVT as is recommended for a symptomatic DVT [52]. This recommendation makes clear that while the morbidity of the two may not be equivalent, morbidity remains possible in either case. With regard to the clinical significance of distal DVT, there is more data available, but as with asymptomatic DVT there are no definitive conclusions. The value of committing resources to the diagnosis of distal DVT is debated [53, 54], and furthermore, the necessity to treat distal DVT remains controversial [53, 54]. Close examination of the same data [55] has been used by some authors as the basis for recommending aggressive treatment with 3 months of anticoagulation [52], and by others to suggest that distal DVT does not pose significant risk [56]. The argument that distal DVT poses limited risk to the patient is supported by outcome studies that show little difference between only screening the proximal venous system compared with screening the entire lower extremity. When looking at all patients presenting with symptoms of DVT, the cumulative 3-month risk of a thromboembolic event when only the proximal venous system is screened is 0.6 %. Evaluating the venous system of the entire lower extremity only decreases that risk to 0.4 % [56]. With respect to valvular incompetence and PTS, a 3-year follow-up study demonstrated that 30 % of patients with isolated calf vein thrombi develop reflux, but only 5 % reported symptoms of PTS [57]. A direct relationship between reflux isolated to a calf vein and severe PTS with ulceration has not been established [53]. The counter argument, that distal DVT are clinically significant, begins simply with natural history. The prevailing theory is an ascending thrombosis; distal DVT begets proximal DVT [18]. The rate of clot progression is, however, unclear. Reviews have estimated that anywhere from 0 to 40 % of distal DVT propagate into the proximal venous system [56, 58, 59]. More concerning evidence of the potential morbidity of distal DVT comes from autopsy series showing 13–15 % of PE originating from distal DVT [60, 61]. The American College of Chest Physicians (ACCP) recommended that distal DVT be treated with the same regimen as proximal DVT in AT8 [52]. In AT9 the ACCP states that patients can choose between anticoagulation and 2 weeks of serial ultrasounds to monitor for clot progression [62]. Some distal DVT are probably benign, but at present no risk factors have been found which could be used to identify those distal DVT capable of progressing to significant morbidity or mortality [58, 63]. The existing body of literature describing the relationship between VTE and AKS reveals an incidence of clinically significant DVT to be 0.12–0.8 % and clinically significant PE to be 0.03–0.3 %. It is also evident that as many as 10 % of patients will experience a subclinical thromboembolic event after AKS, the significance of which, at present, is not understood.

W. C. Graham, D. C. Flanigan

3 Pharmacologic Thromboprophylaxis After Knee Arthroscopy: National and International Guidelines Guidelines for prescribing pharmacologic thromboprophylaxis after AKS have been issued by seven national and international organizations (Table 4) [26, 27, 64, 65]. The ACCP provided recommendations specific to knee arthroscopy in AT8 and again in AT9. In both versions the ACCP recommend against routine use of pharmacologic thromboprophylaxis following AKS, noting that AKS is usually minor surgery in mobile patients [26, 27]. In AT8 the ACCP recommended thromboprophylaxis with lowmolecular-weight heparin (LMWH) after AKS in patients at higher risk, secondary to patient-specific risk factors or after a prolonged or complicated procedure [26]. With AT9 the ACCP simplified their recommendation, encouraging pharmacologic prophylaxis only in the setting of a patient with personal history of a DVT [27]. The French Society for Anaesthesiology and Intensive Care (SFAR), the Cardiovascular Disease Educational and Research Trust (ICS), and the Czech Medical Association recommend pharmacologic prophylaxis in the presence of patient-specific risk factors [64, 65]. The Scottish Intercollegiate Guidelines Network (SIGN) and a Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV) simply recommend no prophylaxis [64]. The Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) does not recommend routine prophylaxis after diagnostic arthroscopy, but does recommend use of LMWH for a minimum of 7 days following surgical knee arthroscopy [66]. The Czech Medical Association recommends routine

use of LMWH for 3 weeks specifically following arthroscopic-assisted ACL reconstruction [65]. Published guidelines for VTE prophylaxis after AKS provided limited practical guidance. Seven national or international organizations have produced five different recommendations. Four organizations reference patientspecific risk factors without further direction as to which factors or combination of factors incur sufficient risk to merit prophylaxis. Complicated arthroscopic procedures are suggested to place the patient at risk, but again further definition of this caveat is not provided. The importance of considering each patient’s unique presentation has been reiterated by each organization.

4 Pharmacologic Thromboprophylaxis After Knee Arthroscopy: Randomized Controlled Trials Six randomized controlled trials (Table 5) evaluating the effect of routine pharmacologic thromboprophylaxis after AKS have been published. Four examined the use of LMWH after all AKS [34, 37, 39, 46], and two specifically after ACL reconstruction [40, 47]. Wirth et al. [34] and Camporese et al. [46, 67] demonstrated reduction of the relative risk of DVT after AKS by 60–80 % with LMWH. Michot et al. [39] also demonstrated a statistically significant reduction in the number of DVT after AKS with routine use of LMWH. Forty-four DVT were identified in the untreated control groups from the above three studies, 81 % (36/44) of which were distal, and 61 % (27/44) of which were asymptomatic.

Table 4 Guidelines for VTE prevention after AKS published by national and international organizations Organization

Recommendation

The American College of Chest Physicians: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed (2012) [27]

Pharmacologic prophylaxis is not recommended unless the patient has a history of a DVT

The American College of Chest Physicians: Antithrombotic Therapy and Prevention of Thrombosis, 8th ed (2008) [26]

Pharmacologic prophylaxis is recommended for patients at higher risk or after a prolonged or complicated procedure

French Society for Anaesthesiology and Intensive Care [64]

Pharmacologic prophylaxis recommended only in the presence of patient-specific risk factors

Cardiovascular Disease Educational and Research Trust [64]

Pharmacologic prophylaxis recommended only in the presence of patient-specific risk factors

Scottish Intercollegiate Guidelines Network [64] Sociedade Brasileira de Angiologia e Cirurgia Vascular [64]

No prophylaxis recommended No prophylaxis recommended

Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften [66]

No prophylaxis recommended following diagnostic AKS, minimum of 7 days of LMWH following surgical AKS

Czech Medical Association [65]

5–7 days of LMWH for patients with VTE risk factors or tourniquet time [60 min 3 weeks of LMWH for arthroscopic-assisted ACL reconstruction

ACL anterior cruciate ligament, AKS arthroscopic knee surgery, DVT deep vein thrombosis, LMWH low-molecular-weight heparin, VTE venous thromboembolism

VTE Following Knee Arthroscopy Table 5 Randomized controlled trials of VTE prophylaxis with LMWH after AKS

References

AKS arthroscopic knee surgery, DVT deep vein thrombosis, LMWH low-molecular-weight heparin, VTE venous thromboembolism

Control

DVT control (%)

DVT LMWH (%)

Roth et al. [37]

61

61

5 (8.2)

1 (1.6)

Wirth et al. [34]

122

117

5 (4.1)

1 (0.9)

Michot et al. [39]

64

66

10 (15.6)

1 (1.5)

Canata and Chiey [47]

18

18

Marlovits et al. [40]

68

72

28 (41.2)

2 (2.8)

660

657

29 (4.4)

10 (1.5)

Camporese et al. [46]

Given that the majority of the thrombi prevented in these studies are of unclear clinical significance, it is not surprising that the response to these RCTs has been mixed. After demonstrating a 60 % relative risk reduction in VTE after AKS with a 7-day course of LMWH, Camporese et al. [46, 67] strongly recommend routine use of pharmacologic thromboprophylaxis following AKS, and they are not alone [25, 68, 69]. Yet many authors, including those from a Cochrane review of VTE prophylaxis after AKS 70], do not advocate routine thromboprophylaxis following AKS [18, 25, 38, 49, 71–74]. While these RCTs may not definitively clarify the role of VTE prophylaxis after AKS, they do provide evidence regarding the safety of using LMWH after AKS. Four of the six studies reported bleeding events (Table 6), though the authors’ definitions of minor and major bleeding episodes varied. Local or minor bleeding defined as injection site bleeding, wound hematoma, or hemarthrosis not requiring intervention occurred in 2.5–12 % of patients receiving prophylaxis with LMWH. Systemic or major bleeding events defined as minor gastrointestinal bleeding, hemarthrosis requiring drainage, or intracranial or retroperitoneal bleeds occurred in 0–0.9 % of patients receiving prophylaxis with LMWH.

Table 6 Randomized controlled trials reporting on the safety of VTE prophylaxis with LMWH following AKS References

Treated with LMWH

Wirth et al. [34]

117

4 (3.4)

1 (0.85)

Michot et al. [39]

66

8 (12)

0

Local or minor bleeding events n (%)

a

Systemic or major bleeding events n (%)

Marlovits et al. [40]

72

13 (2.5)

0

Camporese et al. [46]

657

23 (3.5)

6 (0.9)

a

LMWH

Reported 13 minor bleeding events per 513 total injections

AKS arthroscopic knee surgery, LMWH low-molecular-weight heparin, VTE venous thromboembolism

0 (0)

0 (0)

5 Pharmacologic Thromboprophylaxis After Knee Arthroscopy: Current Practice Patterns Published accounts of actual clinical implementation of pharmacologic thromboprophylaxis after AKS demonstrate wide-ranging practice patterns. Prophylaxis with LMWH is standard perioperative management of patients undergoing outpatient AKS in Germany [75]. Routine use was reported by 96 % of respondents in a survey of the German Association of Outpatient Arthroscopy (BVASK) [75]. A survey of 14 Swiss hospitals found that 73 % of patients discharged after surgical knee arthroscopy were prescribed pharmacologic thromboprophylaxis [65]. In the Netherlands, approximately 60 % of patients undergoing outpatient AKS receive routine pharmacologic thromboprophylaxis [31]. A 2009 survey of 134 members of the Arthroscopy Association of North America (AANA) found only 31 % of respondents routinely use pharmacologic thromboprophylaxis following AKS [76]. When specifically addressing thromboprophylaxis after cruciate ligament reconstruction, 44 % of AANA members surveyed reported routinely using pharmacologic prophylaxis [76]. Data from the Scandinavian ACL registries provide further evidence of varied practice patterns as 17 % of patients in Denmark, 41 % in Sweden, and 78 % in Norway received pharmacologic thromboprophylaxis [77]. Only two of these reports provided details on duration of treatment. When patients in the Netherlands undergoing outpatient AKS received pharmacologic thromboprophylaxis it was usually in the form of a single dose of LMWH [31]. In contrast, patients discharged from Swiss hospitals following surgical knee arthroscopy received extended pharmacologic thromboprophylaxis for 9–37 days [78].

6 Preoperative Venous Thromboembolism Risk Assessment: Applying the Individual Model to Knee Arthroscopy VTE risk assessment for both medical and surgical patients follows one of two models, group or individual [79]. The group model is exemplified by guidelines presenting standardized prevention regimens for all patients undergoing a

W. C. Graham, D. C. Flanigan

specific surgical intervention. The group model works well for procedures such as hip and knee arthroplasty, when the surgical intervention itself incurs significant thromboembolic risk [80]. Meta-analyses have shown that in the absence of prophylaxis 48.5 % of hip arthroplasty patients and 60.2 % of knee arthroplasty patients develop DVT [81, 82]. These studies included all DVT; proximal, distal, symptomatic, and asymptomatic. The comparable metaanalysis of patients following knee arthroscopy has already been described, in which Ilahi et al. [49] found the incidence of all DVT after AKS to be 9.9 %. For hip and knee arthroplasty, such major procedure-associated VTE risk makes any additional risk incurred by patient-specific factors negligible. In contrast, the procedure-associated VTE risk of knee arthroscopy is not so great that the surgeon can ignore patient-specific factors. The group model of VTE risk assessment provides surgeons with limited practical guidance for evaluating patients prior to AKS. Existing guidelines provide varying recommendations based on incompletely defined caveats. The individual model of VTE risk assessment facilitates the collection and synthesis of both patient-specific risk factors and medical or surgical intervention-specific risk factors into a VTE risk score. VTE risk scoring systems guide use of prophylaxis specific to each individual patient. The orthopaedic literature has identified patient-specific risk factors for VTE after AKS. Morgan et al. [29] in 2011 confirmed the work of Delis et al. [43] from 2001 demonstrating that having two or more patient-specific ‘classic VTE risk factors’ was associated with a statistically significant increased risk of VTE after AKS. ‘Classic VTE risk factors’ as described by the orthopaedic literature include age greater than 65 years, body mass index (BMI) greater than 30 kg/m2, smoking, use of oral contraception or hormone replacement therapy, and chronic venous insufficiency. Both studies also confirmed that a personal history of VTE independently increased the risk for VTE after AKS, and Morgan et al. demonstrated that a history of malignancy independently increased the risk for VTE after Table 7 Patient-specific VTE risk factors described by the orthopaedic literature

AKS. Table 7 summarizes the patient-specific VTE risk factors identified by the orthopaedic literature. The patient-specific VTE risk factors reported in the orthopaedic literature are not a comprehensive list of known VTE risk factors. The VTE risk scoring system in Fig. 2 [83] and Table 8 [83] developed by Caprini presents a more exhaustive list of patient-specific VTE risk factors. This example of the individual model of VTE risk assessment was developed for general and vascular surgery patients, [80, 84] and validated and implemented for medical inpatients [79, 85]. Though some of these risk factors are specific to acutely ill patients, not likely to be relevant to patients undergoing AKS, Caprini’s model does present several relevant risk factors not included in the orthopaedic literature: family history of VTE, history of inflammatory bowel disease, age as a continuum with risk beginning at 40 years and additional risk incurred at age greater than 60 years, and BMI greater than 25 kg/m2 rather than BMI greater than 30 kg/m2. It is also interesting to note that neither smoking history nor female sex are included in this list. Both Caprini and others have also pointed out that the predictive value of all patient-specific risk factors is not the same [83, 86]. Where guidelines prescribe unquantified risk based simply on the presence or absence of patient-specific risk factors, a risk scoring system allows clinicians to quantify VTE risk by assigning relative value to different risk factors. For example, a positive family history of VTE, noted by Caprini to be the risk factor most commonly missed by clinicians, incurs three times as much risk as a positive history of oral contraceptive use. A VTE risk scoring system for patients undergoing AKS has been previously recommended [87]. The Caprini scoring system has been successfully adapted to and validated for use in plastic surgery [50, 88, 89], and it may be possible to simply adapt an established risk scoring system directly to patients undergoing AKS. It is also possible that adequate sensitivity will not be achieved without determining the relative risk of different arthroscopic

Independently increased risk of VTE after AKS

Presence of two or more of these factors increased risk of VTE after AKS [29, 43]

History of malignancy [29, 43]

Age [65 years

Previous VTE [29, 43]

BMI [30 kg/m2

Age [40 years [10, 30]

Smoking

Age [50 years [53]

Oral contraceptives or hormone replacement therapy

Oral contraceptives or hormone replacement therapy [15]

Chronic venous insufficiency

Female sex (when age [65 years) [28] AKS arthroscopic knee surgery, BMI body mass index, VTE venous thromboembolism

Female sex [10] Varicose veins [36]

VTE Following Knee Arthroscopy Fig. 2 The risk assessment guide developed by Caprini. Reproduced from Caprini [83], with permission from Elsevier. BMI body mass index, COPD cardiopulmonary disease, DVT deep vein thrombosis, PE pulmonary embolism

procedures about the knee [70, 90]. The differential risk of surgical knee arthroscopy compared with diagnostic knee arthroscopy has long been understood [91, 92], but there is limited and conflicting evidence to support that one arthroscopic procedure about the knee incurs greater VTE risk than another (Table 9). Large retrospective reviews of AKS and VTE have found no relationship between specific procedures and VTE [11, 15, 29]. ACL reconstruction is presumed to be a higher-risk procedure with respect to VTE [44, 49]; however, this has not been demonstrably proven. Studies that include patients undergoing AKS with and without associated ACL reconstruction failed to demonstrate an increased incidence of VTE associated with cruciate ligament reconstruction [11, 33, 44, 46]. Despite lack of evidence, patients undergoing ACL reconstruction were excluded from the 2005 meta-analysis of Ilahi et al. [49] that reported a 9.9 % incidence of DVT after AKS. In 1999, Jaureguito et al. [41] divided patients undergoing AKS into two groups based on procedures

hypothesized to be low risk or high risk for DVT. The incidence of DVT was compared both retrospectively (N = 2050) and prospectively (N = 239). Ten perioperative DVT were observed, and though a statistically significant difference was not detected, seven of the DVT identified in both the retrospective and prospective arms of the study were found in patients from the high-risk group. The lack of statistical significance as well as the inclusion in the high-risk group not only of patients undergoing ACL reconstruction but also of those undergoing osteotomies makes it difficult to draw definitive conclusions from this work. Camporese et al. [46] in 2008 included partial meniscectomy, chondroplasty, ACL reconstruction, as well as patients undergoing combined procedures. Subgroup analysis demonstrated that performing a partial meniscectomy either as a singular or combined procedure was associated with a statistically significant increased risk of VTE. Some authors have postulated that rather than specific arthroscopic knee procedures incurring greater or lesser

W. C. Graham, D. C. Flanigan Table 8 VTE risk score as a suggested guide to thrombosis prophylaxis All moderate-risk and high-risk patients should receive UFH, LMWH, or FXa I unless contraindicated by bleeding risk Scores of 2–3: IPC perioperatively and during hospitalization Scores of 3–4: UFH, LMWH, FXa I, foot pump, or IPC during hospitalization Start AC 12–24 h postoperatively Scores of 5–8: AC ? IPC during hospitalization and 7–10 d UFH, LMWH, or FXa I Start AC 12 h preoperatively Scores of [8: AC ? IPC during hospitalization and 30 d UFH, LMWH, or FXa I AC anticoagulation, FXa I factor Xa inhibitor, IPC intermittent pneumatic compression, LMWH low-molecular-weight heparin, UFH unfractionated heparin, VTE venous thromboembolism. Reproduced from Caprini [79], with permission from Elsevier

Table 9 Procedure-specific VTE risk factors described by the orthopaedic literature Procedure-specific risk factors for VTE following AKS

Evidence for increased risk of VTE

Preoperative immobilization

Statistically significant risk factor for VTE in patients undergoing arthroscopic-assisted ACL reconstruction [40]

Tourniquet use Longer tourniquet time

Did not correlate with increased risk in two prospective cohorts [36, 40] Trend towards significance [41] Statistically significant increase in VTE incidence with longer tourniquet time in one prospective cohort, [44] and in one retrospective review [32]

Longer total operative time

Evidence against increased risk of VTE

Trend towards significance [25] Statistically significant increase in PE incidence with increasing operative time [10]

More daily hours of inactivity or more days of immobilization (1-5 days) during immediate postoperative period

Did not correlate with increased risk in two prospective cohorts [43, 46]

Did not correlate with increased risk in three prospective cohorts [36, 40, 44] Did not correlate with increased risk in two prospective cohorts [31, 44] nor in one retrospective review [31]

Type of procedure performed ACL reconstruction

Trended towards higher incidence (though group also included patients undergoing AKS with concomitant osteotomy) [41]

Did not correlate with increased risk in two prospective cohorts [44, 47]

Meniscectomy

Performing a meniscectomy as an isolated or combined procedure showed statistically significant increased risk of VTE [47]

Trended towards lower risk [41]

Significantly higher incidence of thrombophlebitis in patients undergoing debridement of Grade IV cartilage lesions in one retrospective review [32]

Trended towards lower risk [41]

Chondroplasty

Did not correlate with increased risk in two prospective cohorts [43, 44] Did not correlate with increased risk in two prospective cohorts [43, 44]

ACL anterior cruciate ligament, AKS arthroscopic knee surgery, PE pulmonary embolism, VTE venous thromboembolism

VTE risk, the risk lies in the particular operative and perioperative circumstances surrounding a specific case. Marlovits et al. [40] identified preoperative immobilization as a statistically significant risk for VTE following ACL reconstruction. Others have identified a trend of VTE in patients prone to self-splinting [93]. Demers et al. [44] identified tourniquet time greater than 60 min as a statistically significant risk factor; however, Camporese et al. [46] found no relationship between tourniquet time and VTE. Other authors hypothesize that longer tourniquet times are simply representative of a more complex case,

with the complexity being the real VTE risk factor [92]. Hetsroni et al. [10] provide some evidence to support that theory as they found total surgical time to be a statistically significant risk for PE after AKS. The most difficult choices regarding thromboprophylaxis are presented in the setting of patients with risk factors undergoing low-risk procedures [80]. At least one known patient-specific VTE risk factor is found in 37 % of patients undergoing AKS [39] and the paradigm of knee arthroscopy continues to evolve in a way that generates more VTE risk for patients that will not be observed post-

VTE Following Knee Arthroscopy

operatively in inpatient settings. Concurrent with increasing surgical volume, arthroscopic procedures of increasing complexity are being performed in outpatient settings, and older patients with more comorbidity are undergoing outpatient surgery [71, 94]. Faced with such difficult clinical choices there is much appeal to the generation of guidelines and standardized treatment regimens. Yet, while the group model of VTE risk assessment serves patients undergoing hip and knee arthroplasty well, with regards to AKS the varying recommendations and incompletely defined caveats from existing guidelines suggest that patients undergoing knee arthroscopy may be better served by the individual model of VTE risk assessment.

consent, current literature provides little guidance for how that information should influence the use of prophylaxis. A VTE risk scoring system for patients undergoing AKS would better articulate appropriate use of pharmacologic thromboprophylaxis after AKS. At present there is incomplete and conflicting data to determine which procedure-specific factors would need to be included. Further investigation is needed to define what role an AKS-specific VTE risk scoring system could play in minimizing thromboembolic complications after knee arthroscopy. Acknowledgments The authors received no funding in support of this work. David C. Flanigan is a consultant for Smith & Nephew and Sanofi. William C. Graham has no conflicts of interest that are directly relevant to the content of this article.

7 Conclusions The existing literature describing the incidence of VTE after AKS can be separated into two clear categories. Small prospective studies suggest that 10 % of patients may experience some thromboembolic phenomenon after knee arthroscopy, but 60–80 % of those events are of unclear clinical significance. Large retrospective studies report the incidence of symptomatic VTE after AKS to be less than 1 %. These studies are well powered, utilize primary outcome measures with definite clinical significance, and have been replicated multiple times yielding similar results. At present the results of these retrospective studies are the best literature on which to base patient education and preoperative VTE risk assessment for patients undergoing knee arthroscopy. However, the findings of the prospective studies should not be disregarded. While most subclinical and distal DVT are likely benign, the ACCP continues to recommend treating incidentally discovered asymptomatic DVT and distal DVT with similar anticoagulation regimens as are recommended for symptomatic DVT and proximal DVT. These treatment recommendations make clear that even though the potential morbidity of subclinical DVT cannot be quantified, the potential for morbidity or even mortality remains. Whether the rate of VTE following AKS is 1 or 10 %, the millions of knee arthroscopies performed each year will generate a minimum annual burden of thousands of patients with thromboembolic complications. The role of VTE prophylaxis after AKS cannot be completely defined until the cost of prophylaxis is analyzed in the context of the cost of these complications. Nevertheless, thorough VTE risk assessment must be a routine part of preoperative evaluation before knee arthroscopy. There is ample evidence from both the orthopaedic and general medical literature to encourage orthopaedic surgeons to screen for patient-specific VTE risk factors prior to AKS. Yet, beyond improved patient education and appropriate informed

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Venous thromboembolism following arthroscopic knee surgery: a current concepts review of incidence, prophylaxis, and preoperative risk assessment.

The purpose of this review was to compile existing knowledge regarding venous thromboembolism (VTE) after arthroscopic knee surgery (AKS). We reviewed...
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