Oguzhan Korkmaz, Yutaka Inaba, Taro Tezuka, Ibrahim Azboy.
Response/Recommendation: Given the low rate of venous thromboembolism (VTE) in patients undergoing elective pelvic and/or femoral osteotomy, as well as the absence of robust data in current literature, this workgroup recommends that aspirin (ASA) and/or mechanical prophylaxis should be used as VTE prophylaxis in this patient population. Only patients at a high risk of VTE should be given more potent or additional chemoprophylaxis.
Strength of Recommendation: Limited.
Rationale: Periacetabular osteotomy (PAO) and/or femoral osteotomy are surgical options available to treat young patients with developmental dysplasia of the hip or other hip conditions1–6. Although isolated femoral osteotomy is performed in the pediatric patient population, femoral osteotomy is often combined with a pelvic osteotomy in adults. Patients undergoing these surgical procedures are often young and healthy4,5,7. However, the nature of the surgical procedure is such that these patients are often required to limit weight-bearing postoperatively8, which could potentially increase the risk of VTE. The other aspect to consider is that these patients are also at increased risk for bleeding as the surgery involves multiple cuts through pelvic bone and/or femoral shaft. Thus, the use of an anticoagulant agent needs to be carefully considered, taking into account the potential risk for bleeding and VTE.
The issue of VTE after pelvic and/or femoral osteotomy has been evaluated previously. The incidence of VTE in patients undergoing PAO has been reported to be very low at 0% to 5%9–14. Although the incidence of VTE after osteotomy seems to be lower than that after total joint arthroplasty without prophylaxis, these values are not negligible and VTE prophylaxis should still be considered. Notwithstanding, there are no specific recommendations regarding the most appropriate method of VTE prophylaxis in patients undergoing pelvic and/or femoral osteotomy.
In a study by Thawrani et al., on 76 patients undergoing PAO (83 hips) with a mean age of 15.6 years, there was no detected VTE event without any VTE prophylaxis15. Ito et al., retrospectively reviewed the long-term outcomes of PAO in patients younger than 40 years of age (N=103; mean age 27.1 years) and older patients (N=36; mean age 47.2 years)16. Only high-risk patients with a previous history of VTE were given 2 weeks of ASA for VTE prophylaxis, although the dose of ASA administered is not disclosed in the study. One patient in the older cohort died of pulmonary embolism on day four16 . The latter patient was not receiving ASA for prophylaxis. In another retrospective study, Sugano et al., evaluated the role of mechanical prophylaxis for VTE in 70 patients with a mean age of 32.5 years who underwent pelvic and femoral osteotomy17. Epidural anesthesia, perioperative calf compression, early mobilization, and intermittent pneumatic compression were used in the patient group. VTE was not observed in any patient at the 6-month follow-up17.
In another study by Wassilew et al., weight-adjusted subcutaneous low-molecular-weight heparin (LMWH) was used in 48 patients, with a mean age of 31.7 years, undergoing PAO. LMWH was administered until the patient was allowed to fully weight-bear at around 12 weeks, and no patients developed VTE18.
Polkowski et al., studied 134 patients (149 hips) undergoing PAO at a mean age of 30 years. The patients received ASA 325 mg twice daily and compression stockings for 6 weeks, following which, proximal deep venous thrombosis (DVT) was detected in 2 patients (1.3%)19. Wingerter et al., evaluated 100 patients who underwent PAO with tranexamic acid (TXA) (50 hips) and without TXA (50 hips), analyzing the cohort for development of VTE and other complications. No VTE prophylaxis was administered to patients younger than 18 years of age in that study. Older patients were given contralateral mobile mechanical compression device intraoperatively and bilateral mechanical compression device for 10 days postoperatively. All patients older than 18 received 325 mg of ASA twice daily for 6 weeks, and none of the patients in either group developed VTE20. The issue of TXA and its influence on VTE was also studied by Bryan et al., in a study on 150 patients undergoing PAO21. Of these, 75 patients received intravenous TXA and 75 patients did not receive TXA. All patients received mechanical prophylaxis in the hospital and 325 mg ASA twice a day for 6 weeks. The authors reported two VTE events (2.7%) in patients receiving TXA and 1 (1.3%) in the group that did not receive TXA21. Yamanaka et al., examined the incidence of VTE in patients who underwent a total of 820 major hip surgeries, including 144 PAO22. The mean age of these patients was 32.2 years. Mechanical prophylaxis and LMWH were used in combination in 79 patients, and mechanical prophylaxis only was used in 65 patients. VTE rate was 1.3% in patients who received mechanical prophylaxis and chemical prophylaxis together, and 3.1% in patients who received mechanical prophylaxis only (p=0.43)22.
Another study investigated the incidence of VTE after PAO in 1,067 patients with a mean age of 24 years (range, 13-56) who had surgery at six North American centers13. Multiple types of VTE prophylaxis were employed including mechanical, pharmacological, and combined mechanical and pharmacological methods. Pulmonary embolism (PE) was observed in four patients and DVT in seven patients, and the incidence of clinically symptomatic VTE was reported to be 0.94% (9.4/1,000). Two of the six participating hospitals used both chemoprophylaxis and mechanical prophylaxis for VTE, and the crude incidence of VTE per 1,000 patients after PAO were 6.73 (2/297) and 8.73 (2/297), respectively. In two other hospitals, only pharmacological or mechanical prophylaxis were used, and the incidence of VTE was 9.37 (3/32) and 12.05 (3/249), respectively. These results suggested that the combination of pharmacological and mechanical prophylaxis methods was useful in preventing VTE after PAO. Conversely, two of the participating hospitals that treated younger patients had a lower incidence of VTE compared to the others, even though they did not adopt pharmacological nor mechanical prophylaxis or only used one of them. This suggested that the risk of postoperative VTE after PAO may be lower in children than in adolescents. However, Allahabadi et al.,23 noted that 9 patients among 1,480 operated joints in a cohort aged 10-18 years developed VTE within 90 days, concluding that pharmacologic prophylaxis had no effect on the incidence of VTE. Prevention of VTE after osteotomy in children remains controversial, and further research is necessary to address this knowledge gap. Although the risk of VTE after PAO in adolescents remains contentious, according to the report by Salih et al.,24, the incidence of grade IV complications according to the modified Dindo-Clavien grading system (which included PE) was higher in patients aged 40 years or older (odds ratio [OR] 3.126, p= 0.012), with body mass index >30kg/m2 (OR 2.506, p= 0.031) and joint laxity (Beighton’s score of ≥6, OR). However, they focused not only on VTE, but also on other complications after PAO, and only one case (0.45%) of PE occurred among 223 patients treated with mechanical and pharmacological prophylaxis using LMWH and ASA on outpatient basis. Regarding the effectiveness of pharmacological prophylaxis, Azboy et al.,25 described the usefulness of ASA (325 mg bid) in 87 patients who underwent PAO, and only one patient developed uneventful DVT in the cohort.
Table 1: Data extracted from the literature.
| Author | Year | Sample Size | Prophylaxis Method | Mean Age (years) | Dosage | Duration | Major Bleeding | VTE Rate |
| Sugano et al.17 | 2009 | 70 | Mechanical + ASA* | 30.2 | Unmentioned | 2 weeks | No | 0 |
| Thawrani et al.15 | 2010 | 83 | No Prophylaxis | 15.6 | Unmentioned | Unmentioned | No | 0 |
| Ito et al.16 | 2011 | 158 | ASA** | 32 | Unmentioned | 2 weeks | No | 0.6% |
| Zaltz et al.13 | 2011 | 1067 | 24 | Unmentioned | Unmentioned | No | 0.94% | |
| Polkowski et al.19 | 2014 | 134 | Mechanical + ASA | 30 | 2×325 mg per day | 6 weeks | No | 1.3% |
| Wassilew et al.18 | 2015 | 48 | LMWH | 31.7 | Unmentioned | Unmentioned | No | 0 |
| Wingerter et al.20 | 2015 | 50 | Mechanical + ASA | 28 | 2×325 mg per day | 6 weeks | No | 0 |
| Bryan et al.21 | 2016 | 75 | Mechanical/ASA | 28 | 2×325 mg per day | 6 weeks | No | 1.33% |
| Yamanaka et al.22 | 2016 | 144 | Mechanical ± LMWH(Enoxoparin/Edoxaban) | 32.2 | Unmentioned | Unmentioned | No | 2.1% |
| Azboy et al.25 | 2018 | 87 | ASA (High dose) / ASA (Low dose) / Warfarin | 31.3 | 2x325mg ASA (High dose) 2x81mg (Low dose) Warfarin dose Unmentioned | 4 weeks | No | 1.1% |
VTE=Venous thromboembolism; ASA=Aspirin; mg=milligrams; LMWH=Low-molecular-weight heparin.
*Only a few patients take chemical prophylaxis.
**Given to patients at high-risk for thrombosis.
Both the American College of Chest Physicians (ACCP) and the American Academy of Orthopedic Surgeons (AAOS) recognize ASA as a safe and effective prophylactic agent for total joint arthroplasty26,27. ASA has also been employed as VTE prophylaxis in patients undergoing joint preservation procedures25. A recent retrospective study investigating VTE prophylaxis methods in patients undergoing PAO included a total of 80 patients (87 hips; mean age 31.3 years). Three different chemical prophylaxis methods were used in the study. A total of 33 patients were given ASA 325 mg BID, 31 were given ASA 81 mg BID, and 23 were given warfarin. Uneventful PE developed in only 1 patient who was on 325 mg ASA. No significant difference in the incidence of VTE was seen among the three cohorts (p=0.516)25.
Our search of the literature did not reveal any high-quality studies related to VTE risk after pelvic and/or femoral osteotomy. In the absence of robust data and guidance from the ACCP and/or AAOS, this workgroup recommends that mechanical prophylaxis and/or ASA may be sufficient to minimize the risk of VTE in adult patients undergoing pelvic and/or femoral osteotomy. Adolescents and children appear to be at extremely low risk of VTE after osteotomy. The issue of whether VTE prophylaxis should be administered to these patients is discussed in the pediatric section of this document.
References:
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