144 – Concerning VTE risk, which surgeries can be considered major, and which surgeries can be considered non-major in pediatric orthopaedics?

144 – Concerning VTE risk, which surgeries can be considered major, and which surgeries can be considered non-major in pediatric orthopaedics?

Benjamin J. Shore, Samir Sabharwal, Sabharwal.

Response/Recommendation: The overall risk of venous thromboembolism (VTE) in pediatric patients undergoing orthopaedic surgery is low. Pediatric orthopaedic patients undergoing surgery for the management of certain severe musculoskeletal infections (Methicillin-resistant Staphylococcus aureus [MRSA] with Panton-Valentine Leukocidin [PVL] +) are an increased risk of VTE. Additionally, hip, spine, and sports surgery have been identified as risk factors of VTE. Furthermore, the risk of VTE after pediatric orthopaedic surgery appears to be greatest in adolescents. Moreover, coagulation disorders (such as familial thrombophilia), as well as the presence of indwelling central venous catheters (CVC), were found to increase VTE risk substantially more than any specific orthopaedic surgical procedure. In conclusion, adolescents with identifiable confounding VTE risk factors in this setting would benefit greatly from the utilization of perioperative VTE screening tools and risk stratification models.

Strength of Recommendation: Moderate.

Rationale: VTE, a disease process that encompasses both deep venous thrombosis (DVT) and pulmonary embolism (PE), is a rare occurrence in pediatric patients. Estimates have placed the occurrence of VTE in pediatric patients to be between 0.07 to 0.49 per 10,000. However, it is the second most common cause of hospital-acquired morbidity for pediatric patients in the United States, with a reported incidence of 5.3 per 10,000 pediatric hospital admissions1-5. Previous literature has demonstrated that the incidence of VTE in pediatric patients has a bimodal distribution, with the highest proportions reported in infants aged 1 to 23 months and in adolescent females5,6. In hospitalized pediatric patients, the risk factors for VTE development include venous catheterization/central line, malignancy, infection/sepsis, congenital heart disease, trauma/surgery, and inherited thrombophilia. From the aforementioned list, the presence of a central venous catheter/center line demonstrated the greatest risk of VTE development7-9. Despite this, there is a paucity of pediatric-specific literature aimed at determining the risk of VTE risk after orthopaedic surgery.

Recent studies have demonstrated that the incidence of VTE in pediatric patients has been rising over the last two decades1,10-12. It is hypothesized that this rise may be attributed to a combination of factors. These include: increasing awareness of pediatric VTE, increasing medical complexity of pediatric patients, and increased frequency of application of central venous access13. In adults, certain orthopaedic procedures are associated with an increased risk of VTE. Despite this, the same association has not been demonstrated in pediatric patients. Conversely, in pediatric patients, individual patient attributes are more predictive of VTE risk than the procedure being performed. Georgopoulous et al.14, first reported on the incidence of pediatric VTE after elective orthopaedic surgery. In a study evaluating the Pediatric Health Information System (PHIS) database, the authors found that the incidence of pediatric VTE after elective orthopaedic surgery was 0.0515%. Increased age, a diagnosis of a metabolic condition (such as fluid-electrolyte imbalance), obesity, and complications associated with implanted devices and/or surgical procedures were independently identified as significant risk factors for VTE development.

Central catheter-related thrombosis has been reported to have the greatest risk for VTE development in pediatric patients15. In a retrospective study of 78 patients, Sandoval et al.1, found that in patients with a CVC, 45% experienced a DVT episode, 50% of which occurred in the femoral vein. To summarize, recognition of increased VTE risk in pediatric patients undergoing orthopaedic surgery with a CVC in place is critical. Furthermore, immediate removal of the catheter as soon as it is no longer needed is paramount.

Infection is a known risk factor for the development of VTE as inflammatory mediators contribute to the activated blood coagulation cascade16. This risk is compounded in patients with immobility associated with musculoskeletal infections such as osteomyelitis or septic arthritis of the lower extremity17. In particular, children suffering from disseminated musculoskeletal infection with Staphylococcus aureus appear to be at the greatest risk of VTE development17. Specifically, infection with MRSA possessing the PVL gene has been implicated18. In one study, Crary et al.17, retrospectively reviewed 35 patients with confirmed osteomyelitis. They found that 29% of patients with an active MRSA infection developed DVT during the acute infection phase, of which eight occurred adjacent to an infection, and two secondary to CVC use. Additionally, Hollmig et al.19, found that patients > 8 years old presenting with MRSA and a C-reactive protein > 6 mg/dL are at an increased risk for the development of VTE. Clinicians must be wary of the increased risk of VTE associated with pediatric patients undergoing orthopaedic surgery for the management of disseminated musculoskeletal infection. Moreover, chemical VTE prophylaxis in this population must be considered.

Age is an important factor when considering the risk of VTE in pediatric patients undergoing orthopaedic surgery. When stratified by age, the incidence ranges from 0.02% for patients < 5 years to 0.13% in those aged 10 – 15 years. A 10-year survey of a single trauma center reported zero cases of VTE in patients < 13 years of age20. Additionally, recent date from the American National Trauma Bank suggests that the incidence of VTE is 0.1% in patients < 12 years, 0.3% in those 13 – 15 years, and 0.8% in patients > 16 years21. In conclusion, pediatric patients > 13 years old are at an increased risk for developing VTE after orthopaedic surgery. Furthermore, chemical prophylaxis should be initiated in this patient population if additional risk factors are identified preoperatively.

Although the rates of VTE in patients < 15 years-old are 100-fold less compared to VTE rates in an 80 years-old patient, adolescents are known to have significantly increased risk of VTE after trauma than their younger counterparts21,22. In a study of the PHIS database, Murphy et al.23, found the incidence of VTE to be 0.058% after lower extremity trauma. Additionally, Allen et al.24, found that at a single institution, the incidence of VTE after orthopaedic trauma was 1.1%. Interestingly, in this cohort, 86% of children who developed VTE were receiving thromboprophylaxis. Moreover, motor vehicle injuries and orthopaedic surgery were found to be synergistic predictors for the development of VTE after orthopaedic trauma. Careful consideration of the mechanism of injury, age of the patient, and identification of additional comorbid risk is paramount in these patients. Due to the high risk of VTE occurrence, the use of chemoprophylaxis in trauma patients is warranted.

The incidence of anterior cruciate ligament (ACL) reconstruction in patients aged 15 – 18 has nearly doubled in the last 10 years25. Although major complications after knee arthroscopy are rare, pediatric VTE has been reported after elective knee arthroscopy26. In one study, Murphy et al.26, reported a VTE incidence of 0.25% at a single institution. Similarly, in a study of the National Health Service (NHS) database, Nogaro et al.27, found the incidence of VTE in patients undergoing ACL reconstruction to be approximately 0.37%. Additionally, in a more recent study, Ellis et al.28, found that risk factors for VTE development were present in 32.5% of adolescents undergoing elective arthroscopic procedures. In conclusion, the findings of the aforementioned studies suggest that adolescents undergoing knee arthroscopy may benefit from the utilization of a preoperative VTE screening tool.

Adolescent idiopathic scoliosis (AIS) is the most common cause of structural spinal deformity in patients between the ages of 10 and 1829. Although surgical correction provides good outcomes for most patients, it carries significant risk of medical complications, including VTE30. In one study of the National Inpatient Sample (NIS) database, the overall complication rate of AIS surgery was 7.6%, with 0.2% of patients experiencing a VTE event31. Jain et al.32, found that using the same database the incidence of VTE in pediatric patients over a 10 year period was low. Additionally, univariate analysis identified increasing age and the presence of congenital or syndromic scoliosis as independent risk factors for the development of VTE. Fatal VTE is a rare occurrence after pediatric spine surgery. However, the risk of bleeding following administration of VTE chemoprophylaxis is well-established. Therefore, expert opinion has recommended against the routine use of chemical prophylaxis in this patient population33. Despite this, VTE chemoprophylaxis should always be considered in pediatric spine surgery patients immobilized for prolonged periods of time31,33.

Although recent literature has demonstrated an increase in incidence of pediatric VTE, the overall rate of VTE occurrence in pediatric orthopaedic patients remains quite low. Furthermore, particular risk factors specific to individual patients, rather than type of orthopaedic procedure, are more predictive of the risk of VTE development in this patient population. In conclusion, chemical prophylaxis should be considered in both pediatric patients with disseminated musculoskeletal infection (especially MRSA PVL +) and in adolescents undergoing orthopaedic procedures who have additional risk factors for the development of VTE.


1.         Sandoval JA, Sheehan MP, Stonerock CE, Shafique S, Rescorla FJ, Dalsing MC. Incidence, risk factors, and treatment patterns for deep venous thrombosis in hospitalized children: an increasing population at risk. J Vasc Surg. 2008;47(4):837-843.

2.         Connelly CR, Laird A, Barton JS, et al. A Clinical Tool for the Prediction of Venous Thromboembolism in Pediatric Trauma Patients. JAMA Surg. 2016;151(1):50-57.

3.         Monagle P, Chan AKC, Goldenberg NA, et al. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e737S-e801S.

4.         Andrew M, Mitchell L, Vegh P, Ofosu F. Thrombin regulation in children differs from adults in the absence and presence of heparin. Thromb Haemost. 1994;72(6):836-842.

5.         Stein PD, Kayali F, Olson RE. Incidence of venous thromboembolism in infants and children: data from the National Hospital Discharge Survey. J Pediatr. 2004;145(4):563-565.

6.         Victoria T, Mong A, Altes T, et al. Evaluation of pulmonary embolism in a pediatric population with high clinical suspicion. Pediatr Radiol. 2009;39(1):35-41.

7.         Spentzouris G, Scriven RJ, Lee TK, Labropoulos N. Pediatric venous thromboembolism in relation to adults. J Vasc Surg. 2012;55(6):1785-1793.

8.         Kim SJ, Sabharwal S. Risk factors for venous thromboembolism in hospitalized children and adolescents: a systemic review and pooled analysis. J Pediatr Orthop B. 2014;23(4):389-393.

9.         Kerlin BA. Current and future management of pediatric venous thromboembolism. Am J Hematol. 2012;87 Suppl 1:S68-74.

10.       Raffini L, Huang YS, Witmer C, Feudtner C. Dramatic increase in venous thromboembolism in children’s hospitals in the United States from 2001 to 2007. Pediatrics. 2009;124(4):1001-1008.

11.       Vu LT, Nobuhara KK, Lee H, Farmer DL. Determination of risk factors for deep venous thrombosis in hospitalized children. J Pediatr Surg. 2008;43(6):1095-1099.

12.       Wright JM, Watts RG. Venous thromboembolism in pediatric patients: epidemiologic data from a pediatric tertiary care center in Alabama. J Pediatr Hematol Oncol. 2011;33(4):261-264.

13.       Revel-Vilk S, Chan A, Bauman M, Massicotte P. Prothrombotic conditions in an unselected cohort of children with venous thromboembolic disease. J Thromb Haemost. 2003;1(5):915-921.

14.       Georgopoulos G, Hotchkiss MS, McNair B, Siparsky G, Carry PM, Miller NH. Incidence of Deep Vein Thrombosis and Pulmonary Embolism in the Elective Pediatric Orthopaedic Patient. J Pediatr Orthop. 2016;36(1):101-109.

15.       Oschman A, Kuhn RJ. Venous thromboembolism in the pediatric population. Orthopedics. 2010;33(3):180-184.

16.       Amaral A, Opal SM, Vincent JL. Coagulation in sepsis. Intensive Care Med. 2004;30(6):1032-1040.

17.       Crary SE, Buchanan GR, Drake CE, Journeycake JM. Venous thrombosis and thromboembolism in children with osteomyelitis. J Pediatr. 2006;149(4):537-541.

18.       Martinez-Aguilar G, Avalos-Mishaan A, Hulten K, Hammerman W, Mason EO, Jr., Kaplan SL. Community-acquired, methicillin-resistant and methicillin-susceptible Staphylococcus aureus musculoskeletal infections in children. Pediatr Infect Dis J. 2004;23(8):701-706.

19.       Hollmig ST, Copley LA, Browne RH, Grande LM, Wilson PL. Deep venous thrombosis associated with osteomyelitis in children. J Bone Joint Surg Am. 2007;89(7):1517-1523.

20.       Azu MC, McCormack JE, Scriven RJ, Brebbia JS, Shapiro MJ, Lee TK. Venous thromboembolic events in pediatric trauma patients: is prophylaxis necessary? J Trauma. 2005;59(6):1345-1349.

21.       Van Arendonk KJ, Schneider EB, Haider AH, Colombani PM, Stewart FD, Haut ER. Venous thromboembolism after trauma: when do children become adults? JAMA Surg. 2013;148(12):1123-1130.

22.       White RH. The epidemiology of venous thromboembolism. Circulation. 2003;107(23 Suppl 1):I4-8.

23.       Murphy RF, Naqvi M, Miller PE, Feldman L, Shore BJ. Pediatric orthopaedic lower extremity trauma and venous thromboembolism. J Child Orthop. 2015;9(5):381-384.

24.       Allen CJ, Murray CR, Meizoso JP, et al. Risk factors for venous thromboembolism after pediatric trauma. J Pediatr Surg. 2016;51(1):168-171.

25.       Herzog MM, Marshall SW, Lund JL, Pate V, Mack CD, Spang JT. Incidence of Anterior Cruciate Ligament Reconstruction Among Adolescent Females in the United States, 2002 Through 2014. JAMA Pediatr. 2017;171(8):808-810.

26.       Murphy RF, Heyworth B, Kramer D, et al. Symptomatic Venous Thromboembolism After Adolescent Knee Arthroscopy. J Pediatr Orthop. 2016.

27.       Nogaro MC, Abram SGF, Alvand A, Bottomley N, Jackson WFM, Price A. Paediatric and adolescent anterior cruciate ligament reconstruction surgery. Bone Joint J. 2020;102-B(2):239-245.

28.       Ellis HB, Jr., Sabatino MJ, Clarke Z, et al. The Importance of a Standardized Screening Tool to Identify Thromboembolic Risk Factors in Pediatric Lower Extremity Arthroscopy Patients. J Am Acad Orthop Surg. 2019;27(9):335-343.

29.       James JI. Idiopathic scoliosis; the prognosis, diagnosis, and operative indications related to curve patterns and the age at onset. J Bone Joint Surg Br. 1954;36-B(1):36-49.

30.       Coe JD, Arlet V, Donaldson W, et al. Complications in spinal fusion for adolescent idiopathic scoliosis in the new millennium. A report of the Scoliosis Research Society Morbidity and Mortality Committee. Spine (Phila Pa 1976). 2006;31(3):345-349.

31.       De la Garza Ramos R, Goodwin CR, Abu-Bonsrah N, et al. Patient and operative factors associated with complications following adolescent idiopathic scoliosis surgery: an analysis of 36,335 patients from the Nationwide Inpatient Sample. J Neurosurg Pediatr. 2016;25(6):730-736.

32.       Jain A, Karas DJ, Skolasky RL, Sponseller PD. Thromboembolic complications in children after spinal fusion surgery. Spine (Phila Pa 1976). 2014;39(16):1325-1329.

33.       Cheng JS, Arnold PM, Anderson PA, Fischer D, Dettori JR. Anticoagulation risk in spine surgery. Spine (Phila Pa 1976). 2010;35(9 Suppl):S117-124.

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.

%d bloggers like this: