178 – Concerning VTE risk, which surgeries can be considered major, and which surgeries can be considered non-major in orthopaedic sports surgery?

178 – Concerning VTE risk, which surgeries can be considered major, and which surgeries can be considered non-major in orthopaedic sports surgery?

Martina Rama, Bryson Kemler, Sommer Hammoud.

Response/Recommendation: Overall, venous thromboembolism (VTE) incidence in sports surgery is low, and risk of VTE increases with immobilization and non-weight bearing. For this reason, upper extremity sports procedures are considered non-major concerning VTE risk due to the low impact on patient ambulation and post-operative mobility. Lower extremity procedures can be considered non-major if patients can weight bear and mobilize post-operatively. Patients undergoing lower extremity sports procedures that places weight-bearing restriction and/or limits ambulation may be considered major.

Strength of recommendation: Consensus.

Rationale: There have been several large cohort studies looking at overall risk of symptomatic VTE in common orthopaedic sports procedures1–5 with overall a much lower incidence of VTE in this patient population than those undergoing trauma or arthroplasty procedures6–9. Despite this, VTE still remains an important, and potentially fatal, complication of orthopaedic surgery which warrants investigations. In 2012, the American College of Chest Physicians (ACCP) published guidelines on VTE prevention in patients undergoing knee arthroscopy, recommending that no thromboprophylaxis is needed in these patients7. There have not been significant revisions to these guidelines since their publication.

Risks for VTE after orthopaedic sports procedures have been described in various studies. While duration of surgery has been shown to be a risk factor in patients who develop VTE10, this risk factors is not universally accepted as a reliable metric for determining the overall risk of a patient for VTE. Several studies have shown that orthopaedic procedures which require postoperative immobilization put patients at an increased risk of developing symptomatic VTE11,12. Additionally, patients who are required to be non-weight-bearing on their operative extremity have been shown to have increased incidence of VTE postoperatively13. These factors were taken into account when formulating our recommendation above.

Upper extremity procedures in sports medicine primarily consist of open and arthroscopic shoulder and elbow procedures, of which VTE risk is reported to be a rare complication. Systematic reviews report the incidence of VTE to be 0.038% to 0.3% after shoulder arthroscopic procedures4,14. Weight-bearing restrictions are not as provocative for VTE formation in patients, as they typically do not significantly hinder ambulation, which has been shown to decrease VTE risk15,16. Upper limb immobilization was not found to increase VTE risk, with literature reporting only two cases of thrombosis of the arm after shoulder arthroscopy and immobilization on a total of 10,452 cases17,18.

Lower extremity orthopaedic sports medicine procedures are very diverse in nature and severity. Arthroscopic and open procedures about the hip, including labral repair and reconstruction, osteochondroplasty procedures, and tendon repairs such as of the gluteus medius or proximal hamstring are more recently being treated with accelerated early weight-bearing and range of motion19–21. While there is a paucity of studies specifically evaluating the incidence of deep venous thrombosis (DVT) following these procedures, a recent systematic review estimated the risk in patients undergoing hip arthroscopy to be ~ 2%5. Similarly, for hamstring avulsion repair the estimated VTE incidence was found to be 0.5%22.

Knee arthroscopy is one of the most common procedures in all of orthopaedics, and concomitant procedures can include anterior and/o posterior cruciate ligament repair/reconstruction, meniscus excision/repair/transplantation, osteochondral defect fixation/drilling/grafting, among others. The reported incidence of DVT without prophylaxis after knee arthroscopy varies from 0.2% to 18%, with higher rates detected when screening asymptomatic patients23–25. The higher-than-expected rate of DVT in knee arthroscopy without prophylaxis, has led some studies to recommend chemoprophylaxis after this procedure26–29. Nevertheless, consensus on VTE prophylaxis after knee arthroscopy has not been reached and varies by country. In the US, the ACCP guidelines suggest no VTE prophylaxis is necessary for arthroscopic knee procedures for patients without prior history of VTE7. For open procedures about the knee such as high tibial osteotomy (HTO), distal femoral osteotomy (DFO), and tibial tubercle osteotomy (TTO) the reported VTE risk varies over a wide range depending on inclusion of asymptomatic VTE. HTO has a reported VTE incidence that ranges from 2.4 – 41% 30,31 A recent study by Erickson et al., estimated symptomatic VTE rates after HTO, DFO or TTO to be less than 2%32. Currently, there is no consensus regarding thromboprophylaxis in HTO, DFO or TTO, however, given the need for prolonged restricted weight-bearing, administration of VTE prophylaxis may need to be considered in this patient population.

In conclusion, the overall VTE risk is very low in patients undergoing orthopaedic sports surgery. Based on expert opinion and limited evidence, upper extremity sports medicine procedures should be considered non-major concerning VTE risk due to their low impact on ambulation and postoperative mobility. Similarly, lower extremity procedures for which patients are allowed to bear weight and mobilize postoperatively should be considered non-major. Lower extremity procedures for which patients have their weight-bearing restricted or their operative extremity immobilized in the postoperative period should be considered major as it pertains to VTE risk. Although rare, knee sports surgeries have a slightly higher VTE risk with VTE prophylaxis recommended based on risk stratification. For this reason, knee procedures in which patients are non-weight bearing and immobilized are considered major, while all other ones with no limitations on weight-bearing and range of motion are considered non-major.


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2.         Sun Y, Chen D, Xu Z, et al. Deep venous thrombosis after knee arthroscopy: a systematic review and meta-analysis. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 2014;30(3):406-412. doi:10.1016/j.arthro.2013.12.021

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27.       Michot M, Conen D, Holtz D, et al. Prevention of deep-vein thrombosis in ambulatory arthroscopic knee surgery: A randomized trial of prophylaxis with low–molecular weight heparin. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 2002;18(3):257-263. doi:10.1053/jars.2002.30013

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