Manuel G. Mazzoleni, Maxime Fabre-Aubrespy, Ryan W. Paul, Fotios P. Tjoumakaris, Filippo Randelli.
Response/Recommendation: There are no studies in the literature that have specifically investigated the correlation between non-weight-bearing after knee arthroscopy and the incidence of venous thromboembolism (VTE). Consequently, no specific prophylactic measures have been recommended for this patient population. Considering that non-weight bearing is a known risk factor for VTE, we support the routine use of VTE prophylaxis in these patients unless a high risk of bleeding is present or postoperative bleeding occurs.
Strength of Recommendation: Consensus.
Rationale: Knee arthroscopy (KA) is one of the most common orthopaedic procedures performed worldwide, with an estimated 4 million surgeries performed each year1. One of the most frequent complication, and the most common cause of perioperative mortality after KA is VTE.2,3. The incidence of VTE after KA has been reported to be 0.4% when clinically diagnosed and up to 17.9% when screening asymptomatic patients4–7. The largest retrospective cohort study in the literature (n=20,770) showed a ninety-day incidence of 0.02% for pulmonary embolism (PE) and 0.25% for deep venous thrombosis (DVT) in patients undergoing KA without thromboembolic prophylaxis8. When diagnosed with ultrasound or venography, a previous meta-analysis found an overall DVT rate of 9.9% and a proximal DVT rate of 2.1% in KA patients who did not receive prophylaxis9.
Although the main purpose of VTE prophylaxis is to avoid fatal PE, DVT alone can lead to substantial pain and swelling, as well as the development of post-thrombotic syndrome. This complication occurs in the lower extremities in approximately 30% of symptomatic DVT patients within 5 years of surgery10. Despite this, the use of VTE prophylaxis following KA procedures is controversial, and current recommendations vary across different countries11–18. A recent Cochrane Systematic Review and four separate meta-analyses concluded that the incidence of PE and symptomatic DVT following KA was not reduced with the use of low-molecular-weight heparin (LMWH), aspirin (ASA) or rivaroxaban (moderate- to low-evidence)2,19–22. On the other hand, LMWH use may reduce the risk of asymptomatic DVT when compared to no treatment, and a meta-analysis of randomized controlled trials (RCT) concluded that anticoagulants could reduce the overall incidence of VTE in patients undergoing KA1,2,6,23–27. The authors estimated that, in order to prevent one symptomatic or asymptomatic VTE, the Number Needed to Treat (NNT) was 26, and one major or fatal bleeding event could occur with every 869 patients treated with VTE prophylaxis (Number Needed to Harm [NNH] = 869)23. The conflicting conclusions regarding VTE prophylaxis underscores the need to consider the specific KA procedure performed and the post-operative protocol implemented21,28.
There is a lack of studies investigating the risk of VTE in patients undergoing KA procedures that require a period of non-weight-bearing after surgery. Consequently, there may be a risk of underestimating the efficacy of DVT and VTE prophylaxis according to different KA procedures29. For example, Kosiur et al.30, studied 567 osteochondral autograft transfer surgery (OATS) patients who were provided different instructions for non-weight-bearing after surgery. Overall, 68 patients were instructed not to bear weight for 4 weeks postoperatively (29 of which had a concomitant anterior cruciate ligament reconstruction), while 437 were allowed to bear weight as tolerated immediately after surgery. Thromboembolic prophylaxis was not provided to any patient. The authors found a significant difference between the incidence of DVT in patients who were non-weight-bearing (3.0%) and in those who were allowed to bear weight as tolerated (0.69%). Only one patient developed a PE in the non-weight-bearing group (1.5%), whereas no patients developed a PE in the weight-bearing as tolerated group.
Although current literature does not focus on non-weight-bearing KA procedures in particular, the use of LMWH, rivaroxaban, and ASA as thromboembolic prophylaxis appears to be safe (moderate-certainty evidence) and logical in high-risk patients2. It has been shown that a higher incidence of VTE after KA is associated with patient-specific risk factors, such as classic VTE risk factors, be it genetic or acquired17,29,31. Age is considered a significant risk factor, with patients 50 years of age or older having a 1.54 times greater risk of VTE (LoE II)8. Also, ligament reconstruction, more complex procedures (cartilage or meniscal repair), and prolonged surgical and tourniquet time have been identified as possible VTE risk factors5,8,17,32,33.
Overall, there is a paucity of research on the optimal VTE prophylaxis regime for patients undergoing non-weight-bearing KA procedures, and thus the current recommendations are based on expert consensus on general KA literature. Due to the significantly increased incidence of DVT in non-weight-bearing patients (3.0% vs. 0.7%), the NNT and NNH can be assumed to be much smaller for non-weight-bearing patients relative to data on overall KA (NNT = 26, NNH = 869)23. Until further evidence is available, clinicians should consider utilizing LMWH, rivaroxaban, or ASA after non-weight-bearing KA procedures such as autologous chondrocyte implantation (ACI), OATS, microfracture, or meniscal repair in order to limit the thrombotic risk associated with prolonged non-weight-bearing. Future research should focus on preventing VTE specifically after non-weight-bearing KA procedures, rather than pooling all KA procedures together regardless of weight-bearing status. Clinical trials comparing different VTE prophylactic agents should be performed to determine the optimal drug and dosage to be administered.
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