Renny Cárdenas Q, Carlos Sanchez V.
Response/Recommendation: There is insufficient evidence to recommend routine thromboprophylaxis to all otherwise healthy patients undergoing a knee arthroscopic procedure.
Strength of Recommendation: Moderate.
Rationale: Knee arthroscopy (KA) is the most common outpatient orthopaedic procedure worldwide. Approximately 1 million knee arthroscopies are performed annually in the US, and 5 million worldwide1,2. Despite the high prevalence of this intervention, the risk of symptomatic venous thromboembolism (VTE), including deep venous thrombosis (DVT) or pulmonary embolus (PE), following the procedure is extremely low1. In addition, consideration must be given to the fact that thromboprophylaxis is not without its risks, with many reports of minor or major bleeding in the literature3.
In a recent meta-analysis of seven randomized controlled trials (RCT), Huang et al.4, found that the use of low-molecular-weight heparin (LMWH) after KA was not associated with reduced rates of symptomatic VTE. A subsequent systematic review and meta-analysis by the same authors included all RCT reporting the use of other types of anticoagulants (rivaroxaban and aspirin [ASA]) and found that these agents were also ineffective in the prevention of VTE as compared to no thromboprophylaxis5.
In regards to patients undergoing KA ligament reconstruction, thromboprophylaxis should take into account the patient’s risk factors6,7,8. Perrota et al., performed a meta-analysis of eight RCT and controlled clinical trials with 3,818 patients, comparing different thromboprophylactic methods in patients who had undergone KA procedures. While their results suggested that LMWH could reduce the incidence of asymptomatic DVT, there was no clear benefit of LMWH, ASA, or rivaroxaban over placebo or no intervention in the prevention of PE or symptomatic DVT. They also found no difference in the rate of adverse events such as major or minor bleeding but acknowledged that the data for this endpoint was limited due to a low number of events8.
In evaluating the efficacy and safety of anticoagulants after KA, Yu et al.9, performed another systematic review and meta-analysis, which included 4,097 patients. They concluded that anticoagulants could effectively reduce the overall risk of VTE after KA, although the increased risk of bleeding should be considered. They also found that the Number Needed to Harm (NNH) for any bleeding event was 20 and the NNH for a major bleeding or fatal event was 869.
In light of the evidence presented above, it is the recommendation of this workgroup that there is not sufficient data to recommend thromboprophylaxis to all otherwise healthy patients undergoing KA who will be weight-bearing postoperatively. This question still remains valid when encountering patients with procoagulant comorbidities, or those who are taking oral contraceptives (e.g., younger patients undergoing anterior cruciate ligament reconstruction). More research is needed to clarify if routine prophylaxis should be indicated in this group of individuals6,9, and prophylactic measures should be individualized, taking into account all the risk factors present at the time of the surgical intervention.
1. Mauck KF, Froehling DA, Daniels PR, Dahm DL, Ashrani AA, Crusan DJ, Petterson TM, Bailey KR, Heit JA. Incidence of venous thromboembolism after elective knee arthroscopic surgery: a historical cohort study. J Thromb Haemost. 2013 Jul;11(7):1279-86.
2. Camporese G, Bernardi E, Noventa F, Bosco M, Monteleone G, Santoro L, Bortoluzzi C, Freguja S, Nardin M, Marullo M, Zanon G, Mazzola C, Damiani G, Maniscalco P, Imberti D, Lodigiani C, Becattini C, Tonello C, Agnelli G; ERIKA Study Group. Efficacy of Rivaroxaban for thromboprophylaxis after Knee Arthroscopy (ERIKA). A phase II, multicentre, double-blind, placebo-controlled randomised study. Thromb Haemost. 2016 Aug 1;116(2):349-55.
3. Joseph W. Greene, MD, W Ajit J. Deshmukh, MD, and Fred D. Cushner, MD. Thromboembolic Complications in Arthroscopic Surgery. Sports Med Arthrosc Rev 2013;21:69–74.
4. Hai-Feng Huang1,2, Jia-Liang Tian2, Xian-Teng Yang1,2, Li Sun2, Ru-Yin Hu2, Zhi-Hui Yan2, Shan-Shan Li3, Quan Xie4*, Xiao-Bin Tian2* Efficacy and safety of low-molecular-weight heparin after knee arthroscopy: A meta- analysis. SICOT ; 2018 https://doi.org/10.1371/journal.pone.0197868
5. Huang HF, Tian JL, Sun L, Yang XT, Shen YK, Li SS, Xie Q, Tian XB. The effect of anticoagulants on venous thrombosis prevention after knee arthroscopy: a systematic review. Int Orthop. 2019 Oct;43(10):2303-2308.
6. Jing Zhu,* MS, Hai Jiang,y MD, Brandon Marshall,z MS, Jian Li,* MD, and Xin Tang,y§ MD Low-Molecular-Weight Heparin or the Prevention of Venous Thromboembolism in Patients Undergoing Knee Arthroscopic Surgery and Anterior Cruciate Ligament Reconstruction. A Meta-analysis of Randomized Controlled Trials. AJSM. 2018; Vol. XX, No. X, XXXX , 1-9
7. Gang Zheng · Qian Tang1 · Ping Shang2 · Xiao‐Yun Pan · Hai‐Xiao Liu . No effectiveness of anticoagulants for thromboprophylaxis after non- major knee arthroscopy: a systemic review and meta-analysis of randomized controlled trials . Journal of Thrombosis and Thrombolysis, published online: March 2018, springer https://doi.org/10.1007/s11239-018-1638-x
8. Perrotta C, Chahla J, Badariotti G, Ramos J. Interventions for preventing venous thromboembolism in adults undergoing knee arthroscopy. Cochrane Database Syst Rev. 2020 May 6;5(5).
9. Yu Y, Lu S, Sun J, Zhou W, Liu H. Thromboprophylactic Efficacy and Safety of Anticoagulants After Arthroscopic Knee Surgery: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost. 2019 Jan-Dec;25.