Mohammad S. Abdelaal, Ryan Sutton, Oliver Marín-Peña, Javad Parvizi.
Response/Recommendation: There is dearth of data related to this question. Available evidence suggests that aspirin is an effective prophylactic agent against venous thromboembolism (VTE) in standard-risk patients undergoing mini-open femoroacetabular osteoplasty (FAO).
Strength of Recommendation: Low.
Rationale: The majority of patients undergoing FAO are young, healthy, active, and may not be considered at high-risk for VTE1. The optimal VTE prophylaxis regimen after mini-open FAO remains unclear with little published on this subject matter2,3. VTE prophylaxis after hip preservation procedures is not addressed by the American College of Chest Physicians (ACCP)4, the American Academy of Orthopaedic Surgeons (AAOS) or any other guidelines. Hence, specific VTE prevention protocols are required to implement an optimal prophylaxis method after FAO. Azboy et al.2 compared different VTE pharmacological prophylaxis in patients undergoing hip preservation surgery between 2003 and 2016. Their cohort had 603 patients who underwent mini-open FAO and 80 patients who underwent periacetabular osteotomy (PAO)2. Their results demonstrated a symptomatic VTE rate of 0.16% and 1.1% after mini-open FAO and PAO surgery, respectively2. There were no significant differences in symptomatic VTE rates in patients receiving warfarin, aspirin (ASA) 325 mg or ASA 81 mg, with no events of bleeding or hematoma formation2. In a prospective case series of 407 consecutive patients who underwent mini-open FAO procedure, Tischler et al.,5 found that the rate of symptomatic VTE was 0.25% when ASA 325 mg daily dose was administered. The majority of the patients included in this cohort were young, healthy and active, and were ambulated within hours of their surgery5. Based on institutional experience, a review study from the Rothman Institute recommended that ASA 81 mg two times daily is a safe and effective modality in minimizing the risk of VTE in patients undergoing hip preservation surgery1. Regarding patient factors, increased age, obesity, oral contraceptive use, trauma, and prolonged traction were identified as factors in patients who had VTE events after arthroscopic FAO procedures6. However, it is unclear how these factors might contribute to the VTE events after mini-open FAO. Further research on potential risk factors for VTE and the optimal prophylaxis modality for FAO surgery via the mini-open approach is warranted.
References:
1. Aali Rezaie A, Azboy I, Parvizi J. Venous thromboembolism prophylaxis after hip preservation surgery: a review and presentation of institutional experience. J Hip Preserv Surg. 2018;5(3):181-189. doi:10.1093/jhps/hny016
2. Azboy I, M Kheir M, Huang R, Parvizi J. Aspirin provides adequate VTE prophylaxis for patients undergoing hip preservation surgery, including periacetabular osteotomy. J Hip Preserv Surg. 2018;5(2):125-130. doi:10.1093/jhps/hny010
3. Cohen SB, Huang R, Ciccotti MG, Dodson CC, Parvizi J. Treatment of femoroacetabular impingement in athletes using a mini-direct anterior approach. Am J Sports Med. 2012;40(7):1620-1627. doi:10.1177/0363546512445883
4. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e278S-e325S. doi:10.1378/chest.11-2404
5. Tischler EH, Ponzio DY, Diaz-Ledezma C, Parvizi J. Prevention of venous thromboembolic events following femoroacetabular osteoplasty: aspirin is enough for most. Hip Int. 2014;24(1):77-80. doi:10.5301/hipint.5000079
6. Haldane CE, Ekhtiari S, de Sa D, et al. Venous Thromboembolism Events After Hip Arthroscopy: A Systematic Review. Arthroscopy. 2018;34(1):321-330.e1. doi:10.1016/j.arthro.2017.07.006