Damian R. Griffin, Óliver Marín-Peña, Marc W. Nijhof.
Response/Recommendation: The risk of venous thromboembolism (VTE) after hip arthroscopy (HA) is low and routine VTE prophylaxis is not required. In patients with particular risk factors, VTE prophylaxis might be considered.
Strength of Recommendation: Limited.
Rationale: The use of arthroscopic techniques in and around the hip has rapidly increased in recent years1,2. For some conditions, such as femoroacetabular impingement (FAI) syndrome, there is randomized controlled trial evidence of the clinical effectiveness of HA3. The risk of complications, including VTE, following HA is low4. In order to answer the question whether patients undergoing HA require routine VTE prophylaxis, we conducted a comprehensive systematic review of the available literature (Table 1). Most studies related to this subject matter are of low methodological quality5: retrospective case reports or series6–15 or national guidelines16,17. There are three retrospective database studies that specifically evaluated the incidence of symptomatic VTE after HA10,18,19. Three prospective cohort studies used ultrasound screening to identify asymptomatic VTE20–22. Four previous systematic reviews found that their conclusions were limited by overall low-quality evidence, incomplete reporting, and poor definition of surgical and patient risk factors, and by heterogeneity of procedures performed, type and duration of prophylaxis, and method of detection of VTE events23–26.
The overall risk of VTE, after HA, was reported to be between 0.2% to 9.5%6,7,10,12,13,15,19,21,22,26,27. Symptomatic deep venous thrombosis (DVT) rates were 0.4-3.5%6,8,18,20,22,23,25,27, whilst the rate of asymptomatic DVT detected by ultrasound screening was 6.9%21. The risk of pulmonary embolism (PE) was 0.08-1.5%6,7,18,23,25 with a mortality rate of 0.02%18. Some studies attempted to identify risk factors for VTE among patients undergoing HA that included smoking, diabetes, chronic obstructive pulmonary disease (COPD), age, obesity, oral contraceptive use, history of trauma, prolonged intraoperative traction, or prolonged postoperative immobilization27. No prospective cohort studies had adequate sample size to explore these suggested risk factors. One retrospective database study of 9,477 patients6, identified age ≥ 45, obesity, smoking, diabetes, and COPD as independent risk factors, but neither gender nor oral contraceptive use were risk factors for VTE after HA.
Based on our review of the literature, no clinical trial to evaluate the effectiveness of thromboprophylaxis in patients undergoing HA was identified. One systematic review26 explored the role of chemoprophylaxis in this patient population, which included aspirin (ASA), low-molecular-weight heparin or other unspecified drugs. The pooled VTE rate was 2.0% in patients with prophylaxis compared with 3.6% in those without, a difference which was not statistically significant. In a prospective study with 880 HA involved, high-risk VTE patients were treated with chemoprophylaxis and low-risk VTE patients with early mobilization and physiotherapy in first 24 hours. VTE rate in low-risk group was 0.16% and in high-risk group 1.2%27.
In conclusion, although the evidence is sparse, the risk of VTE after HA is low. Thus, based on available data routine administration of VTE prophylaxis for patients undergoing HA is not justified. Patients at higher risk of VTE may benefit from the use of mechanical and/or chemical prophylaxis, which includes ASA.
Table 1. Overview of the results of selected studies.
| Authors | Year | Number of patients | Description of patients | Comment | Procedures | Incidence VTE | Risk factors | Effect of prophylaxis |
| Khazi et al.6 | 2019 | 9,477 | Age > 20 (77.5% age ≥ 45) | Retrospective study. | HA | Overall VTE: 0.77% at 1-month and 1.14% at 3-months. DVT: 0.57% at 1-month and 0,82% at 3-months. PE: 0,3% at 1-month and 0,43% at 3-months. | Risk factor: obesity, smoking, diabetes. No risk factor: age, gender in comparison VTE vs. No-VTE cohort at 90-days. | No info. |
| Malviya et al.18 | 2015 | 6,395 | Age 38 (11-38) | Retrospective NHS database. | HA 2005-2013 | 0.08% (5/6,395) for both 90-day DVT and PE rate 0.08%) | No info. | No info. |
| Bushnell et al.24 | 2008 | 5,554 | No info. | Review 27 papers 1797-2007 | HA | 0% | No info. | No info. |
| Bolia et al.25 | 2018 | 4,577 | Age 36 ± 1.8 | Systematic review 2000-2017, 28 studies. Remark on publication bias. | HA for FAI | 1.18%; 95% CI [0.8–1.74%] for DVT, 0.59%; 95% CI [0.38–0.92%] for PE. When corrected for publication bias: 2.02% for DVT (Small studies with low DVT rates were more likely to be published than larger studies with low DVT rates). | No info. | No info. |
| Haldane et al.26 | 2018 | 2,850 | Age 40.7 | Systematic review 14 papers (not included papers from 2016 to 2021) Only 2 studies level III/IV. | HA | 2.0% (n 6/25 asymptomatic). To 3,6% (excluded 1 study 0% without treatment). | No clear statement about this topic | 2.0% with prophylaxis vs. 4.2% without prophylaxis. |
| Truntzer et al.10 | 2017 | 2,581 | Age not specified. | Retrospective | HA 2007-2014 | 0.79% (16)/2,581) | No info. | No info. |
| Nicolay et al.9 | 2019 | 2,023 | Age of all pts 50.86 ± 14.6, 46.7% obese (27,8% of HA obese). | Retrospective. Not specified for HA | HA 2006-2016 | Overall, 0,27% (382/all 141,335 scopes), not specified for HA. | All scopes (not specified for HA: overweight, BMI (OR 1.474) and class I obesity with DM (OR 1.469). | No info. |
| Larson et al.19 | 2016 | 1,615 | Age 30.5 (12-76) | Retrospective. | HA | 0.2% (3/1615) | DVT cases: clotting cascade disorder (n = 2) or arteriovenous anomaly (n = 1) | No pharmacological prophylaxis, except ASA (650 mg daily) for patients with a known thromboembolic history or clotting cascade disorder or those flying soon (within 3 weeks) after surgery. |
| Schüttler et al.8 | 2018 | 485 | Age 43.9 (w/o range). | Retrospective, low quality. | HA 2006-2014 | 0,4% (2/484) | No info. | No info. |
| Seijas et al.14 | 2017 | 258 | Age 36.6 ± 17.5 (18–61) | Retrospective (review of literature). | HA 2011-2014 | 0% (0/258) | Not studied. | Not studied (enoxaparin 10 days all patients). |
| Dutton et al.11 | 2016 | 159 | Military, age 30.9 ± 8.3 years (range, 18-52 years). | Retrospective. | HA 2000-2014 | 0% (0 | No info. | No info. |
| Niroopan et al.23 | 2016 | 144 | Trauma patients, age range, 10 to 53 years. | systematic review 2015. 32 studies (25 case reports -7 case series). | HA after trauma | 0,7% (1 PE/144 0,7%) | No info. | Not studied (PE case on LMWH) |
| Alaia et al.20 | 2014 | 139 | Age 37.7, all low risk VTE. | Case series. Use US only 58,3% cases. Only low VTE risk patients (exclude 5 high-risk). No VTE prophylaxis. | HA | 1,4% symptomatic. | No clear statement about this topic. | No prophylaxis. |
| Mohtadi et al.22 | 2016 | 115 | Age 35.4 ± 10.3 (> 18). | Prospective, US. | HA | 4.4% (5/115, 4/5 symptomatic.3,5 %). | No statistically significant patient or surgical factors (not powered for). | Not studied (all without prophylaxis) |
| Chaharbakhshi et al.15 | 2019 | 107 | Age 41.6 ± 9.8 (21-61) 42.7 ± 9.9 (20 – 58). | Retrospective. | HA + microfracture (2008-2014); (57 large 50 small defect). | 2,8% (3/107). | Not studied (DVT only in large defect, but similar traction times). | No info (not routinely administered). |
| Bayley et al.12 | 2017 | 82 | Age 20.4 ± 2.5 (16-25). | Retrospective. | HA 2005-2013 | 1,2% (1/82) | No info. | No info. |
| Fukushima et al.21 | 2016 | 72 | Age 46,3 mean. | Not included in systematic review by Brown et al.28. Asymptomatic DVT. Recommended prophylaxis in “old ” patients. | HA | 6.94% ultrasound distal DVT (up to 7 days after surgery). | DVT mean age 62. No traction time or surgical time. | No prophylaxis. |
| Perets et al.7 | 2018 | 66 | Athletes, age 21.4 ± 8.1. | Prospective case series. No info on prophylaxis. | HA 2009-2011 | 1,5% (1 PE /66) | No info. | No info. |
| Collins et al.13 | 2015 | 39 | 21 obese/ 18 non-obese patients; Age 38 ± 11.7 (21-64). | Retrospective | HA 2009-2012 | 5% (2/39) (9,5% 2/21 in obese, 0% 0/18 in non-obese) | Obesity? (Both DVT in obese). | Not studied: all on ASA 325 mg daily for 2 weeks. |
| Randelli et al.17 | 2013 | 0 | Expert consensus of every orthopaedic procedure. No VTE Prophylaxis low risk patients. LMWH 7 days in high risk. | HA & others. | Up to 3.7 % no prophylaxis (literature review). | No info. | No info. | |
| Jenny et al.16 | 2020 | 0 | Survey French surgeons: 69.3% (131/189) of surgeons: prophylaxis in >90% of cases. | HA | No info. | Not mentioned/advised in SFAR guideline 2011. | ||
| Verhoogt et al.27 | 2020 | 880 | Two groups compared: High VTE risk vs. low VTE risk | HA | Oral contraceptives; BMI > 30kg/m2; Previous VTE; Family Story; Hormone replacement Therapy; DM; Cardiac Pathology; Steroids; Malignancy. | High-risk with pharmacological prophylaxis: 1.2%. Low-risk with early ambulation: 0.16%. |
VTE=Venous thromboembolism; HA=Hip arthroplasty; DVT=Deep venous thrombosis; PE=Pulmonary embolism; NHS=National health service; FAI=Femoroacetabular impingement; CI=Confidence interval; BMI=Body mass index; OR=Odds ratio; DM=Diabetes mellitus; ASA=Aspirin; LMWH=Low-molecular-weight heparin; US=United States; SFAR= Société Française d’Anesthésie et de Réanimation.
References:
1. Marin-Peña O, Tey-Pons M, Perez-Carro L, et al. The current situation in hip arthroscopy. EFORT Open Rev. 2017;2(3):58-65. doi:10.1302/2058-5241.2.150041
2. von Glinski A, Yilmaz E, Goodmanson R, et al. The impact of the 30 most cited articles on hip arthroscopy: what is the subject matter? J Hip Preserv Surg. 2020;7(1):14-21. doi:10.1093/jhps/hnz067
3. Griffin DR, Dickenson EJ, Wall PDH, et al. Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial. Lancet. 2018;391(10136):2225-2235. doi:10.1016/S0140-6736(18)31202-9
4. Hanke MS, Lerch TD, Schmaranzer F, Meier MK, Steppacher SD, Siebenrock KA. Complications of hip preserving surgery. EFORT Open Rev. 2021;6(6):472-486. doi:10.1302/2058-5241.6.210019
5. Duong A, Kay J, Khan M, Simunovic N, Ayeni OR. Authorship in the field of femoroacetabular impingement: an analysis of journal publications. Knee Surg Sports Traumatol Arthrosc. 2017;25(1):94-100. doi:10.1007/s00167-016-4058-5
6. Khazi ZM, An Q, Duchman KR, Westermann RW. Incidence and Risk Factors for Venous Thromboembolism Following Hip Arthroscopy: A Population-Based Study. Arthroscopy. 2019;35(8):2380-2384.e1. doi:10.1016/j.arthro.2019.03.054
7. Perets I, Craig MJ, Mu BH, Maldonado DR, Litrenta JM, Domb BG. Midterm Outcomes and Return to Sports Among Athletes Undergoing Hip Arthroscopy. Am J Sports Med. 2018;46(7):1661-1667. doi:10.1177/0363546518765969
8. Schüttler KF, Schramm R, El-Zayat BF, Schofer MD, Efe T, Heyse TJ. The effect of surgeon’s learning curve: complications and outcome after hip arthroscopy. Arch Orthop Trauma Surg. 2018;138(10):1415-1421. doi:10.1007/s00402-018-2960-7
9. Nicolay RW, Selley RS, Terry MA, Tjong VK. Body Mass Index as a Risk Factor for 30-Day Postoperative Complications in Knee, Hip, and Shoulder Arthroscopy. Arthroscopy. 2019;35(3):874-882.e3. doi:10.1016/j.arthro.2018.10.108
10. Truntzer JN, Hoppe DJ, Shapiro LM, Abrams GD, Safran M. Complication Rates for Hip Arthroscopy Are Underestimated: A Population-Based Study. Arthroscopy. 2017;33(6):1194-1201. doi:10.1016/j.arthro.2017.01.021
11. Dutton JR, Kusnezov NA, Lanzi JT, Garcia EJ, Pallis MP. The Success of Hip Arthroscopy in an Active Duty Population. Arthroscopy. 2016;32(11):2251-2258. doi:10.1016/j.arthro.2016.05.042
12. Bayley G, Poitras S, Parker G, Beaulé PE. Hip arthroscopy in patients less than 25 years of age in the treatment of labral tears: aetiology and clinical outcomes. Hip Int. 2017;27(5):436-442. doi:10.5301/hipint.5000493
13. Collins JA, Beutel BG, Garofolo G, Youm T. Correlation of obesity with patient-reported outcomes and complications after hip arthroscopy. Arthroscopy. 2015;31(1):57-62. doi:10.1016/j.arthro.2014.07.013
14. Seijas R, Ares O, Sallent A, et al. Hip arthroscopy complications regarding surgery and early postoperative care: retrospective study and review of literature. Musculoskelet Surg. 2017;101(2):119-131. doi:10.1007/s12306-016-0444-x
15. Chaharbakhshi EO, Hartigan DE, Spencer JD, Perets I, Lall AC, Domb BG. Do Larger Acetabular Chondral Defects Portend Inferior Outcomes in Patients Undergoing Arthroscopic Acetabular Microfracture? A Matched-Controlled Study. Arthroscopy. 2019;35(7):2037-2047. doi:10.1016/j.arthro.2019.01.047
16. Jenny J-Y, Francophone Arthroscopy Society (SFA). Thromboprophylaxis in arthroscopy: Survey of current practices in France and comparison with recommendations. Orthop Traumatol Surg Res. 2020;106(8S):S183-S187. doi:10.1016/j.otsr.2020.08.004
17. Randelli F, Romanini E, Biggi F, et al. II Italian intersociety consensus statement on antithrombotic prophylaxis in orthopaedics and traumatology: arthroscopy, traumatology, leg immobilization, minor orthopaedic procedures and spine surgery. J Orthop Traumatol. 2013;14(1):1-13. doi:10.1007/s10195-012-0214-y
18. Malviya A, Raza A, Jameson S, James P, Reed MR, Partington PF. Complications and survival analyses of hip arthroscopies performed in the national health service in England: a review of 6,395 cases. Arthroscopy. 2015;31(5):836-842. doi:10.1016/j.arthro.2014.12.013
19. Larson CM, Clohisy JC, Beaulé PE, et al. Intraoperative and Early Postoperative Complications After Hip Arthroscopic Surgery: A Prospective Multicenter Trial Utilizing a Validated Grading Scheme. Am J Sports Med. 2016;44(9):2292-2298. doi:10.1177/0363546516650885
20. Alaia MJ, Patel D, Levy A, et al. The incidence of venous thromboembolism (VTE)–after hip arthroscopy. Bull Hosp Jt Dis (2013). 2014;72(2):154-158.
21. Fukushima K, Takahira N, Uchiyama K, Moriya M, Minato T, Takaso M. The incidence of deep vein thrombosis (DVT) during hip arthroscopic surgery. Arch Orthop Trauma Surg. 2016;136(10):1431-1435. doi:10.1007/s00402-016-2508-7
22. Mohtadi NG, Johnston K, Gaudelli C, et al. The incidence of proximal deep vein thrombosis after elective hip arthroscopy: a prospective cohort study in low risk patients. J Hip Preserv Surg. 2016;3(4):295-303. doi:10.1093/jhps/hnw027
23. Niroopan G, de Sa D, MacDonald A, Burrow S, Larson CM, Ayeni OR. Hip Arthroscopy in Trauma: A Systematic Review of Indications, Efficacy, and Complications. Arthroscopy. 2016;32(4):692-703.e1. doi:10.1016/j.arthro.2015.12.029
24. Bushnell BD, Anz AW, Bert JM. Venous thromboembolism in lower extremity arthroscopy. Arthroscopy. 2008;24(5):604-611. doi:10.1016/j.arthro.2007.11.010
25. Bolia IK, Fagotti L, McNamara S, Dornan G, Briggs KK, Philippon MJ. A systematic review-meta-analysis of venous thromboembolic events following primary hip arthroscopy for FAI: clinical and epidemiologic considerations. J Hip Preserv Surg. 2018;5(3):190-201. doi:10.1093/jhps/hny029
26. 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
27. Verhoogt WAM, Pietrzak JRT, Ayeni OR, Cakic JN. Post-operative oral chemoprophylaxis in patients undergoing hip arthroscopy mitigates VTE risk with a low side-effect profile. J Hip Preserv Surg. 2020;7(3):524-532. doi:10.1093/jhps/hnaa063
28. Brown CA, McAdams TR, Harris AHS, Maffulli N, Safran MR. ACL reconstruction in patients aged 40 years and older: a systematic review and introduction of a new methodology score for ACL studies. Am J Sports Med. 2013;41(9):2181-2190. doi:10.1177/0363546513481947