Yasushi Oshima, Hasan Raza Mohammad, Tokifumi Majima, Hemant Pandit.
Response/Recommendation: Routine use ofmechanical and/or chemical thromboprophylaxis for patients undergoing osteotomy around the knee is recommended.
Strength of Recommendation: Moderate.
Rationale: Osteotomies around the knee are used for deformity correction / realignment and is an effective alternative to total knee arthroplasty (TKA) for certain patients with isolated compartment arthritis of the knee. Through osteotomy the mechanical axis is transferred from the arthritic compartment to the adjacent compartment that provides pain relief as well a possible delay in progression of osteoarthritis1. There is currently a general consensus about venous thromboembolism (VTE) prophylaxis following TKA2–4. However, the treatment of VTE following knee osteotomy has not been well-established although the incidence was relatively high from 2.4 to 41%5,6. The rates of deep venous thrombosis (DVT) in the included studies ranged between 0.5% to 25.5%. Sidhu et al., and Giuseffi et al., did not use imaging modalities routinely to check for DVT and reported rates of 0.5% and 1.1%, respectively7,8. Kubota et al., and Onishi et al., performed ultrasonography one week post-operatively and found DVT rates several times higher, with rates of 25.5% and 13.8%, respectively9,10. Kobayashi et al., performed a randomized controlled trial investigating DVT rates via venography following tibial osteotomy. The edoxaban (a factor Xa inhibitor) treated group had a rate of 16.7% compared to the non-edoxaban rate of 21.7%11. The incidence of pulmonary embolism (PE), as reported in three of the five studies. Sidhu et al., report a rate of 0.5%, Giuseffi et al., a rate of 1.1% and Kobayashi et al., reported PE rate of 6.3% in the edoxaban group and 16.7% in the non-edoxaban group7,8,11. None of the studiesreported any VTE related complications such as death, bleeding, or others.
There is scant literature related to the subject of VTE after knee osteotomy. Based on the available data, however, it likely that these patients are at increased risk of DVT and some form of thromboprophylaxis may need to be administered to these patients. Combined with extrapolation from the data from TKA literature, we believe that mechanical and/or chemoprophylaxis (including aspirin) should be effective in these patients.
Table 1. Descriptive and rates of VTE in the included studies.
| Study year (Type) | Number of knees | VTE prophylaxis | Follow up | Demographics | DVT rate | PE rate | Stroke rate | Myocardial infarction rate | Mortality from thromboembolic event | Significant bleeding events |
| Sidhu et al.7 2020 (Observational) | 200 | None unless risk factors in which aspirin prescribed | Minimum 2 years follow up | Mean age: 52.6 years Sex: 143 males Mean BMI 31.7 11 smokers | 1 case (0.5%). Resolved with anticoagulants. | 1 (0.5%) | 0 | 0 | 0 | 0 |
| Kubota et al.9 2021 (Observational) | 137 | None preop. One case prasugurel, aspirin, sarpogrelate and ethyl icospenatate. Post op edoxaban for 2 weeks | 1 weeks. US performed in all cases | Mean age: 62.1 Sex: 37 males Mean BMI 26.2 Smokers: N/A | 35 (25.5%). No symptomatic DVT and all in soleus vein. | 0 | 0 | 0 | 0 | 0 |
| Giuseffi et al.8 2015 (Observational) | 89 | Not stated | Mean: 4 years | Mean age: 48.1 Sex: 64 males Mean BMI: N/A Smokers: 17 | 2 (2.2%) 1 of the above required vascular surgery in the popliteal artery. | 1 (1.1%) | 0 | 0 | 0 | 0 |
| Onishi et al.10 2020 (Observational) | 326 | Postop elastic compression stockings and mechanical compression devices. All patients had edoxaban for one week | US performed 1 month before and 7 days after surgery | Mean age: 61.7 Sex: 151 males Mean BMI: 25.2 Smokers: 17 | 45 (13.8%) | 0 | 0 | 0 | 0 | 0 |
| Kobayashi et al.11 2017 (RCT) | 135 66 edoxaban group 69 non edoxaban group | All had elastic stockings and foot pump. Edoxaban 15/30mg for 14 days. Non edoxaban group had no chemical propylaxis | Angiography performed on day 7 post op | Mean age: 66 Sex: 45 males Mean BMI: 25.6 Smokers: 17 | 11 (16.7%) in edoxaban group 15 (21.7%) in non edoxaban group | 4 (6%) in edoxaban group 11 (15.9%) in non edoxaban group | 0 | 0 | 0 | 0 |
VTE=Venous thromboembolism; DVT=Deep venous thrombosis; PE=Pulmonary embolism; BMI=Body mass index; US=Ultrasound.
References:
1. Sabzevari S, Ebrahimpour A, Roudi MK, Kachooei AR. High Tibial Osteotomy: A Systematic Review and Current Concept. Arch Bone Jt Surg. 2016;4(3):204-212.
2. Bala A, Huddleston JI, Goodman SB, Maloney WJ, Amanatullah DF. Venous Thromboembolism Prophylaxis After TKA: Aspirin, Warfarin, Enoxaparin, or Factor Xa Inhibitors? Clin Orthop Relat Res. 2017;475(9):2205-2213. doi:10.1007/s11999-017-5394-6
3. Tateiwa T, Ishida T, Masaoka T, et al. Clinical course of asymptomatic deep vein thrombosis after total knee arthroplasty in Japanese patients. J Orthop Surg (Hong Kong). 2019;27(2):2309499019848095. doi:10.1177/2309499019848095
4. Zeng Y, Si H, Wu Y, et al. The incidence of symptomatic in-hospital VTEs in Asian patients undergoing joint arthroplasty was low: a prospective, multicenter, 17,660-patient-enrolled cohort study. Knee Surg Sports Traumatol Arthrosc. 2019;27(4):1075-1082. doi:10.1007/s00167-018-5253-3
5. Martin R, Birmingham TB, Willits K, Litchfield R, Lebel M-E, Giffin JR. Adverse event rates and classifications in medial opening wedge high tibial osteotomy. Am J Sports Med. 2014;42(5):1118-1126. doi:10.1177/0363546514525929
6. Miller BS, Downie B, McDonough EB, Wojtys EM. Complications after medial opening wedge high tibial osteotomy. Arthroscopy. 2009;25(6):639-646. doi:10.1016/j.arthro.2008.12.020
7. Sidhu R, Moatshe G, Firth A, Litchfield R, Getgood A. Low rates of serious complications but high rates of hardware removal after high tibial osteotomy with Tomofix locking plate. Knee Surg Sports Traumatol Arthrosc. Published online August 12, 2020. doi:10.1007/s00167-020-06199-8
8. Giuseffi SA, Replogle WH, Shelton WR. Opening-Wedge High Tibial Osteotomy: Review of 100 Consecutive Cases. Arthroscopy. 2015;31(11):2128-2137. doi:10.1016/j.arthro.2015.04.097
9. Kubota M, Kim Y, Inui T, Sato T, Kaneko H, Ishijima M. Risk factor for venous thromboembolism after high tibial osteotomy -analysis of patient demographics, medical comorbidities, operative valuables, and clinical results. J Orthop. 2021;25:124-128. doi:10.1016/j.jor.2021.04.003
10. Onishi S, Iseki T, Kanto R, et al. Incidence of and risk factors for deep vein thrombosis in patients undergoing osteotomies around the knee: comparative analysis of different osteotomy types. Knee Surg Sports Traumatol Arthrosc. Published online October 21, 2020. doi:10.1007/s00167-020-06326-5
11. Kobayashi H, Akamatsu Y, Kumagai K, et al. The use of factor Xa inhibitors following opening-wedge high tibial osteotomy for venous thromboembolism prophylaxis. Knee Surg Sports Traumatol Arthrosc. 2017;25(9):2929-2935. doi:10.1007/s00167-016-4065-6