William Geerts, Nicholas Siegel, Jose A. Canseco.
Response/Recommendation: While surgical positioning may influence the venous thromboembolism (VTE) risk after some orthopaedic surgical procedures, there are no high-quality studies addressing this issue. We recommend that surgeons base these decisions on optimal surgical site access/exposure as well as their technical expertise rather than as a strategy to reduce VTE risk.
Strength of Recommendation: Consensus.
Rationale: Intraoperative patient positioning has been shown influence operative time, blood loss, and VTE risk in a variety of surgical procedures1. Surgical positioning, which is inextricably related to surgical site approach, may affect all three components of Virchow’s triad. For example, the prone position often leads to reduced venous return due to abdominal compression and compression of femoral veins1; intraoperative hip and knee extension may also decrease venous drainage from the legs2. Therefore, patient positioning has been proposed as a potentially modifiable risk factor for VTE in orthopaedic patients. However, data on this topic is extremely limited and is too heterogenous to allow the determination of VTE rates with different intraoperative positions for any given orthopaedic procedure. More important surgical risk factors include the surgical approach as well as type of procedure.
Shoulder: Open or arthroscopic shoulder surgery can be performed either with the patient positioned in the lateral decubitus or the beach-chair position3. Although the risk of VTE is very low after shoulder surgery, some reports have suggested that DVT of the upper or lower extremity is more common following the lateral decubitus position4–6. However, due to the paucity of studies on this issue, it is still premature to conclude whether or not patient position affects VTE rate after shoulder surgery.
Spine: The prone position during spine surgery may significantly increase intra-abdominal pressure, reduce venous return and increase bleeding rates compared to other positions7,8. In a population database that included 357,926 spine surgeries, VTE was recorded in 0.9% of patients operated in the supine position and 1.6% after a procedure in the prone position (hazard ratio [HR] = 1.8)9. However, the rate of VTE was more affected by the underlying diagnosis and type of procedure. The recent 2019 Congress of Neurological Surgeons evidence-based guidelines on treatment of thoracolumbar spine trauma did not address intraoperative positioning and did not recommend a specific surgical approach10.
Pelvic fracture repair: Various surgical approaches in pelvic fracture repair may be associated with different rates of deep venous thrombosis (DVT); however, there were no high-quality studies assessing the impact of patient positioning on the risk of VTE following this procedure11,12.
Hip fracture repair: A randomized trial that allocated 120 elderly patients with intertrochanteric hip fractures to the lateral decubitus or supine intraoperative position reported only one DVT after surgery13. Similarly, another study of 102 patients undergoing intertrochanteric hip fracture repair found no significant difference in any postoperative complication, including VTE, between supine and lateral positioning, although surgical time and blood loss were greater in the supine group14.
Total hip arthroplasty (THA): Using intraoperative venography or Doppler ultrasound, previous studies have shown that posterior and lateral approaches to the hip may result in obstruction of the common femoral vein15,16. However, femoral vein compression was not seen with anterior approaches17. No cases of VTE were reported in a randomized trial of 100 patients undergoing THA using an anterior or lateral approach18. In a small, retrospective, before-after study, Kawano et al., utilized a lateral approach for THA performed in the lateral decubitus position and then switched to an anterior approach in the supine position19. Surprisingly, asymptomatic DVT based on routine screening with either computer tomography (CT) or ultrasound two weeks after surgery was found in 5% of the 80 patients in the lateral decubitus group and 19% of the 36 patients in the supine group. However, DVT was more common in earlier cases in the supine group compared to later cases (33% vs 6%), suggesting that surgical experience had a greater impact on DVT incidence compared to surgical approach or patient position.
Total knee arthroplasty (TKA): A Doppler ultrasound study conducted intraoperatively before a TKA procedure found that calf venous blood flow was significantly reduced with knee flexion of at least 90o, and that postoperative DVT (especially proximal DVT) occurred more commonly in patients with the lowest preoperative venous flow velocity after knee flexion20. The authors concluded that marked knee flexion during TKA reduced venous blood flow and may have increased DVT risk. However, two meta-analyses of randomized control trial (RCT) in TKA patients found that postoperative knee flexion following TKA was not associated with a significant difference in VTE rate compared to knee extension21,22.
Other orthopaedic procedures: A study on 68 patients undergoing elective Achilles tendon repair reported no VTE events in patients who underwent surgery in the prone and lateral decubitus positions23.
Conclusion: There appears to be a difference in VTE rates with different intraoperative patient positions following certain orthopaedic procedures such as spine surgery. However, any observed differences were small compared to the risk associated with the procedure itself. Consequently, it is recommended that intraoperative patient positioning should be based on considerations such as optimal access to the surgical site as well as the technical proficiency of the surgeon, rather than VTE risk. Regardless of patient positioning, other important factors that may decrease VTE risk include careful intraoperative positioning and padding, avoidance of dehydration, prevention of increased intraabdominal pressure, use of regional anesthesia, minimally invasive procedures, rapid postoperative mobilization, and adequate postoperative pain control24. When excessive venous stasis is anticipated to occur, intraoperative use of sequential compression devices should be considered alongside risk-appropriate pharmacologic thromboprophylaxis25.
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2. Pannucci CJ, Henke PK, Cederna PS, et al. The effect of increased hip flexion using stirrups on lower-extremity venous flow: a prospective observational study. Am J Surg. 2011;202(4):427-432. doi:10.1016/j.amjsurg.2011.04.002
3. Li X, Eichinger JK, Hartshorn T, Zhou H, Matzkin EG, Warner JP. A comparison of the lateral decubitus and beach-chair positions for shoulder surgery: advantages and complications. J Am Acad Orthop Surg. 2015;23(1):18-28. doi:10.5435/JAAOS-23-01-18
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8. Akinci IO, Tunali U, Kyzy AA, et al. Effects of prone and jackknife positioning on lumbar disc herniation surgery. J Neurosurg Anesthesiol. 2011;23(4):318-322. doi:10.1097/ANA.0b013e31822b4f17
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12. Chen K, Ji Y, Huang Z, et al. Single Modified Ilioinguinal Approach for the Treatment of Acetabular Fractures Involving Both Columns. J Orthop Trauma. 2018;32(11):e428-e434. doi:10.1097/BOT.0000000000001303
13. Xue L, Zha L, Chen Q, et al. Randomized controlled trials of proximal femoral nail antirotation in lateral decubitus and supine position on treatment of intertrochanteric fractures. ScientificWorldJournal. 2013;2013:276015. doi:10.1155/2013/276015
14. Li M, Chen J, Ma Y, Li Z, Qin J. [Comparison of proximal femoral nail anti-rotation operation in traction bed supine position and non-traction bed lateral position in treatment of intertrochanteric fracture of femur]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2020;34(1):32-36. doi:10.7507/1002-1892.201905076
15. Stamatakis JD, Kakkar VV, Sagar S, Lawrence D, Nairn D, Bentley PG. Femoral vein thrombosis and total hip replacement. Br Med J. 1977;2(6081):223-225. doi:10.1136/bmj.2.6081.223
16. Warwick D, Martin AG, Glew D, Bannister GC. Measurement of femoral vein blood flow during total hip replacement. Duplex ultrasound imaging with and without the use of a foot pump. J Bone Joint Surg Br. 1994;76(6):918-921.
17. Stryker LS, Gilliland JM, Odum SM, Mason JB. Femoral Vessel Blood Flow Is Preserved Throughout Direct Anterior Total Hip Arthroplasty. J Arthroplasty. 2015;30(6):998-1001. doi:10.1016/j.arth.2015.01.012
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19. Kawano T, Kijima H, Yamada S, et al. A Comparison of the Incidences of Venous Thromboembolism after Total Hip Arthroplasty between the Direct Anterior Approach and the Direct Lateral Approach, Especially in the Early Period after Introduction of the Direct Anterior Approach. Adv Orthop. 2020;2020:4649207. doi:10.1155/2020/4649207
20. Hadžimehmedagić A, Gavrankapetanović I, Vranić H, et al. Haemodynamic assessment in simulated operative positions before knee arthroplasty can be useful in deep vein thrombosis prediction. Int Orthop. 2015;39(9):1793-1796. doi:10.1007/s00264-015-2837-0
21. Fu X, Tian P, Li Z, Sun X, Ma X. Postoperative leg position following total knee arthroplasty influences blood loss and range of motion: a meta-analysis of randomized controlled trials. Curr Med Res Opin. 2016;32(4):771-778. doi:10.1185/03007995.2016.1142431
22. Wu Y, Yang T, Zeng Y, Si H, Li C, Shen B. Effect of different postoperative limb positions on blood loss and range of motion in total knee arthroplasty: An updated meta-analysis of randomized controlled trials. Int J Surg. 2017;37:15-23. doi:10.1016/j.ijsu.2016.11.135
23. Bullock MJ, DeCarbo WT, Hofbauer MH, Thun JD. Repair of Chronic Achilles Ruptures Has a High Incidence of Venous Thromboembolism. Foot Ankle Spec. 2017;10(5):415-420. doi:10.1177/1938640016679706
24. Petersen PB, Kehlet H, Jørgensen CC, Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement Collaborative Group. Safety of In-Hospital Only Thromboprophylaxis after Fast-Track Total Hip and Knee Arthroplasty: A Prospective Follow-Up Study in 17,582 Procedures. Thromb Haemost. 2018;118(12):2152-2161. doi:10.1055/s-0038-1675641
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