Leanne Ludwick, Noam Shohat.
Response/Recommendation: Patients with a previous history of venous thromboembolism (VTE), including both deep venous thrombosis (DVT) and pulmonary embolism (PE), are at a higher risk of developing VTE following orthopaedic procedures.
Strength of Recommendation: Strong.
Rationale: Patients with a previous history of VTE, including both DVT and PE, present a challenge to orthopaedic surgeons when considering postoperative VTE prevention. The recent VTE prophylaxis guidelines presented by the American College of Chest Physicians (ACCP) as well as the American Academy of Orthopaedic Surgeons (AAOS) have identified patients with a previous history of VTE as high-risk for thromboembolism1,2. While questions concerning history of VTE are an important part of a patient’s preoperative protocol when undergoing orthopaedic surgery, it is important to determine if a prior history of VTE, is a significant risk factor for VTE following orthopaedic surgery.
A substantial body of literature exists that reports an increased risk of VTE following surgery in patients with a prior history of a VTE event3–5. Nemeth et al., longitudinal follow-up cohort study determined that patients with a history of VTE who undergo surgery have a significantly higher risk of recurrent VTE compared to those with no history of VTE3. Major orthopaedic surgery was associated with one of the highest risks of recurrence. These findings corroborate with those presented by Bahl et al., which utilized data from the National Surgical Quality Improvement Program (NSQIP) to validate an external VTE risk calculator4. History of VTE was identified as a significant risk factor for developing VTE after general and major orthopaedic surgery.
The association between a previous history of VTE and an increased VTE risk has also been thoroughly studied in the orthopaedic surgery literature. Many of these studies focus on total joint arthroplasty (TJA)6–9, spine surgery7,10,11, and below the knee procedures12, as they carry the highest risk of postoperative VTE13. Zhang et al., systematic review on VTE risk factors following TJA identified nine significant risk factors for VTE and found history of VTE to be the most significant9. Additionally, a VTE risk calculator developed by Parvizi et al., for patients undergoing TJA using National Inpatient Sample (NIS) data identified history of VTE to be a major risk factor6. Studies focusing on VTE in other orthopaedic specialties, such as spine and foot and ankle, have similarly found history of VTE to incur a greater postoperative VTE risk. The NSQIP data utilized in McLynn et al., study, looked into characterize risk factors for VTE after elective spine surgery14. Through the use of multivariate logistic regression analysis, the authors found a significant association between history of prior VTE with postoperative VTE. Similarly, in Heijboer et al., study on VTE following below the knee orthopaedic surgeries, they determined history of VTE to be a significant risk factor12. While the incidence is low, history of VTE has also been associated with an increased rate of VTE following both lower and upper limb arthroscopic procedures15–17.
While it is widely accepted that a previous history of VTE is associated with a greater VTE risk, it is difficult to validate through a randomized controlled trial as patients with a history of VTE are generally excluded from these studies. However, the vast amount of retrospective data from both institutional and national patient databases demonstrates the important association between the two events. Additionally, as many externally-validated risk stratification tools include history of VTE in their calculation, it is essential to consider history of VTE when deciding on postoperative VTE prevention in patients undergoing orthopaedic surgery6,18.
1. 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
2. Jacobs JJ, Mont MA, Bozic KJ, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Bone Joint Surg Am. 2012;94(8):746-747. doi:10.2106/JBJS.9408.ebo746
3. Nemeth B, Lijfering WM, Nelissen RGHH, et al. Risk and Risk Factors Associated With Recurrent Venous Thromboembolism Following Surgery in Patients With History of Venous Thromboembolism. JAMA Network Open. 2019;2(5):e193690-e193690. doi:10.1001/jamanetworkopen.2019.3690
4. Bahl V, Hu HM, Henke PK, Wakefield TW, Campbell DAJ, Caprini JA. A Validation Study of a Retrospective Venous Thromboembolism Risk Scoring Method. Annals of Surgery. 2010;251(2):344-350. doi:10.1097/SLA.0b013e3181b7fca6
5. Anderson FA, Spencer FA. Risk Factors for Venous Thromboembolism. Circulation. 2003;107(23_suppl_1):I-9. doi:10.1161/01.CIR.0000078469.07362.E6
6. Parvizi J, Huang R, Rezapoor M, Bagheri B, Maltenfort MG. Individualized Risk Model for Venous Thromboembolism After Total Joint Arthroplasty. J Arthroplasty. 2016;31(9 Suppl):180-186. doi:10.1016/j.arth.2016.02.077
7. Charen DA, Qian ET, Hutzler LH, Bosco JA. Risk Factors for Postoperative Venous Thromboembolism in Orthopaedic Spine Surgery, Hip Arthroplasty, and Knee Arthroplasty Patients. Bull Hosp Jt Dis (2013). 2015;73(3):198-203.
8. Memtsoudis SG, Besculides MC, Gaber L, Liu S, González Della Valle A. Risk factors for pulmonary embolism after hip and knee arthroplasty: a population-based study. International Orthopaedics (SICOT). 2008;33(6):1739. doi:10.1007/s00264-008-0659-z
9. Zhang Z hao, Shen B, Yang J, Zhou Z ke, Kang P de, Pei F xing. Risk factors for venous thromboembolism of total hip arthroplasty and total knee arthroplasty: a systematic review of evidences in ten years. BMC Musculoskeletal Disorders. 2015;16(1):24. doi:10.1186/s12891-015-0470-0
10. Cloney M, Dhillon ES, Roberts H, Smith ZA, Koski TR, Dahdaleh NS. Predictors of Readmissions and Reoperations Related to Venous Thromboembolic Events After Spine Surgery: A Single-Institution Experience with 6869 Patients. World Neurosurg. 2018;111:e91-e97. doi:10.1016/j.wneu.2017.11.168
11. Brambilla S, Ruosi C, La Maida GA, Caserta S. Prevention of venous thromboembolism in spinal surgery. Eur Spine J. 2004;13(1):1-8. doi:10.1007/s00586-003-0538-7
12. Heijboer RRO, Lubberts B, Guss D, Johnson AH, DiGiovanni CW. Incidence and Risk Factors Associated with Venous Thromboembolism After Orthopaedic Below-knee Surgery. J Am Acad Orthop Surg. 2019;27(10):e482-e490. doi:10.5435/JAAOS-D-17-00787
13. Kahn SR, Shivakumar S. What’s new in VTE risk and prevention in orthopedic surgery. Res Pract Thromb Haemost. 2020;4(3):366-376. doi:10.1002/rth2.12323
14. McLynn RP, Diaz-Collado PJ, Ottesen TD, et al. Risk factors and pharmacologic prophylaxis for venous thromboembolism in elective spine surgery. The Spine Journal. 2018;18(6):970-978. doi:10.1016/j.spinee.2017.10.013
15. Bushnell BD, Anz AW, Bert JM. Venous Thromboembolism in Lower Extremity Arthroscopy. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2008;24(5):604-611. doi:10.1016/j.arthro.2007.11.010
16. Hastie GR, Pederson A, Redfern D. Venous thromboembolism incidence in upper limb orthopedic surgery: do these procedures increase venous thromboembolism risk? J Shoulder Elbow Surg. 2014;23(10):1481-1484. doi:10.1016/j.jse.2014.01.044
17. Krych AJ, Sousa PL, Morgan JA, Levy BA, Stuart MJ, Dahm DL. Incidence and Risk Factor Analysis of Symptomatic Venous Thromboembolism After Knee Arthroscopy. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2015;31(11):2112-2118. doi:10.1016/j.arthro.2015.04.091
18. Cronin M, Dengler N, Krauss ES, et al. Completion of the Updated Caprini Risk Assessment Model (2013 Version). Clin Appl Thromb Hemost. 2019;25. doi:10.1177/1076029619838052