Paul W. Ackermann, Mathias Granqvist, Gregg R. Klein.
Response/Recommendation: Available data suggests that patients with proximal (above the knee) lower extremity deep venous thrombosis (DVT) may be at higher risk of pulmonary embolism (PE). From the limited evidence, it appears that the majority of patients with distal DVT may be left untreated with no adverse consequences.
Strength of Recommendation: Limited.
Rationale: DVT is a common post-operative complication among patients undergoing orthopaedic procedures1. Compared to other surgical specialities, orthopaedic procedures are associated with a disproportionally high risk of DVT2. Although the incidence of DVT vary between orthopaedic procedures, highest rates of mortality are observed in patients with fractures compared to elective procedures, proximal lower limb as compared to distal and post-operative immobilized and non-weight bearing compared to mobilized and early weightbearing3. Even with thromboprophylaxis, the rate of symptomatic venous thromboembolism (VTE) may be as high as 12% after internal fixation of pelvic fractures, 3.8% after proximal tibia fracture and 3.7% after total knee arthroplasty (TKA)3. Common complications of symptomatic DVT include a risk of PE, post-thrombotic syndrome and chronic venous insufficiency as well as recurrence of DVT and PE4–6. Although DVT proximal to the popliteal vein, as compared to distal DVT, have been thought to exhibit an increased risk of PE, older studies from the 1980’s have shown equal risk between the two7,8. Despite these findings post-surgical venographic or ultrasonographic screening for DVT are not recommended by American Academy of Orthopaedic Surgeons guidelines as it has not been associated with lower complication or readmission rates9. For patients with confirmed above knee DVT, anticoagulant therapy is generally recommended10.
Although perioperative thromboprophylaxis has been widely incorporated into orthopaedic clinical routine, the clinical course of untreated DVT is scarcely documented, especially in Western populations. Moreover, findings are conflicting when compared to studies from Asian populations.
In a randomized control trial (RCT) by McKenna et al., from 1980, 46 patients undergoing TKA were randomized to receive aspirin vs. placebo for VTE11. Nine of these 12 patients in the placebo group who did not receive any prophylaxis developed DVT shown on 123I-fibrinogen scanning and confirmed with phlebography. Three of the four patients who had calf DVT had a PE, one of the two with a popliteal DVT had a PE and none of three patients with femoral DVT developed a PE.
In three prospective studies by Grady-Benson & Oishi et al., from the 1990’s patients undergoing TKA or total hip arthroplasty (THA) were screened with duplex ultrasonography to detect DVT12–14. While all patients with proximal DVT were treated with anticoagulants, distal DVT were left untreated. It was not stated whether the DVT were asymptomatic or not. DVT not diagnosed in the screening procedure but presenting symptomatically at a later point were treated in all three studies. Outcomes from the three studies were conflicting. In one study, no patients with distal DVT presented with either proximal DVT or PE12. In the two other studies, 20% of untreated distal DVT patients propagated to become proximal DVT13,14.
In contrast, a prospective study by Solis from 2002 et al screened 201 patients from Australia undergoing foot and/or ankle surgery with calf duplex ultrasound at the first postoperative visit15. Patients who were not treated with perioperative anticoagulants, and patients with prior VTE or prior on-going anticoagulant treatment due to other medical conditions were excluded. In total, 7 asymptomatic patients screened positive for DVT and were left untreated. Although the duration of the subsequent follow-up of the patients with DVT was not stated, none had evidence of progression on ultrasound or symptoms consistent with thrombosis or pulmonary embolism.
Several studies on Asian populations have documented untreated distal DVT without any severe adverse events16,17.
In a study by Tsuda et al., from 2010 on a South Korean population 185 patients undergoing THA were screened for preoperatively and postoperatively18. Nine patients (5%) with asymptomatic distal DVT were identified, all resolved at 6-months follow-up despite not being treated with anticoagulants.
A subsequent study by the same group followed 742 patients from South Korea undergoing elective THA and recorded 237 postoperative asymptomatic DVT of which 231 were located in calf veins, 5 in popliteal veins and 1 extending from calf to femoral vein, all left untreated19. One of the 5 patients with popliteal vein DVT developed symptomatic non-fatal PE, two of the other four resolved at 6 months follow-up. Of the 231 distal DVT, 93% resolved at 2 years and none developed symptomatic or fatal PE or were readmitted for VTE.
Kim et al.20, reported on 200 Korean patients operated with unilateral THA or one-staged bilateral THA and were screened with venograms postoperative day 6 or 7 and lung perfusions day 7 or 8. They identified 72 patients with DVT out of which 42 (58%) had DVT at or proximal to the popliteal vein. No patients were treated with anticoagulants, and none developed PE or had other adverse effects. All DVT were completely resolved on follow-up venograms after 6 months.
There is limited recent literature available documenting untreated DVTs in patients undergoing orthopaedic procedures. The outcomes differ between study populations where findings from Western populations show higher (though inconsistent) rates of DVT progression compared to studies from Asia. Although data exist to improve patient VTE risk assessment based on factors such as age, body mass index, malignancy, genetic coagulation deficiency and previous VTE, the exact individual risk stratification for adverse consequences and propagation of established DVT is difficult. Repeated duplex ultrasonography or treatment is sometimes recommended for distal DVT, while for proximal DVT antithrombotic therapy is commonly recommended. The risk of adverse consequences for individuals with DVT that are left untreated after orthopaedic procedures is highly variable and mostly inconclusive from current studies.
1. Leclerc JR, Geerts WH, Desjardins L, et al. Prevention of deep vein thrombosis after major knee surgery–a randomized, double-blind trial comparing a low molecular weight heparin fragment (enoxaparin) to placebo. Thromb Haemost. 1992;67(4):417-423.
2. Calfon M, Seddighzadeh A, Piazza G, Goldhaber SZ. Deep vein thrombosis in orthopedic surgery. Clin Appl Thromb Hemost. 2009;15(5):512-516. doi:10.1177/1076029608330471
3. Lapidus LJ, Ponzer S, Pettersson H, de Bri E. Symptomatic venous thromboembolism and mortality in orthopaedic surgery – an observational study of 45 968 consecutive procedures. BMC Musculoskelet Disord. 2013;14:177. doi:10.1186/1471-2474-14-177
4. Khan F, Tritschler T, Kahn SR, Rodger MA. Venous thromboembolism. The Lancet. 2021;398(10294):64-77. doi:10.1016/S0140-6736(20)32658-1
5. Kearon C. Natural history of venous thromboembolism. Circulation. 2003;107(23 Suppl 1):I22-30. doi:10.1161/01.CIR.0000078464.82671.78
6. Beckman MG, Hooper WC, Critchley SE, Ortel TL. Venous thromboembolism: a public health concern. Am J Prev Med. 2010;38(4 Suppl):S495-501. doi:10.1016/j.amepre.2009.12.017
7. Moser KM, LeMoine JR. Is embolic risk conditioned by location of deep venous thrombosis? Ann Intern Med. 1981;94(4 pt 1):439-444. doi:10.7326/0003-4819-94-4-439
8. Turpie AG, Levine MN, Hirsh J, et al. A randomized controlled trial of a low-molecular-weight heparin (enoxaparin) to prevent deep-vein thrombosis in patients undergoing elective hip surgery. N Engl J Med. 1986;315(15):925-929. doi:10.1056/NEJM198610093151503
9. Mont MA, Jacobs JJ, Boggio LN, et al. Preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Am Acad Orthop Surg. 2011;19(12):768-776. doi:10.5435/00124635-201112000-00007
10. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016;149(2):315-352. doi:10.1016/j.chest.2015.11.026
11. McKenna R, Galante J, Bachmann F, Wallace DL, Kaushal PS, Meredith P. Prevention of venous thromboembolism after total knee replacement by high-dose aspirin or intermittent calf and thigh compression. Br Med J. 1980;280(6213):514-517. doi:10.1136/bmj.280.6213.514
12. Grady-Benson JC, Oishi CS, Hanson PB, Colwell CW, Otis SM, Walker RH. Routine postoperative duplex ultrasonography screening and monitoring for the detection of deep vein thrombosis. A survey of 110 total hip arthroplasties. Clin Orthop Relat Res. 1994;(307):130-141.
13. Grady-Benson JC, Oishi CS, Hanson PB, Colwell CW, Otis SM, Walker RH. Postoperative surveillance for deep venous thrombosis with duplex ultrasonography after total knee arthroplasty. J Bone Joint Surg Am. 1994;76(11):1649-1657. doi:10.2106/00004623-199411000-00008
14. Oishi CS, Grady-Benson JC, Otis SM, Colwell CW, Walker RH. The clinical course of distal deep venous thrombosis after total hip and total knee arthroplasty, as determined with duplex ultrasonography. J Bone Joint Surg Am. 1994;76(11):1658-1663. doi:10.2106/00004623-199411000-00009
15. Solis G, Saxby T. Incidence of DVT following surgery of the foot and ankle. Foot Ankle Int. 2002;23(5):411-414. doi:10.1177/107110070202300507
16. Yokote R, Matsubara M, Hirasawa N, Hagio S, Ishii K, Takata C. Is routine chemical thromboprophylaxis after total hip replacement really necessary in a Japanese population? J Bone Joint Surg Br. 2011;93(2):251-256. doi:10.1302/0301-620X.93B2.25795
17. Wang CJ, Wang JW, Weng LH, Hsu CC, Lo CF. Outcome of calf deep-vein thrombosis after total knee arthroplasty. J Bone Joint Surg Br. 2003;85(6):841-844.
18. Tsuda K, Kawasaki T, Nakamura N, Yoshikawa H, Sugano N. Natural course of asymptomatic deep venous thrombosis in hip surgery without pharmacologic thromboprophylaxis in an Asian population. Clin Orthop Relat Res. 2010;468(9):2430-2436. doi:10.1007/s11999-009-1220-0
19. Tsuda K, Takao M, Kim J, Abe H, Nakamura N, Sugano N. Asymptomatic Deep Venous Thrombosis After Elective Hip Surgery Could Be Allowed to Remain in Place Without Thromboprophylaxis After a Minimum 2-Year Follow-Up. J Arthroplasty. 2020;35(2):563-568. doi:10.1016/j.arth.2019.08.062
20. Kim Y-H, Oh SH, Kim JS. Incidence and natural history of deep-vein thrombosis after total hip arthroplasty. A prospective and randomised clinical study. J Bone Joint Surg Br. 2003;85(5):661-665.