94 – Should the post-operative rehabilitation of patients who have confirmed symptomatic DVT be modified?

Yong-Han Cha, Yavuz Saglam, Jun-Il Yoo, Kyung-Hoi Koo.

Response/Recommendation: There is no supportive evidence to modify or change patients’ post-operative rehabilitation with symptomatic venous thromboembolic (VTE) events following total joint arthroplasty (TJA). The postoperative rehabilitation needs not to be modified in symptomatic VTE patients.

Strength of Recommendation: Strong.

Rationale: Patients undergoing orthopaedic surgery are at risk of VTE1-8. Rehabilitation including early ambulation is of utmost importance to prevent VTE9,10. Even with multimodal thromboprophylaxis, some patients undergoing orthopaedic surgery acquire VTE11-13.

A concern: whether the post-operative rehabilitation protocol including early ambulation in symptomatic VTE patients should be changed or not, was raised. To address that concern, we have conducted an extensive search and identified 544 articles: 275 from MEDLINE/PubMed; 237 from EMBASE; nine from the Cochrane Library; and 23 from a hand search. However, we found no study, which reported that the post-operative rehabilitation aggravates the VTE or suggested modifying the post-operative rehabilitation program in symptomatic VTE patients. At this time, there is no evidence to change the rehabilitation in these patients, and the post-operative rehabilitation of patients who have confirmed symptomatic deep venous thrombosis (DVT) need not be modified.

References:

1.         Born TR, Engasser WM, King AH, Krych AJ, Dahm DL, Levy BA, et al., Low frequency of symptomatic venous thromboembolism after multiligamentous knee reconstruction with thromboprophylaxis. Clinical orthopaedics and related research. 2014;472(9):2705-11.

2.         Schick CW, Westermann RW, Gao Y, and Wolf BR. Thromboembolism Following Shoulder Arthroscopy: A Retrospective Review. Orthopaedic journal of sports medicine. 2014;2(11):2325967114559506.

3.         Khazi ZM, An Q, Duchman KR, Westermann and RW. Incidence and Risk Factors for Venous Thromboembolism Following Hip Arthroscopy: A Population-Based Study. Arthroscopy : The journal of arthroscopic & related surgery 2019;35(8):2380-4.e1.

4.         Raksin PB, Harrop JS, Anderson PA, Arnold PM, Chi JH, Dailey AT, et al., Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Prophylaxis and Treatment of Thromboembolic Events. Neurosurgery. 2019;84(1):E39-e42.

5.         Grossfeld A, Dekel S, Lerman Y, Sherman S, Atzmony L, Salai M, et al., Symptomatic venous thromboembolism in elderly patients following major orthopedic surgery of the lower limb is associated with elevated vitamin B12 serum levels. Clinical biochemistry. 2013;46(1-2):54-8.

6.         Lee YK, Choi YH, Ha YC, Lim JY, and Koo KH. Does venous thromboembolism affect rehabilitation after hip fracture surgery? Yonsei medical journal. 2013;54(4):1015-9.

7.         Reynolds AW, Garay M, Lynch S, Black KP,  and Gallo RA. Incidence of Venous Thromboembolism following Knee Arthroscopy: Effectiveness of a Risk-Based Stratified Chemoprophylaxis Protocol. The journal of knee surgery. 2020.

8.         Saragas NP,  and Ferrao PN. The incidence of venous thromboembolism in patients undergoing surgery for acute Achilles tendon ruptures. Foot and ankle surgery  2011;17(4):263-5.

9.         Pearse EO, Caldwell BF, Lockwood RJ, and Hollard J. Early mobilisation after conventional knee replacement may reduce the risk of postoperative venous thromboembolism. The Journal of bone and joint surgery British volume. 2007;89(3):316-22.

10.       Windisch C, Kolb W, Kolb K, Grützner P, Venbrocks R, and Anders J. Pneumatic compression with foot pumps facilitates early postoperative mobilisation in total knee arthroplasty. International orthopaedics. 2011;35(7):995-1000.

11.       Dorr LD, Gendelman V, Maheshwari AV, Boutary M, Wan Z, and Long WT. Multimodal thromboprophylaxis for total hip and knee arthroplasty based on risk assessment. The Journal of bone and joint surgery American volume. 2007;89(12):2648-57.

12.       Harrison-Brown M, Scholes C, Douglas SL, Farah SB, Kerr D, and Kohan L. Multimodal thromboprophylaxis in low-risk patients undergoing lower limb arthroplasty: A retrospective observational cohort analysis of 1400 patients with ultrasound screening. Journal of orthopaedic surgery (Hong Kong). 2020;28(2):2309499020926790.

13.       Lewis S, Glen J, Dawoud D, Dias S, Cobb J, Griffin XL, et al., Venous thromboembolism prophylaxis strategies for people undergoing elective total knee replacement: a systematic review and network meta-analysis. The Lancet Haematology. 2019;6(10):e530-e9.