- Email: [email protected]
The Role of Deep Venous Thrombosis Prophylaxis After Anterior Cruciate Ligament Reconstruction
The Role of Deep Venous Thrombosis Prophylaxis After Anterior Cruciate Ligament Reconstruction Ljiljana Bogunovic, MD,* Akshay Jain, BS,* Kirk Campbell, MD,* and Rick W. Wright, MD† Anterior cruciate ligament (ACL) reconstruction is one of the most commonly performed orthopaedic procedures. Venous thromboembolism is a rare, but potentially serious complication of ACL reconstructions and having a thorough understanding of the potential risk factors could help to minimize the incidence of postoperative deep vein thrombosis or pulmonary embolism. We review some of the literature on the risk factors, diagnosis and treatment of deep vein thrombosis or pulmonary embolism. Although current data does not support the routine use of thromboprophylaxis in all patients undergoing ACL reconstruction, it is important for the clinician to be aware of that some consideration should be given for initiating pharmacological prophylaxis in some patients who may be at increased risk for thromboembolic disease. Oper Tech Sports Med ]:]]]-]]] C 2015 Published by Elsevier Inc. KEYWORDS ACL, Anterior cruciate ligament, DVT, PE, DVT prophylaxis
Introduction
V
enous thromboembolism (VTE) is an infrequent, but potentially fatal complication of orthopaedic surgery.1 This disease process consists of 2 entities: deep venous thrombosis (DVT) and the more life-threatening manifestation, pulmonary embolism (PE). Anterior cruciate ligament (ACL) reconstruction is one of the most common orthopaedic procedures, with over 100,000 cases performed each year in the United States alone.2 Postoperative VTE is an uncommon, but potentially devastating complication of this operation. The associated morbidity and mortality can be significant. As such, a thorough understanding of the incidence, risk factors and potential methods for prevention is critical to optimizing the safety of our surgical patients.
Incidence The reported incidence of VTE following arthroscopic procedures of the knee ranges from 0.03%-41.2%.3-7 This variability *Department of Orthopaedic Surgery, Rush University, Chicago, IL. †Department of Orthopaedics, Washington University, Saint Louis, MO. Address reprint requests to Lily Bogunovic, Department of Orthopaedic Surgery, Rush University, 1611 Harrison St, Suite 300, Chicago, IL 60612. E-mail: [email protected]
http://dx.doi.org/10.1053/j.otsm.2015.09.003 1060-1872//& 2015 Published by Elsevier Inc.
arises from inclusion of mixed patient cohorts (routine arthroscopy combined with arthroscopically assisted ACL reconstruction) and from differences in postoperative surveillance with some studies utilizing routine DVT screening on all patients and others reporting screening in symptomatic patients only. In a retrospective review of over 400,000 arthroscopic knee procedures, a symptomatic PE occurred within 90 days of surgery in 0.028% of patients, including one death (rate 0.0002%).6 In the 117 patients with a postoperative PE, an ACL reconstruction was performed in 15%. In another retrospective review of 20,770 arthroscopic knee procedures, a symptomatic DVT and PE developed in 0.25% and 0.17% of patients, respectively.8 Increased rates of postoperative VTE have been reported by several prospective studies, which utilize routine postoperative screening with ultrasound or venography. In a cohort of 537 patients undergoing ACL reconstruction, posterior cruciate ligament (PCL) reconstruction or combined ACL and PCL reconstruction, routine postoperative venography identified a DVT in 14.5% of patient; however, clinical signs and symptoms of DVT were evident in only 3.7% of patients.9 StrujikMulder et al,10 prospectively evaluated 100 patients with compression ultrasonography following ACL reconstruction. Routine screening identified a proximal DVT in 9% of patients, in whom, less than half (4%) were symptomatic.10 One patient developed a non–fatal PE during the 8-week follow-up 1
L. Bogunovic et al.
2 period.10 In a systematic review assessing the rate of DVT and PE following ACL reconstruction in patients who did not receive postprocedural anticoagulation, the overall DVT rate was noted to 8.4%, and the rate of symptomatic PE in was found to be 0.2%.2 Of those patients found to have a DVT, only 27% were symptomatic.
Risk Factors Multiple factors have been identified to affect the risk of VTE following orthopaedic surgery. Recognition of these factors allows for improved understanding of a given patient’s overall DVT or PE risk and provides guidance for potential risk factor modification.
Age Increased patient age is one of the most consistently reported risk factors for VTE following ACL reconstructions.5,6,8-11 The impact of age appears to be dose dependent with risk progressively increasing with increasing age.6,12 An increase in the rate of DVT or PE has been shown to occur as early as 30-35 years of age.5,9,11 For patients over the age of 40, the risk of a PE has been reported to be increased more than 6 fold.6
Inherent Hypercoagulability Inherited abnormalities in clotting function can predispose patients to postoperative VTE. Protein C and Protein S deficiency are 2 of the most common inherited clotting disorders, occurring in approximately 1 of every 500 people. Deficiency of either anticoagulant increases the affected individual’s risk of developing a DVT or PE by up to 11-fold.1,13 All surgical patients should be questioned about a personal or family history thromboembolic events. A significant history may signal an inherited disorder and warrants further testing and/or referral to a hematologist. In those patients with a confirmed diagnosis of hypercoagulability, measures such as perioperative chemoprophylaxis should be taken to minimize the risk of postoperative thromboembolic complications.
Gender The impact of gender on the risk of postoperative VTE remains unclear. Although some studies identify female gender as an independent risk factor, others report no difference in DVT/PE rates among genders.5,6,9,14 In a study of over 400,000 mixed knee arthroscopy procedures, female gender was associated with a 1.5-fold increase risk of PE.6 Notably, the use of oral contraceptives among female patients, a well-known risk factor for thromboembolism, was not reported in this cohort.
Malignancy Underlying malignancy has been shown to increase an individual’s propensity toward VTE. The risk of PE following arthroscopic knee surgery has been reported to be 3 times as high in patients with a history of cancer.6 The prothrombotic
mileu generated by a cancerous state is implicated in the increased propensity to abnormal clotting.
Oral Contraceptive Use The use of oral contraceptive is also associated with an increased risk of VTE.1,8,13 Maletis et al8 reported a postoperative incidence of symptomatic VTE in 0.63% of females taking oral contraceptives, compared with 0.30% in those females not taking medication. In this study, female gender was not an independent risk factor for postoperative DVT or PE.8 The increase risk associated with oral contraceptive use is further heightened in women with an underlying inherited hypercoagulability syndrome.13 Jannsen and Sala,1 reported a case of fatal PE following ACL reconstruction in an 18-year-old female patients. In this patient, oral contraceptive use combined with an underlying inherited hypercoagulability syndrome was implicated as the primary cause.1
Tourniquet Time A lower extremity tourniquet is frequently utilized during knee arthroscopy and ACL reconstruction. Tourniquet use has been associated with an increased rate of postoperative DVT or PE.15,16 The endothelial injury generated by surgery, combined with the stasis created with a tourniquet is believed to promote intravascular clot formation. In as meta-analysis of randomized controlled trials comparing the rate of VTE following total knee arthroplasty, Yi et al15 reported a higher rate of postoperative DVT (relative risk ¼ 2.63) when a tourniquet was utilized compared to when it was not. The length of use appears to affect of impact of tourniquet use on DVT/PE risk. Multiple studies demonstrate increased rates of VTE when tourniquet times exceed 90 minutes.6,16,17
Surgical Complexity Increased operative time and surgical complexity have been reported as a risk factors for postoperative VTE.6,16,18 These 2 factors are likely linked, with greater surgical complexity requiring greater time to complete. Compared to arthroscopic knee procedures performed in o30 minutes, those requiring o90 minutes have been associated with a 3-fold increase rate of PE.6 Compared to isolated ACL reconstruction, both Sun et al9 and Dong et al,16 reported an increased rate of postoperative DVT following multiligamentous knee reconstruction, with a particular increase in DVT with procedures involving reconstruction of the PCL.
Diagnosis The diagnosis of DVT or PE can prove difficult. The classic physical examination signs of increased pain, swelling, warmth and redness, are found in less than 50% of patients and may be masked by postoperative pain and swelling. The surgeon must maintain a high index of suspicion, especially in those patients with known risk factors. Advanced imaging with ultrasound or venography can help to confirm the diagnosis in those patients
DVT Prophylaxis for ACL Reconstruction in whom a DVT is suspected, but routine screening is not recommended for all patients.19
Treatment Anticoagulation therapy is recommended in all patients with an acute symptomatic or asymptomatic proximal lower extremity DVT and PE.20 Postsurgical DVT or PE should be treated with paternal anticoagulant therapy (low-molecularweight heparin [LMWH]) or with oral rivaroxaban for a duration of 3 months.20 Additional thrombolytic therapy is recommended in patients presenting with combined PE and hypotension. Patients with distal DVTs (both symptomatic and asymptomatic) can choose between the standard anticoagulation treatment and serial screening to monitor for progression. Progression, if noted, is managed with standard anticoagulation therapy regimen.
Prophylaxis Several studies have been performed to investigate the efficacy of routine thromboprophylaxis following knee arthroscopy.11,21-23 In a randomized control trial of 1317 patients undergoing knee arthroscopy Camporese et al,22 reported a 72% relative risk reduction in DVT in patients who received LMWH for 7 days postoperatively in comparison to patients who only wore graduated compression stockings for that same time period. There were no significant differences found in clinically relevant bleeding episodes between the 2 groups.22 In a randomized clinical trial of 130 patients, Michot et al,21 reported similar results when comparing thromboprophylaxis with dalteparin to placebo. Over 15% of patients who received no prophylaxis developed a DVT, compared to 1.5% of treated patients. In this study, an increased rate of bleeding complication was seen with dalteparin therapy (12% vs 16%).21 Wirth et al,23 compared routine prophylaxis with LMWH to no intervention in 262 patients. In this study, thromboprophylaxis was associated with a decreased rate of DVT detected by ultrasound (4.1% treated vs 0.85% controls) without an increased rate of bleeding complications.23 Finally, Marvoltis et al,11 examined the efficacy of LMWH for the prevention of DVT or PE in 175 patients undergoing ACL reconstruction. Routine postoperative venography demonstrated a DVT in 2.8% of treated patients compared to 41.2% of untreated patients.11 The routine postoperative DVT screening in all patients in the above studies must be considered along with the data provided. In a recent review of studies utilizing routine screening following ACL reconstruction, up to 73% of identified DVTs were noted to be asymptomatic.2 The clinical relevance of asymptomatic DVT remains unknown, as does the potential benefit of prevention. As such, several authors and the American College of Chest Physicians currently recommend against the routine use of thromboprophylaxis following knee arthroscopy in individuals with no history of DVT or PE.7,11,24,25
3
Conclusion VTE is a rare but potentially serious complication of ACL reconstructions. Factors known to increase an individual’s risk of DVT or PE include increasing age, inherited hypercoagulability, a history of malignancy, oral contraceptive use, and prolonged surgical and tourniquet time. Although routine postoperative screening is not recommended in all patients, assessment with ultrasound or venography can help confirm the diagnosis in patients in whom DVT is suspected. Patients with a PE or proximal DVT should be placed on an anticoagulation therapy regimen, whereas those with distal DVTs may elect for serial monitoring. The current data does not support the routine use of thromboprophylaxis in patients undergoing ACL reconstruction.
References 1. Janssen RPA, Sala HAGM: Fatal pulmonary embolism after anterior cruciate ligament reconstruction. Am J Sports Med 35(6):1000-1002, 2007 2. Erickson B, Saltzman B, Campbell K, et al: Rates of deep venous thrombosis and pulmonary emobolus after anterior anterior cruciate ligament reconstruction: A systematic review. Sports Health 7 (3):261-266, 2015 3. Cullison TR, Muldoon MP, Gorman JD, et al: The incidence of deep venous thrombosis in anterior cruciate ligament reconstruction. Arthroscopy 12(6):657-659, 1996 4. Andrés-Cano P, Godino M, Vides M, et al: Postoperative complications of anterior cruciate ligament reconstruction after ambulatory surgery. Rev Esp Cir Ortop Traumatol 59(3):157-164, 2015 5. Ye S, Dongyang C, Zhihong X, et al: The incidence of deep venous thrombosis after arthroscopically assisted anterior cruciate ligament reconstruction. Arthroscopy 29(4):742-747, 2013 6. Hetsroni I, Lyman S, Do H, et al: Symptomatic pulmonary embolism after outpatient arthroscopic procedures of the knee: The incidence and risk factors in 418,323 arthroscopies. J Bone Joint Surg Br 93(1):47-51, 2011 7. Adala R, Anand A, Kodikal G: Deep vein thrombosis and thromboprophylaxis in arthroscopic anterior cruciate ligament reconstruction. Indian J Orthop 45(5):450-453, 2011 8. Maletis GB, Inacio MCS, Reynolds S, et al: Incidence of symptomatic venous thromboembolism after elective knee arthroscopy. J Bone Joint Surg Am 94(8):714-720, 2012 9. Sun Y, Chen D, Xu Z, et al: Incidence of symptomatic and asymptomatic venous thromboembolism after elective knee arthroscopic surgery: A retrospective study with routinely applied venography. Arthroscopy 30(7):818-822, 2014 10. Struijk-Mulder MC, Ettema HB, CCPM Verheyen, et al: Deep vein thrombosis after arthroscopic anterior cruciate ligament reconstruction: A prospective cohort study of 100 patients. Arthroscopy 29 (7):1211-1216, 2013 11. Marlovits S, Striessnig G, Schuster R, et al: Extended-duration thromboprophylaxis with enoxaparin after arthroscopic surgery of the anterior cruciate ligament: A prospective, randomized, placebo-controlled study. Arthroscopy 23(7):696-702, 2007 12. Mauck KF, Froehling DA, Daniels PR, et al: Incidence of venous thromboembolism after elective knee arthroscopic surgery: A historical cohort study. J Thromb Haemost 11(7):1279-1286, 2013 13. Lipe B, Ornstein DL: Deficiencies of natural anticoagulants, protein C, protein S, and antithrombin. Circulation 124(14):e365-e368, 2011 14. Sun Y, Chen D, Xu Z, et al: Deep venous thrombosis after knee arthroscopy: A systematic review and meta-analysis. Arthroscopy 30 (3):406-412, 2014 15. Yi S, Tan J, Chen C, et al: The use of pneumatic tourniquet in total knee arthroplasty: A meta-analysis. Arch Orthop Trauma Surg 134 (10):1469-1476, 2014
4 16. Dong J-T, Wang X, Men X-Q, et al: Incidence of deep venous thrombosis in Chinese patients undergoing arthroscopic knee surgery for cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 23 (12):3540-3544, 2015 17. Demers C, Marcoux S, Ginsberg JS, et al: Incidence of venographically proved deep vein thrombosis after knee arthroscopy. Arch Intern Med 158(1):47-50, 1998 18. Kim S-J, Kim S-H, Kim S-G, et al: Comparison of the clinical results of three posterior cruciate ligament reconstruction techniques: Surgical technique. J Bone Joint Surg Am 92(1):145-157, 2010 (suppl Pt 2) 19. Bates SM, Jaeschke R, Stevens SM, et al: Diagnosis of DVT: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2): e351S-e418S, 2012 (suppl) 20. Kearon C, Akl EA, Comerota AJ, et al: Antithrombotic therapy for VTE disease: Antithromboitc therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 142(6):1698-1704, 2012
L. Bogunovic et al. 21. Michot M, Conen D, Holtz D, et al: Prevention of deep-vein thrombosis in ambulatory arthroscopic knee surgery: A randomized trial of prophylaxis with low-molecular weight heparin. Arthroscopy 18(3):257-263, 2002 22. Camporese G, Bernardi E, Prandoni P, et al: Low-molecular-weight heparin versus compression stockings for thromboprophylaxis after knee arthroscopy: A randomized trial. Ann Intern Med 149(2):73-82, 2008 23. Wirth T, Schneider B, Misselwitz F, et al: Prevention of venous thromboembolism after knee arthroscopy with low-molecular weight heparin (reviparin): Results of a randomized controlled trial. Arthroscopy 17(4):393-399, 2001 24. Ageno W, Gallus AS, Wittkowsky A, et al: Oral anticoagulant therapy: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2):e44S-e88S, 2012 (suppl) 25. Graham WC, Flanigan DC: Venous thromboembolism following arthroscopic knee surgery: A current concepts review of incidence, prophylaxis, and preoperative risk assessment. Sports Med 44(3):331-343, 2014
Introduction
V
enous thromboembolism (VTE) is an infrequent, but potentially fatal complication of orthopaedic surgery.1 This disease process consists of 2 entities: deep venous thrombosis (DVT) and the more life-threatening manifestation, pulmonary embolism (PE). Anterior cruciate ligament (ACL) reconstruction is one of the most common orthopaedic procedures, with over 100,000 cases performed each year in the United States alone.2 Postoperative VTE is an uncommon, but potentially devastating complication of this operation. The associated morbidity and mortality can be significant. As such, a thorough understanding of the incidence, risk factors and potential methods for prevention is critical to optimizing the safety of our surgical patients.
Incidence The reported incidence of VTE following arthroscopic procedures of the knee ranges from 0.03%-41.2%.3-7 This variability *Department of Orthopaedic Surgery, Rush University, Chicago, IL. †Department of Orthopaedics, Washington University, Saint Louis, MO. Address reprint requests to Lily Bogunovic, Department of Orthopaedic Surgery, Rush University, 1611 Harrison St, Suite 300, Chicago, IL 60612. E-mail: [email protected]
http://dx.doi.org/10.1053/j.otsm.2015.09.003 1060-1872//& 2015 Published by Elsevier Inc.
arises from inclusion of mixed patient cohorts (routine arthroscopy combined with arthroscopically assisted ACL reconstruction) and from differences in postoperative surveillance with some studies utilizing routine DVT screening on all patients and others reporting screening in symptomatic patients only. In a retrospective review of over 400,000 arthroscopic knee procedures, a symptomatic PE occurred within 90 days of surgery in 0.028% of patients, including one death (rate 0.0002%).6 In the 117 patients with a postoperative PE, an ACL reconstruction was performed in 15%. In another retrospective review of 20,770 arthroscopic knee procedures, a symptomatic DVT and PE developed in 0.25% and 0.17% of patients, respectively.8 Increased rates of postoperative VTE have been reported by several prospective studies, which utilize routine postoperative screening with ultrasound or venography. In a cohort of 537 patients undergoing ACL reconstruction, posterior cruciate ligament (PCL) reconstruction or combined ACL and PCL reconstruction, routine postoperative venography identified a DVT in 14.5% of patient; however, clinical signs and symptoms of DVT were evident in only 3.7% of patients.9 StrujikMulder et al,10 prospectively evaluated 100 patients with compression ultrasonography following ACL reconstruction. Routine screening identified a proximal DVT in 9% of patients, in whom, less than half (4%) were symptomatic.10 One patient developed a non–fatal PE during the 8-week follow-up 1
L. Bogunovic et al.
2 period.10 In a systematic review assessing the rate of DVT and PE following ACL reconstruction in patients who did not receive postprocedural anticoagulation, the overall DVT rate was noted to 8.4%, and the rate of symptomatic PE in was found to be 0.2%.2 Of those patients found to have a DVT, only 27% were symptomatic.
Risk Factors Multiple factors have been identified to affect the risk of VTE following orthopaedic surgery. Recognition of these factors allows for improved understanding of a given patient’s overall DVT or PE risk and provides guidance for potential risk factor modification.
Age Increased patient age is one of the most consistently reported risk factors for VTE following ACL reconstructions.5,6,8-11 The impact of age appears to be dose dependent with risk progressively increasing with increasing age.6,12 An increase in the rate of DVT or PE has been shown to occur as early as 30-35 years of age.5,9,11 For patients over the age of 40, the risk of a PE has been reported to be increased more than 6 fold.6
Inherent Hypercoagulability Inherited abnormalities in clotting function can predispose patients to postoperative VTE. Protein C and Protein S deficiency are 2 of the most common inherited clotting disorders, occurring in approximately 1 of every 500 people. Deficiency of either anticoagulant increases the affected individual’s risk of developing a DVT or PE by up to 11-fold.1,13 All surgical patients should be questioned about a personal or family history thromboembolic events. A significant history may signal an inherited disorder and warrants further testing and/or referral to a hematologist. In those patients with a confirmed diagnosis of hypercoagulability, measures such as perioperative chemoprophylaxis should be taken to minimize the risk of postoperative thromboembolic complications.
Gender The impact of gender on the risk of postoperative VTE remains unclear. Although some studies identify female gender as an independent risk factor, others report no difference in DVT/PE rates among genders.5,6,9,14 In a study of over 400,000 mixed knee arthroscopy procedures, female gender was associated with a 1.5-fold increase risk of PE.6 Notably, the use of oral contraceptives among female patients, a well-known risk factor for thromboembolism, was not reported in this cohort.
Malignancy Underlying malignancy has been shown to increase an individual’s propensity toward VTE. The risk of PE following arthroscopic knee surgery has been reported to be 3 times as high in patients with a history of cancer.6 The prothrombotic
mileu generated by a cancerous state is implicated in the increased propensity to abnormal clotting.
Oral Contraceptive Use The use of oral contraceptive is also associated with an increased risk of VTE.1,8,13 Maletis et al8 reported a postoperative incidence of symptomatic VTE in 0.63% of females taking oral contraceptives, compared with 0.30% in those females not taking medication. In this study, female gender was not an independent risk factor for postoperative DVT or PE.8 The increase risk associated with oral contraceptive use is further heightened in women with an underlying inherited hypercoagulability syndrome.13 Jannsen and Sala,1 reported a case of fatal PE following ACL reconstruction in an 18-year-old female patients. In this patient, oral contraceptive use combined with an underlying inherited hypercoagulability syndrome was implicated as the primary cause.1
Tourniquet Time A lower extremity tourniquet is frequently utilized during knee arthroscopy and ACL reconstruction. Tourniquet use has been associated with an increased rate of postoperative DVT or PE.15,16 The endothelial injury generated by surgery, combined with the stasis created with a tourniquet is believed to promote intravascular clot formation. In as meta-analysis of randomized controlled trials comparing the rate of VTE following total knee arthroplasty, Yi et al15 reported a higher rate of postoperative DVT (relative risk ¼ 2.63) when a tourniquet was utilized compared to when it was not. The length of use appears to affect of impact of tourniquet use on DVT/PE risk. Multiple studies demonstrate increased rates of VTE when tourniquet times exceed 90 minutes.6,16,17
Surgical Complexity Increased operative time and surgical complexity have been reported as a risk factors for postoperative VTE.6,16,18 These 2 factors are likely linked, with greater surgical complexity requiring greater time to complete. Compared to arthroscopic knee procedures performed in o30 minutes, those requiring o90 minutes have been associated with a 3-fold increase rate of PE.6 Compared to isolated ACL reconstruction, both Sun et al9 and Dong et al,16 reported an increased rate of postoperative DVT following multiligamentous knee reconstruction, with a particular increase in DVT with procedures involving reconstruction of the PCL.
Diagnosis The diagnosis of DVT or PE can prove difficult. The classic physical examination signs of increased pain, swelling, warmth and redness, are found in less than 50% of patients and may be masked by postoperative pain and swelling. The surgeon must maintain a high index of suspicion, especially in those patients with known risk factors. Advanced imaging with ultrasound or venography can help to confirm the diagnosis in those patients
DVT Prophylaxis for ACL Reconstruction in whom a DVT is suspected, but routine screening is not recommended for all patients.19
Treatment Anticoagulation therapy is recommended in all patients with an acute symptomatic or asymptomatic proximal lower extremity DVT and PE.20 Postsurgical DVT or PE should be treated with paternal anticoagulant therapy (low-molecularweight heparin [LMWH]) or with oral rivaroxaban for a duration of 3 months.20 Additional thrombolytic therapy is recommended in patients presenting with combined PE and hypotension. Patients with distal DVTs (both symptomatic and asymptomatic) can choose between the standard anticoagulation treatment and serial screening to monitor for progression. Progression, if noted, is managed with standard anticoagulation therapy regimen.
Prophylaxis Several studies have been performed to investigate the efficacy of routine thromboprophylaxis following knee arthroscopy.11,21-23 In a randomized control trial of 1317 patients undergoing knee arthroscopy Camporese et al,22 reported a 72% relative risk reduction in DVT in patients who received LMWH for 7 days postoperatively in comparison to patients who only wore graduated compression stockings for that same time period. There were no significant differences found in clinically relevant bleeding episodes between the 2 groups.22 In a randomized clinical trial of 130 patients, Michot et al,21 reported similar results when comparing thromboprophylaxis with dalteparin to placebo. Over 15% of patients who received no prophylaxis developed a DVT, compared to 1.5% of treated patients. In this study, an increased rate of bleeding complication was seen with dalteparin therapy (12% vs 16%).21 Wirth et al,23 compared routine prophylaxis with LMWH to no intervention in 262 patients. In this study, thromboprophylaxis was associated with a decreased rate of DVT detected by ultrasound (4.1% treated vs 0.85% controls) without an increased rate of bleeding complications.23 Finally, Marvoltis et al,11 examined the efficacy of LMWH for the prevention of DVT or PE in 175 patients undergoing ACL reconstruction. Routine postoperative venography demonstrated a DVT in 2.8% of treated patients compared to 41.2% of untreated patients.11 The routine postoperative DVT screening in all patients in the above studies must be considered along with the data provided. In a recent review of studies utilizing routine screening following ACL reconstruction, up to 73% of identified DVTs were noted to be asymptomatic.2 The clinical relevance of asymptomatic DVT remains unknown, as does the potential benefit of prevention. As such, several authors and the American College of Chest Physicians currently recommend against the routine use of thromboprophylaxis following knee arthroscopy in individuals with no history of DVT or PE.7,11,24,25
3
Conclusion VTE is a rare but potentially serious complication of ACL reconstructions. Factors known to increase an individual’s risk of DVT or PE include increasing age, inherited hypercoagulability, a history of malignancy, oral contraceptive use, and prolonged surgical and tourniquet time. Although routine postoperative screening is not recommended in all patients, assessment with ultrasound or venography can help confirm the diagnosis in patients in whom DVT is suspected. Patients with a PE or proximal DVT should be placed on an anticoagulation therapy regimen, whereas those with distal DVTs may elect for serial monitoring. The current data does not support the routine use of thromboprophylaxis in patients undergoing ACL reconstruction.
References 1. Janssen RPA, Sala HAGM: Fatal pulmonary embolism after anterior cruciate ligament reconstruction. Am J Sports Med 35(6):1000-1002, 2007 2. Erickson B, Saltzman B, Campbell K, et al: Rates of deep venous thrombosis and pulmonary emobolus after anterior anterior cruciate ligament reconstruction: A systematic review. Sports Health 7 (3):261-266, 2015 3. Cullison TR, Muldoon MP, Gorman JD, et al: The incidence of deep venous thrombosis in anterior cruciate ligament reconstruction. Arthroscopy 12(6):657-659, 1996 4. Andrés-Cano P, Godino M, Vides M, et al: Postoperative complications of anterior cruciate ligament reconstruction after ambulatory surgery. Rev Esp Cir Ortop Traumatol 59(3):157-164, 2015 5. Ye S, Dongyang C, Zhihong X, et al: The incidence of deep venous thrombosis after arthroscopically assisted anterior cruciate ligament reconstruction. Arthroscopy 29(4):742-747, 2013 6. Hetsroni I, Lyman S, Do H, et al: Symptomatic pulmonary embolism after outpatient arthroscopic procedures of the knee: The incidence and risk factors in 418,323 arthroscopies. J Bone Joint Surg Br 93(1):47-51, 2011 7. Adala R, Anand A, Kodikal G: Deep vein thrombosis and thromboprophylaxis in arthroscopic anterior cruciate ligament reconstruction. Indian J Orthop 45(5):450-453, 2011 8. Maletis GB, Inacio MCS, Reynolds S, et al: Incidence of symptomatic venous thromboembolism after elective knee arthroscopy. J Bone Joint Surg Am 94(8):714-720, 2012 9. Sun Y, Chen D, Xu Z, et al: Incidence of symptomatic and asymptomatic venous thromboembolism after elective knee arthroscopic surgery: A retrospective study with routinely applied venography. Arthroscopy 30(7):818-822, 2014 10. Struijk-Mulder MC, Ettema HB, CCPM Verheyen, et al: Deep vein thrombosis after arthroscopic anterior cruciate ligament reconstruction: A prospective cohort study of 100 patients. Arthroscopy 29 (7):1211-1216, 2013 11. Marlovits S, Striessnig G, Schuster R, et al: Extended-duration thromboprophylaxis with enoxaparin after arthroscopic surgery of the anterior cruciate ligament: A prospective, randomized, placebo-controlled study. Arthroscopy 23(7):696-702, 2007 12. Mauck KF, Froehling DA, Daniels PR, et al: Incidence of venous thromboembolism after elective knee arthroscopic surgery: A historical cohort study. J Thromb Haemost 11(7):1279-1286, 2013 13. Lipe B, Ornstein DL: Deficiencies of natural anticoagulants, protein C, protein S, and antithrombin. Circulation 124(14):e365-e368, 2011 14. Sun Y, Chen D, Xu Z, et al: Deep venous thrombosis after knee arthroscopy: A systematic review and meta-analysis. Arthroscopy 30 (3):406-412, 2014 15. Yi S, Tan J, Chen C, et al: The use of pneumatic tourniquet in total knee arthroplasty: A meta-analysis. Arch Orthop Trauma Surg 134 (10):1469-1476, 2014
4 16. Dong J-T, Wang X, Men X-Q, et al: Incidence of deep venous thrombosis in Chinese patients undergoing arthroscopic knee surgery for cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 23 (12):3540-3544, 2015 17. Demers C, Marcoux S, Ginsberg JS, et al: Incidence of venographically proved deep vein thrombosis after knee arthroscopy. Arch Intern Med 158(1):47-50, 1998 18. Kim S-J, Kim S-H, Kim S-G, et al: Comparison of the clinical results of three posterior cruciate ligament reconstruction techniques: Surgical technique. J Bone Joint Surg Am 92(1):145-157, 2010 (suppl Pt 2) 19. Bates SM, Jaeschke R, Stevens SM, et al: Diagnosis of DVT: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2): e351S-e418S, 2012 (suppl) 20. Kearon C, Akl EA, Comerota AJ, et al: Antithrombotic therapy for VTE disease: Antithromboitc therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 142(6):1698-1704, 2012
L. Bogunovic et al. 21. Michot M, Conen D, Holtz D, et al: Prevention of deep-vein thrombosis in ambulatory arthroscopic knee surgery: A randomized trial of prophylaxis with low-molecular weight heparin. Arthroscopy 18(3):257-263, 2002 22. Camporese G, Bernardi E, Prandoni P, et al: Low-molecular-weight heparin versus compression stockings for thromboprophylaxis after knee arthroscopy: A randomized trial. Ann Intern Med 149(2):73-82, 2008 23. Wirth T, Schneider B, Misselwitz F, et al: Prevention of venous thromboembolism after knee arthroscopy with low-molecular weight heparin (reviparin): Results of a randomized controlled trial. Arthroscopy 17(4):393-399, 2001 24. Ageno W, Gallus AS, Wittkowsky A, et al: Oral anticoagulant therapy: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2):e44S-e88S, 2012 (suppl) 25. Graham WC, Flanigan DC: Venous thromboembolism following arthroscopic knee surgery: A current concepts review of incidence, prophylaxis, and preoperative risk assessment. Sports Med 44(3):331-343, 2014