Advertisement

Perioperative Thromboprophylaxis Is Associated With Lower Risk of Venous Thromboembolism After Knee Arthroscopy

      Purpose

      To determine the rate of symptomatic venous thromboembolism (VTE) among patients undergoing arthroscopic knee procedures, risk factors associated with postoperative VTE, and current perioperative thromboprophylaxis prescription patterns associated with this population in the United States.

      Methods

      Medical records for patients ≥18 years of age were queried from the Mariner database using Current Procedural Terminology codes for knee arthroscopy performed in the United States from 2010 to 2020 in this cross-sectional study. Patients who received thromboprophylaxis and those diagnosed with VTE, including deep-vein thrombosis or pulmonary embolism, within 90 days of surgery were identified using International Classification of Diseases and National Drug Codes. Two multivariable logistic regression models were used to identify VTE risk factors and likelihood of perioperative thromboprophylaxis. Covariates included procedure type, age, oral contraceptive pill (OCP) use, and medical comorbidities.

      Results

      A total of 718,289 patients met inclusion criteria and 7,618 patients (1.06%) experienced VTE, including deep-vein thrombosis (n = 6,394, 0.9%) and/or pulmonary embolism (n = 2,211, 0.3%). A total of 10,769 patients (1.5%) filled perioperative thromboprophylaxis, including aspirin (n = 5,353, 0.7%), low-molecular-weight heparin (n = 4,563, 0.6%), and oral factor Xa inhibitors (n = 947, 0.1%). Perioperative thromboprophylaxis was associated with decreased odds of experiencing VTE (adjusted odds ratio [aOR] 0.65, 95% confidence interval [CI] 0.51-0.80). Procedure types categorized as moderate-to-greater risk were associated with increased odds of VTE (aOR 1.42, 95% CI 1.34-1.50). OCP use (aOR 1.63, 95% CI 1.38-1.91), obesity (aOR 1.17, 95% CI 1.11-1.24), renal disease (aOR 1.33, 95% CI 1.18-1.50) and congestive heart failure (aOR 1.30, 95% CI 1.13-1.50) were associated with increased odds of VTE.

      Conclusions

      While the overall rate of symptomatic VTE following knee arthroscopy remains low, procedure types that are more complex and generally require restrictive rehabilitation protocols, OCP use, obesity, renal disease, and congestive heart failure are associated with increased odds of postoperative VTE. Conversely, the use of perioperative thromboprophylaxis is associated with significantly lower VTE risk.

      Level of Evidence

      III, retrospective comparative prognostic trial.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Kim S.
        • Bosque J.
        • Meehan J.P.
        • Jamali A.
        • Marder R.
        Increase in outpatient knee arthroscopy in the United States: A comparison of National Surveys of Ambulatory Surgery, 1996 and 2006.
        J Bone Joint Surg Am. 2011; 93: 994-1000
        • Maletis G.B.
        • Inacio M.C.S.
        • Reynolds S.
        • Funahashi T.T.
        Incidence of symptomatic venous thromboembolism after elective knee arthroscopy.
        J Bone Joint Surg Am. 2012; 94: 714-720
        • Kahn S.R.
        • Shivakumar S.
        What’s new in VTE risk and prevention in orthopedic surgery.
        Res Pract Thromb Haemost. 2020; 4: 366-376
        • Abram S.G.F.
        • Judge A.
        • Beard D.J.
        • Price A.J.
        Adverse outcomes after arthroscopic partial meniscectomy: A study of 700 000 procedures in the national Hospital Episode Statistics database for England.
        Lancet. 2018; 392: 2194-2202
        • Traven S.A.
        • Farley K.X.
        • Gottschalk M.B.
        • et al.
        Combined oral contraceptive use increases the risk of venous thromboembolism after knee arthroscopy and anterior cruciate ligament reconstruction: An analysis of 64,165 patients in the Truven Database.
        Arthroscopy. 2021; 37: 924-931
        • Martin C.T.
        • Pugely A.J.
        • Gao Y.
        • Wolf B.R.
        Risk factors for thirty-day morbidity and mortality following knee arthroscopy: A review of 12,271 patients from the national surgical quality improvement program database.
        J Bone Joint Surg Am. 2013; 95: e98.1-10
        • Mauck K.F.
        • Froehling D.A.
        • Daniels P.R.
        • et al.
        Incidence of venous thromboembolism after elective knee arthroscopic surgery: A historical cohort study.
        J Thromb Haemost. 2013; 11: 1279-1286
        • Ramos J.
        • Perrotta C.
        • Badariotti G.
        • Berenstein G.
        Interventions for preventing venous thromboembolism in adults undergoing knee arthroscopy.
        Cochrane Database Syst Rev. 2008; 4: CD005259
        • Ashrani A.A.
        • Heit J.A.
        Incidence and cost burden of post-thrombotic syndrome.
        J Thromb Thrombolysis. 2009; 28: 465-476
        • ISTH Steering Committee for World Thrombosis Day
        Thrombosis: A major contributor to the global disease burden.
        J Thromb Haemost. 2014; 12: 1580-1590https://doi.org/10.1111/jth.12698
      1. Incidence and mortality of venous thrombosis: A population-based study—PubMed.
        https://pubmed.ncbi.nlm.nih.gov/17367492/
        Date accessed: October 22, 2021
        • Falck-Ytter Y.
        • Francis C.W.
        • Johanson N.A.
        • 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
        • Anderson D.R.
        • Morgano G.P.
        • Bennett C.
        • et al.
        American Society of Hematology 2019 guidelines for management of venous thromboembolism: Prevention of venous thromboembolism in surgical hospitalized patients.
        Blood Adv. 2019; 3: 3898-3944
        • Thorlund J.B.
        • Juhl C.B.
        • Roos E.M.
        • Lohmander L.S.
        Arthroscopic surgery for degenerative knee: Systematic review and meta-analysis of benefits and harms.
        BMJ. 2015; 350: h2747
        • Perrotta C.
        • Chahla J.
        • Badariotti G.
        • Ramos J.
        Interventions for preventing venous thromboembolism in adults undergoing knee arthroscopy.
        Cochrane Database Syst Rev. 2020; 5: CD005259
        • van Adrichem R.A.
        • Nelissen R.G.H.H.
        • Schipper I.B.
        • Rosendaal F.R.
        • Cannegieter S.C.
        Risk of venous thrombosis after arthroscopy of the knee: Results from a large population-based case-control study.
        J Thromb Haemost. 2015; 13: 1441-1448
        • van Adrichem R.A.
        • Debeij J.
        • Nelissen R.G.H.H.
        • Schipper I.B.
        • Rosendaal F.R.
        • Cannegieter S.C.
        Below-knee cast immobilization and the risk of venous thrombosis: Results from a large population-based case-control study.
        J Thromb Haemost. 2014; 12: 1461-1469
        • Aglietti P.
        • Baldini A.
        • Vena L.M.
        • Abbate R.
        • Fedi S.
        • Falciani M.
        Effect of tourniquet use on activation of coagulation in total knee replacement.
        Clin Orthop Relat Res. 2000; 371: 169-177
        • Kageyama K.
        • Nakajima Y.
        • Shibasaki M.
        • Hashimoto S.
        • Mizobe T.
        Increased platelet, leukocyte, and endothelial cell activity are associated with increased coagulability in patients after total knee arthroplasty.
        J Thromb Haemost. 2007; 5: 738-745
        • Reikerås O.
        • Clementsen T.
        Time course of thrombosis and fibrinolysis in total knee arthroplasty with tourniquet application. Local versus systemic activations.
        J Thromb Thrombolysis. 2009; 28: 425-428
        • Hoppener M.R.
        • Ettema H.B.
        • Henny C.P.
        • Verheyen C.C.P.M.
        • Büller H.R.
        Low incidence of deep vein thrombosis after knee arthroscopy without thromboprophylaxis: A prospective cohort study of 335 patients.
        Acta Orthop. 2006; 77: 767-771
        • Hetsroni I.
        • Lyman S.
        • Do H.
        • Mann G.
        • Marx R.G.
        Symptomatic pulmonary embolism after outpatient arthroscopic procedures of the knee: The incidence and risk factors in 418,323 arthroscopies.
        J Bone Joint Surg Br. 2011; 93: 47-51
        • National Guideline Centre (UK)
        Venous Thromboembolism in over 16s: Reducing the Risk of Hospital-Acquired Deep Vein Thrombosis or Pulmonary Embolism.
        National Institute for Health and Care Excellence (UK), 2018
        http://www.ncbi.nlm.nih.gov/books/NBK493720/
        Date accessed: October 22, 2021
        • 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. 2008; 149: 73-82
        • Taylor S.A.
        • Khair M.M.
        • Roberts T.R.
        • DiFelice G.S.
        Primary repair of the anterior cruciate ligament: A systematic review.
        Arthroscopy. 2015; 31: 2233-2247
        • Simhal R.K.
        • Bovich M.
        • Bahrun E.A.
        • Dreese J.C.
        Postoperative rehabilitation of posterior cruciate ligament surgery: A systematic review.
        Sports Med Arthrosc Rev. 2021; 29: 81-87
        • O’Donnell K.
        • Freedman K.B.
        • Tjoumakaris F.P.
        Rehabilitation protocols after isolated meniscal repair: A systematic review.
        Am J Sports Med. 2017; 45: 1687-1697
        • Grimm N.L.
        • Lazarides A.L.
        • Amendola A.
        Tibial tubercle osteotomies: A Review of a treatment for recurrent patellar instability.
        Curr Rev Musculoskelet Med. 2018; 11: 266-271
        • Krych A.J.
        • Pareek A.
        • King A.H.
        • Johnson N.R.
        • Stuart M.J.
        • Williams R.J.
        Return to sport after the surgical management of articular cartilage lesions in the knee: A meta-analysis.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 3186-3196
        • Nemeth B.
        • van Adrichem R.
        • Nelissen R.
        • le Cessie S.
        • Cannegieter S.C.
        Individualized thromboprophylaxis in patients with lower-leg cast immobilization—A validation and subgroup analysis in the POT-CAST Trial.
        Thromb Haemost. 2019; 119: 1508-1516
        • van Adrichem R.A.
        • Nemeth B.
        • Algra A.
        • et al.
        Thromboprophylaxis after knee arthroscopy and lower-leg casting.
        N Engl J Med. 2017; 376: 515-525
        • Horner D.
        • Stevens J.W.
        • Pandor A.
        • et al.
        Pharmacological thromboprophylaxis to prevent venous thromboembolism in patients with temporary lower limb immobilization after injury: Systematic review and network meta-analysis.
        J Thromb Haemost. 2020; 18: 422-438
        • Yu Y.
        • Lu S.
        • Sun J.
        • Zhou W.
        • Liu H.
        Thromboprophylactic efficacy and safety of anticoagulants after arthroscopic knee surgery: A systematic review and meta-analysis.
        Clin Appl Thromb Hemost. 2019; 251076029619881409
        • Qin C.
        • Qin M.M.
        • Baker H.
        • Shi L.L.
        • Strelzow J.
        • Athiviraham A.
        Pharmacologic thromboprophylaxis other than aspirin is associated with increased risk for procedural intervention for arthrofibrosis after anterior cruciate ligament reconstruction.
        Arthroscopy. 2021; 37: 619-623
        • Zhang A.L.
        • Montgomery S.R.
        • Ngo S.S.
        • Hame S.L.
        • Wang J.C.
        • Gamradt S.C.
        Analysis of rotator cuff repair trends in a large private insurance population..
        Arthroscopy. 2013; 29: 623-629