Recommendations of International Consensus Group on VTE after orthopaedic sports surgeries

Patients undergoing orthopedic procedures are at higher risk of mortality from venous thromboembolism (VTE)". Although there is little evidence for this statement in modern orthopaedic practice, it is still frequently seen in publications exploring the issue of VTE in orthopedics (Fig. 1). This has perpetuated a long-standing fear of VTE-related morbidity and mortality among both the medical community and patients alike. Hence, numerous organizations such as the American Academy of Orthopaedic Surgeons (AAOS)2 and the American College of Chest Physicians (ACCP) in the U.S., and numerous other organizations across the globe, have created guidelines related to the issue of VTE in orthopedics.

The guidelines have been published in the journal of bone and joint surgery.

1- Concerning VTE risk, which surgeries can be considered major, and which surgeries can be considered non-major in orthopaedic sports surgery?

Overall, venous thromboembolism (VTE) incidence in sports surgery is low, and risk of VTE increases with immobilization and non-weight bearing. For this reason, upper extremity sports procedures are considered non-major concerning VTE risk due to the low impact on patient ambulation and post-operative mobility. Lower extremity procedures can be considered non-major if patients can weight bear and mobilize post-operatively. Patients undergoing lower extremity sports procedures that places weight bearing restriction and/or limits ambulation may be considered major.

2- Is routine VTE prophylaxis required for patients undergoing knee arthroscopy who will be allowed to fully weight bear after surgery?

There is insufficient evidence to recommend routine thromboprophylaxis to all otherwise healthy patients undergoing a knee arthroscopic procedure.

3- What is the most optimal VTE prophylaxis for patients undergoing arthroscopic knee surgery who are instructed to remain non-weight bearing for a prolonged period of time?

There are no studies in the literature that have specifically investigated the correlation between non-weightbearing after knee arthroscopy and the incidence of venous thromboembolism (VTE). Consequently, no specific prophylactic measures have been recommended for this patient population. Considering that non-weight bearing is a known risk factor for VTE, we support the routine use of VTE prophylaxis in these patients unless a high risk of bleeding is present or postoperative bleeding occurs.

4- What is the most optimal VTE prophylaxis for patients undergoing ACL reconstruction?

There is a small risk of venous thromboembolism (VTE) following anterior cruciate ligament (ACL) reconstruction in healthy adult patients. There is moderate- to low-evidence supporting the use of low-molecularweight heparin (LMWH), aspirin (ASA) or rivaroxaban in the prevention of pulmonary embolism (PE) and symptomatic deep venous thrombosis (DVT). Similarly, there is a very low level of evidence supporting the use of LMWH in preventing asymptomatic DVT when compared to no treatment. No difference in the rate of adverse events (including major and minor bleeding) between LMWH, ASA and rivaroxaban has been shown, although data on this safety endpoint is limited due to low numbers of events in existing studies. To this end, appropriate risk stratification, considering factors such as medical comorbidities, weight-bearing status, and the use of immobilization, is therefore necessary.

5- Do patients undergoing hip arthroscopy require routine VTE prophylaxis?

The risk of venous thromboembolism (VTE) after hip arthroscopy (HA) is low and routine VTE prophylaxis is not required. In patients with particular risk factors, VTE prophylaxis might be considered.

6- Should patients undergoing mini-open femoroacetabular osteoplasty receive routine VTE prophylaxis?

There is dearth of data related to this question. Available evidence suggests that aspirin is an effective prophylactic agent against venous thromboembolism (VTE) in standard-risk patients undergoing mini-open femoroacetabular osteoplasty (FAO).

7- How should athletes receiving chemical anticoagulation for VTE prophylaxis or treatment of active VTE be managed?

There is no consensus regarding the optimal management of venous thromboembolism (VTE) in athletes. Treatment of active VTE consists of early mobilization and uninterrupted anticoagulation for at least 3 months with abstinence from contact sports during the entire treatment duration. The choice of pharmacologic agent should be tailored according to patient-, physician-, and sport-related factors. However, some authors favor direct-acting oral anticoagulant agents (DOAC), which may allow earlier return to sport in athletes requiring prolonged anticoagulation. Athletes receiving treatment for active VTE may begin low-risk exercises (e.g., swimming) 3 weeks after initial diagnosis, progressing to full participation in non-contact sports at 6 weeks.

Further reading:

RECOMMENDATIONS FROM THE ICM-VTE AFTER ORTHOPEDIC PROCEDURES

THE JOURNAL OF BONE & JOINT SURGERY

VOLUME 104-A NUMBER 6 (SUPPLEMENT 1) MARCH 16, 2022