Deep Venous Thrombosis Prophylaxis in Anterior Cruciate Ligament Reconstructive Surgery: What Is the Current State of Practice?

Abstract

Background:Venous thromboembolism (VTE) is a significant perioperative risk with many common orthopaedic procedures. Currently, there is no standardized recommendation for the use of VTE prophylaxis during anterior cruciate ligament (ACL) reconstruction. This study sought to evaluate the current prophylactic practices of fellowship-trained sports medicine orthopaedic surgeons in the United States.Hypothesis:Very few surgeons use perioperative VTE prophylaxis for ACL reconstructive surgery.Study Design:Survey.Methods:Surveys were emailed to the alumni networks of 4 large ACGME-accredited sports medicine fellowship programs. Questions were focused on their current use of chemical and nonchemical VTE prophylaxis.Results:Surveys were completed by 142 surgeons in the United States, yielding a response rate of 32%. Of those who responded, 50.7% stated that they routinely use chemical prophylaxis, with 95.5% of those using aspirin (acetylsalicylic acid [ASA]). There was no standardized dosing protocol, with respondents using ASA 325 mg once (46%) or twice daily (26%) or ASA 81 mg once (18%) or twice (10%) daily. The most common reason for not including chemical prophylaxis within the reconstruction procedure was that it is unnecessary given the low risk of VTE. Physicians also based their prophylaxis regimen more on their own clinical experience than concern for litigation.Conclusion:Half of all sports medicine fellowship–trained surgeons surveyed routinely use chemical VTE prophylaxis after ACL reconstruction, with more than 90% of those using ASA. Of those using ASA, there was no prevailing dosing protocol. For those not using chemical prophylaxis, the most important reason was that it was felt to be unnecessary due to the risks outweighing the benefits. Those who do not regularly use chemical prophylaxis would be willing to, however, if a patient had a personal or family history of clotting disorder or is currently on birth control. Additionally, clinical experience was the primary driver for a current prophylaxis protocol.Clinical Relevance:This survey study evaluating the use of VTE prophylaxis with ACL reconstruction lends clinical insight to the current practice of a large, geographically diverse group of fellowship-trained sports medicine orthopaedic surgeons in the United States.

Rates of Adverse Outcomes and Revision Surgery After Anterior Cruciate Ligament Reconstruction: A Study of 104,255 Procedures Using the National Hospital Episode Statistics Database for England, UK

“…Previous work suggested that while antibiotic prophylaxis is routine in most countries, VTE prophylaxis rates vary from around 17% in Norway and 51% in the United States to 79% in Denmark. 17,21 The findings in this study may support further investigation and consideration of routine VTE prophylaxis in this population.…”

Effect of Operative Time on Short-Term Adverse Events After Isolated Anterior Cruciate Ligament Reconstruction

“…20,23 Despite DVT being a significant complication after lower extremity orthopaedic procedures, only 50% of sports medicine fellowship–trained surgeons routinely utilize thrombus prophylaxis in ACL reconstruction. 31 Because of the lack of a standardized protocol for thrombus prophylaxis, clinical experience and personal opinion are the primary factors for determining usage and dosage protocols. Age older than 35 years, nicotine use, tourniquet time longer than 2 hours, surgery at higher elevations, and concomitant high tibial osteotomy or posterior cruciate ligament reconstruction have been associated with an increased risk of thrombus formation after ACL reconstruction.…”

Risk Factors for Deep Vein Thrombosis or Pulmonary Embolus Following Anterior Cruciate Ligament Reconstruction

“… 22 Although these guidelines do not extend to nonarthroplasty procedures, chemoprophylaxis is still prescribed routinely for other lower extremity operations, such as anterior cruciate ligament reconstruction (ACLR). According to the survey results by Keller et al, 17 50.7% of sports medicine fellowship–trained surgeons use chemoprophylaxis following ACLR to protect against the occurrence of VTE; the majority of these surgeons use aspirin, with wide variation in both the dose and duration of treatment.…”