Interventions for preventing venous thromboembolism in adults undergoing knee arthroscopy

Ramos, Jorge; Perrotta, Carla; Badariotti, Gustavo; Berenstein, Graciela

doi:10.1002/14651858.cd005259.pub3

Cited by 72 publications

(65 citation statements)

References 11 publications

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“…A systematic review 129 that included four RCTs examined the use of LMWH vs no thromboprophylaxis after arthroscopic knee surgery in 527 patients. [130][131][132][133] The knee surgeries included were anterior cruciate ligament reconstruction, meniscectomies, and other diagnostic and therapeutic arthroscopies.…”

Section: Knee Arthroscopymentioning

confidence: 99%

Prevention of VTE in Orthopedic Surgery Patients

Falck‐Ytter

Francis²,

Johanson³

et al. 2012

Chest

1,738

963

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Background: VTE is a serious, but decreasing complication following major orthopedic surgery. This guideline focuses on optimal prophylaxis to reduce postoperative pulmonary embolism and DVT. Methods: The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. Results: In patients undergoing major orthopedic surgery, we recommend the use of one of the following rather than no antithrombotic prophylaxis: low-molecular-weight heparin; fondaparinux; dabigatran, apixaban, rivaroxaban (total hip arthroplasty or total knee arthroplasty but not hip fracture surgery); low-dose unfractionated heparin; adjusted-dose vitamin K antagonist; aspirin (all Grade 1B); or an intermittent pneumatic compression device (IPCD) (Grade 1C) for a minimum of 10 to 14 days. We suggest the use of low-molecular-weight heparin in preference to the other agents we have recommended as alternatives (Grade 2C/2B), and in patients receiving pharmacologic prophylaxis, we suggest adding an IPCD during the hospital stay (Grade 2C). We suggest extending thromboprophylaxis for up to 35 days (Grade 2B). In patients at increased bleeding risk, we suggest an IPCD or no prophylaxis (Grade 2C). In patients who decline injections, we recommend using apixaban or dabigatran (all Grade 1B). We suggest against using inferior vena cava fi lter placement for primary prevention in patients with contraindications to both pharmacologic and mechanical thromboprophylaxis (Grade 2C). We recommend against Doppler (or duplex) ultrasonography screening before hospital discharge (Grade 1B). For patients with isolated lowerextremity injuries requiring leg immobilization, we suggest no thromboprophylaxis (Grade 2B). For patients undergoing knee arthroscopy without a history of VTE, we suggest no thromboprophylaxis (Grade 2B). Conclusions: Optimal strategies for thromboprophylaxis after major orthopedic surgery include pharmacologic and mechanical approaches. CHEST 2012; 141(2)(Suppl):e278S-e325SAbbreviations: DUS 5 Doppler (or duplex) ultrasonography; GCS 5 graduated compression stockings; HFS 5 hip fracture surgery; INR 5 international normalized ratio; IPCD 5 intermittent pneumatic compression device; IVC 5 inferior vena cava; LDUH 5 low-dose unfractionated heparin; LMWH 5 low-molecular-weight heparin; PE 5 pulmonary embolism; PEP 5 Pulmonary Embolism Prevention trial; RCT 5 randomized controlled trial; RR 5 risk ratio; THA 5 total hip arthroplasty; TKA 5 total knee arthroplasty; UFH 5 unfractionated heparin; VFP 5 venous foot pump; VKA 5 vitamin K antagonist

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Section: Knee Arthroscopymentioning

confidence: 99%

Prevention of VTE in Orthopedic Surgery Patients

Falck‐Ytter

Francis²,

Johanson³

et al. 2012

Chest

1,738

963

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“…From this EndNote library, 12 potentially relevant systematic reviews that appeared to assess GCSs in postoperative surgical patients (including the two reviews identified during the protocol development stage 1,17 ) were obtained so that their lists of included and excluded studies could be systematically searched for potentially relevant primary studies. 1,17,19,[51][52][53][54][55][56][57][58][59] A total of 137 records were added to the EndNote library from the included and excluded studies lists of the 12 relevant systematic reviews (after removal of duplicates).…”

Section: Flow Of Studies Through the Review Of Effectivenessmentioning

confidence: 99%

Graduated compression stockings for the prevention of deep-vein thrombosis in postoperative surgical patients: a systematic review and economic model with a value of information analysis

Wade

Sideris

Paton

et al. 2015

Health Technol Assess

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BackgroundDeep-vein thrombosis (DVT) can occur in surgical patients. Routine prophylaxis can be pharmacological and/or mechanical [e.g. graduated compression stockings (GCSs)]. GCSs are available in knee length or thigh length.ObjectiveTo establish the expected value of undertaking additional research addressing the relative effectiveness of thigh-length GCSs versus knee-length GCSs, in addition to pharmacoprophylaxis, for prevention of DVT in surgical patients.DesignSystematic review and economic model, including value of information (VOI) analysis.Review methodsRandomised controlled trials (RCTs) assessing thigh- or knee-length GCSs in surgical patients were eligible for inclusion. The primary outcome was incidence of DVT. DVT complications and GCSs adverse events were assessed. Random-effects meta-analysis was performed. To draw on a wider evidence base, a random-effects network meta-analysis (NMA) was undertaken for the outcome DVT. A review of trials and observational studies of patient adherence was also conducted. A decision-analytic model was developed to assess the cost-effectiveness of thigh- and knee-length GCSs and the VOI.ResultsTwenty-three RCTs were included in the review of effectiveness. There was substantial variation between trials in terms of the patient characteristics, interventions and methods of outcome assessment. Five trials comparing knee-length with thigh-length GCSs with or without pharmacoprophylaxis were pooled; the summary estimate of effect indicated a non-significant trend favouring thigh-length GCSs [odds ratio (OR) 1.48, 95% confidence interval (CI) 0.80 to 2.73]. Thirteen trials were included in the NMA. In the base-case analysis, thigh-length GCSs with pharmacoprophylaxis were more effective than knee-length GCSs with pharmacoprophylaxis (knee vs. thigh OR 1.76, 95% credible interval 0.82 to 3.53). Overall, thigh-length stockings with pharmacoprophylaxis was the most effective treatment, with a 0.73 probability of being the most effective treatment in a new trial of all the treatments. Patient adherence was generally higher with knee-length GCSs, and patients preferred knee-length GCSs. Thigh-length GCSs were found to be cost-effective in all but the subgroup with the lowest baseline risk, although the absolute differences in costs and effects were relatively small. The expected value of perfect information ranged from £0.2M to £178.0M depending on the scenario and subgroup. The relative effect parameters had the highest expected value of partial perfect information and ranged from £2.0M to £39.4M. The value of further research was most evident in the high-risk subgroups.LimitationsThere was substantial variation across the included trials in terms of patient and intervention characteristics. Many of the included trials were old and poorly reported, which reduces the reliability of the results of the review.ConclusionsGiven that the results from both the standard meta-analysis and the NMA lacked precision (CIs were wide) owing to the heterogeneous evidence base, a new definitive trial in high-risk patients may be warranted. However, the efficiency of any further research (i.e. whether this represents value for money) is dependent on several factors, including the acquisition price of GCSs, expected compliance with thigh-length GCSs wear, and whether or not uncertainty can be resolved around possible effect modifiers, as well as the feasibility and actual cost of undertaking the proposed research.Study registrationThis study is registered as PROSPERO CRD42014007202.FundingThe National Institute for Health Research Health Technology Assessment programme.

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“…A 2008 meta-analysis by Ramos et al (11) analysed four trials involving a total of 527 patients. Although the relative risk of thrombotic events was found to be 0.16 (CI 0.05-0.52) in the intervention group, the authors also found a higher incidence of adverse events (n = 66) in this group; in fact, the number of adverse events exceeded the number needed to harm (n = 20) in the analysis.…”

Section: Discussionmentioning

confidence: 99%

Deep vein thrombosis in arthroscopic surgery and chemoprophylaxis recommendation in an Asian population

Yeo

Lim

Lee

2016

smedj

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INTRODUCTIONThere are currently no guidelines supporting the use of routine chemoprophylaxis to prevent deep vein thrombosis (DVT) in arthroscopic surgery. Studies and meta-analysis show opposing views on its routine use in arthroscopy. This study aimed to examine the incidence of DVT in a prospective cohort of knee arthroscopy and knee arthroplasty patients, and to analyse the risk factors contributing to DVT. METHODSAll patients scheduled to undergo knee arthroscopy or arthroplasty over a two-year period were included.A standardised regimen of postoperative mechanical prophylaxis and rehabilitation was applied to all patients. Only patients who were postoperatively symptomatic were referred for ultrasonography. DVT incidence was calculated, and univariate and multivariate analyses of the risk factors were performed. RESULTSThe overall incidence of DVT was 0.5% among the 1,410 arthroscopy patients and 3.1% among the 802 arthroplasty patients. The incidence of proximal DVT among the arthroscopy and arthroplasty patients was 0.4% and 1.1%, respectively. Multivariate analysis showed that age was the only signifi cant predictor of DVT incidence. Using the receiver operating characteristic method, the cut-off age for the arthroscopy and arthroplasty patients was 52 years, while that for the arthroscopy patients only was 40 years (increased risk of DVT: 5.46 and 6.44 times, respectively; negative predictive value: 99.7% and 99.8%, respectively).CONCLUSION DVT incidence among Asian arthroplasty and arthroscopy patients remains low, even without chemoprophylaxis. Since age was found to be a signifi cant risk factor for DVT, DVT prophylaxis can be considered for patients in high-risk age groups.

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Interventions for preventing venous thromboembolism in adults undergoing knee arthroscopy

Cited by 72 publications

References 11 publications

Prevention of VTE in Orthopedic Surgery Patients

Prevention of VTE in Orthopedic Surgery Patients

Graduated compression stockings for the prevention of deep-vein thrombosis in postoperative surgical patients: a systematic review and economic model with a value of information analysis

Deep vein thrombosis in arthroscopic surgery and chemoprophylaxis recommendation in an Asian population

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