Thromboprophylaxis in Knee Arthroscopy Patients: Revisiting Values and Preferences

The most common orthopedic operation worldwide is knee arthroscopy. The best-practice guidelines for thromboprophylaxis for knee arthroscopy patients remain to be determined. Because of uncertainty about the perioperative and postoperative risk for deep venous thrombosis (DVT), physicians have been noncommittal about the need for thromboprophylaxis in such patients, especially because diagnostic arthroscopy and arthroscopy-assisted knee surgery are mostly performed in young patients. This debate about the need for thromboprophylaxis is important, because approximately 3.5 million knee arthroscopies are performed per year globally (1, 2). Although clinical venous thromboembolism (VTE) is uncommon and deaths are rare, this huge volume of surgery has the potential to substantially increase the burden of VTE in young patients.

Guidelines for thromboprophylaxis with knee arthroscopy are ambiguous, reflecting the gap between the potential for aggregate harm and the slender body of evidence. In 2004, the American College of Chest Physicians guidelines (3) recommended that “clinicians do not use routine thromboprophylaxis in these patients, other than early mobilization (Grade 2B). … For patients undergoing arthroscopic knee surgery who are at a higher than usual risk, based on preexisting VTE risk factors or following a prolonged or complicated procedure, [they] suggest thromboprophylaxis with LMWH [low-molecular-weight heparin] (Grade 2B).” The 2006 International Consensus Statement guidelines (4) state that for simple diagnostic arthroscopy, “routine prophylaxis is not recommended unless other risk factors are present (Grade C).” For patients undergoing arthroscopic knee surgery, such as ligament reconstructions, “LMWH starting before or after surgery (Grade B) or IPC [intermittent pneumatic compression] in the presence of contraindications to LMWH are recommended (Grade C) until full ambulation.” The B and C ratings of these recommendations reflect the limited available data at that time.

Randomized trials published in 2001 (5), 2002 (6), and 2007 (7) suggest that LMWH thromboprophylaxis reduces the frequency …