DVTs and Routine Arthroscopy
DVTs and Routine Arthroscopy
Abstract & Commentary
Synopsis: The risk of DVT was 15% following routine arthroscopy. This was reduced to less than 2% with prophylactic treatment using low molecular weight heparin.
Source: Michot M, et al. Arthroscopy. 2002;18(3):257-263.
The risk of deep vein thrombosis (DVT) in patients undergoing arthroscopic knee surgery is not well known. The purpose of this study was to determine the incidence of DVT in an outpatient setting to demonstrate the efficacy of prophylaxis against DVT with use of dalteparin and to determine the safety and feasibility of dalteparin administration in these patients. A prospective, randomized trial of 218 consecutive outpatients scheduled for ambulatory arthroscopic knee surgery were entered into the study. Of these 218 patients, 130 met the inclusion criteria and were randomized to a treatment group with LMWH (dalteparin n = 66) or a control group (n = 64) with no prophylaxis. Ultrasonography was used to detect DVT.
Thromboembolism was significantly lower in the dalteparin treatment group (1/66 vs 10/64). All DVTs were in the operated leg and none were above the knee. No severe side effects of LMWH were observed. Two knees in the treatment group had to undergo arthrocentesis for hemorrhage. Only 5% of patients refused subcutaneous LMWH injections at home. In conclusion, patients undergoing ambulatory arthroscopic knee surgery without antithrombotic prophylaxis are at noteworthy risk for DVT. Prophylaxis with dalteparin is an effective and safe means of reducing this risk in outpatient arthroscopic knee surgery.
Comment by James R. Slauterbeck, MD
In general, the risk of DVT in patients undergoing out patient arthroscopy knee surgery without prophylaxis is higher than anticipated. Most studies addressing DVT risk in these patients have been retrospective and reported an incidence as high as 18%. This study prospectively identified a 15% incidence of DVT in healthy patients. The exclusion criteria eliminated most sick patients with additional risk factors. Therefore, the actual incidence would likely be higher in the general population.
Treatment with dalteparin 1 hour before surgery, 6 hours after surgery, and then daily for 4 weeks postoperatively reduced the incidences of DVT to 1.8%. All DVTs were confined to the calf, admittedly of questionable clinical significance. The patients accepted the daily subcutaneous injections well and no major bleeding episodes were reported postoperatively. However, 2 knees underwent arthrocentesis for hematoma evacuations without any further problems.
This is an excellent article and may change the way I practice medicine. I plan to prophylax my older patients and those with additional risk factors, such as obesity or oral contraceptives. Since 2 hematomas were evacuated from knees during routine arthroscopy, I am concerned about prophylaxis during ACL reconstruction because the bleeding could lead to arthrofibrosis, which is a significant complication. Therefore, I will probably not prophylax the ACL reconstruction patients until I determine how many problematic hematomas require additional treatment.
Dr. Slauterbeck, Associate Professor, Department of Orthopedic Surgery, Texas Tech University Health Sciences Center, Lubbock, is Associate Editor of Sports Medicine Reports.
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