Venous Thromboembolism After Knee Arthroscopy in Undiagnosed Familial Thrombophilia

Abstract

Venous thromboembolism is uncommon after knee arthroscopy, and there are no guidelines for thromboprophylaxis in elective routine knee arthroscopy. Preoperative evaluation of common thrombophilias should provide guidance for postarthroscopy thromboprophylaxis in otherwise healthy patients who are at high risk for venous thromboembolism. This study assessed 10 patients with venous thromboembolism after total hip or knee arthroplasty. Patients were assessed if venous thromboembolism occurred within 6 months after knee arthroscopy (n=10) or total hip or knee arthroplasty (n=21). This study assessed gene mutations (factor V Leiden, prothrombin G20210A, plasminogen activator inhibitor, methylenetetrahydrofolate reductase) and serologic thrombophilias (high levels of factors VIII and XI, homocysteine, anticardiolipin immunoglobulin G and immunoglobulin M antibodies, and lupus anticoagulant; low antigenic protein C, S, and free S; and antithrombin III deficiency). The same coagulation data were obtained for normal subjects (n=110). The major thrombophilias in the arthroscopy group were factor V Leiden heterozygosity (40%), high factor VIII level (50%), and high homocysteine (30%). The respective values in control subjects were 2% (P=.0004), 7% (P=.0011), and 5% (P=.02). When the arthroscopy group was compared with the 21 patients who had venous thromboembolism after total hip or knee arthroplasty, the sole difference was factor V Leiden heterozygosity, which was 40% vs 0%, respectively (P=.007). Although venous thromboembolism after knee arthroscopy is uncommon, to identify high-risk patients and guide postoperative thromboprophylaxis, the authors suggest routine preoperative measurement of 3 common familial thrombophilias: factor V Leiden, factor VIII, and homocysteine. [Orthopedics. 2016; 39(6):e1052-e1057.].

Recommendations from the ICM-VTE: General

“…Performing surgery in a patient with inherited thrombophilia supposes a 13-fold increased risk of VTE within 1 year (odds ratio [OR], 13.3 95% confidence interval [CI]; 7.2 -24.7) 1513 . Furthermore, VTE risk was highest within the first 30days following surgery (OR adj 17.5; 95% CI, 9.2 -33.4) and remained high up to 90-days postoperatively in this population [1513][1514][1515][1516][1517][1518] .…”

Patients Undergoing Primary Total Joint Arthroplasty with Primary Hypercoagulable States

“…Therefore, genetic predispositions are associated with increased odds of the occurrence of embolization events. However, these previous published studies usually investigated a rather small sample of patients, such as the 14 or 44 patients mentioned above, and patient samples were usually from a single or limited number of hospitals 13,22,31,32 . Even worse, conclusions of the actual impacts of PHS for orthopaedic surgeries vary from different studies, because they were surveyed among different selected patient cohorts or with dissimilar adverse outcome criterions 5,21,33 .…”

“…Therefore, genetic predispositions are associated with increased odds of the occurrence of embolization events. However, these previous published studies usually investigated a rather small sample of patients, such as the 14 or 44 patients mentioned above, and patient samples were usually from a single or limited number of hospitals 13,22,31,32 .…”

An unusual case of symptomatic deep vein thrombosis and pulmonary embolism after arthroscopic meniscus surgery

“…Moreover, a recent study deem these history of “classic” risk factors for venous thromboembolism in patients undergoing routine arthroscopy is very insensitive, preoperative diagnosis of thrombophilia should be both specific and sensitive, including 3 common familial thrombophilias: factor V Leiden, factor VIII, and homocysteine. They were significantly more common in patients who had symptomatic venous thromboembolism after elective routine knee arthroscopy than in healthy normal control subjects, with factor V Leiden heterozygosity (40% vs 2%), high factor VIII level (50% vs 7%), and high homocysteine (30% vs 5%) respectively [ 19 ]. Recently, High altitude also is regard as potential risk factor of VTE.…”