Venous thromboembolism in orthopaedic oncology

Abstract

Aims Malignancy and surgery are risk factors for venous thromboembolism (VTE). We undertook a systematic review of the literature concerning the prophylactic management of VTE in orthopaedic oncology patients. Methods MEDLINE (PubMed), EMBASE (Ovid), Cochrane, and CINAHL databases were searched focusing on VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), bleeding, or wound complication rates. Results In all, 17 studies published from 1998 to 2018 met the inclusion criteria for the systematic review. The mean incidence of all VTE events in orthopaedic oncology patients was 10.7% (1.1% to 27.7%). The rate of PE was 2.4% (0.1% to 10.6%) while the rate of lethal PE was 0.6% (0.0% to 4.3%). The overall rate of DVT was 8.8% (1.1% to 22.3%) and the rate of symptomatic DVT was 2.9% (0.0% to 6.2%). From the studies that screened all patients prior to hospital discharge, the rate of asymptomatic DVT was 10.9% (2.0% to 20.2%). The most common risk factors identified for VTE were endoprosthetic replacements, hip and pelvic resections, presence of metastases, surgical procedures taking longer than three hours, and patients having chemotherapy. Mean incidence of VTE with and without chemical prophylaxis was 7.9% (1.1% to 21.8%) and 8.7% (2.0% to 23.4%; p = 0.11), respectively. No difference in the incidence of bleeding or wound complications between prophylaxis groups was reported. Conclusion Current evidence is limited to guide clinicians. It is our consensus opinion, based upon logic and deduction, that all patients be considered for both mechanical and chemical VTE prophylaxis, particularly in high-risk patients (pelvic or hip resections, prosthetic reconstruction, malignant diagnosis, presence of metastases, or surgical procedures longer than three hours). Additionally, the surgeon must determine, in each patient, if the risk of haemorrhage outweighs the risk of VTE. No individual pharmacological agent has been identified as being superior in the prevention of VTE events. Cite this article: Bone Joint J 2020;102-B(12)1743:–1751.

Recommendations from the ICM-VTE: General

“…The study by Yamaguchi et al, identified age > 70 years as a risk factor for VTE events in 94 patients undergoing musculoskeletal tumor resection 98 . In contrast, other studies were not able to detect an association between age and VTE occurrence 96,97,99,100 .…”

“…The influence of age on VTE risk in patients with fractures of the lower extremity and oncologic orthopaedic surgeries were not consistent 92-101 . In patients undergoing surgical treatment of fractures below the hip, age ≥ 60 years was identified as a risk factor for VTE (RR 1.85 [95% CI 1.34 - 2.55]) in 191,294 patients 92 .…”

“…Rationale: Cancer patients have a hypercoagulable state due to the presence of all components of Virchow's triad. There is evidence of platelet activation along with elevated levels of inflammatory cytokines (vascular endothelial growth factor, tissue factor), tumor mass effect compressing adjacent veins and damage to the endothelium 295 .…”

“…The authors recommended apixaban, rivaroxaban, or LMWH in high-risk cancer patients and advised for the start of pharmacotherapy prior to surgery and to continue 7 - 10 days after surgery. A systematic review by Lex et al, was performed regarding VTE prophylaxis in orthopaedic oncology patients 1443 . The authors concluded that there is limited evidence to guide clinicians in VTE prophylaxis in this population.…”

Recommendations from the ICM-VTE: Oncology

“…Rationale: Major orthopaedic surgeries and oncological patients have increased risk for VTE, with the mean incidence of all VTE events in orthopaedic oncology patients being 10.7% (1.1% to 27.7%). Risk factors for increased events include endoprosthetic replacements, hip and pelvic resections, surgical procedures taking longer than 3 hours, and chemotherapy 14 , all of which are common with sarcoma surgeries. Higher preoperative white blood cell count (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.01-1.29) and post-operative wound complications (OR 5.01, 95% CI 1.93-13.55) were found to be independent risk factors for VTE 15 .…”