Low Frequency of Symptomatic Venous Thromboembolism After Multiligamentous Knee Reconstruction With Thromboprophylaxis
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.Get Access
Reconstruction of the multiligament-injured knee often involves extended surgical and tourniquet use times and often is performed in patients who have sustained concomitant fractures as well as vascular injuries, all of which would appear to predispose the patient to the potentially serious complications of deep vein thrombosis and perhaps pulmonary embolism, yet little is known about the frequency of venous thromboembolic (VTE) events after multiligamentous knee reconstruction.
The purposes of this study were to (1) determine the frequency of symptomatic VTE after multiligamentous knee reconstruction at a single institution; and (2) to determine associated risk factors for VTE in these patients.
The records of 134 (63% of the 213 consented individuals in our longitudinal database) patients who underwent primary (129 [96%]) or revision (five [4%]) multiligamentous knee reconstruction at a single institution between 1992 and 2013 were retrospectively reviewed. With two patients undergoing procedures bilaterally, this resulted in a total of 136 multiligamentous knee reconstructions. VTE for which clinical symptoms were evident and confirmed by imaging within 3 months after the reconstructive procedure was noted. Pre- and perioperative data were collected with respect to demographics, associated injuries, medical history, smoking status, and surgical data. Standard rehabilitation and thromboprophylaxis protocols were used in all patients.
Three cases of symptomatic VTE (three deep vein thromboses) occurred after the 136 reconstructions (2%; 95% confidence interval, 0.53%–7.3%). Two of the three patients were obese and the remaining patient smoked and abused alcohol. However, as a result of a low frequency of VTE, no risk factors could be identified in this series.
Symptomatic VTE occurred in 2% of multiligamentous knee reconstructions at our institution while receiving thromboprophylaxis. This is similar to rates documented after anterior cruciate ligament reconstruction without thromboprophylaxis. Further multicenter research is required to identify the true frequency of and risk factors for developing VTE in patients undergoing multiligamentous knee reconstruction after knee dislocation.
Level of Evidence
Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
- Adala R, Anand A, Kodikal G. Deep vein thrombosis and thromboprophylaxis in arthroscopic anterior cruciate ligament reconstruction. Indian J Orthop. 2011;45:450–453. CrossRef
- Berry DJ. Surveillance for venous thromboembolic disease after total knee arthroplasty. Clin Orthop Relat Res. 2001;392:257–266. CrossRef
- Bushnell BD, Anz AW, Bert JM. Venous thromboembolism in lower extremity arthroscopy. Arthroscopy. 2008;24:604–611. CrossRef
- Camporese G, Bernardi E, Prandoni P, Noventa F, Verlato F, Simioni P, Ntita K, Salmistraro G, Frangos C, Rossi F, Cordova R, Franz F, Zucchetta P, Kontothanassis D, Andreozzi GM. Low-molecular-weight heparin versus compression stockings for thromboprophylaxis after knee arthroscopy: a randomized trial. Ann Intern Med. 2008;149:73–82. CrossRef
- Dahl OE, Gudmundsen TE, Haukeland L. Late occurring clinical deep vein thrombosis in joint-operated patients. Acta Orthop Scand. 2000;71:47–50. CrossRef
- Delis KT, Hunt N, Strachan RK, Nicolaides AN. Incidence, natural history and risk factors of deep vein thrombosis in elective knee arthroscopy. Thromb Haemost. 2001;86:817–821.
- Demers C, Marcoux S, Ginsberg JS, Laroche F, Cloutier R, Poulin J. Incidence of venographically proved deep vein thrombosis after knee arthroscopy. Arch Intern Med. 1998;158:47–50. CrossRef
- Edson CJ, Fanelli GC, Beck JD. Rehabilitation after multiple-ligament reconstruction of the knee. Sports Med Arthrosc. 2011;19:162–166. CrossRef
- Engebretsen L, Risberg MA, Robertson B, Ludvigsen TC, Johansen S. Outcome after knee dislocations: a 2–9 years follow-up of 85 consecutive patients. Knee Surg Sports Traumatol Arthrosc. 2009;17:1013–1026. CrossRef
- Fahmy NR, Patel DG. Hemostatic changes and postoperative deep-vein thrombosis associated with use of a pneumatic tourniquet. J Bone Joint Surg Am. 1981;63:461–465.
- Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S, Ortel TL, Pauker SG, Colwell CW Jr. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141:e278S–325S. CrossRef
- Fanelli GC. Posterior cruciate ligament rehabilitation: how slow should we go? Arthroscopy. 2008;24:234–235. CrossRef
- Fanelli GC, Stannard JP, Stuart MJ, MacDonald PB, Marx RG, Whelan DB, Boyd JL, Levy BA. Management of complex knee ligament injuries. J Bone Joint Surg Am. 2010;92:2235–2246.
- Giuseffi SA, Bishop AT, Shin AY, Dahm DL, Stuart MJ, Levy BA. Surgical treatment of peroneal nerve palsy after knee dislocation. Knee Surg Sports Traumatol Arthrosc. 2010;18:1583–1586. CrossRef
- Harner CD, Waltrip RL, Bennett CH, Francis KA, Cole B, Irrgang JJ. Surgical management of knee dislocations. J Bone Joint Surg Am. 2004;86:262–273.
- Hetsroni I, Lyman S, Do H, Mann G, Marx RG. Symptomatic pulmonary embolism after outpatient arthroscopic procedures of the knee: the incidence and risk factors in 418,323 arthroscopies. J Bone Joint Surg Br. 2011;93:47–51. CrossRef
- Hoppener MR, Ettema HB, Henny CP, Verheyen CC, Buller HB. Symptomatic deep vein thrombosis and immobilization after day-care arthroscopy of the knee. J Thromb Haemost. 2005;3:185–187. CrossRef
- Janssen RP, Sala HA. Fatal pulmonary embolism after anterior cruciate ligament reconstruction. Am J Sports Med. 2007;35:1000–1002. CrossRef
- Jones RE, Smith EC, Bone GE. Vascular and orthopedic complications of knee dislocation. Surg Gynecol Obstet. 1979;149:554–558.
- Kapoor A, Chew P, Silliman RA, Hylek EM, Katz JN, Cabral H, Berlowitz D. Venous thromboembolism after joint replacement in older male veterans with comorbidity. J Am Geriatr Soc. 2013;61:590–601. CrossRef
- Kieser C. A review of the complications of arthroscopic knee surgery. Arthroscopy. 1992;8:79–83. CrossRef
- Lapidus LJ, Ponzer S, Pettersson H, de Bri E. Symptomatic venous thromboembolism and mortality in orthopaedic surgery–an observational study of 45 968 consecutive procedures. BMC Musculoskelet Disord. 2013;14:177. CrossRef
- Levy BA, Dajani KA, Whelan DB, Stannard JP, Fanelli GC, Stuart MJ, Boyd JL, MacDonald PA, Marx RG. Decision making in the multiligament-injured knee: an evidence-based systematic review. Arthroscopy. 2009;25:430–438. CrossRef
- Levy BA, Fanelli GC, Whelan DB, Stannard JP, MacDonald PA, Boyd JL, Marx RG, Stuart MJ. Controversies in the treatment of knee dislocations and multiligament reconstruction. J Am Acad Orthop Surg. 2009;17:197–206.
- Levy BA, Krych AJ, Shah JP, Morgan JA, Stuart MJ. Staged protocol for initial management of the dislocated knee. Knee Surg Sports Traumatol Arthrosc. 2010;18:1630–1637. CrossRef
- Levy BA, Stuart MJ. Treatment of PCL, ACL, and lateral-side knee injuries: acute and chronic. J Knee Surg. 2012;25:295–305. CrossRef
- Levy BA, Zlowodzki MP, Graves M, Cole PA. Screening for extermity arterial injury with the arterial pressure index. Am J Emerg Med. 2005;23:689–695. CrossRef
- Marlovits S, Striessnig G, Schuster R, Stocker R, Luxl M, Trattnig S, Vecsei V. Extended-duration thromboprophylaxis with enoxaparin after arthroscopic surgery of the anterior cruciate ligament: a prospective, randomized, placebo-controlled study. Arthroscopy. 2007;23:696–702. CrossRef
- Mauck KF, Froehling DA, Daniels PR, Dahm DL, Ashrani AA, Crusan DJ, Petterson TM, Bailey KR, Heit JA. Incidence of venous thromboembolism after elective knee arthroscopic surgery: a historical cohort study. J Thromb Haemost. 2013;11:1279–1286. CrossRef
- Meyers MH, Moore TM, Harvey JP Jr. Traumatic dislocation of the knee joint. J Bone Joint Surg Am. 1975;57:430–433.
- Michot M, Conen D, Holtz D, Erni D, Zumstein MD, Ruflin GB, Renner N. Prevention of deep-vein thrombosis in ambulatory arthroscopic knee surgery: a randomized trial of prophylaxis with low-molecular weight heparin. Arthroscopy. 2002;18:257–263. CrossRef
- Montebugnoli M, Bugamelli S, Calo P, Zangheri E, Ferrari P. Prophylaxis of venous thromboembolism in minor orthopedic surgery with parnaparin. Clin Appl Thromb Hemost. 2007;13:249–258. CrossRef
- Mook WR, Ligh CA, Moorman CT 3rd, Leversedge FJ. Nerve injury complicating multiligament knee injury: current concepts and treatment algorithm. J Am Acad Orthop Surg. 2013;21:343–354. CrossRef
- Navarro-Sanz A, Fernandez-Ortega JF. Fatal pulmonary embolism after knee arthroscopy. Am J Sports Med. 2004;32:525–528. CrossRef
- O’Reilly RF, Burgess IA, Zicat B. The prevalence of venous thromboembolism after hip and knee replacement surgery. Med J Aust. 2005;182:154–159.
- Peskun CJ, Levy BA, Fanelli GC, Stannard JP, Stuart MJ, MacDonald PB, Marx RG, Boyd JL, Whelan DB. Diagnosis and management of knee dislocations. Phys Sportsmed. 2010;38:101–111. CrossRef
- Plancher KD, Siliski J. Long-term functional results and complications in patients with knee dislocations. J Knee Surg. 2008;21:261–268. CrossRef
- Price AJ. Hemostatic changes and postoperative deep-vein thrombosis associated with use of a pneumatic tourniquet. J Bone Joint Surg Am. 1982;64:1260.
- Rihn JA, Groff YJ, Harner CD, Cha PS. The acutely dislocated knee: evaluation and management. J Am Acad Orthop Surg. 2004;12:334–346.
- Rozencwaig R, Shilt JS, Ochsner JL Jr. Fatal pulmonary embolus after knee arthroscopy. Arthroscopy. 1996;12:240–241. CrossRef
- Salvo JP, Troxell CR, Duggan DP. Incidence of venous thromboembolic disease following hip arthroscopy. Orthopedics. 2010;33:664.
- Schenk R. Classification of knee dislocations. Oper Tech Sports Med. 2003;11:193–198. CrossRef
- Sems SA, Levy BA, Dajani K, Herrera DA, Templeman DC. Incidence of deep venous thrombosis after temporary joint spanning external fixation for complex lower extremity injuries. J Trauma. 2009;66:1164–1166. CrossRef
- Sherman OH, Fox JM, Snyder SJ, Del Pizzo W, Friedman MJ, Ferkel RD, Lawley MJ. Arthroscopy–’no-problem surgery.’ An analysis of complications in two thousand six hundred and forty cases. J Bone Joint Surg Am. 1986;68:256–265.
- Small NC. Complications in arthroscopic surgery performed by experienced arthroscopists. Arthroscopy. 1988;4:215–221. CrossRef
- Smith TO, Hing CB. Is a tourniquet beneficial in total knee replacement surgery? A meta-analysis and systematic review. Knee. 2010;17:141–147.
- Stringer MD, Steadman CA, Hedges AR, Thomas EM, Morley TR, Kakkar VV. Deep vein thrombosis after elective knee surgery. An incidence study in 312 patients. J Bone Joint Surg Br. 1989;71:492–497.
- Struijk-Mulder MC, Ettema HB, Verheyen CC, Buller HR. Deep vein thrombosis after arthroscopic anterior cruciate ligament reconstruction: a prospective cohort study of 100 patients. Arthroscopy. 2013;29:1211–1216. CrossRef
- Tay AK, MacDonald PB. Complications associated with treatment of multiple ligament injured (dislocated) knee. Sports Med Arthrosc. 2011;19:153–161. CrossRef
- Wascher DC, Becker JR, Dexter JG, Blevins FT. Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts. Am J Sports Med. 1999;27:189–196.
- Wascher DC, Dvirnak PC, DeCoster TA. Knee dislocation: initial assessment and implication for treatment. J Orthop Trauma. 1997;11:525–529. CrossRef
- Welling RE, Kakkasseril J, Cranley JJ. Complete dislocations of the knee with popliteal vascular injury. J Trauma. 1981;21:450–453.
- Williams JS Jr, Hulstyn MJ, Fadale PD, Lindy PB, Ehrlich MG, Cronan J, Dorfman G. Incidence of deep vein thrombosis after arthroscopic knee surgery: a prospective study. Arthroscopy. 1995;11:701–705. CrossRef
- Wirth T, Schneider B, Misselwitz F, Lomb M, Tuylu H, Egbring R, Griss P. Prevention of venous thromboembolism after knee arthroscopy with low-molecular weight heparin (reviparin): results of a randomized controlled trial. Arthroscopy. 2001;17:393–399. CrossRef
- Ye S, Dongyang C, Zhihong X, Dongquan S, Jin D, Jianghui Q, Jizhen Q, Pu Y, Huacheng H, Wei S, Qing J. The incidence of deep venous thrombosis after arthroscopically assisted anterior cruciate ligament reconstruction. Arthroscopy. 2013;29:742–747. CrossRef
- Low Frequency of Symptomatic Venous Thromboembolism After Multiligamentous Knee Reconstruction With Thromboprophylaxis
Clinical Orthopaedics and Related Research®
Volume 472, Issue 9 , pp 2705-2711
- Cover Date
- Print ISSN
- Online ISSN
- Springer US
- Additional Links
- Industry Sectors