Do We Need Chemoprophylaxis to Prevent Venous Thromboembolism following Medial Open-Wedge High Tibial Osteotomy?

Abstract

The aim of this study was to investigate the overall incidence of venous thromboembolism (VTE) and to assess the efficacy of chemoprophylaxis to prevent VTE following medial open-wedge high tibial osteotomy (MOWHTO) in Asian patients. A total of 133 patients who consecutively underwent MOWHTO for the treatment of knee osteoarthritis with varus deformity were enrolled. All patients underwent preoperative ultrasonography and computed tomography venography on postoperative day 5 to detect deep vein thrombosis (DVT). Patients were divided into two groups: chemoprophylaxis group included patients (n = 66) who received 2.5 mg fondaparinux for 5 days postoperatively, whereas control group comprised patients (n = 67) who received placebo (67 patients). We evaluated the efficacy and safety outcomes of the treatment. We also assessed the predisposing factors that may affect the occurrence of VTE. The incidence of overall DVT was 14.9% in the control group and 10.6% in the chemoprophylaxis group (p > 0.05). Proximal DVT occurred in one patient in the control group. There was no symptomatic DVT or pulmonary embolism in either group. The patients with DVT had significantly higher mean body mass index (BMI) than the patients without DVT. Multivariate logistic regression showed BMI > 30 kg/m² that was significantly correlated with the development of DVT (odds ratio = 0.8; p = 0.017). There were no cases of major bleeding; however, minor bleeding episodes occurred in four patients in the chemoprophylaxis group. The current study showed that the overall incidence of VTE following MOWHTO was low in Asian patients even without chemoprophylaxis. Therefore, routine chemoprophylaxis following MOWHTO seems to be not necessary in a population with low-VTE incidence. However, selective chemoprophylaxis should be considered in patients with BMI > 30 kg/m².

Keywords

medial open-wedge high tibial osteotomy - high tibial osteotomy - deep vein thrombosis - venous thromboembolism - chemoprophylaxis

Ethical Review Statement

The protocol of present study was approved by the medical ethics committee of Kyung Hee University Hospital at Gangdong. The study was conducted in compliance with the Declaration of Helsinki.

Publication History

Received: 05 April 2019

Accepted: 27 November 2019

Article published online:
13 January 2020

• References

• 1 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 (03) 492-497
• 2 Jaureguito JW, Greenwald AE, Wilcox JF, Paulos LE, Rosenberg TD. The incidence of deep venous thrombosis after arthroscopic knee surgery. Am J Sports Med 1999; 27 (06) 707-710
• 3 Howie C, Hughes H, Watts AC. Venous thromboembolism associated with hip and knee replacement over a ten-year period: a population-based study. J Bone Joint Surg Br 2005; 87 (12) 1675-1680
• 4 Wang C-J, Wang J-W, Weng L-H, Hsu CC, Huang CC, Yu PC. Prevention of deep-vein thrombosis after total knee arthroplasty in Asian patients. Comparison of low-molecular-weight heparin and indomethacin. J Bone Joint Surg Am 2004; 86 (01) 136-140
• 5 Kim Y-H, Kim J-S. Incidence and natural history of deep-vein thrombosis after total knee arthroplasty. A prospective, randomised study. J Bone Joint Surg Br 2002; 84 (04) 566-570
• 6 Chung KS, Shin TY, Park SH, Kim H, Choi CH. Rivaroxaban and acetylsalicylic acid for prevention of venous thromboembolism following total knee arthroplasty in korean patients. Knee Surg Relat Res 2018; 30 (03) 247-254
• 7 Lee W-S, Kim K-I, Lee H-J, Kyung HS, Seo SS. The incidence of pulmonary embolism and deep vein thrombosis after knee arthroplasty in Asians remains low: a meta-analysis. Clin Orthop Relat Res 2013; 471 (05) 1523-1532
• 8 Chung LH, Chen WM, Chen CF, Chen TH, Liu CL. Deep vein thrombosis after total knee arthroplasty in asian patients without prophylactic anticoagulation. Orthopedics 2011; 34 (01) 15
• 9 Kim K-I, Cho K-Y, Jin W, Khurana SS, Bae DK. Recent Korean perspective of deep vein thrombosis after total knee arthroplasty. J Arthroplasty 2011; 26 (07) 1112-1116
• 10 Kobayashi H, Akamatsu Y, Kumagai K. et al. The use of factor Xa inhibitors following opening-wedge high tibial osteotomy for venous thromboembolism prophylaxis. Knee Surg Sports Traumatol Arthrosc 2017; 25 (09) 2929-2935
• 11 Bauer KA, Eriksson BI, Lassen MR, Turpie AG. ; Steering Committee of the Pentasaccharide in Major Knee Surgery Study. Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after elective major knee surgery. N Engl J Med 2001; 345 (18) 1305-1310
• 12 Staubli AE, De Simoni C, Babst R, Lobenhoffer P. TomoFix: a new LCP-concept for open wedge osteotomy of the medial proximal tibia--early results in 92 cases. Injury 2003; 34 (Suppl. 02) B55-B62
• 13 Lobenhoffer P, Agneskirchner JD. Improvements in surgical technique of valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 2003; 11 (03) 132-138
• 14 Toftdahl K, Nikolajsen L, Haraldsted V, Madsen F, Tønnesen EK, Søballe K. Comparison of peri- and intraarticular analgesia with femoral nerve block after total knee arthroplasty: a randomized clinical trial. Acta Orthop 2007; 78 (02) 172-179
• 15 Haeger K. Problems of acute deep venous thrombosis. I. The interpretation of signs and symptoms. Angiology 1969; 20 (04) 219-223
• 16 Anderson Jr. FA, Wheeler HB, Goldberg RJ. et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT study. Arch Intern Med 1991; 151 (05) 933-938
• 17 Investigators P. ; PIOPED Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). JAMA 1990; 263 (20) 2753-2759
• 18 Abdollahi M, Cushman M, Rosendaal FR. Obesity: risk of venous thrombosis and the interaction with coagulation factor levels and oral contraceptive use. Thromb Haemost 2003; 89 (03) 493-498
• 19 Pomp ER, Rosendaal FR, Doggen CJ. Smoking increases the risk of venous thrombosis and acts synergistically with oral contraceptive use. Am J Hematol 2008; 83 (02) 97-102
• 20 Petrauskiene V, Falk M, Waernbaum I, Norberg M, Eriksson JW. The risk of venous thromboembolism is markedly elevated in patients with diabetes. Diabetologia 2005; 48 (05) 1017-1021
• 21 Faris PM, Ritter MA, Keating EM, Valeri CR. Unwashed filtered shed blood collected after knee and hip arthroplasties. A source of autologous red blood cells. J Bone Joint Surg Am 1991; 73 (08) 1169-1178
• 22 Colwell Jr. CW, Kwong LM, Turpie AG, Davidson BL. Flexibility in administration of fondaparinux for prevention of symptomatic venous thromboembolism in orthopaedic surgery. J Arthroplasty 2006; 21 (01) 36-45
• 23 Comp PC, Spiro TE, Friedman RJ. et al; Enoxaparin Clinical Trial Group. Prolonged enoxaparin therapy to prevent venous thromboembolism after primary hip or knee replacement. J Bone Joint Surg Am 2001; 83 (03) 336-345
• 24 Stein PD, Beemath A, Olson RE. Obesity as a risk factor in venous thromboembolism. Am J Med 2005; 118 (09) 978-980
• 25 Park SH, Ahn JH, Park YB, Lee SG, Yim SJ. Incidences of deep vein thrombosis and pulmonary embolism after total knee arthroplasty using a mechanical compression device with and without low-molecular-weight heparin. Knee Surg Relat Res 2016; 28 (03) 213-218
• 26 Turner RS, Griffiths H, Heatley FW. The incidence of deep-vein thrombosis after upper tibial osteotomy. A venographic study. J Bone Joint Surg Br 1993; 75 (06) 942-944
• 27 Motycka T, Eggerth G, Landsiedl F. The incidence of thrombosis in high tibial osteotomies with and without the use of a tourniquet. Arch Orthop Trauma Surg 2000; 120 (3,4): 157-159
• 28 Kanchanabat B, Stapanavatr W, Meknavin S, Soorapanth C, Sumanasrethakul C, Kanchanasuttirak P. Systematic review and meta-analysis on the rate of postoperative venous thromboembolism in orthopaedic surgery in Asian patients without thromboprophylaxis. Br J Surg 2011; 98 (10) 1356-1364
• 29 Park K-H, Cheon S-H, Lee J-H, Kyung HS. Incidence of venous thromboembolism using 64 channel multidetector row computed tomography-indirect venography and anti-coagulation therapy after total knee arthroplasty in Korea. Knee Surg Relat Res 2012; 24 (01) 19-24
• 30 Warwick D, Friedman RJ, Agnelli G. et al. Insufficient duration of venous thromboembolism prophylaxis after total hip or knee replacement when compared with the time course of thromboembolic events: findings from the Global Orthopaedic Registry. J Bone Joint Surg Br 2007; 89 (06) 799-807
• 31 Spahn G. Complications in high tibial (medial opening wedge) osteotomy. Arch Orthop Trauma Surg 2004; 124 (10) 649-653
• 32 Anderson Jr. FA, Spencer FA. Risk factors for venous thromboembolism. Circulation 2003; 107 (23, Suppl 1): I9-I16
• 33 Chen CW, Pan ZE, Zhou YL, Liu CL, Wu LC, Chen L. [Incidence and risk factors of early deep venous thrombosis after knee arthroscopy operation under conventional tourniquet]. Zhongguo Gu Shang 2018; 31 (09) 829-834
• 34 Nathan S, Aleem MA, Thiagarajan P, Das De S. The incidence of proximal deep vein thrombosis following total knee arthroplasty in an Asian population: a Doppler ultrasound study. J Orthop Surg (Hong Kong) 2003; 11 (02) 184-189
• 35 Hernandez AJ, Almeida AM, Fávaro E, Sguizzato GT. The influence of tourniquet use and operative time on the incidence of deep vein thrombosis in total knee arthroplasty. Clinics (São Paulo) 2012; 67 (09) 1053-1057
• 36 White RH, Henderson MC. Risk factors for venous thromboembolism after total hip and knee replacement surgery. Curr Opin Pulm Med 2002; 8 (05) 365-371
• 37 Cohen J. Statistical power analysis for the behavioral sciences. New York, NY: Routledge; 2013
• 38 Koh IJ, Kim MW, Kim JH, Han SY, In Y. Trends in high tibial osteotomy and knee arthroplasty utilizations and demographics in Korea from 2009 to 2013. J Arthroplasty 2015; 30 (06) 939-944