The n e w e ng l a n d j o u r na l of m e dic i n e

Cl inic a l Decisions
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Thromboprophylaxis after Knee Arthroscopy

This interactive feature addresses the approach to a clinical issue. A case vignette is followed by specific options, neither of which
can be considered either correct or incorrect. In short essays, experts in the field then argue for each of the options. Readers can
participate in forming community opinion by choosing one of the options and, if they like, providing their reasons.

C a s e V igne t t e mass index (the weight in kilograms divided by

A Woman Considering the square of the height in meters) is 31. The
physical examination is notable for a positive
Thromboprophylaxis after McMurrays test, with pain on application of mild
Arthroscopic Knee Surgery valgus force on the right knee. She is scheduled
to resume physical therapy after her surgery, once
RebeccaE. Berger, M.D. the postoperative pain subsides. Ms. Benson asks
Ms. Benson is a 60-year-old woman who comes your advice on how she can prevent blood clots
to your office to discuss her upcoming arthroscop- after her procedure. What do you recommend?
ic knee surgery. She recently received a diagnosis
of a right lateral meniscus tear and is scheduled T r e atment O p t i ons
to undergo arthroscopic meniscectomy. She has Which of the following options would you rec-
heard that knee surgery increases the risk of ommend for this patient?
blood clots, and she wants to know whether she
should take an anticoagulant after her surgery to 1. Receive postoperative thromboprophylaxis.
reduce the risk. Ms. Bensons medical history is 2. Do not receive postoperative thromboprophy-
notable for hypertension and diabetes mellitus laxis.
type 2, for which she takes lisinopril and met-
formin. She is a former smoker who quit 10 years To aid in your decision making, each of these
ago after having smoked one pack of cigarettes approaches is defended in a short essay by an
per day for 30 years. She has no personal history expert in the field. Given your knowledge of the
of venous thromboembolic disease or bleeding patient and the points made by the experts, which
diathesis. Her sister had a pulmonary embolism option would you choose? Make your choice, vote,
after a pregnancy. In the office today, Ms. Bensons and offer your comments at NEJM.org.
blood pressure is 125/75 mm Hg, and her body-

O p t i on 1 molecular-weight heparin or a direct oral antico-

Receive Postoperative
Thromboprophylaxis
Menaka Pai, M.D.
Prophylaxis for postoperative venous thrombo-
embolism (VTE) should be tailored to the indi-
vidual patient. In addition to considering the pro-
cedural risk of thrombosis and bleeding, we must
assess the patients individual risk and willingness
to accept risk. In this case, Ms. Benson is a good
candidate for postoperative prophylaxis with low-
agulant.
Total knee replacement is associated with an
estimated 35-day rate of symptomatic VTE of
4.3%.1 In contrast, arthroscopic meniscectomy
carries a low risk of thrombosis, with a reported
incidence of symptomatic VTE of approximately
0.34% without prophylaxis.2 However, even with
arthroscopic surgery, certain patients are at in-
creased risk for VTE, such as patients with a his-
tory of cancer or VTE, those who require hospi-
talization, or those who have two or more risk
factors such as older age, obesity, smoking, hor-
mone use, or chronic venous insufficiency.2,3

580 n engl j med 376;6nejm.org February 9, 2017

The New England Journal of Medicine

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 Clinical Decisions
Randomized trials involving patients under-
going knee arthroscopy have shown a benefit of
VTE prophylaxis with low-molecular-weight hep-
arin and with rivaroxaban.4,5 However, these trials
have been criticized for overestimating the true
benefit of prophylaxis, since their outcomes in-
cluded distal leg clots and asymptomatic proximal
clots. The goal of prophylaxis is to prevent symp-
tomatic VTE, since distal and asymptomatic clots
are generally considered to be clinically insig-
nificant. Current guidelines recommend VTE pro-
phylaxis with low-molecular-weight heparin or a
direct oral anticoagulant after total knee replace-
ment but recommend against thromboprophylaxis
for patients undergoing knee arthroscopy who do
not have a history of VTE.1 The guidelines do
state that thromboprophylaxis may be warranted
if the patient is at increased risk for VTE owing
to known predisposing risk factors.
The results of the Prevention of Thrombosis
after Knee Arthroscopy (POT-KAST) trial pub-
lished in this issue of the Journal show that in
patients undergoing arthroscopic knee surger-
ies, there was no effect of low-molecular-weight
heparin on symptomatic VTE or major bleeding.6
However, patients enrolled in the trial appear to
have had a low baseline risk of thrombosis; the
mean age was 49 years, and the vast majority
were nonsmokers, were nonobese, and had no
history of cancer. Less than 15% reported a fam-
ily history of VTE. Ms. Benson is not an aver-
age POT-KAST patient. There is nothing in her
history to suggest an increased bleeding risk.
Whether former smokers have a higher risk of
VTE after arthroscopy is unclear.2 However, Ms.
Benson is obese (BMI of 31), which doubles to
triples the risk of thrombosis.7 Her age also in-
creases her risk; the baseline risk and case fatal-
ity rate associated with VTE rise sharply among
patients older than 45 years of age.7 In addition,
Ms. Benson has a first-degree relative who had a
pulmonary embolism. Even though her sisters
VTE was provoked and there is no evidence of an
inherited hypercoagulable state, the history of
VTE in a sister doubles Ms. Bensons risk of
thrombosis.8 Risk predictors developed with the
use of patient cohorts from the outpatient data-
base of the American College of Surgeons Na-
tional Surgical Quality Improvement Program
reinforce Ms. Bensons higher-than-average base-
line risk of a clinically significant VTE.9
n engl j med 376;6nejm.org February 9, 2017
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Finally, a conversation with Ms. Benson about
her willingness to accept risk is warranted, es-
pecially since it may be influenced by her sisters
VTE. How concerned is Ms. Benson about devel-
opment of a clot? How does she perceive the bleed-
ing risks associated with anticoagulant therapy?
Offering Ms. Benson safe VTE prophylaxis may
not only prevent thrombosis but also give her peace
of mind.
There are many patient populations, such as
hospitalized medical patients and ambulatory
surgical patients, in which the overall risk of
symptomatic VTE is low. However, within these
large populations, there are distinct groups of
patients who have a relatively higher risk. It is
vital to identify these patients and offer them safe,
effective prophylaxis in order to reduce health care
costs, complications, and death. In conclusion,
after considering her personal willingness to ac-
cept risk and her preferences, I would recommend
VTE prophylaxis to Ms. Benson on the basis of
her age, BMI, and family history of VTE, all of
which increase her risk of thrombosis, and the
absence of major risk factors for bleeding.
Disclosure forms provided by the author are available with the
full text of this article at NEJM.org.
From the Division of Hematology and Thromboembolism,
McMaster University, Hamilton, ON, Canada.
O p t i on 2
Do Not Receive Postoperative
Thromboprophylaxis
Anita Rajasekhar, M.D.
Knee arthroscopy is the most frequently per-
formed orthopedic procedure for the diagnosis
and treatment of knee injuries worldwide. Given
the available evidence, I would recommend against
thromboprophylaxis for Ms. Benson. Thrombopro-
phylaxis carries a potential benefit of preventing
postoperative VTE, but the benefit must be
weighed against the risk of bleeding as well as
other factors, such as inconvenience to the pa-
tient and cost. In addition to these risks and
benefits, Ms. Bensons values and preferences re-
garding anticoagulation therapy should be incor-
porated in a shared decision-making model.
Patients undergoing total knee or hip arthro-
plasty or surgery for hip fracture have a 35-day
baseline risk of symptomatic VTE of 4 to 5%.
581
 The n e w e ng l a n d j o u r na l
Contemporary thromboprophylaxis regimens re-
duce this risk by about 50 to 60%.1 Accordingly,
evidence-based guidelines recommend extend-
ing thromboprophylaxis after hospital discharge
in these patients.1 In contrast, the risk of VTE
after knee arthroscopy and casting of the lower
leg is less well defined. The reported incidence
of deep-vein thrombosis without thromboprophy-
laxis after knee arthroscopy varies from 0.2 to
18%,5,10 with one study reporting all deep-vein
thromboses occurring within 6 weeks after sur-
gery.10 However, these data were derived from
heterogeneous studies that had methodologic lim-
itations.5,10 Previous studies comparing thrombo-
prophylaxis with either placebo or compression
stockings reported conflicting results. Studies
that showed a reduction in the incidence of deep-
vein thrombosis in the lower leg with the use of
thromboprophylaxis included distal and asymp-
tomatic deep-vein thromboses as outcomes.5,11
Distal and asymptomatic deep-vein thromboses
are generally thought to have minimal clinical
significance, and it is unclear whether patients
benefit from prevention of such thromboses. In
addition, a meta-analysis of studies of thrombo-
prophylaxis after knee arthroscopy showed an
increase in all adverse events and in minor bleed-
ing.5 As such, there is no consensus on thrombo-
prophylaxis after arthroscopy. The 2012 Ameri-
can College of Chest Physicians guidelines on
the prevention of VTE give a weak recommenda-
tion against routine thromboprophylaxis after
knee arthroscopy (Grade 2B).1
In this case, Ms. Benson is scheduled for elec-
tive knee arthroscopy and inquires about whether
thromboprophylaxis is indicated for her. Ms. Ben-
son is obese and has a family history of provoked
VTE but does not have other patient-specific risk
factors for VTE, such as previous VTE, active can-
cer, or known inherited or acquired thrombophil-
ia. The POT-KAST and Prevention of Thrombosis
after Lower Leg Plaster Cast (POT-CAST) studies,
the results of which are published in this issue of
the Journal,6 were high-quality multicenter, prag-
matic, randomized, open-label trials in which post-
operative thromboprophylaxis with low-molecular-
weight heparin for 8 days was compared with no
postoperative thromboprophylaxis in patients un-
dergoing knee arthroscopy, and the use of ex-
tended thromboprophylaxis was compared with
no prophylaxis for the duration of lower-leg cast-
ing. They are the largest randomized trials to date
582 n engl j med 376;6nejm.org February 9, 2017
The New England Journal of Medicine
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of m e dic i n e
to address the question of thromboprophylaxis in
patients after knee arthroscopy or lower-leg cast-
ing. In the POT-KAST study, patients underwent
knee arthroscopy for a variety of indications;
77% had meniscectomies. It should be noted
that 19 to 23% of the patients in the POT-KAST
trial were obese and 12% had a family history of
VTE in a first-degree relative features similar
to those of Ms. Benson. At 3 months, there was
no significant difference in the incidence of symp-
tomatic VTE (relative risk, 1.6; 95% confidence
interval [CI], 0.4 to 6.8), major bleeding (relative
risk, 1.0; 95% CI, 0.1 to 15.7), or clinically rele-
vant nonmajor bleeding (relative risk, 0.3; 95%
CI, 0 to 3.1). The most notable feature of this
study, which distinguishes it from prior studies,
is that the investigators included only symptom-
atic VTE in their outcomes and did not routinely
perform ultrasonography to assess for asymp-
tomatic clots. Since the ultimate therapeutic
objective of postoperative thromboprophylaxis
is to prevent clinical VTE, which can affect
morbidity and mortality, this outcome measure
highlights outcomes that are important to pa-
tients, which allows more accurate estimation of
the real-world risks and benefits of thrombopro-
phylaxis.
Ms. Benson is a patient who would have been
eligible for the POT-KAST trial, so it is reason-
able to apply the results of the trial in deciding
on her individual treatment. The POT-KAST trial
reinforced evidence that there is a low inci-
dence of clinically significant deep-vein throm-
bosis among patients undergoing knee arthros-
copy. The inconvenience, cost, and bleeding risk
associated with thromboprophylaxis are not
counterbalanced by a clear therapeutic benefit.
Instead, Ms. Benson should be encouraged to
ambulate early after surgery and should be edu-
cated on the signs and symptoms of venous
thromboembolism.
Disclosure forms provided by the author are available with the
full text of this article at NEJM.org.
From the Division of Hematology and Oncology, University of
Florida, Gainesville.
1. Falck-Ytter Y, Francis CW, Johanson NA, et al. 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(2 Suppl):e278S-325S.
2. Krych AJ, Sousa PL, Morgan JA, Levy BA, Stuart MJ, Dahm
DL. Incidence and risk factor analysis of symptomatic venous
 Clinical Decisions

thromboembolism after knee arthroscopy. Arthroscopy 2015;
31:2112-8.
3. van Adrichem RA, Nelissen RG, Schipper IB, Rosendaal FR,
Cannegieter SC. Risk of venous thrombosis after arthroscopy of
the knee: results from a large population-based case-control
study. J Thromb Haemost 2015;13:1441-8.
4. Camporese G, Bernardi E, Noventa F, et al. Efficacy of Ri-
varoxaban for thromboprophylaxis after Knee Arthroscopy
(ERIKA): a phase II, multicentre, double-blind, placebo-con-
trolled randomised study. Thromb Haemost 2016;116:349-55.
5. Ramos J, Perrotta C, Badariotti G, Berenstein G. Interven-
tions for preventing venous thromboembolism in adults under-
going knee arthroscopy. Cochrane Database Syst Rev 2008;4:
CD005259.
6. van Adrichem RA, Nemeth B, Algra A, et al. Thrombopro-
phylaxis after knee arthroscopy and lower-leg casting. N Engl J
Med 2017;376:515-25.
7. Cushman M. Epidemiology and risk factors for venous
thrombosis. Semin Hematol 2007;44:62-9.
8. Couturaud F, Leroyer C, Tromeur C, et al. Factors that pre-
dict thrombosis in relatives of patients with venous thromboem-
bolism. Blood 2014;124:2124-30.
9. Pannucci CJ, Shanks A, Moote MJ, et al. Identifying patients
at high risk for venous thromboembolism requiring treatment
after outpatient surgery. Ann Surg 2012;255:1093-9.
10. Mauck KF, Froehling DA, Daniels PR, et al. Incidence of
venous thromboembolism after elective knee arthroscopic sur-
gery: a historical cohort study. J Thromb Haemost 2013;11:
1279-86.
11. Camporese G, Bernardi E, Prandoni P, et al. Low-molecular-
weight heparin versus compression stockings for thrombopro-
phylaxis after knee arthroscopy: a randomized trial. Ann Intern
Med 2008;149:73-82.
Copyright 2017 Massachusetts Medical Society.

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