Journal of Hip Preservation Surgery Vol. 5, No. 2, pp. 119–124 doi: 10.1093/jhps/hny008 Advance Access Publication 5 March 2018 Research article Incidence of deep venous thrombosis following periacetabular and derotational femoral osteotomy: a case for mechanical prophylaxis 1 2 3 Matthew J. Kraeutler , Sivashanmugam Raju , Tigran Garabekyan and Omer Mei-Dan * Department of Orthopaedics, Seton Hall-Hackensack Meridian School of Medicine, 400 S Orange Ave, South Orange, NJ 07079, USA, 2 th Department of Orthopedics, University of Colorado School of Medicine, 12631 East 17 Avenue, Mail Stop B202, Room L15-4505, Aurora, CO 80045, USA and Southern California Hip Institute, 10640 Riverside Dr, North Hollywood, CA 91602, USA *Correspondence to: O. Mei-Dan. E-mail: email@example.com Submitted 5 October 2017; Revised 29 December 2017; revised version accepted 11 February 2018 ABSTRACT There are currently no established guidelines for appropriate antithrombotic prophylaxis following periacetab- ular osteotomy (PAO) or derotational femoral osteotomy (DFO). The purpose of this study was to determine the incidence of clinical deep venous thrombosis (DVT) following PAO and/or DFO wherein a portable, mech- anical device and low-dose aspirin were used postoperatively for DVT prophylaxis. Patients who had undergone staged hip arthroscopy and primary PAO and/or DFO were prospectively reviewed. Following PAO/DFO, pa- tients were prophylactically treated for thromboembolic disease with a portable, mechanical compression device for 3 weeks and low-dose aspirin for 4 weeks. Patients were followed in clinic until 24 months postoperatively. During the study period, 145 hips (124 patients) underwent surgery (PAO: 109, DFO: 24, PAO þ DFO: 12). Overall, the incidence of clinically apparent DVT was 0% in the study cohort. Average estimated blood loss dur- ing surgery was 601 mL and ﬁve cases required blood transfusions of 1 or 2 units. Ten patients were seen in the emergency room 10–20 days after surgery presenting with calf tenderness and DVT was ruled out in all cases with ultrasound. There were no postoperative bleeding or wound complications. A portable, mechanical com- pression device and low-dose aspirin effectively lessens the risk of DVT following staged hip arthroscopy and PAO/DFO without an increased risk of bleeding complications. no study has sought to determine the risk of thrombo- INTRODUCTION embolic disease following DFO alone. Periacetabular osteotomies (PAO) to address hip dysplasia A high incidence of intra-articular pathology has been re- are increasingly performed and little information is avail- ported in patients with hip dysplasia in various studies able in the literature regarding appropriate antithrombotic [9, 10] and hip arthroscopy has been recommended prior prophylaxis for these complex procedures. The incidence to a PAO to address labral and cartilage pathology and of thromboembolic complications following PAO alone is femoral head-neck offset abnormalities in patients with between 0% and 2.1% based on prior reports [1–6]. concomitant FAI. Routine thromboprophylaxis is not indi- However, this incidence increases to approximately 5% when PAO is combined with a proximal femoral oste- cated following hip arthroscopy except in high-risk pa- otomy . A derotational femoral osteotomy (DFO) is tients, as the risk of deep venous thrombosis (DVT) or indicated to correct femoral torsion in cases of femoroace- pulmonary embolism (PE) following this procedure is tabular impingement (FAI) and/or hip dysplasia associated around 0.1% [11, 12]. However, when hip arthroscopy is with excessive femoral ante- or retroversion . To date, performed concomitantly with a PAO, small case series V C The Author(s) 2018. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact firstname.lastname@example.org Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/119/4921013 by Ed 'DeepDyve' Gillespie user on 20 June 2018 120 M. J. Kraeutler et al. have reported a substantially higher risk of postoperative parameters included in the decision-making process were: venous thromboembolism (VTE) for the combined pro- hyperlaxity, anterior under-coverage and acetabular ante/ cedure, from 2.3% to 5.9% [13, 14]. Hip arthroscopy may retro version and excessive femoral anteversion (> 37 )or be performed either concomitantly with a pelvic osteotomy retroversion (< 7 ). or in a staged manner and, in either case, can poten- Common indications for hip arthroscopy were cam- tially increase the risk of thromboembolism and warrant type FAI, cartilage damage/subchondral cyst and labral thromboprophylaxis. tears (prior to PAO) and/or excessive femoral torsion Chemical antithrombotic prophylaxis is associated with (prior to DFO) with or without FAI. Some patients a higher cost, issues with patient compliance, bleeding- with excessive femoral ante/retroversion or borderline hip related complications and other medication side effects dysplasia had failed an arthroscopic-only approach used [15–17]. However, mechanical prophylaxis requires patient as first-line treatment and required a bony realignment compliance and appropriate application in order to be ef- procedure. fective [18, 19]. Recent studies have demonstrated that Demographic variables including age, clinical diagnosis, portable compression devices (PCDs) have improved com- gender, height, weight and body mass index (BMI) were pliance and reduce the risk of postoperative DVT com- recorded for all patients. pared to non-mobile devices [20–22]. Furthermore, mobile compression devices have been shown to signifi- Imaging protocol and measurements cantly reduce the risk of bleeding events following total hip After a comprehensive clinical evaluation by the senior au- or knee arthroplasty, with a symptomatic DVT rate that is thor, patients underwent a standardized series of AP pelvis equivalent to that of chemical antithrombotic agents such radiographs, MRI dGEMRIC and whole-pelvis computed as low-molecular-weight heparin [23, 24]. The purpose of tomography (CT) scans with 3D reconstructions. this study was to determine the incidence of clinical DVT Standard AP pelvis films were obtained with the patient following staged hip arthroscopy and PAO and/or DFO at positioned supine or upright with the lower extremities in- our institution using a portable, mechanical compression ternally rotated 15 to maximize femoral neck length. The device and low-dose aspirin postoperatively. X-ray beam was directed midway between the anterior su- MATERIALS AND METHODS perior iliac spine (ASIS) and the pubic symphysis, with a After Institutional Review Board approval was obtained, focus film distance of 120 cm . Radiographs were the authors performed a single-center prospective study on determined to be adequate given symmetric obturator fora- a cohort of patients who had undergone staged hip arthros- mina and a distance of 1–3 cm between the coccyx and copy and primary PAO and/or DFO. Inclusion criteria for pubic symphysis . patients undergoing these procedures were as follows: (1) persistent hip pain and mechanical symptoms refrac- Surgical technique tory to non-operative management (physical therapy, non- All patients underwent hip arthroscopy without a perineal steroidal anti-inflammatory drugs, activity modifications, post  prior to PAO/DFO in order to address intra- corticosteroid injections) lasting at least 3 months, (2) re- articular hip pathology such as labral tears, chondral dam- producible clinical examination findings suggestive of intra- age, cam lesions and/or LT tendinopathy. The osteotomy articular pathology and (3) joint-space width exceeding procedure was performed 7–14 days following arthroscopy. 3 mm on all views of plain radiography and cross-sectional For cases in which patients underwent all three procedures, imaging. Some of the physical examination tests used hip arthroscopy was performed combined with DFO or included passive hip range of motion (supine, lateral, 2–5 days prior, while PAO was performed 1 week later. prone), the FADIR (flexion, adduction, internal rotation) The reason for not performing these procedures together test, the FABER (flexion, abduction, external rotation) is that the senior author believes that the intra-articular test, the ligamentum teres (LT) test, the posterior im- bleeding associated with hip arthroscopy may result in sig- pingement test, use of the Beighton Hypermobility score nificant scarring and adhesions due to immobility after and subjective reports of hip instability . The lateral PAO surgery. Patients use a stationary bicycle intensively center edge angle (LCEA) was determined on anteropos- between hip arthroscopy and PAO (up to 30 min daily) in terior (AP) pelvis radiographs as described previously an effort to reduce the chances of this happening. Various . Patients with a LCEA between 20 and 24.9 were diagnosed with borderline hip dysplasia and those with val- techniques of periacetabular osteotomy (PAO)  and ues< 20 were diagnosed with frank hip dysplasia. Other DFO  were performed as previously described. Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/119/4921013 by Ed 'DeepDyve' Gillespie user on 20 June 2018 DVT after PAO/DFO 121 Medication and thromboprophylaxis regimen gradually increasing the duration to 10–15 min of biking For patients undergoing a PAO, tranexamic acid (TXA) twice per day by postoperative day (POD) 7 following hip was used in 70% of the study’s cohort to reduce intraopera- arthroscopy. Following the osteotomy procedure, patients tive bleeding. Patients are given 1 g of intravenous TXA are either non-weight bearing for 5 weeks if microfracture 30 min prior to the incision and an additional 1 g 3 h later. was performed during hip arthroscopy or partial weight If a large cam resection was performed during hip arth- bearing at 50% for 2 weeks followed by weight bearing as roscopy, patients were prophylactically treated to prevent tolerated with two crutches thereafter. Patients are dis- heterotopic ossification with Naprosyn (naproxen) 500 mg charged from the hospital 2–6 days postoperatively. twice per day beginning the day following hip arthroscopy until 2 days prior to the scheduled PAO/DFO. Naprosyn was restarted on the day following PAO/DFO and contin- Patient education and follow-up ued for 4 weeks postoperatively. All patients were educated on the signs and symptoms of Immediately following PAO/DFO, patients are placed DVT preoperatively and were provided with handouts on a battery-operated, PCD (ActiveCare, Medical with information on DVT based on the published literature Compression Systems, Inc., Or Akiva, Israel) and low-dose . All patients were evaluated while inpatients and in (81 mg) aspirin (Fig. 1). PCD is continued for 3 weeks the clinic at 2 weeks, 6 weeks, 3 months, 6 months, 1 year (23 h per day, 7 days per week during first 2 weeks; at night and 2 years following the osteotomy procedure. only during the third week) and aspirin for 4 weeks postoperatively. RESULTS Postoperative rehabilitation During the study period, 145 hips (124 patients) under- Patients are encouraged to use a stationary bicycle begin- went surgery (PAO: 109, DFO: 24, PAO þ DFO: 12). ning the day of hip arthroscopy for 3–5 min twice per day, Average age at the time of surgery was 30.1 years (range, 15–50 years) and average BMI was 23.8 kg/m (range, 16.3–44.9 kg/m ). Additional demographic characteristics are summarized in Table I. Average estimated blood loss during surgery was 601 ml and 5 cases (5/133, 3.8%) required blood transfusions of 1 or 2 units (Table II). Ten patients (10/124, 8.1%) were seen in the emergency room presenting with calf tender- ness associated with non-weight bearing status and DVT was ruled out in all cases following Doppler sonography. There were no postoperative bleeding or wound complica- tions in any patients. Table I. Patient demographics and baseline characteristics Patient variables Value No. of hips (patients) 145 (124) Age, mean (SD), years 30.1 (8.9) Female gender, n (%) 118 (95.2) Height, mean (SD), cm 165.9 (16.6) Weight, mean (SD), kg 70.0 (20.0) BMI, mean (SD), kg/m 23.8 (5.1) Fig. 1. The PCD (ActiveCare, Medical Compression Systems, Current or former smoker, n (%) 29 (23.3) Inc., Or Akiva, Israel) worn by all patients in this study. Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/119/4921013 by Ed 'DeepDyve' Gillespie user on 20 June 2018 122 M. J. Kraeutler et al. Table II. Intraoperative characteristics undergone concomitant hip arthroscopy and PAO, Domb et al.  found one case of PE (1/17, 5.9%) in a patient No. of Estimated blood Transfusion who had refused to discontinue an oral contraceptive. Kim cases loss (mean), ml requirements et al.  prospectively evaluated 43 hips undergoing con- PAO 109 668 5 (4.6%) comitant hip arthroscopy and PAO, with one patient (1/ 43, 2.3%) developing a DVT postoperatively. At our insti- DFO 24 100 0 tution, hip arthroscopy and osteotomy procedures were PAO, periacetabular osteotomy, DFO, derotational femoral osteotomy. performed in a staged fashion within 1–2 weeks and showed no cases of DVT. No prior studies have sought to DISCUSSION determine the risk of thromboembolic disease following In our study, the incidence of clinically apparent DVT was staged hip arthroscopy and PAO/DFO. 0% following PAO and/or DFO using portable mechanical Chemical thromboprophylaxis with enoxaparin or rivar- compression devices for 3 weeks postoperatively and low- oxaban following joint arthroplasty has been associated dose (81 mg) aspirin for 4 weeks postoperatively. This with major postoperative complications such as bleeding thromboprophylaxis regimen effectively lessens the risk of and infection [16, 17, 35] which, aside from the clinical thromboembolic complications without increasing the risk and subjective discomfort and delay in rehabilitation pro- of postoperative bleeding complications. gression, sometimes requires taking the patient back to the The reported incidence of DVT following either iso- operating room to address the developing hematoma lated hip arthroscopy [11, 12] or pelvic osteotomy [1–6]is and bleeding. These complications must be taken into ac- low. However, postoperative DVT has been reported in count when selecting an appropriate thromboprophylaxis the literature following hip arthroscopy. In a database study regimen following complex orthopedic procedures. using the National Surgical Quality Improvement Program Mechanical prophylaxis in the form of intermittent pneu- (NSQIP), Cvetanovich et al.  identified 1338 patients matic compression devices do not interfere with blood who underwent hip arthroscopy and found only two cases homeostasis and recent reports in patients undergoing hip (0.1%) of postoperative DVT. Additionally, in a study of or knee arthroplasty have demonstrated that mechanical 139 patients who underwent hip arthroscopy without prophylaxis using portable devices is as effective as chem- mechanical or chemoprophylaxis, Alaia et al.  found ical prophylaxis without the associated bleeding- or two cases of VTE (1.4%)—one case of symptomatic DVT wound-related complications [23, 24]. However, mechan- and one symptomatic PE. ical devices require patient compliance in order to be The risk of DVT following isolated osteotomy proced- effective. ures about the knee is also low , and therefore heparin- With the use of portable, mechanical compression de- oids are not commonly used and the related risk in this vices, patient compliance can be improved [20–22]. osteotomy population is unknown. Erickson et al.  per- Because these devices are small and portable, patients can formed a retrospective study of 141 patients (mean age wear them during daily activities or at work during the 34 years) who had undergone either a high tibial osteot- early postoperative period. These devices have been used omy (HTO), distal femoral osteotomy or tibial tubercle successfully following total hip arthroplasty and the osteotomy (TTO) without postoperative chemical throm- American College of Chest Physicians has recommended boprophylaxis. At a mean follow-up of 17.1 months, only the use of portable, battery-powered mechanical compres- two patients (1.4%) developed a below-the-knee DVT, sion devices without concomitant chemical prophylaxis fol- including one patient who had undergone HTO and one lowing total hip or knee arthroplasty or hip fracture who had undergone TTO. This 1.4% is higher than in our surgery . Antithrombotic prophylaxis is recommended cohort (0%), and PAO and DFO are longer surgeries with for a minimum of 10–14 days following these procedures a higher theoretical risk for DVT compared with HTO/ . In our study, no patients presented with clinical signs TTO. Tanaka et al.  found a DVT rate of 3.8% (6/ of DVT using these PCDs and low-dose aspirin following 156) in a retrospective chart review of patients who had PAO and/or DFO. undergone TTO. Postoperative anticoagulation was used TXA has been used in prior studies to reduce bleeding in 45 cases (28.8%), though the authors did not comment on any heparinoid-related complications in this cohort. and transfusion requirements for patients undergoing PAO [37, 38]. These studies demonstrated a reduction in esti- In patients undergoing combined hip arthroscopy and pelvic osteotomy, thromboembolic risk may increase [13, mated blood loss and transfusion requirements during this 14]. In a retrospective case series of 17 patients who had procedure. Similar to these studies, the authors also use Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/119/4921013 by Ed 'DeepDyve' Gillespie user on 20 June 2018 DVT after PAO/DFO 123 3. Polkowski GG, Duncan ST, Bloemke AD et al. 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Journal of Hip Preservation Surgery – Oxford University Press
Published: Mar 5, 2018
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