Can a patient with a normal coagulation profile be cleared for knee arthroscopy?

Clearance for Knee Arthroscopy with Normal Coagulation Profile

Yes, a patient with a normal coagulation profile can be cleared for knee arthroscopy, as this is a low-risk procedure that does not routinely require thromboprophylaxis in patients without a history of VTE.

Risk Assessment for Knee Arthroscopy

The baseline thromboembolic risk for knee arthroscopy is extremely low, making it fundamentally different from major orthopedic surgery:

• Patients undergoing knee arthroscopy without a history of VTE do not require routine thromboprophylaxis according to the American College of Chest Physicians guidelines 1, 2
• The absolute risk of nonfatal PE is 0 per 1,000 patients, and symptomatic DVT occurs in only 15 per 1,000 patients without prophylaxis 1
• Evidence from 4 studies involving 529 patients showed no estimable increase in PE risk with or without prophylaxis 1

Normal Coagulation Profile Implications

A normal coagulation profile indicates:

• Standard surgical bleeding risk, allowing the procedure to proceed without additional hemostatic concerns 3
• No contraindication to standard surgical techniques, including tourniquet use if needed 4
• No requirement for special perioperative management beyond routine surgical protocols 5

When to Reconsider or Add Prophylaxis

The decision changes only in specific high-risk scenarios:

• Previous history of VTE is the primary indication for considering thromboprophylaxis even for knee arthroscopy 2
• If prophylaxis is deemed necessary based on VTE history, use LMWH for 7-8 days postoperatively 2, 6
• Recent high-quality evidence from the POT-KAST trial (1,451 patients) demonstrated that even with prophylaxis, VTE rates remained extremely low (0.7% with LMWH vs 0.4% without), with no significant benefit from routine prophylaxis 6

Critical Pitfalls to Avoid

Do not routinely prescribe thromboprophylaxis for standard knee arthroscopy patients, as this exposes them to unnecessary bleeding risk without proven benefit 1, 2, 6:

• Major bleeding events, though rare, can include hemarthrosis and compartment syndrome 1, 3
• The POT-KAST trial showed no reduction in VTE with prophylaxis (relative risk 1.6,95% CI 0.4-6.8) 6
• In patients with bleeding disorders like hemophilia, even minor arthroscopic procedures carry increased risk of vascular complications including pseudoaneurysm formation 7

Do not assume anticoagulated patients cannot undergo arthroscopy, as evidence suggests simple arthroscopic procedures can be performed safely even with therapeutic anticoagulation (INR in therapeutic range), though this requires careful consideration of bleeding risk 5:

• A retrospective study of 24 patients on warfarin showed only minor complications (prolonged effusions and ecchymosis) with no major bleeding events 5
• However, extremity bleeds in anticoagulated patients can lead to critical complications including compartment syndrome and irreversible joint damage 3

Clearance Algorithm

For a patient with normal coagulation profile:

1. Confirm no history of VTE - if negative, proceed without prophylaxis 1, 2
2. Verify normal PT/INR, aPTT, and platelet count - standard preoperative screening 3
3. Clear for surgery with standard perioperative protocols 5
4. No routine postoperative anticoagulation needed unless VTE history present 2, 6