Incidence of Deep Vein Thrombosis and Pulmonary Embolism in the Elective Pediatric Orthopaedic Patient

Abstract

Background Although venous thromboembolism has been well studied in the pediatric trauma population, rates of VTE associated with elective pediatric orthopaedic procedures have not been addressed in current literature. The purpose of this retrospective study was to identify the incidence of venous thromboembolism (VTE) in the elective pediatric orthopaedic surgical population and delineate subsets of this population at greatest risk. This study may provide valuable data to begin the process of resolving the controversy surrounding DVT prophylaxis in the pediatric orthopaedic population. Methods The Pediatric Health Information System (PHIS) was queried for patients admitted on an ambulatory or inpatient basis aged <18 years from 1/2006 to 3/2011 during which an elective orthopaedic surgery was the principal procedure performed. Patients with diagnoses or procedures related to infection, trauma, malignancy, or coagulopathies were excluded. Patients admitted through the emergency department (ED) or whose orthopedic procedure was not performed on the admission date were excluded. Age, gender, ethnicity, race, admission year, and all procedures/diagnoses were recorded. The presence of VTE at the index admission or any subsequent readmission within 90 days was recorded. All criteria were coded using ICD-9-CM codes. Generalized logistic regression analyses were used to identify factors related to VTE. Results 143,808 admissions (117,676 patients) matched the inclusion criteria. 33 had a VTE during the index admission with an additional 41 at subsequent readmissions, for a total incidence of 0.0515% by admission and 0.0629% by patient. In the multivariable model, variables significantly [p<0.05] related to VTE included increasing age, admission type, diagnosis of metabolic conditions, obesity, and/or syndromes, and complications of implanted devices and/or surgical procedures. No procedure variables were significantly related to VTE in the multivariable model. Conclusions The incidence of VTE in this cohort of pediatric patients undergoing elective orthopaedic surgery was 0.0515%. In children, underlying diagnosis appears to be a stronger predictor of VTE than procedures performed. Diagnosis with a metabolic condition, syndrome, and/or obesity, complications of implanted devices and/or surgical procedures, older age, and admission as an inpatient were significantly related to the development of a VTE. Level of Evidence Level II; Retrospective prognostic study

Complications and 30-day Outcomes Associated With Venous Thromboembolism in the Pediatric Orthopaedic Surgical Population

“…The first of these was obesity, which has been demonstrated to be a risk factor for VTE in both adult and pediatric populations. 12,38 LE fracture and osteotomy procedures were also expected to be a risk for VTE based on previous literature, but no association was identified in this analysis. 38 Older age did not emerge as a risk factor despite previous studies implicating older age as a risk factor for VTE in children.…”

“…In a study of the pediatric orthopaedic population, Georgopoulos et al 12 reported that the incidence of VTE in 1 in 1,000 patients differs greatly from the adult orthopaedic population and is nearly double the incidence reported in previous pediatric orthopaedic retrospective studies. However, the authors excluded pediatric orthopaedic patients with procedures or diagnoses related to trauma, infection, malignancy, or coagulopathies as well as patients admitted through the emergency department or whose orthopaedic procedure was not performed on the admission date, potentially contributing to differences in VTE rates between studies.…”

“…11 In a retrospective review of 143,808 elective pediatric orthopaedic procedures, older age, admission type, metabolic conditions, obesity, and complications of implanted devices and/or surgical procedures were associated with deep vein thrombosis (DVT). 12 A recall survey of 354 pediatric orthopaedic surgeons identified prior DVT, prior pulmonary embolism (PE), family history of DVT, oral contraceptive use, and current malignancy as perceived predisposing factors for DVT. 13 In the spine study by Jain et al, 11 the authors used the Nationwide Inpatient Sample; this is an inpatient-only database with no postdischarge follow-up, and it has a tendency to overestimate risk factors.…”

“…13 In the spine study by Jain et al, 11 the authors used the Nationwide Inpatient Sample; this is an inpatient-only database with no postdischarge follow-up, and it has a tendency to overestimate risk factors. 14 In a large retrospective review by Georgopoulos et al, 12 the authors analyzed elective orthopaedic procedures only and did not examine preoperative laboratory values, gastrointestinal (GI) comorbidities, pulmonary comorbidities, cardiovascular comorbidities, or renal comorbidities as risk factors for VTE, several of which have been previously identified as risk factors for VTE in children. 3,6–9 In addition, procedures or diagnoses associated with trauma, infection, coagulopathies, or malignancy were excluded, as well as patients who had procedures performed after the day of admission.…”

The identification of at‐risk patients and prevention of venous thromboembolism in pediatric cancer: guidance from the SSC of the ISTH

“…A retrospective study examining the risk of VTE in 171 sarcoma patients undergoing surgery included pediatric patients and reported an overall VTE rate of 4.1% . In comparison, another retrospective study that specifically excluded patients with malignancy found the overall incidence of pediatric VTE in elective orthopedic surgery to be only 0.06% . Although a direct comparison is not possible, these study results do suggest that surgery is an additional risk factor for VTE formation.…”