Low molecular weight heparin for prevention of venous thromboembolism in patients with lower-leg immobilization

Testroote, M.J.; Stigter, Willem AH; Visser, Dianne C de; Janzing, H

doi:10.1002/14651858.cd006681.pub2

Cited by 56 publications

(35 citation statements)

References 41 publications

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“…The incidence of symptomatic VTE in our study among foot and ankle patients undergoing below-knee immobilization for non-operative injury falls well within the wide range of findings from previous studies, which themselves ranged from 0.0% to 17.3%. [4][5][6][7][8][9][10][11][12][13][14] The largest retrospective study of which we are aware included 14,777 patients treated non-operatively for an ankle fracture and demonstrated a rate of symptomatic VTE of 0.22%. Two smaller studies involving 200 and 150 patients treated non-operatively for foot and ankle fractures found 1 (0.5%) symptomatic DVT and 3 (2%) symptomatic VTE respectively.…”

Section: Discussionmentioning

confidence: 99%

“…3 In contradistinction, a recent Cochrane meta-analysis alternatively concluded that patients treated non-operatively with lower-leg immobilization demonstrate a heightened risk of VTE-and recommended the routine use of chemoprophylaxis. 4 Notably, such studies demonstrated sizeable variability in VTE incidence, ranging from 0.0% to 17.3%, [4][5][6][7][8][9][10][11][12][13][14] possibly stemming from variations in patient risk factors. [7][8][9] This high variability in VTE incidence suggests that specific subpopulations of patients who present with foot or ankle injury may be at heightened risk of VTE, and may therefore benefit from chemoprophylaxis when undergoing below-knee immobilization.…”

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confidence: 99%

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Symptomatic venous thromboembolism after non‐operatively treated foot or ankle injury

Prince

Lubberts

Buda

et al. 2018

Journal Orthopaedic Research

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The purpose was to assess the incidence and risk factors associated with symptomatic venous thromboembolism in patients undergoing below knee immobilization for non‐operative foot or ankle injury. We included all foot and ankle patients between January 2005 and May 2016 who underwent non‐operative management using below knee immobilization with cast, splint, brace, and/or boot. The primary outcome was the development of a venous thromboembolism within 90 days of immobilization initiation. Of 6,088 patients, twenty‐three (0.38%) developed a venous thromboembolism. Risk factors for venous thromboembolism were age>50 years, unremovable immobilization, Achilles tendon rupture, Modified Charlson Comorbidity Index>2, patients on chemoprophylaxis, varicose veins, history of venous thromboembolism, known hypercoagulability disorder, and rheumatoid arthritis. Routine thromboprophylaxis after below‐knee immobilization for non‐operative foot or ankle injury may be beneficial in these specific subpopulations. These data can facilitate more substantive shared decision‐making between providers and patients with respect to use of thromboprophylaxis. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Symptomatic venous thromboembolism after non‐operatively treated foot or ankle injury

Prince

Lubberts

Buda

et al. 2018

Journal Orthopaedic Research

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“…Many risk factors for venous thrombosis have been identified, both genetic and environmental [8,9]. One of these known risk factors is cast immobilization, especially immobilization of the lower extremity [10,11]. However, the exact size of the risk attributable to lower leg cast immobilization is not known.…”

Section: Introductionmentioning

confidence: 99%

Below‐knee cast immobilization and the risk of venous thrombosis: results from a large population‐based case–control study

Adrichem

Debeij

Nelissen

et al. 2014

Journal of Thrombosis and Haemostasis

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To cite this article: van Adrichem RA, Debeij J, Nelissen RGHH, Schipper IB, Rosendaal FR, Cannegieter SC. Below-knee cast immobilization and the risk of venous thrombosis: results from a large population based case-control study. J Thromb Haemost 2014; 12: 1461-9.Summary. Background: From the available evidence, the risk of venous thrombosis in patients with below-knee cast immobilization remains unclear. Objectives: To estimate the risk of venous thrombosis after below-knee cast immobilization and to identify high-risk groups. Patients and methods: We used data from a large populationbased case-control study (MEGA study) on the etiology of venous thrombosis (4418 cases; 6149 controls). Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated, and adjusted for age, sex, body mass index, and regular exercise. Absolute risks were estimated from the ORs. Results: One hundred and thirty-four patients and 23 controls had below-knee plaster cast immobilization in the year before the index date, resulting in an eight-fold increased risk ). Traumatic indications led to a higher risk than non-traumatic indications: OR 12.7 (95% CI 6.6-24.6) vs. OR 7.6 (95% CI 0.9-66.4). An additionally increased risk was found for combinations with genetic or acquired risk factors: oral contraceptives (OR 18.2 [95% CI 6.2-53.4]); obesity (OR 17.2 [95% CI 5.4-55.2]); factor V Leiden, factor II 20210A mutation, and/or non-O blood group ); all for a period of 1 year. Ninety per cent of the events occurred in the first 3 months after cast application. This led to a 56-fold increased risk ) in this period. Conclusions: Below-knee cast immobilization strongly increases the risk of venous thrombosis. We found distinct differences in intrinsic risk between individuals with respect to indication for cast immobilization and the presence of genetic or acquired risk factors.

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“…While the risk for clinically relevant thrombosis in a cast is not clearly established, imaging studies suggest a rate between 4.3% and 40%, 15 so prophylaxis should be considered. Whether prophylaxis should be universal, or solely for those with identifiable risk factors, is controversial.…”

Section: Introductionmentioning

confidence: 99%

“…The most suitable prophylaxis has not been established: a chemical agent can be given for the time in plaster, for which there is some evidence of effect. 1,15 Mechanical methods would be more suitable for those with a risk of bleeding, particularly soon after injury or surgery; however, traditional mechanical methods are not practical for those in a plaster cast.…”

Section: Introductionmentioning

confidence: 99%

Neuromuscular electrostimulation via the common peroneal nerve promotes lower limb blood flow in a below-knee cast

Warwick

Stokes

et al. 2013

Bone & Joint Research

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ObjectivesWe aimed to examine the characteristics of deep venous flow in the leg in a cast and the effects of a wearable neuromuscular stimulator (geko; FirstKind Ltd) and also to explore the participants’ tolerance of the stimulator.MethodsThis is an open-label physiological study on ten healthy volunteers. Duplex ultrasonography of the superficial femoral vein measured normal flow and cross-sectional area in the standing and supine positions (with the lower limb initially horizontal and then elevated). Flow measurements were repeated during activation of the geko stimulator placed over the peroneal nerve. The process was repeated after the application of a below-knee cast. Participants evaluated discomfort using a questionnaire (verbal rating score) and a scoring index (visual analogue scale).ResultsThe geko device was effective in significantly increasing venous blood flow in the lower limb both with a plaster cast (mean difference 11.5 cm/sec-1; p = 0.001 to 0.13) and without a plaster cast (mean difference 7.7 cm/sec-1; p = 0.001 to 0.75). Posture also had a significant effect on peak venous blood flow when the cast was on and the geko inactive (p = 0.003 to 0.69), although these differences were less pronounced than the effect of the geko (mean difference 3.1 cm/sec-1 (-6.5 to 10)). The geko device was well tolerated, with participants generally reporting only mild discomfort using the device.ConclusionThe geko device increases venous blood flow in the lower limb, offering a potential mechanical thromboprolylaxis for patients in a cast.Cite this article: Bone Joint Res 2013;2:179–85.

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Low molecular weight heparin for prevention of venous thromboembolism in patients with lower-leg immobilization

Abstract: Use of LMWH in outpatients significantly reduces VTE when immobilization of the lower leg is required.

Cited by 56 publications

References 41 publications

Symptomatic venous thromboembolism after non‐operatively treated foot or ankle injury

Symptomatic venous thromboembolism after non‐operatively treated foot or ankle injury

Below‐knee cast immobilization and the risk of venous thrombosis: results from a large population‐based case–control study

Neuromuscular electrostimulation via the common peroneal nerve promotes lower limb blood flow in a below-knee cast

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