Venous Thromboembolic Disease in Foot and Ankle Surgery

Guss, Daniel; DiGiovanni, Christopher W.

doi:10.2106/jbjs.rvw.o.00012

Cited by 6 publications

(7 citation statements)

References 60 publications

(50 reference statements)

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“…Cast immobilization of the lower limb has been implicated by some authors in the occurrence of VTE events. 89 A 2014 meta-analysis showed a 4.3% to 40% incidence of DVT after casting and recommended the use of LMWH for all patients undergoing casting. 90 A recent update of that study reported moderate-quality evidence and showed that the use of LMWH in outpatients reduced DVT when immobilization of the lower limb was required, when compared with no prophylaxis or placebo.…”

Section: Guidelinesmentioning

confidence: 99%

Thromboembolism prophylaxis in orthopaedics: an update

et al. 2018

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Venous thromboembolism (VTE) is a serious complication during and after hospitalization, yet is a preventable cause of in-hospital death.Without VTE prophylaxis, the overall VTE incidence in medical and general surgery hospitalized patients is in the range of 10% to 40%, while it ranges up to 40% to 60% in major orthopaedic surgery. With routine VTE prophylaxis, fatal pulmonary embolism is uncommon in orthopaedic patients and the rates of symptomatic VTE within three months are in the range of 1.3% to 10%.VTE prophylaxis methods are divided into mechanical and pharmacological. The former include mobilization, graduated compression stockings, intermittent pneumatic compression device and venous foot pumps; the latter include aspirin, unfractionated heparin, low molecular weight heparin (LMWH), adjusted dose vitamin K antagonists, synthetic pentasaccharid factor Xa inhibitor (fondaparinux) and newer oral anticoagulants. LMWH seems to be more efficient overall compared with the other available agents. We remain sceptical about the use of aspirin as a sole method of prophylaxis in total hip and knee replacement and hip fracture surgery, while controversy still exists regarding the use of VTE prophylaxis in knee arthroscopy, lower leg injuries and upper extremity surgery.Cite this article: EFORT Open Rev 2018;3:136-148. DOI: 10.1302/2058-5241.3.170018

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Section: Guidelinesmentioning

confidence: 99%

Thromboembolism prophylaxis in orthopaedics: an update

et al. 2018

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“…This retrospective study was approved by the Institutional Review Board. Eleven Current Procedural Terminology (CPT) codes, five International Classification of Diseases, ninth revision (ICD-9-CM) codes, and fourteen International Classification of Diseases, tenth revision (ICD-10-PCS) codes were used to identify patients 18 years of age or older, that were immobilized with a cast, splint, brace, and/or boot for their foot and ankle condition between January 2005 and May 2016 at three hospitals (Table S-1) ( Table S- 2). Medical record data of patients with one of these CPT codes and ICD-9/10-CM codes were retrieved through our Research Patient Data Registry (RPDR).…”

Section: Study Design and Participantsmentioning

confidence: 99%

“…Despite the widespread use of below-knee immobilization for treating non-operative foot and ankle injuries, 1 there remains no consensus regarding the need for venous thromboembolic (VTE) prophylaxis in such patients. 2 The most recent American College of Chest Physicians guidelines in fact did not recommend the routine use of VTE prophylaxis in patients with isolated lower-leg injuries requiring below-knee immobilization. This recommendation, however, was rated as "weak"underscoring its basis in low-quality evidence-and it did not differentiate between operative and non-operative injury.…”

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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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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“…Third, we were not able to capture data on type of surgery (eg, reconstructive, traumatic) and postoperative immobilization, which have been described as potential risk factors. 5,16,17 An increased number of trauma patients in the current database could potentially have caused the higher rate of VTE compared with those in other previously analyzed databases. Fourth, we were not able to capture data on the location of the DVT.…”

Section: Discussionmentioning

confidence: 97%

“…A mong patients undergoing hip or knee replacement, pharmacologic thromboprophylaxis has been demonstrated to play an important role in reducing the rate of venous thromboembolism (VTE). 1,2 However, among patients undergoing below-knee orthopaedic surgery, no "best practice" guidelines predicate which patients should receive VTE prophylaxis, [3][4][5] how long thromboprophylaxis should be administered, 3 and which type of prophylaxis to administer. 6 Previous attempts to shed light on this important issue include large-scale, retrospective reviews, but none of these studies adjusted for the variability in type of pharmacologic thromboprophylaxis used.…”

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confidence: 99%

Incidence and Risk Factors Associated with Venous Thromboembolism After Orthopaedic Below-knee Surgery

Heijboer

Lubberts

Guss

et al. 2019

J Am Acad Orthop Surg

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Introduction: Among patients undergoing below-knee orthopaedic surgery, no consensus exists regarding the need for or type of postoperative prophylaxis to prevent venous thromboembolic (VTE) events. The purpose of this study was to assess the incidence and risk factors associated with symptomatic VTE among orthopaedic patients undergoing below-knee surgery who were subject to different types of pharmacologic thromboprophylactic strategies. Methods: A total of 20,043 adult patients who underwent surgery for a below-knee orthopaedic condition between August 2005 and August 2015 were identified. Retrospective chart review recorded patient demographics, comorbid data, and anatomic location of any procedures performed. Multivariable logistic regression analysis was used to determine factors associated with postoperative development of symptomatic VTE among patients receiving various thromboprophylactic regimens. Results: The incidence of symptomatic VTE in patients who underwent below-knee surgery was 2.5% (492/20,043). For patients who did not receive thromboprophylaxis, the incidence was 1.5% (134/9,127 patients). In this group, risk factors for developing VTE were male sex; nonwhite race; surgery performed below the knee but above the ankle; combination procedures of the forefoot/midfoot, hindfoot/ankle, and/or lower leg; history of VTE; and Charlson Comorbidity Index score greater than 2. Among patients who received an antiplatelet agent, the VTE incidence was 1.7% (33/1,992 patients). The incidence of VTE among patients who received an oral or injectable anticoagulant was 3.6% (325/8,924 patients). In this group, risk factors for developing VTE were male sex; surgery performed below the knee but above the ankle; combination procedures of the forefoot/midfoot, hindfoot/ankle, and/or lower leg; and history of VTE. Conclusion: Allowing for different types of thromboprophylactic strategies, the results of this study demonstrate a higher rate of symptomatic thromboembolic disease compared with previously reported ,1% VTE incidence rates among orthopaedic patients undergoing below-knee surgery. Certain patients are at higher risk for thromboembolic disease after below-knee orthopaedic surgery. This risk was not found to be lowered by thromboprophylaxis as performed in patients in this database. Future research should be directed at determining what the best thromboprophylactic strategies are for lowering this risk.

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Venous Thromboembolic Disease in Foot and Ankle Surgery

Cited by 6 publications

References 60 publications

Thromboembolism prophylaxis in orthopaedics: an update

Thromboembolism prophylaxis in orthopaedics: an update

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

Incidence and Risk Factors Associated with Venous Thromboembolism After Orthopaedic Below-knee Surgery

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