Venous Thromboembolism Prophylaxis in Patients Immobilised in Plaster Casts

Kocialkowski, Cezary; Bhosale, Abhijit; Pillai, A.

doi:10.4172/2329-910x.1000203

Cited by 3 publications

(3 citation statements)

References 16 publications

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“…However confounding effect of sex and BMI must be considered as the groups were not matched in the present study. Post hoc power analysis showed limited power because the incidence of venous thromboembolism was lower than expected, although this incidence is in line with other similar studies [12,[21][22][23][24][25]. It is considered a limitation of the present study.…”

Section: Discussionsupporting

confidence: 42%

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The Effect of Aspirin and Enoxaparin on the Prevention of Venous Thromboembolism in Patients With Ankle Sprain and Cast Immobilization: A Randomized Clinical Trial

Razavipour

Ghaffari

Mohebi

et al. 2021

J. Res. Orthop. Sci.

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Background: The incidence of Venous Thromboembolism (VTE) and its prophylaxis in patients with an ankle injury and cast immobilization are controversial. Objectives: This study aimed to investigate the effect of aspirin and enoxaparin on VTE prevention in patients with an ankle sprain and cast immobilization. Methods: In a double-blind, randomized clinical trial, 90 eligible patients were divided into three groups: patients who did not receive the drugs (the control group), patients who received aspirin (325 mg/d) for 3 weeks (the ASA group), and patients who received enoxaparin (40 mg/d subcutaneously) for 3 weeks (the enoxaparin group). After 3 weeks, the plaster was opened, and the D-dimer level was measured if there was a VTE symptom during the study. Otherwise, at the end of the study, the bilateral lower-limb Complete Compression Ultrasonography (CCUS) and color Doppler ultrasound were used to image the lower limb venous system. Results: Sixty-eight patients completed the study. The mean±SD values of D-dimer in the control, ASA, and enoxaparin groups were 0.33 (0.47) μg/dL (Median=0.18 μg/dL), 0.32 (0.14) μg/dL (Median=0.3 μg/dL) and 0.32 (0.25) μg/dL (Median=0.21 μg/dL), respectively (P>0.05). The positive D-dimer was seen in 2 patients (8%) of the control group, 2 patients (8.3%) of the ASA group, and 2 patients (10.5%) of the enoxaparin group (P>0.05). The color Doppler ultrasound was negative in all patients. Conclusion: Because none of the 68 patients in the current study developed VTE during our 30 days follow-up period, it seems that prophylaxis treatment is unnecessary in patients with an ankle sprain and cast immobilization. Further studies on more patients with a longer period of follow-up are recommended.

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Section: Discussionsupporting

confidence: 42%

“…However, enoxaparin has some serious side effects, such as major bleeding episodes and Heparin-Induced Thrombocytopenia (HIT) [23]. These side effects limit the use of enoxaparin in low-risk outpatients [12,24].…”

Section: Introductionmentioning

confidence: 99%

The Effect of Aspirin and Enoxaparin on the Prevention of Venous Thromboembolism in Patients With Ankle Sprain and Cast Immobilization: A Randomized Clinical Trial

Razavipour

Ghaffari

Mohebi

et al. 2021

J. Res. Orthop. Sci.

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“…Rationale: The presence of specific thromboembolic risk factors such as older age, along with the nature of extremity injury, are the main determinants when deciding whether to administer thromboprophylaxis in patients with lower leg trauma immobilized in a cast or a splint [113][114][115] .…”

Section: -Is Routine Vte Prophylaxis Necessary In Children With Chron...mentioning

confidence: 99%

Recommendations from the ICM-VTE: Pediatric

2022

Journal of Bone and Joint Surgery

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The ICM-VTE Pediatric Delegates* 1 -Are the risk factors for VTE following orthopaedic procedures different between children and adults?Response/Recommendation: Many risk factors for venous thromboembolism (VTE) in pediatric orthopaedic patients are similar to those in adults. These include older age (adolescents), trauma, malignancy, certain infections, clotting disorders and a personal or family history of VTE. However, certain VTE risk factors reported in adult literature (e.g., smoking) may be less prevalent in children, and vice versa (e.g., congenital thrombophilia).Strength of Recommendation: Moderate.Delegates vote: Agree 100.00% Disagree 0.00% Abstain 0.00% (Unanimous Strong Consensus).Rationale: VTE is a common complication in adults undergoing orthopaedic surgery, and the risk factors for this condition are well established. In contrast, VTE is extremely rare in pediatric orthopaedic patients 1 . The incidence of VTE has been reported at 0.0515% for pediatric patients admitted following elective orthopaedic procedures 2 . The incidence rises to 0.10% when non-elective procedures are included 3 , and peaks at 0.68% in trauma patients 4,5 .Epidemiologic data has demonstrated that the incidence of pediatric VTE is bimodal, with the highest incidence rates in infants and adolescents 6 . Pediatric patient populations with certain conditions are at an increased risk for VTE. These conditions include: congenital heart disease, nephrotic syndrome, prior splenectomy in patients with hemolytic anemia, colectomy in patients with inflammatory bowel disease, congenital thrombophilia and other genetic or metabolic diseases 7 . Catheter-related thrombosis is the single most common cause of pediatric VTE [8][9][10] . Central venous catheters (CVC) may directly damage the vessel wall, increase blood flow turbulence, introduce substances that damage endothelial cells, and contain thrombogenic materials.Due to the complex pathophysiology of pediatric patients, pediatric orthopaedic patients have different risk factors for VTE compared to their non-orthopaedic counterparts 11,12 . Currently, literature suggests that the most common risk factors for VTE in pediatric orthopaedic patients are adolescent age, trauma, infection, cancer, clotting disorders, and a personal or family history of VTE 9,11,13 .Pediatric trauma patients are an identifiable subgroup that is at highest risk of VTE 14 . However, the risk of VTE is not uniform across age groups, with most cases occurring in children aged 10 -15 years (0.1%). In one study, Guzman et al. 4 , found that younger pediatric trauma patients (i.e., under 10 years) had a much lower risk of VTE compared to adolescents aged 13 -15. Moreover, older adolescent patients (> 16 years) physiologically resembled adults, and had similar VTE frequencies to the adult population 4,8,11,[15][16][17][18] .Another specific pediatric orthopaedic population at increased risk of VTE is children with musculoskeletal infections such as osteomyelitis or septic arthritis, especially if the infectin...

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Different strategies for pharmacological thromboprophylaxis for lower-limb immobilisation after injury: systematic review and economic evaluation

Pandor

Horner

Davis

et al. 2019

Health Technol Assess

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Background Thromboprophylaxis can reduce the risk of venous thromboembolism (VTE) during lower-limb immobilisation, but it is unclear whether or not this translates into meaningful health benefit, justifies the risk of bleeding or is cost-effective. Risk assessment models (RAMs) could select higher-risk individuals for thromboprophylaxis. Objectives To determine the clinical effectiveness and cost-effectiveness of different strategies for providing thromboprophylaxis to people with lower-limb immobilisation caused by injury and to identify priorities for future research. Data sources Ten electronic databases and research registers (MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Review of Effects, the Cochrane Central Register of Controlled Trials, Health Technology Assessment database, NHS Economic Evaluation Database, Science Citation Index Expanded, ClinicalTrials.gov and the International Clinical Trials Registry Platform) were searched from inception to May 2017, and this was supplemented by hand-searching reference lists and contacting experts in the field. Review methods Systematic reviews were undertaken to determine the effectiveness of pharmacological thromboprophylaxis in lower-limb immobilisation and to identify any study of risk factors or RAMs for VTE in lower-limb immobilisation. Study quality was assessed using appropriate tools. A network meta-analysis was undertaken for each outcome in the effectiveness review and the results of risk-prediction studies were presented descriptively. A modified Delphi survey was undertaken to identify risk predictors supported by expert consensus. Decision-analytic modelling was used to estimate the incremental cost per quality-adjusted life-year (QALY) gained of different thromboprophylaxis strategies from the perspectives of the NHS and Personal Social Services. Results Data from 6857 participants across 13 trials were included in the meta-analysis. Thromboprophylaxis with low-molecular-weight heparin reduced the risk of any VTE [odds ratio (OR) 0.52, 95% credible interval (CrI) 0.37 to 0.71], clinically detected deep-vein thrombosis (DVT) (OR 0.40, 95% CrI 0.12 to 0.99) and pulmonary embolism (PE) (OR 0.17, 95% CrI 0.01 to 0.88). Thromboprophylaxis with fondaparinux (Arixtra®, Aspen Pharma Trading Ltd, Dublin, Ireland) reduced the risk of any VTE (OR 0.13, 95% CrI 0.05 to 0.30) and clinically detected DVT (OR 0.10, 95% CrI 0.01 to 0.94), but the effect on PE was inconclusive (OR 0.47, 95% CrI 0.01 to 9.54). Estimates of the risk of major bleeding with thromboprophylaxis were inconclusive owing to the small numbers of events. Fifteen studies of risk factors were identified, but only age (ORs 1.05 to 3.48), and injury type were consistently associated with VTE. Six studies of RAMs were identified, but only two reported prognostic accuracy data for VTE, based on small numbers of patients. Expert consensus was achieved for 13 risk predictors in lower-limb immobilisation due to injury. Modelling showed that thromboprophylaxis for all is effective (0.015 QALY gain, 95% CrI 0.004 to 0.029 QALYs) with a cost-effectiveness of £13,524 per QALY, compared with thromboprophylaxis for none. If risk-based strategies are included, it is potentially more cost-effective to limit thromboprophylaxis to patients with a Leiden thrombosis risk in plaster (cast) [L-TRiP(cast)] score of ≥ 9 (£20,000 per QALY threshold) or ≥ 8 (£30,000 per QALY threshold). An optimal threshold on the L-TRiP(cast) receiver operating characteristic curve would have sensitivity of 84–89% and specificity of 46–55%. Limitations Estimates of RAM prognostic accuracy are based on weak evidence. People at risk of bleeding were excluded from trials and, by implication, from modelling. Conclusions Thromboprophylaxis for lower-limb immobilisation due to injury is clinically effective and cost-effective compared with no thromboprophylaxis. Risk-based thromboprophylaxis is potentially optimal but the prognostic accuracy of existing RAMs is uncertain. Future work Research is required to determine whether or not an appropriate RAM can accurately select higher-risk patients for thromboprophylaxis. Study registration This study is registered as PROSPERO CRD42017058688. Funding The National Institute for Health Research Health Technology Assessment programme.

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Venous Thromboembolism Prophylaxis in Patients Immobilised in Plaster Casts

Cited by 3 publications

References 16 publications

The Effect of Aspirin and Enoxaparin on the Prevention of Venous Thromboembolism in Patients With Ankle Sprain and Cast Immobilization: A Randomized Clinical Trial

The Effect of Aspirin and Enoxaparin on the Prevention of Venous Thromboembolism in Patients With Ankle Sprain and Cast Immobilization: A Randomized Clinical Trial

Recommendations from the ICM-VTE: Pediatric

Different strategies for pharmacological thromboprophylaxis for lower-limb immobilisation after injury: systematic review and economic evaluation

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