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Carr P, Ehredt DJ, Dawoodian A. Prevention of Deep Venous Thromboembolism in Foot and Ankle Surgery. Clin Podiatr Med Surg 2019; 36:21-35. [PMID: 30446043 DOI: 10.1016/j.cpm.2018.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although rare, deep vein thrombosis (DVT) and pulmonary embolism remain a concern for foot and ankle surgeons. Most prophylactic measures against DVT formation are synthesized from orthopedic hip and knee data, and therefore the routine use of these recommendations may place patients at risk for complications associated with unnecessary prophylaxis. In this article we review and present the most current literature specific to venous thromboembolism (VTE) in foot and ankle surgery. It is clear that, given our current literature, a case-by-case approach for VTE prophylaxis should be used following foot and ankle surgery.
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Affiliation(s)
- Preston Carr
- Kent State University College of Podiatric Medicine, 6000 Rockside Woods Boulevard, Independence, OH 44131, USA
| | - Duane J Ehredt
- Division of Foot and Ankle Surgery, Kent State University College of Podiatric Medicine, 6000 Rockside Woods Boulevard, Independence, OH 44131, USA; Podiatric Medicine and Surgery Residency Program, Saint Vincent Charity Medical Center, 2351 East 22nd Street, Cleveland, OH 44115, USA.
| | - Alex Dawoodian
- Podiatric Medicine and Surgery Residency Program, Saint Vincent Charity Medical Center, 2351 East 22nd Street, Cleveland, OH 44115, USA
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Matthews JH, Terrill AJ, Barwick AL, Butterworth PA. Venous Thromboembolism in Podiatric Foot and Ankle Surgery. Foot Ankle Spec 2018; 11:444-450. [PMID: 29338332 DOI: 10.1177/1938640017750256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The extent to which podiatric surgeons follow venous thromboembolism guidelines is unknown. The aim of this study therefore, was 2-fold: (a) to determine the rate of venous thromboembolism following podiatric surgery and (b) to investigate the factors that influence the use of thromboprophylaxis. METHODS Data from 4238 patients who underwent foot and ankle surgery over 2 years were analyzed. Venous thromboembolism within the first 30 days following surgery was recorded using the Australasian College of Podiatric Surgeons surgical audit tool. Logistic regression analyses were undertaken to determine the factors that influenced thromboprophylaxis. RESULTS Of the 4238 patient records, 3677 records (87%) provided complete data (age range 2-94 years; mean ± SD, 49.1 ± 19.7 years; 2693 females). A total of 7 venous thromboembolic events (0.2% rate) were reported. Operative duration and age (OR 12.63, 95% CI 9.47 to 16.84, P < 0.01), postoperative immobilization (OR 6.94, 95% CI 3.95 to 12.20, P < 0.01), and a prior history of VTE (OR 3.41, 95% CI 1.01 to 11.04, P = 0.04) were the strongest predictors of thromboprophylaxis. CONCLUSION Podiatric foot and ankle surgery is associated with a low rate of venous thromboembolism. This may be due in part to the thromboprophylaxis regime implemented by podiatric surgeons, which closely aligns with current evidence-based guidelines. LEVELS OF EVIDENCE Level II: Prospective cohort study.
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Affiliation(s)
- Jemma H Matthews
- School of Health and Human Sciences, Southern Cross University, Bilinga, Queensland, Australia (JHM, AJT, ALB, PAB).,Australasian College of Podiatric Surgeons, Melbourne, Victoria, Australia (PAB).,Faculty of Podiatric Medicine, Royal College of Physicians and Surgeons Glasgow, Glasgow, Scotland (PAB)
| | - Alexander J Terrill
- School of Health and Human Sciences, Southern Cross University, Bilinga, Queensland, Australia (JHM, AJT, ALB, PAB).,Australasian College of Podiatric Surgeons, Melbourne, Victoria, Australia (PAB).,Faculty of Podiatric Medicine, Royal College of Physicians and Surgeons Glasgow, Glasgow, Scotland (PAB)
| | - Alex L Barwick
- School of Health and Human Sciences, Southern Cross University, Bilinga, Queensland, Australia (JHM, AJT, ALB, PAB).,Australasian College of Podiatric Surgeons, Melbourne, Victoria, Australia (PAB).,Faculty of Podiatric Medicine, Royal College of Physicians and Surgeons Glasgow, Glasgow, Scotland (PAB)
| | - Paul A Butterworth
- School of Health and Human Sciences, Southern Cross University, Bilinga, Queensland, Australia (JHM, AJT, ALB, PAB).,Australasian College of Podiatric Surgeons, Melbourne, Victoria, Australia (PAB).,Faculty of Podiatric Medicine, Royal College of Physicians and Surgeons Glasgow, Glasgow, Scotland (PAB)
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Flevas DA, Megaloikonomos PD, Dimopoulos L, Mitsiokapa E, Koulouvaris P, Mavrogenis AF. Thromboembolism prophylaxis in orthopaedics: an update. EFORT Open Rev 2018; 3:136-148. [PMID: 29780621 PMCID: PMC5941651 DOI: 10.1302/2058-5241.3.170018] [Citation(s) in RCA: 133] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
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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Affiliation(s)
- Dimitrios A Flevas
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panayiotis D Megaloikonomos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Leonidas Dimopoulos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Evanthia Mitsiokapa
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panayiotis Koulouvaris
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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Chien BY, Dixon T, Guss D, DiGiovanni C. Venous Thromboembolism Disease Prophylaxis in Foot and Ankle Surgery. Orthop Clin North Am 2018; 49:265-276. [PMID: 29499827 DOI: 10.1016/j.ocl.2017.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
There are limited data to guide the use of venous thromboembolism disease (VTED) prophylaxis after foot and ankle surgery. Although there is general consensus that the overall risk is lower than after hip or knee replacement, subpopulations of patients may be at relatively heightened risk. Furthermore, existing data are often conflicting regarding the efficacy of prophylaxis, with little acknowledgment of the tradeoffs between VTED prophylaxis and potential complications associated with the use of such medications. This article provides an overview of currently available evidence to guide decision making regarding VTED prophylaxis in patients who undergo foot and ankle surgery.
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Affiliation(s)
- Bonnie Y Chien
- Harvard Combined Orthopaedic Residency Program, Harvard University, 55 Fruit Street, Boston, MA 02114, USA.
| | - Tonya Dixon
- Department Foot and Ankle Center, Massachusetts General Hospital Orthopaedics, 55 Fruit Street, Yawkey Building, Suite 3F, Boston, MA 02114, USA
| | - Daniel Guss
- Department Foot and Ankle Center, Massachusetts General Hospital Orthopaedics, 55 Fruit Street, Yawkey Building, Suite 3F, Boston, MA 02114, USA; Foot and Ankle Center, Newton-Wellesley Hospital, 2014 Washington Street, Newton, MA 02462, USA
| | - Christopher DiGiovanni
- Department Foot and Ankle Center, Massachusetts General Hospital Orthopaedics, 55 Fruit Street, Yawkey Building, Suite 3F, Boston, MA 02114, USA; Foot and Ankle Center, Newton-Wellesley Hospital, 2014 Washington Street, Newton, MA 02462, USA
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Robinson R, Wirt C, Barbosa C, Amidi A, Chen S, Joseph R, Fleischer A. Routine Use of Low-Molecular-Weight Heparin For Deep Venous Thrombosis Prophylaxis After Foot and Ankle Surgery: A Cost-Effectiveness Analysis. J Foot Ankle Surg 2018; 57:543-551. [PMID: 29685566 PMCID: PMC6392007 DOI: 10.1053/j.jfas.2017.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Indexed: 02/03/2023]
Abstract
The purpose of the present study was to determine whether certain foot/ankle surgeries would benefit from the routine use of low-molecular-weight heparin (LMWH) as postoperative deep venous thrombosis prophylaxis. We conducted a formal cost-effectiveness analysis using a decision analytic tree to explore the healthcare costs and health outcomes associated with a scenario of no prophylaxis and a scenario of routine LMWH prophylaxis for 4 weeks. The 2 scenarios were compared for 5 procedures: (1) Achilles tendon repair (ATR), (2) total ankle arthroplasty (TAA), (3) hallux valgus surgery (HVS), (4) hindfoot arthrodesis (HA), and (5) ankle fracture surgery (AFS). The outcomes assessed included short- and long-term costs, quality-adjusted life-years (QALYs), and incremental cost per QALY gained. The costs were evaluated from the healthcare system perspective and are expressed in U.S. dollars at a 2015 price base. In the short term, routine prophylaxis was always associated with greater costs compared with no prophylaxis. For ATR, TAA, HA, and AFS, prophylaxis was associated with slightly better health outcomes; however, the gain in QALYs was minimal compared with the cost of prophylaxis (incremental cost-effectiveness ratio well above $50,000/QALY threshold). For HVS, prophylaxis was associated with both worse health outcomes and greater costs. In the long term, routine prophylaxis was always associated with worse health outcomes and either cost more (HA, AFS, HVS) or saved very little (ATR, TAA). We concluded that policies encouraging the routine use of LMWH after foot/ankle surgery are unlikely to be cost-effective. Decisions to perform prophylaxis should be on a case-by-case basis and should emphasize individual patient risk factors.
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Affiliation(s)
- Richmond Robinson
- Assistant Professor, Department of Medicine and Radiology, Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science. 3333 Green Bay Road, North Chicago, IL 60064. United States.
| | - Craig Wirt
- Podiatry Student, Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science. 3333 Green Bay Road, North Chicago, IL 60064. United States.
| | - Carolina Barbosa
- Health Economist, RTI International. 230 West Monroe St. #2100. Chicago, IL 60606. United States.
| | - Arezou Amidi
- PGY3, Advocate Illinois Masonic Medical Center Podiatric Residency Program. 836 W Wellington Ave, Chicago, IL 60657. United States.
| | - Shirley Chen
- Podiatry Student, Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science. 3333 Green Bay Road, North Chicago, IL 60064. United States.
| | - Robert Joseph
- Chairman, Department of Medicine and Radiology, Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science. 3333 Green Bay Road, North Chicago, IL 60064. United States.
| | - Adam Fleischer
- Associate Professor, Department of Medicine and Radiology, Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science. 3333 Green Bay Road, North Chicago, IL 60064. United States.
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Strudwick K, McPhee M, Bell A, Martin-Khan M, Russell T. Review article: Best practice management of common ankle and foot injuries in the emergency department (part 2 of the musculoskeletal injuries rapid review series). Emerg Med Australas 2017; 30:152-180. [PMID: 29235235 DOI: 10.1111/1742-6723.12904] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 09/26/2017] [Indexed: 12/16/2022]
Abstract
Ankle and foot injuries are the most common musculoskeletal injuries presenting to Australian EDs and are associated with a large societal and economic impact. The quality of ED care provided to patients with ankle and foot fractures or soft tissue injuries is critical to ensure the best possible outcomes for the patient. This rapid review investigated best practice for the assessment and management of common ankle and foot injuries in the ED. Databases including PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites, were searched in 2017. Primary studies, systematic reviews and guidelines were considered for inclusion. English language articles published in the last 12 years that addressed the acute assessment, management or prognosis in the ED were included. Data extraction of included articles was conducted, followed by quality appraisal to rate the level of evidence where possible. The search revealed 1242 articles, of which 71 were included in the review (n = 22 primary articles, n = 35 systematic reviews and n = 14 guidelines). This rapid review provides clinicians managing fractures and soft tissue injuries of the ankle and foot in the ED a summary of the best available evidence to enhance the quality of care for optimal patient outcomes. Following a thorough history and physical examination, including the application of the Ottawa ankle rules, ED clinicians should not only provide a diagnosis, but rate the severity of soft tissue injuries, or stability of fractures and dislocations, which are the pivotal decision points in guiding ED treatment, specialist referral and the follow-up plan.
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Affiliation(s)
- Kirsten Strudwick
- Emergency Department, Queen Elizabeth II Jubilee Hospital, Metro South Hospital and Health Service, Brisbane, Queensland, Australia.,Physiotherapy Department, Queen Elizabeth II Jubilee Hospital, Metro South Hospital and Health Service, Brisbane, Queensland, Australia.,School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Megan McPhee
- Physiotherapy Department, Queen Elizabeth II Jubilee Hospital, Metro South Hospital and Health Service, Brisbane, Queensland, Australia
| | - Anthony Bell
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Melinda Martin-Khan
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Trevor Russell
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
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Deep Vein Thrombosis in Combined Ankle Arthroscopy for the Anterior and Posterior Ankle Impingement Syndrome. Asian J Sports Med 2017. [DOI: 10.5812/asjsm.55563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
RATIONALE The operative procedure for Achilles tendon rupture is relatively simple, but venous thromboembolism is serious complication with a high incidence after Achilles tendon rupture. However, the guideline for thromboprophylaxis in Achilles tendon rupture is unclear. PATIENT CONCERNS The patient was 32-year-old male and underwent Achilles tendon open repair surgery. He was healthy and there are no abnormal findings other than Achilles tendon rupture. At 3 weeks after operation, the episode of loss of consciousness with convulsive movement occurred. The next day, suddenly cardiac arrest occurred. DIAGNOSES Extensive pulmonary thromboembolism in both pulmonary arteries was identified in chest computed tomography and thrombus was also identified at the left popliteal vein on ultrasonography. INTERVENTION Anticoagulant therapy with heparin sodium was performed to manage the pulmonary thromboembolism. OUTCOMES Brain swelling after ischemic brain damage, acute kidney injury, and pneumonia gradually occurred and aggravated. His condition became worse and he died about 2 weeks after the cardiac arrest episode. LESSONS Although the incidence of venous thromboembolism in Achilles tendon rupture is higher than that in lower leg injury patients, guideline for thromboprophylaxis is unclear. We suggest that thromboprophylaxis for Achilles tendon rupture should be considered and appropriate guidelines should be established.
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Affiliation(s)
- Dong Il Chun
- Department of Orthopedic Surgery, Seoul Hospital, Soonchunhyang University College of Medicine, Seoul
| | - Sanghyeon Lee
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, Chuncheon, Republic of Korea
| | - Sung Hun Won
- Department of Orthopedic Surgery, Seoul Hospital, Soonchunhyang University College of Medicine, Seoul
| | - Jaeho Cho
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, Chuncheon, Republic of Korea
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60
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Prophylaxis of Venous Thromboembolism in Orthopedic Trauma Patients: A Review. JOURNAL OF ORTHOPEDIC AND SPINE TRAUMA 2017. [DOI: 10.5812/jost.58053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Zheng X, Li DY, Wangyang Y, Zhang XC, Guo KJ, Zhao FC, Pang Y, Chen YX. Effect of Chemical Thromboprophylaxis on the Rate of Venous Thromboembolism After Treatment of Foot and Ankle Fractures. Foot Ankle Int 2016; 37:1218-1224. [PMID: 27521353 DOI: 10.1177/1071100716658953] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a well-documented complication in patients with lower limb fractures, but management guidelines for its prevention in isolated foot and ankle fracture patients are conflicting. The aim of this study was to conduct a multicenter, prospective cohort study to define the prevalence of VTE in patients with isolated foot and ankle fractures and determine whether routine prophylaxis is necessary in these patients. METHODS In a double-blind, placebo-controlled study, consecutive patients in 3 hospitals who met our criteria were enrolled. After randomization, patients received either thromboprophylaxis with low-molecular-weight heparin units (LMWH group) or placebo (placebo group) for a period of 2 weeks. All patients underwent routine ultrasonography 1 day preoperatively, 1 week postoperatively, and 1 month postoperatively. Demographic parameters were then collected and compared. RESULTS Of the 814 patients who met our criteria, 19 patients (2.3%, 95% confidence interval [CI], 0%-31.9%) were found to have objectively confirmed VTE, but none of the patients were symptomatic. Of the 411 patients in the LMWH group, 2 developed VTEs preoperatively and 4 postoperatively; of the 403 patients in the placebo group, 5 developed VTEs preoperatively and 8 postoperatively. The overall incidence of asymptomatic postoperative deep vein thrombosis (DVT) was 0.98% (95% CI 0%-20.3%) in the LMWH group and 2.01% (95% CI 0%-29.5%) in the placebo group without significant difference. Advanced age (odds ratio [OR] 1.050, 95% CI 1.014-1.088, P = .007) and high body mass index (OR 1.201, 95% CI 1.034-1.395, P = .016) were identified as risk factors in predicting occurrence of DVT. No fatal pulmonary emboli or major bleeding complication occurred in either group. CONCLUSION Routine anticoagulant prophylaxis was not found to be necessary for patients with foot and ankle fractures, although further investigation with a properly powered study design is required to definitively determine which foot and ankle patients are best served by anticoagulation and which ones are not. LEVEL OF EVIDENCE Level II, prospective comparative study.
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Affiliation(s)
- Xin Zheng
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical College, Xuzhou, China.,Department of Orthopaedics, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Dong-Ya Li
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical College, Xuzhou, China
| | - Yufan Wangyang
- Department of Orthopaedics, The Central Hospital of Xuzhou City, Xuzhou, China
| | - Xing-Chen Zhang
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical College, Xuzhou, China
| | - Kai-Jin Guo
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical College, Xuzhou, China
| | - Feng-Chao Zhao
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical College, Xuzhou, China
| | - Yong Pang
- Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical College, Xuzhou, China
| | - Yi-Xin Chen
- Department of Orthopaedics, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
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Effects of intermittent pneumatic compression of the thigh on blood flow velocity in the femoral and popliteal veins: developing a new physical prophylaxis for deep vein thrombosis in patients with plaster-cast immobilization of the leg. J Thromb Thrombolysis 2016; 42:579-84. [DOI: 10.1007/s11239-016-1403-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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63
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Kerkhoffs GMMJ, Kennedy JG, Calder JDF, Karlsson J. There is no simple lateral ankle sprain. Knee Surg Sports Traumatol Arthrosc 2016; 24:941-3. [PMID: 27023097 DOI: 10.1007/s00167-016-4043-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- G M M J Kerkhoffs
- Department of Orthopedic Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Academic Center for Evidence Based Sports Medicine (ACES), Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - J G Kennedy
- Hospital for Special Surgery, New York, NY, USA.,Weil Cornell University, New York, NY, USA
| | - J D F Calder
- Fortius Clinic, London, UK.,Imperial College, London, UK
| | - J Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
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