Meta-analysis and suggested guidelines for prevention of venous thromboembolism (VTE) in foot and ankle surgery

Long-term patient outcome is affected by deep venous thrombosis after Achilles tendon rupture repair

PURPOSE

The aim of the study was to examine the impact of a deep venous thrombosis (DVT) on patient outcomes 3 years after Achilles tendon rupture (ATR) repair and if there were continued improvements between 1 and 3 years after surgery. A secondary aim was to determine risk factors associated with impaired patient outcomes in the long term.

METHODS

This cohort study consisted of 181 ATR-repaired patients, from two large randomized clinical trials, who attended a 3-year follow-up evaluation. Patients were postoperatively randomized to two different weight-bearing interventions compared with immobilization in a below-knee plaster cast for 2 weeks. During immobilization, screening for DVT was performed with Doppler ultrasound. At 1 and 3 years postoperatively, functional- and patient-reported outcomes were evaluated by the validated heel-rise test and self-reported questionnaire, Achilles tendon Total Rupture Score (ATRS).

RESULTS

In total, 76 out of 181 (42%) patients exhibited a DVT at the 2- or 6-week screening after ATR surgery. Suffering from a DVT during immobilization resulted at 3 years in a worse limb symmetry index (LSI) of heel-rise total work compared to patients without DVT, adjusted for age (DVT mean LSI 68% vs. no DVT 78%, p = 0.027). At 3 years, patients with a DVT during immobilization displayed lower ATRS (DVT median 88 vs. no DVT 93, p = 0.046), which was not significant after adjustment for age. However, patients with DVT exhibited an improvement in ATRS, LSI total work, and LSI maximum height between 1 and 3 years, which was not seen among patients without DVT. Independent risk factors for reduced patient functional outcomes at 3 years were older age, greater calf muscle hypotrophy, and suffering a DVT.

CONCLUSIONS

DVT during immobilization affects patients' long-term functional outcomes 3 years after ATR repair. Clinicians should adequately address risk factors contributing to impaired patient outcomes in the long term, including calf muscle hypotrophy, DVT, and older age.

LEVEL OF EVIDENCE

Level Ⅲ.

Incidence and Time Course of Symptomatic Thromboembolic Outcomes After Lower Extremity Arthroscopic Surgery, Ankle Fracture Surgery, and Achilles Tendon Repair

BACKGROUND

The incidence and time course of acute venous thromboembolism (VTE) after ambulatory surgery for lower extremity orthopaedic conditions is not well-defined.

HYPOTHESIS

The purpose of this study was to analyze the incidence, the time course, and risk factors associated with clinically diagnosed acute deep vein thrombosis or pulmonary embolism within 3 months of surgery in patients undergoing specific operations for lower extremity injuries.

METHODS

Patients undergoing arthroscopic procedures of the knee, ankle fracture surgery, Achilles tendon repair, and ankle arthroscopy from January 1, 2005, to December 31, 2010, were identified in the California Ambulatory Surgery database with linkage to hospital discharge data, emergency department data, and a death registry. Outcomes were acute VTE and death within 90 days. Time courses were compared using Kaplan-Meier analysis, and risk factors were analyzed using proportional hazard modeling.

RESULTS

Analysis of data from 468,699 surgeries showed that the cumulative incidence of acute VTE was significantly higher after Achilles tendon repair (0.72%, P < 0.001) than ankle fracture surgery (0.33%), knee arthroscopy procedures (range, 0.29% to 0.41%), or ankle arthroscopy (0.24%). The time course of diagnosis of VTE was similar for all arthroscopic procedures (median postoperative day for diagnosis = 9 to 10; 80% by 22 to 36 days), whereas for Achilles tendon surgery, the time course was protracted (median postoperative day for diagnosis = 29 days; 80% by 51 days). Ninety-day mortality was low (<0.06%) after all procedures except ankle fracture (0.12%). Predictors of pulmonary embolism included age older than 60 years (HR, 3.1; 95% CI; 2.0 to 4.8, versus younger than 30 years), Achilles tendon repair (HR, 3.8; 95% CI; 2.8 to 5.3), and ankle fracture surgery (Hazard Ratio [HR], 2.1; 95% Confidence Interval [CI]; 1.5 to 2.8); Asian/Pacific Islander (HR, 0.3; 95% CI; 0.1 to 0.6) and Hispanic patients (HR, 0.5; 95% CI; 0.4 to 0.7) had significantly lower risk.

DISCUSSION

The incidence and time course of onset of acute VTE after lower extremity orthopaedic surgeries varies significantly depending on the surgical procedure. These findings have implications regarding the use and duration of pharmacologic thromboprophylaxis.

Characteristics of Patients Not Receiving Chemical Thromboprophylaxis Following Foot and Ankle Surgery: Data From the Multicenter, Prospective UK Foot and Ankle Thrombo-Embolism Audit (UK-FATE)

BACKGROUND

Although the rate of venous thromboembolism (VTE) after foot and ankle surgery is low, multiple factors influence risk for individual patients. Furthermore, there are no clear guidelines on which patients may benefit from chemical thromboprophylaxis. Our aim was to assess patients not treated with chemical thromboprophylaxis after foot and ankle surgery, and to report on their specific patient and surgical risk factors for VTE.

METHODS

This was a multicenter, prospective, national audit of patients undergoing foot and ankle surgery (including Achilles tendon ruptures) from 68 participating UK centers. The study was conducted between June 1, 2022, and November 30, 2022, with a further 3-month follow-up. Following data cleansing, 3309 patients were included who did not receive postoperative thromboprophylaxis.

RESULTS

Most patients were elective cases (2589 patients, 78.24%) with ASA grade I or II (2679 patients, 80.96%), fully weightbearing postoperatively (2752 patients, 83.17%), and either without ankle splintage, or splinted in a plantigrade boot (2797 patients, 84.53%). The VTE rate was 0.30% overall (11 cases), with no VTE-related mortality. No single demographic, surgical, or postoperative factor was associated with reduced risk of VTE. However, patients who had elective or trauma surgery not involving the ankle, who were ASA grade I or II and who were weightbearing immediately postoperatively (without splinting or in a plantigrade boot) had a VTE rate of 0.05% (1 of 1819 patients), compared with 0.67% (10 of 1490 patients, P = .002).

CONCLUSION

Patients not receiving chemical thromboprophylaxis had a low incidence of symptomatic VTE, although they do represent a curated group considered lower risk. Within this group we describe characteristics associated with a substantially lower risk of VTE. All patients should be assessed on an individual basis, and further work is required to substantiate our findings.

The efficacy and safety of tranexamic acid utilization in total ankle arthroplasty: a systematic review and meta-analysis

INTRODUCTION

There is still a lack of information on the role of Tranexamic acid (TXA) in total ankle arthroplasty (TAA). The purpose of this study is to comprehensively review, consolidate, and analyze findings from existing research on the effectiveness and safety of TXA in TAA.

MATERIALS AND METHODS

The comprehensive literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) using PubMed, Embase, Web of Science, and Cochrane databases, for original, English-language studies investigating the efficacy and safety of TXA in TAA, through February 2023. Evaluated data for the meta-analysis included estimated blood loss (EBL), change in perioperative hemoglobin, need for transfusion, and complications including DVT/PE, and wound complications.

RESULTS

A total of nine studies were included in this study. In total, 450 TAA were included, with 244 receiving TXA (54.2%) and 206 not receiving TXA (45.8%). TXA in TAA significantly decreased EBL. A significantly lower rate of wound complications in the TXA group with the relative risk (RR) of 0.51. We classified wound complications into wound infection and delayed wound healing/dehiscence. A significant decrease in the rate of wound infection and a tendency showing a decrease in the rate of delayed wound healing/dehiscence in the TXA group were noted: the RR of 0.29, and 0.63, respectively. TXA did not increase the incidence of DVT/PE following TAA.

CONCLUSIONS

In conclusion, the utilization of TXA during TAA demonstrated a statistically significant reduction in EBL and relative risk for wound complications. However, further RCTs with larger sample sizes will be necessary to establish a more robust conclusion regarding the efficacy and safety of TXA in TAA.

LEVEL OF EVIDENCE

Level III, systematic review and meta-analysis.

Using machine learning in the prediction of symptomatic venous thromboembolism following ankle fracture

BACKGROUND

Venous thromboembolism (VTE) is a major cause of morbidity and mortality in the trauma setting, and both prediction and prevention of VTE have long been a concern for healthcare providers in orthopedic surgery. The purpose of this study was to evaluate the use of novel statistical analysis and machine-learning in predicting the risk of VTE and the usefulness of prophylaxis following ankle fractures.

METHODS

The medical profiles of 16,421 patients with ankle fractures were screened retrospectively for symptomatic VTE. In total, 238 patients sustaining either surgical or nonsurgical treatment for ankle fracture with subsequently confirmed VTE within 180 days following the injury were placed in the case group. Alternatively, 937 patients who sustained ankle fractures managed similarly but had no documented evidence of VTE were randomly chosen as the control group. Individuals from both the case and control populations were also divided into those who had received VTE prophylaxis and those who had not. Over 110 variables were included. Conventional statistics and machine learning methods were used for data analysis.

RESULTS

Patients who had a motor vehicle accident, surgical treatment, increased hospital stay, and were on warfarin were shown to have a higher incidence of VTE, whereas patients who were on statins had a lower incidence of VTE. The highest Area Under the Receiver Operating Characteristic Curves (AUROC) showing the performance of our machine learning approach was 0.88 with 0.94 sensitivity and 0.36 specificity. The most balanced performance was seen in a model that was trained using selected variables with 0.86 AUROC, 0.75 sensitivity, and 0.85 specificity.

CONCLUSION

By using machine learning, this study successfully pinpointed several predictive factors linked to the occurrence or absence of VTE in patients who experienced an ankle fracture. Training these algorithms using larger, more granular, and multicentric data will further increase their validity and reliability and should be considered the standard for the development of such algorithms.

LEVEL OF EVIDENCE

Case-Control study - 3.

While the Incidence of Venous Thromboembolism After Shoulder Arthroscopy Is Low, the Risk Factors Are a Body Mass Index Greater than 30 and Hypertension

Purpose

This study aims to determine the overall incidence of venous thromboembolism (VTE) following shoulder arthroscopy and to define potential risk factors associated with its development that may help define guidelines for the use of thromboprophylaxis.

Methods

A systematic review was performed using PubMed, Embase, Web of Science, CINAHL, and Cochrane databases per PRISMA guidelines. The search terms consisted of variations of "Venous Thromboembolism" and "Shoulder Arthroscopy." Information regarding arthroscopy indication, risk factors, outcomes, and patient demographics was recorded and analyzed, and pooled odds ratios were reported for each variable.

Results

Six hundred eighty-five articles were identified in the initial search, and 35 articles reported DVT, PE, or VTE incidence following shoulder arthroscopy. Seventeen nonoverlapping articles with a unique patient population incidence rates. Four articles were then used for subgroup meta-analysis. The incidence rate of VTE was 0.24%, ranging from 0.01% to 5.7%. BMI >30 (OR = 1.46; 95% CI = [1.22, 1.74]; I2 = 0%) and hypertension (OR = 1.64; 95% CI = [1.03, 2.6]; I2 = 75%) were significant risk factors (P < .05) for developing VTE following shoulder arthroscopy. Diabetes (OR = 1.2; 95% CI = [0.97, 1.48]; I2 = 0%), insulin-dependent diabetes (OR = 5.58; 95% CI = [0.12, 260.19]; I2 = 85%), smoking (OR = 1.04; 95% CI = [0.79, 1.37]; I2 = 12%), male sex (OR = 0.95; 95% CI = [0.49, 1.85]; I2 = 86%) and age over 65 (OR = 4.3; 95% CI = [0.25, 72.83]; I2 = 85%) were not associated with higher VTE risk.

Conclusion

The VTE incidence following shoulder arthroscopy is low at 0.24%. Patients with BMI >30 and hypertension are at a higher risk for VTE after shoulder arthroscopy.

Level of Evidence

Level IV, systematic review and meta-analysis of Level I-IV studies.

Venous Thromboembolism Prophylaxis in Foot and Ankle Surgery: A Worldwide Survey

Current recommendations on thromboprophylaxis for foot and ankle (FA) surgery are often inconsistent and generally based on weak evidence. The aim of this survey study was to evaluate the current practice among orthopedic surgeons regarding venous thromboembolism (VTE) prophylaxis following FA surgery. From February 2019 to March 2020, an online questionnaire was sent by e-mail to orthopedic societies across the world. The questionnaire was hosted by the International Society of Thrombosis and Haemostais RedCAP platform. Topics of interest were VTE rates following FA surgery, duration and type of thromboprophylaxis, bleeding complications, VTE risk factors for prophylaxis and use of risk assessment. A total of 693 FA orthopedic surgeons from all continents completed the survey of whom 392 (57%) performed more than 200 FA procedures per year. A total of 669/693 (97%) respondents stated that thromboprophylaxis is necessary in FA surgeries. When thromboprophylaxis was prescribed, half of surgeons prescribed it for the duration of immobilization. Acetylsalicylic acid, low molecular weight heparin and direct-oral anticoagulants were, in this order, the preferred choice. Acetylsalicylic acid and low molecular weight heparin were predominantly prescribed in North America and Europe, respectively. Previous deep vein thrombosis, immobility, obesity and inherited thrombophilia were considered the main risk factors indicative of thromboprophylaxis use. In this survey, most surgeons agree that thromboprophylaxis is indicated for FA surgery, but the prescription, type and duration of prophylaxis differs greatly with a large intercontinental discrepancy. These survey results could be a foundation for developing uniform guidelines to optimize thromboprophylactic strategies in FA procedures around the world.

Correlation Between Statin Use and Symptomatic Venous Thromboembolism Incidence in Patients With Ankle Fracture: A Machine Learning Approach

BACKGROUND

Identifying factors that correlate with the incidence of venous thromboembolism (VTE) has the potential to improve VTE prevention and positively influence decision-making regarding prophylaxis. In this study, we aimed to investigate the correlation between statin consumption and the incidence of VTE in patients who sustained an ankle fracture.

METHODS

In this retrospective, case-controlled study, cases were those who developed VTE and controls were those who had no VTE, and the ratio was 1:4. Patients' demographics, history of hyperlipidemia, and reported statins use were obtained. A random forest classifier (RFC) model was used to predict whether statin consumers were at risk of VTE after ankle fracture regardless of VTE prophylaxis administration based on statin consumption, body mass index (BMI), age, and biological sex.

RESULTS

Of the 1175 patients with ankle fractures, 238 had confirmed VTE (case group), and 937 had no symptomatic VTE (control group; ratio 1:4). Fifty (21%) cases and 407 (43%) controls were on a statin. Statin users had a significantly lower incidence of VTE after ankle fracture, odds ratio (OR) = 0.35, 95% CI: 0.25, 0.49, P < .001. Our model showed an area under the receiving operator curve (AUROC) of 78%, a sensitivity of 73%, and a specificity of 83% in predicting the risk of VTE. The importance of the predictors of VTE, other than the use of statins (model importance = 0.1), were age (model importance of 0.72), BMI (model importance of 0.24), and biological sex (model importance of 0.02).

CONCLUSION

Statins were significantly associated with a lower rate of VTE in our population of patients who sustained an ankle fracture.

LEVELS OF EVIDENCE

3.

Postoperative venous thromboembolism risk-prediction in foot and ankle fracture surgery

BACKGROUND

Venous thromboembolism (VTE) are rare but serious complications after foot and ankle fracture surgery. A consensus definition of a high-risk patient has not been reached, leading to significant variability in the use of pharmacologic agents for VTE prophylaxis. The aim of this study was to develop a model for predicting VTE risk in patients undergoing surgery for foot and ankle fractures that is usable and scalable in clinical practice.

METHODS

A retrospective review of 15,342 patients, within the ACS-NSQIP database, who had undergone surgical repair of foot and ankle fractures from 2015 to 2019 was performed. Univariate analysis evaluated differences in demographics and comorbidities. Stepwise multivariate logistic regression was generated based on a 60 % development cohort to evaluate risk factors for VTE. A receiver operator curve based on the 40 % test cohort calculated area under the curve (AUC) to measure the accuracy of the model in predicting VTE within the 30-day postoperative period.

RESULTS

Of the 15,342 patients, 1.2 % patients experienced VTE, and 98.8 % patients did not. Patients who experienced VTE were significantly older and had an overall higher comorbidity burden. Those who had VTE spent on average 10.5 more minutes in the operating room. In the final model, age over 65, diabetes, dyspnea, CHF, dialysis, wound infection and bleeding disorders were all found to be significant predictors of VTE after controlling for all other factors. The model generated an AUC of 0.731, indicating good predictive accuracy. The predictive model is publicly available at https://shinyapps.io/VTE_Prediction/.

CONCLUSIONS

In alignment with previous studies, we identified increased age and bleeding disorders as independent risk factors for VTE after foot and ankle fracture surgery. This is one of the first studies to generate and test a model for identifying patients at risk for VTE in this population. This evidence-based model may help surgeons prospectively identify high-risk patients who may benefit from pharmacologic VTE prophylaxis.

The Association between the Hematocrit at Admission and Preoperative Deep Venous Thrombosis in Hip Fractures in Older People: A Retrospective Analysis

Hematocrit, a commonly used hematological indicator, is a simple and easily applicable test. As a marker of anisocytosis and anemia, it indicates the percentage of blood cells per unit volume of whole blood. This study aimed to evaluate the association between the level of the hematocrit at admission and preoperative deep vein thrombosis (DVT) in hip fractures of older people. We collected the demographic and clinical characteristics of patients with geriatric hip fractures between 1 January 2015, and 30 September 2019, at the largest trauma center in northwestern China. Doppler ultrasonography was used to diagnose DVT. The correlation between hematocrit levels at admission and preoperative DVT was assessed using linear and nonlinear multivariate logistic regression, according to the adjusted model. All analyzes were performed using EmpowerStats and R software. In total, 1840 patients were included in this study, of which 587 patients (32%) had preoperative DVT. The mean hematocrit level was 34.44 ± 5.64 vol%. Linear multivariate logistic regression models showed that admission hematocrit levels were associated with preoperative DVT (OR = 0.97, 95% CI: 0.95−0.99; p = 0.0019) after adjustment for confounding factors. However, the linear association was unstable, and nonlinearity was identified. An admission hematocrit level of 33.5 vol% was an inflection point for the prediction. Admission hematocrit levels <33.5 vol% were not associated with preoperative DVT (OR = 1.00, 95% CI: 0.97−1.04, p = 0.8230), whereas admission hematocrit levels >33.5 vol% were associated with preoperative DVT (OR = 0.94, 95% CI: 25 0.91−0.97, p = 0.0006). Hematocrit levels at admission were nonlinearly associated with preoperative DVT, and hematocrit at admission was a risk factor for preoperative DVT. However, the severity of a low hematocrit was not associated with preoperative DVT when the hematocrit was <33.5 vol%.

Incidence of Venous Thromboembolism in Patients Receiving Anticoagulation for Foot and Ankle Surgery

Venous thromboembolism (VTE) is a serious medical condition that can be an unfortunate complication arising from foot and ankle surgery. Many factors may predispose a patient to a VTE event including prolonged postoperative immobilization, comorbidities, extended length of tourniquet time, and higher risk surgeries. Unfortunately, there is no clinical consensus for guidelines on VTE prophylaxis following foot and ankle surgery. In this retrospective cohort study, we present our patient population who were prophylactically anticoagulated following foot and ankle surgery along with their incidence of deep vein thrombosis and pulmonary embolism (PE). Included in the study were patients who had undergone elective and traumatic foot and ankle surgery from June 2017 to December 2018. Using retrospective data obtained we compared patient demographics, surgery type, length of tourniquet time, postoperative immobilization, type of VTE prophylaxis, and comorbidities including history of smoking, peripheral vascular disease, bleeding disorders, and patients undergoing dialysis. Five of 425 (1.2%) patients were diagnosed with a deep vein thrombosis and 1 of 425 (0.2%) patients was diagnosed with a pulmonary embolism. Risks factors statistically significant for developing a VTE in our patient population included extended periods of immobilization and an increasing patient age. We were able to conclude that routine prophylaxis for elective and traumatic foot and ankle surgery is both effective and safe for especially in older patients requiring extended immobilization. It's also important to take into consideration comorbidities, smoking history, tourniquet time, and the type of surgery that is being performed.

Risk factors for venous thromboembolism following fractures isolated to the foot and ankle fracture

OBJECTIVE

Venous thromboembolism (VTE) is an uncommon, but potentially morbid, complication following foot and ankle fractures. Current standard is to not administer thromboprophylaxis to patients with such injuries. Nonetheless, patient and fracture factors might affect this risk/benefit consideration. The goal of this study was to determine what patients are most at risk.

METHODS

The M53Ortho Pearldiver database was used to identify patients with fractures isolated to the foot and ankle that were treated non-operatively or operatively. Patients with pilon, other appendicular fractures remote from the foot and ankle, and other traumatic injuries were excluded. The 90-day occurrence of VTE was identified based on codes for deep vein thrombosis or pulmonary embolism. Characteristics of those patients who did and did not have VTEs were compared using chi-square analyses. Multivariate logistical regression was then performed to determined factors independently associated with VTE. Finally, timing of VTE relative to fracture was analyzed.

RESULTS

A total of 298,886 patients with isolated foot or ankle fractures were identified, of which 1,661 (0.56%) had VTE in the 90 days following fracture. In terms of timing, 27.3% occurred in the first week, and 49.8% occurred in the first three weeks. Independent risk factors for VTE included (in decreasing order):prior VTE (odd ratio [OR] = 25.44), factor V Leiden (OR = 24.34), active cancer (OR = 1.84), specific fracture relative to metatarsal fracture (multiple fractures [OR: 1.51], ankle fracture [OR = 1.51], and calcaneus fracture [OR = 1.24]), surgical treatment (OR = 1.41), male sex (OR = 1.19), greater Elixhauser index (OR = 1.05), and increasing age (OR:1.05 per decade) (p<0.05 for each).

CONCLUSIONS

The present study found that, although only 0.56% of isolated foot and ankle fractures had a VTE within ninety days. Defined risk factors, such as Factor V Leiden, prior VTE, surgical treatment, active cancer, specific fracture patterns, and surgical treatment significantly affected the odds of their occurrence.

Cost-Effective Modeling of Thromboembolic Chemoprophylaxis for Total Ankle Arthroplasty

BACKGROUND

Symptomatic venous thromboembolism (VTE) following total ankle arthroplasty (TAA) can cause substantial morbidity and mortality. To prevent this complication, surgeons often prescribe postoperative chemoprophylaxis. However, much controversy exists regarding the efficacy of chemoprophylaxis because of the limited studies exploring its use. Furthermore, even less is known about its cost-effectiveness. Therefore, this study sought to determine the cost-effectiveness of commonly prescribed chemoprophylactic agents using a break-even analysis economic model.

METHODS

The literature was searched, and an online database was used to identify patients who developed a symptomatic VTE after undergoing TAA. Our institutional records were used to estimate the cost of treating a symptomatic VTE, and an online drug database was used to obtain the cost of commonly prescribed chemoprophylactic agents. A break-even analysis was then performed to determine the final break-even rate necessary to make a drug cost-effective.

RESULTS

The low and high rates of symptomatic VTE were determined to be 0.46% and 9.8%. From 2011 to 2021, a total of 3455 patients underwent total ankle arthroplasty. Of these patients, 16 developed a postoperative symptomatic VTE (1.01%). Aspirin 81 mg was cost-effective if the initial symptomatic VTE rates decreased by an absolute risk reduction (ARR) of 0.0003% (NNT = 31 357). Aspirin 325 mg was also cost-effective if the initial rates decreased by an ARR 0.02% (NNT = 5807). Likewise, warfarin (5 mg) was cost-effective at all initial rates with an ARR of 0.02% (NNT = 4480). In contrast, enoxaparin (40 mg) and rivaroxaban (20 mg) were only cost-effective at higher initial symptomatic VTE rates with ARRs of 1.48% (NNT = 68) and 5.36% (NNT = 19). Additional analyses demonstrated that enoxaparin (40 mg) and rivaroxaban (20 mg) become cost-effective when costs of treating a symptomatic VTE are higher than our estimates.

CONCLUSION

Chemoprophylaxis following TAA can be cost-effective. A tailored approach to VTE prophylaxis with cost-effectiveness in mind may be beneficial to the patient and health system.

Achilles: Failed Acute Repair

Acute Achilles tendon ruptures are commonly managed with surgical repair. This particular surgery is prone to rerupture, wound complications, deep vein thrombosis, and sural nerve injuries. In this chapter the authors discuss complications, how to avoid them, and ultimately how to manage complications with your patients.

Characteristics of Deep Venous Thrombosis in Isolated Lower Extremity Fractures and Unsolved Problems in Guidelines: A Review of Recent Literature

Deep venous thrombosis (DVT) has been characterized by a disorder of venous return caused by abnormal blood clotting in deep veins. It often occurs in the lower limbs and is a common complication in orthopaedics. Therefore, relevant professional organizations domestic and overseas had formulated and constantly updated relevant guidelines to prevent the occurrence of DVT. According to the management strategy of the guidelines, the incidence of DVT can be significantly reduced. However, due to the variety of fractures types, the guidelines cannot expound precautions and characteristics of DVT for all fracture types at present, and there are other related unresolved problems. For example, there is still a lack of consistent optimal strategies for the management of DVT following isolated lower extremity fractures with a higher incidence. The best anticoagulant strategies for patients with upper limb fractures, pediatric fractures, and those combined with other injuries are rarely described in orthopaedic guidelines, but such fractures are common in clinical orthopaedics. The long‐term complications after DVT, such as post‐thrombotic syndrome, are not well‐understood. In the absence of clear guidance, orthopaedic surgeons often resort to empiric anticoagulation or conservative treatment, so the prevention effects of DVT are inconsistent. The purpose of this review is to summarize the characteristics of DVT events after isolated lower extremity fractures and to discuss the unsolved issues in the guidelines by reviewing the previous literature and tracing the history of DVT discovery, to provide more scientific and comprehensive recommendations for the prediction and prevention of DVT.

Age, personal and family history are independently associated with venous thromboembolism following acute Achilles tendon rupture

PURPOSE

The primary aim was to determine independent patient, injury and management-related factors associated with symptomatic venous thromboembolism (VTE) following acute Achilles tendon rupture (ATR). The secondary aim was to suggest a clinical VTE risk assessment tool for patients with acute ATR.

METHODS

From 2010-2018, 984 consecutive adults (median age 47yrs, 73% [n = 714/984] male) sustaining an acute ATR were retrospectively identified. Ninety-five percent (n = 939/984) were managed non-operatively in a below-knee cast (52%, n = 507/984) or walking boot (44%, n = 432/984), with 5% (n = 45/984) undergoing primary operative repair (<6wks post-injury). VTE was diagnosed using local medical records and national imaging archives, reviewed at a mean 5yrs (range 1-10) post-injury. Multivariate logistic regression was performed to determine independent factors associated with VTE.

RESULTS

The incidence of VTE within 90 days of ATR was 3.6% (n = 35/984; deep vein thrombosis 2.1% [n = 21/984], pulmonary embolism 1.9% [n = 19/984]), and the median time to VTE was 24 days (interquartile range 15-44). Age ≥50yrs (adjusted OR [aOR] 2.3, p = 0.027), personal history of VTE/thrombophilia (aOR 6.1, p = 0.009) and family history of VTE (aOR 20.9, p<0.001) were independently associated with VTE following ATR. These non-modifiable risk factors were incorporated into a VTE risk assessment tool. Only 23% of patients developing VTE (n = 8/35) had a relevant personal or family history, but incorporating age ≥50yrs into the VTE risk assessment tool (alongside personal and family history) identified 69% of patients with VTE (n = 24/35). Non weight-bearing for ≥2wks after ATR was also independently associated with VTE (aOR 3.2, p = 0.026).

CONCLUSIONS

Age ≥50 years, personal history of VTE/thrombophilia and a positive family history were independently associated with VTE following ATR. Incorporating age into our suggested VTE risk assessment tool enhanced its sensitivity in identifying at-risk patients. Early weight-bearing in an appropriate orthosis may be beneficial to all patients in VTE risk reduction.

The Impact of Anticoagulant Activity of Tissue Factor Pathway Inhibitor Measured by a Novel Functional Assay for Predicting Deep Venous Thrombosis in Trauma Patients: A Prospective Nested Case-Control Study

Deep venous thrombosis (DVT) is a common complication in patients with traumatic injury. Tissue factor pathway inhibitor (TFPI) is a natural anticoagulant protein in the extrinsic coagulation pathway. However, the relationship between DVT after trauma and the anticoagulant activity of TFPI remains unclear. In this prospective study, we investigated the role of TFPI in trauma patients with DVT to evaluate whether the anticoagulant activity of TFPI measured by a new functional assay can be used to help predict the risk of DVT. Patients and methods: This prospective nested case-control study enrolled trauma patients and healthy volunteers. Forty-eight trauma patients diagnosed with DVT and forty-eight matched trauma patients without DVT were included in the study. 120 healthy volunteers were also included as controls. Blood samples and case information were collected at admission. Patients accepted angiography before surgery to diagnose DVT. The parameters examined included TFPI anticoagulant activity, free-TFPI antigen, blood cell counts, and routine clinical coagulation tests. Results: For the parameters of TFPI anticoagulant activity, three were markedly increased in the DVT group compared to the non-DVT group (TFPI initial anticoagulant time ratio, P  =  .022; TFPI whole anticoagulant time ratio, P  =  .048; and TFPI anticoagulant rate, P  =  .034). The free-TFPI antigen concentration also showed a significant increasing trend in trauma patients with DVT compared with trauma patients without DVT (P  =  .035). Multivariate logistic regression analysis identified four independent factors for the development of DVT (TFPI initial anticoagulant time ratio, free-TFPI antigen, prothrombin time, and red blood cell count). We calculated the TFPI correlation coefficient and found that the area under the receiver operating characteristic curve was .821. Conclusions: A novel functional assay was developed to measure the anticoagulant activity of TFPI. The anticoagulant activity of TFPI can be used as a potential biomarker for diagnosing DVT in trauma patients.

Endoscopic speed bridge: A new treatment for insertional Achilles tendinopathy

Surgical treatment may be indicated after failure of medical management of insertional Achilles tendinopathy, and may consist in simple calcaneoplasty, increasingly performed endoscopically, or in open detachment-reattachment. Isolated calcaneoplasty sometimes shows poor results in case of multiple overlooked lesions (bone, tendon, pre- or retro-tendinous bursitis). Detachment-reattachment may be indicated in case of tendon lesion, but incurred scar and infection related risk in up to 30% of cases in certain reports. In this context, we describe a new original technique using an endoscopic Achilles speed bridge, which we call the "snake technique" for the S-shaped order of performance of the 6 necessary approaches.

The Surgical Care Practitioner role in Achilles tendon re-rupture: A case study

The value of a Surgical Care Practitioner to an orthopaedic team is demonstrated in this case study of a patient who presented with a re-ruptured Achilles tendon. It highlights the role the practitioner plays in the patient journey and illustrates it's value throughout the clinical course from consultation through to discharge. The Surgical Care Practitioner, as a member of the extended surgical team can help to explain the diagnosis and associated treatment options, facilitate informed consent and provide expert procedural assistance to the surgeon. A Surgical Care Practitioner is ideally placed to answer patient queries and aid in rehabilitation.

STOP leg clots-Swedish multicentre trial of outpatient prevention of leg clots: study protocol for a randomised controlled trial on the efficacy of intermittent pneumatic compression on venous thromboembolism in lower leg immobilised patients

INTRODUCTION

Leg immobilisation in a cast or an orthosis after lower limb injuries is associated with a high risk of complications of venous thromboembolism (VTE) and hampered healing. Current pharmacoprophylaxes of VTE are inefficient and associated with adverse events. Intermittent pneumatic compression (IPC) could represent a novel, efficient and safe VTE-prophylactic alternative that may enhance injury healing. The aim of STOP leg clots is to assess the efficacy of adjuvant IPC-therapy on reduction of VTE incidence and improvement of healing in lower leg immobilised outpatients.

METHODS AND ANALYSIS

STOP leg clots is a multicentre randomised controlled superiority trial. Eligible patients (700 patients/arm) with either an acute ankle fracture or Achilles tendon rupture will be randomised to either addition of IPC during lower-leg immobilisation or to treatment-as-usual. The primary outcome will be the total VTE incidence, that is, symptomatic and asymptomatic deep venous thrombosis (DVT) or symptomatic pulmonary embolism (PE), during the leg immobilisation period, approximately 6-8 weeks. DVT incidence will be assessed by screening whole leg compression duplex ultrasound at removal of leg immobilisation and/or clinically diagnosed within the time of immobilisation. Symptomatic PE will be verified by CT.Secondary outcomes will include patient-reported outcome using validated questionnaires, healing evaluated by measurements of tendon callus production and changes in VTE-prophylactic mechanisms assessed by blood flow and fibrinolysis. Data analyses will be blinded and based on the intention-to-treat.

ETHICS AND DISSEMINATION

Ethical approval was obtained by the ethical review board in Stockholm, Sweden, Dnr 2016/1573-31. The study will be conducted in accordance with the Helsinki declaration. The results of the study will be disseminated in peer-reviewed international journals.

TRIAL REGISTRATION

NCT03259204.

TIME SCHEDULE

1 September 2018 to 31 December 2022.

Xueshuantong Injection in Treating Deep Venous Thrombosis: A Systematic Review and Trial Sequential Analysis

AIMS

In recent years, the incidence of deep venous thrombosis (DVT) presents an increasing trend year by year. The current evidence regarding the efficacy and safety of Xueshuantong injection for DVT is controversial. This systematic review (SR) aimed to assess the efficacy and safety of Xueshuantong injection in the treatment of DVT systematically and provide an evidence-based reference for clinical treatment.

METHODS

Nine electronic databases were used to identify the literature consisting of randomized controlled trials (RCTs) with a date of search of 1 November 2020. Clinical effective rate and incidence rate of adverse events were investigated as primary outcomes. Patency rate of femoral vein, patency rate of popliteal vein, patency rate of posterior tibial vein, circumference difference, activated partial thromboplastin time (APTT), and D-dimer (D-D) were investigated as secondary outcomes. Revman 5.4.1 was used to analyze the results. Analysis of the power of evidence was performed with Trial Sequential Analysis (TSA).

RESULTS

A total of 12 articles including 1018 patients were included. The results of the meta-analysis showed that the clinical effective rate in the experimental group was higher than that in the control group, the incidence rate of adverse events in the experimental group was higher than that in the control group; after the operation, the patency rate of femoral vein, patency rate of popliteal vein, patency rate of posterior tibial vein, circumference difference, APTT, and D-D in the experimental group were significantly improved compared with those in the control group, and the difference between the groups was statistically significant. TSA suggested that the meta-analysis concerning the clinical effectiveness of Xueshuantong injection in the treatment of DVT was of adequate power to reach firm conclusions.

CONCLUSION

Based on the current analysis, Xueshuantong injection as an add-on treatment provided better treatment effect for DVT with adequate power but this benefit should be considered with caution because of the small number of studies included in the meta-analysis and the high or unclear risk of bias of the included trials, suggesting that further studies are needed.

Acute Achilles Tendon Ruptures

There is an ever-evolving debate about the best treatment option for Achilles tendon ruptures. There was a relative consensus that operative treatment yielded the best outcomes. Much of this is based on results in athletic populations. Conservative treatment was considered only for the elderly and those with very inactive lifestyles. There has been an evolution, however, with more surgeons utilizing an aggressive functional rehabilitation with conservative management. Surgical intervention still is the treatment of choice for elite-level athletes. The treatment of choice for patient populations other than elite athletes remains an individual choice between patient and physician.

Comparing Surgical and Conservative Treatment on Achilles Tendon Rupture: A Comprehensive Meta-Analysis of RCTs

Background: The Achilles tendon is the strongest tendon in human and is frequently injured, mainly in the young to middle age active population. Increasing incidence of Achilles tendon rupture (ATR) is still reported in several studies. Surgical repair and conservative treatment are two major management strategies widely adopted in ATR patients, but the consensus of the optimal treatment strategy is still debated. We aimed at thoroughly reviewing the ATR topic with additional assessments and performed a most comprehensive meta-analysis of randomized controlled trials (RCTs). Method: We comprehensively searched PubMed, Embase, Cochrane, and ClinicalTrial.gov and retrieved all RCTs comparing surgical and conservative treatment on ATR for further analysis. Two independent reviewers performed data extraction and random effect model was adopted when I 2 > 50%, with data presentation of risk ratio, risk difference, or mean difference and 95% confidence interval. Results: A total of 13 RCTs were included in this meta-analysis. A significant difference was observed in re-rupture, complication rate, adhesion to the underlying tendon, sural nerve injury, and superficial infection. A substantial reduction in re-rupture rate could be observed for surgical treatment while the complication rate was higher compared with conservative treatment. Conclusion: Surgical treatment revealed significance in reducing the re-rupture rate but was associated with a higher complication rate, while conservative treatment showed similar outcomes with a lower complication rate. Collectively, we recommend conservative treatment if patients' status and expectations are suitable, but surgeon and physician discretion is also crucial in decision making.

High risk of venous thromboembolism after orthopedic surgery in patients with thrombophilia

OBJECTIVE

This study aimed at evaluating the effect of thrombophilia on the risk of venous thromboembolism (VTE) in patients undergoing any type of orthopedic surgery.

BACKGROUND

Patients undergoing orthopedic surgery are at high risk for VTE. Although patients with thrombophilia have an increased risk of VTE, it is currently unclear whether there is a synergetic effect in patients with thrombophilia who undergo orthopedic surgery.

METHODS

Data from a large population-based case-control study (the Multiple Environmental and Genetic Assessment [MEGA] of risk factors for venous thrombosis study) were used. Odds ratios (ORs) with 95% confidence intervals (CIs), adjusted for age, sex, and body mass index (BMI) (ORadj) were calculated for patients undergoing any orthopedic intervention.

RESULTS

Of 4721 cases and 5638 controls, 263 cases and 94 controls underwent orthopedic surgery. Patients who had any orthopedic intervention in the year before the index date were at higher risk of VTE (ORadj 3.7; 95% CI, 2.9-4.8) than those who did not undergo any orthopedic surgery. There was an additionally increased risk in patients with factor V Leiden (OR 17.5, 95% CI, 4.1-73.6), non-O blood group (OR 11.2; 95% CI, 3.4-34.0), or elevated plasma levels of factor VIII (OR 18.6; 95% CI, 7.4-46.9) all relative to patients without these defects, not undergoing orthopedic surgery.

CONCLUSIONS

Patients with factor V Leiden, high levels of factor VIII, or blood group non-O were found to have a high risk of VTE after orthopedic surgery. Identification of these patients may enable individualized thromboprophylactic treatment to efficiently reduce VTE risk.

Risk Factors for Short-Term Complication After Open Reduction and Internal Fixation of Ankle Fractures: Analysis of a Large Insurance Claims Database

Although fractures of the ankle are common injuries treated by surgical podiatrists and orthopaedic surgeons specializing in foot and ankle surgery, postoperative complications can occur, often imposing an economic burden on the patient. As health care in the United States moves toward value-based care, cost reduction has primarily focused on reducing complications and unplanned episodes of care. We used a large modern database of insurance claims to examine patterns of complications after open reduction internal fixation of ankle fractures, identifying diabetes mellitus and history of myocardial infarction as risk factors for postoperative infection within 30 days of surgery. Lateral malleolar repair was less likely to lead to infection, or need for repeated surgery, than was medial malleolar fracture repair. Diabetes mellitus, neuropathy, and chronic obstructive pulmonary disease were associated with development of postoperative cellulitis. Patients with a history of cerebrovascular accident were more likely to return to the emergency department or to have a pulmonary embolism. Male sex, presence of lupus, and increased age were associated with repeat surgery.

Incidence and Hematological Biomarkers Associated With Preoperative Deep Venous Thrombosis Following Foot Fractures

BACKGROUND

This study was designed to investigate the incidence and hematological biomarker levels that are associated with deep venous thrombosis (DVT) following closed foot fractures (except calcaneal fractures).

METHODS

A retrospective analysis of data on patients presenting with closed foot fractures (excluding the calcaneus) between October 2014 and December 2018 was conducted. Duplex ultrasonography was used to screen preoperative DVT of bilateral lower extremities. Data on demographics, comorbidities, types of fracture, and laboratory biomarkers at admission were collected. Univariate analyses and multivariate logistic regression analyses were carried out to determine the independent risk factors associated with DVT.

RESULTS

A total of 537 patients were included, among whom 28 patients had preoperative DVTs, indicating a crude incidence rate of 5.2%. In isolated closed foot fractures, DVT occurred in 12 (2.9%) out of 410 patients, while in patients with concurrent fracture in other locations, 16 (12.6%) out of 127 patients developed DVT. The average interval between fracture occurrence and diagnosis of DVT was 4.2 days (median, 2 days), ranging from 0 to 17 days. Twenty-four patients (85.7%) developed DVT in the injured extremity, 3 (10.7%) in the uninjured extremity, and 1 (3.5%) in bilateral extremities. Seven risk factors were identified to be associated with DVT, including alcohol consumption, concomitant other fractures, platelet distribution width (PDW) <12%, high-density lipoprotein cholesterol (HDL-C) <1.1mmol/L, serum alkaline phosphatase (ALP) >100 U/L, serum sodium concentration (Na⁺) <135 mmol/L, and D-dimer >0.5 mg/L.

CONCLUSION

Being aware of the prevalence of DVT in closed foot fractures can help physicians to carry out the overall assessment, risk stratification, and individual prevention programs.

LEVEL OF EVIDENCE

Level III, a prospective cohort study.

Meta-Analysis of Randomized Controlled Trials of Xueshuantong Injection in Prevention of Deep Venous Thrombosis of Lower Extremity after Orthopedic Surgery

Objective

To systematically evaluate the clinical efficacy of Xueshuantong injection (Panax notoginseng saponins) in preventing deep venous thrombosis (DVT) of lower extremity after orthopedic surgery.

Methods

The randomized controlled trials (RCTs) of Xueshuantong injection in prevention of lower extremity DVT after orthopedic surgery were retrieved from CNKI, Wanfang database, VIP, PubMed, and Cochrane Library by August 2020. Revman5.2 was used to analyze the results.

Results

A total of 20 articles including 2336 patients were included. The results of meta-analysis showed that the incidence of DVT in the experimental group was lower than that in the control group; after operation, the D-dimer (Ddimer), thrombin time (APTT), and prothrombin time (PT) in the experimental group were significantly improved compared with those in the control group, and the difference between the two groups was statistically significant.

Conclusion

Xueshuantong injection can effectively prevent the formation of lower extremity DVT after orthopedic surgery and antagonize the postoperative hypercoagulable state of blood, which has high clinical value.

Tranexamic Acid Use in Foot and Ankle Surgery

Background:

There is a potential role for tranexamic acid (TXA) use in foot and ankle procedures; however, the benefits of this intervention have not been fully elucidated. The purpose of this study was to explore the safety, outcomes, and medical complication profile of the use of intravenous TXA in patients undergoing foot and ankle surgery.

Methods:

A prospective study with retrospective review of 241 patients undergoing elective and traumatic foot and ankle procedures was performed. One gram of intravenous (IV) TXA was administered prior to incision. Patients were followed and evaluated for medical comorbidities, intraoperative blood loss, wound complication, superficial and deep infections, hematoma formation, medical complications, 30-day hospital readmission rate, and return visits to the emergency department or urgent care setting prior to first postoperative visit. Descriptive statistics were used for subgroup analysis. Mean postoperative follow-up was 4.5 months.

Results:

Estimated blood loss in all cases was less than 20 mL. There was 1 case of superficial cellulitis (1/241, 0.4%), 1 deep infection after Achilles tendon repair (1/241, 0.4%), 4 cases of delayed wound healing (4/241, 1.6%), 1 instance of deep vein thrombosis (1/241, 0.4%), and 2 cases of postoperative pulmonary embolism (2/241, 0.8%). There were no instances of postoperative hematoma formation. There were no additional recorded thromboembolic events. There were no adverse drug reactions. There were no 30-day hospital readmissions or return visits to the emergency department or urgent care setting before the first postoperative visit. In a subgroup analysis, there was no significant difference in wound complications or infections between nondiabetics and diabetics (P > .05) and traumatic and nontraumatic cases (P > .05).

Conclusions:

The use of IV TXA in foot and ankle surgeries was associated with low risk of wound complications, infections, hematoma formation, thromboembolic events, and overall complication rates with minimal side effect profile. Perioperative tranexamic acid use may prove to be beneficial in foot and ankle surgery patients but especially in higher-risk patients such as those with diabetes, trauma, and those that are immunocompromised.

Level of Evidence:

Level IV, case series.

Prophylaxis of Venous Thromboembolism in Ankle and Foot Surgeries

Venous thromboembolism (VTE) is among the most feared complications by orthopedists both for due to its potentially lethal outcome and the uncertainties related to its prevention. Despite the vast literature on VTE prevention in major orthopedic surgeries, little is known about it in ankle and foot procedures. In orthopedics, adequate thromboprophylaxis requires a careful assessment of the thrombotic and hemorrhagic risks based on the procedure to be performed, as well as and knowledge on anticoagulant agents. The presentis review has the goal of assessing the risk of developingdiscusses VTE risk assessment, the modalities of thromboprophylaxis modalities, and the drugs used, with an emphasis on foot and ankle surgeries.

Developing patient information and clinician education resources for venous thromboembolism in a physiotherapy department in response to the COVID-19 pandemic

Venous thromboembolism is a major contributor to global disease burden and is associated with significant morbidity and mortality. Physiotherapists often encounter people who are at elevated risk of venous thromboembolism, and as such are a vital part of an interdisciplinary approach to the prevention and management venous thromboembolism. In response to the COVID-19 pandemic, appropriate and accessible patient and clinician information resources regarding venous thromboembolism are of paramount importance, to facilitate safety netting and optimise health outcomes with minimal face-to-face contact. This article describes an interdisciplinary approach to the development of patient and clinician information resources within an acute hospital physiotherapy department in the UK. This was conducted with the intention of providing appropriate safety netting for patients at risk of lower extremity venous thromboembolism and to actively facilitate prevention, detection and early intervention.

Risk factors for symptomatic venous thromboembolism following surgery for closed ankle fractures: A case-control study

BACKGROUND

We analyzed risk factors for venous thromboembolism (VTE) within 6 months after surgery for closed ankle fractures.

METHODS

This was a case-control study based on data from chart review in a cohort of patients having open reduction and internal fixation (ORIF) for closed ankle fractures in two large general hospitals 2009-2011. Cases with symptomatic VTE (pulmonary embolism or deep venous thrombosis) were identified in the cohort, and additional cases of VTE were identified by computerized search of discharge diagnoses in the same hospitals in 2004-2008 and 2012-2016. In total, we identified 60 cases with VTE and compared with 240 randomly selected controls among 998 patients without VTE in the cohort. Risk factors were assessed using logistic regression analysis.

RESULTS

Among cases, 27 (45%) had pulmonary embolism, 33 (55%) deep venous thrombosis. Those with VTE were older, had higher BMI, had more often a family history of VTE, and more often had antibiotic prophylaxis during surgery than controls. In multivariable logistic regression analysis age/10 (OR 25.75, 95%CI 3.52-188.44, p=0.001), (age/10)² (OR 0.77, 95%CI 0.65-0.93, p=0.005), BMI (1.15 per kg/m², 95%CI 1.07-1.24, p<0.001) and Charlson comorbidity index ≥2 vs.0 (OR 0.27, 95%CI 0.08-0.92, p=0.036) and 1 vs. 0 (OR 0.27, 95%CI 0.09-0.86, p=0.026) were associated with VTE within 6 months of surgery.

CONCLUSIONS

The odds of symptomatic VTE within 6 months of ORIF increased with increasing age and BMI, but were lower with increasing comorbidity.

Thromboembolism prophylaxis in orthopaedic surgery and trauma

Thromboembolism prophylaxis is well-established in major orthopaedic surgery (hip and knee arthroplasty and hip fracture surgery), with low-molecular-weight heparins the most often chosen agent. In recent years, however, direct-acting anticoagulants have been gaining ground and can be used in this scenario (except for hip fracture surgery). In the US, even aspirin could be indicated for low-risk patients who undergo hip or knee arthroplasty. For other orthopaedic procedures (leg surgery below the knee, ankle and foot; knee arthroscopy; arm surgery; and spine surgery), thromboembolism prophylaxis requires individualisation based on the patient's risk factors and the surgery's characteristics, given that the risk of venous thromboembolic disease is minor. In this patient group, the agent of choice is low-molecular-weight heparin, given that direct-acting anticoagulants are not approved for these types of surgery.

Risk of Deep Vein Thrombosis After Acute Achilles Tendon Rupture: A Secondary Analysis of a Randomized Controlled Trial Comparing Early Controlled Motion of the Ankle Versus Immobilization

Background:

Immobilization of the ankle joint has been suggested as a key element in the pathogenesis leading to deep vein thrombosis (DVT).

Purpose:

To investigate whether early controlled ankle motion (ECM) could reduce the incidence of DVT compared with immobilization (IM) in the treatment of acute Achilles tendon rupture.

Study Design:

Randomized controlled trial; Level of evidence, 2.

Methods:

Patients aged 18 to 70 years were eligible for inclusion, and treatment was nonoperative. The ECM group performed movements of the ankle 5 times a day from weeks 3 to 8 after rupture. The control group was immobilized for 8 weeks. The outcome measure was DVT diagnosed with color Doppler ultrasound for above- and below-knee DVT at 2 and 8 weeks. The Achilles tendon Total Rupture Score, the heel-rise work test, and the Copenhagen Achilles ultrasonographic Length Measurement were performed at 4-, 6-, and 12-month follow-up.

Results:

A total of 189 patients were assessed for eligibility from February 2014 to December 2016. Of these, 130 were randomized: 68 patients were allocated to the ECM group and 62 to the IM group. All patients participated in follow-up at 8 weeks assessing for DVT. In total, 62 (47.7%) patients were diagnosed with DVT: 33 of 68 (48.5%) in the ECM group and 28 of 61 (46.8%) in the IM group (P = .84). DVT did not affect treatment outcomes at 4, 6, and 12 months. D-dimer had low sensitivity (71%) for detecting DVT.

Conclusion:

We found that 1 in 2 patients presented with DVT in nonoperative treatment of acute Achilles tendon rupture. The ECM protocol revealed no benefit versus IM in reducing the incidence of DVT. DVT did not influence functional and patient-reported outcomes the first year after rupture. D-dimer seems an inappropriate test for detection of DVT in patients with acute Achilles tendon rupture.

Registration:

NCT02015364 (ClinicalTrials.gov identifier).

Early mobilization does not reduce the risk of deep venous thrombosis after Achilles tendon rupture: a randomized controlled trial

PURPOSE

The hypothesis was that early functional mobilization would reduce the incidence of deep venous thrombosis (DVT) during leg immobilization after Achilles tendon rupture surgery. A secondary aim was to evaluate if the amount of weightbearing and daily steps influenced the risk of sustaining a DVT.

METHODS

One-hundred and fifty patients with Achilles tendon rupture repair were randomized to treatment with early functional mobilization, encouraging full weightbearing and ankle motion in orthosis, or treatment-as-usual, i.e., 2 weeks of unloading in plaster cast followed by 4 weeks weightbearing in orthosis. At 2 and 6 weeks postoperatively, all patients were screened for DVT using compression duplex ultrasound. During the first 2 weeks postoperatively, patient-reported loading, pain and step counts were assessed.

RESULTS

At 2 weeks, 28/96 (29%) of the patients in early functional mobilization group and 15/49 (31%) in the control group (n.s) had sustained a DVT. At 6 weeks, the DVT rate was 35/94 (37%) in the early functional mobilization and 14/49 (29%) in the control group (n.s). During the first postoperative week, the early functional mobilization group reported low loading and higher experience of pain vs. the control group (p = 0.001). Low patient-reported loading ≤ 50% (OR = 4.3; 95% CI 1.28-14.3) was found to be an independent risk factor for DVT, in addition to high BMI and higher age.

CONCLUSIONS

Early functional mobilization does not prevent the high incidence of DVT during leg immobilization in patients with Achilles tendon rupture as compared to treatment-as-usual. The low efficacy of early functional mobilization is mainly explained by postoperative pain and subsequent low weightbearing. To minimize the risk of DVT, patients should be encouraged to load at least 50% of body weight on the injured leg 1 week after surgery.

LEVEL OF EVIDENCE

Therapeutic, level 1.

Deep venous thrombosis after Achilles tendon rupture is associated with poor patient-reported outcome

PURPOSE

The aim of this study was to investigate whether patient subjective and functional outcomes after Achilles tendon rupture (ATR) are related to deep venous thrombosis (DVT) during leg immobilization.

METHODS

A cohort study with prospectively collected randomized data was conducted between 2010 and 2017. Two-hundred and fifty-one Patients with an Achilles tendon rupture (mean age = 41 ± 8), treated with uniform surgical techniques, were retrospectively analyzed. DVT incidence at 2 and 6 weeks was assessed using compression duplex ultrasound. At 12 months patient-reported outcomes were assessed using the Achilles tendon Total Rupture Score (ATRS), Foot- and Ankle Outcome Score (FAOS), Physical Activity Scale (PAS) and functional outcome with the calf-muscle endurance test. ANOVA analyses were used and adjusted for assumed confounding factors (patient age, sex, BMI and rehabilitation).

RESULTS

The total DVT incidence was 122 out of 251 (49%). Patients suffering a DVT exhibited significantly lower ATRS at 1 year compared to patients without DVT (mean 76 vs 83, 95% CI 71-79 vs 80-87; p < 0.01). Sixty-seven percent (95% CI 57-77%) of the patients devoid of DVT reported a good outcome (ATRS > 80) compared to 51% (95% CI 41-61%) of the patients sustaining a DVT (p < 0.05). Quality of life displayed significantly better outcome in the non-DVT versus DVT patients (mean = 75 (95% CI 71-79) vs. mean = 68 (95% CI 64-72); p < 0.05). A significant difference in total concentric work was observed between non-DVT and DVT patients (median = 1.9 kJ (IQR = 0.9 kJ) vs. median = 1.6 kJ (IQR = 1.0 kJ); p < 0.01).

CONCLUSION

Sustaining a DVT during leg immobilization significantly impairs patient-reported outcome at 1 year after surgical repair of ATR.

LEVEL OF EVIDENCE

III.

Incidence of Deep Venous Thrombosis Associated With Proximal Hamstring Rupture

Background:

Rates of deep venous thrombosis (DVT) have been studied for most common orthopaedic injuries. However, rates and risk factors have not been published for proximal hamstring injuries.

Purpose:

To determine the incidence of symptomatic DVT associated with proximal hamstring rupture and associations with prophylactic anticoagulation.

Study Design:

Case series; Level of evidence, 4.

Methods:

Inclusion criteria included all complete and, in a separate cohort, partial proximal hamstring ruptures treated by the senior author from 2007 through 2018 with at least 8 weeks of follow-up. Tendinopathy without tear was excluded. No DVT screening was performed. Charts of patients with symptomatic DVT were reviewed for the treatment method, the presence of imaging-confirmed DVT or pulmonary embolism, and risk factors for DVT. No patients received postinjury DVT prophylaxis. Surgical patients were routinely instructed to take aspirin (325 mg bid) or apixaban (2.5 mg bid) for 4 weeks. Patients with risk factors for DVT received enoxaparin (40 mg daily) for 2 weeks followed by aspirin (325 mg bid) for 2 weeks.

Results:

A total of 144 complete proximal hamstring ruptures were included: 132 treated operatively and 12 treated nonoperatively. There were 10 DVTs associated with the injury, for an overall rate of 6.9%. Five of the DVTs were diagnosed preoperatively in patients who had not received DVT prophylaxis; the other 5 were diagnosed postoperatively in patients on DVT prophylaxis. Six of the 10 DVTs had identifiable risk factors. All patients with postoperatively diagnosed DVTs were on prophylactic aspirin or enoxaparin. In the partial proximal hamstring rupture cohort of 114 ruptures, there were no DVTs.

Conclusion:

There is a high incidence of DVT associated with complete proximal hamstring ruptures (6.9%) despite many patients receiving DVT prophylaxis. This is substantially higher than that in other lower extremity injuries. Clinicians should have a high index of suspicion for DVT after these injuries, and postinjury DVT prophylaxis may be warranted.

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

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.

Symptomatic Venous Thromboembolism After Achilles Tendon Rupture: A Nationwide Danish Cohort Study of 28,546 Patients With Achilles Tendon Rupture

BACKGROUND

Venous thromboembolism (VTE) is a well-known complication of Achilles tendon rupture (ATR) and carries a high risk of morbidity and mortality. Although routine thromboprophylaxis for patients with ATR is not recommended, sparse knowledge is available regarding risk factors associated with VTE in patients with ATR.

PURPOSE

To use Danish nationwide registers to identify incidence rates for symptomatic VTE and risk factors associated with increased risk of developing VTE in patients with ATR.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

By crosslinking nationwide registers, we identified all patients with diagnosed ATR in Denmark from 1997 to 2015. We stratified patients into 4 groups by age and treatment modality (ie, operative vs nonoperative treatment). The main outcome was VTE within 180 days. We calculated crude incidence rates and considered age, sex, year, comorbidities, and medications as risk factors for VTE in Poisson regression models.

RESULTS

We identified 28,546 patients with ATR, of whom 389 (1.36%) were hospitalized with VTE during the follow-up period: 278 due to deep vein thromboses and 138 due to pulmonary embolism. Incidence rates were highest during the first month and ranged from 4.6 to 14.6 events per 100 person-years. VTEs were most frequent among nonoperatively treated patients aged ≥50 years. In Poisson regression analyses, having had VTE beforehand was associated with an increased risk of VTE, as was male sex in the nonoperative treatment group aged ≥50 years; among women <50 years of age, hormonal contraceptives led to a 4- to 6-fold higher risk of VTE compared with patients in the same group without the equivalent risk factor.

CONCLUSION

In this nationwide cohort of patients with ATR, 1.36% developed symptomatic VTE during follow-up. Hormonal contraception, previous VTE, older age group, and male sex increased the risk of VTE. Taken together, the results of the present study suggest that focus on risk stratification and initiatives to prevent VTE might be warranted. A randomized controlled trial could answer this question.

Acute Deep Venous Thrombosis and Pulmonary Embolism in Foot and Ankle Trauma in the National Trauma Data Bank: An Update and Reanalysis

The data regarding rates of deep venous thrombosis and pulmonary embolism after foot and ankle trauma remain sparse. In this study of the National Trauma Data Bank Data set (2007-2009 and 2010-2016), these rates were reexamined and risk factors associated with these complications were assessed. Data quality is improved in the later data set; the incidence of deep venous thrombosis and pulmonary embolism was 0.28% and 0.21%, respectively, in the 2010-2016 data. Prophylaxis, male gender, treatment in a university hospital, open reduction, chronic obstructive pulmonary disease, and hypertension were notable significant risk factors for pulmonary embolism. For deep venous thrombosis, male gender, bleeding disorder, angina, and prophylaxis were risk factors. Careful, individualized assessment of the risk factors associated with deep venous thrombosis and pulmonary embolism is important, and the merits of routine prophylaxis remain in question.

Long-Term Results With the Use of Modified Percutaneous Repair of the Ruptured Achilles Tendon Under Local Anaesthesia (15-Year Analysis With 270 Cases)

Controversy regarding the optimal treatment of fresh total Achilles tendon rupture remains. This article presents results with the use of modified percutaneous Achilles tendon repair under local anesthesia performed from January 1991 to December 2005 with a 2- to 10-year follow-up. There were 270 procedures in 247 male patients (92.51%) and 20 female patients (7.49%), mean ± SD age 38.7 ± 11.56 (range 20 to 83) years, in all consecutively treated patients within 7 days after acute total rupture; 3 patients sustained ruptures on both sides in different periods. Postoperative care consisted of wearing a cast or soft cast or functional immobilization for 6 weeks. The procedure was well tolerated in all patients. There were 3 (1.11%) complete and 5 (1.85%) partial repeat ruptures (8 [2.96%] altogether). Fourteen patients (5.18%) developed transient sural neuritis that spontaneously resolved in 2 to 10 months. One case (0.3%) of deep venous thrombosis was successfully treated. There were 25 (9.36%) major and minor complications altogether, with no cases of increased postoperative dorsiflexion, deep infection, or necrosis. Forty-four patients (16.48%) had a slightly decreased range of ankle motion, and 216 (80.89%) patients, including all high-caliber athletes, resumed all their previous activities. The mean American Orthopedic Foot and Ankle Society hindfoot-ankle score was 96.10 points. Long-term results of the analyzed modified method suggest a reasonable treatment option for acute total Achilles tendon ruptures, with a low number of complications and repeat rupture rate and return to preinjury activities comparable to those of open procedures.

Increased risk of deep venous thrombosis in patients with poor ankle dorsiflexion after lower limb immobilization

Objective

Many trauma patients are at risk of pulmonary embolism due to unrecognized deep vein thrombosis (DVT). Restricted ankle dorsiflexion (AD) range of motion during leg immobilization is known to cause reduced venous blood flow. The aim of the present study was to assess whether AD at plaster cast removal is related to the incidence of DVT and to patient outcome.

Design

Prospective observational cohort study.

Setting

Level 1 Trauma Center.

Patients

A total of 124 patients (97 men, 27 women; mean age 40.3 years) with plaster cast leg immobilization after surgical repair of Achilles tendon rupture were assessed.

Main outcome measures

At 2 weeks postoperatively, assessments of AD and the incidence of DVT using compression duplex ultrasound were performed with observers blinded to patient grouping. Patients were dichotomized into 2 groups; poor or good AD, according to the mean AD, -7°. At 3- and 12 months patient-reported outcome was examined using validated questionnaires (ATRS and FAOS), and functional outcome using the heel-rise test.

Results

Patients with poor AD sustained 42% DVTs, while patients with good AD exhibited a DVT-rate of 23% (P = .036). Logistic regression analysis corroborated this finding (OR = 2.62, P = .036; 95% CI = 1.06-6.44). AD was not linked to any long-term functional or patient-reported outcome.

Conclusions

Reduced AD after plaster cast removal is associated with a higher risk of DVT. The results of this observational study warrant further prospective studies to confirm the effects of ankle dorsiflexion on the risk of developing venous thromboses.Level of evidence: II.

Postoperative Complications Following Repair of Acute Achilles Tendon Rupture

BACKGROUND

Controversy remains regarding which patients with acute Achilles tendon rupture would best be treated nonoperatively and which might benefit from operative repair. The primary aim of this study was to characterize the overall incidence of-and specific risk factors associated with-postoperative complications that follow operative repair. We also evaluated the specific differences between complications after the use of an open or minimally invasive surgical (MIS) approach.

METHODS

Retrospective chart review identified 615 adult patients who underwent operative repair for an acute Achilles tendon rupture between January 1, 2001, and May 1, 2016, at 3 level I trauma centers. Minimum follow-up was 3 months. Patient demographics, comorbidities, injury mechanism, procedural details, and surgeon subspecialty were collected. Assessed complications included wound healing issues, rerupture, hematoma, nerve injury, deep vein thrombosis, and pulmonary embolism.

RESULTS

Seventy-two patients (11.7%) developed a postoperative complication. Risk factors included advancing patient age (odds ratio [OR], 1.04, P = .007), active tobacco use (OR, 3.20, P = .007), and specific subspecialty training (OR, 2.04, P = .046). No difference in overall complication rate was found between the open and MIS approaches (11.6% vs 13.2%, P = .658). A subgroup analysis among orthopedic subspecialties demonstrated that patients treated by trauma surgeons had increased rates of wound complication ( P = .043) and rerupture ( P = .025) compared with those treated by other subspecialties. Patients treated by trauma surgeons were also more likely to be younger or have a body mass index (BMI) > 30, although neither factor was found to be independently predictive for postoperative complications.

CONCLUSION

Approximately 1 in 9 patients undergoing operative repair of an acute Achilles tendon rupture developed a postoperative complication. Advancing age and active tobacco use were independent risk factors for developing such complications. Differences in subspecialty training also appear to impact complication rates, but the potential reason for this discrepancy remains unclear. As controversy remains regarding which patients who sustain acute Achilles tendon rupture should be treated nonoperatively and which would benefit most from surgical repair, a better understanding of postoperative complication rates and associated risk factors may enhance the decision-making processes in treating these injuries. It is not clear whether MIS techniques are superior to traditional open repair in terms of postoperative complications.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

A ten-year retrospective study investigating the rate of venous thromboembolism in patients who require immobilization in a total contact lower limb cast

Aims

To our knowledge, there is currently no information available about the rate of venous thromboembolism (VTE) or recommendations regarding chemoprophylaxis for patients whose lower limb is immobilized in a plaster cast. We report a retrospective case series assessing the rate of symptomatic VTE in patients treated with a lower limb cast. Given the complex, heterogeneous nature of this group of patients, with many risk factors for VTE, we hypothesized that the rate of VTE would be higher than in the general population.

Patients and Methods

Patients treated with a lower limb cast between 2006 and 2018 were identified using plaster room records. Their electronic records and radiological reports were reviewed for details about their cast, past medical history, and any VTE recorded in our hospital within a year of casting.

Results

There were 136 episodes of casting in 100 patients. The mean age was 55 years (22 to 91). The mean time in a cast was 45 days (five days to eight months). A total of 76 patients had neuropathy secondary to diabetes. No patient received chemical thromboprophylaxis while in a cast. One VTE (0.7% of casting episodes) was documented. This was confirmed by Doppler scan nine days after removing the cast.

Conclusion

The frequency of VTE was higher than that of the general population (0.05%); this is most likely attributable to our patients’ apparent increase in VTE risk as suggested by The National Institute for Health and Care Excellence (NICE). These findings suggest that thromboprophylaxis is not routinely indicated in patients who undergo immobilization of the lower limb in a cast, although the risks of VTE should be assessed. While the cast itself does not pose an increased risk, other pathologies, such as active cancer, mean that each individual case needs to be considered on their merit. Cite this article: Bone Joint J 2019;101-B:691–694.

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

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.

LEVEL OF EVIDENCE

Therapeutic study level III.

Venous Thromboembolism and Bleeding Adverse Events in Lower Leg, Ankle, and Foot Orthopaedic Surgery with and without Anticoagulants

BACKGROUND

Currently, there is insufficient knowledge about the benefits of anticoagulant use for primary prevention of venous thromboembolism (VTE) and its inherent risk of bleeding adverse events in patients undergoing surgery distal to the knee.

METHODS

The study included patients who had undergone an orthopaedic procedure distal to the tibial articular surface when they were 18 years of age or older. Using retrospective information from a tertiary care referral center, we compared patient demographics, clinical findings, diagnostic reports, procedures performed, and the rate of symptomatic VTE and bleeding adverse events between patients who had and those who had not received anticoagulant prophylaxis. Propensity score matching was used to minimize selection bias due to prophylactic treatment allocation.

RESULTS

A total of 5,286 patients who had received anticoagulant prophylaxis for below-the-knee surgery were successfully matched with 5,286 patients who had not received anticoagulant prophylaxis for such surgery. After propensity score matching, the standardized difference between the groups was <0.1 for all baseline characteristics, indicating a negligible difference between the groups. Patients who received anticoagulant prophylaxis had a significantly lower risk of developing a VTE compared with patients who did not (39 patients [0.7%] versus 99 patients [1.9%]), with an odds ratio (OR) of 0.38 (95% confidence interval [CI], 0.25 to 0.56; p < 0.001). In contradistinction, patients who received anticoagulant prophylaxis had a significantly higher risk of developing a bleeding adverse event than those who did not (115 [2.2%] versus 55 [1.0%]; OR, 2.18 [95% CI, 1.55 to 3.09]; p < 0.001).

CONCLUSIONS

Anticoagulant prophylaxis reduced the risk of VTE after surgery distal to the tibial articular surface by 3-fold but resulted in a concomitant 2-fold increase in the risk of a bleeding adverse event. Large-scale, prospective studies are necessary to better understand the true incidence of such events, associated patient-specific risk factors, efficacy of various thromboprophylactic regimens, and patient-reported implications of such events.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Retrospective cohort study on the risk factors of deep vein thrombosis (DVT) for patients with traumatic fracture at Honghui Hospital

OBJECTIVE

To explore the risk factors of perioperative deep vein thrombosis (DVT) in patients with traumatic fracture after orthopaedic surgery and their potential diagnostic values in clinical.

DESIGN

Retrospective cohort study.

SETTING

Clinical Laboratory of Honghui Hospital, Xi'an JiaoTong University College of Medicine, Xi'an, Shaanxi, China.

MATERIALS AND METHODS

A retrospective cohort study was conducted with surgically treated fracture patients in Honghui Hospital from 1 May 2016 to 31 February 2017. χ² test, independent sample t test and regression analysis were applied to examine the correlation between perioperative DVT and the factors of preoperative time, fracture sites, D-dimer value and chronic diseases (hypertension, diabetes and coronary disease).

RESULTS

462 patients were enrolled for analysis. The preoperative time of patients with DVT was significantly longer than that of non-DVT patients (7.14±5.51 vs 5.45±3.75) (P<0.01). χ² test showed the significant differences in the rate of DVT among patients with different fracture sites (P<0.01). By the receiver-operating characteristic curve analysis, the cut-off value of preoperative D-dimer and postoperative D-dimer in diagnosing perioperative DVT was 4.01 µg/mL and 5.03 µg/mL, respectively. Area under the curve was 0.593 (95% CI 0.533 to 0.652) and 0.728 (95% CI 0.672 to 0.780), respectively. The sensitivity and specificity of preoperative D-dimer for DVT diagnosis were 71.30% and 44.83%, and as for postoperative D-dimer were 63.90% and 70.51%.

CONCLUSIONS

Fracture site was correlated to the incidence of DVT; prolonged preoperative time and increased D-dimer value were independent risk factors for DVT in patients with lower extremity traumatic fractures.

Prevalence of Deep Vein Thrombosis in Low-Risk Patients After Elective Foot and Ankle Surgery

BACKGROUND:

The evidence regarding the prevalence of deep vein thrombosis (DVT) after foot and ankle surgery in elective patients that need to be 6 weeks non-weight bearing postoperatively is incomplete and has limitations.

METHODS:

The prevalence of DVT in 114 procedures involving the hindfoot and midfoot was determined using ultrasonographic surveillance at 2 and 6 weeks after surgery.

RESULTS:

The prevalence of DVT was observed to be 25.4%. The majority (68.9%) of DVTs were diagnosed at the ultrasonographic scan performed 2 weeks postoperatively. The remainder (31.1%) of DVTs were diagnosed at the 6-week postoperative ultrasonographic scan. At least 75% of the patients who had early and late DVT had no clinical symptoms or signs of DVT. The prevalence of DVT in clinically detectable patients was 6%. The average age of patients with early DVT was 62.2 years, significantly higher compared to those who had no DVT. The mean tourniquet time for patients with early DVT was 68.1 minutes, significantly higher compared to those without DVT. All DVTs detected were distal to the popliteal vein.

CONCLUSIONS:

The prevalence of clinically silent DVT was significantly higher than was previously thought. We believe this increased rate is directly attributable to the use of ultrasonographic surveillance postsurgery both at 2 and 6 weeks. The risk of DVT continued after the 2-week visit, and 30% of the DVTs were detected at the ultrasonographic scan at 6 weeks.

LEVEL OF EVIDENCE:

Level II, prospective cohort.

Incidence and Risk Factors of Symptomatic Venous Thromboembolism Following Foot and Ankle Surgery

BACKGROUND:

The incidence rate of venous thrombotic events (VTEs) following foot and ankle surgery is low. Currently, there is no consensus regarding postoperative prophylaxis or evidence to support risk stratification.

METHODS:

A 2-part study assessing the incidence and factors for the development of VTE was conducted: (1) a retrospective observational cohort study of 22 486 adults to calculate the overall incidence following foot and/or ankle surgery from January 2008 to May 2011 and (2) a retrospective matched case-control study to identify risk factors for development of VTE postsurgery. One control per VTE case matched on age and sex was randomly selected from the remaining patients.

RESULTS:

The overall incidence of VTE was 0.9%. Predictive risk factors in bivariate analyses included obesity, history of VTE, history of trauma, use of hormonal replacement or oral contraception therapy, anatomic location of surgery, procedure duration 60 minutes or more, general anesthesia, postoperative nonweightbearing immobilization greater than 2 weeks, and use of anticoagulation. When significant variables from bivariate analyses were placed into the multivariable regression model, 4 remained statistically significant: adjusted odds ratio (aOR) for obesity, 6.1; history of VTE, 15.7; use of hormone replacement therapy, 8.9; and postoperative nonweightbearing immobilization greater than 2 weeks, 9.0. The risk of VTE increased significantly with 3 or more risk factors ( P = .001).

CONCLUSION:

The overall low incidence of VTE following foot and ankle surgery does not support routine prophylaxis for all patients. Among patients with 3 or more risk factors, the use of chemoprophylaxis may be warranted.

LEVEL OF EVIDENCE:

Level III, retrospective case series.