Risk of postoperative venous thromboembolism in Indian patients sustaining pelvi-acetabular injury

Incidence of deep vein thrombosis and symptomatic pulmonary embolism in Taiwanese patients with pelvic and/or acetabular fractures: a retrospective study

Venous thromboembolism (VTE) is common in patients with trauma, and thromboprophylaxis has been advocated. However, conflicting results regarding VTE rates in the Asian population following orthopaedic procedures have been presented. We aimed to investigate the VTE incidence in Taiwanese patients with pelvic and/or acetabular fractures and identify the associated risk factors. We included 402 patients who underwent surgery for pelvic and/or acetabular fractures. All patients received mechanical thromboprophylaxis with graduated compression stockings. Duplex scanning was performed postoperatively or during follow-up when signs or symptoms of deep vein thrombosis (DVT) developed. Variables with a significance level of ≤ 0.1 in the univariate analyses were introduced into the multivariate logistic regression analysis to identify DVT risk factors. The overall DVT and symptomatic pulmonary embolism (PE) rate was 3.48% (14/402 patients). Among patients with DVT, 46.1% were asymptomatic. Patients with VTE were significantly older than those without. Multivariate logistic regression analysis revealed that age was a VTE risk factor. The incidence of DVT and symptomatic PE in our cohort was low. Advanced age was a risk factor for VTE. These findings could help clinicians develop appropriate prevention and treatment strategies for VTE in Taiwanese patients with pelvic and/or acetabular fractures.

Perioperative management of acetabular and pelvic fractures: evidence-based recommendations

PURPOSE

The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and consolidate the relevant historical and recent literature in important topics pertaining to perioperative management of PAF.

METHODS

A thorough literature review using PubMed, Cochrane and Embase databases was performed to assess preoperative, intraoperative and postoperative management of PAF fracture. Topics reviewed included: time from injury to definitive fixation, the role of inferior vena cava filters (IVCF), tranexamic acid (TXA) use, intraopoperative cell salvage, incisional negative pressure wound therapy (NPWT), intraoperative antibiotic powder use, heterotopic ossification prophylaxis, and pre- and postoperative venous thromboembolism (VTE) prophylaxis.

RESULTS

A total of 126 articles pertaining to the preoperative, intraoperative and postoperative management of PAF were reviewed. Articles reviewed by topic include 13 articles pertaining to time to fixation, 23 on IVCF use, 14 on VTE prophylaxis, 20 on TXA use, 10 on cell salvage, 10 on iNPWT 14 on intraoperative antibiotic powder and 20 on HO prophylaxis. An additional eight articles were reviewed to describe background information. Five articles provided information for two or more treatment modalities and were therefore included in multiple categories when tabulating the number of articles reviewed per topic.

CONCLUSION

The literature supports the use of radiation therapy for HO prophylaxis, early (< 5 days from injury) surgical intervention and the routine use of intraoperative TXA. The literature does not support the routine use of iNPWT or IVCF. There is inadequate information to make a recommendation regarding the use of cell salvage and wound infiltration with antibiotic powder. While the routine use of chemical VTE prophylaxis is recommended, there is insufficient evidence to recommend the optimal agent and duration of therapy.

Risk factors for venous thromboembolism in patients with spinal cord injury: A systematic review and meta-analysis

CONTEXT

Patients with spinal cord injury (SCI) are at high risk for venous thromboembolism (VTE). The risk factors for VTE in patients with SCI are complex.

OBJECTIVE

This meta-analysis was conducted to clarify the risk factors for VTE in patients with SCI.

METHODS

The Cochrane Library, PubMed, EBSCO, Web of Science, China National Knowledge Infrastructure (CNKI), China Biomedical Literature Database (CBM), Wanfang Med Data Database, and VIP Database were searched to identify studies reporting on risk factors for VTE in patients with SCI.

RESULTS

The meta-analysis included 25 studies. Findings showed that risk of VTE in patients with SCI was significantly associated with middle- and old-age (OR = 2.08, 95%CI, 1.47, 2.95), male sex (OR = 1.41, 95%CI, 1.26, 1.59), complete paralysis (OR = 3.69, 95%CI, 2.60, 5.24), personal/family history of venous thrombosis (OR = 1.95, 95%CI, 1.35, 2.81), history of smoking (OR = 2.67, 95%CI, 1.79, 3.98), lack of compression therapy (OR = 2.44, 95%CI, 1.59, 3.73), presence of lower limb/pelvic fracture (OR = 3.47, 95%CI, 1.79, 6.75), paraplegia (OR = 1.81, 95%CI, 1.49, 2.19), and diabetes (OR = 4.24, 95%CI, 2.75, 6.52).

CONCLUSION

The meta-analysis identified 9 risk factors for VTE in patients with SCI. Healthcare providers should be aware of the risk factors for VTE when rehabilitating patients with SCI.

Safety and efficacy of perioperative tranexamic acid infusion in acetabular fracture fixation: A randomized placebo-controlled double-blind prospective study

INTRODUCTION

Open reduction and internal fixation of acetabular fracture is associated with significant blood loss. Although Tranexamic acid (TXA) infusion effectively reduces perioperative blood loss and transfusion requirements in elective orthopedic surgery, its efficacy in major orthopedic trauma surgery is controversial.

MATERIAL AND METHODS

Sixty-three patients undergoing open reduction and internal fixation of acetabular fracture were randomized into either TXA (n = 36) or placebo (n = 27) group. TXA group received a bolus dose of TXA (10 mg/kg) 15 min prior to incision, followed by another similar dose after 3 h of surgery. The placebo group received the same volume of normal saline similarly. All patients were operated on by a single pelviacetabular surgeon with a uniform perioperative protocol. The intraoperative blood loss, drain output, the number of blood transfusions, postoperative hemoglobin (Hb) drop, and hematocrit (Hct) drop were calculated.

RESULTS

Both groups were similar in relation to age, sex, BMI, preoperative Hb, the timing of surgery, fracture pattern, operative time, and surgical approaches. The mean postoperative Hb was 10.35 ± 1.36 gm% in TXA group and 9.74 ± 1.98 gm% in placebo group (p-value 0.158). There were no differences in intraoperative blood loss (438.11 ml vs. 442.81, p=.947), drain output (131.94 ml vs. 129.63, p=.870), and blood transfusion (8 patients vs. five patients, p=.719) between the groups. The drop in Hb and Hct in the postoperative period was also statistically not significant between the groups.

CONCLUSION

There is no significant reduction in blood loss and blood transfusion with the use of intravenous Tranexamic acid in open reduction and internal fixation of acetabular fractures.

Thromboembolic events in pelvic and acetabulum fractures: a systematic review of the current literature on incidence, screening, and thromboprophylaxis

PURPOSE

Rates of venous thromboembolic events (VTEs) as high as 41% deep vein thrombosis (DVT) were reported in association with pelvic and acetabular fractures (PAFs). There is no clear consensus on VTE prophylaxis for PAFs. Extracting evidence-based guidelines is key to overcome this challenging complication. The aims of this review are (A) to highlight the incidence of VTEs in PAFs, (B) to examine the screening and prophylaxis methods available in the current literature, and (C) direct future creation of a best practice protocol to reduce the risk of VTE in PAFs.

METHODS

We performed a systematic search of Medline, EMBASE databases, and the Cochrane library. MESH terms were used to identify studies pertinent to VTE in PAFs, including incidence, prophylaxis, and screening.

RESULTS

In total, 28 studies were identified and grouped into four categories including incidence, screening, prophylaxis, and the use of inferior vena cava filters (IVCFs). Incidence of VTE ranged from 0.21 to 41% for DVT and 0 to 21.7% for PE. Nine studies screened 1360 patients using different imaging modalities. Ten articles, 2836 patients, examined different thromboprophylaxis protocols. Two out of three studies investigating the use of IVCF showed significant reduction of the rates of PE.

CONCLUSION

Incidence of VTE in PAF varies significantly with different protocols. The current literature shows that screening is still controversial. The combination of chemical and mechanical prophylaxis starting at 24 hours from the injury would provide the best protection. Guidelines were extracted; however, higher level multicenter studies are still required to guide future protocols.

Incidence and risk factors of preoperative deep venous thrombosis following pelvic and acetabular fractures: a retrospective case–control study

The objective of this study was to investigate the prevalence of preoperative deep venous thrombosis (DVT) in the pelvic cavity and lower extremities following pelvic and acetabular fractures and to identify the risk factors of the occurrence of DVT. Duplex ultrasound (DUS) screening and blood tests were conducted in patients admitted from June 2012 to December 2020 for surgical treatment of pelvic and acetabular fractures. Univariate analyses were performed on data of demographics, comorbidities, time from injury to surgery, injury mechanism, accompanied injury, and laboratory results. The optimal cutoff values of continuous variables with statistical significance were obtained by using the receiver operating characteristic (ROC) curve. A multivariate logistic regression analysis was then employed to examine the independent values in terms of predicting preoperative DVT. A total of 607 patients with pelvic and acetabular fractures were included, among whom 82 (13.5%) patients sustained preoperative DVTs. Specifically, 31.7% (26/82) were diagnosed with proximal DVTs. Fifty-two (63.4%) patients had DVT within 7 days after injury, and 67 (81.7%) patients within 10 days. The multivariate logistic regression analysis identified 6 factors independently associated with the presence of preoperative DVT, including age > 46 years (odds ratio [OR] = 2.94), BMI > 26.73 kg/m2 (OR = 3.91), time from injury to surgery > 9 days (OR = 5.39), associated injury (OR = 7.85), ALB < 32.8 g/L (OR = 2.71) and FIB > 3.095 g/L (OR = 3.34). Despite the modern prophylactic regimen, the preoperative DVT in patients with pelvic and acetabular fractures still draws the attention of orthopaedic surgeons. Better understanding these risk factors can help surgeons refine the risk stratification profile and perform early interdisciplinary management for patients at high risk of DVT.

Relationship Between the Incidence of Deep Vein Thrombosis During Hospitalization and the Energy of Injury in Tibial Plateau Fractures

This study aimed to investigate the relationship between the incidence of deep vein thrombosis (DVT) during hospitalization and the energy of injury in tibial plateau fractures (TPFs). One hundred and forty patients were enrolled between September 1, 2014, and October 1, 2017. According to Schatzker's classification, they were classified into the low-energy (type I-III) and high-energy (type IV-VI) groups. For DVT evaluation, duplex ultrasonography was performed in the lower extremities preoperatively and postoperatively. The location and changes of DVT were recorded. All patients underwent mechanical and chemical thromboprophylaxis. The incidence of DVT in TPFs was 36.43% and 46.43% preoperatively and postoperatively, respectively. The DVT incidence was 31.75% (20/63) in the low-energy group and 40.26% (31/77) in the high-energy group preoperatively, and 44.44% (28/63) in the low-energy group and 48.05% (37/77) in the high-energy group postoperatively. There was no significant difference between the 2 groups preoperatively (P = .298) and postoperatively (P = .785). The days between operation and discharge (P = .016), blood loss during surgery (P = .016), and preoperative d-dimer level (P = .02) showed differences between the 2 groups. Additionally, 29 new thrombi (14 [48.28%] in the high-energy group and 15 [51.72%] in the low-energy group) appeared and 16 preoperative thrombi disappeared postoperatively. Despite mechanical and chemical thromboprophylaxis, the DVT risk in patients with TPFs remains high. Although the DVT incidence is not significantly different between high-energy and low-energy injuries, the occurrence of DVT should be carefully monitored.

Factors affecting quality of life after pelvic fracture

INTRODUCTION

Functional outcome and health-related quality of life (HRQOL) after pelvis fracture is suboptimal; majority of the patients do not return to their preinjury activities. Many researchers reported that late morbidity in pelvis fracture is associated with severity of the fracture, associated trauma, pelvic fracture-related complications and methods of treatment.

MATERIAL AND METHODS

One hundred and twelve patients with pelvis fracture who were treated either conservatively (n = 88) or surgically (n = 24) with a minimum of two years follow up were evaluated clinically and radiologically. The clinical outcome was evaluated using Majeed score and self-reported Short Musculoskeletal Function Assessment (SMFA). Their HRQOL was evaluated using the 36-item Short Form Survey (SF-36) and WHOQOL-BREF questionnaires. The fracture-displacement in the anterior or posterior pelvis ring was measured from the anteroposterior radiograph or inlet/outlet view.

RESULTS

The average Majeed score was 76.65 ± 14.73 (range, 36 to 96). There were 81 patients with good to excellent outcomes and 31 patients with poor to fair outcomes. The average SF-36 Physical Component Summary (PCS) score was 47.71 ± 7.88 (range, 27.3 to 61.5) and SF-36 Mental Component Summary (MCS) was 49.20 ± 9.37 (range, 23.1 to 56.8). The functional level of the general population in the physical and mental domain was achieved in 48.23% and 65.3% of pelvic-fractured patients respectively. General population norms were achieved in 56.3%, 63.4%, 65.2% and 84.8% of patients in WHOQOL-BREF domain one, two, three and four respectively. The patients had significantly worse functional outcome and HRQOL if residual displacement was > 1 cm. Age, sex, associated injuries and injury mechanism were not affecting the HRQOL in patients with acceptable residual displacement of ≤ 1 cm.

CONCLUSION

Pelvic fracture with the residual displacement of ≤ 1 cm in the sacroiliac joint/symphysis pubis result in better functional outcome and HRQOL. Injury mechanism and associated injury have no impact on the HRQOL if the residual displacement is within the acceptable limit.

Guidelines for the prevention of venous thromboembolism in hospitalized patients with pelvi-acetabular trauma

BACKGROUND

Venous thromboembolism is a dreaded complication leading to increased morbidity and mortality in patients having pelvi-acetabular fractures.

OBJECTIVES

These evidence based guidelines aim to provide the decision making ability in the prevention of venous thromboembolism in patients with pelvi-acetabular trauma planned for operative or non operative treatment.

METHODS

The patients were subclassified into 5 categories. The PICO framework was used to devise research questions in each category. The systematic reviews were performed for each research question. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess outcomes of critical interest. The guideline panel consisting of expert members of different subspecialties, analyzed the evidence and made recommendations.

RESULTS

The guideline panel proposed 21 recommendations. There are five recommendations in category 1 to 3, two recommendations in category 4 and four recommendations in category 5.

CONCLUSION

In pelvi-acetabular fractures there is strong evidence to suggest that thromboprophylaxis should be given. It should be initiated as early as possible after control of hemorrhage. The chemical prophylaxis is the preferred mode and LMWH is the preferred agent of choice. The mechanical methods can be used as an adjunct. The routine prophylactic use of IVC filters is not recommended. However, the use of retrievable IVC filters in high risk patients with established VTE in preoperative period can be considered. The use of newer directly acting oral anticoagulants is gaining importance.

Incidence and Risk Factors of Deep Vein Thrombosis in Patients With Pelvic and Acetabular Fractures

This study aimed to investigate the incidence and risk factors for deep vein thrombosis (DVT) in patients with pelvic and acetabular fractures. Patients with pelvic or acetabular fractures were included. Demographic data, fracture classification, time to surgery, and d-dimer levels at admission and one day after surgical intervention were recorded. Duplex ultrasonography was performed in the lower extremities for DVT evaluation. All patients received mechanical and chemical thromboprophylaxis. One hundred ten patients with a mean age of 44.2 ± 13.8 years were included. There were 48 patients with pelvic fractures and 62 patients with acetabular fractures. Thirty-two (29.09%) patients sustained DVT; 21 (19.09%) patients exhibited proximal thrombosis, and 3 patients suffered pulmonary embolism. The incidence of DVT in patients with acetabular fractures was significantly higher than that of patients with pelvic fractures (χ² = 4.42, P = .04). The incidence of proximal DVT was significantly higher in patients with complex acetabular fractures than in patients with simple acetabular fractures (χ² = 6.65, P = .01). Multivariate analysis showed that age older than 60 years, associated injuries, and the time to surgery longer than 2 weeks were independent risk factors (P < .05). Despite mechanical and chemical thromboprophylaxis, the risk of DVT in patients with pelvic and acetabular fractures is still very high, and most of the thromboses were localized proximally. The risk of DVT is higher in patients older than 60 years, in those with associated injuries, and when the time from injury to operation is more than 2 weeks.

Correlation of Interleukin-18 and High-Sensitivity C-Reactive Protein with Perioperative Deep Vein Thrombosis in Patients with Ankle Fracture

BACKGROUND

In the present study, we aimed to inspect the correlation of interleukin-18 (IL-18) and high-sensitivity C-reactive protein (hs-CRP), if any present, with the occurrence of perioperative deep vein thrombosis (DVT) in patients suffering from an ankle fracture (AF).

METHODS

Sixty-seven AF patients with complicated DVT (DVT group) and 448 AF patients without DVT (non-DVT group) were enrolled in the present study. To begin with, hemorheological indexes were detected. Turbidimetric immunoassay and enzyme-linked immunosorbent assay were used for the determination of the expressions of hs-CRP and IL-18, respectively. Coagulation method was used to detect prothrombin time (PT), thrombin time (TT), fibrinogen, and activated partial thromboplastin time (APTT). Logistic regression analysis was used to analyze the independent risk factors for DVT occurrence in AF patients after operation.

RESULTS

The results revealed that the DVT group presented an increased expression of hs-CRP and IL-18 1 day before operation and 1, 3, and 7 days after operation in comparison with the non-DVT group. The DVT group also had increased levels of PT, APTT, and prolonged TT and fibrinogen at 3 and 7 days after operation compared to the non-DVT group. After operation, it was observed that the patients in the DVT group had increased plasma viscosity, whole blood reduced viscosity, red blood cell (RBC) aggregation index, RBC deformation index, erythrocyte sedimentation rate, and declined erythrocrit. The independent risk factors for the occurrence of DVT were identified to be high-energy injury, TT, fibrinogen, hs-CRP, and IL-18 in AF patients after operation.

CONCLUSIONS

Based on the results obtained from the study, it was concluded that AF patients with DVT have higher levels of IL-18 and hs-CRP expressions, which is associated with the occurrence and development of DVT. These results may be particularly useful for diagnosis and treatment on DVT occurrence in AF patients.

Prevalence of deep vein thrombosis in patients with lower limb trauma

INTRODUCTION

Venous thrombo-embolism (VTE), which consists of deep vein thrombosis (DVT) and pulmonary embolism, is a potentially fatal condition. According to Western literature, DVT of lower limb veins is one of the most common complications following surgeries for lower limb. Few studies have been published from India on the subject and little is known about the true prevalence of the DVT and hence there are no clear guidelines regarding the prophylaxis for DVT for Indian patients.

MATERIALS AND METHOD

We carried out a prospective study to determine the prevalence of DVT in 125 patients with lower limb trauma. All the patients underwent Colour Doppler pre-operatively, 4th post-operative day, at 3rd month post operatively and at 6th month post operatively only in patients who remained DVT positive at 3rd month post operatively, to see for the recanalisation. No mechanical or chemical form of DVT prophylaxis was used in DVT negative patients either pre-operatively or post-operatively.

RESULTS

In our series of 125 patients, 107 were males and 18 females (M:F = 5.9:1). Majority of our DVT positive patients were above 60 years of age. Out of 47 patients with periacetabular fractures, 8.51% developed DVT. Out of 8 patients with floating knee injury, 25% developed DVT. Combination of risk factors rather than a single risk factor had played important role for development of DVT in our study. 6 patients were DVT positive (4.8%). Amongst them 3 (2.4%) had proximal DVT and 3 (2.4%) had distal DVT. There was single case of pulmonary embolism (PE).

Methods and Guidelines for Venous Thromboembolism Prevention in Polytrauma Patients with Pelvic and Acetabular Fractures

Sequential compression devices and chemical prophylaxis are the standard venous thromboembolism (VTE) prevention for trauma patients with acetabular and pelvic fractures. Current chemical pharmacological contemplates the use of heparins or fondaparinux. Other anticoagulants include coumarins and aspirin, however these oral agents can be challenging to administer and may need monitoring. When contraindications to anticoagulation in high-risk patients are present, prophylactic inferior vena cava filters can be an option to prevent pulmonary emboli. Unfortunately strong evidence about the most effective method, and the timing of their commencement, in patients with pelvic and acetabular fractures remains controversial.

The incidence and the risk factors of venous thromboembolism in Korean patients with pelvic or acetabular fractures

BACKGROUND

Pelvic ring and acetabular fractures are the results of high energy trauma, but there is a paucity of information available regarding the incidence and risk factors of venous thromboembolism (VTE) after these injuries in Asians. This study was undertaken to evaluate the incidence of VTE after a pelvic or an acetabular fracture and to identify predictive factors.

METHODS

A prospective evaluation was performed by indirect computed tomography (CT) venography in patients with pelvic or acetabular fractures. Ninety-five patients were examined by indirect CT venography. Fifty-five patients suffered from a pelvic ring injury (anteroposterior compression 5, lateral compression 25, vertical shear 25), and the remaining 40 from acetabular fractures (simple 18, complex 22). Indirect CT venography was performed within 1-2 weeks of initial trauma. Relationships between VTE and sex, age, fracture pattern, body mass index, injury severity score, period of immobilization, and need for surgical treatment were analyzed. Deep vein thrombosis (DVT) in a more proximal to popliteal vein and the existence of PE were considered clinically significant.

RESULTS

Thirty-two patients (33.7 %) were found to have VTE at an average of 11 days after initial injury. Clinically significant DVT was found 20 cases (21.1 %). No statistical difference was found between pelvic ring injuries and acetabular fractures with respect to the development of VTE. For those with pelvic ring injury, the incidence of VTE in those with a vertical shear injury (52 %) was significantly greater than in others with a pelvic ring injury (p = 0.014). Patients with an age >50 were found to be at greater risk of VTE (p = 0.032).

CONCLUSION

Our findings demonstrate that Korean patients with pelvic or acetabular fractures have a higher risk of VTE than is generally believed, and caution should be taken to prevent and treat VTE, especially in high energy pelvic ring injury and elderly patients.

Risk factors and distribution of symptomatic venous thromboembolism in total hip and knee replacements: prospective study

PURPOSE

Venous thromboembolism (VTE) is a common complication of orthopaedic surgery in the industrialised world; though there may be variability between population groups. This study aims to define the incidence and risk factors for symptomatic VTE following primary elective total hip and knee arthoplasty surgery in a single centre in Eastern Europe.

METHODS

This prospective study included 499 adult patients undergoing total hip and knee arthroplasty for symptomatic osteoarthritis over a two-year period at the Clinic of Orthopaedic Surgery and Traumatology, Belgrade.

RESULTS

The overall rate of confirmed symptomatic VTE during hospitalisation was 2.6%. According to the univariate logistic regression, an age greater than 75 years (OR = 3.08; 95%CI = 1.01-9.65), a family history of VTE (OR = 6.61; 95% CI = 1.33-32.90), varicose veins (OR = 3.13; 95% CI = 1.03-9.48), and ischemic heart disease (OR = 4.93; 95% CI = 1.61-15.09) were significant risk factors for in-hospital VTE. A family history of VTE and ischemic heart disease were independent risk factors according to multivariate regression analysis. Preoperative initiation of pharmacological thromboprophylaxis (p = 0.03) and a longer duration of thromboprophylaxis (p = 0.001) were protective for postoperative DVT. Though thromboprophylaxis was safe, with very few patients suffering major haemorrhage or heparin-induced thrombocytopenia, there was a general reluctance by our local surgeons to use prolonged thromboprophylaxis.

CONCLUSION

VTE is common following hip and knee arthroplasty surgery. Orthopaedic patients with a family history of VTE, heart failure and coronary heart disease are at a considerable risk of thromboembolic complications in the postoperative period. There may be a role for preoperative thromboprophylaxis in addition to prolonged postoperative treatment.