Thromboembolic Disease After Orthopedic Trauma

Comparative study of two models predicting the risk of deep vein thrombosis progression in spinal trauma patients after operation

OBJECTIVE

Patients with preoperative deep vein thrombosis (DVT) exhibit a notable incidence of postoperative deep vein thrombosis progression (DVTp), which bears a potential for silent, severe consequences. Consequently, the development of a predictive model for the risk of postoperative DVTp among spinal trauma patients is important.

METHODS

Data of 161 spinal traumatic patients with preoperative DVT, who underwent spine surgery after admission, were collected from our hospital between January 2016 and December 2022. The least absolute shrinkage and selection operator (LASSO) combined with multivariable logistic regression analysis was applied to select variables for the development of the predictive logistic regression models. One logistic regression model was formulated simply with the Caprini risk score (Model A), while the other model incorporated not only the previously screened variables but also the age variable (Model B). The model's capability was evaluated using sensitivity, specificity, positive predictive value, negative predictive value, accuracy, F1 score, and receiver operating characteristic (ROC) curve. Nomograms simplified and visually presented Model B for the clinicians and patients to understand the predictive model. The decision curve was used to analyze the clinical value of Model B.

RESULTS

A total of 161 DVT patients were enrolled in this study. Postoperative DVTp occurred in 48 spinal trauma patients, accounting for 29.81% of the total patient enrolled. Model A inadequately predicted postoperative DVTp in spinal trauma patients, with ROC AUC values of 0.595 for the training dataset and 0.593 for the test dataset. Through the application of LASSO regression and multivariable logistic regression, a screening process was conducted for seven risk factors: D-dimer, blood platelet, hyperlipidemia, blood group, preoperative anticoagulant, spinal cord injury, lower extremity varicosities. Model B demonstrated superior and consistent predictive performance, with ROC AUC values of 0.809 for the training dataset and 0.773 for the test dataset. According to the calibration curves and decision curve analysis, Model B could accurately predict the probability of postoperative DVTp after spine surgery. The nomograms enhanced the interpretability of Model B in charts and graphs.

CONCLUSIONS

In summary, we established a logistic regression model for the accurate predicting of postoperative deep vein thrombosis progression in spinal trauma patients, utilizing D-dimer, blood platelet, hyperlipidemia, blood group, preoperative anticoagulant, spinal cord injury, lower extremity varicosities, and age as predictive factors. The proposed model outperformed a logistic regression model based simply on CRS. The proposed model has the potential to aid frontline clinicians and patients in identifying and intervening in postoperative DVTp among traumatic patients undergoing spinal surgery.

Venous thromboembolic disease in admitted blunt trauma patients: what matters?

BACKGROUND

Venous thromboembolic events (VTE) are a significant cause of morbidity and mortality following traumatic injury. We examined demographic characteristics, chemoprophylaxis, and outcomes of VTE patients with blunt trauma requiring hospitalization.

METHODS

A retrospective review of adult blunt trauma hospitalizations with and without VTE between 2012 and 2019 was conducted. Deaths in the emergency department were excluded. Univariate and multivariable analyses, including machine learning classification algorithms for VTE, were performed.

RESULTS

Of 10,926 admitted adult blunt trauma patients, 177 had VTE events. VTE events occurred at a median of 6 [IQR 3-11] days, with 7.3% occurring within 1 day of admission. VTE patients were more often male, and more often underwent surgery. They had higher injury severity as well as longer intensive care unit and hospital lengths of stay. While VTE occurred throughout the spectrum of injury severity, 27.7% had low injury severity (ISS < = 9). In multivariable analyses, both heparin and enoxaparin had reduced adjusted odds ratios for VTE.

CONCLUSION

Approximately 7.3% of VTE events occurred within one day of admission. A substantial proportion of VTE events occurred in patients with low injury severity (ISS < = 9). Subcutaneous unfractionated heparin and enoxaparin chemoprophylaxis were both inversely associated with VTE. These findings underscore the need for vigilance for VTE identification in blunt trauma patients throughout their hospitalization and VTE prevention efforts.

The efficacy of various Enoxaparin dosing regimens in general surgery patients: A systematic review

BACKGROUND

Patients undergoing surgical procedures are at an increased risk of venous thromboembolism events. A fixed Enoxaparin dosing regimen is the standard of care for chemoprophylaxis in most institutions; however, breakthrough venous thromboembolism events are still reported. We aimed to systematically review the literature to determine the ability of various Enoxaparin dosing regimens to achieve adequate prophylactic anti-Xa levels for venous thromboembolism prevention in hospitalized general surgery patients. Additionally, we aimed to assess the correlation between subprophylactic anti-Xa levels and the development of clinically significant venous thromboembolism events.

METHODS

A systematic review was conducted using major databases from January 1, 1993, to February 17, 2023. Two independent researchers screened titles and abstracts, followed by a full-text review. Articles were included if Enoxaparin dosing regimens were evaluated by anti-Xa levels. Exclusion criteria included systematic reviews, pediatric population, nongeneral surgery (defined as trauma, orthopedics, plastics, and neurosurgery), and non-Enoxaparin chemoprophylaxis. The primary outcome was peak Anti-Xa level measured at steady state concentration. The risk of bias was assessed using the Risk of Bias in Nonrandomized studies-of Intervention tool.

RESULTS

A total of 6,760 articles were extracted, of which 19 were included in the scoping review. Nine studies included bariatric patients, whereas 5 studies explored abdominal surgical oncology patients. Three studies assessed thoracic surgery patients, and 2 studies included patients undergoing "general surgery" procedures. A total of 1,502 patients were included. The mean age was 47 years, and 38% were males. The percentages of patients reaching adequate prophylactic anti-Xa levels were 39%, 61%, 15%, 50%, and 78% across the 40 mg daily, 40 mg twice daily, 30 mg twice daily, and weight-tiered, and body mass index-based groups, respectively. The overall risk of bias was low to moderate.

CONCLUSION

Fixed Enoxaparin dosing regimens are not correlated with adequate anti-Xa levels in general surgery patients. Additional research is warranted to assess the efficacy of dosing regimens based on novel physiologic parameters (such as estimated blood volume).

Forensic autopsy-confirmed thrombosis-related deaths: the danger in the bones

Thrombosis is a potentially life-threatening condition related to roughly a quarter of all deaths globally. Many of these deaths occur inside healthcare facilities due to possibly preventable causes. Therefore, understanding the etiological factors involved in excessive thrombosis may significantly contribute to the successful identification, management and education of people who have an increased risk of thrombosis. We performed a retrospective file-audit of all forensic autopsy reports conducted at the Free State Forensic Pathology Mortuary in Bloemfontein, South Africa, over 10 years. We collected the age at death, gender and ethnicity of each person included in the study. The presence and location of the thrombosis and any underlying disorder or disease were noted. The overall prevalence of thrombosis for the total study population was 0.97%. Pulmonary embolisms (PE's) were much more common than coronary thromboses. Most PE's had known contributory risk factors, where coronary thrombosis-related deaths occurred suddenly without known risk factors. Bone fractures were the most prominent risk factor associated with PE's. Females of African descent had a consistently high prevalence of thrombosis after the age of 30 years. Males of European descent showed an unexpected peak in prevalence during the 4th decade. Since most deaths occurred in patients with conditions known to contribute to venous thrombosis, we conclude that intensified public awareness efforts are required in our region to assist the general public in identifying risk factors for thrombosis, thereby decreasing the burden this potentially preventable disorder places on society.

Incidence and risk factors of preoperative deep vein thrombosis in patients with intertrochanteric fractures: a retrospective study

BACKGROUND

The risk of perioperative complications remains high in patients with intertrochanteric fractures. Immobilization after injury may predispose these patients to deep vein thrombosis (DVT) while waiting for surgery. The aims of this study were to determine the incidence of preoperative DVT in patients with intertrochanteric fractures and identify independent risk factors.

METHODS

This retrospective study included patients with intertrochanteric fractures waiting for surgical interventions at our institution from June 2018 to December 2020. All patients received pharmacologic thromboprophylaxis after admission and ultrasound screening for DVT in both lower limbs before surgery. Demographic, clinical and laboratory data of these patients were collected to perform univariate analysis first. Subsequently, factors with a significant difference in univariate analysis were introduced into the multivariate logistic regression analysis to determine the independent risk factors for preoperative DVT.

RESULTS

A total of 266 patients were enrolled in this study. Seventy-one patients (26.7%) developed DVTs before surgery. The majority of DVTs were distal types (91.5%). There were 40 patients with DVTs only in the affected limb, 7 patients with DVTs only in the unaffected limb, and 24 patients with DVTs in both lower limbs. Advanced age, female, prolonged period from injury to admission, combined cranial trauma, shorter thrombin time, increased level of D-dimer and lower level of albumin proved to be the independent risk factors for preoperative DVT.

CONCLUSIONS

We observed a high incidence of preoperative DVT in patients with intertrochanteric fractures. Identification of patients at high risk may improve the prevention and treatment of preoperative DVT in this population.

[Arm Swelling with a Camouflaged Cause]

Arm Swelling with a Camouflaged Cause Abstract. We report on a 72-year-old patient who presented to the emergency department due to a proximal multiple-fragment humeral fracture on the left. Despite correct therapeutic approaches, there was no improvement in the left arm swelling. Further investigations showed a provoked arm vein thrombosis on the left with a post-humeral fracture on the left. After therapeutic anticoagulation, the swelling regressed immediately, but with persistent lymphedema of the left hand.

Patients with venous thromboembolism after spontaneous intracerebral hemorrhage: a review

Background

Patients with spontaneous intracerebral hemorrhage (ICH) have a higher risk of venous thromboembolism (VTE) and in-hospital VTE is independently associated with poor outcomes for this patient population.

Methods

A comprehensive literature search about patients with VTE after spontaneous ICH was conducted using databases MEDLINE and PubMed. We searched for the following terms and other related terms (in US and UK spelling) to identify relevant studies: intracerebral hemorrhage, ICH, intraparenchymal hemorrhage, IPH, venous thromboembolism, VTE, deep vein thrombosis, DVT, pulmonary embolism, and PE. The search was restricted to human subjects and limited to articles published in English. Abstracts were screened and data from potentially relevant articles was analyzed.

Results

The prophylaxis and treatment of VTE are of vital importance for patients with spontaneous ICH. Prophylaxis measures can be mainly categorized into mechanical prophylaxis and chemoprophylaxis. Treatment strategies include anticoagulation, vena cava filter, systemic thrombolytic therapy, catheter-based thrombus removal, and surgical embolectomy. We briefly summarized the state of knowledge regarding the prophylaxis measures and treatment strategies of VTE after spontaneous ICH in this review, especially on chemoprophylaxis and anticoagulation therapy. Early mechanical prophylaxis, especially with intermittent pneumatic compression, is recommended by recent guidelines for patients with spontaneous ICH. While decision-making on chemoprophylaxis and anticoagulation therapy evokes debate among clinicians, because of the concern that anticoagulants may increase the risk of recurrent ICH and hematoma expansion. Uncertainty still exists regarding optimal anticoagulants, the timing of initiation, and dosage.

Conclusion

Based on current evidence, we deem that initiating chemoprophylaxis with UFH/LMWH within 24–48 h of ICH onset could be safe; anticoagulation therapy should depend on individual clinical condition; the role of NOACs in this patient population could be promising.

Thromboprophylaxis and Bleeding Complications in Orthopedic and Trauma Patients: A Systematic Review

This systematic review was conducted to investigate the effects of currently used chemoprophylactic modalities to assess concerns regarding their usage. Preventive benefits of thromboprophylaxis were weighed against potential complications in orthopedic and trauma patients. The Ovid MEDLINE® database was used to identify relevant studies. The authors independently screened the initial study articles by title and abstract, eliminating articles not dealing with venous thromboembolism (VTE) chemoprophylaxis in orthopedic or trauma populations. The remaining articles were assessed for eligibility through full-text analysis. The analyzed studies within this review suggested that Factor X_a inhibitors and direct oral anticoagulants hold promise as safe and potentially more effective thromboprophylactic entities when compared to low molecular weight heparin in trauma and orthopedic patients. Thromboprophylaxis had little to no effect on major bleeding incidence, although we could not definitively conclude there was no effect on overall bleeding. Early thromboprophylaxis, especially when identifiable risk factors are present, can improve VTE prevention without changing major bleeding rates. Additionally, we could not conclude whether extended prophylaxis affects VTE incidence, although it seemed to have no effect on major bleeding. Finally, we determined that thromboprophylaxis in the lower extremity trauma population is questionable without the presence of underlying risk factors.

Upper-Extremity Deep Venous Thrombosis following a Fracture of the Proximal Humerus: An Orthopaedic Case Report

Deep venous thrombosis of the lower extremities following orthopaedic surgery is well-documented. Though less common than its lower extremity counterpart, upper extremity deep venous thrombosis (UEDVT) has been documented in the literature as well, largely in the context of arthroscopic shoulder surgery. However, there is a paucity of literature documenting UEDVT following surgical fixation of upper extremity fractures, specifically fractures involving the proximal humerus. We present a case of UEDVT following a fracture to the proximal humerus and subsequent surgery. Though UEDVT is considered a rare complication following this type of surgery based on a lack of documentation within the literature, we believe a high-index of suspicion is required to prevent potentially life-threatening sequelae, such as pulmonary embolism (PE) and post-thrombotic syndrome.

Is the Caprini Score Predictive of Venothromboembolism Events in Orthopaedic Fracture Patients?

OBJECTIVE

Explore the validity of the Caprini Score in orthopaedic patients with lower-extremity fractures.

DESIGN

Retrospective cohort study.

SETTING

Level I trauma academic medical center.

PATIENTS/PARTICIPANTS

Eight hundred forty-eight patients with lower-extremity fractures from 2002 to 2015 with exclusion criteria: minors, follow-up less than 30 days.

INTERVENTION

Stratify patients into 2 groups: high-risk (pelvic and acetabular fractures) and low-risk groups (isolated foot and ankle fractures).

MAIN OUTCOME

Caprini Score, fracture classification, length of follow-up, deep vein thrombosis (DVT) chemoprophylaxis, and venothromboembolism (VTE) events [DVT and/or pulmonary embolism (PE)] diagnosed with objective testing.

RESULTS

Eight hundred forty-eight patients (499 M; 349 F) 18-93 years of age (average 43.7) with average body mass index of 29. Three hundred high-risk and 548 low-risk patients with no differences in demographics with average follow-up of 288 days. There were 33 (3.9%) VTE events, which were more common in the high-risk group (8%: 9 DVT, 15 PE) than the low-risk group (1.6%: 8 DVT, 1 PE) (P < 0.0001). The cutoff that best-predicted VTE events based on receiver-operating curves was 12 (c = 0.74) in the high-risk group, 11 (c = 0.79) in the low-risk group, and 12 (c = 0.83) overall.

CONCLUSION

There was a significant lower VTE rate found in the low-risk group, but the Caprini prediction model was not significantly different between the 2 groups. This displays that patient factors play a large role in the development of VTE events independent of injury type. The Caprini score may help identify patients who may require increased protection.

LEVEL OF EVIDENCE

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

Intense Triceps Surae Contraction Increases Lower Extremity Venous Blood Flow

Objective

Venous thromboembolism can be prevented by physical prophylaxis, such as active ankle exercise (AAE), in addition to pharmacological treatment. However, the relationship between the intensity of triceps surae (TS) exercise and venous flow is unclear, and physical thromboprophylaxis has not been established for patients with leg cast immobilization. The goals of the current study were to clarify the degree of intensity of TS isotonic contraction required to increase peak blood velocity (PV) in the superficial femoral vein to higher than that at no resistance and to determine if TS isometric contraction can increase PV.

Methods

A prospective, nonrandomized, controlled trial was performed in 20 healthy young adult men. PVs at rest and during one TS isotonic or isometric contraction were measured using Doppler ultrasonography. Isotonic contraction intensity was defined as no resistance with contraction of maximum effort and 25%, 50%, 75%, and 100% of one repetition maximum (1RM). Isometric contraction intensity was defined as 15-35%, 40-60%, 65-85%, and 90-100% of the maximal voluntary contraction.

Results

Isotonic contraction at 75% 1RM (51.4 cm/s [95% CI, 40.1-62.6]) and 100% 1RM (54.9 cm/s [95% CI, 43.1-66.7]) significantly increased PV compared to that with no resistance (41.0 cm/s [95% CI, 32.2-49.8]) (P=0.005, 0.001, respectively). Isometric contraction increased PV significantly at all intensities (all P≤0.002).

Conclusions

Applying resistance at ≥75% 1RM increases venous flow and enhances the effect of AAE with TS isotonic contraction. TS isometric contraction may serve as thromboprophylaxis for patients undergoing leg cast immobilization.