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

Venous Thromboembolism in Foot and Ankle Trauma

Every surgeon may have experienced a tragic event associated with death or debilitation secondary to deep vein thrombosis (DVT) or pulmonary embolism (PE) after foot and ankle trauma and surgery. Nevertheless, the prevention of such a tragic event needs to be carefully evaluated rationally with currently available epidemiologic data. With great postoperative protocols and access to care, most PE events can be prevented. There are modifiable risk factors, such as length/type of immobilization and operative trauma/time that can lower the incidence of DVT/PE. In addition, chemical prophylaxis may be warranted in certain people within the foot and ankle trauma population.

Combination of neutrophil to lymphocyte ratio, platelet to lymphocyte ratio with plasma D-dimer level to improve the diagnosis of deep venous thrombosis (DVT) following ankle fracture

PURPOSE

To investigate the relationship between neutrophil to lymphocyte ratio (NLR)/platelet to lymphocyte ratio (PLR) with deep venous thrombosis (DVT) following ankle fracture and the diagnostic ability of combination model.

METHOD

This retrospective study included patients with a diagnosis of ankle fracture who had undergone preoperative Duplex ultrasound (DUS) examination for detecting the possible deep venous thrombosis (DVT). The variables of interest, the calculated NLR and PLR and others (demographics, injury, lifestyles and comorbidities) were extracted from the medical records. Two independent multivariate logistics regression models were used to detect the relationship between NLR or PLR and DVT. If any, combination diagnostic model was constructed and its diagnostic ability was evaluated.

RESULTS

There were 1103 patients included, and 92 (8.3%) were found to have preoperative DVT. The NLR and PLR, which had respective optimal cut-off point of 4 and 200, were significantly different between patients with and without DVT either in continuous or categorical variable. After adjustment for covariates, both NLR and PLR were identified as independent risk factors associated with DVT, with odd ratio of 2.16 and 2.84, respectively. The combination diagnostic model, including NLR, PLR and D-dimer, demonstrated to significantly improved the diagnostic performance than any one alone or combined (all P < 0.05), and the area under the curve was 0.729 (95% CI 0.701-0.755).

CONCLUSION

We concluded the relatively low incidence rate of preoperative DVT after ankle fracture, and both NLR and PLR were independently associated with DVT. The combination diagnostic model can be considered as a useful auxiliary tool for identifying high-risk patients for DUS examination.

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.

Preoperative incidence and risk factors of deep vein thrombosis in patients with an isolated patellar fracture

Purpose

This study aimed to investigate the incidence, location, and related factors of preoperative deep venous thrombosis (DVT) in patients with isolated patellar fractures.

Methods

Patients with an isolated patellar fracture, admitted between January 2013 and December 2019 at our institution, were retrospectively analyzed. Upon admission, patients underwent routine Doppler ultrasound scanning (DUS) of the bilateral lower extremities to detect DVT; those with DVT were assigned to the case group and those without DVT to the control group. Patients in both groups did not perform preoperative off-bed weight-bearing exercises. Data on demographics, comorbidities, and laboratory test results upon admission were extracted. Variables were evaluated between the two groups using univariate analyses, and independent risk factors associated with DVT were identified by logistic regression analysis.

Results

During the study period, 827 patients were included, of whom 5.8% (48/827) were found to have preoperative DVT. In DVT patients, 85.4%(41/48) were injured, 8.3%(4/48) were not injured, and 6.3%(3/48) were lower limbs. Multivariate analysis showed that male (male vs. female, odds ratio, OR = 2.25), delayed from injury to DUS (in each day, OR = 1.29), and elevated plasma D-dimer level (> 0.5 µg/mL, OR = 2.47) were independent risk factors associated with DVT.

Conclusions

Despite the low prevalence of DVT after an isolated patellar fracture, this study underscores the importance of identifying those with a high risk of DVT, especially those with multiple identifiable factors, and encourage the early targeted use of anti-thromboembolic agents to reduce DVT occurrence.

Nonspecific ST-Segment and T-Wave (NS-STT) on Electrocardiogram is Associated with Increasing the Incidence of Perioperative Deep Vein Thrombosis in Patients with Lower Extremity Fracture Under 75 Years Old

Objective

This study aims to explore the clinical correlation between nonspecific ST-segment or T-wave (NS-STT) changes and perioperative deep vein thrombosis (DVT) in patients with lower extremity fractures.

Methods

One thousand four hundred sixty-nine consecutive patients who suffered lower extremity fractures were screened at Xi’an Honghui Hospital between Feb 2016 and Nov 2018. According to the included and excluded criteria, the patients were included in this retrospective study. After collecting the electrocardiogram baseline, the patients were divided into the NS-STT group and the non-NS-STT group. After comparing the demographic and clinical characteristics, multivariate logistic regression models were used to identify the role of NS-STT changes on perioperative DVT. All analyses were performed with R and EmpowerStats software.

Results

Nine hundred and sixty-eight patients were included in the study. Ninety-seven patients (10.02%) had NS-STT changes on the electrocardiogram at admission. A total of 303 patients (31.30%) developed perioperative DVT in lower extremities. The univariate analysis showed that NS-STT segment changes were correlated with perioperative DVT significantly (OR = 3.45, 95% CI: 2.25–5.30, P < 0.0001). In addition, age ≥50 (P < 0.0001), female (OR = 1.50, 95% CI: 1.14–1.97, P = 0.0038), hypertension (OR = 1.54, 95% CI: 1.08–2.20, P = 0.0161), blood transfusion (OR = 1.78, 95% CI: 1.34–2.37, P < 0.0001), joint prosthesis (OR = 3.26, 95% CI: 2.21–4.81, P < 0.0001), and blood loss ≥300 mL (OR = 2.12, 95% CI: 1.50–3.01, P < 0.0001) were associated with perioperative DVT in lower extremities. We identified the confounding factors of age, gender, classification of internal implants, operation time, blood loss, and infusion. After adjustment for potential confounding factors, NS-STT changes were associated with perioperative DVT (OR = 2.13, 95% CI: 1.33–3.42; P = 0.0017). The sensitive analysis showed that the result was stable.

Conclusion

The NS-STT changes on electrocardiograms are associated with an increase in the incidence of perioperative DVT by 2.13-fold in patients with lower extremity fractures under 75 years old. In clinical practice, surgeons should pay more attention to these patients.

The outcome of isolated calf muscle vein thrombosis after open reduction and internal fixation for closed intra-articular distal femur fractures: a prospective cohort study

Background

To observe the outcome of isolated calf muscle vein thrombosis (ICMVT) undergoing open reduction and internal fixation (ORIF) for closed intra-articular distal femur fractures (DFFs) and to analyze related factors.

Methods

The study was designed as a prospective clinical cohort study at our hospital. From August 2018 to August 2020,a total of 140 patients with flesh ICMVT after ORIF for closed intra-articular DFFs were collected during hospitalization. After the administration of antithrombotic agents immediately after diagnosis, the location and prognosis of postoperative ICMVT were examined by Duplex ultrasonography (DUS) with a three-month follow-up. There were 29 males and 111 females with the average age of 70.16 ± 8.75 years old. Sonography was used to evaluate the resolution of muscular vein thrombosis at the time point of the third month postoperatively and the results were compared between the two time points. Multivariable analysis was performed to evaluate the relationship between the resolution of ICMVT three months postoperatively and risk factors including age, Body Mass Index (BMI), gender, thrombosis length (> 5 / ≤5 cm), thrombosis diameter(> 0.6/≤0.6 cm), and thrombosis-related biochemistry indices.

Results

The postoperative ICMVTs was diagnosed at 5.47 ± 2.46 days after ORIF for closed intra-articular DFFs. At the follow up of 3 months,120 cases was tending to disappear with 88 cases(62.9 %) completely dissolved and 32 cases(22.9 %) partly dissolved. There existed 14 cases (10.0 %) without change on the size and 6 cases (4.2 %) with proximal propagation. Multivariate analysis revealed that thrombus diameter over 0.6 cm (odds ratio [OR], 8.900; 95 % confidence interval [CI]: 3.623–21.865), thrombus length over 5.0 cm (OR, 3.904; 95 % CI, 1.121–13.603), FIB over 3.0 g/L (OR, 3.627; 95 % CI, 1.356–9.689), and D-dimer over 1.0 mg/L (OR, 2.602; 95 % CI, 1.075–6.296) were four independent risk factors of non-completely dissolved ICMVTs.

Conclusions

85.8 % of ICMVT was tending to disappear at the third months after ORIF for closed intra-articular DFFs. Thrombus diameter, thrombus length, FIB, and D-dimer were four independent risk factors of non-completely dissolved ICMVTs. The Thrombus diameter has a significant effect on the natural course of ICMVTs, especially with diameter larger than 0.6 cm.

Post-operative deep vein thrombosis in patients over sixty years of age diagnosed with closed distal femur fractures undergoing open reduction internal fixation

BACKGROUND AND PURPOSE

New-onset deep vein thrombosis (DVT) reportedly affects prognosis and surgical outcomes of elderly patients. However, its effect on distal femur fractures (DFFs) remains unclear. We aimed to address the epidemiological characteristics and the associated predictors for post-operative DVT in patients with closed DFFs over age 60 years old.

PATIENTS AND METHODS

We designed a prospective cohort trial at our hospital between October 2018 and June 2020 and recruited consecutive 140 patients over age 60 years diagnosed with closed DFFs. We examined location and prognosis of postoperative DVT and then conducted a three month follow-up. We used Duplex ultrasonography (DUS) to diagnose DVT in all patients and then classified the subjects into DVT and non-DVT groups. We further classified DVTs into proximal, distal, and mixed thromboses and then performed Whitney U test or t test, receiver operating characteristic (ROC) curve analysis, Chi-square test, and multiple logistic regression analysis to confirm the adjusted factors of post-operative DVT.

RESULTS

We found a 35% (n = 49) overall incidence of post-operative DVTs, which occurred 5.7 days following open reduction internal fixation (ORIF). Among patients with post-operative DVTs, 53.1% (n = 26) and 10.2% (n = 5) were distal and proximal thromboses, respectively. Additionally, peroneal veins were the most common DVT sites (71.4%, n = 35). Multivariate analysis revealed that venous thrombosis at admission (odds ratio [OR], 4.619; 95% confidence interval [CI]: 2.072-10.299; P = 0.000), operation duration over 195 minutes (OR, 3.289; 95% CI, 1.155-9.370; P = 0.026), intra-operative blood loss over 325 mL (OR, 2.538; 95% CI, 1.047-6.155; P = 0.039) were the three independent risk factors of post-operative DVT. Unified antithrombotic agents after diagnosis showed that 16.3% (n = 8) of DVTs were completely recanalized, 12.6 days after first diagnosis.

CONCLUSION

Our findings indicate a strong association between venous thrombosis at admission, the longer operation duration, and considerable intra-operative blood loss with high risk of post-operative DVTs in patients over age 60 years with closed DFFs. Preventive approaches for postoperative DVTs should seek to shorten operation duration and reduce intra-operative blood loss.

Age over 65 years and high levels of C-reactive protein are associated with the risk of preoperative deep vein thrombosis following closed distal femur fractures: a prospective cohort study

Background

In this study, we investigated the epidemiological characteristics and predictors of preoperative new-onset deep vein thrombosis (DVT) in adult patients with closed distal femur fractures (DFFs).

Methods

The study was designed as a prospective cohort trial at the Third Hospital of Hebei Medical University. From October 2018 to June 2020, a total of 160 patients with closed DFFs were enrolled to assess the location and prognosis of preoperative DVT. The patients were followed up for 2 months. Duplex ultrasonography (DUS) was used to diagnose patients with DVT. The patients were divided into two groups (DVT group and non-DVT group). The DVT was then classified into proximal, distal, and mixed thromboses. The Mann-Whitney U test or t test, receiver operating characteristic (ROC) analyses, univariate Chi-square analyses, and multiple logistic regression analyses were used to analyze the adjusted predictors of DVT.

Results

The overall incidence of preoperative DVTs was 52.5% (n = 84), which was diagnosed at a mean period of 3.1 days after injury. Among patients diagnosed with DVTs, 50.0% (n = 42) had distal thrombosis while 47.6% (n = 40) had mixed thrombosis. The calf muscle veins were the most common sites of DVTs (90.5%, n = 76). Of note, 45.2% (n = 38) of diagnosed DVTs were completely recanalized at a mean period of 12.0 days after the initial (first) diagnosis. Multivariate analysis revealed that age of ≥ 65 years of age (odds ratio [OR], 4.390; 95% confidence interval [CI] 1.727–11.155; p = 0.002), C-reactive protein (CRP) levels exceeding 11 mg/L (OR 4.158; 95% CI 1.808–11.289; p = 0.001), platelet (PLT) levels over 217 × 109/L (OR, 2.55; 95% CI 1.07–6.07; p = 0.035), D-dimer levels over 1.0 mg/L (OR 3.496; 95% CI 1.483–8.237; p = 0.004), and an American Society of Anesthesiologists (ASA) score of III-V (OR 2.753; 95% CI 1.216–6.729; p = 0.026) were the independent risk factors of preoperative DVT.

Conclusions

High levels of CRP, PLT, D-dimer, ASA, and ≥ 65 years of age increase the risk of preoperative DVTs in adult patients with closed DFFs. Thus, the prediction of preoperative DVTs can significantly be improved by identifying older patients over the age of 65, and establishing the biochemical cut-off values of CRP, PLT, ASA, and D-dimer.

Trial registration

No. 2018-026-1, 24 October 2018, prospectively registered.

This trial was registered prospectively on 24 October 2018 before the first participant was enrolled. This study protocol conformed to the Declaration of Helsinki and approved by the Institutional Review Board. The ethics committee approved the study on the factors of prognosis for patients with fractures. Data used in this study were obtained from the patients who underwent orthopedic surgery between October 2018 and June 2020.