Venous Thromboembolism Prophylaxis in Orthopaedic Trauma Patients: A Survey of OTA Member Practice Patterns and OTA Expert Panel Recommendations

Timing of venous thromboembolism prophylaxis initiation and complications in polytrauma patients with high-risk bleeding orthopedic interventions: A nationwide analysis

INTRODUCTION

There are no clear recommendations for the perioperative timing and initiation of venous thromboembolism pharmacologic prophylaxis (VTEp) among polytrauma patients undergoing high-risk bleeding orthopedic operative intervention, leading to variations in VTEp administration. Our study examined the association between the timing of VTEp and VTE complications in polytrauma patients undergoing high-risk operative orthopedic interventions nationwide.

METHODS

We performed a retrospective cohort study of trauma patients 18 years or older who underwent high-risk bleeding operative orthopedic interventions for pelvic, hip, and femur fractures within 24 hours of admission at American College of Surgeons-verified trauma centers using the 2019-2020 American College of Surgeons Trauma Quality Improvement Program databank. We excluded patients with a competing risk of nonorthopedic surgical bleeding. We assessed operative orthopedic polytrauma patients who received VTEp within 12 hours of orthopedic surgical intervention compared with VTEp received beyond 12 hours of intervention. The primary outcome assessed was overall VTE events. Secondary outcomes were orthopedic reinterventions within 72 hours after primary orthopedic surgery, deep venous thromboembolism, and pulmonary embolism rates.

RESULTS

The study included 2,229 patients who underwent high-risk orthopedic operative intervention. The median time to VTEp initiation was 30 hours (interquartile range, 18-44 hours). After adjustment for baseline patient, injury, and hospital characteristics, VTEp initiated more than 12 hours from primary orthopedic surgery was associated with increased odds of VTE (adjusted odds ratio, 2.02; 95% confidence interval, 1.08-3.77). Earlier initiation of prophylaxis was not associated with an increased risk for surgical reintervention (hazard ratio, 0.90; 95% confidence interval, 0.62-1.34).

CONCLUSION

Administering VTEp within 24 hours of admission and within 12 hours of major orthopedic surgery involving the femur, pelvis, or hip demonstrated an associated decreased risk of in-hospital VTE without an accompanying elevated risk of bleeding-related orthopedic reintervention. Clinicians should reconsider delays in initiating or withholding perioperative VTEp for stable polytrauma patients needing major orthopedic intervention.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Venous thromboembolism testing practices after orthopaedic trauma: prophylaxis regimen does not influence testing patterns

Objectives

To determine venous thromboembolism (VTE) testing patterns in an orthopaedic trauma population and to evaluate for differences in VTE surveillance by prophylaxis regimen through a secondary analysis of the ADAPT trial.

Design

Prospective randomized trial.

Setting

Level I trauma center.

Patients

Three hundred twenty-nine adult (18 years and older) trauma patients presenting with an operative extremity fracture proximal to the metatarsals/carpals or any pelvic or acetabular fracture requiring VTE prophylaxis.

Intervention

VTE imaging studies recorded within 90 days post injury.

Main Outcome Measurements

Percentage of patients tested for VTE were compared between treatment groups using Fisher's exact test. Subsequently, multivariable regression was used to determine patient factors significantly associated with risk of receiving a VTE imaging study.

Results

Sixty-seven patients (20.4%) had VTE tests ordered during the study period. Twenty (29.9%) of these 67 patients with ordered VTE imaging tests had a positive finding. No difference in proportion of patients tested for VTE by prophylaxis regimen (18.8% on aspirin vs. 22.0% on LMWH, P = 0.50) was observed. Factors associated with increased likelihood of VTE testing included White race (adjusted odds ratio [aOR]: 2.61, 95% CI: 1.26-5.42), increased Injury Severity Score (aOR for every 1-point increase: 1.10, 95% CI: 1.05-1.15), and lower socioeconomic status based on the Area Deprivation Index (aOR for every 10-point increase: 1.14, 95% CI: 1.00-1.30).

Conclusions

VTE surveillance did not significantly differ by prophylaxis regimen. Patient demographic factors including race, injury severity, and socioeconomic status were associated with differences in VTE surveillance.

Level of Evidence

Level I, Therapeutic.

Effect of Aspirin Versus Low-Molecular-Weight Heparin Thromboprophylaxis on Medication Satisfaction and Out-of-Pocket Costs: A Secondary Analysis of a Randomized Clinical Trial

BACKGROUND

Current guidelines recommend low-molecular-weight heparin for thromboprophylaxis after orthopaedic trauma. However, recent evidence suggests that aspirin is similar in efficacy and safety. To understand patients' experiences with these medications, we compared patients' satisfaction and out-of-pocket costs after thromboprophylaxis with aspirin versus low-molecular-weight heparin.

METHODS

This study was a secondary analysis of the PREVENTion of CLots in Orthopaedic Trauma (PREVENT CLOT) trial, conducted at 21 trauma centers in the U.S. and Canada. We included adult patients with an operatively treated extremity fracture or a pelvic or acetabular fracture. Patients were randomly assigned to receive 30 mg of low-molecular-weight heparin (enoxaparin) twice daily or 81 mg of aspirin twice daily for thromboprophylaxis. The duration of the thromboprophylaxis, including post-discharge prescription, was based on hospital protocols. The study outcomes included patient satisfaction with and out-of-pocket costs for their thromboprophylactic medication measured on ordinal scales.

RESULTS

The trial enrolled 12,211 patients (mean age and standard deviation [SD], 45 ± 18 years; 62% male), 9725 of whom completed the question regarding their satisfaction with the medication and 6723 of whom reported their out-of-pocket costs. The odds of greater satisfaction were 2.6 times higher for patients assigned to aspirin than those assigned to low-molecular-weight heparin (odds ratio [OR]: 2.59; 95% confidence interval [CI]: 2.39 to 2.80; p < 0.001). Overall, the odds of incurring any out-of-pocket costs for thromboprophylaxis medication were 51% higher for patients assigned to aspirin compared with low-molecular-weight heparin (OR: 1.51; 95% CI: 1.37 to 1.66; p < 0.001). However, patients assigned to aspirin had substantially lower odds of out-of-pocket costs of at least $25 (OR: 0.15; 95% CI: 0.12 to 0.18; p < 0.001).

CONCLUSIONS

Use of aspirin substantially improved patients' satisfaction with their medication after orthopaedic trauma. While aspirin use increased the odds of incurring any out-of-pocket costs, it protected against costs of ≥$25, potentially improving health equity for thromboprophylaxis.

LEVEL OF EVIDENCE

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

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.

Aspirin versus LMWH for VTE prophylaxis after orthopedic surgery

Low molecular weight heparin (LMWH) is often used to prevent perioperative venous thrombosis after surgery, but aspirin is also recommended by academics. Studies were searched in electronic databases until February 24, 2023. We performed a meta-analysis to evaluate the safety and efficacy of aspirin and LMWH for venous thromboembolism (VTE) prophylaxis in patients after orthopedic surgery. The outcomes were death from any causes, deep vein thrombosis (DVT), pulmonary embolism (PE), etc. This study was registered with INPLASY, number 202320117. Six randomized controlled trials enrolled 13,851 patients with postoperative joint surgery. The risk of DVT was comparable between the two groups when aspirin was combined with mechanical devices (RR 0.61 [95% CI 0.27-1.39], I² = 62%, P = 0.24). No significant differences in all cause death, PE, wound infection, and wound complication were found between the aspirin and LMWH groups. In this meta-analysis, the mortality rate was comparable between the aspirin and LMWH groups. However, aspirin alone had a higher risk of DVT than LMWH. Based on the results of this meta-analysis, we suggest aspirin combined with mechanical devices for VTE prophylaxis in patients after orthopedic surgery.

Timing of venous thromboemboli in patients with acetabular and pelvic ring fractures

PURPOSE

To determine the timing of symptomatic venous thromboemboli (VTE) in patients sustaining a pelvic and/or acetabular fracture. Secondly, to evaluate for any factors that may influence this timing.

METHODS

A retrospective cohort of 47 patients with acetabular and/or pelvic ring injuries who developed VTEs at a single academic level I trauma center were identified from 2012 to 2018. The chronology of VTE diagnosis in relation to date of injury, initial surgery, final surgery, and date of discharge was evaluated. Patients who developed VTEs were then evaluated based on known risk factors for VTE to determine if any of these affected timing.

RESULTS

Symptomatic VTEs were diagnosed in 3.8% of patients with pelvic and/or acetabular fractures. In patients who developed a thromboembolism, diagnosis occurred on average 21.5 (± 19.2), 20.7 (± 19.9), 9.8 (± 23.4), and 4.3 (± 27.6) days after injury, index procedure, final procedure, and date of discharge. 25% of patients developed VTE more than 4 weeks after their initial injury. No known risk factors effected the timing of VTE.

CONCLUSION

The 2015 OTA expert panel recommends 4 weeks of anticoagulation for orthopedic trauma patients at high risk of VTE, which may be too short a duration. In our cohort, 25% of VTEs occurred greater than 4 weeks after injury. Additional research is needed to clarify the exact duration of anticoagulation after pelvic and acetabular fractures; however, surgeons may want to consider anticoagulating patients for greater than 4 weeks.

LEVEL OF EVIDENCE

Level III-retrospective cohort.

Comparison of the Efficacy and Safety of Aspirin and Low-Molecular-Weight Heparin in Patients With a Fracture: A Meta-Analysis

The aim of this study is to compare the efficacy and safety of aspirin and low-molecular-weight heparin (LMWH) in preventing thromboembolic events in patients with fractures. The present meta-analysis was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched EMBASE, PubMed, and EBSCO to find articles comparing aspirin and LMWH in patients with orthopedic trauma from inception to April 15, 2023. Limits were set to studies published in the English language only. Outcomes assessed in this meta-analysis included VTE and all-cause mortality. VTE can manifest as deep venous thrombosis (DVT) and pulmonary embolism. For safety analysis, rates of wound complication, infection, and bleeding complications were compared between the two study groups. A total of three studies were included in this meta-analysis enrolling 12884 patients. The study found no significant difference between the two groups in the risk of DVT and pulmonary embolism, and aspirin was non-inferior to LMWH for the prevention of all-cause mortality in patients. Additionally, no significant safety risk was associated with aspirin thromboprophylaxis. These findings suggest that inexpensive over-the-counter aspirin is as effective as LMWH in terms of safety and efficacy profile, making it a feasible option to consider in clinical practice.

Administration of Prophylactic Enoxaparin on the Morning of Surgery Does Not Increase Risk of Blood Transfusion or Wound Drainage Following Internal Fixation of Geriatric Femur Fractures

BACKGROUND

Despite standard use of chemoprophylaxis, 30-day incidence of venous thromboembolism after geriatric, those older than 60 years, femur fracture surgery is reported to be up to 10%. Missing one dose of enoxaparin has been proven to increase the risk of developing venous thromboembolism. It is commonplace to hold preoperative chemoprophylaxis the morning of surgery because of concern for intraoperative bleeding or wound drainage. We sought to determine whether administration of prophylactic enoxaparin the morning of surgery resulted in an increased rate of blood transfusion or wound drainage in geriatric patients undergoing femur fracture treatment.

METHODS

We retrospectively reviewed patients older than 60 years who underwent internal fixation of an isolated femur fracture, including femoral neck, intertrochanteric, subtrochanteric, femoral shaft, and distal femur fractures, at a Level 1 trauma center. Medical records, hospital billing data, and radiographs were reviewed to determine patient characteristics such as Charlson Comorbidity Index, enoxaparin dosing, packed red blood cell transfusion, and persistent wound drainage, defined as any drainage requiring utilization of closed incision negative pressure wound therapy. Thirty-day mortality served as the secondary outcome measure.

RESULTS

Five hundred seven patients were included. One hundred sixty-four (32%) received enoxaparin on the morning of surgery, whereas 343 (68%) did not. 27% of patients received PRBC transfusion, and this did not differ between groups (27% vs. 28%, P = 0.72). Subgroup analysis of fixation strategies revealed no difference in the frequency of blood transfusion for any fixation type as related to the timing of enoxaparin dosage. Utilization of closed incision negative pressure wound therapy for the treatment of postoperative wound drainage did not differ between dosing groups. No difference was observed in thirty-day mortality between groups (2.4% vs. 2.7%, P = 0.9).

DISCUSSION

Administration of a prophylactic dose of enoxaparin on the morning of surgery does not seem to increase the rate of postoperative blood transfusion or wound drainage after fixation of geriatric femur fracture.

LEVEL OF EVIDENCE

Level III, therapeutic.

Aspirin or Low-Molecular-Weight Heparin for Thromboprophylaxis after a Fracture

BACKGROUND

Clinical guidelines recommend low-molecular-weight heparin for thromboprophylaxis in patients with fractures, but trials of its effectiveness as compared with aspirin are lacking.

METHODS

In this pragmatic, multicenter, randomized, noninferiority trial, we enrolled patients 18 years of age or older who had a fracture of an extremity (anywhere from hip to midfoot or shoulder to wrist) that had been treated operatively or who had any pelvic or acetabular fracture. Patients were randomly assigned to receive low-molecular-weight heparin (enoxaparin) at a dose of 30 mg twice daily or aspirin at a dose of 81 mg twice daily while they were in the hospital. After hospital discharge, the patients continued to receive thromboprophylaxis according to the clinical protocols of each hospital. The primary outcome was death from any cause at 90 days. Secondary outcomes were nonfatal pulmonary embolism, deep-vein thrombosis, and bleeding complications.

RESULTS

A total of 12,211 patients were randomly assigned to receive aspirin (6101 patients) or low-molecular-weight heparin (6110 patients). Patients had a mean (±SD) age of 44.6±17.8 years, 0.7% had a history of venous thromboembolism, and 2.5% had a history of cancer. Patients received a mean of 8.8±10.6 in-hospital thromboprophylaxis doses and were prescribed a median 21-day supply of thromboprophylaxis at discharge. Death occurred in 47 patients (0.78%) in the aspirin group and in 45 patients (0.73%) in the low-molecular-weight-heparin group (difference, 0.05 percentage points; 96.2% confidence interval, -0.27 to 0.38; P<0.001 for a noninferiority margin of 0.75 percentage points). Deep-vein thrombosis occurred in 2.51% of patients in the aspirin group and 1.71% in the low-molecular-weight-heparin group (difference, 0.80 percentage points; 95% CI, 0.28 to 1.31). The incidence of pulmonary embolism (1.49% in each group), bleeding complications, and other serious adverse events were similar in the two groups.

CONCLUSIONS

In patients with extremity fractures that had been treated operatively or with any pelvic or acetabular fracture, thromboprophylaxis with aspirin was noninferior to low-molecular-weight heparin in preventing death and was associated with low incidences of deep-vein thrombosis and pulmonary embolism and low 90-day mortality. (Funded by the Patient-Centered Outcomes Research Institute; PREVENT CLOT ClinicalTrials.gov number, NCT02984384.).

A Prospective Randomized Controlled Trial Comparing Enoxaparin & Rivaroxaban for Venous Thromboembolism Prophylaxis in Orthopaedic Trauma

OBJECTIVES

To determine whether there is a difference in orthopaedic trauma patient medication satisfaction and adherence using an oral versus subcutaneous injectable anticoagulant for venous thromboembolism chemoprophylaxis.

DESIGN

Randomized controlled trial.

SETTING

Single academic Level 1 trauma center.

PARTICIPANTS

One hundred twenty adult orthopaedic trauma patients with operative pelvic or lower extremity fractures were randomized and completed the study.

INTERVENTION

Three weeks of either the service standard 40 mg once daily enoxaparin versus trial medication 10 mg once daily rivaroxaban postoperatively.

MAIN OUTCOME MEASURES

Patient satisfaction as measured by the Treatment Satisfaction Questionnaire for Medication (TSQM-9). Medication adherence as measured by the Morisky Medication Adherence Scale (MMAS-8).

RESULTS

Medication adherence was similar in both groups. Medication satisfaction was significantly higher in the oral rivaroxaban group based on the TSQM-9 and patient-reported data. Secondary outcomes found no significant difference in the incidence of bleeding events or clinically relevant venous thromboembolism. The enoxaparin group experienced more adverse medication-related events. The rivaroxaban medication regimen costs 7.5-10× less out of pocket for uninsured patients.

CONCLUSION

The results of this randomized controlled trial demonstrate that patients with surgical orthopaedic trauma prefer an oral anticoagulant for postoperative venous thromboembolism chemoprophylaxis and suggest that rivaroxaban may be a viable option. Furthermore, large-scale studies are needed to confirm safety and efficacy for rivaroxaban in this population as a potential alternative to enoxaparin and aspirin.

LEVEL OF EVIDENCE

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

Identifying Patients at Risk for Venous Thromboembolic Events After Isolated Upper Extremity Trauma: A Predictive Scale

Previous studies have defined risk factors for development of venous thromboembolisms (VTEs) among patients with lower extremity orthopedic trauma. Limited data exist on this risk after upper extremity orthopedic trauma. A total of 269,137 incidents of upper extremity orthopedic trauma (fractures of the clavicle, scapula, humerus, elbow, or lower arm) were identified in the State Inpatient Database for 4 states included in the analysis (California, Florida, New York, and Washington) from 2006 to 2014. These patients were split into 2 cohorts, a derivation cohort (California and New York) and a validation cohort (Florida and Washington). Univariate and multivariate logistic regression analyses of risk factors for VTE within 90 days of discharge in the derivation group were used to develop the Thromboembolic Risk after Upper Extremity Trauma (TRUE-T) scale. Linear regression was used to determine fit of the TRUE-T scale to the 2 cohorts. We found that 2.61% of patients in the derivation cohort and 2.72% of patients in the validation cohort had a VTE within 90 days of discharge. Risk factors associated with increased rates of VTE were age older than 40 years, Medicare payer, anemia, chronic lung disease, coagulopathy, heart failure, malignancy, obesity, renal failure, head injury, chest injury, abdominal injury, rib fracture, humerus fracture, elbow fracture, and closed reduction. Application of the TRUE-T scale to the validation cohort showed an R² value of 0.88. The patient factors, concomitant injuries, and fracture treatment modalities included in the TRUE-T scale can be used to identify patients at increased risk for VTE after upper extremity orthopedic trauma. [Orthopedics. 2022;45(6):345-352.].

Quality evaluation of clinical practice guidelines for thromboprophylaxis in orthopaedic trauma based on AGREE II and AGREE-REX: a systematic review protocol

INTRODUCTION

Orthopaedic trauma patients are at high risk of venous thromboembolism (VTE). As VTE prophylaxis has gradually raised public concerns, guidelines related to this topic have increased over time. However, the existing recommendations of thromboprophylaxis guidelines in orthopaedic trauma patients are still inconsistent, and the quality of the guidelines and recommendations for the topic still lacks comprehensive assessments. This review aims to critically appraise clinical practice guidelines for thromboprophylaxis in orthopaedic trauma patients.

METHODS AND ANALYSIS

We will conduct a comprehensive literature search up to 31 October 2022 in databases (PubMed, EMBASE, CINAHL, Web of Science, the Cochrane Library, etc), academic websites and guideline repositories. The quality of the guidelines and recommendations will be assessed by five reviewers independently using the Appraisal of Guidelines Research and Evaluation II instrument (AGREE-II) and the AGREE - Recommendation EXcellence (AGREE-REX). We will summarise the characteristics of the guidelines and compare the differences between these recommendations.

ETHICS AND DISSEMINATION

This study will follow the Declaration of Helsinki and has received approval from the Ethics Committee on Biomedical Research, West China Hospital, Sichuan University (ethics approval no. 2021-989). The results will be summarised as a paper, disseminated through peer-reviewed journals, and will help guide further research in the future.

PROTOCOL REGISTRATION NUMBER

CRD42021273405.

Incidence and risk factors of clinically important venous thromboembolism in tibial plateau fractures

While there are multiple reports on venous thromboembolism (VTE) associated with several orthopedic procedures, the knowledge regarding incidence and risk factors of VTE in tibial plateau fractures is limited. This study aimed to investigate the incidence and risk factors of clinically important venous thromboembolism (CIVTE) in patients with tibial plateau fractures. All adult patients who underwent surgical treatment of tibia plateau fractures between 2003 and 2018 in our level 1 trauma center were included in the study. All patients suspected CIVTE were assessed by the ultrasonography and/or CT scan. Univariate and multivariate analysis were used to evaluate the association between potential risk factors and CIVTE Variables. Thirty-nine of 462 patients (8.4%) developed clinically important venous thromboembolism, in which pulmonary embolism (PE) and deep vein thrombosis (DVT) were observed in 18 (3.9%) and 21 (4.54%) patients, respectively. Male gender (OR 9.75; 95% CI 2.34-40.66), spine injury (OR 9.51; 95% CI 3.39-26.64), other extremity injury (OR 3.7; 95% CI 1.58-8.66), length of stay in ICU (OR 1.14; 95% CI 1.09-1.2) were all risk factors for CIVTE. The incidence of CIVTE in tibial plateau fracture was relatively high (8.4%); The male gender, spine injury, other extremity injury, length of stay in ICU were the independent risk factors.

Venous thromboembolism prophylaxis with low molecular weight heparin versus unfractionated heparin for patients undergoing operative treatment of closed femoral shaft fractures

BACKGROUND

The objective of this study was to compare inpatient mortality rates for patients with operatively treated closed femoral shaft fractures (AO/OTA 32 A-C) who received venous thromboembolism (VTE) prophylaxis with either low molecular weight heparin (LMWH) or unfractionated heparin.

METHODS

This was a retrospective cohort study of a national database of patients presenting to Level I through IV trauma centers in the United States. All patients ≥18 years of age who sustained an operatively treated closed femoral shaft fracture were included. The primary outcome of inpatient mortality was compared between two groups: those who received LMWH or unfractionated heparin for VTE prophylaxis. Secondary outcomes were complications including VTE and bleeding events. Groups were compared using a multivariate regression model.

RESULTS

There were 2058 patients included in the study. Patients who received VTE prophylaxis with LMWH had lower odds of inpatient mortality compared to patients who received VTE prophylaxis with unfractionated heparin (OR 0.19; 95% CI 0.05 to 0.68, p = 0.011).

CONCLUSIONS

VTE prophylaxis with LMWH is associated with lower inpatient mortality compared to VTE prophylaxis with unfractionated heparin for patients undergoing operative treatment of closed femoral shaft fractures. To our knowledge this is the first study to report these associations for a specific subset of orthopedic trauma 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.

High Altitude as a Risk Factor for Venous Thromboembolism in Tibial Plateau Fractures

Background: Tibial plateau fractures are often significant injuries that can require complex surgical interventions with prolonged perioperative immobilization, thereby increasing the risk of developing venous thromboembolic (VTE) events, specifically, deep vein thrombosis (DVT) and pulmonary embolism (PE). Risk stratification is paramount for guiding VTE prophylaxis. Although high altitude has been suggested to create a prothrombotic state, virtually no studies have explored its clinical effects in lower extremity trauma. The purpose of this study was to compare surgical fixation of tibial plateau fractures at high and low altitudes and its effects on post-operative VTE development.

Methods: The Truven MarketScan claims database was used to retrospectively identify patients who underwent surgical fixation of isolated and closed tibial plateau fractures using Current Procedural Terminology (CPT) codes over a 10-year period. Extraneous injuries were excluded using the International Classification of Diseases, 10^th edition (ICD-10), and CPT codes. Patient demographics, comorbidities, and DVT chemoprophylaxis prescriptions were obtained. Patients were partitioned into high altitude (>4000 feet) or low altitude (<100 feet) cohorts based on the zip codes of their surgery locations. One-to-one matching and univariate analysis were used to assess and control any baseline discrepancies between cohorts; multivariate regression was then performed between cohorts to determine the odds ratios (OR) for developing VTEs post-operatively.

Results: There were 7,832 patients included for analysis. There was no statistical difference between high and low altitude cohorts in developing VTEs within 30 days post-operatively. Higher altitudes were associated with increased odds of developing DVT (OR 1.21, p = 0.043) and PE (OR 1.27, p = 0.037) within 90 days post-operatively.

Conclusions: Surgical fixation of tibial plateau fractures is associated with an increased risk of developing VTEs at high altitudes within 90 days post-operatively. Understanding such risk factors in specific orthopaedic patient populations is essential for optimizing DVT prophylaxis protocols. Further studies should investigate this relationship and the role of DVT prophylaxis regimens in this population. 

Qualitative analysis of randomized controlled trials informing recommendations for venous thromboembolism prophylaxis after distal lower extremity injuries

Purpose:

The purpose of this study is to assess the quality of evidence to stratify recommendations for chemoprophylaxis following distal lower extremity trauma.

Methods:

Literature review identified primary studies investigating venous thromboembolism (VTE) chemoprophylaxis following traumatic injury distal to the knee. Inclusion criteria were randomized controlled trials in adult patients treated with and without operative intervention. Each primary study was assessed by the Consolidated Standards of Reporting Trials 2010 checklist and Modified Coleman methodology score.

Results:

Literature review resulted in 462 studies, of which 9 met inclusion and exclusion criteria. All studies included low molecular weight heparin as a treatment group with 2 (22%) also including a treatment group with a direct factor Xa inhibitor. Five studies (56%) used placebo as a control group. The mean Modified Coleman Methodology score was 63% (range 51%–72%), a categorical rating of Fair. The mean Consolidated Standards of Reporting Trials score was 78% (range 56%–97%). Most studies (89%) screened all asymptomatic subjects for deep venous thrombosis. Statistical significance in VTE incidence among prophylactic treatment groups was not achieved in 78%.

Conclusions:

Development of consensus for VTE prophylaxis recommendations following traumatic injury distal to the knee is complicated by heterogenous study populations, low incidence of VTE in study populations, and inconsistent definitions of clinically important VTE. Low molecular weight heparin is not consistently superior for preventing VTE. Chemoprophylaxis should be considered on an individual basis in the presence of additional risk factors, although an externally validated, evidence-based risk assessment tool does not currently exist.

Level of Evidence: IV, therapeutic

Systemic Complications of Obesity in Operative Acetabular Fractures

OBJECTIVE

To determine the effect of obesity on rates of systemic complications in operatively treated acetabular fractures.

DESIGN

Retrospective Case-Control study.

SETTING

Level 1 Trauma Center.

PATIENTS/PARTICIPANTS

All patients with acetabular fractures managed operatively from January 2015 to December 2019. Patients were divided into groups based on their body mass index (BMI) (normal weight = BMI <25 kg/m2, overweight = BMI 25-30, obese = BMI 30-40, and morbidly obese = BMI >40).

INTERVENTION

Operative management of an acetabular fracture.

MAIN OUTCOME MEASUREMENT

Systemic complications, including mortality, sepsis, pneumonia, acute respiratory distress syndrome, deep vein thrombosis, pulmonary embolism, or venous thrombotic event.

RESULTS

A total of 428 patients were identified. One hundred nine patients (25.4%) were in normal weight, 133 (31.1%) were overweight, 133 (31.1%) were obese, and 53 (12.4%) were morbidly obese. The rate of systemic complications was 17.5%, and overall mortality rate was 0.005%. There were no significant differences between the different BMI groups in all-cause complications or any individual complications. When the morbidly obese group was compared with all other patients, there were also no significant differences in all-cause complications or any individual complications.

CONCLUSION

In conclusion, in this study, there was no association with increasing BMI and inpatient systemic complications after operative management of acetabular fractures. As we continue to refine our understanding of how obesity affects outcomes after acetabular fracture surgery, other indices of obesity might prove more useful in predicting complications. In the obese population, there are well-documented risks of postoperative infections and challenges in obtaining an anatomic reduction, but the fear of postoperative systemic complications should not deter surgeons from undertaking operative management of acetabular fractures in the obese population. Because the prevalence of obesity in trauma patients continues to increase, it is incumbent on us to continue to improve our understanding of optimal treatment for our patients.

LEVEL OF EVIDENCE

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

Administration of Venous Thromboembolism Chemoprophylaxis Within 12 Hours of Pelvic and Acetabular Surgery Has No Effect on Estimated Blood Loss, Perioperative Change in Hemoglobin, or Need for Transfusion

OBJECTIVE

To determine if preoperative administration of venous thromboembolism (VTE) chemoprophylaxis (PPx) before pelvic and acetabular fracture surgery affects estimated blood loss (EBL), perioperative change in hemoglobin (ΔHgb), or transfusion rates.

DESIGN

Retrospective cohort study.

SETTING

Level 1 trauma center, southeastern United States.

PATIENTS/PARTICIPANTS

All pelvic and acetabular surgeries performed between April 2014 and February 2020.

MAIN OUTCOME MEASUREMENTS

EBL, immediate and 24-hour postoperative ΔHgb, and intraoperative/postoperative transfusion.

RESULTS

In all, 267 surgeries were included: 97 prechange and 170 postchange. Median injury severity score was 17 before versus 14 after the change. One surgeon retired and two started during the study, producing differences in acetabular approaches. Median surgical duration was longer postchange. Cohorts were otherwise similar. No differences were observed in EBL, ΔHgb, or transfusion rates. Rates of VTE and surgical site complications were unchanged. No VTE-related deaths occurred. In the as-treated analysis (63 patients given low-molecular-weight heparin <12 hours preoperatively vs. 190 patients not given PPx), no differences were observed.

CONCLUSIONS

Administration of VTE PPx within 12 hours of pelvic and acetabular surgery had no effect on perioperative blood loss. This study is limited by changes in faculty, but it suggests that traumatologists need not advocate for holding VTE PPx before pelvic and acetabular trauma surgery.

LEVEL OF EVIDENCE

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

Chemoprophylaxis for venous thromboembolism in pelvic and/or acetabular fractures: A systematic review

BACKGROUND

It is unclear which pharmacological agents, and at what dosage and timing, are most effective for venous thromboembolism (VTE) prophylaxis in patients with pelvic/acetabular fractures.

METHODS

We searched the Cochrane Database of Systematic Reviews, Embase, Web of Science, EBSCO, and PubMed on October 3, 2020, for English-language studies of VTE prophylaxis in patients with pelvic/acetabular fractures. We applied no date limits. We included studies that compared efficacy of pharmacological agents for VTE prophylaxis, timing of administration of such agents, and/or dosage of such agents. We recorded interventions, sample sizes, and VTE incidence, including deep vein thrombosis (DVT) and pulmonary embolism.

RESULTS

Two studies (3604 patients) compared pharmacological agents, reporting that patients who received direct oral anticoagulants (DOACs) were less likely to develop DVT than those who received low molecular weight heparin (LMWH) (p < 0.01). Compared with unfractionated heparin (UH), LMWH was associated with lower odds of VTE (odds ratio [OR] = 0.37, 95% confidence interval [CI]: 0.22-0.63) and death (OR = 0.27, 95% CI: 0.10-0.72). Three studies (3107 patients) compared timing of VTE prophylaxis, reporting that late prophylaxis was associated with higher odds of VTE (OR = 1.9, 95% CI: 1.2-3.2) and death (OR = 4.0, 95% CI: 1.5-11) and higher rates of symptomatic DVT (9.2% vs. 2.5%, p = 0.03; and 22% vs. 3.1%, p = 0.01). One study (31 patients) investigated dosage of VTE prophylaxis, reporting that a higher proportion of patients with acetabular fractures were underdosed (23% of patients below range of anti-Factor Xa [aFXa] had acetabular fractures vs. 4.8% of patients within adequate range of aFXa, p<0.01).

CONCLUSIONS

Early VTE chemoprophylaxis (within 24 or 48 h after injury) was better than late administration in terms of VTE and death. Many patients with acetabular fractures are underdosed with LMWH, with inadequate aFXa levels. Compared with UH, LMWH was associated with lower odds of VTE and death. DOACs were associated with lower risk of DVT compared with LMWH.

LEVEL OF EVIDENCE

III, systematic review of retrospective cohort studies.

Upper-Extremity Venous Thromboembolism Following Operative Treatment of Distal Radius Fractures: An Uncommon but Dangerous Complication

PURPOSE

Distal radius fractures are the most common long bone fracture in the United States, with an estimated incidence of 640,000 cases per year. Operative fixation presents a theoretical risk factor for the development of upper-extremity venous thromboembolism (UE-VTE). Additionally, patients presenting with distal radius fracture commonly have preexisting comorbidities that further increase the risk of UE-VTE. Finally, UE-VTE is considered the highest risk for eventual development of pulmonary embolism. Despite this, scant attention has been paid to studying UE-VTE in this population. The purpose of this study was to measure the incidence of this complication and to identify possible medical factors that increased the risk of developing UE-VTE.

METHODS

We queried the Truven MarketScan Commercial Claims and Encounters Database for all patients who experienced a distal radius fracture and were subsequently treated with open reduction and internal fixation between 2012 and 2016. Patients were identified using relevant Common Procedural Terminology codes. Demographic and medical variables were tabulated. Our primary outcome was the development of ipsilateral UE-VTE or pulmonary embolism in the first 60 days after surgery.

RESULTS

The study included 24,494 patients. The mean age was 50.7 years (range, 18-91), and 58% were women. There were 79 cases (0.3%) of UE-VTE and 19 cases of pulmonary embolism in the study population (24.1% of all UE-VTE cases; 0.08% of total sample). Multivariable logistic regression showed that coexisting heart failure and estrogen use were associated with increased risk of UE-VTE.

CONCLUSIONS

Although uncommon, the development of UE-VTE after open reduction and internal fixation for distal radius fractures is a concerning complication. Coexisting heart failure and estrogen use are associated with increased risk of UE-VTE.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Inpatient compliance with venous thromboembolism prophylaxis after orthopaedic trauma: results from a randomized controlled trial of aspirin versus low molecular weight heparin

Objectives:

To compare inpatient compliance with venous thromboembolism prophylaxis regimens.

Design:

A secondary analysis of patients enrolled in the ADAPT (A Different Approach to Preventing Thrombosis) randomized controlled trial.

Setting:

Level I trauma center.

Patients/Participants:

Patients with operative extremity or any pelvic or acetabular fracture requiring venous thromboembolism prophylaxis.

Intervention:

We compared patients randomized to receive either low molecular weight heparin (LMWH) 30 mg or aspirin 81 mg BID during their inpatient admission.

Main Outcome Measurements:

The primary outcome measure was the number of doses missed compared with prescribed number of doses.

Results:

A total of 329 patients were randomized to receive either LMWH 30 mg BID (164 patients) or aspirin 81 mg BID (165 patients). No differences observed in percentage of patients who missed a dose (aspirin: 41.2% vs LMWH: 43.3%, P = .7) or mean number of missed doses (0.6 vs 0.7 doses, P = .4). The majority of patients (57.8%, n = 190) did not miss any doses. Missed doses were often associated with an operation.

Conclusions:

These data should reassure clinicians that inpatient compliance is similar for low molecular weight heparin and aspirin regimens.

Effects of Anticoagulant Medication on Bone-Healing

»

A substantial proportion of patients undergoing orthopaedic care are prescribed some form of anticoagulant medication, whether for perioperative venous thromboembolism prophylaxis or chronic anticoagulation in the setting of a cardiac or other condition.

»

An abundance of preclinical data suggests that many commonly used anticoagulant medications may have a harmful effect on bone-healing.

»

The orthopaedic surgeon should be informed and mindful of the added variable that anticoagulation may play in the outcomes of fracture treatment and bone-healing.

»

Heparin and warfarin appear to have a greater detrimental impact than low-molecular-weight heparin. Factor Xa inhibitors may confer the least risk, with some studies even suggesting the potential for enhancement of bone-healing.

PREVENTion of CLots in Orthopaedic Trauma (PREVENT CLOT): a randomised pragmatic trial protocol comparing aspirin versus low-molecular-weight heparin for blood clot prevention in orthopaedic trauma patients

INTRODUCTION

Patients who sustain orthopaedic trauma are at an increased risk of venous thromboembolism (VTE), including fatal pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin (LMWH) for VTE prophylaxis in orthopaedic trauma patients. However, emerging literature in total joint arthroplasty patients suggests the potential clinical benefits of VTE prophylaxis with aspirin. The primary aim of this trial is to compare aspirin with LMWH as a thromboprophylaxis in fracture patients.

METHODS AND ANALYSIS

PREVENT CLOT is a multicentre, randomised, pragmatic trial that aims to enrol 12 200 adult patients admitted to 1 of 21 participating centres with an operative extremity fracture, or any pelvis or acetabular fracture. The primary outcome is all-cause mortality. We will evaluate non-inferiority by testing whether the intention-to-treat difference in the probability of dying within 90 days of randomisation between aspirin and LMWH is less than our non-inferiority margin of 0.75%. Secondary efficacy outcomes include cause-specific mortality, non-fatal PE and deep vein thrombosis. Safety outcomes include bleeding complications, wound complications and deep surgical site infections.

ETHICS AND DISSEMINATION

The PREVENT CLOT trial has been approved by the ethics board at the coordinating centre (Johns Hopkins Bloomberg School of Public Health) and all participating sites. Recruitment began in April 2017 and will continue through 2021. As both study medications are currently in clinical use for VTE prophylaxis for orthopaedic trauma patients, the findings of this trial can be easily adopted into clinical practice. The results of this large, patient-centred pragmatic trial will help guide treatment choices to prevent VTE in fracture patients.

TRIAL REGISTRATION NUMBER

NCT02984384.

Institutional differences in management of compartment syndrome at academic and community-based trauma centers: A survey of Orthopaedic Trauma Association (OTA) members

OBJECTIVES

The purpose of this study was to compare management of compartment syndrome at academic and community trauma centers and to identify any institutional variables that influence the number of adverse events reported to the hospital's peer review process.

DESIGN

Web-based survey.

SETTING

N/A.

PARTICIPANTS

Orthopedic Trauma Association (OTA) members.

METHODS

A link to a 9-item web-based questionnaire was sent to members of the OTA.

RESULTS

Two hundred twenty-four (21%) of 1031 OTA members completed the survey. Respondents indicated that residents were primarily responsible for checking compartments at academic trauma centers (91%), while community trauma centers reported higher utilization rates of ortho attendings (81%), trauma attendings (26%), and nurses (27%). Seventy-five percent of respondents at academic trauma centers relied on intra-compartmental pressure monitoring to make the diagnosis in intubated/obtunded patients as opposed to just 56% of respondents at community centers. Seventy percent of all respondents utilizing prophylactic fasciotomies practiced at community trauma centers. Forty-four percent indicated that they had submitted cases involving management of compartment syndrome to their hospital peer review process. While most submitted only 1 or 2 cases (75% of positive replies), 5% had submitted 5 or more cases for peer review. Use of a pressure monitor and orthopaedic surgeons performing all fasciotomies were associated with a lower number of cases submitted to peer review (P < .02 and P < .04, respectively).

CONCLUSION

Academic and community trauma centers differ in their utilization of in-house staff for early assessment, in the diagnostic modalities employed in obtunded patients, and in their threshold for fasciotomy. Adverse events are regularly reported for peer review at both academic and community trauma centers. As there is great variability between institutions in terms of clinical practice as demonstrated by the responses to this survey, it is recommended that institutions devise their own written protocol based on the resources they have available to reduce adverse events.

LEVEL OF EVIDENCE

Therapeutic Level V.

Venous Thromboembolism Prophylaxis After Pelvic and Acetabular Fractures: A Survey of Orthopaedic Surgeons' Current Practices

INTRODUCTION

The goal of this study was to identify the current practices and rationale of orthopaedic surgeons regarding venous thromboembolism (VTE) prophylaxis for pelvic and acetabular (P&A) fractures.

METHODS

A 25-item web-based questionnaire was made available to all Orthopaedic Trauma Association (OTA) members on the OTA website. Analysis of data was performed after the three-month study period.

RESULTS

One hundred three active OTA members completed the survey. Most respondents practiced at an academic level I trauma centers. The most important factor in selecting a VTE regimen was its effectiveness, whereas cost was the least important. Low-molecular-weight heparin (LMWH) remains the preferred agent for VTE prophylaxis after P&A trauma. Factors such as surgical intervention and weight-bearing had a variable effect on surgeons' opinions regarding the type and duration of VTE prophylaxis.

CONCLUSION

Most surgeons treating P&A fractures use LMWH for VTE prophylaxis, but the decision on which agent to use and duration of treatment is multifactorial. Published VTE prophylaxis literature and guidelines provide some guidance, but there is no consensus. Overall, LMWH appears to be the VTE prophylaxis agent of choice for most orthopaedic trauma surgeons, irrespective of nonsurgical or surgical management of these fractures.

Aspirin versus low-molecular-weight heparin for venous thromboembolism prophylaxis in orthopaedic trauma patients: A patient-centered randomized controlled trial

Background

Emerging evidence suggests aspirin may be an effective venous thromboembolism (VTE) prophylaxis for orthopaedic trauma patients, with fewer bleeding complications. We used a patient-centered weighted composite outcome to globally evaluate aspirin versus low-molecular-weight heparin (LMWH) for VTE prevention in fracture patients.

Methods

We conducted an open-label randomized clinical trial of adult patients admitted to an academic trauma center with an operative extremity fracture, or a pelvis or acetabular fracture. Patients were randomized to receive LMWH (enoxaparin 30-mg) twice daily (n = 164) or aspirin 81-mg twice daily (n = 165). The primary outcome was a composite endpoint of bleeding complications, deep surgical site infection, deep vein thrombosis, pulmonary embolism, and death within 90 days of injury. A Global Rank test and weighted time to event analysis were used to determine the probability of treatment superiority for LMWH, given a 9% patient preference margin for oral administration over skin injections.

Results

Overall, 18 different combinations of outcomes were experienced by patients in the study. Ninety-nine patients in the aspirin group (59.9%) and 98 patients in the LMWH group (59.4%) were event-free within 90 days of injury. Using a Global Rank test, the LMWH had a 50.4% (95% CI, 47.7–53.2%, p = 0.73) probability of treatment superiority over aspirin. In the time to event analysis, LMWH had a 60.5% probability of treatment superiority over aspirin with considerable uncertainty (95% CI, 24.3–88.0%, p = 0.59).

Conclusion

The findings of the Global Rank test suggest no evidence of superiority between LMWH or aspirin for VTE prevention in fracture patients. LMWH demonstrated a 60.5% VTE prevention benefit in the weighted time to event analysis. However, this difference did not reach statistical significance and was similar to the elicited patient preferences for aspirin.

The Incidence of Venous Thromboembolism Following Pelvic and Lower Extremity Trauma Despite Adherence to Modern Prophylactic Protocols

OBJECTIVES

Describe the incidence of venous thromboembolism (VTE) in patients with pelvic and lower extremity long bone trauma in the setting of modern prophylaxis.

DESIGN

Retrospective health-system database study.

SETTING

Multi-center health care system.

PATIENTS

Database query from 2010 to 2017 identified 11,313 adult trauma patients who received open reduction internal fixation of pelvic, acetabular, femoral neck, or intertrochanteric fractures, or received intramedullary nailing (IMN) of the femoral or tibial shaft. Patients with incomplete prophylaxis, prior history of VTE, coagulopathy, or concomitant lower extremity fracture were excluded.

INTERVENTION

Mechanical and chemical VTE prophylaxis following pelvic or lower extremity fracture fixation.

MAIN OUTCOME MEASUREMENTS

VTE rates.

RESULTS

The overall VTE rate was 0.82% [0.39% deep venous thromboses (DVT); 0.43% pulmonary emboli (PE)]. By procedure, pelvic open reduction and internal fixation (ORIF) and femoral IMN had the highest VTE rates 1.70% (0.98% DVT; 0.78% PE) and 1.33% (0.75% DVT; 0.58% PE), whereas tibial IMN had the lowest incidence of VTE 0.34% (0.17% DVT; 0.17% PE). Among hip fractures, femoral neck ORIF had a VTE rate of 0.98% (0.59% DVT; 0.39% PE), whereas intertrochanteric ORIF had lower rates of 0.59% (0.20% DVT; 0.39% PE).

CONCLUSIONS

Despite adherence to modern VTEp protocols, nonpreventable VTE occur in 0.82% of pelvic and lower extremity orthopaedic trauma patients. Incidence ranged between 0.34% and 1.70% depending on injury/fixation method with the highest rate observed in pelvis ORIF followed by femoral IMN. In the era of pay for quality performance, it is important for health systems and auditing agencies to reconcile the difference between preventable and nonpreventable VTEs.

LEVEL OF EVIDENCE

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

Legal Implications in the Care of Orthopedic Patients: Serious Complications

To help reduce potentially devastating outcomes from spinal complications and venous thromboembolism, it is essential for the bedside nurse to have a comprehensive understanding of risk factors and assessments. The orthopedic nurse carries a responsibility for accurately assessing, documenting, and mobilizing the team when abnormal changes occur. Nurses act as patient advocates. The bedside nurse must communicate with the physician. If a patient or family sues the health care team, after a careful screening of the case for merit, the legal process begins. A health care provider should never give in to the temptation to alter medical records.

Venous thromboembolism after hospital discharge in pelvic and acetabular fracture patients treated operatively

PURPOSE

The purposes of this study were to determine the rate of venous thromboembolism (VTE) after discharge from the hospital in patients treated operatively with a pelvic ring or acetabular fracture and to define the main time frame in which VTE occurs within the 90-day period after hospital discharge.

METHODS

California and Florida State Inpatient Databases from 2005 to 2009 were used to identify patients with clinically significant VTEs within 90 days of hospital discharge. ICD-9 diagnosis codes identified patients with a pelvic ring or acetabular fracture and a VTE. Procedure codes distinguished patients having surgical fracture treatment. Deep vein thrombosis (DVT) and pulmonary embolus (PE) were included.

RESULTS

Overall, 13,589 patients had a pelvic ring or acetabular fracture and operative treatment. One hundred thirteen patients (0.83%) had a VTE within 90 days after hospital discharge: 69 (0.51%) had a DVT, 28 (0.21%) had a PE, and 16 (0.12%) had both. Twenty-four (28%) of DVTs and 10 (23%) of PEs occurred >35 days after discharge, being evenly distributed out to 90 days. There were five fatal PEs, occurring 2, 3, 7, 31, and 51 days after discharge. Therefore, overall, <0.2% of patients developed a DVT and <0.1% were diagnosed with a PE (only 1 fatal; <0.01%) >35 days after the index hospitalization.

CONCLUSIONS

A substantial proportion of VTE events occur over 35 days after discharge; however, the overall risk is low with fatal PE being extremely low (<0.01%). Given the diminished VTE risk after 35 days, the decision to further extend antithrombotic drug therapy may be guided by patient-specific factors, such as prolonged immobility.

Heparin-induced thrombocytopenia and acute colonic pseudo-obstruction after therapeutic anticoagulation in a very elderly patient with hip fracture: a case report

BACKGROUND

Hip fractures have become a severe public health problem, especially in very elderly patients. Most of them are treated with low molecular weight heparin as prophylaxis or treatment of venous thromboembolism. Heparin-induced thrombocytopenia is one of the complications induced by low molecular weight heparin, which may cause poor prognosis. However, there is not enough awareness for heparin-induced thrombocytopenia in very elderly trauma patients.

CASE PRESENTATION

We report a case of hip fracture with heparin-induced thrombocytopenia in a very elderly patient. The patient developed heparin-induced thrombocytopenia, digestive hemorrhage and acute colonic pseudo-obstruction after the use of low molecular weight heparin, which eventually led to death.

CONCLUSIONS

This is the first case report of digestive hemorrhage and acute colonic pseudo-obstruction in heparin-induced thrombocytopenia patients with major trauma. This case highlights the severity of HIT in very elderly patients with hip fractures using low molecular weight heparin, and the need for platelet monitoring in these patients. We indicate that there may be a correlation of pathogenesis between digestive hemorrhage and acute colonic pseudo-obstruction in heparin-induced thrombocytopenia patients.

Thromboprophylaxis an update of current practice: Can we reach a consensus?

Diagnosis, prophylaxis, and management of venous thromboembolism (VTE) in patients with fractures remain a highly controversial topic with little consensus in clinical practice or the literature. The following manuscript represents a summary of evidence presented at the 2017 OTA Annual Meeting Symposium; "Thromboprophylaxis an Update of Current Practice: Can We Reach A Consensus?" The need for prophylaxis in pelvic and acetabular fracture patients; the existing body of evidence related to VTE, pulmonary embolism (PE), and prophylaxis for patients with fractures about the knee; current evidence in Edinburgh Scotland, regarding VTE prophylaxis in patients with isolated ankle fractures and the risk of VTE in patients with a hip fracture are topics that are addressed. The reader will benefit from the wisdom of this compilation of global contributions on thromboprophylaxis.

Underdosing of Prophylactic Enoxaparin Is Common in Orthopaedic Trauma and Predicts 90-Day Venous Thromboembolism

OBJECTIVES

To determine the feasibility and impact of real-time anti-factor Xa (aFXa) level monitoring and enoxaparin dose adjustment in orthopaedic trauma. To examine the adequacy of standard fixed-dose enoxaparin chemoprophylaxis and to examine whether patient-specific factors influence enoxaparin metabolism.

DESIGN

Prospective cohort.

SETTING

Academic Level-I trauma center.

PATIENTS

Postoperative adult orthopaedic trauma patients undergoing acute fracture or nonunion surgery of the pelvis, acetabulum, or lower extremity placed on 30 mg of enoxaparin twice daily.

INTERVENTION

Peak steady-state aFXa levels were drawn with a goal range of 0.2-0.4 IU/mL. Patients with out-of-range levels underwent a 10-mg dose adjustment followed by repeat aFXa draws.

MAIN OUTCOME MEASURES

Peak and trough aFXa levels, 90-day venous thromboembolism, and bleed events.

RESULTS

Of 109 enrolled patients, 43% had inadequate initial peak aFXa levels (aFXa < 0.2 IU/mL) with standard dosing. Higher gross weight, acetabular surgery, and operation length predicted low aFXa levels (P < 0.001, 0.006, 0.004, respectively). Dose adjustment increased the proportion of patients with in-range aFXa levels from 53.2% to 87.8% (P < 0.001). Patients with low aFXa levels during hospitalization or at discharge had significantly higher 90-day deep vein thrombosis and pulmonary embolism rates compared to those with adequate aFXa levels (deep vein thrombosis 12% vs. 1.36%; P = 0.023, pulmonary embolism 8% vs. 0%; P = 0.027). There were no major bleed events.

CONCLUSIONS

Patients receiving inadequate enoxaparin chemoprophylaxis were at significantly increased risk of 90-day venous thromboembolism. Standard fixed-dose enoxaparin provided inadequate chemoprophylaxis in 43% of postoperative orthopaedic trauma patients, which significantly improved with dose adjustment. Weight, acetabular surgery, and operation length predicted inadequate enoxaparin prophylaxis.

LEVEL OF EVIDENCE

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

Venous thromboembolism rates remained unchanged in operative lower extremity orthopaedic trauma patients from 2008 to 2016

BACKGROUND

Venous thromboembolism (VTE) is a serious complication that contributes to morbidity, mortality, and healthcare costs during the surgical care of patient with lower extremity fractures. Despite this, few recommendations on the topic exist and the literature on VTE incidence is incomplete. Therefore, this study will attempt to estimate annual incidence and trends in 30-day thrombotic events and mortality for the following fractures: (1) hip, (2) femur, (3) patella, (4) tibia and/or fibula, and (5) ankle.

METHODS

We identified 120,521 operative lower extremity orthopaedic trauma patients from 2008 to 2016 using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. To evaluate the relationship between the year in which surgery was performed and comorbidities and demographic information bivariate analysis was performed. Bivariate analysis was also performed for the outcomes of interest and year in which the surgery was performed to assess for change. Additionally, bimodal multivariate logistic regression models for hip, femur, and ankle fractures were built, comparing the years 2009 to 2016 using 2008 as a baseline.

RESULTS

Overall incidence for VTE over the study period was 1.7% for hip fractures, 2.4% for femur fractures, 0.9% for patella fractures, 1.1% in tibia and/or fibula fractures, and 0.6% in ankle fractures. Over the study period VTE incidence saw a significant decrease (p < 0.05) in hip and femur fractures, but not for patella, tibia and/or fibula, and ankle fractures. After adjusting for confounding factors with multivariate analysis, the change in hip and femur fractures was no longer significant, while no significant decrease was again found for ankle fractures (p > 0.05).

CONCLUSION

Our study demonstrates that VTE rates have remained unchanged in operative lower extremity orthopaedic trauma from 2008 to 2016. This highlights the need for higher quality evidence on this important topic in orthopaedic trauma, including a reevaluation on the necessity of thromboprophylaxis guidelines.

LEVEL OF EVIDENCE

III.

Ankle Fractures: An Expert Survey of Orthopaedic Trauma Association Members and Evidence-Based Treatment Recommendations

OBJECTIVES

To describe current practice patterns of orthopaedic trauma experts regarding the management of ankle fractures, to review the current literature, and to provide recommendations for care based on a standardized grading system.

DESIGN

Web-based survey.

PARTICIPANTS

Orthopaedic Trauma Association (OTA) members.

METHODS

A 27-item web-based questionnaire was advertised to members of the OTA. Using a cross-sectional survey study design, we evaluated the preferences in diagnosis and treatment of ankle fractures.

RESULTS

One hundred sixty-six of 1967 OTA members (8.4%) completed the survey (16% of active members). There is considerable variability in the preferred method of diagnosis and treatment of ankle fractures among the members surveyed. Most responses are in keeping with best evidence available.

CONCLUSIONS

Current controversy remains in the management of ankle fractures. This is reflected in the treatment preferences of the OTA members who responded to this survey.

LEVEL OF EVIDENCE

Therapeutic Level V. See Instructions for authors for a complete description of levels of evidence.

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.

Chemoprophylaxis for the Hip Fracture Patient: A Comparison of Warfarin and Low-Molecular-Weight Heparin

OBJECTIVE

To compare the rates of deep venous thrombosis (DVT), rates of pulmonary embolus (PE), and complication profiles of warfarin and low-molecular-weight heparin (LMWH) in patients undergoing operative fixation of hip fractures.

DESIGN

Retrospective cohort study.

SETTING

Insurance-based database of more than 22 million patient records.

PATIENTS

Adult hip fracture patients who were treated operatively and received chemoprophylaxis from 2007 to 2016. A total of 7594 patients met inclusion criteria and were available for final analysis.

INTERVENTION

Pharmacological anticoagulation with warfarin or LMWH to prevent postoperative venous thromboembolism after hip fracture surgery.

MAIN OUTCOME MEASURES

Development of DVT or PE within 30 and 90 days of surgery.

RESULTS

Patients prescribed warfarin had higher rates of DVT and PE compared with those prescribed LMWH. Patients on warfarin were more likely to develop a postoperative hematoma and to be readmitted within 30 and 90 days compared with those on LMWH. Patients in both groups had similar rates of total complications.

CONCLUSIONS

Patients prescribed warfarin after hip fractures had higher rates of DVT and PE compared with those prescribed LMWH, although both agents had similar complication profiles.

LEVEL OF EVIDENCE

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

Post-discharge adherence with venous thromboembolism prophylaxis after orthopedic trauma: Results from a randomized controlled trial of aspirin versus low molecular weight heparin

BACKGROUND

Orthopedic trauma patients are often treated with venous thromboembolism (VTE) chemoprophylaxis with aspirin or low molecular weight heparin (LMWH) after discharge from their index admission, but adherence patterns are not known. We hypothesized that overall adherence would be moderate and greater with aspirin compared to LMWH.

METHODS

We conducted a randomized controlled trial of adult trauma patients with an operative extremity fracture or any pelvic/acetabular fracture requiring VTE prophylaxis. Patients were randomized to receive either LMWH 30 mg BID or aspirin 81 mg BID. Patients prescribed outpatient prophylaxis were contacted between 10 and 21 days after discharge to assess adherence measured by the validated Morisky Medication Adherence Scale (MMAS-8). Adherence scores were compared between the two treatment arms with similar results for intention-to-treat and as-treated analyses. As-treated multivariable logistic regression was performed to determine factors associated with low-medium adherence scores.

RESULTS

One hundred fifty patients (64 on LMWH, 86 on aspirin) on chemoprophylaxis at time of follow-up completed the questionnaire. As-treated analysis showed that adherence was high overall (mean MMAS 7.2 out of 8, SD 1.5) and similar for the two regimens (LMWH: 7.4 vs. aspirin: 7.0, p = 0.13). However, patients on LMWH were more likely to feel hassled by their regimen (23% vs. 9%, p = 0.02). In a multivariable model, low-medium adherence was associated with taking LMWH as the prophylaxis medication (aOR 2.34, CI 1.06-5.18, p = 0.04), having to self-administer the prophylaxis (aOR 4.44, CI 1.45-13.61, p < 0.01), being of male sex (aOR 2.46, CI 1.10-5.49, p = 0.03), and of younger age (aOR 0.72 per additional 10 years of age, CI 0.57-0.91, p < 0.01).

CONCLUSIONS

Overall post-discharge adherence with VTE prophylaxis was high. Several factors, including prophylaxis by LMWH, were associated with decreased adherence. These factors should be considered when managing patients and designing efficacy trials.

LEVEL OF EVIDENCE

Therapeutic, level II.

Venous Thromboembolism in Upper Extremity Fractures

BACKGROUND

Venous thromboembolism (VTE) has been studied in lower extremity fractures but little is known of its relation with upper extremity (UE) fractures. As an often overlooked but serious complication, VTE may compromise patient outcomes.

METHODS

Using data on inpatients (aged ≥ 18 years) at a level-I trauma center and patients in the National Surgical Quality Improvement Program database who sustained UE fractures (clavicle, humerus, or radius/ulna) and VTE in the same hospitalization between 2007 and 2014, the authors analyzed data on demographic characteristics, fracture type, VTE location (pulmonary embolism, lower extremity, or UE), VTE onset, polytrauma, operative or nonoperative management, comorbidities, and mortality.

RESULTS

Of 1984 inpatients with UE fractures at 1 instution, 9 experienced VTE on admission, and 17 (15 received thromboprophylaxis) experienced VTE during hospitalization, for an overall VTE rate of 1.3%. VTE occurred most often in patients with fractures of the proximal humerus (3.0%) followed by the clavicle (2.0%), midshaft humerus (1.9%), distal radius/ulna (0.95%), and distal humerus/elbow (0.36%) (p = 0.0035). There were no significant trends in the incidence of PE (p = 0.33) over the study period, but there was a sharp rise since 2011. In the national database, 42 of 11570 (0.36%) patients with UE fracture had VTE, with incidence by fracture location ranging from 0.14% (radius/ulna) to 0.98% (proximal humerus) (p = 0.00001). Predictors were chronic steroid use (odds ratio [OR] = 6.22, p = .030), inpatient status (OR = 4.09, p = .002), and totally disabled functional status (OR = 3.31, p = .021).

CONCLUSIONS

VTE incidence was highest following proximal humerus or clavicle fractures and are rarely associated with radius/ulna fractures. There may have been a rise in the incidence of PE since 2007, warranting further investigation.

Use of reprocessed external fixators in orthopaedic surgery: a survey of 243 orthopaedic trauma surgeons

Background

The increasing financial burden of orthopaedic implants on our health care system has prompted cost-control measures, such as implant reprocessing. The purpose of this study was to describe the current usage by orthopaedic trauma surgeons of reprocessed external fixators (EFs) for treatment of complex fractures.

Methods

A 16-question survey about use and perceptions of reprocessed EFs was distributed to 894 Orthopaedic Trauma Association members between August 2016 and June 2017 using a web-based survey system.

Results

The authors received 243 responses (27%). Thirty-seven percent of respondents reported using reprocessed EFs. Nonprofit hospitals used reprocessed EFs more commonly than did for-profit hospitals (41% vs 15%, P = .0004). Eighty-seven percent of respondents believed reprocessing could be cost-effective. The most common reason (32%) for not using reprocessed EFs was coordination/logistics of reprocessing. Concern about litigation was also reported as a main reason for not using (20%) or having recently stopped using (21%) reprocessed EFs.

Conclusions

Many orthopaedic traumatologists are interested in the reprocessing of EF components but few have reprocessing systems in place at their institutions. A major barrier to implementation is concern about litigation, which is likely unwarranted on the basis of Food and Drug Administration approval and a lack of previous litigation. Reprocessing by the original device manufacturers has yielded substantial savings at our institution and is an example of the cost savings that can be expected when implementing an EF reprocessing system.

Assessment of 30-day mortality and complication rates associated with extended deep vein thrombosis prophylaxis following hip fracture surgery

BACKGROUND

DVT is a common complication following lower extremity surgery, occurring in up to 60% of patients undergoing hip fracture surgery without postoperative anticoagulation. The risk of fatal PE continues well-beyond two weeks postoperatively, thus extended DVT prophylaxis beyond 14 days may be warranted. This investigation sought to examine the association between prescription of extended DVT prophylaxis and 30-day postoperative complications following hip fracture surgery.

METHODS

This study utilized the ACS NSQIP Hip Fracture Procedure Targeted dataset, a newly available set of patient variables for 2016. The outcome measures were death, occurrence of any postoperative complication, complication subtype, readmission or reoperation within 30-days postoperatively, and length of stay. The primary independent variable was medical DVT prophylaxis continued 28-days postoperatively ("extended DVT prophylaxis"). The control group contains both patients receiving no prophylaxis and those receiving short-duration prophylaxis. Multivariate stepwise logistic regression was employed to control for potential demographic, comorbidity, and procedural/medical confounding factors.

RESULTS

In total, 7533 surgically treated hip fracture patients treated in 2016 were analyzed. Overall, 57.8% of patients (n = 4354) were prescribed extended DVT prophylaxis. On bivariate analysis, prescription of extended DVT prophylaxis was associated with significantly lower incidence of death (7.7% without vs. 2.7% with, p < 0.0001) and stroke/CVA (1.4% vs. 0.6%, p = 0.0016). In multivariate analysis, prescription of extended DVT prophylaxis was significantly associated with lower odds of death (OR 0.33, p < 0.0001), stroke/CVA (OR 0.44, p = 0.0010), and acute kidney injury (AKI) (OR 0.31, p = 0.0010).

CONCLUSIONS

This retrospective cohort study of the 2016 ACS NSQIP found that hip fracture surgery patients prescribed ≥28 days of postoperative DVT prophylaxis exhibited 67% lower odds of death and significantly lower rates of AKI and stroke/CVA as compared to those prescribed short-duration prophylaxis. Given the retrospective and uncontrolled nature of this analysis, these results should be interpreted with caution, and additional prospective randomized controlled trials examining the association between extended DVT prophylaxis and postoperative outcomes are warranted. If these observations accurately reflect real-world experience, these data suggest that ≥28 days of DVT prophylaxis following hip fracture surgery should be strongly considered for patients without explicit contraindications.

Acute Compartment Syndrome: An Expert Survey of Orthopaedic Trauma Association Members

OBJECTIVES

The goal of this study was to describe current opinions of orthopaedic trauma experts regarding acute compartment syndrome (ACS).

DESIGN

Web-based survey.

PARTICIPANTS

Active Orthopaedic Trauma Association (OTA) members.

METHODS

A 25-item web-based questionnaire was advertised to active members of the OTA. Using a cross-sectional survey study design, we evaluated the perceived importance of ACS, as well as preferences in diagnosis and treatment.

RESULTS

One hundred thirty-nine of 596 active OTA members (23%) completed the survey. ACS was believed to be clinically important and with severe sequelae, if missed. Responses indicated that diagnosis should be based on physical examination in an awake patient, and that intracompartmental pressure testing was valuable in the obtunded or unconscious patient. The diagnosis of ACS with monitoring should be made using the difference between diastolic blood pressure and intracompartmental pressure (ΔP) of ≤30 mm Hg. Once ACS is diagnosed, respondents indicated that fasciotomies should be performed as quickly as is reasonable (within 2 hours). The consensus for wound management was closure or skin grafting within 1-5 days later, and skin grafting was universally recommended if closure was delayed to >7 days.

CONCLUSIONS

ACS is a challenging problem with poor outcomes if missed or inadequately treated. OTA members demonstrated agreement to many diagnostic and treatment choices for ACS.

LEVEL OF EVIDENCE

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

Venous Thromboembolism Disease Prophylaxis in Foot and Ankle Surgery

There are limited data to guide the use of venous thromboembolism disease (VTED) prophylaxis after foot and ankle surgery. Although there is general consensus that the overall risk is lower than after hip or knee replacement, subpopulations of patients may be at relatively heightened risk. Furthermore, existing data are often conflicting regarding the efficacy of prophylaxis, with little acknowledgment of the tradeoffs between VTED prophylaxis and potential complications associated with the use of such medications. This article provides an overview of currently available evidence to guide decision making regarding VTED prophylaxis in patients who undergo foot and ankle surgery.

Venous Thromboembolism-Related Readmission in Emergency General Surgery Patients: A Role for Prophylaxis on Discharge?

BACKGROUND

Patients undergoing emergency general surgery (EGS) operations experience high rates of venous thromboembolism (VTE). The rates at which thrombus formation occurs after discharge, and whether VTE prophylaxis at discharge might be warranted to prevent readmission, are unknown. This analysis aimed to determine risk factors associated with VTE formation after discharge for EGS operations.

STUDY DESIGN

An analysis of the American College of Surgeons NSQIP database from 2013 and 2014 of patients undergoing 10 common EGS operations in an emergent fashion. Multivariable logistic regression modeling was used to determine factors that predicted VTE after discharge.

RESULTS

A total of 130,036 patients were included. The 30-day VTE rate was 1.30%, with 35% of all VTEs occurring after discharge. Of those who had VTE develop after discharge, 69.4% required readmission. Predictive factors for post-discharge VTE included prolonged length of stay (odds ratio [OR] 5.25; p < 0.001), presence of metastatic cancer (OR 2.23; p < 0.001), urinary tract infection (OR 1.91; p < 0.001), and postoperative sepsis (OR 1.55; p < 0.001). Identified high-risk groups had a rate of readmission with thrombus 6 times greater than that of average-risk EGS patients.

CONCLUSIONS

More than 30% of VTEs in the EGS population occur after discharge; of these, a vast majority require readmission. Select high-risk EGS subgroups might benefit from prophylactic anticoagulation at discharge.

Evaluation of Appropriate Venous Thromboembolism Prophylaxis in Patients With Orthopaedic Trauma With Symptom-Driven Vascular and Radiographic Studies

OBJECTIVE

To evaluate venous thromboembolism (VTE) prophylaxis adherence and effectiveness in orthopaedic trauma patients who had vascular or radiographic studies showing deep vein thromboses or pulmonary emboli.

DESIGN

Retrospective review.

SETTING

A level I trauma center that independently services a 5-state region.

PATIENTS

Four hundred seventy-six patients with orthopaedic trauma who underwent operative treatments for orthopaedic injuries and had symptom-driven diagnostic VTE studies.

INTERVENTION

The medical records of patients treated surgically between July 2010 and March 2013 were interrogated using a technical tool that electronically captures thrombotic event data from vascular and radiologic imaging studies by natural language processing.

MAIN OUTCOME MEASUREMENTS

Patients were evaluated for hospital guideline-directed VTE prophylaxis adherence with mechanical or chemical prophylaxis. Patient demographics, associated injuries, mechanism of injury, and symptoms that led to imaging for a VTE were also assessed.

RESULTS

Of the 476 orthopaedic patients who met inclusion criteria, 100 (mean age 52.3 median 52, SD 18.3, 70% men) had positive VTE studies. Three hundred seventy-six (age 47.3, SD 17.3, 69% men) had negative VTE studies. Of the 100 patients with VTE, 63 deep vein thromboses, and 49 pulmonary emboli were found. Eight-five percent of all patients met hospital guideline-VTE prophylaxis standards.

CONCLUSION

The study population had better than previously reported VTE prophylaxis adherence, however, patients still developed VTEs.

LEVEL OF EVIDENCE

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

Chemoprophylaxis for Venous Thromboembolism in Operative Treatment of Fractures of the Tibia and Distal Bones: A Systematic Review and Meta-analysis

OBJECTIVES

Clinical practice has shifted from therapeutic anticoagulation of any lower extremity venous thromboembolism (VTE) to only thromboses with risk of proximal extension or embolization-clinically important VTE (CIVTE). Isolated operative fractures of the tibia or distal bone of the lower extremity are associated with low-to-intermediate VTE risk, and there is wide variability in the choice to anticoagulate as well as anticoagulant. We sought to evaluate the role for chemoprophylaxis of VTE and CIVTE in these injuries by meta-analysis of Level I evidence.

DATA SOURCES

Articles in English, Chinese, French, and German in MEDLINE, Biosis, and EMBASE from 1988 to 2016.

STUDY SELECTION

Randomized controlled trials describing chemoprophylaxis of VTE after operative management of fractures of the tibia and distal bones. Independent review of 1502 citations yielded 5 studies (1181 patients) meeting inclusion criteria.

DATA EXTRACTION

Chemoprophylaxis regimen, VTE, CIVTE, and major bleeding events were recorded. Study quality was assessed with regard to randomization, outcome assessment allocation and treatment concealment, and commercial funding.

DATA SYNTHESIS

A random-effects model meta-analysis determined that chemoprophylaxis with a low-molecular-weight heparin (LMWH) compared with placebo or no intervention significantly reduced the risk of any VTE [pooled relative risk (RR) = 0.696, 95% confidence interval (0.490-0.989), P = 0.043; homogeneity P = 0.818, I = 0%]. However, chemoprophylaxis with a LMWH compared with placebo did not significantly reduce the risk of CIVTE [RR = 0.865, 95% confidence interval (pooled RR = 0.112-3.863), P = 0.790; homogeneity P = 0.718, I = 0%]. No major bleeding events occurred. Funnel plots did not suggest publication bias. The number needed to treat was 31 patients treated with chemoprophylaxis using a LMWH to prevent 1 VTE and 584 patients to prevent 1 CIVTE.

CONCLUSIONS

Meta-analysis of Level I evidence suggests that routine postoperative anticoagulation after surgical management of an isolated fracture of the tibia or distal bone in patients without risk factors for VTE is unlikely to provide a clinical benefit, based on the absence of a treatment effect for preventing VTE warranting therapeutic anticoagulation.

LEVEL OF EVIDENCE

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

Patient preferences for venous thromboembolism prophylaxis after injury: a discrete choice experiment

OBJECTIVE

Limited evidence for the optimal venous thromboembolism (VTE) prophylaxis regimen in orthopaedic trauma leads to variability in regimens. We sought to delineate patient preferences towards cost, complication profile, and administration route (oral tablet vs. subcutaneous injection).

DESIGN

Discrete choice experiment (DCE).

SETTING

Level 1 trauma center in Baltimore, USA.

PARTICIPANTS

232 adult trauma patients (mean age 47.9 years) with pelvic or acetabular fractures or operative extremity fractures.

PRIMARY AND SECONDARY OUTCOME MEASURES

Relative preferences and trade-off estimates for a 1% reduction in complications were estimated using multinomial logit modelling. Interaction terms were added to the model to assess heterogeneity in preferences.

RESULTS

Patients preferred oral tablets over subcutaneous injections (marginal utility, 0.16; 95% CI: 0.11 - 0.21, P<0.0001). Preferences changed in favor of subcutaneous injections with an absolute risk reduction of 6.98% in bleeding, 4.53% in wound complications requiring reoperation, 1.27% in VTE, and 0.07% in death from pulmonary embolism (PE). Patient characteristics (sex, race, type of injury, time since injury) affected patient preferences (P<0.01).

CONCLUSIONS

Patients preferred oral prophylaxis and were most concerned about risk of death from PE. Furthermore, the findings estimated the trade-offs acceptable to patients and heterogeneity in preferences for VTE prophylaxis.