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Yakkanti RR, Mohile NV, Cohen-Levy WB, Haziza S, Lavelle MJ, Bellam KG, Quinnan SM. Perioperative management of acetabular and pelvic fractures: evidence-based recommendations. Arch Orthop Trauma Surg 2023; 143:1311-1321. [PMID: 34854977 DOI: 10.1007/s00402-021-04278-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 11/24/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and consolidate the relevant historical and recent literature in important topics pertaining to perioperative management of PAF. METHODS A thorough literature review using PubMed, Cochrane and Embase databases was performed to assess preoperative, intraoperative and postoperative management of PAF fracture. Topics reviewed included: time from injury to definitive fixation, the role of inferior vena cava filters (IVCF), tranexamic acid (TXA) use, intraopoperative cell salvage, incisional negative pressure wound therapy (NPWT), intraoperative antibiotic powder use, heterotopic ossification prophylaxis, and pre- and postoperative venous thromboembolism (VTE) prophylaxis. RESULTS A total of 126 articles pertaining to the preoperative, intraoperative and postoperative management of PAF were reviewed. Articles reviewed by topic include 13 articles pertaining to time to fixation, 23 on IVCF use, 14 on VTE prophylaxis, 20 on TXA use, 10 on cell salvage, 10 on iNPWT 14 on intraoperative antibiotic powder and 20 on HO prophylaxis. An additional eight articles were reviewed to describe background information. Five articles provided information for two or more treatment modalities and were therefore included in multiple categories when tabulating the number of articles reviewed per topic. CONCLUSION The literature supports the use of radiation therapy for HO prophylaxis, early (< 5 days from injury) surgical intervention and the routine use of intraoperative TXA. The literature does not support the routine use of iNPWT or IVCF. There is inadequate information to make a recommendation regarding the use of cell salvage and wound infiltration with antibiotic powder. While the routine use of chemical VTE prophylaxis is recommended, there is insufficient evidence to recommend the optimal agent and duration of therapy.
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Affiliation(s)
- Ramakanth R Yakkanti
- Department of Orthopaedic Surgery, University of Miami University Hospital, West Wing, 1321 NW 14th st, Suite 306, Miami, FL, 33125, USA
| | - Neil V Mohile
- Department of Orthopaedic Surgery, University of Miami University Hospital, West Wing, 1321 NW 14th st, Suite 306, Miami, FL, 33125, USA
| | | | - Sagie Haziza
- Department of Orthopaedic Surgery, University of Miami University Hospital, West Wing, 1321 NW 14th st, Suite 306, Miami, FL, 33125, USA.
| | - Matthew J Lavelle
- Department of Orthopaedic Surgery, University of Miami University Hospital, West Wing, 1321 NW 14th st, Suite 306, Miami, FL, 33125, USA
| | - Krishna G Bellam
- Warren Alpert Medical School at Brown University, Providence, RI, USA
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Crush J, Seah M, Chou D, Rawal J, Hull P, Carrothers A. Sequential low molecular weight heparin and rivaroxaban for venous thromboprophylaxis in pelvic and acetabular trauma. Arch Orthop Trauma Surg 2022; 142:3271-3277. [PMID: 34495362 DOI: 10.1007/s00402-021-04152-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 08/31/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Patients with pelvic trauma are at high risk of thromboembolic complications, but effective methods of prophylaxis are still to be accepted widely. The incidence of venous thromboembolism (VTE) has been reported to be as high as 61%, which represents the commonest cause of morbidity and mortality in this cohort. New oral anticoagulants are now available and may be used instead of LMWH injections for extended prophylaxis. Rivaroxaban has not been comprehensively considered in the previous pelvic and acetabular trauma literature, but its known benefits include increased patient compliance, especially in the minority of patients who are unable to self-administer injections, and that it does not require monitoring. MATERIALS AND METHODS All patients referred to our pelvic trauma service between 2015 and 2020 were considered for this study, exclusion criteria involved those patients who had contraindications to rivaroxaban, those who were referred to our service but were never managed at our centre and those managed by other teams (e.g. neurosurgery). Operative patients were initially managed with LMWH until 24 h post-operatively when they started rivaroxaban. Conservatively managed patients started Rivaroxaban straight away. Data were collected on demographics, injury mechanism, fracture classification and clinically relevant VTE and bleeding events up until 3 months post discharge. RESULTS The overall incidence of VTE was 2%. These represented 3 DVTs and 3 PEs, and occurred in patients who were managed operatively. No major bleeding events were observed. There were two minor bleeding events, both occurring in patients who were managed conservatively with rivaroxaban alone, and they did not require further intervention. 90% of patients surveyed expressed preference for oral prophylaxis. Reported compliance with rivaroxaban was 100%. CONCLUSION Our data show that this VTE regimen protocol is safe and effective in this group of injured patients and is at least non-inferior to the standard prophylaxis of LMWH alone.
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Affiliation(s)
- Jos Crush
- Division of Trauma and Orthopaedic Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK.
| | - Matthew Seah
- Division of Trauma and Orthopaedic Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Daud Chou
- Division of Trauma and Orthopaedic Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Jaikirty Rawal
- Division of Trauma and Orthopaedic Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Peter Hull
- Division of Trauma and Orthopaedic Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Andrew Carrothers
- Division of Trauma and Orthopaedic Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
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Mahmoud SS, Esser M, Jain A. Thromboembolic events in pelvic and acetabulum fractures: a systematic review of the current literature on incidence, screening, and thromboprophylaxis. INTERNATIONAL ORTHOPAEDICS 2022; 46:1707-1720. [PMID: 35543748 DOI: 10.1007/s00264-022-05431-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/03/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Rates of venous thromboembolic events (VTEs) as high as 41% deep vein thrombosis (DVT) were reported in association with pelvic and acetabular fractures (PAFs). There is no clear consensus on VTE prophylaxis for PAFs. Extracting evidence-based guidelines is key to overcome this challenging complication. The aims of this review are (A) to highlight the incidence of VTEs in PAFs, (B) to examine the screening and prophylaxis methods available in the current literature, and (C) direct future creation of a best practice protocol to reduce the risk of VTE in PAFs. METHODS We performed a systematic search of Medline, EMBASE databases, and the Cochrane library. MESH terms were used to identify studies pertinent to VTE in PAFs, including incidence, prophylaxis, and screening. RESULTS In total, 28 studies were identified and grouped into four categories including incidence, screening, prophylaxis, and the use of inferior vena cava filters (IVCFs). Incidence of VTE ranged from 0.21 to 41% for DVT and 0 to 21.7% for PE. Nine studies screened 1360 patients using different imaging modalities. Ten articles, 2836 patients, examined different thromboprophylaxis protocols. Two out of three studies investigating the use of IVCF showed significant reduction of the rates of PE. CONCLUSION Incidence of VTE in PAF varies significantly with different protocols. The current literature shows that screening is still controversial. The combination of chemical and mechanical prophylaxis starting at 24 hours from the injury would provide the best protection. Guidelines were extracted; however, higher level multicenter studies are still required to guide future protocols.
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Affiliation(s)
- Samer Ss Mahmoud
- The Alfred Hospital, 55 Commercial Road, Melbourne, VIC, 3000, Australia.
| | - Max Esser
- Department of Orthopaedic Surgery, The Alfred Hospital, Melbourne, Australia.,Associate Professor, Department of Surgery, Monash University, Melbourne, Australia
| | - Arvind Jain
- Department of Orthopaedic Surgery, The Alfred Hospital, Melbourne, Australia.,Associate Professor, Department of Surgery, Monash University, Melbourne, Australia.,Melbourne Bone and Joint Clinic, 27 Erin Street Richmond, Melbourne, VIC, 3121, Australia
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Lameka M, Mabry S, Montgomery T, Wilson AL, Fellows K, McGwin G, Spitler CA. Systemic Complications of Obesity in Operative Acetabular Fractures. J Orthop Trauma 2022; 36:184-188. [PMID: 34456314 DOI: 10.1097/bot.0000000000002253] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Megan Lameka
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL; and
| | - Scott Mabry
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL; and
| | - Tyler Montgomery
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL; and
| | - Anthony L Wilson
- University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Kenneth Fellows
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL; and
| | - Gerald McGwin
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL; and
| | - Clay A Spitler
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL; and
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Cerbasi S, Bernasconi A, Balato G, Dimitri F, Zingaretti O, Orabona G, Pascarella R, Mariconda M. Assessment of deep vein thrombosis using routine pre- and postoperative duplex Doppler ultrasound in patients with pelvic trauma : a prospective study. Bone Joint J 2022; 104-B:283-289. [PMID: 35094570 DOI: 10.1302/0301-620x.104b2.bjj-2021-0764.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aims of this study were to assess the pre- and postoperative incidence of deep vein thrombosis (DVT) using routine duplex Doppler ultrasound (DUS), to assess the incidence of pulmonary embolism (PE) using CT angiography, and to identify the factors that predict postoperative DVT in patients with a pelvic and/or acetabular fracture. METHODS All patients treated surgically for a pelvic and/or acetabular fracture between October 2016 and January 2020 were enrolled into this prospective single-centre study. The demographic, medical, and surgical details of the patients were recorded. DVT screening of the lower limbs was routinely performed using DUS before and at six to ten days after surgery. CT angiography was used in patients who were suspected of having PE. Age-adjusted univariate and stepwise multiple logistic regression analysis were used to determine the association between explanatory variables and postoperative DVT. RESULTS A total of 191 patients were included. A DVT was found preoperatively in 12 patients (6.3%), of which six were proximal. A postoperative DVT was found in 42 patients (22%), of which 27 were proximal. Eight patients (4.2%) had a PE, which was secondary to a DVT in three. None of the 12 patients in whom a vena cava filter was implanted prophylactically had a PE. Multivariate logistic regression analysis indicated that the association with the need for spinal surgery (odds ratio (OR) 19.78 (95% confidence interval (CI) 1.12 to 348.08); p = 0.041), intramedullary nailing of a long bone fracture (OR 4.44 (95% CI 1.05 to 18.86); p = 0.043), an operating time > two hours (OR 3.28 (95% CI 1.09 to 9.88); p = 0.035), and additional trauma surgery (OR 3.1 (95% CI 1.03 to 9.45); p = 0.045) were statistically the most relevant independent predictors of a postoperative DVT. CONCLUSION The acknowledgement of the risk factors for the development of a DVT and their weight is crucial to set a threshold for the index of suspicion for this diagnosis by medical staff. We suggest the routine use of the DUS screening for DVT in patients with a pelvic and/or acetabular fracture before and six to ten days after surgery. Cite this article: Bone Joint J 2022;104-B(2):283-289.
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Affiliation(s)
- Simone Cerbasi
- Department of Surgery, Orthopedic and Trauma Unit, Ospedali Riuniti, Ancona, Italy
| | - Alessio Bernasconi
- Orthopaedic and Traumatology Unit, University Federico II, Naples, Italy
| | - Giovanni Balato
- Orthopaedic and Traumatology Unit, University Federico II, Naples, Italy
| | - Federica Dimitri
- Department of Cardiovascular Sciences, Section of Vascular Medicine, Ospedali Riuniti, Ancona, Italy
| | - Oriana Zingaretti
- Department of Cardiovascular Sciences, Section of Vascular Medicine, Ospedali Riuniti, Ancona, Italy
| | - Gianclaudio Orabona
- Department of Surgery, Orthopedic and Trauma Unit, Ospedali Riuniti, Ancona, Italy
| | - Raffaele Pascarella
- Department of Surgery, Orthopedic and Trauma Unit, Ospedali Riuniti, Ancona, Italy
| | - Massimo Mariconda
- Orthopaedic and Traumatology Unit, University Federico II, Naples, Italy
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Tan Z, Hu H, Wang Z, Wang Y, Zhang Y. Prevalence and risk factors of preoperative deep venous thrombosis in closed patella fracture: a prospective cohort study. J Orthop Surg Res 2021; 16:404. [PMID: 34162417 PMCID: PMC8220698 DOI: 10.1186/s13018-021-02558-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/15/2021] [Indexed: 11/12/2022] Open
Abstract
Background The preoperative prevalence of deep venous thromboembolism (DVT) of patella fracture is not well established. The study aimed to investigate the preoperative prevalence, the associated risk factors, and the locations of deep venous thrombosis (DVT) in patients with closed patella fracture. Methods Patients who sustained closed patella fracture between January 1, 2016, and April 1, 2019, were included. Blood analyses and ultrasonography of bilateral lower extremities were routinely performed. Data of demographics, comorbidities, mechanism of injury, fracture type, total hospital stay, time from injury to DVT, and laboratory indexes were prospectively collected and compared between groups with and with non-DVT. Multivariate logistic regression analyses were performed to determine the independent risk factors of DVT. Results Among the study cohort of 790 patients, 35 cases occurred in preoperative DVTs, indicating a prevalence of 4.4%, with 3.2% distal and 1.2% proximal DVT. Age ≥ 65 years old (OR, 3.0, 95% CI, 1.1–8.1), D-dimer > 0.5 mg/L (OR, 2.3, 95% CI, 1.1–4.8), and albumin < 35 g/L (OR, 2.5, 95% CI, 1.2–5.3) were identified to be risk factors of DVT in closed patella fracture. Among the DVTs, 30 cases (85.7%) occurred in the injured extremity, 3 cases (8.6%) in bilateral extremities, and 2 cases (5.7%) solely in the uninjured extremity. Conclusion The prevalence of preoperative DVT in closed patella fracture was 4.4%, with 3.2% for distal and 1.2% for proximal DVT. We recommend individualized risk stratification and early anticoagulation for patients with risk factors (age ≥ 65 years, D-dimer > 0.5 mg/L and albumin < 35g/L).
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Affiliation(s)
- Zhanchao Tan
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, NO.139 Ziqiang Road, Shijiazhuang, 050051, Hebei, China
| | - Hongzhi Hu
- Department of Orthopedics, Union Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Zhongzheng Wang
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, NO.139 Ziqiang Road, Shijiazhuang, 050051, Hebei, China
| | - Yuchuan Wang
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, NO.139 Ziqiang Road, Shijiazhuang, 050051, Hebei, China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, NO.139 Ziqiang Road, Shijiazhuang, 050051, Hebei, China. .,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China. .,NHC Key Laboratory of Intelligent Orthopaedic Equipment, The Third Hospital of Hebei Medical University, Shijiazhuang, China.
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Broggi MS, Yoon CJ, Allen J, Maceroli M, Moore T, Schenker M, Hernandez-Irizarry R. Higher altitude leads to increased risk of venous thromboembolism after acetabular and pelvic ring injury. J Clin Orthop Trauma 2021; 19:192-195. [PMID: 34141573 PMCID: PMC8178120 DOI: 10.1016/j.jcot.2021.05.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 05/14/2021] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION There is a high post-operative incidence of venous thromboembolisms (VTEs), specifically deep vein thrombosis (DVT) and pulmonary embolism (PE), in pelvic ring and acetabular fractures, and identification of risk factors for VTEs is crucial to decrease this highly morbid complication. High altitudes have a known physiological effect on the body that may predispose patients to developing VTEs in the postoperative period. The purpose of this study was to investigate the relationship between pelvic ring and acetabular fractures occurring at high altitudes and the development of postoperative VTEs. METHODS In this retrospective study, the Truven MarketScan claims database was used to identify patients who underwent surgical fixation of a pelvic ring and/or acetabular fracture from January 2009 to December 2018 using Current Procedural Terminology (CPT) codes. Patient characteristics, including medical comorbidities, were collected. The zip codes of where the surgeries took place were used to determine recovery altitude and patients were separated into either the high altitude (>4000 feet) or low altitude (<100 feet) cohorts. Chi-squared and multivariate analyses were performed to investigate the association between altitude and the development of VTE postoperatively. RESULTS In total, 68,923 patients were included for analysis. At 30-days postoperatively, a higher altitude was associated with increased odds of developing a PE (OR 1.47, p = 0.019). At 90-days postoperatively, a higher altitude was associated with increased odds of DVT (OR 1.24, p = 0.029) and PE (OR 1.63, p < 0.001). CONCLUSION Surgical fixation of pelvic ring and acetabular fractures performed at a higher altitude (>4,000feet) are associated with increased odds of developing a PE in the first 30 days as well as developing a DVT or PE at 90 days postoperatively. Future prospective studies are needed to further elucidate the causality of altitude on the development of postoperative VTEs.
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Affiliation(s)
- Matthew S. Broggi
- Emory University, Department of Orthopaedic Surgery, 59 Executive Park South, Suite 200, Atlanta, GA 30324, USA,Corresponding author. MD 59 Executive Park South, Atlanta, GA 30324, USA.
| | - Camilla J. Yoon
- Emory University, Department of Orthopaedic Surgery, 59 Executive Park South, Suite 200, Atlanta, GA 30324, USA
| | - Jerad Allen
- Emory University, Department of Orthopaedic Surgery, 59 Executive Park South, Suite 200, Atlanta, GA 30324, USA
| | - Michael Maceroli
- Emory University, Department of Orthopaedic Surgery, 59 Executive Park South, Suite 200, Atlanta, GA 30324, USA
| | - Thomas Moore
- Emory University, Department of Orthopaedic Surgery, 59 Executive Park South, Suite 200, Atlanta, GA 30324, USA
| | - Mara Schenker
- Emory University, Department of Orthopaedic Surgery, 59 Executive Park South, Suite 200, Atlanta, GA 30324, USA
| | - Roberto Hernandez-Irizarry
- Emory University, Department of Orthopaedic Surgery, 59 Executive Park South, Suite 200, Atlanta, GA 30324, USA
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Incidence and risk factors for deep venous thrombosis of lower extremity after surgical treatment of isolated patella fractures. J Orthop Surg Res 2021; 16:90. [PMID: 33509241 PMCID: PMC7844981 DOI: 10.1186/s13018-021-02240-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/17/2021] [Indexed: 01/27/2023] Open
Abstract
Background Limited information exists on the incidence of postoperative deep venous thromboembolism (DVT) in patients with isolated patella fractures. The objective of this study was to investigate the postoperative incidence and locations of deep venous thrombosis (DVT) of the lower extremity in patients who underwent isolated patella fractures and identify the associated risk factors. Methods Medical data of 716 hospitalized patients was collected. The patients had acute isolated patella fractures and were admitted at the 3rd Hospital of Hebei Medical University between January 1, 2016, and February 31, 2019. All patients met the inclusion criteria. Medical data was collected using the inpatient record system, which included the patient demographics, patient’s bad hobbies, comorbidities, past medical history, fracture and surgery-related factors, hematological biomarkers, total hospital stay, and preoperative stay. Doppler examination was conducted for the diagnosis of DVT. Univariate analyses and multivariate logistic regression analyses were used to identify the independent risk factors. Results Among the 716 patients, DVT was confirmed in 29 cases, indicating an incidence of 4.1%. DVT involved bilateral limbs (injured and uninjured) in one patient (3.4%). DVT involved superficial femoral common vein in 1 case (3.4%), popliteal vein in 6 cases (20.7%), posterior tibial vein in 11 cases (37.9%), and peroneal vein in 11 cases (37.9%). The median of the interval between surgery and diagnosis of DVT was 4.0 days (range, 1.0-8.0 days). Six variables were identified to be independent risk factors for DVT which included age category (> 65 years old), OR, 4.44 (1.34-14.71); arrhythmia, OR, 4.41 (1.20-16.15); intra-operative blood loss, OR, 1.01 (1.00-1.02); preoperative stay (delay of each day), OR, 1.43 (1.15-1.78); surgical duration, OR, 1.04 (1.03-1.06); LDL-C (> 3.37 mmol/L), OR, 2.98 (1.14-7.76). Conclusion Incidence of postoperative DVT in patients with isolated patella fractures is substantial. More attentions should be paid on postoperative DVT prophylaxis in patients with isolated patella fractures. Identification of associated risk factors can help clinicians recognize the risk population, assess the risk of DVT, and develop personalized prophylaxis strategies.
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Aggarwal S, Patel S, Vashisht S, Kumar V, Sehgal IS, Chauhan R, Chaluvashetty DSB, Hemanth Kumar DK, Jindal DK. Guidelines for the prevention of venous thromboembolism in hospitalized patients with pelvi-acetabular trauma. J Clin Orthop Trauma 2020; 11:1002-1008. [PMID: 33192002 PMCID: PMC7656470 DOI: 10.1016/j.jcot.2020.09.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 09/09/2020] [Accepted: 09/09/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Venous thromboembolism is a dreaded complication leading to increased morbidity and mortality in patients having pelvi-acetabular fractures. OBJECTIVES These evidence based guidelines aim to provide the decision making ability in the prevention of venous thromboembolism in patients with pelvi-acetabular trauma planned for operative or non operative treatment. METHODS The patients were subclassified into 5 categories. The PICO framework was used to devise research questions in each category. The systematic reviews were performed for each research question. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess outcomes of critical interest. The guideline panel consisting of expert members of different subspecialties, analyzed the evidence and made recommendations. RESULTS The guideline panel proposed 21 recommendations. There are five recommendations in category 1 to 3, two recommendations in category 4 and four recommendations in category 5. CONCLUSION In pelvi-acetabular fractures there is strong evidence to suggest that thromboprophylaxis should be given. It should be initiated as early as possible after control of hemorrhage. The chemical prophylaxis is the preferred mode and LMWH is the preferred agent of choice. The mechanical methods can be used as an adjunct. The routine prophylactic use of IVC filters is not recommended. However, the use of retrievable IVC filters in high risk patients with established VTE in preoperative period can be considered. The use of newer directly acting oral anticoagulants is gaining importance.
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Affiliation(s)
| | - Sandeep Patel
- Department of Orthopaedics PGIMER, Chandigarh, India
| | | | - Vishal Kumar
- Department of Orthopaedics PGIMER, Chandigarh, India
| | | | - Rajeev Chauhan
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
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10
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Elnahal WA, Bassett J, Acharya MR, Chesser T, Ward AJ. Incidence of DVT and PE after surgical reconstruction for pelvic and acetabular fractures: Does routine duplex scanning affect management? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:491-495. [PMID: 32955697 DOI: 10.1007/s00590-020-02795-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 09/10/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Prevention and detection of thromboembolism with pelvic and acetabular fractures remains controversial. The aim of this study was to evaluate a protocol using LMWH prophylaxis and duplex screening both pre-operatively (if there is a delay > 72 h to surgery) and post-operatively at day 5-7. We assessed the incidence of thromboembolism and associated risk factors. METHODS A total of 255 consecutive patients who underwent pelvic and/or acetabular reconstruction in a major trauma and tertiary referral centre between January 2013 and December 2015 were studied. Forty-three patients were excluded due to non-adherence to protocol leaving 212 patients included in the study. RESULTS Patients were of mean age 49 years (15-94) and mean ISS 24.5 (4-66). Pre-operative screening detected two patients with asymptomatic above-knee DVT who then underwent pre-operative IVC filter insertion. Post-operative screening detected seven patients (3%) with lower limb DVTs (3 proximal and 4 below knee). The three patients with proximal DVTs were fully anticoagulated and did not develop symptomatic PE. Six patients (2.8%) developed post-operative PE, four of which were symptomatic and confirmed by CT angiography. Seven patients (3%) died in the post-operative period due to non-VTE-related causes. The overall rate of VTE was 6%, including DVT 4% and PE 2.8%. PE was associated with administration of tranexamic acid in ED (p > 0.03) and total amount of blood transfused during admission (p > 0.001). VTE was not associated with age, injury type, ISS, delay to surgery or associated injuries. CONCLUSION A protocol-based approach to VTE prophylaxis and screening in trauma patients with pelvic and/or acetabular reconstruction resulted in no VTE-related mortality. Pre- and post-operative screening for DVT changed the management in five patients, with none developing PE. Patients requiring more aggressive resuscitation had a higher rate of PE. The VTE rate was lower than previously reported.
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Affiliation(s)
- Walid A Elnahal
- Trauma and Orthopaedic Department, North Bristol NHS Trust, Westbury-On-Trym, Bristol, BS10 5NB, UK. .,Trauma and Orthopaedic Department, Cairo University, Cairo, Egypt.
| | - James Bassett
- Trauma and Orthopaedic Department, North Bristol NHS Trust, Westbury-On-Trym, Bristol, BS10 5NB, UK
| | - Mehool R Acharya
- Trauma and Orthopaedic Department, North Bristol NHS Trust, Westbury-On-Trym, Bristol, BS10 5NB, UK
| | - Tim Chesser
- Trauma and Orthopaedic Department, North Bristol NHS Trust, Westbury-On-Trym, Bristol, BS10 5NB, UK
| | - Anthony J Ward
- Trauma and Orthopaedic Department, North Bristol NHS Trust, Westbury-On-Trym, Bristol, BS10 5NB, UK
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Cohen-Levy WB, Rush AJ, Goldstein JP, Sheu JI, Hernandez-Irizarry RC, Quinnan SM. Tranexamic acid with a pre-operative suspension of anticoagulation decreases operative time and blood transfusion in the treatment of pelvic and acetabulum fractures. INTERNATIONAL ORTHOPAEDICS 2020; 44:1815-1822. [DOI: 10.1007/s00264-020-04595-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/27/2020] [Indexed: 12/18/2022]
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12
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Dwyer EP, Moed BR. Venous thromboembolism after hospital discharge in pelvic and acetabular fracture patients treated operatively. J Orthop Surg (Hong Kong) 2020; 27:2309499019832815. [PMID: 30827175 DOI: 10.1177/2309499019832815] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Emma P Dwyer
- 1 Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Berton R Moed
- 2 Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO, USA
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13
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Total hip arthroplasty in acetabular fractures. J Clin Orthop Trauma 2020; 11:1090-1098. [PMID: 33192013 PMCID: PMC7656485 DOI: 10.1016/j.jcot.2020.10.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 01/22/2023] Open
Abstract
Total Hip Arthroplasty (THA) is a well-accepted treatment for established hip arthritis following acetabular fractures. If a conservatively managed or operated case progresses to non-union/mal-union failing to restore the joint integrity, it may eventually develop secondary arthritis warranting a total hip arthroplasty. Also, in recent years, acute total hip arthroplasty is gaining importance in conditions where the fracture presents with pre-existing hip arthritis, is not amenable to salvage by open reduction and internal fixation, or, a poor prognosis is anticipated following fixation. There are several surgical challenges in performing total hip arthroplasty for acetabular fractures whether acute or delayed. As a separate entity elderly patients pose a distinct challenge due to osteoporosis and need stable fixation for early weight bearing alleviating the risk of any thromboembolic event, pulmonary complications and decubitus ulcer. The aim of surgery is to restore the columns for acetabular component implantation rather than anatomic fixation. Meticulous preoperative planning with radiographs and Computed Tomography (CT) scans, adequate exposure to delineate the fracture pattern, and, availability of an array of all instruments and possible implants as backup are the key points for success. Previous implants if any should be removed only if they are in the way of cup implantation or infected. Press fit uncemented modern porous metal acetabular component with multiple screw options is the preferred implant for majority of cases. However, complex fractures may require major reconstruction with revision THA implants especially when a pelvic discontinuity is present.
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Thromboprophylaxis an update of current practice: Can we reach a consensus? OTA Int 2019; 2:e027. [PMID: 33937659 PMCID: PMC7997114 DOI: 10.1097/oi9.0000000000000027] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 12/17/2018] [Indexed: 12/21/2022]
Abstract
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.
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Donnally CJ, Vakharia AM, Sheu JI, Vakharia RM, Damodar D, Shenoy K, Gjolaj JP. High Altitude Is an Independent Risk Factor for Developing a Pulmonary Embolism, but Not a Deep Vein Thrombosis Following a 1- to 2-Level Lumbar Fusion. Global Spine J 2019; 9:729-734. [PMID: 31552154 PMCID: PMC6745647 DOI: 10.1177/2192568219828349] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To identify if a 1- to 2-level posterior lumbar fusion at higher altitude is an independent risk factor for postoperative deep vein thrombosis (DVT) and pulmonary embolism (PE). METHODS A national Medicare database was queried for all patients undergoing 1- to 2-level lumbar fusions from 2005 to 2014. Those with a prior history of DVT, PE, coagulopathy, or peripheral vascular complications were excluded to better isolate altitude as the dependent variable. The groups were matched 1:1 based on age, gender, and comorbidities to limit potential cofounders. Using ZIP codes of the hospitals where the procedure occurred, we separated our patients into high (>4000 feet) and low (<100 feet) altitudes to investigate postoperative rates of DVTs and PEs at 90 days. RESULTS Compared with lumbar fusions performed at low-altitude centers, patients undergoing the same procedure at high altitude had significantly higher PE rates (P = .010) at 90 days postoperatively, and similar rates of 90-day postoperative DVTs (P = .078). There were no significant differences in age or comorbidities between these cohorts due to our strict matching process (P = 1.00). CONCLUSION Spinal fusions performed at altitudes >4000 feet incurred higher PE rates in the first 90 days compared with patients receiving the same surgery at <100 feet but did not incur higher rates of postoperative DVTs.
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Affiliation(s)
- Chester J. Donnally
- University of Miami Hospital, Miami, FL, USA,Chester J. Donnally III, Department of
Orthopaedics, University of Miami Hospital, 1400 NW 12th Avenue, Miami, FL
33136, USA.
| | | | - Jonathan I. Sheu
- University of Miami Leonard M. Miller School of Medicine, Miami, FL,
USA
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Wang P, Kandemir U, Zhang B, Wang B, Li J, Zhuang Y, Wang H, Zhang H, Liu P, Zhang K. Incidence and Risk Factors of Deep Vein Thrombosis in Patients With Pelvic and Acetabular Fractures. Clin Appl Thromb Hemost 2019; 25:1076029619845066. [PMID: 31014089 PMCID: PMC6714909 DOI: 10.1177/1076029619845066] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study aimed to investigate the incidence and risk factors for deep vein thrombosis (DVT) in patients with pelvic and acetabular fractures. Patients with pelvic or acetabular fractures were included. Demographic data, fracture classification, time to surgery, and d-dimer levels at admission and one day after surgical intervention were recorded. Duplex ultrasonography was performed in the lower extremities for DVT evaluation. All patients received mechanical and chemical thromboprophylaxis. One hundred ten patients with a mean age of 44.2 ± 13.8 years were included. There were 48 patients with pelvic fractures and 62 patients with acetabular fractures. Thirty-two (29.09%) patients sustained DVT; 21 (19.09%) patients exhibited proximal thrombosis, and 3 patients suffered pulmonary embolism. The incidence of DVT in patients with acetabular fractures was significantly higher than that of patients with pelvic fractures (χ2 = 4.42, P = .04). The incidence of proximal DVT was significantly higher in patients with complex acetabular fractures than in patients with simple acetabular fractures (χ2 = 6.65, P = .01). Multivariate analysis showed that age older than 60 years, associated injuries, and the time to surgery longer than 2 weeks were independent risk factors (P < .05). Despite mechanical and chemical thromboprophylaxis, the risk of DVT in patients with pelvic and acetabular fractures is still very high, and most of the thromboses were localized proximally. The risk of DVT is higher in patients older than 60 years, in those with associated injuries, and when the time from injury to operation is more than 2 weeks.
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Affiliation(s)
- Pengfei Wang
- 1 Department of Orthopedics and Traumatology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Utku Kandemir
- 2 Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
| | - Binfei Zhang
- 1 Department of Orthopedics and Traumatology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Baohui Wang
- 1 Department of Orthopedics and Traumatology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Jiahao Li
- 3 Shaanxi University of Traditional Chinese Medicine, Xian Yang, China
| | - Yan Zhuang
- 1 Department of Orthopedics and Traumatology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Hu Wang
- 1 Department of Orthopedics and Traumatology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Hong Zhang
- 4 Department of Radiology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Ping Liu
- 1 Department of Orthopedics and Traumatology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Kun Zhang
- 1 Department of Orthopedics and Traumatology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
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Dickerson JC, Harriel KL, Dambrino RJ, Taylor LI, Rimes JA, Chapman RW, Desrosiers AS, Tullis JE, Washington CW. Screening duplex ultrasonography in neurosurgery patients does not correlate with a reduction in pulmonary embolism rate or decreased mortality. J Neurosurg 2019; 132:1589-1597. [PMID: 31026839 DOI: 10.3171/2018.12.jns182800] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/18/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Deep vein thrombosis (DVT) is a major focus of patient safety indicators and a common cause of morbidity and mortality. Many practices have employed lower-extremity screening ultrasonography in addition to chemoprophylaxis and the use of sequential compression devices in an effort to reduce poor outcomes. However, the role of screening in directly decreasing pulmonary emboli (PEs) and mortality is unclear. At the University of Mississippi Medical Center, a policy change provided the opportunity to compare independent groups: patients treated under a prior paradigm of weekly screening ultrasonography versus a post-policy change group in which weekly surveillance was no longer performed. METHODS A total of 2532 consecutive cases were reviewed, with a 4-month washout period around the time of the policy change. Criteria for inclusion were admission to the neurosurgical service or consultation for ≥ 72 hours and hospitalization for ≥ 72 hours. Patients with a known diagnosis of DVT on admission or previous inferior vena cava (IVC) filter placement were excluded. The primary outcome examined was the rate of PE diagnosis, with secondary outcomes of all-cause mortality at discharge, DVT diagnosis rate, and IVC filter placement rate. A p value < 0.05 was considered significant. RESULTS A total of 485 patients met the criteria for the pre-policy change group and 504 for the post-policy change group. Data are presented as screening (pre-policy change) versus no screening (post-policy change). There was no difference in the PE rate (2% in both groups, p = 0.72) or all-cause mortality at discharge (7% vs 6%, p = 0.49). There were significant differences in the lower-extremity DVT rate (10% vs 3%, p < 0.01) or IVC filter rate (6% vs 2%, p < 0.01). CONCLUSIONS Based on these data, screening Doppler ultrasound examinations, in conjunction with standard-of-practice techniques to prevent thromboembolism, do not appear to confer a benefit to patients. While the screening group had significantly higher rates of DVT diagnosis and IVC filter placement, the screening, additional diagnoses, and subsequent interventions did not appear to improve patient outcomes. Ultimately, this makes DVT screening difficult to justify.
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Affiliation(s)
- James C Dickerson
- 1University of Mississippi School of Medicine, Jackson, Mississippi.,2Department of Medicine, Stanford University, Stanford, California
| | | | - Robert J Dambrino
- 1University of Mississippi School of Medicine, Jackson, Mississippi.,3Department of Neurological Surgery, Vanderbilt University, Nashville, Tennessee
| | - Lorne I Taylor
- 1University of Mississippi School of Medicine, Jackson, Mississippi.,4Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee; and
| | - Jordan A Rimes
- 1University of Mississippi School of Medicine, Jackson, Mississippi
| | - Ryan W Chapman
- 1University of Mississippi School of Medicine, Jackson, Mississippi
| | | | - Jason E Tullis
- 5Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Chad W Washington
- 5Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi
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18
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Aziz HA, Hileman BM, Chance EA. No correlation between lower extremity deep vein thrombosis and pulmonary embolism proportions in trauma: a systematic literature review. Eur J Trauma Emerg Surg 2018; 44:843-850. [PMID: 30382316 DOI: 10.1007/s00068-018-1043-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 10/28/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To assess the effect of surveillance on deep vein thrombosis (DVT) and pulmonary embolism (PE) rates, the efficacy of chemoprophylaxis and mechanical prophylaxis, and the relationship between DVT and PE. METHODS A 23 year, systematic literature review was performed in PubMed. Twenty publications with > 13,000 patients were reviewed. Analyzed traits included: DVT surveillance utilization, the total number of patients included in each study, the number of patients developing DVT and/or PE, chemoprophylaxis and mechanical prophylaxis utilization. When event proportions from individual studies were combined, a weighted mean proportion was computed based on the size of each individual cohort. Combined event proportions were compared with other combined event proportions, according to differences in intervention. Inter-group event proportions were compared using Chi-Square or Fisher's exact test, as appropriate. RESULTS DVT rates increase with surveillance (10.7% vs. 2.5%, p < 0.001). PE rates were similar regardless of surveillance (p = 1.0). Chemoprophylaxis lowered both DVT rates (8.2% vs. 10.7%; p < 0.0001) and PE rates (1.2% vs. 1.9%; p = 0.0050). Mechanical prophylaxis did not decrease DVT rates (10.2% vs. 11.5%; p = 0.2980) or PE rates (1.7% vs. 1.6%; p = 1.0). In patients with neither chemoprophylaxis nor mechanical prophylaxis, DVT rate was 11.5%, PE was 1.6%. When chemoprophylaxis and/or mechanical prophylaxis were given, DVT rate was 8.6% (p < 0.0189) and PE was 1.3% (p = 0.4462). PE proportions were not decreased with mechanical prophylaxis or surveillance. DVT and PE rates were not associated (p = 0.7574). CONCLUSIONS The results suggest that PE is not associated with lower extremity DVT in adult trauma patients.
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Affiliation(s)
- Hiba Abdel Aziz
- Department of Surgical Education, Northeast Ohio Medical University, 4209 State Route 44, Rootstown, OH, 44272, USA.
| | - Barbara M Hileman
- Trauma/Neuroscience Research Department, St. Elizabeth Youngstown Hospital, 1044, Belmont Avenue, Youngstown, OH, 44501, USA
| | - Elisha A Chance
- Trauma/Neuroscience Research Department, St. Elizabeth Youngstown Hospital, 1044, Belmont Avenue, Youngstown, OH, 44501, USA
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Cost-Effectiveness Analysis of Routine Venous Doppler Ultrasound for Diagnosis of Deep Venous Thrombosis at Admission to Inpatient Rehabilitation. Am J Phys Med Rehabil 2018; 97:747-753. [DOI: 10.1097/phm.0000000000000961] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Anaesthesia for the management of traumatic pelvic fractures. BJA Educ 2018; 18:204-210. [DOI: 10.1016/j.bjae.2018.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2018] [Indexed: 11/17/2022] Open
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Meftah M, White PB, Siddiqi A, Perake VS, Kirschenbaum IH. Routine Preoperative Venous Doppler Screening Is Not Effective in Preventing Thromboembolic Events After Total Joint Arthroplasty. Orthopedics 2018; 41:e202-e206. [PMID: 29309713 DOI: 10.3928/01477447-20180102-04] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 11/30/2017] [Indexed: 02/03/2023]
Abstract
Despite advances in thromboprophylaxis, the relationship between preexisting deep venous thromboses (DVTs) and postoperative thromboembolic complications is not fully established. The aim of this study was to assess the utility of selective and nonselective preoperative lower extremity venous Doppler screening protocols as tools in reducing the incidence of thromboembolic events (DVT/pulmonary embolism [PE]) after total joint arthroplasty. In the 2-year period from August 2013 to August 2015, a total of 455 consecutive elective primary total joint arthroplasties were identified from the authors' database. During the first year, a selective preoperative Doppler ultrasound screening protocol (only patients with a history of DVT/PE) was used for 182 patients, 31 of whom had preoperative ultrasound scans. The following year, a nonselective screening protocol was used for 273 consecutive patients, all of whom had preoperative Doppler ultrasound scans. All patients were followed for a minimum of 3 months postoperatively for postoperative Doppler ultrasound scans, emergency department visits, and readmissions related to DVT/PE. Preoperatively, there was no difference between the selective and nonselective cohorts regarding preoperative DVTs (3 and 1, respectively; P=.307); all patients were known to have prior DVT. Postoperative thromboembolic events were found in 4 (2.6%) of the patients in the selective cohort and 2 (0.7%) of the patients in the nonselective cohort (P=.196). Use of a nonselective preoperative Doppler ultrasound screening protocol did not improve the identification of preoperative DVTs or reduce postoperative thromboembolic complications. [Orthopedics. 2018; 41(2):e202-e206.].
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Falzarano G, Rollo G, Bisaccia M, Pace V, Lanzetti RM, Garcia-Prieto E, Pichierri P, Meccariello L. Percutaneous screws CT guided to fix sacroiliac joint in tile C pelvic injury. Outcomes at 5 years of follow-up. SICOT J 2016; 4:52. [PMID: 30480543 PMCID: PMC6256968 DOI: 10.1051/sicotj/2018047] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 09/17/2018] [Indexed: 11/25/2022] Open
Abstract
Introduction: The treatment of the sacroiliac joint (SIJ) vertical instability is a matter of current discussions and remains controversial. The aim of our study is the evaluation of the surgical management of SIJ vertical instability involving the use of cannulated screws introduced under CT guidance and local anesthesia. Materials and methods: In the set time frame of 7 years, 96 poly-trauma patients with Tile's type C fracture of the pelvis with vertical instability of the SIJ were treated. The average distance between the two stumps was 73.4 mm (range: 43–100 mm). All patients were treated with anterior stabilization and subsequent stabilization with cannulated screws (Asnis® Stryker® 6 mm, an average length of 70 mm; range from 55 to 85 mm) of the sacroiliac fracture. The clinical and radiological follow-up was performed with follow-up plain radiograph and Majeed score (from 1 to 60 months after injury). Results: The consolidation of pelvic fractures was obtained after an average of 63 days. The average Majeed score was as follows: 96 points at 1 month, 84 points at 3 months, 62 points at 6 months, 44 points at 12 months, 42 points at 24 months, 32 points at 36 months, 28 points at 48 months and 28 points at 60 months. Complications were as follows: not fatal deep vein thrombosis in five cases, skin infection at the entry point of the screws in six cases, screw breakage in one case and loosening of the screws in one case. Radiological evidence of fracture consolidation was achieved on average at 63 days. Forty-seven patients managed to get back to their pre-trauma employment at the end of the convalescence period. Conclusions: Our results suggest that the stabilization of SI Tile type C fracture/dislocations with CT-guided percutaneous cannulated screws is a valid and feasible management option and associated with a low complication rate.
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Affiliation(s)
- Gabriele Falzarano
- Department of Orthopedics and Traumatology, Azienda Ospedaliera "Gaetano Rummo", Benevento, Italy
| | - Giuseppe Rollo
- Department of Orthopedics and Traumatology, Vito Fazzi Hospital, Lecce, Italy
| | - Michele Bisaccia
- Division of Orthopedics and Trauma Surgery, University of Perugia, "S. Maria della Misericordia" Hospital, Perugia, Italy
| | - Valerio Pace
- Division of Orthopedics and Trauma Surgery, University of Perugia, "S. Maria della Misericordia" Hospital, Perugia, Italy - Department of Trauma and Orthopaedics, The Royal National Orthopaedic Hospital, Stanmore, London, UK
| | - Riccardo Maria Lanzetti
- Division of Orthopedics and Trauma Surgery, University of Perugia, "S. Maria della Misericordia" Hospital, Perugia, Italy
| | - Esteban Garcia-Prieto
- Department of Orthopaedics, "Hospital General de Villalba", 28400 Collado Villalba Spain
| | - Paolo Pichierri
- Department of Orthopedics and Traumatology, Azienda Ospedaliera "Gaetano Rummo", Benevento, Italy
| | - Luigi Meccariello
- Department of Orthopedics and Traumatology, Azienda Ospedaliera "Gaetano Rummo", Benevento, Italy
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Prevention of Venous Thromboembolism in Individuals with Spinal Cord Injury: Clinical Practice Guidelines for Health Care Providers, 3rd ed.: Consortium for Spinal Cord Medicine. Top Spinal Cord Inj Rehabil 2016; 22:209-240. [PMID: 29339863 PMCID: PMC4981016 DOI: 10.1310/sci2203-209] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Michetti CP, Franco E, Coleman J, Bradford A, Trickey AW. Deep vein thrombosis screening and risk factors in a high-risk trauma population. J Surg Res 2015; 199:545-51. [DOI: 10.1016/j.jss.2015.04.069] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 01/29/2015] [Accepted: 04/21/2015] [Indexed: 10/23/2022]
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Should preoperative duplex for orthopedic operations be performed? The answer seems to be negative. Thromb Res 2015; 136:841-2. [PMID: 26388122 DOI: 10.1016/j.thromres.2015.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 08/19/2015] [Indexed: 11/23/2022]
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Machado-Aranda DA, Jakubus JL, Wahl WL, Cherry-Bukowiec JR, To KB, Park PK, Raghavendran K, Napolitano LM, Hemmila MR. Reduction in Venous Thromboembolism Events: Trauma Performance Improvement and Loop Closure Through Participation in a State-Wide Quality Collaborative. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.05.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Patients who sustain orthopaedic trauma are at risk for developing deep venous thrombosis and symptomatic pulmonary emboli. The prevention of venous thromboembolism has moved to the forefront of patient safety initiatives, resulting in the formation of various guidelines to assist the practitioner. Recommendations for venous thromboembolism prophylaxis in the orthopaedic trauma patient exist, but there is insufficient evidence in the literature to make strong recommendations regarding type and duration of prophylaxis. The associated morbidity of chemical anticoagulants used in the orthopaedic trauma patient must also be taken into consideration, specifically the increased risk of bleeding. Mechanical prophylaxis is used in place of, or in addition to, these medications in certain situations. New, potentially superior anticoagulants have been developed but are still understudied. Larger studies are needed to further define the type and duration of deep venous thrombosis prophylaxis in the orthopaedic trauma patient.
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Kim JW, Oh CW, Oh JK, Baek SG, Lee BJ, Hong HP, Min WK. The incidence and the risk factors of venous thromboembolism in Korean patients with pelvic or acetabular fractures. J Orthop Sci 2014; 19:471-7. [PMID: 24627176 DOI: 10.1007/s00776-014-0553-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 02/22/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pelvic ring and acetabular fractures are the results of high energy trauma, but there is a paucity of information available regarding the incidence and risk factors of venous thromboembolism (VTE) after these injuries in Asians. This study was undertaken to evaluate the incidence of VTE after a pelvic or an acetabular fracture and to identify predictive factors. METHODS A prospective evaluation was performed by indirect computed tomography (CT) venography in patients with pelvic or acetabular fractures. Ninety-five patients were examined by indirect CT venography. Fifty-five patients suffered from a pelvic ring injury (anteroposterior compression 5, lateral compression 25, vertical shear 25), and the remaining 40 from acetabular fractures (simple 18, complex 22). Indirect CT venography was performed within 1-2 weeks of initial trauma. Relationships between VTE and sex, age, fracture pattern, body mass index, injury severity score, period of immobilization, and need for surgical treatment were analyzed. Deep vein thrombosis (DVT) in a more proximal to popliteal vein and the existence of PE were considered clinically significant. RESULTS Thirty-two patients (33.7 %) were found to have VTE at an average of 11 days after initial injury. Clinically significant DVT was found 20 cases (21.1 %). No statistical difference was found between pelvic ring injuries and acetabular fractures with respect to the development of VTE. For those with pelvic ring injury, the incidence of VTE in those with a vertical shear injury (52 %) was significantly greater than in others with a pelvic ring injury (p = 0.014). Patients with an age >50 were found to be at greater risk of VTE (p = 0.032). CONCLUSION Our findings demonstrate that Korean patients with pelvic or acetabular fractures have a higher risk of VTE than is generally believed, and caution should be taken to prevent and treat VTE, especially in high energy pelvic ring injury and elderly patients.
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Affiliation(s)
- Joon-Woo Kim
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, 50, 2-Ga, Samdok, Chung-gu, Daegu, 700-721, Republic of Korea
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El-Daly I, Reidy J, Culpan P, Bates P. Thromboprophylaxis in patients with pelvic and acetabular fractures: A short review and recommendations. Injury 2013; 44:1710-20. [PMID: 23816168 DOI: 10.1016/j.injury.2013.04.030] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Revised: 04/07/2013] [Accepted: 04/28/2013] [Indexed: 02/02/2023]
Abstract
The management of thromboprophylaxis in patients with pelvic and acetabular fractures remains a highly controversial topic within the trauma community. Despite anticoagulation, venous thromboembolism (VTE) remains the most common cause of surgical morbidity and mortality in this high-risk patient group. Although various thromboprophylactic regimes are employed, evidence relating to the most effective method remains unclear. Controversies surrounding screening, the use of prophylactic inferior vena cava filters (IVCF) and chemothromboprophylaxis in polytraumatised patients, particularly those with pelvic and acetabular fractures, form the basis of considerable debate. With the absence of a well-designed clinical trial and the presence of ongoing controversies within the literature, this review will explore current treatment options available to trauma surgeons and highlight differing scientific opinions, providing an update on the role of screening and current available preventative measures. We cover existing as well as recent advances in chemical thromboprophylactic agents and discuss external mechanical compression devices, the usefulness of serial duplex ultrasonography and the role of extended chemothromboprophylaxis on discharge. The evidence behind prophylactic IVCF is also considered, along with reported complication profiles. We conclude with a proposed protocol for use in major trauma centres, which can form the basis of local policy for the prevention of VTE in trauma patients with pelvic and acetabular fractures.
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Affiliation(s)
- Ibraheim El-Daly
- The Royal London Hospital, Barts Health NHS Trust, Department of Trauma and Orthopaedic Surgery, Whitechapel, London E1 1BB, UK.
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