Venous thromboembolism in Japanese patients with fractures of the pelvis and/or lower extremities using physical prophylaxis alone

Nomogram based on high-density lipoprotein cholesterol for the occurrence of preoperative deep vein thrombosis in patients with intertrochanteric femur fracture: a retrospective study

BACKGROUND

This study aims to develop a nomogram and forecast the incidence of DVT in individuals suffering from an intertrochanteric femur fracture.

METHOD

This work created a nomogram using the R programming language and employed logistic regression to determine independent predicting features. An external validation dataset was used to validate the nomogram.

RESULT

The findings demonstrated the independence of LYM (0.02[0.01-0.09], p < 0.001), ALB (0.83[0.74, 0.94], p = 0.002), and HDL-C (0.18[0.04, 0.71], p = 0.014). Good prediction performance with modest errors was shown by the nomogram in both the training and validation groups.

CONCLUSION

In conclusion, the nomogram that was created using HDL-C, ALB, and LYM can assist medical professionals in determining the likelihood that DVT will occur.

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Clinical Characteristics, Management Practices, and In-hospital Outcomes among Trauma Patients with Venous Thromboembolism

Background

We aimed to assess the clinical characteristics, management practices, and inhospital outcomes of venous thromboembolism (VTE) among trauma patients.

Methods

A retrospective analysis of all trauma patients with documented venous thromboembolic events in a level 1 trauma center was conducted. Patients were categorized into two groups based on the primary initial presentation postinjury (deep-vein thrombosis [DVT] or pulmonary embolism [PE]).

Results

Across the study period, a total of 662 patients were confirmed to have DVT and 258 patients were diagnosed with acute PE. Among them, 84 patients were identified to have trauma-associated VTE; 56 (8.5%) had DVT and 28 (10.9%) had PE. Two patients who initially presented with DVT developed PE on follow-up. There were 38 females and 46 males with a mean age of 46 ± 18 years. Abnormal coagulation profile was reported as 7 protein C deficiencies, 5 protein S deficiencies, 6 homocystinemia, 4 antithrombin III deficiency, 4 lupus anticoagulant, and 2 Factor V Leiden. Age, sex, obesity, D-dimer level, and treatment (except for heparin) were comparable between the two groups; whereas protein S deficiency, prior history of PE, bedridden status, congestive heart failure, and history of recent surgery, were more evident in the PE group. The incidence of postthrombotic syndrome was significantly higher in the DVT group. Overall mortality rate was 8.3% (DVT; 8.9% vs. PE; 7.1%, respectively = 0.78).

Conclusion

Coagulation profile plays an important role in posttraumatic thromboembolic disease. A thorough assessment for features of thromboembolic disorders is warranted in polytrauma patients to avoid missing this potentially life-threatening diagnosis. Larger studies are needed for better understanding and management of VTE in trauma.

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.

Venous thromboembolism in major trauma patients: a single-center retrospective cohort study of the epidemiology and utility of D-dimer for screening

Aim

Venous thromboembolism (VTE) can be a life‐threatening complication after major trauma. The aim of this study was to investigate the epidemiology of VTE and to assess the usefulness of D‐dimer for screening for VTE in major trauma cases among the Japanese population.

Methods

We examined a single‐center retrospective cohort of severely injured trauma patients who had been admitted to the emergency intensive care unit at Okayama University Hospital (Okayama, Japan) from April 2013 through to March 2016. Venous thromboembolism was confirmed by computed tomography angiography and computed tomography venography, which was determined based on the attending physician monitoring daily D‐dimer levels. Independent risk factors for VTE were determined by multiple logistic regression analysis. D‐dimer levels were evaluated using area under the receiver operating characteristic curve (AUROC) to predict VTE.

Results

The study cohort consisted of 204 trauma patients (median Injury Severity Score, 20). Of the 204 patients, 65 (32%) developed VTE. The median time from admission to VTE diagnosis was 10 days. In multiple logistic regression analysis, higher Injury Severity Score and the presence of lower extremity fractures were revealed to be a risk factor for VTE. D‐dimer levels at day 10 showed moderate accuracy, of which the AUROC was 0.785 (95% confidence interval, 0.704–0.866; P < 0.001). The cut‐off that maximized the Youden index was 12.45 μg/mL.

Conclusions

At least one of every three major trauma patients had potential development of VTE at a median of 10 days following admission to the intensive care unit. D‐dimer levels on day 10 can be a useful predictor of VTE.

Thrombin-antithrombin III complex tests

PURPOSE

Patients with fractures of the pelvis and/or lower extremities are at a high risk of developing postoperative venous thromboembolism (VTE). The purpose of this study was to determine whether the thrombin-antithrombin III complex (TAT) tests could be used for postoperative screening of VTE in patients with lower limb or pelvic fractures.

METHODS

We enrolled 133 patients who underwent surgical treatment for fracture of the pelvis or lower extremities. TAT and D-dimer levels were compared in patients with and without VTE. Receiver operating characteristic (ROC) curve analysis was done and the appropriate TAT and D-dimer cutoff levels were determined for VTE screening.

RESULTS

VTE was diagnosed in 41 patients (30.8%). Patients with VTE had significantly higher levels of TAT and D-dimer on postoperative days 1, 3, and 7 than those without VTE, respectively. ROC curve analysis suggested that TAT test at postoperative day 7 had the highest accuracy for predicting postoperative VTE. With the optimal cutoff TAT level of 3.0 ng/mL, sensitivity and specificity were 93.3% and 70.1%, respectively. With the optimal cutoff D-dimer level of 7.4 µg/mL, sensitivity and specificity were 93.3% and 57.0%, respectively.

CONCLUSION

TAT levels measured at postoperative day 7 could be the most useful parameter for screening postoperative VTE. TAT can be used as a screening tool for screening postoperative VTE in patients with lower limb and pelvic fractures.

Bilateral femoral shaft fractures complicated by fat and pulmonary embolism: a case report

A 25-year-old man was admitted to our hospital because of pulmonary embolism and suspected fat embolism after sustaining bilateral femoral shaft fracture. A left arm weakness, tachycardia and sudden hemoglobin drop delayed his definitive fixation with intramedullary nailing. His clinical course was further complicated by bleeding from the pin sites of the external fixators which had initially been used to temporarily stabilize his femoral fractures (clotting disturbances). A lower leg Doppler ultrasound and a new pelvic-chest CT angiography excluded any remaining thrombus, meanwhile the embolus had broken in smaller pieces, more distally. His unfractionated heparin was revised to a Low Molecular Weight Heparin at prophylactic dose. After a 10 day period and when his condition had been improved bilateral reamed nailing was performed. Although bilateral closed femoral shaft fractures should be stabilized early, fat embolism syndrome (FES) and thromboembolic events (TEV) should always be kept in mind in these patients.

D-dimer levels to screen for venous thromboembolism in patients with fractures caused by high-energy injuries

BACKGROUND

The clinical relevance of D-dimer levels when screening for venous thromboembolism (VTE) in elderly patients with a hip fracture has been reported but has not been fully investigated in patients with fractures caused by high-energy injuries. The purpose of this study was to evaluate the usefulness and limitations of D-dimer in such patients.

METHODS

We enrolled 80 consecutive patients who underwent surgical treatment for fracture of the pelvis or lower extremity caused by high-energy injuries. None had received pharmacological prophylaxis for VTE. All patients underwent routine ultrasonography preoperatively and postoperatively (average 6.1 days after injury and 7.8 days after surgery). Contrast-enhanced computed tomography was performed routinely at the same time points for patients with a pelvic fracture or multiple fractures. D-dimer levels were compared in patients with and without VTE. Receiver operating characteristic (ROC) curve analysis was done and the appropriate D-dimer cutoff level determined for VTE screening.

RESULTS

VTE was diagnosed in 34 of the 80 patients. D-dimer levels were significantly higher in patients with VTE than without it at almost all time points preoperatively and postoperatively except in patients with an isolated lower extremity fracture. ROC curve analysis suggested moderate to high accuracy for predicting VTE in patients with a pelvic fracture or multiple fractures preoperatively and postoperatively. Cutoff levels with high sensitivity and specificity for patients with a pelvic fracture or multiple fractures were set at around 7 days after the injury and surgery.

CONCLUSIONS

D-dimer can be used as a VTE screening tool in patients with fractures caused by high-energy injuries. Our results suggested that D-dimer analysis to predict VTE was useful in patients with a pelvic fracture or multiple fractures. Our results also suggested that it was less useful for predicting VTE in patients with an isolated lower extremity fracture.