Deep-vein thrombosis in high-energy skeletal trauma despite thromboprophylaxis

Sequential low molecular weight heparin and rivaroxaban for venous thromboprophylaxis in pelvic and acetabular trauma

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.

Trauma-induced pulmonary thromboembolism: What's update?

Trauma-induced pulmonary thromboembolism is the second leading cause of death in severe trauma patients. Primary fibrinolytic hyperactivity combined with hemorrhage and consequential hypercoagulability in severe trauma patients create a huge challenge for clinicians. It is crucial to ensure a safe anticoagulant therapy for trauma patients, but a series of clinical issues need to be answered first, for example, what are the risk factors for traumatic venous thromboembolism? How to assess and determine the status of coagulation dysfunction of patients? When is the optimal timing to initiate pharmacologic prophylaxis for venous thromboembolism? What types of prophylactic agents should be used? How to manage the anticoagulation-related hemorrhage and to determine the optimal timing of restarting chemoprophylaxis? The present review attempts to answer the above questions.

Assessment of deep vein thrombosis using routine pre- and postoperative duplex Doppler ultrasound in patients with pelvic trauma : a prospective study

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.

Early Detection of Deep Venous Thrombosis in Trauma Patients

Background

This study was performed to determine whether trauma patients are at an increased risk of developing deep venous thrombosis (DVT) within the first 48 hours of hospitalization.

Materials and methods

A retrospective review was performed using a prospectively maintained database of patients admitted to a trauma center during a five-year time period. Patients hospitalized for greater than 48 hours who received a screening venous duplex for DVT were included in the study.

Results

There were 1067 venous duplex scans obtained, 689 (64.5%) within the first 48 hours of admission (early DVT group), 378 (35.4%) after the first 48 hours (late DVT group). Only 142 (13.2%) patients had a positive duplex scan for DVT, 55 (early group), 87 (late group). Comorbid conditions of congestive heart failure (P = 0.02), pelvic fractures (P = 0.04), and a lower initial systolic blood pressure on presentation (p = 0.04) were associated with early DVT. Head trauma (P < 0.01), mechanical ventilation (P < 0.001), and transfusion of blood products (P < 0.001), were predictors of DVT in the late group.

Conclusions

Trauma patients are at an increased risk of developing venous thrombosis early in the hospital course due to comorbidities associated with trauma. Whereas, venous thrombosis in trauma patients diagnosed after the first 48 hours of hospitalization appears to be associated with prolonged patient immobility.

Risk factors of postoperative deep vein thrombosis (DVT) under low molecular weight heparin (LMWH) prophylaxis in patients with thoracolumbar fractures caused by high-energy injuries

To determine the incidence of DVT and to evaluate the risk factors of DVT under LMWH prophylaxis in patients with thoracolumbar fractures caused by high‑energy injuries postoperatively. A total of 534 patients from January 2016 to November 2019 were included in this retrospective study. Medical record data, including demographic data, perioperative variables, and laboratory results, were collected. LMWH prophylaxis was used for DVT in all the patients. The incidence and risk factors of DVT after surgery were identified by logistic regression analysis and receiver operating characteristic (ROC) curve analysis. The overall incidence of postoperative DVT was 18.91% (101/534). Three patients (0.56%) had proximal DVT and ninety-eight (18.35%) patients had distal DVT. The incidence of postoperative DVT in patients with thoracic fractures was 26.80% and 15.50% with lumbar fractures. The multivariate analysis showed that six risk factors increased the incidence of postoperative DVT, including advanced age, decreased lower extremity motor, blood transfusion, duration of bed rests, fibrinogen (FIB), and D-dimer. The ROC analysis indicated that the diagnostic value of D-dimer was highest whose area under the ROC curves (AUC) value was 0.754. Despite LMWH prophylaxis, the risk of postoperative DVT is still very high, especially in thoracic fracture. Advanced age, decreased lower extremity motor, blood transfusion, duration of bed rests, FIB, and D-dimer are risk factors for DVT. Moreover, the diagnostic value of D-dimer is the highest among these factors.

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.

Incidence and Risk Factors of Deep Vein Thrombosis in Patients With Pelvic and Acetabular Fractures

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.

Acute venous thromboembolism in Indian patients of isolated proximal femur fractures

INTRODUCTION

Venous Thromboembolism (VTE) has a variable incidence in trauma patients and fatal embolism can be the very first manifestation. Proximal femur fractures result from high velocity trauma in younger age groups and could require prolonged immobilisation, which is associated with increased risk of VTE. Therefore we sought to determine the occurrance of VTE in patients with proximal femur fractures.

OBJECTIVES

The present study was initiated to assess the occurrance of deep vein thrombosis (DVT) or pulmonary embolism in isolated proximal femur fractures and identify the requirement of routine thromboprophylaxis in such patients.

METHODS

It was a prospective study conducted over a period of one and a half years. All patients, presenting with isolated proximal femur fractures were included. Patients having any other known risk factors for DVT were excluded, so that the proximal femur fracture remained their only acquired risk for DVT. All the patients were evaluated clinically and with help of diagnostic modalities like Color Doppler with compression ultrasound, D-dimer assays and CT venogram, if indicated. Patients were followed up till 8 weeks post-operatively.

RESULTS

A total of 66 patients with fractures of proximal femur were assessed, out of which there were 42 males with mean age of 48.1 years and 24 females with mean age of 58.3 years. A total of 9 cases of radiologically proved DVT were observed. Clinical DVT was seen in 5 of these cases (54%). Complete resolution of thrombus was noted in all the patients, evaluated by Color Doppler at 6 weeks, post diagnosis. Although the majority of the cases (6) occurred in patients beyond 50 years of age, this was not statistically significant.

CONCLUSION

DVT is common in patients with proximal femur fractures and the provision for screening both clinically and radiologically, should be made routine in all such patients. In case of delay in surgery and patient being bed ridden, we recommend thromboprophylaxis in this subset of trauma patients.

Percutaneous screws CT guided to fix sacroiliac joint in tile C pelvic injury. Outcomes at 5 years of follow-up

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.

Thromboembolic Disease After Orthopedic Trauma

Orthopedic trauma results in systemic physiologic changes that predispose patients to venous thromboembolism (VTE). In the absence of prophylaxis, VTE incidence may be as high as 60%. Mechanical and pharmacologic thromboprophylaxis are effective in decreasing rates of VTE. Combined mechanical and pharmacologic thromboprophylaxis is more efficacious for decreasing VTE incidence than either regimen independently. If pharmacologic thromboprophylaxis is contraindicated, mechanical prophylaxis should be used. Patients with isolated lower extremity fractures who are ambulatory, or those with isolated upper extremity trauma, do not require pharmacologic prophylaxis in the absence of other VTE risk factors.

Risk Factors for Deep Venous Thrombosis Following Orthopaedic Trauma Surgery: An Analysis of 56,000 patients

Background:

Deep venous thrombosis (DVT) and pulmonary embolism (PE) are recognized as major causes of morbidity and mortality in orthopaedic trauma patients. Despite the high incidence of these complications following orthopaedic trauma, there is a paucity of literature investigating the clinical risk factors for DVT in this specific population. As our healthcare system increasingly emphasizes quality measures, it is critical for orthopaedic surgeons to understand the clinical factors that increase the risk of DVT following orthopaedic trauma.

Objectives:

Utilizing the ACS-NSQIP database, we sought to determine the incidence and identify independent risk factors for DVT following orthopaedic trauma.

Patients and Methods:

Using current procedural terminology (CPT) codes for orthopaedic trauma procedures, we identified a prospective cohort of patients from the 2006 to 2013 ACS-NSQIP database. Using Wilcoxon-Mann-Whitney and chi-square tests where appropriate, patient demographics, comorbidities, and operative factors were compared between patients who developed a DVT within 30 days of surgery and those who did not. A multivariate logistic regression analysis was conducted to calculate odds ratios (ORs) and identify independent risk factors for DVT. Significance was set at P < 0.05.

Results:

56,299 orthopaedic trauma patients were included in the analysis, of which 473 (0.84%) developed a DVT within 30 days. In univariate analysis, twenty-five variables were significantly associated with the development of a DVT, including age (P < 0.0001), BMI (P = 0.037), diabetes (P = 0.01), ASA score (P < 0.0001) and anatomic region injured (P < 0.0001). Multivariate analysis identified several independent risk factors for development of a DVT including use of a ventilator (OR = 43.67, P = 0.039), ascites (OR = 41.61, P = 0.0038), steroid use (OR = 4.00, P < 0.001), and alcohol use (OR = 2.98, P = 0.0370). Compared to patients with upper extremity trauma, those with lower extremity injuries had significantly increased odds of developing a DVT (OR = 7.55, P = 0.006). The trend toward increased odds of DVT among patients with injuries to the hip/pelvis did not reach statistical significance (OR = 4.51, P = 0.22). Smoking was not found to be an independent risk factor for developing a DVT (P = 0.1217).

Conclusions:

This is the largest study to date using the NSQIP database to identify risk factors for DVT in orthopaedic trauma patients. Although the incidence of DVT was low in our cohort, the presence of certain risk factors significantly increased the odds of developing a DVT following orthopaedic trauma. These findings will enable orthopaedic surgeons to target at-risk patients and implement post-operative care protocols aimed at reducing the morbidity and mortality associated with DVT in orthopaedic trauma patients.

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

OBJECTIVES

First, to provide the readership with a summation of the current practice patterns of North American orthopaedic surgeons for venous thromboembolism prophylaxis after musculoskeletal trauma. Second, to establish a set of guidelines and recommendations based on the most current and best available evidence for venous thromboembolism (VTE) prophylaxis after musculoskeletal trauma.

METHODS

A 24 item questionnaire titled "OTA VTE Prophylaxis Survey" was sent to active members of the Orthopaedic Trauma Association. PubMed and OVID/MEDLINE were used to search the current published literature regarding VTE prophylaxis in trauma patients using the following search terms: deep venous thrombosis, DVT, pulmonary embolism, PE, venous thromboembolism, VTE, prophylaxis, trauma, fracture, pneumatic compression device, PCD, sequential compression device, SCD, screening, ultrasound, duplex, ultrasonography, DUS, venography, magnetic resonance venography, MRV, inferior vena cava, IVC, filter, and IVCF. Each recommendation was graded using articles that were considered by the subcommittee as "the best available evidence" using the grading system adopted and endorsed by the American Academy of Orthopedic Surgeons' Evidenced Based Quality and Value committee.

RESULTS

Overall, 185 of 1545 members completed the online survey. The range and variety of prophylaxis and screening methods used among orthopaedic trauma surgeons in North America is large, with a number of agents or methods for which no literature exists to support their use in musculoskeletal trauma. A set of recommendations and guidelines were constructed based on the results of the literature analysis and graded according to guidelines mentioned above.

CONCLUSIONS

Due to the wide variability in practice patterns, poor scientific support for various therapeutic regimens and important medical-legal implications highlighted by the survey, a standardized set of guidelines and recommendations for VTE prophylaxis after musculoskeletal trauma will be critical in helping to improve patient care and minimize surgeons' exposure to potentially litigious activity.

LEVEL OF EVIDENCE

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

Methods and Guidelines for Venous Thromboembolism Prevention in Polytrauma Patients with Pelvic and Acetabular Fractures

Sequential compression devices and chemical prophylaxis are the standard venous thromboembolism (VTE) prevention for trauma patients with acetabular and pelvic fractures. Current chemical pharmacological contemplates the use of heparins or fondaparinux. Other anticoagulants include coumarins and aspirin, however these oral agents can be challenging to administer and may need monitoring. When contraindications to anticoagulation in high-risk patients are present, prophylactic inferior vena cava filters can be an option to prevent pulmonary emboli. Unfortunately strong evidence about the most effective method, and the timing of their commencement, in patients with pelvic and acetabular fractures remains controversial.

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.

Incidence of symptomatic and asymptomatic venous thromboembolism after elective knee arthroscopic surgery: a retrospective study with routinely applied venography

PURPOSE

The purpose of this study was to assess the incidence of total venous thromboembolism (VTE) after knee arthroscopy with routinely applied venography.

METHODS

We reviewed 537 consecutive patients undergoing arthroscopic knee surgery from March 2012 to July 2013. The surgical procedure was categorized as simple anterior cruciate ligament reconstruction (ACLR), posterior cruciate ligament reconstruction (PCLR), or reconstruction of both cruciate ligaments. All patients having arthroscopy in our institution were routinely examined with venography on the third postoperative day. Clinical signs of DVT were checked and recorded before venography.

RESULTS

Eighty (14.9%) of 537 patients were diagnosed with VTE by venography. Of the 80 detected cases of VTE, only 20 (3.7%) patients presented with clinical signs of DVT, indicating that there were 60 (11.2%) asymptomatic cases. No patient died or presented with a clinically suspected pulmonary embolism (PE). Sex, body mass index (BMI), operative time, and duration of tourniquet application were not significant risk factors for DVT. Patient age (P < .0001) is a strongly significant risk factor for deep venous thrombosis (DVT). Compared with patients who underwent simple arthroscopic procedures, complex procedures-the reconstruction of 1 (P < .005) or both knee cruciate ligaments (P < .0005)-led to a significantly higher postoperative incidence of DVT.

CONCLUSIONS

The total incidence of VTE diagnosed with venography after arthroscopic knee surgery was 14.9%, of which only 3.7% of cases were symptomatic, indicating 11.2% cases of silent VTE. Advanced age and complex arthroscopic surgery are strongly associated with VTE.

LEVEL OF EVIDENCE

Level IV, prognostic case series.

Multiple lower-extremity and pelvic fractures increase pulmonary embolus risk

The incidence of venous thromboembolism after major trauma has been estimated to be as high as 60%, despite appropriate prophylaxis. Pulmonary embolism is associated with deep venous thrombosis and also with significant rates of morbidity and mortality. This study examined risk factors for pulmonary embolism among patients with pelvic and lower-extremity fractures in the National Trauma Data Bank. Univariate analysis and multiple logistic regression were used to assess potential risk factors for pulmonary embolism during the index hospitalization period. A total of 199,952 patients with pelvic and lower-extremity fracture were identified. Of these patients, 918 (0.46%) had a pulmonary embolism and 117 (12%) of them died during hospitalization. The risk of pulmonary embolism was significantly increased in patients with multiple fractures (odds ratio, 1.89; P<.001) only. No significant relationship was found with fracture location (pelvis, femur, tibia). Other factors that were associated with increased rates of pulmonary embolism were obesity (body mass index >40 odds ratio, 3.38; P<.001), history of warfarin use (P=.009), hospital disposition (surgery odds ratio, 1.68; P<.001; intensive care unit odds ratio, 2.4; P<.001), and hospital setting (university odds ratio, 1.36; P<.001). Multiple pelvic or lower-extremity fractures, but not their anatomic locations, were associated with pulmonary embolism in the National Trauma Data Bank. As expected, obese patients and those with a history of warfarin therapy have higher rates of pulmonary embolism. This study offers guidance in identifying patients with musculoskeletal trauma who are at elevated risk for pulmonary embolism.

Thromboprophylaxis in patients with pelvic and acetabular fractures: A short review and recommendations

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.

Incidence of venous thromboembolism in fractures around and below the knee with physical prophylaxis

Fractures occurring at the distal part of the lower extremities are recognized to have a relatively lower risk of venous thromboembolism (VTE); however, few detailed reports exist on the subject. The purpose of this study was to investigate the incidence of VTE in fractures around and below the knee. Overall, 109 consecutive patients with fractures around and below the knee who were surgically treated at the authors' hospital were analyzed retrospectively. Physical prophylaxis was performed in all patients. Until April 2009, VTE screening was performed by contrast-enhanced computed tomography or ultrasonography when the D-dimer value did not decline predictably, exceeded 20 μg/mL 5 days after trauma and surgery, or increased above 20 μg/mL after a period of decline. After April 2009, ultrasonography was routinely performed pre- and postoperatively irrespective of the D-dimer value. The patients were divided into 2 groups based on the absence or presence of accompanying injuries, including head, chest, abdominal, or spinal injury and other fractures of the pelvis and lower extremities. Overall, VTE and pulmonary thromboembolism were detected in 28 (25.7%) patients and 5 (4.6%) patients, respectively. All cases were asymptomatic. The VTE incidence rates were 8.6% (former screening) and 40% (newer screening) in patients with isolated fractures and 25% (former screening) and 41.7% (newer screening) in patients with accompanying injuries. The pulmonary thromboembolism incidence rates were 2.9% (former screening) and 0% (newer screening) in patients with isolated fractures and 3.2% (former screening) and 25.0% (newer screening) in patients with accompanying injuries. Surgeons should be vigilant for symptoms of VTE in patients with fractures occurring at the distal part of the lower extremities.

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

PURPOSE

To investigate the rate of venous thromboembolism (VTE) in Japanese patients with fractures of the pelvis and/or lower extremities using physical prophylaxis alone.

METHODS

Records of 66 men and 60 women aged 15 to 95 (mean, 57) years with fractures of the pelvis and/ or lower extremities were retrospectively reviewed. They were screened for VTE based on D-dimer values. Contrast-enhanced computed tomography and/or ultrasonography were performed when the D-dimer value did not decline predictably or exceeded 20 μg/ml even 5 days after injury or surgery. Physical prophylaxis for VTE in terms of graduated compression stockings and intermittent pneumatic compression were applied for all patients.

RESULTS

Of the 126 patients, 24 were detected to have VTE (10 of 29 with multiple fractures and 14 of 97 with single fractures). Six patients were detected to have asymptomatic pulmonary thromboembolism (PTE), whereas 20 patients were detected to have deep vein thrombosis (bilaterally in 7). The rates of VTE were high in patients with multiple fractures (35%), pelvic fractures (18%), and femoral shaft fractures (50%). The rate of PTE was high in patients with pelvic fractures (12%).

CONCLUSION

The rate of VTE in the Japanese patients was similar to that in western populations. Our screening method was useful for preventing fatal PTEs. Surgeons should be vigilant for VTE during the first 2 weeks after injury, especially in patients with multiple and pelvic fractures.

Can lumbopelvic fixation salvage unstable complex sacral fractures?

BACKGROUND

Traditional screw or plate fixation options can be used to fix the majority of sacral fractures. However, these techniques are unreliable with dysmorphic upper sacral segments, U-fractures, osseous compression of neural elements, and previously failed fixation. Lumbopelvic fixation can potentially address these injuries but is a technically demanding procedure requiring spinal and pelvic fixation and it is unclear whether it reliably corrects the deformity and restores function.

QUESTIONS/PURPOSES

We therefore assessed reduction quality and loss of fixation, pain related to prominent hardware, subjective dysfunction measured by the Short Musculoskeletal Function Assessment (SMFA), and complications.

METHODS

We retrospectively reviewed 15 patients with unstable sacral fractures treated with lumbopelvic fixation between 2002 and 2010. Patients had radiographic monitoring regarding reduction quality and loss of fixation and clinical followup using the SMFA. The minimum followup was 12 months (mean, 23 months; range, 12-41 months).

RESULTS

Posterior reduction quality was 11 of 15 with less than 5 mm persistent displacement and four of 15 with 5 to 10 mm displacement. Loss of fixation was observed in one patient as a result of a technical error. Prominent hardware resulted in greater pain. Despite daily activity and bother subscores improving over time, we found long-term dysfunction in the SMFA. Eleven of the 15 patients were able to return to previous work or activities.

CONCLUSION

Complex posterior pelvic ring injuries of the sacrum not amenable to traditional fixation options can be salvaged with adherence to the technical details of lumbopelvic fixation. Hardware prominence and pain are markedly reduced with screw head recession. Long-term impairment is noted in patients with complex pelvic ring injuries requiring lumbopelvic fixation compared with normative data.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Sequential duplex ultrasound screening for proximal deep venous thrombosis in asymptomatic patients with acetabular and pelvic fractures treated operatively

BACKGROUND

Recent evidence-based practice guidelines recommend against routine ultrasound screening for proximal deep vein thrombosis (DVT) in asymptomatic pelvic fracture patients. However, the majority of trauma surgeons favor this practice. Furthermore, the timing of screening has been inconsistently described. The purpose of this study was to examine the utility of sequential scans in asymptomatic acetabular and pelvic fracture patients treated operatively.

METHODS

In 2003, a screening protocol for DVT was begun for asymptomatic patients with these fractures treated operatively. Duplex ultrasound screening was used to evaluate the lower extremities for proximal DVT. Scans were to be obtained preoperatively and then postoperatively on the day before planned discharge from the hospital. A DVT prophylaxis protocol was also instituted. Between 2003 and 2007, 343 patients were identified for study. Patients were followed for thromboembolic complications for a minimum of 3 months.

RESULTS

Two hundred twenty-nine patients received both preoperative and postoperative scans. Of these, 35 patients (15%) had an asymptomatic DVT: 16 (7%) preoperatively and 19 (8%) postoperatively. Two patients (1%) with negative scans had a postoperative symptomatic pulmonary embolism (PE) diagnosed the day after surgery, but fatal PE did not occur. In the remaining 114 patients, 27 received a prophylactic inferior vena cava filter, 6 had a preoperative symptomatic DVT or PE before scanning, 25 received only the postoperative scan (3 being positive), and 56 were not scanned postoperatively. Of the 56 not scanned postoperatively, 2 (4%) were readmitted with a symptomatic proximal DVT but none for PE, and a fatal PE did not occur.

CONCLUSIONS

Despite the possible diagnostic utility of sequential duplex ultrasound screening, it does not decrease the risk of PE in acetabular and pelvic fracture patients.

LEVEL OF EVIDENCE

IV.

Incidence of venous thromboembolism in pelvic and acetabular fractures in the Japanese population

BACKGROUND

There are no detailed reports of the incidence of venous thromboembolism (VTE) in pelvic and acetabular fractures in the Asian population. The purpose of this study was to investigate the incidence of VTE in pelvic and acetabular fractures in the Japanese population.

METHODS

Forty-six Japanese patients with pelvic and acetabular fractures treated at our hospital from February 2004 to April 2011 were analyzed retrospectively. Until April 2009, VTE screening was performed by contrast-enhanced computed tomography (CT) or ultrasonography (US) when the D-dimer value did not decline predictably, still exceeded 20 µg/ml at 5 days after trauma and surgery, or increased >20 µg/ml after a period of decline. After April 2009, contrast-enhanced CT and US were performed routinely irrespective of the D-dimer value. Physical prophylaxis was performed in all patients. The effects of the presence of pelvic and acetabular fractures, fracture types, accompanying injuries, and screening strategies on the incidences of VTE and pulmonary thromboembolism (PTE) were investigated.

RESULTS

Overall, 19 patients (41.3%) were diagnosed with VTE and PTE in ten (21.7%). All were asymptomatic. Compared with trauma patients without pelvic and acetabular fractures treated during the same period, significantly higher incidences of VTE and PTE were observed in patients with pelvic and acetabular fractures. No significant differences were observed in the incidences of VTE and PTE between pelvic and acetabular fractures or between patients with and without accompanying injuries. Compared with the previous screening strategy, the detection rates of VTE and PTE were higher for the newer screening strategy; however, the difference did not reach statistical significance.

CONCLUSIONS

We should be vigilant for the high incidence of VTE, especially PTE, in patients with pelvic and acetabular fractures in the Japanese population.

Risk of postoperative venous thromboembolism in Indian patients sustaining pelvi-acetabular injury

Most surgeons believe that Asians have a low risk of developing venous thromboembolism (VTE) and routine thromboprophylaxis therapy is not required after major orthopaedic trauma. This study evaluates the postoperative risk of VTE in Indian patients sustaining pelvi-acetabular injury. Fifty-six patients with pelvi-acetabular injury, who underwent open reduction and internal fixation, were prospectively evaluated for VTE in the postoperative period. They were evaluated, both clinically and radiologically (pulmonary CT angiography and indirect venography of lower limb and pelvis veins), until six weeks after surgery. A total of 16 patients developed VTE, of which 12 had proximal deep vein thrombosis (DVT), ten had pulmonary embolism (PE) and only two had distal DVT. Six patients with proximal DVT had associated PE. The risk of development of VTE among Indian patients after pelvi-acetabular injury is high (28.6%) with increasing chances of proximal DVT and PE; hence, administration of routine thromboprophylaxis is fully justified in them.

Thromboprophylaxis following major skeletal trauma: a systematic review

PURPOSE

Venous thromboembolic disease following skeletal polytrauma is a major issue for trauma surgeons, but there is no consensus of opinion regarding the optimal form of prophylaxis. The purpose of this paper was to compare the incidence of venous thromboembolic events (VTE) after major skeletal trauma managed with different prophylactic methods and their combinations.

METHODS

A search of AMED, CINAHL, Cochrane Library, EMBASE and MEDLINE databases was performed from their inception to July 2010. A search of unpublished literature databases was undertaken. All randomised controlled trials assessing the incidence of VTE events between two or more forms of thromboprophylaxis for patient following major skeletal trauma were included. Two reviewers independently identified all eligible articles, extracted the data, and critically appraised all included publications using the Critical Appraisal Skills Programme tool.

RESULTS

A total of 11 papers were identified. The findings of this study suggest that low molecular weight heparin (LMWH) may be superior to low dose heparin (LDH), and that LMWH should be used in addition to mechanical prophylaxis measures in patients following major skeletal trauma. There is limited evidence for the use of electrostimulation. There appeared to be no significant difference between the use of LDH compared to calf compression devices. However, the evidence-base was insufficient in both size and methodological quality.

CONCLUSIONS

There is currently insufficient research to be able to inform trauma surgeons as to the optimal method of thromboprophylaxis for patients following major skeletal trauma.

Venous thromboembolism in trauma patients

Serial venous duplex scans (VDS) were done in 507 trauma patients with at least one risk factor (RF) for venous thromboembolism (VTE) during a 2-year study period. Deep vein thrombosis (DVT) was detected in 31 (6.1%) patients. This incidence was 3.1 per cent in low (1-2 RFs), 3.4 per cent in moderate (3-5 RFs), and 7.7 per cent in high (> or =6 RFs) VTE scores (P = 0.172). Incidence was statistically different (3% vs. 7.2%, P = 0.048) on reanalyzing patients in two risk categories, low-risk (1-4 RFs) and high-risk (> or =5 RFs). Only 4 of 16 RFs had statistically higher incidence of DVT in patients with or without RFs: previous VTE (27.3% vs. 5.6%, odds ratio (OR) 6.628, P = 0.024), spinal cord injury (22.6% vs. 5%, OR 5.493, P = 0.001), pelvic fractures (11.4% vs. 5.1%, OR 2.373, P = 0.042), and head injury with a greater than two Abbreviated Injury Score (10.5% vs. 4.2%, OR 2.639, P = 0.014). On reanalyzing patients with > or =5 RFs vs. <5RFs, obesity (14.3 vs. 6.1%, P = 0.007), malignancy (5.6% vs. 0.6%, P = 0.006), coagulopathy (10.8% vs. 1.8%, P = 0.000), and previous VTE (3.2% vs. 0%, P = 0.019) were significant on univariate analysis. Patients with DVT had 3.70 +/- 1.75 RFs and a 9.61 +/- 4.93 VTE score, whereas, patients without DVT had 2.66 +/- 1.50 RFs and a 6.83 +/- 3.91 VTE score (P = 0.000). DVTs had a direct positive relationship with higher VTE scores, length of stay, and number of VDS (>1 r, P < or = 0.001). Increasing age was a weak risk factor (0.03 r, P = 0.5). First two VDS diagnosed 77 per cent of DVTs. Patients with injury severity score of > or =15 and 25 had higher DVTs compared with the ones with lower injury severity score levels (P < or = 0.05). Pulmonary embolism was silent in 63 per cent and DVTs were asymptomatic in 68 per cent.

Functional Outcome after Operative Treatment of Displaced Fractures of the Acetabulum: A 12-month to 5-year Follow-up Investigation

PURPOSE

To review our experience with 82 surgically treated displaced acetabular fractures over a 4-year period.

PATIENTS AND METHODS

Ninety-three consecutive displaced acetabular fractures were consecutively operated on at Level I Trauma Center from January 1, 2000 through December 31, 2003, and 82 were available for review with a minimum of 12-month follow-up. Clinical (Merle D'Aubigné modified by Matta et al.) and radiographic (Matta) outcomes were evaluated. Complications and secondary operative procedures were documented.

RESULTS

Anatomical reduction was achieved in 89% of the patients. At follow-up examination 12-60 months postoperatively (mean 32 months), clinical results were satisfactory in 65 patients (79.2% of the cases), with 14 excellent and 51 good results, and roentgenographic results were satisfactory in 70 patients (85.4% of the cases). Complications included a 12.2% incidence of sciatic nerve palsy (10 patients, two postoperative and eight posttraumatic), a 2.4% incidence of intraoperative vascular lesion (one external iliac artery and one external iliac vein), a 1.2% incidence of postoperative loss of reduction, a 1.2% incidence of infection, a 1.2% incidence of Brooker et al. class IV heterotopic ossification, a 2.4% incidence of posttraumatic osteoarthritis, and a 2.4% incidence of osteonecrosis of the femoral head.

CONCLUSIONS

Operative treatment is an effective method for the management of displaced acetabular fractures. Clinical and roentgenographic results correlate closely with an anatomic reduction. Low complication rate can be expected if adequate preoperative assessment and planning is performed. Strategies to minimize the risk of thromboembolism and heterotopic ossification on the basis of mechanical pneumatic compression and antiinflammatory nonsteroidal drugs, respectively, are reliable techniques for these injuries.

“Recovery™” Vena Cava Filter: Experience in 96 Patients

The purpose of the study was to assess the clinical safety and efficacy of the "Recovery(TM)" (Bard) inferior vena cava (IVC) filter. We retrospectively evaluated the clinical and imaging data of patients who had a "Recovery(TM)" IVC filter placed between January 2003 and December 2004 in our institution. The clinical presentation, indications, and procedure-related complications during placement and retrieval were evaluated. Follow-up computed tomography (CT) examinations of the abdomen and chest were evaluated for filter-related complications and pulmonary embolism (PE), respectively. "Recovery" filters were placed in 96 patients (72 males and 24 females; age range: 16-87 years; mean: 46 years). Twenty-four patients presented with PE, 13 with deep vein thrombosis (DVT) and 2 with both PE and DVT. The remaining 57 patients had no symptoms of thromboembolism. Indications for filter placement included contraindication to anticoagulation (n = 27), complication of anticoagulation (n = 3), failure of anticoagulation (n = 5), and prophylaxis (n = 61). The device was successfully deployed in the infrarenal (n = 95) or suprarenal (n = 1) IVC through a femoral vein approach. Retrieval was attempted in 11 patients after a mean period of 117 days (range: 24-426). The filter was successfully removed in nine patients (82%). Failure of retrieval was due to technical difficulty (n = 1) and the presence of thrombus in the filter (n = 1). One of the nine patients who had the filter removed developed IVC thrombus after retrieval and another had an intimal tear of the IVC. Follow-up abdominal CT (n = 40) at a mean of 80 days (range: 1-513) showed penetration of the IVC by the filter arms in 11, of which 3 had fracture of filter components. In one patient, a broken arm migrated into the pancreas. Asymmetric deployment of the filter legs was seen in 12 patients and thrombus within the filter in 2 patients. No filter migration or caval occlusion was encountered. Follow-up chest CT (n = 27) at a mean of 63 days (range: 1-386) showed PE in one patient (3%). During clinical follow-up, 12 of 96 patients developed symptoms of PE and only 1 of the 12 had PE on CT. There was no fatal pulmonary embolism in our group of patients following "Recovery" filter placement. However, the current version of the filter is associated with structure weakness, a high incidence of IVC wall penetration, and asymmetric deployment of the filter legs.