Effect of Chemical Thromboprophylaxis on the Rate of Venous Thromboembolism After Treatment of Foot and Ankle Fractures

Abstract

Background:

Venous thromboembolism (VTE) is a well-documented complication in patients with lower limb fractures, but management guidelines for its prevention in isolated foot and ankle fracture patients are conflicting. The aim of this study was to conduct a multicenter, prospective cohort study to define the prevalence of VTE in patients with isolated foot and ankle fractures and determine whether routine prophylaxis is necessary in these patients.

Methods:

In a double-blind, placebo-controlled study, consecutive patients in 3 hospitals who met our criteria were enrolled. After randomization, patients received either thromboprophylaxis with low-molecular-weight heparin units (LMWH group) or placebo (placebo group) for a period of 2 weeks. All patients underwent routine ultrasonography 1 day preoperatively, 1 week postoperatively, and 1 month postoperatively. Demographic parameters were then collected and compared.

Results:

Of the 814 patients who met our criteria, 19 patients (2.3%, 95% confidence interval [CI], 0%-31.9%) were found to have objectively confirmed VTE, but none of the patients were symptomatic. Of the 411 patients in the LMWH group, 2 developed VTEs preoperatively and 4 postoperatively; of the 403 patients in the placebo group, 5 developed VTEs preoperatively and 8 postoperatively. The overall incidence of asymptomatic postoperative deep vein thrombosis (DVT) was 0.98% (95% CI 0%-20.3%) in the LMWH group and 2.01% (95% CI 0%-29.5%) in the placebo group without significant difference. Advanced age (odds ratio [OR] 1.050, 95% CI 1.014-1.088, P = .007) and high body mass index (OR 1.201, 95% CI 1.034-1.395, P = .016) were identified as risk factors in predicting occurrence of DVT. No fatal pulmonary emboli or major bleeding complication occurred in either group.

Conclusion:

Routine anticoagulant prophylaxis was not found to be necessary for patients with foot and ankle fractures, although further investigation with a properly powered study design is required to definitively determine which foot and ankle patients are best served by anticoagulation and which ones are not.

Level of Evidence:

Level II, prospective comparative study.

Keywords

thromboembolism foot ankle prophylaxis

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References

Bahl

Henke

. A validation study of a retrospective venous thromboembolism risk scoring method. Ann Surg. 2010;251(2):344-350.

Calder

Freeman

Domeij-Arverud

Van Dijk

Ackermann

PW.

Meta-analysis and suggested guidelines for prevention of venous thromboembolism (VTE) in foot and ankle surgery. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1409-1420.

Coleman

Zarzaur

Katona

. Factors associated with pulmonary embolism within 72 hours of admission after trauma: a multicenter study. J Am Coll Surg. 2015;220(4):731-736.

Falck-Ytter

Francis

Johanson

. Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 suppl):E278s-E325s.

Francis

Cw.

Prevention of VTE in patients having major orthopedic surgery. J Thromb Thrombolysis. 2013;35(3):359-367.

Goel

Buckley

Devries

. Prophylaxis of deep-vein thrombosis in fractures below the knee: a prospective randomised controlled trial. J Bone Joint Surg Br. 2009;91(3):388-394.

Griffiths

Matthews

Pearce

Calder

JD.

Incidence of venous thromboembolism in elective foot and ankle surgery with and without aspirin prophylaxis. J Bone Joint Surg Br. 2012;94(2):210-214.

Hamilton

Hariharan

Robinson

AH.

Thromboprophylaxis in elective foot and ankle patients—current practice in the United Kingdom. Foot Ankle Surg. 2011;17(2):89-93.

Hanslow

Grujic

Slater

Chen

Thromboembolic disease after foot and ankle surgery. Foot Ankle Int. 2006;27(9):693-695.

10.

Haque

Davies

MB.

Oral thromboprophylaxis in patients with ankle fractures immobilized in a below the knee cast. Foot Ankle Surg. 2015;21(4):266-268.

11.

Jameson

Augustine

James

. Venous thromboembolic events following foot and ankle surgery in the English National Health Service. J Bone Joint Surg Br. 2011;93(4):490-497.

12.

Jameson

Rankin

Desira

. Pulmonary embolism following ankle fractures treated without an operation—an analysis using National Health Service data. Injury. 2014;45(8):1256-1261.

13.

Jorgensen

Warming

Hansen

. Low molecular weight heparin (Innohep) as thromboprophylaxis in outpatients with a plaster cast: a venografic controlled study. Thromb Res. 2002;105(6):477-480.

14.

Kaufman

Kinney

Streiff

. Guidelines for the use of retrievable and convertible vena cava filters: report from the Society of Interventional Radiology Multidisciplinary Consensus Conference. J Vasc Interv Radiol. 2006;17(3):449-459.

15.

Kock

Schmit-Neuerburg

Hanke

Rudofsky

Hirche

Thromboprophylaxis with low-molecular-weight heparin in outpatients with plaster-cast immobilisation of the leg. Lancet. 1995;346(8973):459-461.

16.

Kujath

Spannagel

Habscheid

Incidence and prophylaxis of deep venous thrombosis in outpatients with injury of the lower limb. Haemostasis. 1993;23(suppl 1):20-26.

17.

Lapidus

Ponzer

Elvin

. Prolonged thromboprophylaxis with dalteparin during immobilization after ankle fracture surgery: a randomized placebo-controlled, double-blind study. Acta Orthop. 2007;78(4):528-535.

18.

Lassen

Borris

Nakov

RL.

Use of the low-molecular-weight heparin reviparin to prevent deep-vein thrombosis after leg injury requiring immobilization. N Engl J Med. 2002;347(10):726-730.

19.

Mizel

Temple

Michelson

. Thromboembolism after foot and ankle surgery. A multicenter study. Clin Orthop Relat Res. 1998;348:180-185.

20.

Obi

Pannucci

Nackashi

. Validation of the caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948.

21.

Ovaska

Madanat

Honkamaa

Makinen

TJ.

Contemporary demographics and complications of patients treated for open ankle fractures. Injury. 2015;46(8):1650-1655.

22.

Ovaska

Madanat

Makinen

TJ.

Predictors of postoperative wound necrosis following primary wound closure of open ankle fractures. Foot Ankle Int. 2016;37(4):401-406.

23.

Pannucci

Bailey

Dreszer

. Validation of the Caprini Risk Assessment Model in plastic and reconstructive surgery patients. J Am Coll Surg. 2011;212(1):105-112.

24.

Radl

Kastner

Aigner

. Venous thrombosis after hallux valgus surgery. J Bone Joint Surg Am. 2003;85-A(7):1204-1208.

25.

Sathiyakumar

Greenberg

Jahangir

. Impact of type of surgery on deep venous thrombi and pulmonary emboli: a look at twenty seven thousand hip fracture patients. Int Orthop. 2015;39(10):2017-2022.

26.

Selby

Geerts

Kreder

. A double-blind, randomized controlled trial of the prevention of clinically important venous thromboembolism after isolated lower leg fractures. J Orthop Trauma. 2015;29(5):224-230.

27.

Shah

Thevendran

Younger

Pinney

SJ.

Deep-vein thrombosis prophylaxis in foot and ankle surgery: what is the current state of practice?

Foot Ankle Spec. 2015;8(2):101-106.

28.

Shibuya

Frost

Campbell

Davis

Jupiter

DC.

Incidence of acute deep vein thrombosis and pulmonary embolism in foot and ankle trauma: analysis of the National Trauma Data Bank. J Foot Ankle Surg. 2012;51(1):63-68.

29.

Simon

Mass

Zarins

. The effect of a thigh tourniquet on the incidence of deep venous thrombosis after operations on the fore part of the foot. J Bone Joint Surg Am. 1982;64(2):188-191.

30.

Solis

Saxby

Incidence of DVT following surgery of the foot and ankle. Foot Ankle Int. 2002;23(5):411-414.

31.

Testroote

Stigter

De Visser

Janzing

Low molecular weight heparin for prevention of venous thromboembolism in patients with lower-leg immobilization. Cochrane Database Syst Rev. 2008;4:CD006681.

32.

Treasure

Hill

Nice guidance on reducing the risk of venous thromboembolism in patients admitted to hospital. J R Soc Med. 2010;103(6):210-212.

33.

Wahlsten

Eckardt

Lyngbaek

. Symptomatic venous thromboembolism following fractures distal to the knee: a nationwide Danish cohort study. J Bone Joint Surg Am. 2015;97(6):470-477.

34.

Wang

Sengupta

Baser

Risk of venous thromboembolism and benefits of prophylaxis use in hospitalized medically ill US patients up to 180 days post-hospital discharge. Thromb J. 2011;9(1):15.

35.

Wolf

Digiovanni

CW.

A survey of orthopedic surgeons regarding DVT prophylaxis in foot and ankle trauma surgery. Orthopedics. 2004;27(5):504-508.

36.

Yang

Zhu

. Meta-analysis of efficacy and safety of new oral anticoagulants compared with uninterrupted vitamin K antagonists in patients undergoing catheter ablation for atrial fibrillation. Am J Cardiol. 2016;117(6):926-934.