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Incidence and Risk Factors for Venous Thromboembolic Disease in Podiatric Surgery
Andrew H. Felcher; Richard A. Mularski; David M. Mosen; Teresa M. Kimes; Thomas G. DeLougehry and Steven E. Laxson Chest, doi:10.1378/chest.08-1631
Background: The Agency for Healthcare Research and Quality ranks prevention of venous thromboembolism (VTE) as a top priority for patient safety, however, no guidelines or population-based research exist to guide management for podiatric surgery patients. The objective of our study was to determine the incidence and risk factors for post-procedure VTE in podiatric surgery.
Methods: A five-year retrospective analysis of patients undergoing podiatric surgery in a large not-for-profit health maintenance organization serving > 485,000 members in the Pacific Northwest from 1999 to 2004.
Results: We identified 16,804 surgical procedures in 7,264 patients and detected 22 symptomatic post-procedure VTEs. The overall incidence of post-procedure VTE was 0.30%. Three risk factors were significantly and independently associated with VTE in podiatric surgery: prior VTE (incidence 4.6%, RR 23.0, p < 0.001), use of hormone replacement therapy or oral contraceptives (incidence 0.55%, RR 4.2, p = 0.01) and obesity (incidence 0.48%, RR 3.0, p = 0.02).
Conclusions: We identified a low overall risk of VTE in podiatric surgery suggesting that routine prophylaxis is not warranted. However, for patients with a history of prior VTE, peri-procedure prophylaxis is suggested based on the level of risk. For podiatry surgery patients with two or more risk factors for VTE, peri-procedure prophylaxis should be considered. Until a prospective study is completed testing recommendations, guidelines and care decisions for podiatric surgery patients will continue to be based on retrospective data, expert consensus, and clinical judgment.
Diagnostic and operative codes are routinely collected for every patient admitted to hospital in the English NHS. Data on post-operative complications following foot and ankle surgery have not previously been available in large numbers. Data on symptomatic venous thromboembolism events and mortality within 90 days were extracted for patients undergoing fixation of an ankle fracture, first metatarsal osteotomy, hindfoot fusions and total ankle replacement over a period of 42 months. For ankle fracture surgery (45 949 patients), the rates of deep-vein thrombosis (DVT), pulmonary embolism and mortality were 0.12%, 0.17% and 0.37%, respectively. For first metatarsal osteotomy (33 626 patients), DVT, pulmonary embolism and mortality rates were 0.01%, 0.02% and 0.04%, and for hindfoot fusions (7033 patients) the rates were 0.03%, 0.11% and 0.11%, respectively. The rate of pulmonary embolism in 1633 total ankle replacement patients was 0.06%, and there were no recorded DVTs and no deaths. Statistical analysis could only identify risk factors for venous thromboembolic events of increasing age and multiple comorbidities following fracture surgery.
Venous thromboembolism following foot and ankle surgery is extremely rare, but this subset of fracture patients is at a higher risk. However, there is no evidence that thromboprophylaxis reduces this risk, and these national data suggest that prophylaxis is not required in most of these patients.
The incidence of venous thromboembolism (VTE) is unknown in elective foot and ankle surgery. The National Institute for Health and Clinical Excellence (NICE) recently published guidelines on reducing the risk of venous thromboembolism in surgical patients. This includes patients undergoing elective foot and ankle surgery.
In March 2010 we surveyed the current practice in VTE prophylaxis in elective foot and ankle surgery amongst members of the British Orthopaedic Foot and Ankle Society (BOFAS).
The response rate was 84 (53%). The total number of elective foot and ankle operations performed by the surveyed group was 33,500 per annum. The estimated incidence of DVT, PE and fatal PE was 0.6%, 0.1% and 0.02%. In our study the number of patients needed to treat to prevent a single fatal PE is 10,000 although this figure is open to important bias.
We question the applicability of the NICE guidelines to patients undergoing elective foot and ankle surgery. We consider that this data justifies the prospective study of the incidence of VTE in patients undergoing elective foot and ankle surgery, without the use of chemical thromboprophylaxis.
This retrospective analysis was prompted by the authors' observation of the relatively high incidence of venous thromboembolism (VTE) in the surgical repair of acute Achilles tendon ruptures.
88 patients were treated surgically for an acute Achilles tendon rupture. No prophylactic anticoagulation was given to any patients. The incidence of VTE was then reviewed retrospectively.
Five patients developed symptomatic deep vein thrombosis (5,7%) and one a near-fatal pulmonary embolus (1.1%). There were no major bleeding or cardiovascular adverse events. One patient developed a thrombus of the lesser saphenous vein (1.1%) and there was one superficial sepsis (1.1%). A temporary peroneal nerve palsy occurred in one patient (1.1%). There were two re-ruptures (2.3%).
There is no doubt that thromboprophylaxis must be given to the high risk patient and is also recommended for major orthopaedic surgery. Limited data is available for the use of thromboprophylaxis in foot and ankle surgery. In light of the unacceptably high incidence of venous thromboembolism in this study, the authors suggest that routine venous thromboembolism prophylaxis should be considered for these patients.
Re: Incidence and Risk Factors for Venous Thromboembolic Disease in Foot Surgery
Incidence of venous thromboembolism in elective foot and ankle surgery with
and without aspirin prophylaxis
J. T. Griffiths, L. Matthews, C. J. Pearce, and J. D. F. Calder J Bone Joint Surg Br 2012;94-B 210-214
The incidence of deep-vein thrombosis (DVT) and pulmonary embolism (PE) is thought to be low following foot and ankle surgery, but the routine use of chemoprophylaxis remains controversial. This retrospective study assessed the incidence of symptomatic venous thromboembolic (VTE) complications following a consecutive series of 2654 patients undergoing elective foot and ankle surgery. A total of 1078 patients received 75 mg aspirin as routine thromboprophylaxis between 2003 and 2006 and 1576 patients received no form of chemical thromboprophylaxis between 2007 and 2010. The overall incidence of VTE was 0.42% (DVT, 0.27%; PE, 0.15%) with 27 patients lost to follow-up. If these were included to create a worst case scenario, the overall VTE rate was 1.43%. There was no apparent protective effect against VTE by using aspirin.
We conclude that the incidence of VTE following foot and ankle surgery is very low and routine use of chemoprophylaxis does not appear necessary for patients who are not in the high risk group for VTE.
The goal of this meta-analysis was to evaluate the efficacy of venous foot pumps in prevention of venous thromboembolism following joint arthroplasty. Using different databases, we found 13 prospective clinical trials published meeting our inclusion criteria. In total, 1514 patients were included in the final analysis. Venous foot pump devices are effective in prevention of venous thromboembolic disease after total hip and knee arthroplasty compared to chemoprophylaxis. This was especially significant in prevention of major deep vein thrombosis and pulmonary emboli rate. The use of mechanical devices like venous calf or foot pump, either alone or in combination with less potent chemical prophylaxis, on the other hand can reduce the rate of venous thromboembolism and complications of potent chemoprophylaxis like wound hematoma.
Re: Incidence and Risk Factors for Venous Thromboembolic Disease in Foot Surgery
Deep Venous Thrombosis and Pulmonary Embolism as Rare Complications After
Hallux Valgus Surgery: Case Report and Literature Review
Faik Altintas, Turhan Ozler, Melih Guven, Afsar Timucin Ozkut, and Cagatay Ulucay J Am Podiatr Med Assoc 2013;103 145-148
The incidence and life-threatening complications of thromboembolic disease after major orthopedic surgical procedures have been extensively defined in the medical literature. However, there are few studies concerning the incidence of thromboembolic disease after foot and ankle surgery. We describe a 57-year-old female patient who underwent surgery for bilateral hallux valgus deformities and was diagnosed as having deep venous thrombosis and pulmonary embolism after the surgery despite early mobilization and mechanical prohylaxis. Her preoperative physical examination revealed varicose veins in both cruris. She was treated for pulmonary embolism with low-molecular-weight heparin and an oral anticoagulant in the postoperative period. Although venous thromboembolism is more commonly described after proximal lower-extremity procedures, it can occur after foot and ankle surgery, particularly if the patient has certain risk factors. Therefore, in addition to mechanical prophylaxis, pharmacologic prophylaxis should be kept in mind in such patients.
The purpose of this prospective study was to determine whether the more frequently quoted, procedure and patient specific risk factors have any impact in the implementation of venous, thromboembolism (VTE) prophylaxis following foot and ankle surgery.
Two hundred and sixteen patients were included in the study. A variety of operative procedures was, carried out with the common denominator being a below knee cast for at least four weeks and, nonweightbearing for an average, of six weeks in 130 patients. The remainder of the patients (88) had hallux surgery not requiring a cast, and were allowed to weightbear. No patient received any form of thromboprophylaxis postoperatively., All patients were, subjected to compression ultrasonography for deep vein thrombosis (DVT) between 2 and 6 weeks, postoperatively.
There was a 5.09% incidence of VTE (0.9% pulmonary embolism) overall. As no VTE (neither DVT nor, pulmonary embolus) developed in the hallux subgroup i.e. patients not requiring immobilization and, were allowed to, weight bear, the incidence of VTE in the cast/nonweightbearing group was 8.46%. The results are, descriptive and only statistically analyzed where, possible, as the sample size of the VTE group was small. There was no significant difference in number, of risk factors and no association between gender in the VTE and non VTE groups. 90.9% of patients in, the VTE group, had a total risk factor score of 5 or more and 73.7% of patients in the non VTE group had a total risk, factor score of 5 or more. The average timing to the diagnosis of VTE in this current study was 33.1, days.
In view of the unacceptable incidence of VTE and the average total risk factor score of 5 or more (for, which thromboprophylaxis is recommended) in the majority of the patients, the authors feel that the, routine use of, thromboprophylaxis in foot and ankle surgery requiring nonweightbearing in combination with short, leg cast immobilization, is warranted. This prophylaxis should continue until the patient regains, adequate mobility either by weightbearing (in or out of the cast) or removal of cast immobilization, (weightbearing or nonweightbearing), usually between 28 to 42 days.
Patients undergoing major amputation of the lower limb are at increased risk of venous thromboembolism (VTE). Risk factors for VTE in amputees include advanced age, sedentary lifestyle, longstanding arterial disease and an identifiable hypercoagulable condition. Evidence suggests that pharmacological prophylaxis (for example heparin, factor Xa inhibitors, vitamin K antagonists, direct thrombin inhibitors, antiplatelets) is effective in preventing deep vein thrombosis (DVT) but it is associated with an increased risk of bleeding. Mechanical prophylaxis (for example antiembolism stockings, intermittent pneumatic compression and foot impulse devices), on the other hand, is non-invasive and has no side effects. However, it is not always appropriate in patients with contraindications such as peripheral arterial disease (PAD), arteriosclerosis or bilateral lower limb amputations. It is important to determine the most effective thromboprophylaxis and whether this is one treatment alone or in combination with another. To date, no systematic review has been conducted examining the effectiveness of thromboprophylaxis in preventing VTE in people undergoing amputation.
To determine the effectiveness of thromboprophylaxis in preventing VTE in people undergoing major amputation of the lower extremity.
The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched May 2013) and CENTRAL (2013, Issue 4). Clinical trials databases were searched (May 2013). No date or language restrictions were applied. Non-English trials were translated where required and reference lists of identified studies were handsearched.
Randomised controlled trials and quasi-randomised controlled trials in which people undergoing a major unilateral or bilateral amputation (for example hip disarticulation, transfemoral, knee disarticulation and transtibial) of the lower extremity were allocated to different types or regimens of thromboprophylaxis (including pharmacological or mechanical prophylaxis) or placebo.
DATA COLLECTION AND ANALYSIS:
Selection of studies, data extraction and risk of bias were completed independently by two review authors. Any disagreements were resolved by discussion. Meta-analysis could not be completed as the two included studies compared different treatments and therefore the data could not be pooled.
Two studies with a combined total of 288 participants met the inclusion criteria for this review. One study compared low molecular weight heparin with unfractionated heparin and found no difference between the treatments in the prevention of DVT (odds ratio (OR) 1.23, 95% confidence interval (CI) 0.28 to 5.35). No bleeding events or deaths occurred. This study was open label and therefore at a high risk of performance bias. Additionally, the method of randomisation was not reported and therefore the risk of selection bias was unclear. In the second study heparin did not significantly improve prevention of pulmonary embolism (OR 1.02, 95% CI 0.44 to 2.37) when compared to placebo. Furthermore, when the level of amputation was considered, the incidence of pulmonary embolism was similar between the two treatment groups: above knee amputation (OR 0.79, 95% CI 0.31 to 1.97) and below knee amputation (OR 1.53, 95% CI 0.09 to 26.43). Ten participants died during the study; five underwent a post-mortem and three were found to have had a recent pulmonary embolism, all of whom had been on placebo. Bleeding events were reported in less than 10% of participants in both treatment groups but specific data were not presented. This study did not report the methods used to conceal allocation of treatment and therefore it was unclear if selection bias occurred. However, this study appeared to be free from all other sources of bias. No study looked at mechanical prophylaxis.
As only two studies were included in this review, each comparing different interventions, there is insufficient evidence to make any conclusions regarding the most effective thromboprophylaxis regimen in patients undergoing lower limb amputation. Further large-scale studies that are of good quality are required.
Re: Incidence and Risk Factors for Venous Thromboembolic Disease in Foot Surgery
Press Release: Best anticoagulants after orthopedic procedures depends on type of surgery
Current guidelines do not distinguish between aspirin and more potent blood thinners for protecting against blood clots in patients who undergo major orthopedic operations, leaving the decision up to individual clinicians. A new analysis published today in the Journal of Hospital Medicine provides much-needed information that summarizes existing studies about which medications are best after different types of surgery.
Every year, hundreds of thousands of Americans undergo major orthopedic surgery such as hip and knee replacements and hip fracture repairs. Patients undergoing such operations are at risk of experiencing serious, potentially fatal blood clots. Attempts to prevent blood clots with medications that thin the blood can be problematic, though, because they can worsen bleeding, which is another serious complication after surgery. Indeed, there is considerable controversy concerning the best type of blood thinner to use: aspirin or stronger blood thinners called anticoagulants. Examples of anticoagulants include heparin and warfarin (Coumadin).
Researchers compiled and compared all relevant studies that have compared these agents following hip or knee surgery. Their analysis, which included 8 randomized trials and 1408 patients, revealed that for hip or knee replacement, aspirin may be a good option because it's as effective as heparin or warfarin for preventing blood clots, but with less risk of bleeding. After hip fracture repair, though, anticoagulation therapy appears to be more beneficial.
"We expect that the number of hip and knee replacements and hip fracture repairs will continue to grow as the population ages. Major complications after these procedures—often clots or bleeding—contribute to suffering and costs," said lead author Frank Drescher, MD of the Veterans Affairs Medical Center in White River Junction, Vermont. "We hope our findings may guide physicians trying to help their patients make decisions about how to best minimize surgical risks."