A prophylaxis algorithm for deep vein thrombosis in ankle and foot surgery
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Published:
Aug 5, 2019
Keywords:
Deep vein thrombosis, surgery, ankle, foot, complications, prophylaxis
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Abstract
Introduction: Deep vein thrombosis (DVT) is a major complication in orthopedic surgery. According to the literature, thromboprophylaxis in foot and ankle surgery is not a standardized practice due to the low incidence of DVT.Materials and Methods: We reviewed the medical records of surgical patients. Between 2011 and 2017, 1591 surgeries were performed, 6 of them due to symptomatic DVT.Results: The incidence of DVT in major orthopedic surgeries, such as knee and hip, is well documented, but there are only a few reports about its incidence in foot and ankle surgery. It is considered a relatively rare complication in many published studies; thus, preventive drug therapy is not routine practice.Conclusions: A multimodal approach to DVT prophylaxis for high-risk patients is recommended. All risk factors should be addressed, such as mechanical prophylaxis, early mobilization, and the use of chemoprophylaxis. Low molecular weight heparin is effective in reducing the rate of clinically significant DVT and is also likely to reduce the rate of pulmonary embolism.
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Masaragian, H., Perin, F., Coria, H., Mizdraji, L., Ameriso, N., & Rega, L. (2019). A prophylaxis algorithm for deep vein thrombosis in ankle and foot surgery. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 84(3), 252-259. https://doi.org/10.15417/issn.1852-7434.2019.84.3.783
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Clinical Research
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References
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2. Saragas NP, Ferrao PN, Saragas E, Jacobson BF. The impact of risk assessment on the implementation of venous thromboembolism prophylaxis in foot and ankle surgery. Foot Ankle Surg 2014;20(2):85-9. https://doi.org/10.1016/j.fas.2013.11.002
3. Jacobson BF, Louw S, Mer M, Haas S, Buller HR, Abdul-Carrim ATO. Venous thromboembolism–prophylactic and therapeutic practice guideline. S Afr Med J 2009;99(6):467-73. https://doi.org/10.7196/samj.6706
4. Heit JA, Cohen AT, Anderson FA. Estimated annual number of incident and recurrent, non-fatal and fatal venous thromboembolism (VTE) events in the United States. Blood 2005;106. Abstract 910. http://www.bloodjournal.org/content/106/11/910
5. Cohen AT, Agnelli G, Anderson FA, Arcelus JI, Bergqvist D. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost 2007;98(4):756-64. https://doi.org/10.1160/TH07-03-0212
6. Griffiths JT, Matthews L, Pearce CJ, Calder JDF. Incidence of venous thromboembolism in elective foot and ankle surgery with and without aspirin prophylaxis. J Bone Joint Surg Br 2012;94:210-4. https://doi.org/10.1302/0301-620X.94B2.27579
7. Chao J. Deep vein thrombosis in foot and ankle surgery. Orthop Clin North Am 2016;47(2):471-5. https://doi.org/10.1016/j.ocl.2015.10.001
8. Mayle RE Jr, DiGiovanni CW, Lin SS; Tabrizi P, Chou LB. Current concepts review: venous thromboembolic disease in foot and ankle surgery. Foot Ankle Int 2007;28(11):1207-16. https://doi.org/10.3113/FAI.2007.1207
9. Fleischer AE, Abicht BP, Baker JR, Boffeli TJ, Jupiter DC, Schade VL. American College of Foot and Ankle Surgeons’ Clinical Consensus Statement: Risk, Prevention, and Diagnosis of Venous Thromboembolism Disease in Foot and Ankle Surgery and Injuries Requiring Immobilization. J Foot Ankle Surg 2015;54:497-507. https://doi.org/10.1053/j.jfas.2015.02.022
10. Shibuya N, Frost CH, Campbell JD, Davis ML, 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;51:63-8. https://doi.org/10.1053/j.jfas.2011.10.017
11. Horne PH, Jennings JM, DeOrio JK, Easley ME, Nunley JA, Adams SB. Low incidence of symptomatic thromboembolic events after total ankle arthroplasty without routine use of chemoprophylaxis. Foot Ankle Int 2015;36(6):611-6. https://doi.org/10.1177/1071100715573717
12. Jameson SS, Augustine A, James P, Serrano-Pedraza I, Oliver K, Townshend D, Reed MR. Venous thromboembolic events following foot and ankle surgery in the English National Health Service. J Bone Joint Surg Br 2011;93:490-7. https://doi.org/10.1302/0301-620X.93B4.25731
13. Ahmad J, Lynch MK, Maltenfort M. Incidence and risk factors of venous thromboembolism after orthopaedic foot and ankle surgery. Foot Ankle Spec 2017;10(5):449-54. https://doi.org/10.1177/1938640017704944
14. Cirlincione AS, Mendicino R, Catanzariti AR, Grossman J. Low-molecular-weight heparin for deep vein thrombosis prophylaxis in foot and ankle surgery: a review. J Foot Ankle Surg 2001;40(2):96-100. https://doi.org/10.1016/S1067-2516(01)80050-8
15. Slaybaugh RS, Beasley BD, Massa EG. Deep venous thrombosis risk assessment, incidence, and prophylaxis in foot and ankle surgery. Clin Podiatr Med Surg 2003;20:269-89. https://doi.org/10.1016/S0891-8422(03)00007-7
16. Wang F, Wera G, Knoblich GO, Chou LB. Pulmonary embolism following operative treatment of ankle fractures: a report of 3 cases and review of the literature. Foot Ankle Int 2002;23:406-10. https://doi.org/10.1177/107110070202300506
17. Mizel MS, Temple HT, Michelson JD, Alvaez RG, Clanton TO, Frey CC, et al. Thromboembolism after foot and ankle surgery: a multicenter study. Clin Orthop Relat Res 1998;348:180-5. https://bit.ly/2ADLs2f
18. Solis G, Saxby T. Incidence of DVT following surgery of the foot and ankle. Foot Ankle Int 2002;23:411-4. https://doi.org/10.1177/107110070202300507
19. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, et al. Prevention of venous thromboembolism: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 2004;126(3 Suppl):338S-400S. https://doi.org/10.1378/chest.126.3_suppl.338S
20. Kadous A, Abdelgawad AA, Kanlic E. Deep venous thrombosis and pulmonary embolism after surgical treatment of ankle fractures: a case report and review of literature. J Foot Ankle Surg 2012;51:457-63. https://doi.org/10.1053/j.jfas.2012.04.016
21. Calder J, Freeman R, Domeij-Arverud E, van Dijk C, Ackermann P. Meta-analysis and suggested guidelines for prevention of venous thromboembolism (VTE) in foot and ankle surgery. Knee Surg Sports Traumatol Arthrosc 2016;24(4):1409-20.
https://doi.org/10.1007/s00167-015-3976-y
22. Hanslow SS, Grujic L, Slater HK, Chen D. Thomboembolic disease after foot and ankle surgery. Foot Ankle Int 2006;27(9):693-5. https://doi.org/10.1177/107110070602700907
23. Scolaro JA, Taylor RM, Wigner NA. Venous thromboembolism in orthopaedic trauma. J Am Acad Orthop Surg 2015;23:1-6. https://doi.org/10.5435/JAAOS-23-01-1
24. Ettema HB, Kollen BJ, Verheyen CCPM, Büller HR. Prevention of venous thromboembolism in patients with immobilization of the lower extremities: a meta-analysis of randomized controlled trials. J Thromb Haemost 2008;6(7):1093-8. https://doi.org/10.1111/j.1538-7836. 2008.02984.x
25. Nokes TJC, Keenan J. Thromboprophylaxis in patients with lower limb immobilization—review of current status. Br J Haematol 2009;146(4):361-8. https://doi.org/10.1111/j.1365-2141. 2009.07737.x
26. Testroote M, Stigter WAH, de Visser DC, Janzing HMJ. Low molecular weight heparin for prevention of venous thromboembolism in patients with lower-leg immobilization (review). Cochrane Database Syst Rev 2011;4:CD006681. https://doi.org/10.1002/14651858.CD006681.pub2
27. Craik JD, Clark A, Hendry J, Sott AH, Hamilton PD. The effect of ankle joint immobilization on lower limb venous flow. Foot Ankle Int 2015;36(1):18-23. https://doi.org/10.1177/1071100714552823
28. Bullock M, DeCarbo W, Hofbauer M. Repair of chronic Achilles ruptures has a high incidence of venous thromboembolism. Foot Ankle Spec 2017;10(5):415-20.
https://doi.org/10.1177/1938640016679706
29. Lapidus LJ, Rosters S, Ponzer S, Levander C, Elvin A, Larfars G, et al. Prolonged thromboprophylaxis with dalteparin after surgical treatment of Achilles tendon rupture: a randomized, placebo-controlled study. J Orthop Trauma 2007;21(1):52-7. https://doi.org/10.1097/01.bot.0000250741.65003.14
30. Nilsson-Helander K, Thurin A, Karlsson J, Eriksson BI. High incidence of deep venous thrombosis after Achilles tendon rupture: a prospective study. Knee Surg Sports Traumatol Arthrosc 2009;17(10):1234-8. https://doi.org/10.1007/s00167-009-0727-y
31. Makhdom AM, Cota A, Saran N, Chaytor R. Incidence of symptomatic deep venous thrombosis after Achilles tendon rupture. J Foot Ankle Surg 2013;52:584-7. https://doi.org/10.1053/j.jfas.2013.03.001
32. Shah K, Thevendran G, Younger A, Pinney SJ. Deep-vein thrombosis prophylaxis in foot and ankle surgery. what is the current state of practice? Foot Ankle Spec 2015;8(2):101-6. https://doi.org/10.1177/1938640014546858
33. Martel N, Lee J, Wells PS. Risk for heparin-induced thrombocytopenia with unfractionated and low-molecular-weight heparin thromboprophylaxis: a meta-analysis. Blood 2005;106(8):2710-5. https://doi.org/10.1182/blood-2005-04-1546
34. Saragas NP, Ferrao PNF, Jacobson BF, Saragas E, Strydom A. The benefit of pharmacological venous thromboprophylaxis in foot and ankle surgery. S Afr Med J 2017 3;107(4):327-30. https://doi.org/10.7196/SAMJ.2017.v107i4.10843
2. Saragas NP, Ferrao PN, Saragas E, Jacobson BF. The impact of risk assessment on the implementation of venous thromboembolism prophylaxis in foot and ankle surgery. Foot Ankle Surg 2014;20(2):85-9. https://doi.org/10.1016/j.fas.2013.11.002
3. Jacobson BF, Louw S, Mer M, Haas S, Buller HR, Abdul-Carrim ATO. Venous thromboembolism–prophylactic and therapeutic practice guideline. S Afr Med J 2009;99(6):467-73. https://doi.org/10.7196/samj.6706
4. Heit JA, Cohen AT, Anderson FA. Estimated annual number of incident and recurrent, non-fatal and fatal venous thromboembolism (VTE) events in the United States. Blood 2005;106. Abstract 910. http://www.bloodjournal.org/content/106/11/910
5. Cohen AT, Agnelli G, Anderson FA, Arcelus JI, Bergqvist D. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost 2007;98(4):756-64. https://doi.org/10.1160/TH07-03-0212
6. Griffiths JT, Matthews L, Pearce CJ, Calder JDF. Incidence of venous thromboembolism in elective foot and ankle surgery with and without aspirin prophylaxis. J Bone Joint Surg Br 2012;94:210-4. https://doi.org/10.1302/0301-620X.94B2.27579
7. Chao J. Deep vein thrombosis in foot and ankle surgery. Orthop Clin North Am 2016;47(2):471-5. https://doi.org/10.1016/j.ocl.2015.10.001
8. Mayle RE Jr, DiGiovanni CW, Lin SS; Tabrizi P, Chou LB. Current concepts review: venous thromboembolic disease in foot and ankle surgery. Foot Ankle Int 2007;28(11):1207-16. https://doi.org/10.3113/FAI.2007.1207
9. Fleischer AE, Abicht BP, Baker JR, Boffeli TJ, Jupiter DC, Schade VL. American College of Foot and Ankle Surgeons’ Clinical Consensus Statement: Risk, Prevention, and Diagnosis of Venous Thromboembolism Disease in Foot and Ankle Surgery and Injuries Requiring Immobilization. J Foot Ankle Surg 2015;54:497-507. https://doi.org/10.1053/j.jfas.2015.02.022
10. Shibuya N, Frost CH, Campbell JD, Davis ML, 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;51:63-8. https://doi.org/10.1053/j.jfas.2011.10.017
11. Horne PH, Jennings JM, DeOrio JK, Easley ME, Nunley JA, Adams SB. Low incidence of symptomatic thromboembolic events after total ankle arthroplasty without routine use of chemoprophylaxis. Foot Ankle Int 2015;36(6):611-6. https://doi.org/10.1177/1071100715573717
12. Jameson SS, Augustine A, James P, Serrano-Pedraza I, Oliver K, Townshend D, Reed MR. Venous thromboembolic events following foot and ankle surgery in the English National Health Service. J Bone Joint Surg Br 2011;93:490-7. https://doi.org/10.1302/0301-620X.93B4.25731
13. Ahmad J, Lynch MK, Maltenfort M. Incidence and risk factors of venous thromboembolism after orthopaedic foot and ankle surgery. Foot Ankle Spec 2017;10(5):449-54. https://doi.org/10.1177/1938640017704944
14. Cirlincione AS, Mendicino R, Catanzariti AR, Grossman J. Low-molecular-weight heparin for deep vein thrombosis prophylaxis in foot and ankle surgery: a review. J Foot Ankle Surg 2001;40(2):96-100. https://doi.org/10.1016/S1067-2516(01)80050-8
15. Slaybaugh RS, Beasley BD, Massa EG. Deep venous thrombosis risk assessment, incidence, and prophylaxis in foot and ankle surgery. Clin Podiatr Med Surg 2003;20:269-89. https://doi.org/10.1016/S0891-8422(03)00007-7
16. Wang F, Wera G, Knoblich GO, Chou LB. Pulmonary embolism following operative treatment of ankle fractures: a report of 3 cases and review of the literature. Foot Ankle Int 2002;23:406-10. https://doi.org/10.1177/107110070202300506
17. Mizel MS, Temple HT, Michelson JD, Alvaez RG, Clanton TO, Frey CC, et al. Thromboembolism after foot and ankle surgery: a multicenter study. Clin Orthop Relat Res 1998;348:180-5. https://bit.ly/2ADLs2f
18. Solis G, Saxby T. Incidence of DVT following surgery of the foot and ankle. Foot Ankle Int 2002;23:411-4. https://doi.org/10.1177/107110070202300507
19. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, et al. Prevention of venous thromboembolism: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 2004;126(3 Suppl):338S-400S. https://doi.org/10.1378/chest.126.3_suppl.338S
20. Kadous A, Abdelgawad AA, Kanlic E. Deep venous thrombosis and pulmonary embolism after surgical treatment of ankle fractures: a case report and review of literature. J Foot Ankle Surg 2012;51:457-63. https://doi.org/10.1053/j.jfas.2012.04.016
21. Calder J, Freeman R, Domeij-Arverud E, van Dijk C, Ackermann P. Meta-analysis and suggested guidelines for prevention of venous thromboembolism (VTE) in foot and ankle surgery. Knee Surg Sports Traumatol Arthrosc 2016;24(4):1409-20.
https://doi.org/10.1007/s00167-015-3976-y
22. Hanslow SS, Grujic L, Slater HK, Chen D. Thomboembolic disease after foot and ankle surgery. Foot Ankle Int 2006;27(9):693-5. https://doi.org/10.1177/107110070602700907
23. Scolaro JA, Taylor RM, Wigner NA. Venous thromboembolism in orthopaedic trauma. J Am Acad Orthop Surg 2015;23:1-6. https://doi.org/10.5435/JAAOS-23-01-1
24. Ettema HB, Kollen BJ, Verheyen CCPM, Büller HR. Prevention of venous thromboembolism in patients with immobilization of the lower extremities: a meta-analysis of randomized controlled trials. J Thromb Haemost 2008;6(7):1093-8. https://doi.org/10.1111/j.1538-7836. 2008.02984.x
25. Nokes TJC, Keenan J. Thromboprophylaxis in patients with lower limb immobilization—review of current status. Br J Haematol 2009;146(4):361-8. https://doi.org/10.1111/j.1365-2141. 2009.07737.x
26. Testroote M, Stigter WAH, de Visser DC, Janzing HMJ. Low molecular weight heparin for prevention of venous thromboembolism in patients with lower-leg immobilization (review). Cochrane Database Syst Rev 2011;4:CD006681. https://doi.org/10.1002/14651858.CD006681.pub2
27. Craik JD, Clark A, Hendry J, Sott AH, Hamilton PD. The effect of ankle joint immobilization on lower limb venous flow. Foot Ankle Int 2015;36(1):18-23. https://doi.org/10.1177/1071100714552823
28. Bullock M, DeCarbo W, Hofbauer M. Repair of chronic Achilles ruptures has a high incidence of venous thromboembolism. Foot Ankle Spec 2017;10(5):415-20.
https://doi.org/10.1177/1938640016679706
29. Lapidus LJ, Rosters S, Ponzer S, Levander C, Elvin A, Larfars G, et al. Prolonged thromboprophylaxis with dalteparin after surgical treatment of Achilles tendon rupture: a randomized, placebo-controlled study. J Orthop Trauma 2007;21(1):52-7. https://doi.org/10.1097/01.bot.0000250741.65003.14
30. Nilsson-Helander K, Thurin A, Karlsson J, Eriksson BI. High incidence of deep venous thrombosis after Achilles tendon rupture: a prospective study. Knee Surg Sports Traumatol Arthrosc 2009;17(10):1234-8. https://doi.org/10.1007/s00167-009-0727-y
31. Makhdom AM, Cota A, Saran N, Chaytor R. Incidence of symptomatic deep venous thrombosis after Achilles tendon rupture. J Foot Ankle Surg 2013;52:584-7. https://doi.org/10.1053/j.jfas.2013.03.001
32. Shah K, Thevendran G, Younger A, Pinney SJ. Deep-vein thrombosis prophylaxis in foot and ankle surgery. what is the current state of practice? Foot Ankle Spec 2015;8(2):101-6. https://doi.org/10.1177/1938640014546858
33. Martel N, Lee J, Wells PS. Risk for heparin-induced thrombocytopenia with unfractionated and low-molecular-weight heparin thromboprophylaxis: a meta-analysis. Blood 2005;106(8):2710-5. https://doi.org/10.1182/blood-2005-04-1546
34. Saragas NP, Ferrao PNF, Jacobson BF, Saragas E, Strydom A. The benefit of pharmacological venous thromboprophylaxis in foot and ankle surgery. S Afr Med J 2017 3;107(4):327-30. https://doi.org/10.7196/SAMJ.2017.v107i4.10843