Thromboembolism Following Foot and Ankle Surgery: A Case Series and Literature Review

Venous thromboembolism following major orthopedic procedures of the hip and knee is well documented and patients are therefore routinely prophylaxed following these proximal lower extremity procedures. In contrast, foot and ankle surgery is considered by most health care professionals to be a low-risk procedure for the development of venous thromboembolism. As a result, pharmacologic deep venous thrombosis prophylaxis is rarely administered. This postoperative practice is supported by the literature regarding deep venous thrombosis following foot and ankle surgery. In this article, we review the risk factors and explore the occurrence of thromboembolism after foot and ankle surgery in the literature. We also present our retrospective study of patients who developed venous thromboembolism after forefoot, midfoot, hindfoot, and ankle procedures. Over the course of 1.5 years, 4 of a consecutive series of 1000 patients (0.4%) developed a deep venous thrombolism and 3 of 1000 (0.3%) developed nonfatal pulmonary emboli. In our series, each of our patients who developed venous thromboembolism had at least 2 identifiable risk factors. The incidence of venous thromboembolism following foot and ankle surgery is rare (less than 1%), and the need for routine propylaxis postoperatively is not supported by any high level of evidence studies. LEVEL OF CLINICAL EVIDENCE: 4.     

Frequency and timing of clinical venous thromboembolism after major joint surgery

Over a 13-year period we studied all patients who underwent major hip and knee surgery and were diagnosed with objectively confirmed symptomatic venous thromboembolism, either deep venous thrombosis or non-fatal pulmonary embolism, within six months after surgery. Low-molecular-weight heparin had been given while the patients were in hospital. There were 5607 patients. The cumulative incidence of symptomatic venous thromboembolism was 2.7% (150 of 5607), of which 1.1% had developed pulmonary embolism, 1.5% had deep venous thrombosis and 0.6% had both. Patients presented with deep venous thrombosis at a median of 24 days and pulmonary embolism at 17 days after surgery for hip fracture. After total hip replacement, deep venous thrombosis and pulmonary embolism occurred at a median of 21 and 34 days respectively. After total knee replacement, the median time to the presentation of deep venous thrombosis and pulmonary embolism was 20 and 12 days respectively. The cumulative risk of venous thromboembolism lasted for up to three months after hip surgery and for one month after total knee replacement. Venous thromboembolism was diagnosed after discharge from hospital in 70% of patients who developed this complication. Despite hospital-based thromboprophylaxis, most cases of clinical venous thromboembolism occur after discharge and at different times according to the operation performed.     

Incidence of venous thromboembolism in elective foot and ankle surgery with and without aspirin prophylaxis

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.     

Aspirin for elective hip and knee arthroplasty: a multimodal thromboprophylaxis protocol

Purpose

Multimodal thromboprophylaxis includes preoperative thromboembolic risk stratification and autologous blood donation, surgery performed under regional anaesthesia, postoperative rapid mobilisation, use of pneumatic compression devices and chemoprophylaxis tailored to the patient’s individual risk. We determined the 90-day rate of venous thromboembolism (VTE), other complications and mortality in patients who underwent primary elective hip and knee replacement surgery with multimodal thromboprophylaxis.

Methods

A total of 1,568 consecutive patients undergoing hip and knee replacement surgery received multimodal thromboprophylaxis: 1,115 received aspirin, 426 received warfarin and 27 patients received low molecular weight heparin and warfarin with or without a vena cava filter.

Results

The rate of VTE, pulmonary embolism, proximal deep vein thrombosis (DVT) and distal DVT was 1.2, 0.36, 0.45 and 0.36?%, respectively, in patients who received aspirin. The rates in those who received warfarin were 1.4, 0.9, 0.47 and 0.47?%, respectively. The overall 90-day mortality rate was 0.2?%.

Conclusions

Multimodal thromboprophylaxis in which aspirin is administered to low-risk patients is safe and effective following primary total joint replacement.     

Epidemiologie der ven?sen Thromboembolie

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are still a common cause of mortality and morbidity. A large proportion of venous thromboembolisms (VTE) occur spontaneously but many would be preventable by implementation of standard prophylactic measures especially in high risk patients. Venous thrombosis occurs at an annual incidence of about 1 per 1,000 adults but this increases with age. About two thirds of thromboembolic episodes manifest as DVT and one third as PE. Thrombosis impairs the quality of life, especially in patients with postthrombotic syndrome and VTE sharply increases mortality. Mortality rates are highest in cancer patients. Tumors activate coagulation and the tumor itself might compress veins and therefore induce venous stasis. In addition immobilization with hospitalization, surgery and chemotherapy increase the risks. Several studies have shown incidences of thromboembolisms of more than 12 per 1,000 even in the first 6 months after cancer has been diagnosed. There are differences in incidences of diagnosed venous thrombosis among ethnic groups with blacks having the highest rates, followed by whites and then Hispanics and Asians. The major risk factors for thromboembolism include endogenous patient characteristics, such as obesity and genetic factors and triggering factors such as surgery, immobility or pregnancy. Obesity as a risk factor is nowadays a worldwide problem and the incidence has more than doubled in many countries with an estimated prevalence as high as 30% in many geographical areas. Patients who experience venous thromboembolism (deep vein thrombosis and/or pulmonary embolism) are more than twice as likely to die within the next 8 years than similar individuals without venous thrombosis or pulmonary embolism.     

Incidence of acute deep vein thrombosis and pulmonary embolism in foot and ankle trauma: analysis of the National Trauma Data Bank

The incidence of deep vein thrombosis (DVT) after foot and ankle surgery is generally believed to be low. However, little information is available regarding DVT as it specifically relates to foot and ankle trauma. The National Trauma Data Bank data set (2007 to 2009) was used to evaluate the incidence of thromboembolism in foot and ankle trauma. Also, the risk factors associated with the thromboembolic events were identified. Data regarding the demographics, comorbidities, procedures, trauma types, and complications, including DVT and pulmonary embolism (PE), were collected from the data set for analysis. The incidence of DVT and PE was 0.28% and 0.21%, respectively. The risk factors statistically significantly associated and clinically relevant for both DVT and PE in foot and ankle trauma were older age (DVT, odds ratio [OR] 1.02, 95% confidence interval [CI] 1.01 to 1.03; PE, OR 1.02, 95% CI 1.01 to 1.03), obesity (DVT, OR 2.35, 95% CI 1.33 to 4.14; PE, OR 3.06, 95% CI 1.68 to 5.59), and higher injury severity score (DVT, OR 1.22, 95% CI 1.16 to 1.28; PE, OR 1.21, 95% CI 1.14 to 1.29). Owing to the low incidence, routine pharmacologic thromboprophylaxis might be contraindicated in foot and ankle trauma. Instead, careful, individualized assessment of the risk factors associated with DVT/PE is important.     

Pulmonary embolism following operative treatment of ankle fractures: a report of three cases and review of the literature

The risks of thromboembolism following operative treatment of ankle fractures are deep vein thrombosis (DVT) and pulmonary embolism (PE). These are potentially life-threatening complications. Many orthopedic surgeons fail to appreciate the potential complications of thromboembolic events because of their rare and delayed occurrence in foot and ankle operations. The purpose of this report is to describe the potential for DVT and PE following ankle operations. We present three cases in which patients who underwent operative treatment of ankle fractures subsequently developed PE. We also review the literature on the prevalence of thrombosis, risk factors, methods of prophylaxis, and use of prophylaxis in surgical procedures of the lower extremity.     

老年股骨颈骨折全髋关节置换术围手术期下肢深静脉血栓形成的特点

目的探讨老年股骨颈骨折行人工全髋关节置换术及规范化预防性抗凝治疗下围手术期下肢深静脉血栓形成的特点。 方法回顾性分析2015年1月~2017年6月华中科技大学同济医学院附属普爱医院骨科行人工全髋关节置换的老年患者363例,年龄（66±5）岁,男性114例（31.4%）,女性249例（68.6%）。将患者分为股骨颈骨折组（n=187）和非股骨颈骨折组（n=176）。按照《中国骨科大手术静脉血栓栓塞症预防指南》进行规范化血栓预防,对围手术期出现下肢深静脉血栓的患者进行回顾性分析,对比两组患者围手术期深静脉血栓形成的特点。 结果骨折组患者中8例出现下肢深静脉血栓,其中2例并发肺栓塞;非骨折组中6例出现下肢深静脉血栓,其中1例并发肺栓塞,差异无统计学意义（χ²=0.185,P>0.05）。骨折组下肢深静脉血栓5例发生于术前,3例发生于术后;非骨折组6例患者均发生于术后,两组比较差异有统计学意义（P<0.05）。 结论老年股骨颈骨折全髋关节置换患者术前和术后均易形成下肢深静脉血栓,对于这类特殊的群体,术前血栓防治也应引起足够的重视。     

Incidence of DVT following surgery of the foot and ankle

A prospective study was undertaken to establish the incidence of deep vein thrombosis (DVT) in patients who had undergone surgery of the foot and ankle. All consecutive patients who underwent foot and ankle surgery in the senior author's practice had duplex ultrasound performed of the bilateral calves at the first postoperative visit. Of 201 patients, deep calf clots were found in seven patients (3.5%), but none of these showed progression on follow-up ultrasound or extension proximal to the calf. By the authors' criteria, none of the studied patients required treatment. The authors feel that the rate and progression of DVT after foot and ankle surgery is low and does not require routine prophylaxis. Factors associated with risk of DVT formation were postoperative immobilization, hindfoot surgery, tourniquet time and advancing age.     

Prevention and treatment of deep venous thrombosis

Postoperative venous thromboembolism (VTE) is a common cause of preventable patient morbidity and mortality. Hospitalized patients have multiple risk factors for VTE, which can exert a cumulative effect on the individual patient. Although effective thromboprophylactic measures are currently available, they are not commonly used for a number of reasons, in addition to heightened concern about increasing bleeding risk. Limited data are available characterizing the incidence of symptomatic VTE following major vascular surgery in the absence of thromboprophylactic therapy. Reported rates vary according to the type of surgery, type of prophylaxis used, and diagnostic modalities used for deep venous thrombosis (DVT) and pulmonary embolism (PE). Hospital-acquired DVT in the absence of thromboprophylaxis can occur in up to 40% of patients, occurring primarily in the proximal deep veins, which elevates the risk of PE. Risk factors for VTE in vascular surgery include limb ischemia, prolonged surgery duration, localized intraoperative trauma, and atherosclerosis. Advanced patient age is also a risk factor for VTE; however, the relationship between age and risk of VTE after surgery is complex and dependent on both the type of surgery and the underlying disease process. Evidence-based guidelines for venous thrombo-prophylaxis are now available; however, adoption of and compliance with these guidelines have lagged. Effective thrombo-prophylactic strategies exist and include both pharmacologic and nonpharmacologic approaches. For those surgical patients who develop a VTE, antithrombotic therapy remains the treatment of choice.     

Incidence of Venous Thromboembolism in Patients Receiving Anticoagulation for Foot and Ankle Surgery

Venous thromboembolism (VTE) is a serious medical condition that can be an unfortunate complication arising from foot and ankle surgery. Many factors may predispose a patient to a VTE event including prolonged postoperative immobilization, comorbidities, extended length of tourniquet time, and higher risk surgeries. Unfortunately, there is no clinical consensus for guidelines on VTE prophylaxis following foot and ankle surgery. In this retrospective cohort study, we present our patient population who were prophylactically anticoagulated following foot and ankle surgery along with their incidence of deep vein thrombosis and pulmonary embolism (PE). Included in the study were patients who had undergone elective and traumatic foot and ankle surgery from June 2017 to December 2018. Using retrospective data obtained we compared patient demographics, surgery type, length of tourniquet time, postoperative immobilization, type of VTE prophylaxis, and comorbidities including history of smoking, peripheral vascular disease, bleeding disorders, and patients undergoing dialysis. Five of 425 (1.2%) patients were diagnosed with a deep vein thrombosis and 1 of 425 (0.2%) patients was diagnosed with a pulmonary embolism. Risks factors statistically significant for developing a VTE in our patient population included extended periods of immobilization and an increasing patient age. We were able to conclude that routine prophylaxis for elective and traumatic foot and ankle surgery is both effective and safe for especially in older patients requiring extended immobilization. It's also important to take into consideration comorbidities, smoking history, tourniquet time, and the type of surgery that is being performed.     

Venous thromboembolism in shoulder surgery: a systematic review

Although it is generally believed that venous thromboembolism (VTE) after shoulder surgery is very rare, there are increasing reports of deep venous thrombosis (DVT) and pulmonary embolism (PE) associated with shoulder surgery. To our knowledge only few studies have reviewed the available evidence on the subject. The purpose of this study was to review the available evidence in the published literature regarding incidence, risk factors, diagnosis and management of DVT/PE following shoulder surgery (Level IV evidence).     

Alignment and technique in total ankle arthroplasty

Total ankle arthroplasty has emerged as a promising alternative to ankle arthrodesis, especially in cases where multiple hindfoot joints are arthritic. Proper alignment of the limb must be restored to be most successful over the long term. Misalignment above the ankle typically involves a malunion of a previous tibia fracture and can be treated by corrective osteotomy. Deformity in the joint itself can arise from congenital malformation or from bony erosion, usually as a late result of joint trauma. Mild amounts of bone loss can be corrected through bone cuts during ankle replacement, but more severe deformity may require distal tibial osteotomy. Misalignment below the ankle (in the foot) is probably the most common deformity. Secondary procedures in the foot and leg, including muscle balancing, osteotomies, or fusions are often a part of the surgical plan and are performed either before or simultaneously with ankle replacement. The goal is to restore an ankle with neutral static and dynamic balance during stance and gait. Achieving that goal will give the best chance for pain free ankle motion over the long term.     

Low-molecular-weight heparin for deep vein thrombosis prophylaxis in foot and ankle surgery: a review.

The necessity of prophylaxis for deep vein thrombosis (DVT) in those patients who undergo foot and ankle surgery remains poorly defined. The authors explore and review the low-molecular-weight heparin (LMWH) preparations for use by foot and ankle surgeons. Recent literature has described a low incidence of DVT and pulmonary embolus (PE) following foot and ankle surgery. Nonetheless, it is paramount that foot and ankle surgeons be aware of the potential risk factors and methods of prophylaxis for DVT. Many options are available for prophylaxis. This article presents a review of DVT with particular attention given to distinguishing risk factors, prophylaxis, and LMWH preparations.     

Symptomatic venous thromboembolism in Asian colorectal cancer surgery patients

Background  

The occurrence of venous thromboembolism (VTE), manifesting as deep vein thrombosis (DVT) or pulmonary embolism (PE), after colorectal cancer surgery in Asian patients remains poorly characterized. The present study was designed to investigate the incidence of symptomatic VTE in Korean colorectal cancer patients following surgery, and to identify the associated risk factors.     

Review of Acute Pulmonary Embolism in a General Hospital

Purpose Acute pulmonary embolism (APE) is a serious cardiovascular disease associated with high mortality rates. We analyzed the clinical characteristics, treatment, and outcome of patients with APE in a general hospital in Japan. Methods The subjects were 14 patients with APE: 6 with out-of-hospital onset and 8 with in-hospital onset. Results The incidence of APE in hospitalized patients was 0.03% (95% confidence interval, 0.01%–0.05%). Eight patients suffered shock and three patients suffered cardiac arrest. Advanced age, deep vein thrombus (DVT), cancer, fracture, obesity, and surgery were common risk factors. In the hospitalized patients, surgery was a major risk factor: APE developed perioperatively in five (63%) of eight patients. Nine patients were treated with heparin alone, three were treated with thrombolysis, and two underwent surgical embolectomy for right heart thrombi. Three of the patients who suffered shock died during hospitalization and another died of recurrence 2 months after the first episode. Overall in-hospital and 3-month mortality rates were 21% and 29%, respectively, and the in-hospital mortality rate of the patients with shock was 38%. Conclusion Acute pulmonary embolism was associated with high mortality rates and surgery was the most common risk factor predisposing to APE in hospitalized patients. Thus, standardized prophylaxis against DVT is essential for patients undergoing surgery.     

Deep vein thrombosis after elective knee surgery. An incidence study in 312 patients

The incidence of venous thromboembolism after elective knee surgery has previously been studied almost exclusively in patients receiving total knee replacements, in whom the risk of a deep vein thrombosis is approximately 60%. We report the results of ipsilateral ascending venography in 312 patients undergoing a wide variety of elective knee operations under tourniquet ischaemia, none of whom received any specific prophylaxis against thromboembolism. Total knee replacement was confirmed to carry a high risk with ipsilateral deep vein thrombosis in 56.4% and symptomatic pulmonary embolism in 1.9%. By contrast, arthroscopy was associated with a low incidence of venous thrombosis (4.2%). Meniscectomy, arthrotomy, patellectomy, synovectomy and arthrodesis were all high-risk procedures, particularly in patients over 40 years of age, and were associated with deep vein thrombosis rates of 25% to 67%. On the basis of these findings, we advise prophylaxis against venous thromboembolism in all patients over 40 years of age undergoing elective knee surgery other than arthroscopy.     

Does thromboprophylaxis reduce symptomatic venous thromboembolism in patients with below knee cast treatment for foot and ankle trauma? A systematic review and meta-analysis

Background

Our aim was to determine the evidence for thromboprophylaxis for prevention of symptomatic venous thromboembolism (VTE) in adults with foot or ankle trauma treated with below knee cast or splint. Our secondary aim was to report major bleeding events.

Thromboembolic complications after spinal surgery in trauma patients

Background Deep venous thrombosis (DVT) and pulmonary embolism (PE) may be significant complications following spinal surgery. The incidence rate ranges from 0.5% to 2.5% in patients with symptomatic thromboembolic disease and up to 15% in patients with non-symptomatic thrombotic complications. We determined the incidence of symptomatic thromboembolism after spinal surgery in patients with postoperative systemic prophylaxis and investigated general and specific risk factors for development of this disease.

Patients and methods We analyzed the clinical records of 978 patients who had undergone surgery of the spine because of trauma and who had been admitted to our level-I trauma center between 1980 and 2004. Spinal procedures included anterior and/or posterior spinal fusion, video-assisted thoracoscopic fusion, and spinal decompression. Symptomatic thromboembolic disease was diagnosed when patients showed significant clinical signs or symptoms of DVT or PE. In cases of DVT, diagnosis was confirmed by duplex scan of the lower limbs; in cases of PE, diagnosis was confirmed by CT-scanning of the thorax or at post mortem.

Results The incidence rate of symptomatic thromboembolic complications was 2.2% (n 22). 17 patients showed clinical signs of deep venous thrombosis, with 4 of them developing pulmonary embolism subsequently. The other 5 patients developed pulmonary embolism without prior clinical signs of deep venous thrombosis. 6 patients died because of thromboembolic disease. Thromboembolic complications were more frequent in older patients and among males, as well as in patients with regular tobacco consumption and obesity. Thromboembolic complications were also seen more frequently in patients with surgical procedures at the lumbar spine, in patients with anterior spinal fusion, and in those with motor deficits in the lower extremities.

Interpretation We found a rather low rate of clinically significant thromboembolic complications after spinal surgery because of trauma, compared to the results reported in the literature. Level of spinal surgery, surgical approach, and motor deficits in the lower extremities were identified as specific risk factors for DVT or PE. Age, sex, obesity and regular smoking were identified as general risk factors.