SLR - December 2012 - Rodriguez

The Incidence of Thromboembolic Events in Surgically Treated Ankle Fracture

References:
Pelet S, Roger M., Belzile EL, & Bouchard M. (2012). The Incidence of Thromboembolic Events in Surgically Treated Ankle Fracture. The Journal of Bone and Joint Surgery, 94, 502-6.

Scientific Literature Review

Reviewed by: Renee Rodriguez, DPM
Residency Program: University Hospitals Richmond Medical Center

Podiatric Relevance:
Ankle fractures are some of the most common types of musculoskeletal trauma confronted by the podiatric physician. While conservative measures and closed reduction may suffice in treating ankle fractures, depending on the extent of injury and the patient, at times surgical intervention proves to be the more appropriate treatment. With all surgical procedures, it is vital that the surgeon assess the patient for risk of deep venous thrombosis and pulmonary embolism. Venous thromboembolism can have serious chronic sequelae such as post-thrombotic syndrome and chronic thromboembolic pulmonary hypertension, and can even be fatal if not recognized. It is important for the podiatric surgeons to have an understanding of thromboembolic events as a means of reducing postoperative morbity and mortality.

Methods:
A retrospective chart review of 2,478 patients that had undergone open reduction and internal fixation of an ankle fracture was performed. Of these, 1,540 of these patients met the inclusion criteria, which included a six month follow-up. Pilon fractures were excluded from the study, as well as polytrauma patients and patients that were already taking antithrombotic drugs. Patient that took aspirin daily were not excluded. These surgeries occurred between a period of eight years and within three different hospitals. Individual risk factors were taken into account and included neoplasia, oral contraceptives, pregnancy, blood dyscrasias, history of deep venous thrombosis or pulmonary embolics, smoking history, obesity, etc. Warfarin and low molecular weight heparin were used, along with sequential compressive devices. Deep venous thrombosis was confirmed by symptomatology, such as calf pain, and the use of Doppler ultrasonography. Pulmonary embolism was confirmed with ventilation and perfusion scintigraphy or helical computed tomography. Positive DVTs and/or PEs were correlated with individual risk factors.

Results:
Out of the 1,540 patients that met criteria, 41 patients developed DVTs, while five patients developed PEs. Two hundred fifty-three patients received heparin or warfarin during their hospital stay, and out of these patients, 2.37 percent had DVT’s and 0.4 percent had PEs. Thromboprophylaxis was given more often to those patients with bimalleolar or trimalleolar fractures. Prophylaxis was usually omitted in those patients without risk factors for DVT. There was no significant difference in thromboembolic event in patients that received antithrombotic prophylaxis and those that did not. Aspirin did not affect these rates. It was found that having more than one risk factor did not modify these results. There was no difference in rate between any of the three hospitals.

Conclusions:
Ultimately, the authors found that thromboembolic events after open reduction and internal fixation of ankle fractures is uncommon, with or without thromboprophylaxis. The authors acknowledge that risk factors for thromboembolic events do make one more susceptible to VTE, and must still be assessed carefully. The authors also suggest a need for prospective studies to determine the efficacy of thromboprophylaxis; hence, economic factors and complications of thromboprophylaxis were not taken into consideration. The authors admit that with low incidence of DVT/PE in this study, that they cannot justify the routine thromboprophylaxis after ankle fracture treatment.

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