SLR - April 2019 - Midy Liou

Incidence of and Risk Factors for Venous Thromboembolism After Foot and Ankle Surgery

Reference: Huntley SR, Abyar E, Lehtonen EJ, Patel HA, Naranje S, Shah A. Incidence of and risk factors for venous thromboembolism after foot and ankle surgery. Foot & Ankle Specialist. 2018 Apr 1:1938640018769740.

Scientific Literature Review

Reviewed By: Midy Liou, DPM
Residency Program: Montefiore Medical Center, Bronx, NY

Podiatric Relevance: Venous thromboembolism (VTE) is a rare complication following foot and ankle surgery with significant morbidity and mortality. Currently, the various governing bodies and specialist societies, including the American College of Foot and Ankle Surgeons (ACFAS) and the American College of Chest Physicians (CHEST), have reached consensus against the use of routine thromboprophylaxis. However, these recommendations are not made for any specific circumstance or type of surgery in the foot and ankle. Surgeons have continued to debate the use and duration of thromboprophylaxis in cases with potentially higher risks. This has resulted in treatment variations between surgeons and hospitals alike. This study is designed to report on the incidence of VTE and to identify the risk factors associated following foot and ankle surgeries.

Methods: This is a retrospective review of prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program database, between 2006 and 2015.   Patients who received CPT codes relating to orthopaedic foot and ankle surgery were included. The primary outcome measure was the incidence of VTE. Secondary outcome measures were the identification of demographic risk factors and types of surgeries associated with development of VTE following foot and ankle procedures.

Results: Of the 23,212 patients identified, a total of 0.6 percent had symptomatic VTE; 0.4 percent were deep vein thrombosis and 0.2 percent were pulmonary embolism. Individual procedures associated with the highest rates of VTE were open treatment of ankle fractures (medial malleolus 0.9 percent, bimalleolar 0.8 percent and trimalleolar fractures 0.7 percent). The types of procedures with the highest frequency of VTE were ankle fractures/dislocations (0.7 percent), foot fractures/amputation/incision/dislocation (0.6 percent) and arthroscopy (0.5 percent). The demographics significantly associated with development of VTE included female gender, older age (58.8 vs. 52.6 years), high BMI (30.6 vs. 28.8 kg/m2), inpatient status and nonelective surgeries. There was no correlation between race and higher development of VTE.

Conclusions: The authors concluded the overall prevalence of symptomatic VTE was low at 0.6 percent following foot and ankle procedures. They agree that routine chemical thromboprophylaxis for all patients is unnecessary; however, careful considerations should be taken for certain subsets of patients with at-risk demographics undergoing higher risk procedures. In my opinion and in view of the significant morbidity and mortality associated with VTE, it may be more advantageous to be on the side of caution and give chemical prophylaxis to all at risk patients. 

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