SLR - August 2022 - Kentston Cripe, DPM
Reference: ICM-VTE Foot & Ankle Delegates. Recommendations from the ICM-VTE:: Foot & Ankle. J Bone Joint Surg Am. 2022 Mar 16;104(Suppl 1):163-175. doi: 10.2106/JBJS.21.01439. PMID: 35315608.Level of Evidence: 1
Scientific Literature Review
Reviewed By: Kentston Cripe, DPM
Residency Program: Creighton University – Phoenix, AZ
Podiatric Relevance: There is presently no good evidence that thromboprophylaxis strategy will protect against fatal pulmonary embolus. There is no current good evidence for a validated risk analysis and assessment stratification tool in Trauma and Orthopedic surgery. CDC data demonstrates up to 900,000 people affected by VTE annually in the US with 60,000-100,000 of these leading to death. Of those who survive, 33-50 percent develop long term post-thrombotic syndrome and 33 percent experience recurrence within 10 years. This publication provides recommendations regarding eight clinical questions addressed below.
Methods: The International Consensus Meeting (ICM) convened a group, of nearly 600 experts from 68 countries and multiple medical specialties, to perform a literature review related to VTE to create practical recommendations. The strict Delphi process was followed over a one-year period with guidance of the steering committee and engagement of the organizing committee, librarians, biostatisticians, epidemiologists, and experts from the Cochrane group to review all published work related to VTE and orthopedics to generate a response/recommendation to the nearly 200 issues (questions) that had been collated from the field.
Results:
I. Should patients undergoing surgical debridement of diabetic foot ulcers receive routine VTE prophylaxis?
a. The authors proposed routine thromboprophylaxis, particularly if the patient has reduced mobility and other medical comorbidities.
II. Is routine VTE prophylaxis needed for patients placed in walker boot immobilization?
a. Patients should be risk assessed, and VTE prophylaxis offered on an individual basis
III. Does the weight-bearing status of the patient after foot and ankle surgery influence the selection of VTE prophylaxis?
a. VTE risk is mitigated by load bearing of the operative limb greater than 50%.
IV. Concerning VTE risk, which surgeries can be considered major, and which surgeries can be considered non-major in foot and ankle surgery?
a. There is insufficient data to characterize foot and ankle surgical procedures
V. Is routine VTE prophylaxis required for patients undergoing forefoot and midfoot surgery who would be allowed to fully weight-bear?
a. We do not recommend routine anticoagulants for VTE prevention in low-risk patients.
VI. Is routine VTE prophylaxis needed for patients undergoing Achilles tendon repair?
a. VTE prophylaxis should be reserved for patients at high-risk of VTE
VII. Is there a role for routine VTE prophylaxis undergoing ankle and/or hindfoot fusion?
a. We cannot recommend routine anticoagulants for VTE prevention in low-risk patients.
VIII. Is routine VTE prophylaxis required for patients undergoing total ankle arthroplasty?
a. Subpopulations of patients may be at sufficiently heightened risk to justify chemoprophylaxis.
Conclusions: These recommendations cannot be applied in every scenario and each patient should be individually assessed for risk and prophylaxis administered when indicated based on the experience, training, and rationale determined by the performing surgeon .
Any scenario involving immobilization or surgical intervention in the treatment of lower extremity pathology should trigger an advanced evaluation including risk stratification for consideration of mechanical and/or chemical venous thromboembolism prophylaxis