SLR - December 2023 - Qureshi
Title: Postoperative venous thromboembolism risk-prediction in foot and ankle fracture surgeryReference: Brennan J, Keblish D, Friedmann E, Spirt A, Holt E, Turcotte J. Postoperative venous thromboembolism risk-prediction in foot and ankle fracture surgery. Foot (Edinb). 2023;56:102017.
Level of Evidence: 3, retrospective review
Reviewed By: Mujtaba Qureshi DPM
Residency Program: St. Mary’s General Hospital, Passaic, New Jersey
Podiatry Relevance: There is no standardized protocol for prophylaxis against venous thromboembolism (VTE) in foot and ankle surgery. Prophylaxis typically has been modeled after hip and knee surgery. Studies thus far have shown that other than achilles repair, foot and ankle surgery is not at a comparably higher risk for patients developing DVT. Thus, there have been no definitive established guidelines, and prophylaxis remains controversial. The aim of this study is to aid in identifying which patients are at higher risk of developing VTE after ankle fracture surgical repair. Furthermore, this article aids the surgeon in screening which patients should be screened and considered more strongly for treatment.
Methods: The authors conducted a retrospective review of 15,342 patients within the ACS-NSQIP database. These patients were screened for surgical repair of foot and ankle fractures from 2015 to 2019. Patients were screened to see if they developed VTE within a 30-day postoperative period. They were then stratified based on age, post-operative complications, comorbidities, and fracture pattern.
Results: Significant predictors included age over 65, diabetes, dyspnea, CHF, dialysis, wound infection at the time of surgery, and bleeding disorders. These factors increased the risk of VTE by two times, and dialysis patients had an increased risk by five times. Independent functional status was found to be protective against VTE, decreasing risk by 58%. Ankle fractures that involved distal tibia fractures along with fibula fractures had a higher risk of developing VTE compared to bimalleolar, trimalleolar, isolated distal tibia fractures, calcaneal fractures, and talar fractures.
Conclusions: The model studied by the authors focused on traumatic patients as a subset, as opposed to elective surgery. The authors found that patients typically with the associated comorbidities listed are at higher risk of developing VTE. Particularly of note, patients on dialysis should be considered as significantly higher risk for VTE formation. Although trauma had been identified as a higher risk for developing VTE in foot and ankle surgery previously, this study provides more predictors that aid the surgeon to guide which patients should be more strongly considered, including fracture patterns. Ankle injuries that more extensively involve the distal tibia should be recognized as higher risk compared to bimalleolar/trimalleolar ankle injuries.
Although a standard VTE prophylaxis protocol does not exist in foot and ankle surgery, literature has already shown increased risks of VTE in certain populations with foot and ankle surgery, including factors that were studied in this study such as increased age, diabetics, patients with cardiopulmonary diseases, and active wound infections. An additional risk factor that was found in this study included fractures involving the distal tibia with concomitant ankle fractures. As a clinician and as a surgeon, fracture patterns and comorbidities have typically aided us in selecting our surgical fixation treatment and our postoperative weight bearing protocols, but this study helps show that VTE prophylaxis should also be dictated based on the extent of the injury. In summary, full consideration of the patient’s risk factors and their functional status should be taken and used when determining the patient's postoperative course of VTE prophylaxis.