VTE Prophylaxis in Foot & Ankle Surgery
VTE can occur in patients undergoing foot and ankle procedures, although with less frequency than in knee and hip arthroplasty. The incidence is difficult to determine, given the diversity of foot and ankle procedures as well as the wide range of their magnitude and complexity.
There is currently insufficient data to recommend for or against routine VTE prophylaxis for patients undergoing foot and ankle surgery. The patients need be assessed pre-operatively for VTE risk. If sufficient risk factors are present, VTE prophylaxis may be considered and weighed against the potential risks of prophylaxis.
The final decision regarding the use, and the method of prophylaxis adopted should follow a risk assessment for VTE and bleeding (preferably at the preoperative assessment clinic) with a discussion usually at the point of consent between the treating surgeon and patient about the pros and cons of this management in each individual.
The known risk factor for VTE include prior thromboembolic disease, hypercoagulable state, malignancy, family history of VTE, obesity, oral contraceptive medications, polytrauma, prolonged immobilisation, non-weight-bearing status and age over 60 years. The correlation of these risk factors with the Foot and Ankle procedures has not been investigated.
Modalities of VTE prophylaxis include mechanical and chemical measures. Mechanical prophylaxis includes elastic compression stockings and sequential compression calf pumps or foot pumps on the contralateral extremity during and after surgery, however the true efficacy of this modality in foot and ankle surgery is unknown. The duration of the surgical procedure for which these are beneficial is unknown, as is the optimal duration of their use post-operatively.
Chemical prophylaxis includes the use of anti-coagulants such as warfarin, unfractionated heparin, and low molecular weight heparins (LMWHs) and may also include aspirin. The specific indications for the use of these agents in foot and ankle surgery remain undefined. For instance, one study failed to demonstrate a statistically significant difference between the incidence of both proximal and distal DVT in patients who underwent Achilles tendon repair and were randomized to receive either Dalteparin or placebo. Another study demonstrated that for patients requiring prolonged immobilization for treatment of either an Achilles rupture or a lower limb fracture, the use of Riviparin resulted in a statistical decrease of only the distal DVT rate. Both these studies were limited due to their small numbers.
Chemical prophylaxis carries its own risks that include major or minor bleeds with varying degrees of morbidity and potential mortality.
In another study of 1,540 ambulatory patients with ankle fractures requiring open reduction and internal fixation, the incidence of thromboembolic events was 2.9%, with 2.6% involving a deep venous thrombosis, and 0.32% involving a non-fatal pulmonary embolism. In this study, the clinically detectable thromboembolic event was not influenced by the use of thromboprophylaxis.
It should be emphasised that the currently available patient specific risk assessment tools, adopted by many Trust thrombosis committees, have significant limitations because none have validated scoring systems and are purely arbitrary. Further research to provide a lower limb surgery specific risk assessment tool is of paramount importance.
American Orthopaedic Foot and Ankle Society, Position Statement: The Use of VTED Prophylaxis in Foot and Ankle Surgery; July 2013.
British Orthopaedic Foot and Ankle Society Guidelines for Venous Thromboembolism Prophylaxis; Position Statement.
Lapidus LJ, et al. Prolonged thromboprophylaxis with Dalteparin during immobilization after ankle fracture surgery. Acta Orthopaedica. 78(4): 528-535, 2007.
Jameson SS, et al. Venous thromboembolic events following foot and ankle surgery in the English national Health Service. J Bone Joint Surg Br. 93: 490-497, 2011.
Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon. 51: 70-78, 2005.
Mayle RE, et al. Current concepts review: venous thromboembolic disease in foot and ankle surgery. Foot Ankle Int. 28(11): 1207-1216, 2007.
Amaragiri SV and Lees TA. Elastic compression stockings for prevention of deep vein thrombosis. Cochrane Database Syst Rev. 3: CD001484, 2000.
Urbankova J, et al. Intermittent pneumatic compression and deep vein thrombosis prevention. A meta-analysis in post-operative patients. Thromb Haemost. 94: 1181-1185, 2005.
Pelet et al. The incidence of thromboembolic events in surgically treated ankle fracture. J Bone Joint Surg Am. 94:502-506, 2012.
Falck-Ytter Y, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 141(2 Suppl):e278S-325S, 2012.
Last Updated: Jan 2018