Abstract
Purpose To perform a meta-analysis investigating venous thromboembolism (VTE) following isolated foot and ankle surgery and propose guidelines for VTE prevention in this group of patients.MethodsFollowing a PRISMA compliant search, 372 papers were identified and meta-analysis performed on 22 papers using the Critical Appraisal Skills Programme and Centre for Evidence-Based Medicine level of evidence.Results 43,381 patients were clinically assessed for VTE and the incidence with and without chemoprophylaxis was 0.6 % (95 % CI 0.4–0.8 %) and 1 % (95 % CI 0.2–1.7 %), respectively. 1666 Patients were assessed radiologically and the incidence of VTE with and without chemoprophylaxis was 12.5 % (95 % CI 6.8–18.2 %) and 10.5 % (95 % CI 5.0–15.9 %), respectively. There was no significant difference in the rates of VTE with or without chemoprophylaxis whether assessed clinically or by radiological criteria. The risk of VTE in those patients with Achilles tendon rupture was greater with a clinical incidence of 7 % (95 % CI 5.5–8.5 %) and radiological incidence of 35.3 % (95 % CI 26.4–44.3 %).ConclusionIsolated foot and ankle surgery has a lower incidence of clinically apparent VTE when compared to general lower limb procedures, and this rate is not significantly reduced using low molecular weight heparin. The incidence of VTE following Achilles tendon rupture is high whether treated surgically or conservatively. With the exception of those with Achilles tendon rupture, routine use of chemical VTE prophylaxis is not justified in those undergoing isolated foot and ankle surgery, but patient-specific risk factors for VTE should be used to assess patients individually.Level of evidenceII.
Highlights
5.5–8.5 %) and radiological incidence of 35.3 %
With the exception of those with Achilles tendon rupture, routine use of chemical venous thromboembolism (VTE) prophylaxis is not justified in those undergoing isolated foot and ankle surgery, but patient-specific risk factors for VTE should be used to assess patients individually
The NICE committee commissioned with assessment of VTE prevention concluded that for patients immobilized in a cast “This is a large patient group for whom the evidence is not clear” and went on to state “There would be a substantial cost to the NHS of providing thromboprophylaxis to all patients with a lower limb plaster cast, if patients use prophylaxis until cast removal which may be a number of weeks” [53]
Summary
5.5–8.5 %) and radiological incidence of 35.3 % (95 % CI 26.4–44.3 %). Conclusion Isolated foot and ankle surgery has a lower incidence of clinically apparent VTE when compared to general lower limb procedures, and this rate is not significantly reduced using low molecular weight heparin. With the exception of those with Achilles tendon rupture, routine use of chemical VTE prophylaxis is not justified in those undergoing isolated foot and ankle surgery, but patient-specific risk factors for VTE should be used to assess patients individually. The risk of VTE for patients with isolated foot and ankle conditions, even with plaster cast immobilization, and the possible benefits of mechanical and chemical prophylaxis are poorly studied. The American College of Chest Physicians (ACCP) most recent review recommends against chemical prophylaxis in lower leg injuries requiring immobilization [15] Despite this conclusion, many hospitals are introducing policies which recommend the routine use of low molecular weight heparin (LMWH) chemoprophylaxis for those in a cast following ankle fractures and all forms of elective foot and ankle surgery. The purpose of this meta-analysis and review of the literature is to establish the incidence of VTE in orthopaedic foot and ankle patients, investigating the effectiveness and risk of chemoprophylaxis comparing clinical to radiographic outcome measures
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