Incidence Of Deep Vein Thrombosis In Patients Research Articles

Release of the tourniquet immediately after the implantation of the components reduces the incidence of deep vein thrombosis after primary total knee arthroplasty.

ObjectivesThe length of the tourniquet time during total knee arthroplasty (TKA) is related to the incidence of post-operative deep vein thrombosis (DVT). Our aim in this study was to investigate the effect of the early release of the tourniquet on the incidence of DVT in patients undergoing TKA.MethodsA total of 200 patients who underwent TKA between November 2015 and November 2016 were prospectively enrolled. The tourniquet was inflated before surgery and released immediately after the introduction of the components (early release group). This group was compared with a retrospective cohort of 200 primary TKAs, in which the tourniquet was released after the dressings had been applied (late release group). The presence of a DVT was detected using bilateral lower limb ultrasonography. Peri-operative clinical and follow-up data were collected for analysis.ResultsThe incidence of DVT in the early release group (9 of 196, 4.6%) was significantly lower compared with the late release group (24 of 200, 12%; odds ratio (OR) 0.35, 95% confidence interval (CI) 0.16 to 0.78, p = 0.008). The incidence of proximal DVT in the early release group (1 of 196 (0.5%)) was significantly lower than in the late release group (8 of 196, 4%; OR 0.12, 95% CI 0.02 to 0.99, p = 0.020). Although the mean intra-operative blood loss was higher in the early release group, the mean post-operative drainage, total blood loss, transfusion requirements and complications were not significantly different in the two groups.ConclusionIn patients who undergo TKA, releasing the tourniquet early is associated with a decreased incidence of DVT, without increasing the rate of complications.Cite this article: Bone Joint Res 2017;6:535–541.

Is DVT prophylaxis necessary after oncology lower limb surgery? A pilot study

Background Deep vein thrombosis (DVT) has been independently associated with both malignant diseases and orthopaedic surgery. Therefore, orthopaedic oncology patients may be at a high risk for thromboembolic events. However, less emphasis is given to this group of patients compared to the patients undergoing total hip and knee replacement. The objective of this study is to determine the incidence of DVT and their risk factors in patients undergoing orthopaedic oncology lower limb surgery without prophylaxis.Questions/purposes(1) What is the incidence of DVT in patients who underwent orthopaedic oncology surgery for the lower limb? (2) What are the risk factors related to DVT in patients who underwent oncology surgery of the lower limb surgery? (3) This is a pilot study to determine if further trial is warranted.MethodsThis is a prospective study. All sequential patients undergoing orthopaedic oncology operations from the period of 1st October 2013 till 30th September 2014 were recruited for the study with their consent. Their demographic data, diagnosis and surgery were documented. Thirty-eight patients who underwent lower limb surgeries for orthopaedic oncology indications were included in the study. No tourniquet was used in these lower limb surgeries. There were 24 men and 14 women with a mean age of 36 years (11–75). All potential risk factors were also identified and documented. All patients were not given any form of DVT prophylaxis (mechanical and chemical) before and after operation as this is a standard protocol in our center and a Medical Ethics Committee approval was taken for this study. DVT surveillance was performed 1 day before operation and 2 weeks after operation with ultrasound Doppler. Patients diagnosed with DVT via ultrasound Doppler were subsequently scheduled for CTPA to look for pulmonary embolism (PE).ResultsDVT was detected in two patients (5 %). Both patients were asymptomatic and they both had proximal thrombosis. One patient (2.6 %) was diagnosed with non-fatal PE and was asymptomatic. PE was detected incidentally by staging computed tomography scan and the patient had negative ultrasound Doppler of the operated and non-operated limb for DVT. We did not carry out a statistical analysis as the study population with DVT and pulmonary embolism is small.ConclusionsThe incidence of DVT in patients after undergoing orthopaedic oncology lower limb surgery was low even without prophylaxis at our center. Further investigation with larger sample size is needed to validate our results and identify the risk factors.Level of evidenceLevel III descriptive study.

Effects of a Foot Pump on the Incidence of Deep Vein Thrombosis After Total Knee Arthroplasty in Patients Given Edoxaban: A Randomized Controlled Study.

We conducted a randomized clinical trial to compare the effectiveness of the A-V Impulse System foot pump for reducing the incidence of deep-vein thrombosis (DVT) after total knee arthroplasty (TKA) in patients under edoxaban thromboprophylaxis.Patients undergoing primary TKA at our institution between September 2013 and March 2015 were enrolled after obtaining informed consent. The patients were randomized to use the foot pump (n = 58) and not to use the foot pump (n = 62). Both groups were given prophylactic edoxaban. Primary outcomes were any DVT as detected by bilateral ultrasonography up to postoperative day 10 (POD10) and pulmonary embolism (PE) up to POD28. The safety outcomes were bleeding and death of any cause up to POD28. Plasma D-dimer levels were measured before TKA and on POD10 after TKA. Immunoglobulin G (IgG)-class anti-PF4/heparin antibodies were measured using an IgG-specific enzyme-linked immunosorbent assay.The incidences of any DVT up to POD28 were 31.0% and 17.7% in patients with or without the foot pump, respectively. The incidences of major bleeding up to POD28 were 5.1% and 4.8% in patients with or without the foot pump, respectively. Foot pump use did not significantly reduce the incidence of DVTs in patients undergoing TKA under edoxaban thromboprophylaxis. Although seroconversion of anti-PF4/heparin antibodies was confirmed in one-fourth of patients, the seroconversion rates did not differ between patients with (20.7%) or without (25.8%) foot pump use.This study shows that the A-V Impulse system foot pump did not affect the incidence of DVT under edoxaban thromboprophylaxis in patients undergoing TKA. Seroconversion of anti-PF4/heparin antibodies was detected in a significant number of patients who underwent TKA under antithrombotic prophylaxis using edoxaban.

The Incidence of Deep Vein Thrombosis in Asian Patients With Chronic Obstructive Pulmonary Disease

Most studies have focused on the prevalence of deep vein thrombosis (DVT) and pulmonary embolism in patients with chronic obstructive pulmonary disease (COPD) and acute exacerbation in Caucasian populations. DVT is supposedly less likely to occur among Asians than Caucasians, and the primary purpose of this study was to determine the actual incidence of DVT in patients with COPD in Asian populations.We enrolled patients over the age of 40 with a diagnosis of COPD (International Classification of Diseases, Ninth Revision [ICD-9]: 490–492, 496; A-code: A323 and A325) between 1998 and 2008. The index date was the date of first-time COPD diagnosis. We excluded the patients who had been diagnosed with COPD and DVT (The International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM]: 453.8) before index date. The control group was frequency-matched according to age (3-year stratum), sex, and the year of admission, at a 2:1 ratio. Patients were followed from index date to when either a diagnosis of DVT was made, death occurred, December 31, 2009 was reached, or when the patients withdrew from the National Health Insurance program.The overall incidence rate of DVT was 18.78 per 10,000 person-years in patients with COPD, and the adjusted hazard ration of DVT in patients with COPD was 1.38 (95% confidence interval 1.06–1.80), which was greater than patients without COPD after adjusting for age, sex, atrial fibrillation, hypertension, diabetes, hyperlipidemia, cerebrovascular accident, congestive heart failure, lower leg fracture or surgery, and cancer.Asian patients with COPD had a higher incidence of DVT than non-COPD patients.

A Case of Deep Vein Thrombosis Following Cellulitis of the Lower Leg

Cellulitis and deep vein thrombosis (DVT) have similar symptoms (lower extremity pain, erythema, and swelling) and there is the potential for misdiagnosis. In cases of cellulitis, DVT should be ruled out, as the symptoms of cellulitis might mask those of DVT, leading to serious complications such as pulmonary thromboembolism. The reported incidence of DVT in patients with cellulitis is low, especially patients with progression to pulmonary thromboembolism. We present a case of pulmonary thromboembolism following cellulitis of the lower leg in a 54-year-old male. (Korean J Med 2014;86:334-338)

Observation on effects of nursing intervention in the prevention of deep vein thrombosis in ICU patients

Objective To study the clinical efficacy of nursing intervention in the prevention of ICU patients with deep vein thrombosis (DVT).Methods We selected 100 patients admitted in our hospital from May 2011 to May 2013,and randomly divided them into experimental and control groups,50 patients in each group.Experimental group took svnthetical nursing care interventions and control group took common nursing care.After the experiment,the incidence of DVT in patients of two groups were analyzed.Results After the experiment,in the experimental group there were there cases with DVT rate of 6.0％,in the control group there were seven cases with DVT rate of 16.0％.By comparing the two groups in the incidence of deep vein thrombosis,statistical significant difference was found,P ＜ 0.05.Conclusion ICU nursing intervention for the prevention of DVT in patients has better clinical efficacy,with a significant reduction in the incidence of DVT. Key words: Nursing intervention; Deep vein thrombosis: Effect

Retrospective comparison of three thromboprophylaxis agents, edoxaban, fondaparinux, and enoxaparin, for preventing venous thromboembolism in total knee arthroplasty

Patients undergoing total knee arthroplasty (TKA) are at high risk of venous thromboembolism, manifesting as deep vein thrombosis (DVT) or pulmonary embolism. The purpose of this study is to evaluate the efficacy and safety of edoxaban 15mg once daily (o.d.) for preventing DVT in patients undergoing TKA. Three hundred patients undergoing primary TKA under general anaesthesia for osteoarthritis were enrolled in this study: 100 treated with enoxaparin 2,000IU twice daily (b.i.d.), 100 treated with fondaparinux 1.5mg o.d. and 100 treated with edoxaban 15mg o.d.. All treatments were scheduled to continue for 14days. The incidence of DVT in patients treated with edoxaban 15mg o.d. was lower than in patients with enoxaparin 2,000IU b.i.d. and fondaparinux 1.5mg o.d.. D-dimer levels were significantly lower in patients with edoxaban than in patients with enoxaparin and fondaparinux 1.5mg o.d. on the first postoperative day; ΔHb levels were lower in patients with edoxaban than in patients with enoxaparin and fondaparinux on postoperative days, However, the difference was not statistically significant. Finally, the incidence of hepatic dysfunction was lower in patients with edoxaban than in patients with enoxaparin and fondaparinux. Edoxaban 15mg o.d. was more efficient than enoxaparin 2,000IU b.i.d. and fondaparinux 1.5mg o.d.. Furthermore, edoxaban was safe compared with enoxaparin and fondaparinux. Edoxaban, an orally administered direct factor Xa (FXa) inhibitor, may offer a new option for preventing DVT, with a level of evidence III.

Lower limb deep vein thrombosis in patients with suspected pulmonary embolism detected with (99m)Tc-MAA simultaneously with lung perfusion scan.

The aim of this study was to evaluate the incidence of deep vein thrombosis (DVT) in patients with suspected pulmonary embolism (PE) and the relation between PE and the site of DVT by using technetium-99m-macroaggregated human serum albumin ((99m)Tc-MAA) radionuclide venography (RNV). Technetium-99m-MAA RNV was performed simultaneously with lung perfusion scintigraphy in 123 patients with suspected PE. The incidence of DVT in patients with suspected PE was 58.54%. The incidence of DVT in patients with PE was 77.46%, while in patients without PE was 32.69%. The rate of proximal DVT in patients with PE was 74.55%, while in patients without PE was 47.06%. The average embolic lung segments in patients with proximal DVT and patients with distal DVT were 6.2±2.3 and 3.1±1.2, respectively. In conclusion, lower limb (99m)Tc-MAA RNV demonstrated a high incidence (58.54%) of DVT in patients with suspected PE. The prevalence of DVT was higher in patients with PE than in patients without PE. Pulmonary embolism was more likely to occur in patients with proximal DVT, and more embolic lung segments were detected in patients with proximal DVT.

The influence of fondaparinux on the diagnosis of postoperative deep vein thrombosis by soluble fibrin and D-dimer

IntroductionThere are many reports concerning the fondaparinux prophylaxis of deep vein thrombosis (DVT) after surgery, but little is known about the usefulness of diagnosing DVT by the thrombotic markers such as soluble fibrin (SF) and D-dimer in patients treated with fondaparinux. The main purpose of this study was to evaluate the accuracy of SF and D-dimer tests for DVT screening in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) treated with fondaparinux. Materials and methodsA total of 519 patients who underwent THA or TKA were evaluated. SF and D-dimer levels were evaluated on postoperative days 1, 4, 7, 14 and 21. DVT was confirmed by ultrasonography 4days after surgery. ResultsThe incidence of DVT in patients treated with fondaparinux was significantly lower than in patients without fondaparinux. The SF test on postoperative day 1, and the D-dimer test on postoperative days 1, 4, and 7 were useful in untreated patients. However, in the patients treated with fondaparinux, the D-dimer test on postoperative day 7 only was useful for DVT screening. ConclusionThe accuracy of SF and D-dimer test for the diagnosis of DVT was decreased by administration of fondaparinux. A new strategy for diagnosing DVT might be required for patients receiving fondaparinux.

Population-Based Analysis of Venous Thrombotic Events Following Saphenous Ablation

Background: Venous thrombotic events following great and small saphenous vein ablation procedures for varicose veins have been reported. Current knowledge of these events is based on single institution studies with small sample sizes. Methods: The National Surgical Quality Improvement Program (NSQIP) database (2005-2009) was used to identify a total of 3,874 patients who underwent radiofrequency ablation (RFA) or endovenous laser ablation (EVLA) of the great and small saphenous veins with or without stab phlebectomy. Outcome variables included clinically documented postoperative deep vein thrombosis (DVT) or pulmonary embolism (PE). Bivariate and multivariate logistic regression analyses were performed to identify factors associated with venous thrombotic events after ablation procedures. Results: A total of 2,897 (74.8%) patients underwent RFA and 977 (25.2%) underwent EVLA for lower extremity varicose veins. Patients who underwent RFA were more likely to be older (53.8 y vs 51.8 y, P .0001), obese (42.8% vs 38%, P .009), diabetic (8.5% vs 6.4%, P .01) hypertensive (31.9% vs 26.8%, P .002) and to have undergone procedures involving both veins (24% vs 4%, P .0001). Patients who underwent EVLA were more likely to have received general anesthesia (56.9% vs 40.8%, P .0001), to have undergone concomitant stab phlebectomy (44.9% vs 31.7%, P .0001), and had longer operative times (63.6 min vs. 57.3 min, P .0001). The incidence of DVT (1.74% vs 1.52%, P .63) and pulmonary embolus (0.07% vs 0%, P 1) were similar between EVLA and RFA. No significant predictors of DVT in the postoperative period were identified on bivariate or multivariate analyses. In the subgroup of patients who underwent ablation procedures only (no stab phlebectomy, N 2514), there was a trend toward higher incidence of DVT in patients undergoing EVLA (2.6% vs 1.4%, P .057). After adjusting for patient demographics, patients presenting with lower extremity ulcers were 2.4 times more likely to develop DVT compared to those without ulcers (OR 2.4, 95% CI 1.01-6.11, P .04). In the multivariate model when only ablation procedures were performed, EVLA was associated with an 83% increase in odds of DVT compare to RFA, although not statistically significant (OR 1.83, 95% CI 0.95-3.52, P .06). Conclusions: The incidence of venous thrombotic events after saphenous ablation is low. However, given that patients with lower extremity ulcers experienced an increased risk of DVT, care should be taken to ensure that the ablation catheter is positioned an appropriate distance from the sapheno-femoral or sapheno-popliteal junction, and postprocedural preventative measures such as early ambulation and lower extremity compression should be emphasized. The finding of a trend toward increased venous thrombotic events in patients undergoing EVLA warrants further investigation in a large patient population.

Incidence of Deep Vein Thrombosis After Spinal Cord Injury: A Prospective Study in 37 Consecutive Patients With Traumatic or Nontraumatic Spinal Cord Injury Treated by Mechanical Prophylaxis

Patients with spinal cord injury (SCI) are at particular risk for deep vein thrombosis (DVT) during their hospital course. In most researches on the prevention of thromboembolic events after SCI, the cause of SCI was usually limited to traumatic origin, and pharmaco-prophylaxis was usually started immediately after SCI irrespective of the presence of DVT. For this reason, it is difficult to determine the exact incidence of DVT after SCI from all possible causes in the absence of anticoagulation treatment. We sought to determine the incidence of DVT and the effect of mechanical treatments without chemical prophylaxis. From November 2009 to October 2010, 37 consecutive patients were admitted to our institute for SCI regardless of causes. Patient data including age, sex, types of injury in motor completeness, causes of SCI, and results of color Doppler ultrasonography (DUS) were collected. Routine mechanical prophylaxis for DVT was performed in all patients; pharmacologic prophylaxis was not used to avoid the potential consequences that may have confounded their benefits. All patients were routinely checked for DVT of lower limbs. Examinations were usually performed within 1 week of injury and repeated fortnightly until any medications for DVT were started in cases of a positive DUS result. In total, 16 of the 37 (43%) patients with acute SCI routinely given mechanical prophylaxis without anticoagulation were found to have DVT in the lower extremities by color DUS. Ten patients showed new thrombosis by DUS within 7 days after injury, three patients after 2 weeks to 3 weeks, and three patients at more than 1 month after injury. The majority of DVT occurred in the distal leg vein (81.2%, soleal vein). The incidence of DVT in patients with traumatic SCI was not different from that of patients with nontraumatic SCI in this study (p>0.05). Age, sex, type of motor impairment, and cause of SCI were not found to be significantly related to the occurrence of DVT. The incidence of DVT in patients with SCI routinely given mechanical prophylaxis without anticoagulation was higher when compared with those reported in the setting of routine pharmaco-prophylaxis. Anticoagulation should not be excluded from initial DVT prophylaxis measures in the SCI patients unless there is any ongoing bleeding or severe coagulopathy. Further studies will be necessary to get a more precise data and to understand the clinical relevance of these results.

Deep vein thrombosis and thromboprophylaxis in arthroscopic anterior cruciate ligament reconstruction

Background:There is no clear evidence in the literature regarding the incidence of deep vein thrombosis (DVT) in patients undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction. Literature also lacks on the recommendations on thromboprophylaxis in patients undergoing elective arthroscopic ACL reconstruction. We conducted a prospective analysis to assess incidence of DVT in patients undergoing arthroscopic ACL reconstruction.Materials and Methods:120 consecutive patients with MRI proven ACL injury who were operated for arthroscopic ACL reconstruction were enrolled in this prospective study. None of the patients had risk factors (on history) for DVT, and all were below the age of 45 years. All cases were operated upon by a single surgeon and a standard rehabilitation regime was followed. The patients underwent clinical examination and screening (Doppler ultrasonography/venous scan) for any DVT, on the day prior to surgery, day of discharge (Day 3) and at 4 weeks postsurgery. None of the patients received any form of thromboprophylaxis against DVT.Results:One hundred and twelve patients (61 males and 51 females) completed the study. The average age was 31.6 years (range 24-42 years). All patients underwent arthroscopic assisted ACL reconstruction surgery within 3 weeks of the injury. Two patients (males) in the series had Doppler venous scan proven DVT. One patient was asymptomatic but the screening Doppler picked up the DVT on the third postoperative day. The other patient was symptomatic at 12 weeks with pain and swelling in the leg and had ultrasound -proven DVT.Conclusion:In our study the incidence of deep vein thrombosis in patients undergoing arthroscopic ACL reconstruction is 1.78%. We do not recommend routine thromboprophylaxis in patients, who are not high risk candidates for thrombosis and are of less than 45 years, in patients undergoing arthroscopic ACL reconstruction, with early postoperative rehabilitation.

Venous Thromboembolism in Trauma Patients

Serial venous duplex scans (VDS) were done in 507 trauma patients with at least one risk factor (RF) for venous thromboembolism (VTE) during a 2-year study period. Deep vein thrombosis (DVT) was detected in 31 (6.1%) patients. This incidence was 3.1 per cent in low (1-2 RFs), 3.4 per cent in moderate (3-5 RFs), and 7.7 per cent in high (> or =6 RFs) VTE scores (P = 0.172). Incidence was statistically different (3% vs. 7.2%, P = 0.048) on reanalyzing patients in two risk categories, low-risk (1-4 RFs) and high-risk (> or =5 RFs). Only 4 of 16 RFs had statistically higher incidence of DVT in patients with or without RFs: previous VTE (27.3% vs. 5.6%, odds ratio (OR) 6.628, P = 0.024), spinal cord injury (22.6% vs. 5%, OR 5.493, P = 0.001), pelvic fractures (11.4% vs. 5.1%, OR 2.373, P = 0.042), and head injury with a greater than two Abbreviated Injury Score (10.5% vs. 4.2%, OR 2.639, P = 0.014). On reanalyzing patients with > or =5 RFs vs. <5RFs, obesity (14.3 vs. 6.1%, P = 0.007), malignancy (5.6% vs. 0.6%, P = 0.006), coagulopathy (10.8% vs. 1.8%, P = 0.000), and previous VTE (3.2% vs. 0%, P = 0.019) were significant on univariate analysis. Patients with DVT had 3.70 +/- 1.75 RFs and a 9.61 +/- 4.93 VTE score, whereas, patients without DVT had 2.66 +/- 1.50 RFs and a 6.83 +/- 3.91 VTE score (P = 0.000). DVTs had a direct positive relationship with higher VTE scores, length of stay, and number of VDS (>1 r, P < or = 0.001). Increasing age was a weak risk factor (0.03 r, P = 0.5). First two VDS diagnosed 77 per cent of DVTs. Patients with injury severity score of > or =15 and 25 had higher DVTs compared with the ones with lower injury severity score levels (P < or = 0.05). Pulmonary embolism was silent in 63 per cent and DVTs were asymptomatic in 68 per cent.

Prevention of Pulmonary Embolism in General Surgery Patients

Case Presentation : A 29-year-old woman presented to the emergency department with complaints of pleuritic chest pain, fever, and left ankle swelling and tenderness. Cardiac examination was normal except for tachycardia. A chest computed tomography scan with contrast demonstrated extensive bilateral pulmonary emboli. Thirteen days previously, an intoxicated driver with multiple prior convictions for driving under the influence of alcohol crashed head-on into her car at a high speed. She was 8 months’ pregnant and suffered the loss of the child. She spent 7 days in the hospital and underwent cesarean section, exploratory laparotomy, and splenectomy. No preoperative pharmacological prophylaxis against venous thromboembolism (VTE) was administered. VTE, which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is an important and common complication of general surgery. A new era in the postoperative management of surgical patients began in 1975 when the effectiveness of low-dose heparin in preventing postoperative DVT and PE was established by the pivotal International Multicenter Trial.1 The dose was 5000 U subcutaneously every 8 hours, with the first injection administered 2 hours before the skin incision. Compared with control, the incidence of DVT in patients receiving heparin decreased from 24.6% to 7.7%. Similarly, the incidence of autopsy-proven PE was reduced 8-fold. The results of this trial introduced and validated the concept of using low-dose heparin to prevent postoperative VTE. This trial revolutionized surgical practice. By 1994, 90% of North American general surgeons reported the routine use of thromboprophylaxis.2 Most postoperative DVT originates in the deep calf veins, primarily within the valve cusps. Most thrombi remain confined to the calf. Propagation into the proximal veins increases the risk of PE. Symptoms and signs of postoperative VTE such as mild hypoxia or low-grade fever are frequently nonspecific. Moreover, clinical manifestations of postoperative VTE may not occur until …

Thromboprophylaxis following cast immobilisation for lower limb injuries—survey of current practice in United Kingdom

The risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) is well documented in patients following cast immobilisation for injuries of lower extremities. There are no generally accepted approaches to preventing this complication and hence there remains substantial practice variation amongst surgeons regarding the use of anticoagulation measures. The present survey was conducted to investigate the current chemothromboprophylaxis practice among UK orthopaedic departments for patients immobilised with plasters for lower extremity injuries and establish any variations in practice. A telephone questionnaire survey was conducted on junior doctors (Senior House Officers and Registrars) in orthopaedic departments of 70 randomly selected hospitals in United Kingdom. This survey assessed the thromboprophylaxis practice for lower limb injuries in plaster casts. Our results show substantial variation amongst British orthopaedic surgeons in the use of chemothromboprophylaxis measures. Sixty-two percent of the departments do not use any DVT prophylaxis in this group of trauma. Furthermore, only 11.4% of the departments performed risk stratification on their patients. Ninety-nine percent of the respondents were unaware of any existing guidelines in this regard. Although the incidence of DVT in patients in plaster for lower extremity injuries is low compared to the Hip/Knee arthroplasty group, this is not insignificant. Both over and under treatment with thromboprophylaxis can have implications in terms of side effects and costs. One possible solution is to use risk stratification to identify individuals who are likely to benefit from prophylaxis. There is a substantial variation and inconsistency in practice among orthopaedic departments in United Kingdom due to a lack of clinical guidelines in this group of trauma and it remains underused even in high-risk group.

A Prospective, Randomized, Placebo-Controlled Study of Extended-Duration Post-Discharge Thromboprophylaxis with Enoxaparin Following Arthroscopic Reconstruction of the Anterior Cruciate Ligament.

Introduction Deep-vein thrombosis (DVT) with subsequent pulmonary embolism (PE) is the most life-threatening complication that occurs after knee arthroscopy. Although the incidence of clinically diagnosed DVT is low, thromboprophylaxis with a low-molecular-weight heparin (LMWH) following arthroscopic reconstruction of the anterior cruciate ligament (ACL) is generally recommended until full weight bearing is achieved. The aim of this study was to compare the effect of extended-duration thromboprophylaxis using the LMWH enoxaparin with placebo on the incidence of DVT and PE during the 20-day post-discharge period after arthroscopic ACL reconstruction.Methods 175 patients, scheduled for arthroscopic ACL reconstruction with a middle-third patellar, bone-tendon-bone autograft, were randomized to two groups. Both groups received enoxaparin 40 mg s.c. once daily, initiated 12–18 hours before the start of surgery and continued 3–8 days during hospitalization. Following hospital discharge, the groups of patients self-administered either enoxaparin 40 mg (n=87) or placebo (n=88) s.c. once daily for a further 20 days in the outpatient setting. The primary endpoint was DVT or PE. DVT was confirmed by magnetic resonance (MR) venography performed on the operated leg in sagittal and coronal views. Filling defects of a deep vein were considered to be an indirect sign of DVT. PE was confirmed by lung scan. The intention-to-treat (ITT) population was all randomized patients who received at least one dose of study drug, underwent baseline examinations and one further examination for DVT.Results In accordance with predefined criteria, 35 patients were excluded from the ITT analysis as they did not undergo an evaluation for the primary endpoint of DVT because of medical reasons (arthroscopy, but no ACL reconstruction; n=16), non-compliance (n=11), MR venography not possible for technical reasons (n=4), lost to follow-up (n=2), withdrawal (n=1), and adverse events (n=1). The ITT analysis of 140 patients (enoxaparin group n=72; placebo group n=68) showed an overall DVT incidence of 21.4% (30/140). The total incidence of DVT was significantly lower in the enoxaparin group compared with the placebo group (relative risk reduction 93%; Table 1). The incidences of DVT in the popliteal and femoral regions were significantly lower in the enoxaparin group compared with the placebo group (Table 1). PE was not observed in either group. Enoxaparin was well tolerated and no major bleeding complications occurred in either group.Conclusion Enoxaparin, self-administered once daily subcutaneously in the outpatient setting, is feasible, safe and significantly reduces the incidence of DVT in patients with arthroscopic ACL reconstruction. Extended-duration thromboprophylaxis with enoxaparin for 20 days post-discharge should be considered for this patient group.Table 1. Incidence of DVT or PE in patients undergoing ACL reconstructionEnoxaparin 40 mgPlaceboP valueN7268-Total DVT*, n (%)2 (2.8)28 (41.2)<0.0001Lower leg DVT, n (%)2 (2.8)28 (41.2)<0.0001Popliteal DVT, n (%)2 (2.8)12 (17.7)0.0034Upper leg DVT, n (%)1 (1.4)6 (8.8)0.0437PE, n (%)0 (0)0 (0)-*DVT was detected in more than one location in some patients

A Prospective Registry on Venous Thromboembolic Events: Findings from PROVE.

Introduction Venous thromboembolism (VTE) is a major health problem, especially in the elderly. A variety of intrinsic factors, acute medical illnesses and surgery have been shown to increase VTE risk. Despite this, VTE has not been adequately described in terms of clinical history, clinical risk factors and VTE prophylaxis. The objective of the Prospective Registry On Venous thromboembolic Events (PROVE) is to characterize the profile of patients with ultrasound-confirmed deep-vein thrombosis (DVT), the prior use and type of VTE prophylaxis and its relationship to demographic and comorbid factors.Methods PROVE is a multinational, multi-center, observational study. Patients were recruited during a 3 month period, beginning in February 2003, in centers possessing an ultrasound laboratory. Patients with ultrasound-confirmed DVT were consecutively enrolled. There were no exclusion criteria once DVT was diagnosed.Results Of 3527 enrolled patients in 254 centers in 19 countries (48% Asian and 52% non-Asian), data from 3508 (99%) were analyzable. Patients were: 51% male, mean age 53±18 years, mean BMI 26.0±5.1 kg/m2, 46.7% Caucasian, 47.1% Asian, 1.6% African and 4.4% other ethnicity. Patient status when DVT was diagnosed was: 59.7% home, 35.7% acute care hospital, 3.3% chronic care facility, 1.3% other. Locations of DVT were 25.0% calf only, 20.8% proximal without calf, and 58.9% proximal and calf. The incidences of idiopathic DVT, DVT following a precipitating factor, and recurrent DVT according to patient status at the time of diagnosis are shown in Table 1. Of patients who had a precipitating factor for DVT (see Table 2), 16% had received prior VTE prophylaxis. Types of VTE prophylaxis were: 53% low-molecular-weight heparin, 10% unfractionated heparin, 17% vitamin K antagonist, 29% elastic stockings, 2% venal caval filter, and 17% other.Conclusion Overall, the incidence of idiopathic DVT was similar to the incidence of DVT occurring after a precipitating event, as observed in other published studies. However, the incidence of idiopathic DVT was higher in patients at home at the time of diagnosis, while the incidence of DVT in patients with a precipitating factor was higher in acute care hospitals and chronic care facilities. The occurrence of DVT in patients who had received VTE prophylaxis may be due, at least in part, to the use of inadequate prophylaxis regimens.Table 1 Type of DVT according to patient status when DVT was diagnosedPatient statusIdiopathic DVT,* n (%)DVT after a precipitating event,* n (%)Recurrent DVT,* n (%)Home (N=2091)1092 (52)818 (39)221 (11)Acute care hospital (N=1250)396 (32)807 (65)74 (6)Chronic care facility (N=115)35 (30)64 (56)16 (14)Other (N=45)19 (42)24 (53)3 (7)Total1542 (44)1713 (49)314 (9)* DVT was recorded as more than one type in some patientsTable 2 VTE prophylaxis received by patients with a precipitating factor for DVT (N=1715)Precipitating factor for DVTPatients with precipitating factor, n (%)Patients who had received VTE prophylaxis, n (%)Acute medical condition775 (45)92 (12)Surgery498 (29)124 (25)Trauma without surgery239 (14)44 (18)Pregnancy/postpartum158 (5)10 (6)Long airplane travel56 (2)3 (5)

Incidence of deep vein thrombosis after varicose vein surgery.

Varicose vein surgery is generally considered to have little risk of postoperative deep vein thrombosis (DVT). This prospective study examined the incidence of DVT in patients undergoing varicose vein surgery. Lower leg veins were assessed before operation by duplex ultrasonography in 377 patients, and reassessed 2-4 weeks after surgery, and again at 6 and 12 months. Patients were instructed to contact a physician if symptoms consistent with DVT occurred before the scheduled follow-up appointment. Preoperative prophylaxis (a single dose of subcutaneous heparin) was left to the discretion of the vascular surgeon. DVT was detected in 20 (5.3 per cent) of the 377 patients. Of these, only eight were symptomatic and no patient developed symptoms consistent with pulmonary embolus. Eighteen of the 20 DVTs were confined to the calf veins. Subcutaneous heparin did not alter the outcome. No propagation of thrombus was observed and half of the DVTs had resolved without deep venous reflux at 1 year. The incidence of DVT following varicose vein surgery was higher than previously thought, but these DVTs had minimal short- or long-term clinical significance.