Symptomatic venous thrombo-embolism in low-energy isolated fractures in hospitalised patients

Aspirin in prevention of venous thromboembolism following hip fracture surgery: A systematic review and meta-analysis

Background

Many orthopaedic surgeons routinely prescribe aspirin (ASA) as prophylaxis for venous thromboembolism (VTE) following hip fracture surgery (HFS). The purpose of this study is to assess the effectiveness of aspirin to other agents in preventing VTE and mortality following hip fracture surgery.

Methods

Following PRISMA guidelines, we performed a search for HFS studies from 1998 to 2023 reporting comparisons between aspirin and other chemoprophylaxis methods for VTE (DVT - deep vein thrombosis; PE - pulmonary embolism). SPSS Meta-analysis function was used to calculate Mean Effect Size Estimate (MESE) and 95 % Confidence Intervals for each outcome. Reverse Fragility Index (RFI) and Fragility Quotient (FQ) were calculated for each study.

Results

Of the 847 articles screened, 4 studies with 5 comparisons met the search criteria to be included for analysis. A total of 1194 participants were included in these studies. There was a decreased risk of mortality seen with use of aspirin compared to other agents (MESE = 0.86, 95 % CI: [0.07-1.66]; p=.03). There was no increased risk of DVT or PE with use of aspirin (both p>.4). The overall RFI and FQ for all 19 outcomes were 12 (IQR: 6.5-15) and 0.080 (IQR: 0.027-0.110), respectively. Ten studies (52.6 %) reported a loss-to-follow-up (LTF) greater than the overall RFI.

Conclusions

Aspirin demonstrates similar protective effects on prevention of VTE compared to other agents and may have significant protective effects on overall mortality following surgical intervention for hip fractures. However, the current evidence concerning its use in this arena is less than robust, with more than half of the studied outcomes considered statistically fragile.

Risk factors for venous thromboembolism following surgical treatment of fractures: A systematic review and meta-analysis

This study aimed to determine the risk factors for postoperative venous thromboembolism (VTE) in patients treated surgically for fractures using a meta-analytic approach. Electronic searches were performed in PubMed, Embase, and the Cochrane library from inception until February 2022. The odds ratio (OR) and 95% confidence interval (CI) were applied to calculate the pooled effect estimate using the random-effects model. Sensitivity, subgroup, and publication bias tests were also performed. Forty-four studies involving 3 239 291 patients and reporting 11 768 VTE cases were selected for the meta-analysis. We found that elderly (OR: 1.72; 95% CI: 1.38-2.15; P < .001), American Society of Anesthesiologists (ASA) ≥ 3 (OR: 1.82; 95% CI: 1.46-2.29; P < .001), blood transfusion (OR: 1.82; 95% CI: 1.14-2.92; P = .013), cardiovascular disease (CVD) (OR: 1.40; 95% CI: 1.22-1.61; P < .001), elevated D-dimer (OR: 4.55; 95% CI: 2.08-9.98; P < .001), diabetes mellitus (DM) (OR: 1.36; 95% CI: 1.19-1.54; P < .001), hypertension (OR: 1.31; 95% CI: 1.09-1.56; P = .003), immobility (OR: 3.45; 95% CI: 2.23-5.32; P < .001), lung disease (LD) (OR: 2.40; 95% CI: 1.29-4.47; P = .006), obesity (OR: 1.52; 95% CI: 1.27-1.82; P < .001), peripheral artery disease (PAD) (OR: 2.13; 95% CI: 1.21-3.73; P = .008), prior thromboembolic event (PTE) (OR: 5.17; 95% CI: 3.14-8.50; P < .001), and steroid use (OR: 2.37; 95% CI: 1.73-3.24; P < .001) were associated with an increased risk of VTE. Additionally, regional anaesthesia (OR: 0.66; 95% CI: 0.45-0.96; P = .029) was associated with a reduced risk of VTE following surgical treatment of fractures. However, alcohol intake, cancer, current smoking, deep surgical site infection, fusion surgery, heart failure, hypercholesterolemia, liver and kidney disease, sex, open fracture, operative time, preoperative anticoagulant use, rheumatoid arthritis, and stroke were not associated with the risk of VTE. Post-surgical risk factors for VTE include elderly, ASA ≥ 3, blood transfusion, CVD, elevated D-dimer, DM, hypertension, immobility, LD, obesity, PAD, PTE, and steroid use.

Identifying Patients at Risk for Venous Thromboembolic Events After Isolated Upper Extremity Trauma: A Predictive Scale

Previous studies have defined risk factors for development of venous thromboembolisms (VTEs) among patients with lower extremity orthopedic trauma. Limited data exist on this risk after upper extremity orthopedic trauma. A total of 269,137 incidents of upper extremity orthopedic trauma (fractures of the clavicle, scapula, humerus, elbow, or lower arm) were identified in the State Inpatient Database for 4 states included in the analysis (California, Florida, New York, and Washington) from 2006 to 2014. These patients were split into 2 cohorts, a derivation cohort (California and New York) and a validation cohort (Florida and Washington). Univariate and multivariate logistic regression analyses of risk factors for VTE within 90 days of discharge in the derivation group were used to develop the Thromboembolic Risk after Upper Extremity Trauma (TRUE-T) scale. Linear regression was used to determine fit of the TRUE-T scale to the 2 cohorts. We found that 2.61% of patients in the derivation cohort and 2.72% of patients in the validation cohort had a VTE within 90 days of discharge. Risk factors associated with increased rates of VTE were age older than 40 years, Medicare payer, anemia, chronic lung disease, coagulopathy, heart failure, malignancy, obesity, renal failure, head injury, chest injury, abdominal injury, rib fracture, humerus fracture, elbow fracture, and closed reduction. Application of the TRUE-T scale to the validation cohort showed an R² value of 0.88. The patient factors, concomitant injuries, and fracture treatment modalities included in the TRUE-T scale can be used to identify patients at increased risk for VTE after upper extremity orthopedic trauma. [Orthopedics. 2022;45(6):345-352.].

The Role of Dexmedetomidine in the Structure of Anesthesia for Hip and Knee Arthroplastyс Surgery in Patients with Diabetes

Hip and knee arthroplasty (HKA) is a surgical procedure when damaged parts of the joint are replaced with artificial ones that replicate the shape of a normal joint and restore its function. Every year more than 1.5 million endoprosthetic operations are performed in the world. Replacement of a damaged joint allows patients to return to the normal life, freeing from pain and limited mobility. However, one of the common diseases that negatively affect the results of these operations is diabetes mellitus (DM). The aim of the study: to determine the efficacy and safety of the combined multimodal low opioid anesthesia with dexmedetomidine sedation in patients with diabetes undergoing HKA surgery. Materials and methods. The study included 45 patients who underwent HKA surgery. Patients were divided into three groups according to the scheme of anesthesia. In patients of the 1st group (n = 15) multicomponent low-flow anesthesia with artificial lung ventilation was performed, in the patients of the 2nd group (n = 15) spinal anesthesia was used, in the 3rd group (n = 15) – combined spinal – epidural anesthesia with dexmedetomidine sedation. The groups of patients were identical in anthropometric and gender characteristics, duration of surgery and anesthesia, baseline somatic status. Statistical analysis was performed using the IBM SPSS Statistics suite (SPSS v.16.0). Results. The course of anesthesia in patients in all groups was satisfactory, but patients in group 3 were less likely to experience hyperdynamic reactions (tachycardia and hypotension), postoperative nausea and vomiting (PONV). Only one patient from group 3 required ondansetron for the treatment of PONV against 3 and 2 patients from groups 1 and 2, respectively (p <0.05). Conclusions. Any of the proposed techniques can be used for anesthesia during hip and knee arthroplasty, but the best results have been obtained with combined spinal-epidural anesthesia with dexmedetomidine sedation. In addition, the use of dexmedetomidine can significantly reduce the use of opioids diring the intraoperative and postoperative period.

Relationship Between the Incidence of Deep Vein Thrombosis During Hospitalization and the Energy of Injury in Tibial Plateau Fractures

This study aimed to investigate the relationship between the incidence of deep vein thrombosis (DVT) during hospitalization and the energy of injury in tibial plateau fractures (TPFs). One hundred and forty patients were enrolled between September 1, 2014, and October 1, 2017. According to Schatzker's classification, they were classified into the low-energy (type I-III) and high-energy (type IV-VI) groups. For DVT evaluation, duplex ultrasonography was performed in the lower extremities preoperatively and postoperatively. The location and changes of DVT were recorded. All patients underwent mechanical and chemical thromboprophylaxis. The incidence of DVT in TPFs was 36.43% and 46.43% preoperatively and postoperatively, respectively. The DVT incidence was 31.75% (20/63) in the low-energy group and 40.26% (31/77) in the high-energy group preoperatively, and 44.44% (28/63) in the low-energy group and 48.05% (37/77) in the high-energy group postoperatively. There was no significant difference between the 2 groups preoperatively (P = .298) and postoperatively (P = .785). The days between operation and discharge (P = .016), blood loss during surgery (P = .016), and preoperative d-dimer level (P = .02) showed differences between the 2 groups. Additionally, 29 new thrombi (14 [48.28%] in the high-energy group and 15 [51.72%] in the low-energy group) appeared and 16 preoperative thrombi disappeared postoperatively. Despite mechanical and chemical thromboprophylaxis, the DVT risk in patients with TPFs remains high. Although the DVT incidence is not significantly different between high-energy and low-energy injuries, the occurrence of DVT should be carefully monitored.

D-Dimer Combined with Fibrinogen Predicts the Risk of Venous Thrombosis in Fracture Patients

Objective

While D-dimer can successfully diagnose venous thrombosis due to its excellent negative predictive value (NPV), it cannot be used to detect venous thromboembolism (VTE) because of its low positive predictive value (PPV). This study aims to investigate if a combination of using D-dimer and fibrinogen can improve PPV in the VTE diagnosis.

Methods

We retrospectively analyzed various data including D-dimer, fibrinogen, C-reactive protein, ultrasound, and others collected from 10775 traumatic fracture patients and categorized them into two groups of VTE and non-VTE. By comparing the difference between the two groups, we employ multiple logistic regression to find risk factors that are useful to detect VTE. The receiver operating characteristic (ROC) curve was used to evaluate the diagnostic yield of using fibrinogen, D-dimer, and their combination, respectively. Also, these data were classified into quartiles by patient age. We perform the same analysis on the quartiles and find if the patient's age has an impact on diagnosing VTE.

Results

The univariate analysis demonstrated that five factors of age, D-dimer, fibrinogen, C-reactive protein, and high-density lipoprotein cholesterol were significant to predict VTE. ROC showed that D-dimer was more useful than fibrinogen for the diagnosis of VTE, while the area under the curve (AUC) was 0.7296 for D-dimer and 0.5209 for fibrinogen. The cutoff point of D-dimer and fibrinogen was 424.89 ng/ml and 3.543 g/L, respectively. The specificity of fibrinogen was 0.777 which was better than D-dimer, while the sensitivity of fibrinogen was lower than that of D-dimer. Both PPV and NPV were similar in D-dimer and fibrinogen. The PPV of combining D-dimer and fibrinogen in ages Q3 (60 < age ≤ 70) and Q4 (age > 70) was better than using either D-dimer or fibrinogen.

Conclusions

Fibrinogen is a promising strategy for the diagnosis of subclinical VTE and postoperative VTE. In particular, a combination of D-dimer and fibrinogen can improve the PPV to successfully diagnose VTE in traumatic fracture patients who are more than 60 years old. Levels of Evidence. This assay is a diagnostic test at level II.

Utilization Patterns, Efficacy, and Complications of Venous Thromboembolism Prophylaxis Strategies in Primary Hip and Knee Arthroplasty as Reported by American Board of Orthopedic Surgery Part II Candidates

BACKGROUND

Many strategies for venous thromboembolism (VTE) prophylaxis following hip and knee arthroplasty exist, with extensive controversy regarding the optimum strategy to minimize risk of VTE and bleeding complications. Data from the American Board of Orthopedic Surgery Part II (oral) Examination case list database was analyzed to determine efficacy, complication rates, and prescribing patterns for different prophylactic strategies.

METHODS

The American Board of Orthopedic Surgery case database was queried utilizing Current Procedural Terminology codes 27447 and 27130 for primary total knee and hip arthroplasty, respectively. Geographic region, patient age, gender, deep vein thrombosis prophylaxis strategy, and complications were obtained. Less aggressive prophylaxis patterns were considered if only aspirin and/or sequential compression devises were utilized. More aggressive VTE prophylaxis patterns were considered if any of low-molecular-weight heparin (enoxaparin), warfarin, rivaroxaban, fondaparinux, or other strategies was used.

RESULTS

In total, 22,072 cases of primary joint arthroplasty were analyzed from 2014 to 2016. The national rate of less aggressive VTE prophylaxis strategies was 45.4%, while more aggressive strategies were used in 54.6% of patients. Significant regional differences in prophylactic strategy patterns exist between the 6 regions. The predominant less aggressive prophylaxis pattern was aspirin with sequential compression devises at 84.8% with 14.8% receiving aspirin alone. Use of less aggressive prophylaxis strategy was significantly associated with patients having no complications (95.5% vs 93.0%). Use of more aggressive prophylaxis patterns was associated with higher likelihood of mild thrombotic (0.9% vs 0.2%), mild bleeding (1.3% vs 0.4%), moderate thrombotic (1.2% vs 0.4%), moderate bleeding (2.7% vs 2.1%), severe thrombotic (0.1% vs 0.0%), severe bleeding events (1.2% vs 0.9%), infections (1.9% vs 1.3%), and death within 90 days (0.7% vs 0.3%). Similar results were found in subgroup analysis of total hip and knee arthroplasty patients.

CONCLUSION

It was not possible to ascertain the individual rationale for use of more aggressive VTE prophylaxis strategies; however, more aggressive strategies were associated with higher rates of bleeding and thrombotic complications. Less aggressive strategies were not associated with a higher rate of thrombosis.

LEVEL OF EVIDENCE

Therapeutic Level III.

DISCLAIMER

All views expressed in the study are the sole views of the authors and do not represent the views of the American Board of Orthopedic Surgery.

Venous Thromboembolism in Upper Extremity Fractures

BACKGROUND

Venous thromboembolism (VTE) has been studied in lower extremity fractures but little is known of its relation with upper extremity (UE) fractures. As an often overlooked but serious complication, VTE may compromise patient outcomes.

METHODS

Using data on inpatients (aged ≥ 18 years) at a level-I trauma center and patients in the National Surgical Quality Improvement Program database who sustained UE fractures (clavicle, humerus, or radius/ulna) and VTE in the same hospitalization between 2007 and 2014, the authors analyzed data on demographic characteristics, fracture type, VTE location (pulmonary embolism, lower extremity, or UE), VTE onset, polytrauma, operative or nonoperative management, comorbidities, and mortality.

RESULTS

Of 1984 inpatients with UE fractures at 1 instution, 9 experienced VTE on admission, and 17 (15 received thromboprophylaxis) experienced VTE during hospitalization, for an overall VTE rate of 1.3%. VTE occurred most often in patients with fractures of the proximal humerus (3.0%) followed by the clavicle (2.0%), midshaft humerus (1.9%), distal radius/ulna (0.95%), and distal humerus/elbow (0.36%) (p = 0.0035). There were no significant trends in the incidence of PE (p = 0.33) over the study period, but there was a sharp rise since 2011. In the national database, 42 of 11570 (0.36%) patients with UE fracture had VTE, with incidence by fracture location ranging from 0.14% (radius/ulna) to 0.98% (proximal humerus) (p = 0.00001). Predictors were chronic steroid use (odds ratio [OR] = 6.22, p = .030), inpatient status (OR = 4.09, p = .002), and totally disabled functional status (OR = 3.31, p = .021).

CONCLUSIONS

VTE incidence was highest following proximal humerus or clavicle fractures and are rarely associated with radius/ulna fractures. There may have been a rise in the incidence of PE since 2007, warranting further investigation.

Perioperative incidence and locations of deep vein thrombosis following specific isolated lower extremity fractures

PURPOSE

To determine perioperative incidence and locations of deep vein thrombosis (DVT) in injured and uninjured lower extremities following isolated lower extremity fractures (ILEFs).

METHODS

Retrospective analysis of a prospectively collected data of a consecutive patient series with ILEFs who underwent surgical treatment between September 2014 and September 2017 was performed. Patients' bilateral lower extremities were screened for DVT with duplex ultrasonography (DUS) before and after surgery. DVT occurrence was analyzed by location of DVT and fracture site. All patients received pharmacologic thromboprophylaxis while hospitalized. Data on demographics, time to surgery, time of DUS examinations, length of hospital stay and symptomatic pulmonary embolism (PE) was collected.

RESULTS

1825 patients were included in the study. The incidence of symptomatic PE was 1.6%. All patients were screened with DUS of the bilateral lower extremities in a mean of 3.5 days (range: 0-18 days) after injury, and a mean of 3.6 days (range: 1-11 days) after surgery. Preoperative DUS detected DVT in 547 patients (30.0%), including 3.7% of patients with proximal DVT. 792 patients (43.4%) were found to have a DVT postoperatively, but only 6.2% of patients with proximal DVT. Proximal DVT was detected postoperatively of the represented fractures: 6.5% of the hip, 14.5% of the femoral shaft, 4.5% of the tibial plateau, 4.6% of the tibial shaft, 1.7% of the patellar, and 2.0% of the peri-ankle. Interestingly, the rate of DVT in an uninjured lower limb was significantly higher postoperatively compared to preoperatively (16.4% vs. 4.9%), however, only 0.2% of patients had proximal DVT.

CONCLUSIONS

While the perioperative incidence of overall DVT is high following ILEFs, the majority were distal DVT, and the rate of symptomatic PE was low. Femoral shaft fractures were associated with the highest incidence for proximal DVT. The incidence was lower in more distal fractures. The majority of patients diagnosed with DVT postoperatively had already shown symptoms of DVT prior to surgery. DVT can occur in both the injured and uninjured leg, with an obviously higher incidence in the injured leg. The incidence of proximal DVT in an uninjured leg is rare.

Chemoprophylaxis for Venous Thromboembolism in Operative Treatment of Fractures of the Tibia and Distal Bones: A Systematic Review and Meta-analysis

OBJECTIVES

Clinical practice has shifted from therapeutic anticoagulation of any lower extremity venous thromboembolism (VTE) to only thromboses with risk of proximal extension or embolization-clinically important VTE (CIVTE). Isolated operative fractures of the tibia or distal bone of the lower extremity are associated with low-to-intermediate VTE risk, and there is wide variability in the choice to anticoagulate as well as anticoagulant. We sought to evaluate the role for chemoprophylaxis of VTE and CIVTE in these injuries by meta-analysis of Level I evidence.

DATA SOURCES

Articles in English, Chinese, French, and German in MEDLINE, Biosis, and EMBASE from 1988 to 2016.

STUDY SELECTION

Randomized controlled trials describing chemoprophylaxis of VTE after operative management of fractures of the tibia and distal bones. Independent review of 1502 citations yielded 5 studies (1181 patients) meeting inclusion criteria.

DATA EXTRACTION

Chemoprophylaxis regimen, VTE, CIVTE, and major bleeding events were recorded. Study quality was assessed with regard to randomization, outcome assessment allocation and treatment concealment, and commercial funding.

DATA SYNTHESIS

A random-effects model meta-analysis determined that chemoprophylaxis with a low-molecular-weight heparin (LMWH) compared with placebo or no intervention significantly reduced the risk of any VTE [pooled relative risk (RR) = 0.696, 95% confidence interval (0.490-0.989), P = 0.043; homogeneity P = 0.818, I = 0%]. However, chemoprophylaxis with a LMWH compared with placebo did not significantly reduce the risk of CIVTE [RR = 0.865, 95% confidence interval (pooled RR = 0.112-3.863), P = 0.790; homogeneity P = 0.718, I = 0%]. No major bleeding events occurred. Funnel plots did not suggest publication bias. The number needed to treat was 31 patients treated with chemoprophylaxis using a LMWH to prevent 1 VTE and 584 patients to prevent 1 CIVTE.

CONCLUSIONS

Meta-analysis of Level I evidence suggests that routine postoperative anticoagulation after surgical management of an isolated fracture of the tibia or distal bone in patients without risk factors for VTE is unlikely to provide a clinical benefit, based on the absence of a treatment effect for preventing VTE warranting therapeutic anticoagulation.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Prevalence of Acute Deep Vein Thrombosis in Patients with Ankle and Foot Fractures Treated with Nonoperative Management-A Pilot Study

The prevalence of deep vein thrombosis (DVT) among patients with ankle and foot fractures in Australia treated nonsurgically is unknown. Indications for thromboprophylaxis screening and management are unclear. The primary outcome was the prevalence rate of DVT among nonsurgically managed ankle and foot fracture patients. Patients were enrolled into a prospective cross-sectional pilot study at an outpatient hospital fracture clinic. DVT risk factors and symptoms were recorded at time of recruitment followed by referral for compression duplex ultrasonography. Independent t-test and Fisher exact test were used to assess the significance of these variables with DVT. A total of 72 patients were included in the final analysis. Overall, 11% (8/72) of patients had DVT-seven distal DVTs and one proximal DVT. Four were symptomatic including the patient with a proximal thrombus. In comparison, the majority of patients were asymptomatic of DVT (63/72). A significant risk factor found to be associated with DVT was age ≥ 45 (p = 0.013) years, and a lack of symptoms (p = 0.006) was associated with no DVT. This pilot study is the first in Australia to investigate the prevalence of DVT in this specific subgroup of patients. We found a prevalence of 11% of DVT in a small group of patients with age ≥ 45 years, being the only significant associated risk factor. Future larger scale prospective studies are warranted to confirm these results.