Venous thromboembolism in children: preliminary results of a survey of POSNA members

Risk of Venous Thromboembolism in Adolescents Undergoing Pelvic Osteotomy: Insights From a Propensity-matched Retrospective Cohort Study

BACKGROUND

Pelvic osteotomies are surgical procedures that are commonly performed in adolescents and young adults to improve stability or correct various deformities. Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), are dreaded complications of any major procedure including pelvic osteotomies. Unlike adults, the incidence of DVT and need for prophylactic measures are not well understood in the adolescents. The purpose of this study is to understand the need for VTE prophylaxis in adolescents and determine if their risk profile aligns with adults, who have more established VTE prophylactic guidelines in place for these surgeries.

METHODS

This retrospective cohort study utilized data from the TriNetX Research Network, which includes records from over 80 healthcare organizations and more than 120 million patients. De-identified patient data from January 1, 2003, to March 1, 2024, were extracted using relevant ICD-9 and ICD-10 procedural codes. The study included 2 cohorts: patients aged 13 to 17 years (adolescents) and patients 18 years and older (adults) who underwent pelvic osteotomies. To control for confounding variables, propensity score matching was employed based on sex and relevant comorbidities, including diabetes mellitus, tobacco use, and overweight/obesity. Statistical significance was set at P <0.01.

RESULTS

A total of 2374 patients successfully matched in each cohort. Within 90 days following surgical intervention, adult patients had overall risks of 4.5%, 1.9%, and 5.9%, whereas adolescent patients had overall risks of 1.3%, 0.5%, and 1.4% for DVT (RR: 3.419), PE (RR: 4.182), and either DVT or PE (RR: 4.118), respectively.

CONCLUSIONS

This study examines the rate of VTE in a large cohort of adolescents undergoing pelvic osteotomies. Although we found the rates to be lower in adolescents compared with adults, the high absolute risk in adolescents-above 1%, the threshold established in the literature for considering prophylaxis-underscores the need for tailored risk stratification strategies and targeted thromboprophylaxis protocols for this population.

LEVELS OF EVIDENCE

Level III: case-control study or retrospective cohort study.

Venous Thromboembolism After Pelvic Osteotomy in Adolescent Patients: A Database Study Characterizing Rates and Current Practices

BACKGROUND

Current risks and practices in medical prophylaxis of venous thromboembolism (VTE) after major elective lower extremity surgeries such as pelvic osteotomies have not been well-defined in the pediatric population. The purpose of this study was to (1) evaluate population rates of VTE in adolescents undergoing pelvic osteotomies, and (2) characterize current practices on types of VTE prophylaxis being utilized after pelvic osteotomies.

METHODS

The study evaluated the Pediatric Health Information System database between October 1, 2015 and January 1, 2020 for patients between 10 and 18 years of age meeting selected ICD-10 procedure and diagnosis codes relating to pelvic osteotomies. The rate of VTE was calculated within 90 days of index procedure. Types of pharmacologic prophylaxis were characterized. Continuous variables were compared with 2-sample t tests; proportions and categorical variables were compared with Fisher exact or χ2 tests, all with 2-tailed significance <0.05.

RESULTS

Of 1480 included patients, 9 were diagnosed with VTE within 90 days of surgery (VTE rate: 0.61%). Four of 9 (44.4%) had received pharmacologic prophylaxis postoperatively. There were no differences in baseline demographics or length of stay between patients that did or did not develop VTE (P>0.05). Overall, 52.0% received at least one form of pharmacologic prophylaxis postoperatively. The most common pharmacologic prophylaxis used was aspirin (47.6%), of which 64.4% received 81 mg dosing. There was no difference in VTE rates in those with or without prophylaxis (0.52% vs. 0.70%, P=0.75). However, those prescribed prophylaxis were significantly older (15.2±2.3 vs. 13.6±2.4 y, P<0.0001) and had a higher proportion of females (71.8% vs. 54.6%, P<0.01).

CONCLUSIONS

The overall rate of VTE in pediatric patients after pelvic osteotomies is non-negligible. There is heterogeneity in the type of anticoagulant utilized; however, VTE prophylaxis is most commonly prescribed in older adolescents and female patients. Guidelines for medical prevention of deep venous thrombosis and pulmonary embolism in the pediatric population are warranted after hip preservation surgery.

LEVEL OF EVIDENCE

Level IV, case series.

Prophylaxis for Pediatric Venous Thromboembolism: Current Status and Changes Across Pediatric Orthopaedic Society of North America From 2011

INTRODUCTION

Pediatric venous thromboembolism (VTE) is a concern for orthopaedic surgeons. We sought to query the Pediatric Orthopaedic Society of North America (POSNA) members on current VTE prophylaxis practice and compare those results with those of a previous survey (2011).

METHODS

A 35-question survey was emailed to all active and candidate POSNA members. The survey consisted of questions on personal and practice demographics; knowledge and implementation of various VTE prophylaxis protocols, mechanical and chemical VTE prophylaxis agents, and risk factors; and utilization of scenarios VTE prophylaxis agents for various clinical scenarios. One- and two-way frequency tables were constructed comparing results from the current survey and those of the 2011 survey.

RESULTS

Two hundred thirty-nine surveys were completed (18% respondent rate), with most respondents from an academic/university practice reporting one or two partners (>60%). Half were in practice ≥15 years, and >90% reported an almost exclusive pediatric practice. One-third of the respondents reported familiarity with their institution-defined VTE prophylaxis protocol, and 20% were aware of an institutionally driven age at which all patients receive VTE prophylaxis. The most frequently recognized risk factors to guide VTE prophylaxis were oral contraceptive use, positive family history, and obesity. Respondents indicated a similar frequency of use of a VTE prophylaxis agent (either mechanical or chemical) for spinal fusion, hip reconstruction, and trauma (60% to 65%), with lower frequency for neuromuscular surgery (34%) (P < 0.001). One hundred thirty-seven respondents had a patient sustain a deep vein thrombosis, and 66 had a patient sustain a pulmonary embolism. Compared with responses from 2011, only 20 more respondents reported familiarity with their institution VTE prophylaxis protocol (75 versus 55). In 2018, aspirin was used more frequently than in 2011 (52% versus 19%; P < 0.0001) and enoxaparin was used less frequently (20% versus 41%; P < 0.0001).

DISCUSSION

Over the past 7 years since the first POSNA survey on VTE prophylaxis, most POSNA members are still unaware of their institution specific VTE prophylaxis protocol. Most respondents agree that either mechanical or chemical VTE prophylaxis should be used for spinal fusion, hip reconstruction, and trauma. The use of aspirin as an agent of chemical VTE prophylaxis has increased since 2011.

LEVEL OF EVIDENCE

Level IV. Type of evidence: therapeutic.

The Importance of a Standardized Screening Tool to Identify Thromboembolic Risk Factors in Pediatric Lower Extremity Arthroscopy Patients

INTRODUCTION

Deep vein thrombosis and pulmonary embolism are major complications that can occur in common orthopaedic procedures such as knee arthroscopy. The purpose of this study is to determine the incidence of venous thromboembolism (VTE) risk factors in adolescent patients undergoing elective lower extremity arthroscopy. A second objective is to determine whether a targeted, standardized screening tool is both cost- and clinically effective in the identification of VTE risk factors in adolescents.

METHODS

A standardized VTE screening tool was prospectively administered to all elective arthroscopic procedures in a pediatric sports medicine practice. A comparison cohort that did not complete the screening tool was isolated through a retrospective chart review identifying VTE risk factors. The incidence and cost between the two cohorts were compared.

RESULTS

Of 332 subjects who did not receive a targeted screening (TS) tool, 103 risk factors were noted. One pulmonary embolism case was identified with a total incidence of 0.15% over 3 years. With TS, we identified 325 subjects with 134 identifiable risk factors. Six patients (1.8%) were noted to be very high risk, requiring consultation with hematology. No VTEs were reported. When compared with the retrospective review, TS identified 30% more risk factors. A significant increase in the identification of family history of blood clots (P < 0.001), history of previous blood clot (P = 0.059), recurrent miscarriages in the family (P = 0.010), and smoking exposure (P = 0.062) was found. Additionally, the total cost of screening was less than the cost of prophylaxis treatment with no screening ($20.98 versus $23.51 per person, respectively).

DISCUSSION

Risk factors for VTE may be present in 32.5% of elective adolescent arthroscopic patients. A TS model for VTE identified 30% more risk factors, especially a significant family history, and was shown to be a cost-effective way to safely implement a VTE prevention program.

LEVEL OF EVIDENCE

Level II.

Venous thromboembolism among pediatric orthopedic trauma patients: a database analysis

Using the 2012 Kids Inpatient Database, we assessed records of pediatric patients (<21 years old) with fractures of the upper limb, lower limb, spine, pelvis, and multiple locations and calculated the overall prevalence of venous thromboembolism (VTE) and associated potential risk factors. 387 (0.68%) of 57 183 patients with one or more fractures were diagnosed with VTE. Children sustaining fractures of the axial skeleton and those with multiple fractures had a higher prevalence of VTE than those with isolated extremity fractures. Associated risk factors included the presence of a central venous catheter. A prospective, multicenter study is needed to confirm our findings.

Complications and 30-day Outcomes Associated With Venous Thromboembolism in the Pediatric Orthopaedic Surgical Population

INTRODUCTION

The risk of morbidity associated with venous thromboembolism (VTE) after pediatric orthopaedic surgery remains unclear despite increased use of thromboprophylaxis measures.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program, Pediatric database was queried for patients undergoing an orthopaedic surgical procedure between 2012 and 2013. Upper extremity and skin/subcutaneous surgeries were excluded. Associations between VTE and procedure, demographics, comorbidities, preoperative laboratory values, and 30-day postoperative outcomes were evaluated.

RESULTS

Of 14,776 cases, 15 patients (0.10%) experienced postoperative VTE. Deep vein thrombosis (DVT) occurred in 13 patients (0.09%), and pulmonary embolism developed in 2 patients (0.01%). The procedure with the highest VTE rate was surgery for infection (1.2%). Patient factors associated with the development of VTE included hyponatremia (P = 0.003), abnormal partial thromboplastin time (P = 0.046), elevated aspartate transaminase level (P = 0.004), and gastrointestinal (P = 0.011), renal (P = 0.016), and hematologic (P = 0.019) disorders. Nearly half (46.2%) of DVTs occurred postdischarge. Complications associated with VTE included prolonged hospitalization (P < 0.001), pneumonia (P < 0.001), unplanned intubation (P = 0.003), urinary tract infection (P = 0.003), and central line-associated bloodstream infection (P < 0.001). Most of the postoperative complications (66.7%) occurred before VTE diagnosis, and no patients with VTE died.

CONCLUSION

In the absence of specified risk factors, thromboprophylaxis may be unnecessary for this population.

Pediatric orthopaedic lower extremity trauma and venous thromboembolism

PURPOSE

Research on venous thromboembolism events (VTE), such as deep venous thrombosis (DVT) and pulmonary embolism (PE), in pediatric orthopaedic trauma patients is sparse. We describe the incidence in the USA of VTE associated with pediatric lower extremity orthopaedic trauma, and characterize injury patterns and VTE treatment methods.

METHODS

The Pediatric Health Information System (PHIS) was queried from 2004 to 2013 using ICD-9 codes for lower extremity fractures (pelvis, femur, tibia, ankle, foot) and dislocations (hip, knee, ankle, subtalar) and VTE. Records were queried for age, diagnoses, and VTE treatment.

RESULTS

During the study period 285,611 clinical encounters reported lower extremity trauma. Of those, 167 patients were simultaneously coded with VTE (99 DVT, 50 PE, 18 combined DVT/PE), to give an incidence of VTE associated with pediatric lower extremity trauma of 0.058 %. Patients were from 39 centers, with an average age of 12.9 years (range 0-19). There were 249 fractures and 21 dislocations, with 25 (15 %) patients sustaining more than one lower extremity injury. The most common fracture locations were the femur/femoral neck (95), tibia/ankle (92), and pelvis (44). 72 % (121/167) of patients were treated with anticoagulation medication, of which the most common was low-molecular-weight heparin (111/167, 66 %).

CONCLUSIONS

The incidence of VTE events associated with lower extremity orthopaedic trauma is 0.058 %. Adolescents and polytrauma patients with injuries of the femur/femoral neck, tibia/ankle, and pelvis are more commonly affected. Low-molecular-weight heparin is commonly used to treat VTE in pediatric and adolescent patients.

What are the patterns of prophylactic postoperative oral antibiotic use after foot and ankle surgery?

BACKGROUND

The CDC estimates 23% of healthcare-associated infections to be surgical site infections, with alarming prevalence of antibiotic-resistant organisms. While there is consensus regarding preoperative prophylaxis, orthopaedic surgeons' use of prophylactic postoperative oral antibiotics is less defined.

QUESTIONS/PURPOSES

We investigated surgeons' use of prophylactic postoperative oral antibiotics after elective outpatient foot or ankle procedures, identifying (1) frequency of use, (2) regimen preferences, (3) personal indications, and (4) associated experience and demographics.

METHODS

Using a cross-sectional survey design, a questionnaire was emailed to all active and candidate members of the American Orthopaedic Foot and Ankle Society. Supplementary questions captured demographic information. We invited 1136 members to participate; 22 addresses produced delivery failure messages, leaving 1114 members as potential participants. After nonresponses and exclusions, 312 (28%) responses were analyzed. Statistical analysis used Pearson's chi-square test, Fisher's exact test, and multivariate regression.

RESULTS

The majority (75%) of respondents reported use of prophylactic postoperative oral antibiotics. Most users (69%) prescribed to fewer than 25% of patients, although 16% prescribed for all elective cases. The most frequent regimen was cephalexin 500 mg four times a day (63%) and the most common duration was 5 to 7 days (50%). Surgeons' most common indications were previous infection (71%), medical comorbidities (65%), and previous wound-healing difficulties (56%). Those who do and do not prescribe prophylactic postoperative oral antibiotics showed no difference in surgical site infection rate or any demographic category.

CONCLUSIONS

Surgeons' reported use of prophylactic postoperative oral antibiotics after elective foot or ankle surgery was common, without demographic association. Commonalities were identified in antibiotic regimen and personal indications for this practice. Comparative clinical studies are warranted to elucidate the efficacy of prophylactic postoperative oral antibiotics and establish evidence-based guidelines for their use.

Risk factors for venous thromboembolism in hospitalized children and adolescents: a systemic review and pooled analysis

We performed a systematic review of published studies that evaluated the potential risk factors and outcomes of venous thromboembolism (VTE) in hospitalized children. A total of 761 VTE patients from six published studies were identified. The mean prevalence of VTE in children admitted to the hospital was 9.7/10 000 admissions. The presence of a central venous catheter was found to be the single most important predisposing cause of VTE, with a pooled percentage of 29%. Infection was the second most common cause of the disease (20%). Pulmonary embolism occurred in 15% (113/745) of the patients. The overall recurrence rate of VTE was 16% (74/464) and the mortality rate was 8% (59/704). Although uncommon, orthopedic surgeons need to be aware of the unique risk factors for VTE among pediatric inpatients. Hospitalized children and adolescents with known risk factors for VTE should be considered candidates for VTE screening or prophylaxis.