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Thromboembolism Following Foot and Ankle Surgery: A Case Series and Literature Review

https://doi.org/10.1053/j.jfas.2008.02.003Get rights and content

Venous thromboembolism following major orthopedic procedures of the hip and knee is well documented and patients are therefore routinely prophylaxed following these proximal lower extremity procedures. In contrast, foot and ankle surgery is considered by most health care professionals to be a low-risk procedure for the development of venous thromboembolism. As a result, pharmacologic deep venous thrombosis prophylaxis is rarely administered. This postoperative practice is supported by the literature regarding deep venous thrombosis following foot and ankle surgery. In this article, we review the risk factors and explore the occurrence of thromboembolism after foot and ankle surgery in the literature. We also present our restrospective study of patients who developed venous thromboembolism after forefoot, midfoot, hindfoot, and ankle procedures. Over the course of 1.5 years, 4 of a consecutive series of 1000 patients (0.4%) developed a deep venous thrombolism and 3 of 1000 (0.3%) developed nonfatal pulmonary emboli. In our series, each of our patients who developed venous thromboembolism had at least 2 identifiable risk factors. The incidence of venous thromboembolism following foot and ankle surgery is rare (less than 1%), and the need for routine propylaxis postoperatively is not supported by any high level of evidence studies. Level of Clinical Evidence: 4

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Patients and Methods

Formal approval of this retrospective study and a waiver of HIPAA authorization to access protected health information was granted by our university's institutional review board before initiation of this study. Patient medical record information over a 1.5-year period, from January 2005 to June 2006, was retrospectively reviewed and evaluated. The inclusion group was a consecutive series of 1000 patients who underwent foot and ankle surgery by one surgeon over a 1.5-year period. None of the

Results

The principal investigator (D.W.) performed foot and ankle surgery on 1000 consecutive patients over the course of 1.5 years. Descriptive results for the case series are depicted in Table 1. No patients undergoing outpatient surgery received prophylaxis against VTE. All patients undergoing surgery that required admission to the hospital received low molecular weight heparin (Lovenox 40 mg) subcutaneously beginning on the morning following surgery. They remained on this during their hospital

Risk Factors

Numerous risk factors of surgery, especially orthopedic procedures, have been linked to increased rates of thromboembolism. Inherited or acquired hypercoagulable states are reported to exist in 20% to 30% of DVT cases (6, 7). The most common of the inherited hypercoagulable states is Factor V Leiden, a mutated form of coagulation factor V (2, 3, 6, 8). Factor V Leiden causes resistance to protein C antithrombotic activity (2, 3, 6, 8). Prothrombin G20210A mutation, anticardiolipin antibody

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