Daniel Scott, Caroline P. Hoch, Terence S. Saxby, Christopher E. Gross.
Response/Recommendation: The risk of venous thromboembolism (VTE) following forefoot and midfoot is rare, with pulmonary embolism (PE) and even more so, fatal PE being exceedingly rare. The rates appear to be lower in forefoot surgery as opposed to midfoot surgery, while both appear low. We do not recommend routine anticoagulants for VTE prevention following elective a forefoot and midfoot in low-risk patients, especially after immediate weight-bearing. We do encourage further high-quality research into routine VTE chemoprophylaxis.
Strength of Recommendation: Limited.
Rationale: There is limited data to support routine prophylaxis for VTE events in foot and ankle (F&A) surgery patients. This is especially true regarding forefoot and midfoot surgery where patients are often allowed to weight-bear fully. In the field of F&A surgery, there is relatively little data available to guide clinical decision-making regarding VTE prophylaxis, especially in comparison to other fields of orthopaedics. One single surgeon study found only 22 clinically symptomatic VTE in 2,774 patients (0.79%) over the span of 10 years1. Other authors have found a relatively high rate of otherwise asymptomatic VTE in F&A surgery patients (25.4%)2 at 2- and 6-week screening ultrasounds. All of the detected deep venous thromboses (DVT) were distal to the popliteal vein and all patients were undergoing hindfoot or midfoot surgery and were made non-weight-bearing2. There is very little data on the risk of VTE in patients who are undergoing forefoot and midfoot surgery.
In our systematic review, we identified 34 potential studies out of 318 reviewed that may discuss the incidence of VTE and prophylaxis in forefoot and midfoot patients who were allowed to weight-bear immediately after surgery. However, only 29 reported on the incidence of VTE after forefoot and midfoot procedures1–29.
In a total of 38,105 reported forefoot procedures, 37 patients (0.097%) had a VTE while 7 patients (0.018%) had a PE. Of these patients, 2 (0.005%) had a fatal PE. Regarding midfoot surgery, 750 patients were included, of which 26 had a DVT (3.4%) and 2 had a PE (0.266%). No fatal PE were reported for patients undergoing midfoot surgery.
Relatively few authors have examined the effect of chemoprophylaxis on the incidence of VTE in forefoot and midfoot surgery. Heijboer et al., retrospectively compared patients who received aspirin (ASA) as DVT prophylaxis to those that received no prophylaxis13. Of the patients undergoing forefoot and midfoot surgery, they found 8 VTE in 1,004 patients (0.79%) who did not receive any DVT prophylaxis, and 2 VTEs in 1,004 patients (0.19%) receiving ASA. Griffiths et al., performed a retrospective review of an unspecified mix of different F&A procedures, some receiving ASA as prophylaxis and others receiving no prophylaxis8. They found similar rates of VTE in both cohorts, with 4 DVT in 1,068 patients receiving ASA (0.37%) and 3 DVT in the 1,559 patients with no prophylaxis (0.19%). Rates of PE were also similar, with 1 PE in the ASA group (0.09%) and 3 in the group with no prophylaxis (0.19%). No studies compared types of routine anticoagulation. There are no randomized controlled trials or even prospective studies comparing routine prophylaxis and its effect on VTE incidence.
Regarding risk factors for VTE, a few studies did examine the impact of various risk factors on rate of VTE. One study that only included patients undergoing forefoot surgery found age over 60 to be a risk factor21. Two studies exclusively evaluating midfoot surgery found longer tourniquet duration and female gender, increasing age, obesity, inpatient status, and non-elective surgery to be risk factors2,14–28. Additionally, Ahmed et al., evaluated a mix of forefoot and midfoot patients and found obesity to be an independent risk factor for VTE1. Finally, Saragas et al., evaluated mix of forefoot, midfoot, and hindfoot patients, and found flat foot reconstruction surgery to be an independent risk factor for VTE25.
The incidence of reported VTE is extremely low in forefoot surgery and low in midfoot surgery. There is little data to support the use of routine prophylaxis for midfoot and especially forefoot surgery. The limited amounted of data impedes clinical decision-making regarding VTE chemoprophylaxis. Based on the data available we do not recommend routine anticoagulants for VTE prevention following elective forefoot and midfoot in low-risk patients. Given the lack of high-quality studies, we strongly encourage further research into the effect of VTE prophylaxis on the incidence of VTE in forefoot and midfoot surgery.
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