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.
1. Ahmad J, Lynch M-K, Maltenfort M. Incidence and Risk Factors of Venous Thromboembolism After Orthopaedic Foot and Ankle Surgery. Foot Ankle Spec. 2017;10(5):449-454. doi:10.1177/1938640017704944
2. Sullivan M, Eusebio ID, Haigh K, Panti JP, Omari A, Hang JR. Prevalence of Deep Vein Thrombosis in Low-Risk Patients After Elective Foot and Ankle Surgery. Foot Ankle Int. 2019;40(3):330-335. doi:10.1177/1071100718807889
3. Arnold H. [The Akin procedure as closing wedge osteotomy for the correction of a hallux valgus interphalangeus deformity]. Oper Orthop Traumatol. 2008;20(6):477-483. doi:10.1007/s00064-008-1503-8
4. Bednarz PA, Manoli A. Modified lapidus procedure for the treatment of hypermobile hallux valgus. Foot Ankle Int. 2000;21(10):816-821. doi:10.1177/107110070002101004
5. Bikdeli B, Visvanathan R, Weinberg I, et al. Clinical characteristics and outcomes of venous thromboembolic events after hallux valgus surgery: insights from the RIETE registry. J Thromb Thrombolysis. 2020;49(4):651-658. doi:10.1007/s11239-019-02025-2
6. Buciuto R. Prospective randomized study of chevron osteotomy versus Mitchell’s osteotomy in hallux valgus. Foot Ankle Int. 2014;35(12):1268-1276. doi:10.1177/1071100714550647
7. Gangadharan R, Roslee C, Kelsall N, Taylor H. Retrospective review of complications following long tourniquet time in foot and ankle surgery. J Clin Orthop Trauma. 2021;16:189-194. doi:10.1016/j.jcot.2020.12.023
8. Griffiths JT, Matthews L, Pearce CJ, Calder JDF. Incidence of venous thromboembolism in elective foot and ankle surgery with and without aspirin prophylaxis. J Bone Joint Surg Br. 2012;94(2):210-214. doi:10.1302/0301-620X.94B2.27579
9. Hamilton PD, Hariharan K, Robinson AHN. Thromboprophylaxis in elective foot and ankle patients–current practice in the United Kingdom. Foot Ankle Surg. 2011;17(2):89-93. doi:10.1016/j.fas.2011.02.004
10. Hammel E, Abi Chala ML, Wagner T. [Complications of first ray osteotomies: a consecutive series of 475 feet with first metatarsal Scarf osteotomy and first phalanx osteotomy]. Rev Chir Orthop Reparatrice Appar Mot. 2007;93(7):710-719. doi:10.1016/s0035-1040(07)73256-7
11. Hanslow SS, Grujic L, Slater HK, Chen D. Thromboembolic disease after foot and ankle surgery. Foot Ankle Int. 2006;27(9):693-695. doi:10.1177/107110070602700907
12. Hassan MK, Karlock LG. Association of Aspirin Use With Postoperative Hematoma and Bleeding Complications in Foot and Ankle Surgery: A Retrospective Study. J Foot Ankle Surg. 2019;58(5):861-864. doi:10.1053/j.jfas.2018.12.022
13. Heijboer RRO, Lubberts B, Guss D, Johnson AH, Moon DK, DiGiovanni CW. Venous Thromboembolism and Bleeding Adverse Events in Lower Leg, Ankle, and Foot Orthopaedic Surgery with and without Anticoagulants. J Bone Joint Surg Am. 2019;101(6):539-546. doi:10.2106/JBJS.18.00346
14. Huntley SR, Abyar E, Lehtonen EJ, Patel HA, Naranje S, Shah A. Incidence of and Risk Factors for Venous Thromboembolism After Foot and Ankle Surgery. Foot Ankle Spec. 2019;12(3):218-227. doi:10.1177/1938640018769740
15. Jameson SS, Augustine A, James P, et al. Venous thromboembolic events following foot and ankle surgery in the English National Health Service. J Bone Joint Surg Br. 2011;93(4):490-497. doi:10.1302/0301-620X.93B4.25731
16. Jupiter DC, Saenz F, Mileski W, Shibuya N. Acute Deep Venous Thrombosis and Pulmonary Embolism in Foot and Ankle Trauma in the National Trauma Data Bank: An Update and Reanalysis. J Foot Ankle Surg. 2019;58(6):1152-1162. doi:10.1053/j.jfas.2019.03.011
17. Kopp FJ, Patel MM, Levine DS, Deland JT. The modified Lapidus procedure for hallux valgus: a clinical and radiographic analysis. Foot Ankle Int. 2005;26(11):913-917. doi:10.1177/107110070502601103
18. Matthews JH, Terrill AJ, Barwick AL, Butterworth PA. Venous Thromboembolism in Podiatric Foot and Ankle Surgery. Foot Ankle Spec. 2018;11(5):444-450. doi:10.1177/1938640017750256
19. McMurrich W, Peters A, Ellis M, et al. MIS Distal Metatarsal Metaphyseal Osteotomy in the treatment of metatarsalgia: MOXFQ patient reported outcomes. Foot (Edinb). 2020;43:101661. doi:10.1016/j.foot.2019.101661
20. Morawe GA, Schmieschek MHT. Minimally invasive bunionette correction. Oper Orthop Traumatol. 2018;30(3):184-194. doi:10.1007/s00064-018-0542-z
21. Radl R, Kastner N, Aigner C, Portugaller H, Schreyer H, Windhager R. Venous thrombosis after hallux valgus surgery. J Bone Joint Surg Am. 2003;85(7):1204-1208. doi:10.2106/00004623-200307000-00004
22. Richey JM, Ritterman Weintraub ML, Schuberth JM. Incidence and Risk Factors of Symptomatic Venous Thromboembolism Following Foot and Ankle Surgery. Foot Ankle Int. 2019;40(1):98-104. doi:10.1177/1071100718794851
23. Richman SH, Siqueira MBP, McCullough KA, Berkowitz MJ. Correction of Hammertoe Deformity With Novel Intramedullary PIP Fusion Device Versus K-Wire Fixation. Foot Ankle Int. 2017;38(2):174-180. doi:10.1177/1071100716671883
24. Rink-Brüne O. Lapidus arthrodesis for management of hallux valgus–a retrospective review of 106 cases. J Foot Ankle Surg. 2004;43(5):290-295. doi:10.1053/j.jfas.2004.07.007
25. Saragas NP, Ferrao PNF, Saragas E, Jacobson BF. The impact of risk assessment on the implementation of venous thromboembolism prophylaxis in foot and ankle surgery. Foot Ankle Surg. 2014;20(2):85-89. doi:10.1016/j.fas.2013.11.002
26. Simon MA, Mass DP. Venous thrombosis after hallux valgus surgery. J Bone Joint Surg Am. 2004;86(4):871; author reply 871-872. doi:10.2106/00004623-200404000-00034
27. Simon MA, Mass DP, Zarins CK, Bidani N, Gudas CJ, Metz CE. The effect of a thigh tourniquet on the incidence of deep venous thrombosis after operations on the fore part of the foot. J Bone Joint Surg Am. 1982;64(2):188-191.
28. Solis G, Saxby T. Incidence of DVT following surgery of the foot and ankle. Foot Ankle Int. 2002;23(5):411-414. doi:10.1177/107110070202300507
29. Touloupakis G, Ghirardelli S, Del Re M, Indelli PF, Antonini G. First metatarsal extracapsular osteotomy to treat moderate hallux valgus deformity: the modified Wilson-SERI techinique. Acta Biomed. 2021;92(1):e2021173. doi:10.23750/abm.v92i1.10662