Christopher E. Gross, Caroline P. Hoch, Mathias Granqvist, Paul W. Ackermann.
Response/Recommendation: The risk of venous thromboembolism (VTE) following ankle or hindfoot fusion surgery is rare, with pulmonary embolism (PE) and even more so, fatal PE being exceedingly rare. We cannot recommend routine anticoagulants for VTE prevention following elective ankle/hindfoot fusion in low-risk patients. We do encourage further high-quality research into routine VTE chemoprophylaxis following foot and ankle (F&A) surgery.
Strength of Recommendation: Limited.
Rationale: The argument for prophylaxis for VTE events in F&A surgery is at best equivocal. Compared to the depth of literature in total joint replacement or trauma, the current state of knowledge in F&A studies is based on a few large cohort studies1–6. As such, the true incidence of VTE is only partially described. In a prevalence study of ultrasonographic surveillance of VTE in low-risk patients after elective F&A surgery, 25.4% of patients had clinically silent VTE7. In contrast, in a single institution, single-surgeon study over a span of 10 years, 22 of 2,774 (0.79%) patients had a clinically symptomatic VTE1. However, not much data has been reported following incidence and prevention of VTE associated with ankle and hindfoot (isolated subtalar, isolated talonavicular, tibiotalocalcaneal, triple, double) fusion.
In our systematic review, we identified 45 potential studies out of 350 screened that that present the incidence of VTE and prophylaxis in ankle and hindfoot fusion patients. However, only 29 reported on the incidence of VTE after ankle and hindfoot fusion procedures2–31. In 84,337 reported procedures, 333 patients (0.39%) had a VTE while 32 patients (0.004%) had a PE. Of these patients, 2 (0.0003%) had a fatal PE.
Of these studies, only two reported prescribing routine VTE prophylaxis after surgery (low-molecular-weight heparin for 6 weeks26 and rivaroxaban for 4-6 weeks27). The incidence of VTE in the two studies was 2.2% (2/90). Of these studies, only one investigated the use of chemoprophylaxis in a prospective, cohort study in which patients took a daily dose of rivaroxaban until they were allowed weight-bearing as tolerated27. Five studies reported no use of routine VTE prophylaxis following ankle and hindfoot surgery2,7,13,28,31. The incidence of clinically diagnosed VTE reported in these studies was 0.18% (13/7,159). Interestingly, patients on thromboprophylaxis had higher incidence of VTE. No studies compared types of routine anticoagulation. There were no randomized controlled trials regarding routine prophylaxis and its effect on VTE incidence.
Of the twenty-nine studies reporting on the incidence of VTE in ankle and hindfoot fusion patients, three performed a statistical analysis which investigated who is at increased risk for developing a VTE6,7,21. Two studies identified obesity as an independent risk factor for developing a VTE6,21. Other risk factors include female gender, increasing age (not defined), inpatient status, nonelective surgery, and increased tourniquet time7,21.
The incidence of reported VTE and PE in patients undergoing ankle and hindfoot fusions is low. While the evidence seems to suggest that routine prophylaxis for ankle and hindfoot fusion surgery is unnecessary, we caution against using poor data to make decisions regarding one’s own surgical practice. Given the paucity of high-quality data regarding the utility of chemoprophylaxis following ankle and hindfoot fusions, we encourage further research into studying the effects of VTE prophylaxis on the incidence of VTE.
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2. 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
3. Jiang JJ, Schipper ON, Whyte N, Koh JL, Toolan BC. Comparison of perioperative complications and hospitalization outcomes after ankle arthrodesis versus total ankle arthroplasty from 2002 to 2011. Foot Ankle Int. 2015;36(4):360-368. doi:10.1177/1071100714558511
4. Menendez ME, Bot AGJ, Neuhaus V, Ring D, Johnson AH. Factors Influencing Discharge Disposition After Ankle Arthrodesis. Foot Ankle Int. 2014;35(6):578-583. doi:10.1177/1071100714528499
5. Probasco WV, Lee D, Lee R, Bell J, Labaran L, Stein BE. Differences in 30-day complications associated with total ankle arthroplasty and ankle arthrodesis: A matched cohort study. Foot (Edinb). 2021;46:101750. doi:10.1016/j.foot.2020.101750
6. Werner BC, Burrus MT, Looney AM, Park JS, Perumal V, Cooper MT. Obesity Is Associated With Increased Complications After Operative Management of End-Stage Ankle Arthritis. Foot Ankle Int. 2015;36(8):863-870. doi:10.1177/1071100715576569
7. 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
8. Bednarz PA, Monroe MT, Manoli A. Triple arthrodesis in adults using rigid internal fixation: an assessment of outcome. Foot Ankle Int. 1999;20(6):356-363. doi:10.1177/107110079902000603
9. Berkes MB, Schottel PC, Weldon M, Hansen DH, Achor TS. Ninety-Five Degree Angled Blade Plate Fixation of High-Energy Unstable Proximal Femur Fractures Results in High Rates of Union and Minimal Complications. J Orthop Trauma. 2019;33(7):335-340. doi:10.1097/BOT.0000000000001505
10. Carranza-Bencano A, Tejero S, Del Castillo-Blanco G, Fernández-Torres JJ, Alegrete-Parra A. Minimal incision surgery for tibiotalocalcaneal arthrodesis. Foot Ankle Int. 2014;35(3):272-284. doi:10.1177/1071100713515447
11. Chalayon O, Wang B, Blankenhorn B, et al. Factors Affecting the Outcomes of Uncomplicated Primary Open Ankle Arthrodesis. Foot Ankle Int. 2015;36(10):1170-1179. doi:10.1177/1071100715587045
12. Chatellard R, Berhouet J, Brilhault J. Efficiency of locking-plate fixation in isolated talonavicular fusion. Orthop Traumatol Surg Res. 2016;102(4 Suppl):S235-239. doi:10.1016/j.otsr.2016.03.003
13. Chiodo CP, Martin T, Wilson MG. A technique for isolated arthrodesis for inflammatory arthritis of the talonavicular joint. Foot Ankle Int. 2000;21(4):307-310. doi:10.1177/107110070002100406
14. Dannawi Z, Nawabi DH, Patel A, Leong JJH, Moore DJ. Arthroscopic ankle arthrodesis: are results reproducible irrespective of pre-operative deformity? Foot Ankle Surg. 2011;17(4):294-299. doi:10.1016/j.fas.2010.12.004
15. Davies MB, Rosenfeld PF, Stavrou P, Saxby TS. A comprehensive review of subtalar arthrodesis. Foot Ankle Int. 2007;28(3):295-297. doi:10.3113/FAI.2007.0295
16. DeVries JG, Berlet GC, Hyer CF. A retrospective comparative analysis of Charcot ankle stabilization using an intramedullary rod with or without application of circular external fixator–utilization of the Retrograde Arthrodesis Intramedullary Nail database. J Foot Ankle Surg. 2012;51(4):420-425. doi:10.1053/j.jfas.2012.03.005
17. DeVries JG, Nguyen M, Berlet GC, Hyer CF. The effect of recombinant bone morphogenetic protein-2 in revision tibiotalocalcaneal arthrodesis: utilization of the Retrograde Arthrodesis Intramedullary Nail database. J Foot Ankle Surg. 2012;51(4):426-432. doi:10.1053/j.jfas.2012.03.007
18. Duan X, Yang L, Yin L. Arthroscopic arthrodesis for ankle arthritis without bone graft. J Orthop Surg Res. 2016;11(1):154. doi:10.1186/s13018-016-0490-y
19. Ebalard M, Le Henaff G, Sigonney G, et al. Risk of osteoarthritis secondary to partial or total arthrodesis of the subtalar and midtarsal joints after a minimum follow-up of 10 years. Orthop Traumatol Surg Res. 2014;100(4 Suppl):S231-237. doi:10.1016/j.otsr.2014.03.003
20. Gross J-B, Belleville R, Nespola A, et al. Influencing factors of functional result and bone union in tibiotalocalcaneal arthrodesis with intramedullary locking nail: a retrospective series of 30 cases. Eur J Orthop Surg Traumatol. 2014;24(4):627-633. doi:10.1007/s00590-013-1347-2
21. 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
22. Klos K, Drechsel T, Gras F, et al. The use of a retrograde fixed-angle intramedullary nail for tibiocalcaneal arthrodesis after severe loss of the talus. Strategies Trauma Limb Reconstr. 2009;4(2):95-102. doi:10.1007/s11751-009-0067-y
23. Mendicino RW, Catanzariti AR, Saltrick KR, et al. Tibiotalocalcaneal arthrodesis with retrograde intramedullary nailing. J Foot Ankle Surg. 2004;43(2):82-86. doi:10.1053/j.jfas.2004.01.012
24. Mückley T, Klos K, Drechsel T, Beimel C, Gras F, Hofmann GO. Short-term outcome of retrograde tibiotalocalcaneal arthrodesis with a curved intramedullary nail. Foot Ankle Int. 2011;32(1):47-56. doi:10.3113/FAI.2011.0047
25. 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
26. Rozis M, Benetos I, Afrati S-R, Polyzois VD, Pneumaticos SG. Results and Outcomes of Combined Cross Screw and Ilizarov External Fixator Frame in Ankle Fusion. J Foot Ankle Surg. 2020;59(2):337-342. doi:10.1053/j.jfas.2019.05.008
27. Saragas NP, Ferrao PNF, Jacobson BF, Saragas E, Strydom A. The benefit of pharmacological venous thromboprophylaxis in foot and ankle surgery. S Afr Med J. 2017;107(4):327-330. doi:10.7196/SAMJ.2017.v107i4.10843
28. 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
29. Winson IG, Robinson DE, Allen PE. Arthroscopic ankle arthrodesis. J Bone Joint Surg Br. 2005;87(3):343-347. doi:10.1302/0301-620x.87b3.15756
30. Zelle BA, Gruen GS, McMillen RL, Dahl JD. Primary Arthrodesis of the Tibiotalar Joint in Severely Comminuted High-Energy Pilon Fractures. J Bone Joint Surg Am. 2014;96(11):e91. doi:10.2106/JBJS.M.00544
31. Dix B, Grant-McDonald L, Catanzariti A, Saltrick K. Preoperative Anemia in Hindfoot and Ankle Arthrodesis. Foot Ankle Spec. 2017;10(2):109-115. doi:10.1177/1938640016666921