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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