135 – Is routine VTE prophylaxis required for patients undergoing finger surgery?

Jacob E. Tulipan. Pedro Beredjiklian.

Response/recommendation: Thromboprophylaxis is not routinely required for patients undergoing finger or thumb surgery.  In patients undergoing digit replantation or microvascular surgery with extended operative time, venous thromboembolism (VTE) prophylaxis may be indicated.

Strength of Recommendation: Limited.

Rationale: Published data on VTE following surgery of the fingers and thumb are extremely limited.  The available literature has focused on digit replantation, which has long operative times and may be associated with reduced postoperative ambulation.  Conversely, many patients are placed on therapeutic thromboprophylaxis post-replantation to protect the replanted digit from occlusive thrombosis.  Barzin et al., analyzed a national database of 15,413 replantations from 1998-2007, and found a rate of 19.55 VTE events per 1,000 discharges.  This rate was not higher in patients over the age of 65¹.  Leung et al., reported a fatal postoperative pulmonary embolism (PE) with lower extremity deep venous thrombosis (DVT) following a digit replantation, but were not able to identify other similar cases in the literature².  A review by Roberts et al., identified 9 cases of VTE following elbow, wrist, and hand surgery, but all of these events followed surgery proximal to the wrist³.  Hastie et al., analyzed 3,357 consecutive upper extremity surgeries at a single center from 2009-2012, and found only one incidence of VTE following digit surgery.  This was a case of a 46-year-old male with bilateral segmental PE following a thumb metacarpophalangeal fusion, in the setting of a strong family history of VTE⁴.

Ultimately, the risk of VTE following non-replantation digit surgeries appears to be extremely low, and routine VTE prophylaxis does not appear to be necessary in this cohort.

References:

1.         Barzin A, Hernandez-Boussard T, Lee GK, Curtin C. Adverse events following digital replantation in the elderly. J Hand Surg Am. 2011;36(5):870-874. doi:10.1016/j.jhsa.2011.01.031

2.         Leung ASM, Fok MWM, Fung BKK. Fatal bilateral lower-limb deep vein thrombosis and pulmonary embolism following single digit replantation. Hong Kong Med J. 2015;21(3):283-285. doi:10.12809/hkmj144262

3.         Roberts DC, Warwick DJ. Venous thromboembolism following elbow, wrist and hand surgery: a review of the literature and prophylaxis guidelines. J Hand Surg Eur Vol. 2014;39(3):306-312. doi:10.1177/1753193412469131

4.         Hastie GR, Pederson A, Redfern D. Venous thromboembolism incidence in upper limb orthopedic surgery: do these procedures increase venous thromboembolism risk? J Shoulder Elbow Surg. 2014;23(10):1481-1484. doi:10.1016/j.jse.2014.01.044