Karan Goswami, Tomas Roca-Sanchez, Nestor Moreno-Moreu.
Response/Recommendation: Patients undergoing removal of hardware from lower extremity are at low risk of venous thromboembolism (VTE). Thus, routine VTE thromboprophylaxis is not recommended.
Strength of Recommendation: Limited.
Rationale: VTE affects thousands of people in the world each year and lower limb surgery is a known acquired risk factor1 However, there is a paucity of evidence relating to thromboembolism after lower extremity hardware removed.
Systematic review of the literature, using the search terms appended below, revealed no studies that directly address thromboembolic complications or thromboprophylaxis around lower extremity hardware removal. Fenelon et al., performed a 10-year retrospective review of complications following 1,482 ankle open reduction internal fixation (ORIF) cases, and identified no deep venous thrombosis (DVT) or pulmonary embolism (PE) in the 185 (12.5%) cases who underwent hardware removal during the follow-up period; however the use of thromboprophylaxis was not reported2. Kovar et al., published a 16-year descriptive outcomes study examining complications following implant removal in proximal femur fractures, and reported that none of the 61 complications seen in the 428 procedures examined were DVT or PE; however, there was no mention of whether or not thromboprophylaxis was implemented3.
Clinical practice guidelines published by the American Academy of Orthopaedic Surgeons (AAOS)4, the American College of Chest Physicians (ACCP)5, and the American College of Foot and Ankle Surgeons (ACFAS)6 do not specifically address hardware removal. The National Institute for Health and Care Excellence (NICE) guidelines11 recommend anticoagulation following foot and ankle surgery if prolonged immobilization if expected, or surgical time is greater than 90 minutes, or when the risk of VTE development outweighs the risk of bleeding7. These recommendations could be extrapolated to cases of lower extremity hardware removal although they are not specifically intended for this setting.
Knowledge of Virchow’s triad (hypercoagulability, endothelial injury, and venous stasis) and the mechanisms of production of thromboembolic disease, can help guide thromboprophylaxis in individual situations where there is no specific evidence8. Hardware removal could be stratified as complicated or not with respect to the difficulty of removal, surgical time, bony manipulation, use of tourniquet, and need for general anesthesia. Although this may seem logical, there is currently no evidence to support this practice.
Clinicians can combine guideline recommendations for other patient groups with individual patient VTE risk factors.9,10 The Caprini score, while not specifically validated in this setting, may be used to guide decisions about VTE prophylaxis.11 The Caprini score has been validated in over 100 trials worldwide involving more than 250.000 patients.12 It has specific items for orthopaedic surgery, but hardware removal has again not been independently assessed.
In conclusion, we have no evidence that lower extremity hardware removal independently increases the risk of VTE over a patient’s own risk factors. There are no guidelines or evidence for this specific surgical process. For this reason, we recommend a comprehensive assessment of risk factors should be performed to aid in the decision-making process. If sufficient risk factors are present, mechanical and/or chemical thromboprophylaxis should be considered and weighed against the potential risks of prophylaxis. However, exactly what constitutes sufficient risk remains unknown, especially in this setting of lower extremity hardware removal. Further studies on this topic are needed to develop more specific and evidence-based recommendations.
References:
1. Samama CM, Laporte S, Rosencher N, et al. Rivaroxaban or Enoxaparin in Nonmajor Orthopedic Surgery. N Engl J Med. 2020;382(20):1916-1925. doi:10.1056/NEJMoa1913808
2. Fenelon C, Murphy EP, Galbraith JG, Kearns SR. The burden of hardware removal in ankle fractures: How common is it, why do we do it and what is the cost? A ten-year review. Foot Ankle Surg Off J Eur Soc Foot Ankle Surg. 2019;25(4):546-549. doi:10.1016/j.fas.2018.05.006
3. Kovar FM, Strasser E, Jaindl M, Endler G, Oberleitner G. Complications following implant removal in patients with proximal femur fractures – an observational study over 16 years. Orthop Traumatol Surg Res OTSR. 2015;101(7):785-789. doi:10.1016/j.otsr.2015.07.021
4. Jacobs JJ, Mont MA, Bozic KJ, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Bone Joint Surg Am. 2012;94(8):746-747. doi:10.2106/JBJS.9408.ebo746
5. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e278S-e325S. doi:10.1378/chest.11-2404
6. Fleischer AE, Abicht BP, Baker JR, Boffeli TJ, Jupiter DC, Schade VL. American College of Foot and Ankle Surgeons’ Clinical Consensus Statement: Risk, Prevention, and Diagnosis of Venous Thromboembolism Disease in Foot and Ankle Surgery and Injuries Requiring Immobilization. J Foot Ankle Surg. 2015;54(3):497-507. doi:10.1053/j.jfas.2015.02.022
7. National Guideline Centre (UK). Venous Thromboembolism in over 16s: Reducing the Risk of Hospital-Acquired Deep Vein Thrombosis or Pulmonary Embolism. National Institute for Health and Care Excellence (UK); 2018. Accessed August 5, 2021. http://www.ncbi.nlm.nih.gov/books/NBK493720/
8. Carr P, Ehredt DJ, Dawoodian A. Prevention of Deep Venous Thromboembolism in Foot and Ankle Surgery. Clin Podiatr Med Surg. 2019;36(1):21-35. doi:10.1016/j.cpm.2018.08.002
9. Özcan M, Erem M, Turan FN. Symptomatic Deep Vein Thrombosis Following Elective Knee Arthroscopy Over the Age of 40. Clin Appl Thromb. 2019;25:1076029619852167. doi:10.1177/1076029619852167
10. Sloan M, Sheth N, Lee GC. Is Obesity Associated With Increased Risk of Deep Vein Thrombosis or Pulmonary Embolism After Hip and Knee Arthroplasty? A Large Database Study. Clin Orthop. 2019;477(3):523-532. doi:10.1097/CORR.0000000000000615
11. Golemi I, Salazar Adum JP, Tafur A, Caprini J. Venous thromboembolism prophylaxis using the Caprini score. Dis–Mon DM. 2019;65(8):249-298. doi:10.1016/j.disamonth.2018.12.005
12. Cronin M, Dengler N, Krauss ES, et al. Completion of the Updated Caprini Risk Assessment Model (2013 Version). Clin Appl Thromb Off J Int Acad Clin Appl Thromb. 2019;25:1076029619838052. doi:10.1177/1076029619838052