Deep Venous Thrombosis, Thromboembolism, Thrombophlebitis in the Lower Extremity

ISHAAN SWARUP

JOHN BOLES

GEOFFREY H. WESTRICH

Significant morbidity and mortality are associated with the development of thromboembolic disease after orthopedic surgery.¹ Thromboembolic disease encompasses the development of deep venous thrombosis (DVT) and pulmonary embolism (PE). Both of these complications are considered to be life threatening, and they are both associated with significant patient morbidity and influence management after foot and ankle trauma and surgery.² As a result, knowledge about the etiology, risk factors, diagnosis, and management of thromboembolic disease is essential to any surgeon who treats patients with foot and ankle disorders.

Although the rates of thromboembolic disease have been thoroughly studied after total joint replacement, hip fracture surgery, and orthopedic trauma, only recently have authors begun to study the rates of thromboembolism after foot and ankle trauma and surgery.³,⁴ The rates of thromboembolic disease after foot and ankle surgery are considered to be lower than those of thromboembolism after hip and knee surgery.⁵ The current incidence of DVT after foot and ankle surgery ranges from 0.12% to 5.7%,⁴,⁵,⁶,⁷,⁸,⁹,¹⁰,¹¹,¹² with highest rates reported after surgery for acute Achilles tendon rupture and hallux valgus.⁸,¹¹ The current incidence of PE after foot and ankle surgery ranges from 0.15% to 1.1%.⁴,⁵,⁶,⁷,⁸,⁹,¹⁰,¹² Generally, the rate of thromboembolic disease after foot and ankle surgery is considered to be less than 1%, but it may be higher in patients with certain risk factors. The reported incidence rates from the most recent studies in foot and ankle surgery are listed in Table 8-1.⁵

In this chapter, we describe the etiology of thromboembolic disease and also its risk factors, clinical presentation, diagnosis, and management. Since disease prevention is an essential component of patient care and an important institutional measure, we also discuss prophylactic strategies for preventing thromboembolic disease after foot and ankle trauma and surgery.

Table 8-1. Reported Incidences of Venous Thromboembolism (VTE) Including Deep Venous Thromboembolism (DVT) and Pulmonary Embolism (PE) Following Foot and Ankle Surgery

Study	Incidence of VTE
Study	DVT	PE
Griffiths et al.⁶	0.27	0.15
Shibuya et al.⁷	0.28	0.21
Saragas and Ferrao⁸	5.7	1.1
Wukich and Waters⁵	0.4	0.3
Hanslow et al.⁴	4	1.3
Mizel et al.⁹	0.22	0.15
Solis and Saxby¹³	3.5	0
Barg et al.¹⁰	3.9	0
Radl et al.¹¹	4	0
Jameson et al.¹²	0.1	0.1

Thromboembolic Disease Overview

Although Rudolf Virchow, a German pathologist and biologist, initially described the phenomenon of venous thromboembolism (VTE) in 1856, its true morbidity and mortality was not appreciated until many years later. Approximately 90% of clinically significant PEs arise from proximal DVT of the lower extremities, and it is estimated that PEs are associated with 5% to 10% of all hospital deaths in the United States annually.³

VTE is the third most common vascular disease, following acute ischemic attacks and cerebrovascular accidents.³ A DVT occurs when one or more of the calf veins become obstructed to venous blood flow. The formation of DVT is multifactorial and best described by Virchow.¹⁴ In fact, Virchow’s triad of hypercoagulability, endothelial injury, and venous stasis provides the foundation for understanding the pathogenesis of DVT formation after foot and ankle surgery and trauma.¹⁵ For example, orthopedic surgery causes the release of thromboplastins that can activate the coagulation cascade and result in a hypercoagulable state. Similarly, endothelial injury is common in surgery, and venous stasis occurs with the use of a tourniquet or postoperative immobilization after foot and ankle surgery. Postoperative swelling and limited ambulation further contribute to venous stasis, and provide an ideal environment for clot formation.³

The majority of these thrombi occur in the deep veins of the calf; however, clot propagation to more proximal veins is known to occur as well. More specifically, the rate of propagation after total knee replacement surgery has been documented at 23%,¹⁶ which underscores the importance of longitudinal follow-up. A PE occurs when a DVT in the pelvis or lower extremity embolizes through the right heart and gets lodged in the pulmonary vasculature. This event results in an obstruction of pulmonary perfusion and subsequent oxygenation of blood. Although the majority of PEs are asymptomatic, these events may be fatal. The size and location of the PE determine the associated morbidity and mortality, with large saddle-type PEs being the most fatal type.³

Risk Factors for Thromboembolic Disease

Multiple risk factors have been identified as increasing a patient’s predisposition to thromboembolic disease. Given the multifactorial nature of thromboembolic disease, it is important to recognize the presence of multiple risk factors in each patient and to stratify the risk of thromboembolic disease in each patient accordingly. A few studies have looked at the most important risk factors for thromboembolic disease in patients undergoing lower extremity surgery, some of which are listed in Table 8-2. For example, Barg et al.¹⁰ concluded that obesity, history of previous thromboembolic disease, and absence of full weight-bearing status postoperatively are independent risk factors for developing symptomatic DVT after total ankle replacement. Similarly, Jameson et al.¹² found increasing age and multiple comorbidities as being risk factors for thromboembolic events after foot and ankle trauma surgery in a British National Health Service registry. More recently, Shibuya et al.⁷ found that older age, obesity, and higher injury severity score are significantly associated with the development of DVT and PE after foot and ankle trauma. Other known risk factors for thromboembolic disease include rheumatoid arthritis, recent air travel, malignancy, hypercoagulable states, pregnancy, and oral contraceptive use.³,⁴

Table 8-2. Reported Relative Risk (RR) or Odds Ratio (OR) of VTE Risk Factors

Study	VTE Risk Factors	RR or OR
Shibuya et al.⁷	Older age	1.02 (OR for DVT); 1.02 (OR for PE)
	Obesity	2.35 (OR for DVT); 3.06 (OR for PE)
	Higher injury severity score	1.22 (OR for DVT); 1.21 (OR for PE)
Wukich and Waters⁵	Many listed	No RR or OR provided
Mayle et al.¹⁷	Many listed	No RR or OR provided
Hanslow et al.⁴	History of rheumatoid arthritis	No RR or OR provided
	Recent history of air travel	No RR or OR provided
	Previous DVT or PE	No RR or OR provided
	Limb immobilization	No RR or OR provided
Wang et al.²	Anticoagulant prophylaxis not prescribed	No RR or OR provided
	Immobilization with a cast or splint	No RR or OR provided
	Age over 40 y	No RR or OR provided
	Obesity	No RR or OR provided
Mizel et al.⁹	Postoperative nonweight bearing and immobilization	0.4% increase in RR for VTE
Solis and Saxby¹³	Hind foot surgery	5.64 (Wald Chi-Square test)
	Increasing age	4.39 (Wald Chi-Square test)
	Tourniquet time	4.80 (Wald Chi-Square test)
	Obesity	3.37 (Wald Chi-Square test)
Cirlincione et al.¹⁸	Many listed	No RR or OR provided
Barg et al.¹⁰	Age	1.06
	Women	1.20
	Obesity	6.54 or 6.94
	ASA classification	1.69
	Tobacco use	2.98
	Previous DVT	5.43 or 7.07
	Surgery duration >120 min	1.77
	Spinal anesthesia	0.99
	Additional surgical procedures	1.36
	Bilateral simultaneous TAR	1.07
	Postoperative mobilization with cast	1.37
	No full weight bearing postoperatively	3.57 or 4.53
Jameson et al.¹²	Age 50-60	2.32 (OR for ankle ORIF); 1.14 (OR for hind foot arthrodesis)
	Age 60-70	3.20 (OR for ankle ORIF); 7.52 (OR for first MTO); 0.88 (OR for hind foot arthrodesis)
	Age >70	4.37 (OR for ankle ORIF); 5.69 (OR for first MTO); 2.24 (OR for hind foot arthrodesis)
	Charlson score 1	1.53 (OR for ankle ORIF); 2.65 (OR for first MTO); 0.84 (OR for hind foot arthrodesis)
	Charlson score ≥2	5.37 (OR for ankle ORIF)
	Past medical Hx: IHD	2.54 (OR for ankle ORIF)
	Past medical Hx: COPD	5.47 (OR for ankle ORIF)
	Past medical Hx: NIDDM	14.6 (OR for ankle ORIF); 1.70 (OR for hind foot arthrodesis)

History of Thromboembolism

Patients with a history of thromboembolic disease are at a significant risk for a repeat thromboembolic event. A hospitalized patient with a history of thromboembolic disease has an almost eightfold increased risk in acute thromboembolism compared to patients without such a history. As a result, patients with a history of thromboembolic disease who undergo major surgery or immobilization should be considered as being at a very high risk for repeat thromboembolic disease.

Lower Extremity Surgery

Orthopedic surgery of the lower extremity should be considered an important risk factor in the development of thromboembolic disease. Without prophylaxis, DVT can develop in more than 50% of patients undergoing elective total joint replacement surgery.¹⁹ Similarly, more than 90% of proximal thrombi occur on the ipsilateral side after total hip replacement, which may be because of twisting and kinking of local veins as well as endothelial damage.³ As previously discussed, lower extremity surgery affects all components of Virchow’s triad, and subsequently could increase the incidence of thromboembolic disease.

Lower Extremity Fractures

Fractures of the hip, pelvis, and long bones of the lower extremity are associated with the development of thromboembolic disease. Patients with pelvic or lower extremity fractures were shown by venography to have an overall DVT incidence of 69%, with the incidence of DVT after tibial fractures being as high as 77%.²⁰ Postoperative immobilization or cast immobilization may contribute to the development of thromboembolic disease in patients with lower extremity fractures.³

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