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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2821_Библиотеки_им_академика_М_И_Перельмана
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SolisandSaxby
13
Hindfootsurgery 5.64(WaldChi-Squaretest)
Increasingage 4.39(WaldChi-Squaretest)
Tourniquettime 4.80(WaldChi-Squaretest)
Obesity 3.37(WaldChi-Squaretest)
Cirlincioneetal.
18
Manylisted NoRRorORprovided
Bargetal.
10
Age 1.06
Women 1.20
Obesity 6.54or6.94
ASAclassification 1.69
Tobaccouse 2.98
PreviousDVT 5.43or7.07
Surgeryduration>120min 1.77
Spinalanesthesia 0.99
Additionalsurgicalprocedures 1.36
BilateralsimultaneousTAR 1.07
Postoperativemobilizationwithcast 1.37
Nofullweightbearingpostoperatively 3.57or4.53
Jamesonetal.
12
Age50–60 2.32(ORforankleORIF);1.14(ORfor
hindfootarthrodesis)
Age60–70 3.20(ORforankleORIF);7.52(ORfor
firstMTO);0.88(ORforhindfoot
arthrodesis)
Age>70 4.37(ORforankleORIF);5.69(ORfor
firstMTO);2.24(ORforhindfoot
arthrodesis)
Charlsonscore1 1.53(ORforankleORIF);2.65(ORfor
firstMTO);0.84(ORforhindfoot
arthrodesis)
Charlsonscore≥2 5.37(ORforankleORIF)
PastmedicalHx:IHD 2.54(ORforankleORIF)
PastmedicalHx:COPD 5.47(ORforankleORIF)
PastmedicalHx:NIDDM 14.6(ORforankleORIF);1.70(ORfor
hindfootarthrodesis)
HistoryofThromboembolism
Patients with a history of thromboembolic disease are at a significant risk for a repeat
thromboembolicevent.Ahospitalizedpatientwithahistoryofthromboembolicdiseasehasan
almosteightfoldincreasedriskinacutethromboembolismcomparedtopatientswithoutsucha
history. As a result, patients witha history of thromboembolic disease whoundergo major
surgery or immobilization should be considered as being at a very high risk for repeat
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thromboembolicdisease.
LowerExtremitySurgery
Orthopedicsurgeryofthelowerextremityshouldbeconsideredanimportantriskfactorinthe
developmentofthromboembolicdisease.Withoutprophylaxis,DVTcandevelopinmorethan
50% of patients undergoing elective total joint replacement surgery.19 Similarly, more than
90%ofproximalthrombioccurontheipsilateralsideaftertotalhipreplacement,whichmay
be because of twisting and kinking of local veins as well as endothelial damage.3 As
previouslydiscussed,lowerextremitysurgeryaffectsallcomponentsofVirchow’striad,and
subsequentlycouldincreasetheincidenceofthromboembolicdisease.
LowerExtremityFractures
Fractures ofthehip, pelvis, andlong bones of the lower extremityare associated withthe
development of thromboembolic disease. Patients with pelvic or lower extremity fractures
wereshownbyvenographytohaveanoverallDVTincidenceof69%,withtheincidenceof
DVT after tibial fractures being as high as 77%.20 Postoperative immobilization or cast
immobilizationmaycontributetothedevelopmentofthromboembolicdiseaseinpatientswith
lowerextremityfractures.
3
MultipleTraumaandGeneralSurgery
It has been shown that polytrauma patients are at a significantly increased risk for the
developmentofthromboembolicdisease.Thisriskisparticularlyhighwhentheprimarysiteof
injuryincludestheface,chest,orabdomen.Infact,theriskisashighas40%inthisgroupof
patients,21andwithoutprophylaxis,theriskofDVTexceeds50%.20Inpatientswithfootand
ankletrauma,ahigherinjuryseverityscoreisassociatedwithahigherriskofDVT(oddsratio
[OR]1.22)andPE(OR1.21).7Abdominalsurgeriesthatrequiregeneral anesthesiagreater
than30minutesalsoincreasestheriskofthromboembolicdisease,whichisoftennecessaryin
polytraumapatients.
21
PatientAge
Therisk ofthromboembolicdiseaseincreases exponentiallybetween theagesof 20 and80
years.22Eventhough40years is traditionallyused as thetransitionpointfor anage-related
increaseintheriskofthromboembolicdisease,theriskcontinuestoincreaseasapatientages
andnearlydoubleswitheachsuccessivedecade.Olderagehasbeenshowntobesignificantly
associatedwiththedevelopmentofDVTandPEinpatientswithfootandankletrauma.
7,12
The
riskofthromboembolismislowforchildren,buttheriskincreasesincertainsituations,such
asmultipletraumaandlowerextremityfracture.
3
Malignancy
Patientswithmalignancyareatanincreasedriskforthromboembolicdiseasebecauseofthe
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hypercoagulablestatethatresultsfrommalignancy.Thehypercoagulablestateoccursbecause
ofanincrease inprocoagulantactivity andareductioninfibrinolysis. Advancedpancreatic
cancer, gynecologic cancer, lung cancer, breast cancer, gastrointestinal cancer, and brain
tumors are specifically associated with an increased risk.23 Chemotherapyalso has a toxic
effect on the endothelium and may increase the risk of thrombus formation. Surgery for
malignant disease results in a two- to threefold increase in the risk for thromboembolism
comparedtosurgeryfornonmalignantconditions.
3
Immobilization
It is well knownthat immobility increases therisk for the developmentofthromboembolic
disease.Anautopsystudyshoweda15%incidenceofthrombosisinpatientsatbedrestfor
lessthan1weekcomparedto80%inpatientsatbedrestforgreaterthan1week.24Asaresult,
earlymobilizationshouldbeanimportantgoalafterfootandankletraumaandsurgeryinorder
topreventthromboembolicdisease. Immobilizationafter spinal cordinjuryandparalysis of
lowerextremitieshasanassociatedriskofthromboembolicdiseasethatapproaches40%.
3
Obesity
Infootandankletraumaandsurgery,obesityhasbeenshowntobeanimportantriskfactorfor
thedevelopmentofthromboembolicdisease.
7,10
Infact,obesityhasbeenshowntosignificantly
increase the risk of symptomatic DVT (OR 2.35) and PE (OR 3.06) in a national trauma
database.7Theetiologyofthisincreasedriskisunclear,butitmayberelatedtogeneralhealth
states,hyperestrogenicstates,orimmobility.
OralContraceptiveandEstrogenTherapy
Historically, oralcontraceptiveswere associatedwithanincreased riskforthromboembolic
disease.Althoughestrogentherapymayincreasetheincidenceofthromboembolisminpatients
with prostate cancer, estrogen therapy in women does not appear to increase the risk of
thromboembolicdisease.
25,26
HypercoagulableStates
Systemic hematologic abnormalities may predispose patients to the development of
thromboembolic disease. For example, the presence of lupus anticoagulant; deficiencies in
proteinS,C,andantithrombinIII;andfactorV Leidenareall showntoincrease theriskof
thromboembolism.3Theseabnormalitiesshouldbeconsideredinallpatientsundergoingfoot
andanklesurgeryandthethromboembolicprophylaxisshouldbeadjustedaccordingly.
CLINICALPRESENTATIONANDDIAGNOSIS
ThesignsandsymptomsofDVTandPEarenonspecific.However,thesignsandsymptomsof
DVTincludeswelling,pain,redness,superficialvenousdilatation,andHoman’ssign(painin
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thecalforbehindthekneewithankledorsiflexion).Similarly,thesignsandsymptomsofPE
includedyspnea,pleuriticchestpain,cough,hemoptysis,andtachycardia.27Sincethesesigns
areunreliableandnonspecific,screeningtestssuchasvenography,ultrasound,andcomputed
tomography(CT)havebecomeincreasinglypopular.
Historically, contrastvenography is considered tobethe gold standard for detectingthe
presence of DVTs.28 Venography of the lower extremity is performed by cannulation of a
dorsalveininthefoot.
28–41
Thistesthasseverallimitationssinceitisexpensive,technically
demanding,invasive,andexposespatientstoradiation.42Asaresult,Dopplerultrasoundhas
become the most commonly used modality to detect DVT formation and has essentially
replacedvenographyintheclinicalsetting.Thistechniqueutilizesultrasoundtodepictflowin
the venous system, and the advantages of this modality include lower cost and lack of
radiation.In thehands ofanexperiencedtechnicianorradiologist,theoverallsensitivity of
ultrasoundindetectingDVTis85%andthespecificityis97%,42andthismethodhasaneven
highersensitivityinsymptomaticpatientsforproximalDVT.
27
Historically, the goldstandardforthedetectionofPEwas pulmonaryangiography. This
methodisinvasive,requiresexpertise,andhadsignificantmorbidity.Thistechniquewasthen
replacedbyventilation-perfusionscintigraphyscanning,butthiswasdifficulttoadministerand
the results were equivocal in many instances. In fact, this test is nondiagnostic in
approximately50%ofcasesandrequiresadditionaltesting.27SimilartothedetectionofDVT,
alternative technologies have been developed and have become increasingly popular in
determiningthepresenceofaPE.Themostcommonlyusedcontemporarymethodismultislice
spiralCTofthechest,whichcanhelptodetectthepresenceofPEaswellasotherpathology
insymptomaticpatients.
THROMBOEMBOLISMPROPHYLAXIS
The goal of a prophylactic regimen is to prevent the formation of a DVT, as well as the
occurrence of a PE.Since the incidence of symptomatic PE is low,comparative studies of
prophylacticregimenswouldhavetoincludethousandsofpatients.Asaresult,themajorityof
studies have focused on the prevention of DVT. Several prophylactic regimens have been
studiedinorthopedicsurgery,themajorityofwhichincludeintraoperativeandpostoperative
modalities.Intraoperatively,thetypeofanesthesia(general,epidural,orhypotensiveepidural
anesthesia) and the duration of surgery have been shown to affect the incidence of
thromboembolic disease. Postoperative prophylaxis includes mechanical devices such as
compression stockings and foot pumps, as well as pharmacologic prophylaxis such as
warfarin, aspirin, and low-molecular-weight heparin (LMWH).43 Newer pharmacologic
regimenssuchasrivaroxabananddabigatranarestartingtobeusedinorthopedicsurgery,and
areincreasinginpopularityastheyareadministeredorallyanddonotrequireanymonitoring.
3
Infootand anklesurgery,DVTprophylaxis is notconsistentlyusedby allsurgeons. In a
recentstudyfromtheUnitedKingdom,onlyafifthofsurgeonsusedthromboprophylaxisafter
elective or trauma foot and ankle surgery.44 Similarly, Wolf and DiGiovanni found that
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approximately44%ofsurgeonsusedDVTprophylaxisafterfootandankletraumasurgery.
45
Although practice patterns vary throughout the world, it is imperative that foot and ankle
surgeonsunderstandthevariousmodalitiesthatareavailabletopreventtheformationofDVTs
andlife-threateningPEs.
MechanicalProphylaxis
MechanicaldevicesandphysicalagentshavebeenusedforDVTprophylaxisafteravarietyof
surgical procedures andtrauma.These devices increase fibrinolysis and decrease stasis by
acceleratingvenousemptying.3Earlymobilization,continuous passivemotionmachines,and
graded compression stockingshave all beenproposed and studied. A compression boot or
stocking canbe appliedtothenonoperativelegpreoperatively,andapplied totheoperative
sidepostoperatively.Thesedevicesareusuallycontinueduntilthepatientisambulating,andin
fact, sequential compression devices (SCDs) are the most commonly used prophylactic
modalityusedbyfootandanklesurgeons.
45
Severalstudieshavedemonstratedtheefficacyofmechanicaldevicesinreducingtherate
ofDVTfollowingtotaljointarthroplasty.
16,20,23,28,33,34,36,37,41,46–63
TheincidenceofDVTwith
theuseofcalfandthighlengthdeviceshasbeenreportedtobebetween7.5%and33%after
unilateral total knee arthroplasty.
54,64–69
In a randomized prospective study comparing
compressionstockingstoaspirin,theincidenceofDVTwasreducedto22%withpneumatic
compressionstockingscomparedto47%withaspirin.54Footpumpdeviceshavebeenshown
tobeeffectiveintotalkneearthroplastyasDVTprophylaxis.70Thesedevicesincreasevenous
circulation by applying a rapid increase in pressure to the plantar plexus.52 However,
proximitytotheoperativesiteaswellastheuseofapostoperativesplintorcastmaylimitthe
useofafootpumpdeviceinfootandanklesurgery.
Overall,mechanicalprophylaxismodalitiesofferseveraladvantagesoverpharmacologic
prophylaxis such as highpatient tolerance, no known risk of bleeding, andlow monitoring
requirements.3Thesedeviceshavebeenshowntobeefficaciousafterorthopedicsurgery,and
continue to be a popular method of prophylaxis after foot and ankle surgery.45 In general,
newer impulse compression high-flow devices appear to be more efficacious than older,
traditionalslow-flowSCD-typedevices.
PharmacologicProphylaxis
Severalpharmacologicprophylaxisregimenshavebeenstudiedinorthopedics.Traditionally,
aspirin,heparin,andLMWHhavebeenusedandstudied,butmorerecently,factorXinhibitors
andthrombininhibitorshavebeenstudiedaswell.LMWHcontinuestobeapopularagentfor
DVT prophylaxis, and it has been specifically studied in the setting of foot and ankle
surgery.
18,45
Aspirin (acetylsalicylic acid) is a nonsteroidal anti-inflammatory agentthat irreversibly
inhibitsthecyclooxygenaseenzymeinplatelets,therebyinhibitingthesynthesisofthromboxane
A2,71whichcausesplateletaggregationandvasoconstriction.Theuseofaspirininorthopedic
surgeryhas received mixedreviews. Itsadvantages includeeaseofuse,lowcost,and low
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monitoringrequirements.However,itslimitationsincludeseveralmedicalcomplicationssuch
asgastritis,gastriculcers,anduppergastrointestinalbleeding,aswellaslimitedefficacyafter
totaljointreplacementsurgeryandtrauma.3ArecentstudybyGriffithsetal.6showedthatthere
was no protective effectof aspirin against VTEafter elective footandankle surgery. As a
result, aspirin alone is not commonly used as a prophylactic regimen after foot and ankle
surgery.
Warfarin (Coumadin) is another form of pharmacologic prophylaxis that has become
increasingly popular in orthopedic surgery. Warfarin works by inhibiting the synthesis of
vitaminK–dependentcoagulation factors (factors II, VII,IX, X, protein C). Since warfarin
affects the synthesis of coagulation factors and does not affect activated factors, it takes
approximately24to72hourstobecometherapeutic.3Thedoseofwarfarinistitrateddailyto
maintainaninternationalnormalizedratio(INR)of2.0to2.5.Thedisadvantagesofwarfarin
includefrequentprothrombintimemonitoring,bleeding,and,lessfrequently,warfarin-induced
skinnecrosis.Morespecifically,bleedingcomplicationshavebeenreportedin0%to4%of
patientsreceivingwarfarinprophylaxis.
72–74
Theadvantages ofwarfarinprophylaxisinclude
itsoralformofadministration,andthefactthatitcanbecontinuedastreatment ifaDVTis
detected.AlthoughwarfarinisaneffectiveagentinreducingtheincidenceofDVTaftertotal
jointarthroplasty,itsefficacyhasnotbeenspecificallystudiedinfootandanklesurgery.Itmay
by an effective strategy in high-risk patients, since it has been shown to be effective after
orthopedic trauma. However,the risksand benefitsmustbecarefully assessed since notall
polytrauma patients may be candidates for anticoagulation due to head or major organ
involvement.
3
LMWHs havebecome a popular form ofDVTprophylaxis inorthopedic surgery. These
agentsweredevelopedinthe1970sandhavebeenshowntohavegoodantithromboticactivity.
Whencomparedtoheparin,LMWHhaveless bleeding per unitofequivalent antithrombotic
effect.LMWHsare thefractionatedform ofheparinandcontaina tetrasaccharidethatbinds
antithrombinIII.Asaresult,thiscomplexcaninactivatecoagulationfactors(factorXagreater
thanfactorIIa)andinhibitcoagulation. Theadvantages ofLMWHsincludefixed dailydose
andlackofneedfordailymonitoringofpartialthromboplastintime.Itsdisadvantagesinclude
itsinvasivemodeofadministration,sinceitisavailableasasubcutaneousinjection.Therisks
ofLMWHincludebleedingandheparin-inducedthrombocytopenia.Majorbleedinghasbeen
reportedin0%to2.8%ofpatients,andthefrequencyofbleedingcomplicationswithLMWH
is greater than that associated withwarfarin.75 In a recent study by Barg et al.,10 3.9% of
patientsundergoingtotalanklereplacementandtreatedwithLMWHdevelopedasymptomatic
DVT.ThisrateiscomparabletotheratesofDVTaftertotalkneeorhiparthroplasty.
Newer pharmacologic prophylaxis regimens include factor X inhibitors such as
rivaroxabananddirectthrombininhibitorssuchasdabigatran.Rivaroxabanhasbeenstudied
in total hip and knee arthroplasty, and compared to LMWH, rivaroxaban demonstrated
superioritywithregardstoprimaryefficacyoutcome,thepreventionofVTE,andsecondary
efficacyoutcome,thepreventionofmajorVTE.Therewerenosignificantdifferencesseenin
bleedingriskbetweenrivaroxabanandLMWH,withmajorbleedingseenin0.3%to1.3%of
patientsreceivingdailydosesof10mgorless.
28,29,47,72,76
Ontheotherhand, dabigatranisa
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prodrug with a half-life of approximately 12 to 17 hours that also does not require daily
monitoring.Inamulticenterdouble-blindedrandomizedstudycomparingdabigatrantoLMWH
aftertotalhipandkneearthroplasty,VTEwassignificantlylowerinpatientsreceivinghigher
doses of dabigatran compared to LMWH. However, major bleeding complications were
significantly lower in the low-dose groups and elevated with higher doses.77 As a whole,
furtherstudyisneededtoclearlydefinetheroleoftheseagentsinthepreventionofDVTand
PEafterfootandankletraumaandsurgery.
RecommendedProphylaxis
It is clear that patients undergoing major orthopedic procedures are at a high risk for the
developmentofthromboembolicdisease.However,themajorityofauthorsstillconsiderfoot
andankle surgery to be a lower-riskprocedure compared to total hip or knee arthroplasty.
Regardless,anindividualpatient’sriskfactorsaswellasthetypeand extentofthesurgical
intervention mustbetakeninto considerationinorder todeterminethe optimal prophylactic
regimen. A combination of mechanical and pharmacologic prophylaxis has been shown to
reducetheincidenceofDVTinasynergisticmanner,70anditistheoptimalstrategytoprevent
thromboembolismafterfootandankletrauma andsurgery. Aspirinalonemaybeinadequate,
while LMWH is associated with greater complications. Warfarin requires frequent patient
monitoring, but may be the optimal strategy in a high-risk patient. The advent of newer
anticoagulantsmaychangethelandscapeofthromboprophylaxisafterorthopedicsurgery,and
theycanbeconsideredforDVTprophylaxisafterfootandankletraumaandsurgery.
The American Academy of Orthopaedic Surgeons (AAOS) has no specific
recommendations for DVT prophylaxis after foot and ankle surgery, and the American
OrthopaedicFootandAnkleSociety(AOFAS)doesnotsupportordiscouragetheuseofDVT
prophylaxisaftersurgery.78Similarly,theAmericanCollegeofChestPhysicians(ACCP)does
notrecommendtheroutineuseofthromboprophylaxisinpatientswithisolatedlowerextremity
injuries distal to the knee.79 However, clinical judgment is recommended in determining
patients that may require thromboprophylaxis. More specifically, patients with certain risk
factors, undergoing higher risk procedures, exposed to general anesthesia, and subject to
postoperativeimmobilizationshouldbemanagedaccordingly.
TREATMENTOFTHROMBOEMBOLISM
TreatmentofDVTandPEinthepostoperativepatientisnotwithoutcomplicationandrequires
acleardiscussionoftreatmentgoals.Preventionofclotembolizationorlife-threateningPEis
the primarygoal, but postphlebitic syndrome and pulmonary hypertensionare also potential
causes of morbidity. Unfortunately, PE is difficult to diagnose and has the potential to be
rapidlyfatal.Infact,among patientswhowilleventuallydieofaPE,two-thirds ofpatients
will survive less than 30 minutes after the event, which is insufficient for most forms of
treatmentstobeeffective.46Thisfactunderscorestheimportanceoftreating DVT.Treatment
regimensfor DVT includeanticoagulants,venacaval interruptiondevices, thrombolytics, or
surgery.
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Anticoagulants
The most widely used anticoagulants are heparin and warfarin. LMWH and newer
anticoagulantssuchasfactorXinhibitors,however,arebecomingincreasinglypopularforthe
treatmentofDVT.Patientswithoutcontraindications toanticoagulationare generallytreated
withinitialadministrationofheparinalongwiththeinitiationofwarfarintherapy.Heparinis
administered intravenously or by subcutaneous injection, with the goal of activated partial
thromboplastin time set to 1.5 to 2.5 times the control.80 When the warfarin dosage is
therapeuticwithanINRbetween2.0and2.5,theheparinmaybediscontinued.Thisoverlapis
necessary to allow warfarin to inactivate vitamin K–dependent factors and reduce the
likelihoodofwarfarin-inducedskinnecrosis.Treatmentistypicallycontinuedfor3monthsfor
isolatedDVTand6monthsforPE.81Complicationsassociatedwithheparinincludebleeding
attheoperativesite,gastrointestinalbleeding,andthrombocytopenia.
3
LMWH has been advocated for the management of DVT as well, and it has become
increasingly popular in clinical medicine today. These medications are administered by
subcutaneous injection, andseveral studies haveshowed equal effectiveness as intravenous
heparin.Furthermore,factorXinhibitorssuchasrivaroxabanwererecentlyapprovedbythe
Food and Drug Administration for the treatment of DVT.82 However, few studies have
specificallyinvestigatedtheuseofanticoagulantsinthetreatmentofDVTafterfootandankle
surgery.
VenaCavalFilterDevices
Indications for an inferior vena cava (IVC) filter include recurrent embolism despite
anticoagulation(anticoagulationfailure)andDVTwithacontraindicationtooracomplication
ofanticoagulation therapy. These devices, typicallyplaced byinterventional radiologists or
vascular surgeons, can be permanently or temporarily inserted. These devices halt the
proximalmigrationofembolifromthedistalvenoussystemtothelungs.IVCfiltershavebeen
showntobeeffectiveinreducingPE,andlong-termfollow-uprevealedarecurrentembolism
rateof4%andpatencyrateof98%.83ComplicationsassociatedwithIVCfiltersareunusual
butincludefiltermisplacement(2.6%)andriskofbleedingattheinsertionsite.Rarely,anIVC
filtercanmigrateorcancausebleedingsecondarytoperforationofthevenacava.
3
Thrombolytics
Thrombolyticssuchasstreptokinaseandtissueplasminogenactivatordissolvethrombi.They
are used inpatients with PEandsignificanthemodynamic changes (systolic blood pressure
lessthan90to100mmHg).27Completeclotlysisoccursin30%to40%ofpatientsmedicated
withtheseagents;however,thereisaveryhighriskofbleeding.84Infact,cerebralhemorrhage
hasbeenreportedinashighas1%ofcases.
80
SurgicalIntervention
Surgical intervention such as venous thrombectomy or pulmonary embolectomy is only
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performedwhenthrombolysishasfailedoriscontraindicated.Surgeryisalsoperformedwhen
venousobstructionexists,whichcanleadtoceruleadolens(massiveclottingoftheleg)and
furtherlimittheviabilityoftheleg.
3
RecommendedTreatment
ItisclearthatlargeproximalthrombiandsymptomaticPEshouldbetreatedaggressively.In
addition to medical treatment with intravenous hydration and supplemental oxygen, these
patientsrequiretreatmentwithanticoagulantsorvenacavalfilterdevices.Thechoicetouse
medicationsorvenacavalfilterdevicesshouldbeindividualizedforeachpatient.Theuseof
thrombolyticsisrestrictedtopatientswithsignificanthemodynamicdisturbancesinthesetting
of a PE. Clinical judgment takes precedence over any guidelines in the treatment of
thromboembolicdisease.Therearenospecificguidelinesforthetreatmentofthromboembolic
diseaseafterfootandankletraumaorsurgery.Anopendiscussionisimportantwithpatientsin
determiningtheoptimaltreatmentstrategyforDVTinthesettingoffootandankletraumaand
surgery.
CONCLUSION
Thromboembolic disease is associated with significant morbidity and mortality. It is an
importantcomplicationthatcanoccurafterfootandankletraumaandsurgery.Severalfactors
contribute to the development of thromboembolic disease after foot and ankle trauma and
surgery,includingstasisandendothelialinjury. Patient riskfactorsfurtherincreasethisrisk,
andasaresult,patientsshouldbescreenedinordertodeterminetheriskofthromboembolic
disease. The diagnosis of DVT and PE is made by physical exam and imaging, and the
treatmentisdictatedbyapatient’sconditionaswellasrisksandbenefitsoftreatment.Even
thoughtherearenospecificDVTprophylaxisguidelinesissuedbyanyofthemajoradvisory
associationsincludingAAOS,AOFAS,andACCP,DVTprophylaxisisrecommendedforall
patients with risk factors for thromboembolic disease. In general, although thromboembolic
disease is rare in the setting of foot and ankle trauma and surgery, clinical judgment is
paramount in preventing the development of thromboembolic disease in this setting and a
patient’sriskfactorprofilemustbeascertained.
In thefuture, randomizedcontrolled trials with solid methodology are neededtofurther
determine the efficacy and risks of anticoagulants in the treatment and prevention of
thromboembolicdiseaseafterfootandanklesurgery.Studiesfocusingonneweranticoagulants
such as factor X inhibitors and direct thrombin inhibitors will be particularly interesting.
Studies specificallydefining riskafter footand ankle trauma andspecific types offoot and
anklesurgerywillfurtherhelptostratifyriskandpreventthedevelopmentofthromboembolic
disease.Withanincreasingemphasisbeingplacedondiseasepreventionataninstitutionaland
nationallevel,wearehopefulthatfutureresearchwillimproveoutcomesforpatientsafterfoot
andankletraumaandsurgery.
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