Thromboprophylaxis in lower limb immobilisation after injury (TiLLI)

Horner, Daniel; Goodacre, Steve; Pandor, Abdullah; Nokes, Timothy J.; Keenan, Jonathan; Hunt, Beverley J.; Davis, Sarah; Stevens, John; Hogg, Kerstin

doi:10.1136/emermed-2019-208944

Cited by 32 publications

(22 citation statements)

References 47 publications

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“…[ 33 ] No published risk assessment models have been externally validated, and recent analysis suggests major components of the models have no association with VTE. [ 34 ]…”

Section: Discussionmentioning

confidence: 99%

Qualitative analysis of randomized controlled trials informing recommendations for venous thromboembolism prophylaxis after distal lower extremity injuries

Folsom

Polmear

Dunn

et al. 2022

OTA International: The Open Access Journal of Orthopaedic Trauma

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The purpose of this study is to assess the quality of evidence to stratify recommendations for chemoprophylaxis following distal lower extremity trauma.Methods: Literature review identified primary studies investigating venous thromboembolism (VTE) chemoprophylaxis following traumatic injury distal to the knee. Inclusion criteria were randomized controlled trials in adult patients treated with and without operative intervention. Each primary study was assessed by the Consolidated Standards of Reporting Trials 2010 checklist and Modified Coleman methodology score.Results: Literature review resulted in 462 studies, of which 9 met inclusion and exclusion criteria. All studies included low molecular weight heparin as a treatment group with 2 (22%) also including a treatment group with a direct factor Xa inhibitor. Five studies (56%) used placebo as a control group. The mean Modified Coleman Methodology score was 63% (range 51%-72%), a categorical rating of Fair. The mean Consolidated Standards of Reporting Trials score was 78% (range 56%-97%). Most studies (89%) screened all asymptomatic subjects for deep venous thrombosis. Statistical significance in VTE incidence among prophylactic treatment groups was not achieved in 78%.Conclusions: Development of consensus for VTE prophylaxis recommendations following traumatic injury distal to the knee is complicated by heterogenous study populations, low incidence of VTE in study populations, and inconsistent definitions of clinically important VTE. Low molecular weight heparin is not consistently superior for preventing VTE. Chemoprophylaxis should be considered on an individual basis in the presence of additional risk factors, although an externally validated, evidence-based risk assessment tool does not currently exist.Level of Evidence: IV, therapeutic

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“…[ 33 ] No published risk assessment models have been externally validated, and recent analysis suggests major components of the models have no association with VTE. [ 34 ]…”

Section: Discussionmentioning

confidence: 99%

Qualitative analysis of randomized controlled trials informing recommendations for venous thromboembolism prophylaxis after distal lower extremity injuries

Folsom

Polmear

Dunn

et al. 2022

OTA International: The Open Access Journal of Orthopaedic Trauma

View full text Add to dashboard Cite

show abstract

“…It is also very important to take precautions against asymptomatic DVT, which can reduce long‐term complications, especially post‐thrombotic syndrome (PTS), and bring benefits to patients. However, it is still recommended to assess the individual risk of DVT through the relevant rating scales, inform the patients of the risks and benefits, and finally decide whether to implement anticoagulant therapy based on patients' willingness and doctors' professional evaluation 67 , 68 .…”

Section: Anticoagulant Therapy On Conservatively Treated or Long‐term...mentioning

confidence: 99%

Characteristics of Deep Venous Thrombosis in Isolated Lower Extremity Fractures and Unsolved Problems in Guidelines: A Review of Recent Literature

Zhao

Zhang

2022

Orthopaedic Surgery

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Deep venous thrombosis (DVT) has been characterized by a disorder of venous return caused by abnormal blood clotting in deep veins. It often occurs in the lower limbs and is a common complication in orthopaedics. Therefore, relevant professional organizations domestic and overseas had formulated and constantly updated relevant guidelines to prevent the occurrence of DVT. According to the management strategy of the guidelines, the incidence of DVT can be significantly reduced. However, due to the variety of fractures types, the guidelines cannot expound precautions and characteristics of DVT for all fracture types at present, and there are other related unresolved problems. For example, there is still a lack of consistent optimal strategies for the management of DVT following isolated lower extremity fractures with a higher incidence. The best anticoagulant strategies for patients with upper limb fractures, pediatric fractures, and those combined with other injuries are rarely described in orthopaedic guidelines, but such fractures are common in clinical orthopaedics. The long‐term complications after DVT, such as post‐thrombotic syndrome, are not well‐understood. In the absence of clear guidance, orthopaedic surgeons often resort to empiric anticoagulation or conservative treatment, so the prevention effects of DVT are inconsistent. The purpose of this review is to summarize the characteristics of DVT events after isolated lower extremity fractures and to discuss the unsolved issues in the guidelines by reviewing the previous literature and tracing the history of DVT discovery, to provide more scientific and comprehensive recommendations for the prediction and prevention of DVT.

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confidence: 93%

“…We read with great interest Horner and colleagues' recent practice review regarding thromboprophylaxis for isolated lower extremity injury. 1 The insight gained from this article, in addition to other recent large reviews, will improve the shared decision-making discussions we have with patients about prevention and risk of venous thromboembolism (VTE) with immobilisation. We have two comments regarding the generalisability and implementation of the study data.…”

mentioning

confidence: 93%

In reply: Is it time to initiate venous thromobolism prophylaxis for acute and ambulatory outpatients with lower limb immobilisation?

Cois

Kea

2020

Emerg Med J

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We read with great interest Horner and colleagues' recent practice review regarding thromboprophylaxis for isolated lower extremity injury. 1 The insight gained from this article, in addition to other recent large reviews, will improve the shared decision-making discussions we have with patients about prevention and risk of venous thromboembolism (VTE) with immobilisation. We have two comments regarding the generalisability and implementation of the study data.Although immobilisation of the lower limb following injury is also a common management strategy from the emergency department (ED) in the USA, we have observed that there is little consideration of VTE prophylaxis compared with Europe. In the USA, there is minimal consensus and lack of distinct guidelines on the routine use of thromboprophylaxis with either oral anticoagulation or subcu-taneous low-molecular-weight heparin (LMWH) for patients with prolonged immobilisation of the lower limb in operative and non-operative settings. This contrast is highlighted by conflicting recommendations for thromboprophylaxis from the American College of Chest Physicians paper in 2012 and the American College of Foot and Ankle Surgeons in 2015. 23 A Cochrane review from Zee et al recommended the routine use of LMWH for the entire duration of lower-extremity immobilisation; however, this recommendation may be poorly implemented in the USA due to a variety of factors that we have observed: scant information about this issue, lack of awareness of this recommendation, and the challenge that LMWH confers on patients with regard to education, cost, as well as minimal experience with self-injections.

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Thromboprophylaxis in lower limb immobilisation after injury (TiLLI)

Cited by 32 publications

References 47 publications

Qualitative analysis of randomized controlled trials informing recommendations for venous thromboembolism prophylaxis after distal lower extremity injuries

Qualitative analysis of randomized controlled trials informing recommendations for venous thromboembolism prophylaxis after distal lower extremity injuries

Characteristics of Deep Venous Thrombosis in Isolated Lower Extremity Fractures and Unsolved Problems in Guidelines: A Review of Recent Literature

In reply: Is it time to initiate venous thromobolism prophylaxis for acute and ambulatory outpatients with lower limb immobilisation?

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