Use of Prophylaxis for Prevention of Venous Thromboembolism in Patients with Isolated Foot or Ankle Surgery: A Systematic Review and Meta-Analysis

Abstract

Although prophylaxis for venous thromboembolism (VTE) is recommended after many surgeries, evidence base for use of VTE prophylaxis after foot or ankle surgery has been elusive, leading into varying guidelines recommendations and notable practice variations. We conducted a systematic review of the literature to determine if use of VTE prophylaxis decreased the frequency of subsequent VTE, including deep vein thrombosis (DVT) or pulmonary embolism (PE), compared with control. We searched PubMed, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov through May 2018, for randomized controlled trials (RCTs) or prospective controlled observational studies of VTE prophylaxis in patients undergoing foot and ankle surgery. Our search retrieved 263 studies, of which 6 were finally included comprising 1,600 patients. Patients receiving VTE prophylaxis had lower risk for subsequent DVT (risk ratio [RR]: 0.72; 95% confidence interval [CI]: 0.55–0.94) and subsequent VTE (RR: 0.72; 95% CI: 0.55–0.94). There was only one case of nonfatal PE, no cases of fatal PE, and no change in all-cause mortality (RR: 3.51; 95% CI: 0.14–84.84). There was no significant difference in the risk for bleeding (RR: 2.12; 95% CI: 0.53–8.56). Very few RCTs exist regarding the efficacy and safety of VTE prophylaxis in foot and ankle surgery. Prophylaxis appears to reduce the risk of subsequent VTE, but the event rates are low and symptomatic events are rare. Future studies should determine the subgroups of patients undergoing foot or ankle surgery in whom prophylaxis may be most useful.

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

“…Surgeons seeking recommendations for VTE chemoprophylaxis following traumatic injury distal to the knee continue to find limited guidance despite numerous systematic reviews and meta-analyses on the topic. [17][18][19] Secondary studies repeatedly mention quality of evidence as the main factor hindering consensus, and many provide a brief assessment of methodological quality or risk of bias. [18][19][20][21] However, this study investigated the strength of evidence via qualitative assessment of the primary literature.…”

Recommendations from the ICM-VTE: Foot & Ankle

“…This must be kept firmly in mind when interpreting studies. For example, a recent meta-analysis that incorporated six prospective randomized controlled trials (RCT) comprising 1,600 patients undergoing isolated F&A surgery found a rate of VTE of 8.3% among patients with chemoprophylaxis as compared to 11.7% without (relative risk [RR] 0.72, 95% confidence interval [CI] 0.55 - 0.94, p = 0.02) 56 . It concluded that, while chemoprophylaxis is efficacious, “event rates are low and symptomatic events are rare”.…”

Thrombosis and Haemostasis 2019 Editor's Choice Papers

“…Although pharmacomechanical interventions combined with thrombolytic therapy, can rapidly remove thrombus and improve outcomes in patients with acute deep vein thrombosis, these benefits could not be observed among the sub-group for whom this was even associated with increased bleeding. The findings exposed in the systematic review and meta-analysis from Bikdeli et al 18 also invite us to rethink mainstay venous thromboembolism (VTE) prophylaxis recommendation in the particular context of foot-ankle surgery. Using a well-recognised national administrative database, Jung et al 19 challenged strict adherence to the reference stroke risk CHA 2 DS 2 -VASc score for atrial fibrillation (AF) patients with hypertrophic cardiomyopathy.…”