JBJS Reviews Editor’s Choice–VTED after Foot and Ankle Surgery
It seems that anytime a lower extremity undergoes operative treatment, the question is raised regarding the need for and type of thromboprophylaxis. However, controversy exists regarding the use of prophylaxis against venous thromboembolic disease (VTED) after foot and ankle surgery, largely because there are insufficient data from large-scale randomized trials to help guide foot and ankle surgeons in their decision-making processes. Currently, foot and ankle surgeons are forced to make decisions on the basis of incomplete information and contradictory guidelines. Moreover, there is inaccuracy in extrapolating findings from hip and knee arthroplasty studies to the foot and ankle population.
In the December 2015 issue of JBJS Reviews, Guss and DiGiovanni review VTED in the setting of foot and ankle surgery and recognize that certain patient populations may be at higher risk, including patients over the age of forty years with acute Achilles tendon ruptures, patients over the age of fifty years with ankle fractures, patients with diabetes mellitus, patients with connective-tissue inflammatory diseases, and patients with a history of VTED. They also consider associated factors such as the use of oral contraceptives, cigarette smoking, recent air travel, and a family history of VTED. They emphasize that there have been limited randomized controlled trials addressing the question of thromboprophylaxis after foot and ankle surgery and that current data suggest that the use of chemoprophylaxis against VTED in patients undergoing foot and ankle surgery may not necessarily lower the incidence of VTED events. Large-scale postoperative randomized trials are necessary to better guide foot and ankle surgeons in their decision-making processes regarding thromboprophylaxis after surgery. As a result, current foot and ankle surgeons continue to have to make decisions on the basis of incomplete information and contradictory guidelines.
In order to provide some clarity to these issues, specialty societies and associations, including the American College of Chest Physicians and the American Academy of Orthopaedic Surgeons, have issued recommendations regarding the appropriate use of prophylaxis against VTED in the postoperative period. However, these guidelines are largely based on literature of variable quality and applicability. For example, there is no agreement on the appropriate framework for risk-benefit analysis of these issues. Furthermore, unlike the American College of Chest Surgeons and the American Academy of Orthopaedic Surgeons, the American Orthopaedic Foot & Ankle Society has repeatedly expressed its inability to provide any guidance because of the lack of available information.
The literature examining the incidence of VTED after foot and ankle surgery is limited. Nevertheless, clinicians must make decisions against the backdrop of global quality initiatives that consider VTED to be a preventable event.
Thomas Einhorn, MD
Editor, JBJS Reviews