DVT with ankle fractures Is thromboprophylaxis warranted Sunit

DVT with ankle fractures: Is thromboprophylaxis warranted? Sunit Patil Jamshid Gandhi Ian Curzon Anthony Hui James Cook University Hospital, Middlesbrough

Background n Thromboprophylaxis for patients in a plaster cast is a standard of care in many European countries Chest (2004), 126: 338 -400 n Incidence of DVT in patients in a plaster - about 20%

Background n Most studies so far have clubbed together patients with soft tissue injuries and fractures n Incidence of DVT is higher in patients with a fracture as opposed to soft tissue injury Archives of Internal Medicine, 2002

Background n Incidence of DVT in patients with ankle fractures : unknown

Research Question n What is the incidence of DVT in patients with ankle fractures treated in a below knee plaster cast?

Methods n Prospective study n R&D and Ethical committee approval n Consecutive patients with ankle fractures treated at JCUH

Methods n Patients were identified from fracture clinic n Exclusion criteria: n Previous DVT n Patients already on thromboprophylaxis n Patients treated with methods other than plaster n Patients requiring surgery

Methods n At 6/52: n Cast removal n Clinical assessment n Colour duplex ultrasound scan

Ultrasound n Colour duplex ultrasound has a sensitivity of 96% and negative predictive value of 99% Journal of thrombosis and haemostasis, 2006 n Doppler ultrasound is the most universally accepted diagnostic test for lower extremity DVT ACCP guidelines, 2004

Ultrasound n Scans were performed by one of the two experienced musculoskeletal ultrasound technicians n Philips IU 22 duplex colour doppler ultrasound

Protocol for patients with DVT n Above knee DVT Anti-coagulate n Below knee DVT Treated as per consultant n Repeat scan at 1/52

Results 112 patients 8 declined to participate 3 required ORIF 1 was started on prophylactic LMWH by geriatrician 100 patients

Results n Males: 51 Females: 49 n Mean age: 43 years (16 -79) n Mean BMI: 28 (18 -51) n Smokers: 29 n Mean duration of plaster cast: 6/52 (3 -7)

Types of fractures n Weber A: 19 n Weber B: 69 n Weber C: 1 n Medial malleolus: 9 n Tillaux fracture: 2

Weight bearing status n Full weight bearing: 72 n Partial weight bearing: 9 n Non weight bearing: 19

DVT n Superficial femoral vein: 1 n Popliteal vein: 1 n Posterior tibial vein + peroneal vein: 1 n Peroneal vein: 2

DVT n All 5 were asymptomatic and had no clinical signs of DVT n All 5 were FWB during the period of immobilisation

DVT Age, Sex Predisposing factors 67, F None 53, M BMI=31. 6, smoker 18, F BMI=28. 3, smoker 69, F BMI=37. 3 44, M BMI=28. 4, smoker

Results n None of the DVTs propagated on a scan done a week later n None developed symptoms or signs of PE

Discussion n Annual incidence of DVT in the western population is 0. 1% Silverstein et al; Archives of Internal Medicine, 1998. n Cumulative probability of venous thromboembolism by the age of 50 is 0. 5% and by 80 is 3. 8%. Hansson et al; Archives of Internal Medicine, 1997.

Discussion n DVT following THR/TKR: n Clinical PE: 4 -10% n Fatal PE: 0. 5 -2% Source: Geerts et al, Chest 2004 40 -80%

Discussion n Our findings suggest a 5% incidence of DVT n 95% confident n Overall incidence of DVT is <9% n Incidence of above knee DVT is <5%

Discussion Author Patients included Incidence of DVT Kujath et al, 1993 n=127 Lower limb injuries 16. 5% Kock et al, 1996 n=163 Lower limb injuries 4. 3% Jorgensen et al, 2002 n=106 Lower limb injuries 20% Lassen et al, 2002 n=187 Lower limb injuries; included post-op as well 19%

Prophylaxis in UK Thromboprophylaxis for ankle # % of hospitals surveyed All patients 8. 6 (n=6) Only if pt was admitted 17. 2 (n=12) Only for high risk patients 5. 7 (n=4) No prophylaxis 62. 8 (n=44) Batra et al; Injury, 2006

Conclusion n Incidence of DVT following ankle fractures is 5% n Routine thromboprophylaxis is not justified If it ain’t broke, don’t fix it!

Acknowledgment n We would like to thank the entire staff of the Orthopaedic Department, JCUH, for their support n Special thanks to Alison Gamble, Chris Cummins (ultrasound technicians) and Dr. R Bellamy n This project was funded by the Orthopaedic Department, James Cook University Hospital, Middlesbrough