The Incidence of Venous Thromboembolism After Achilles Tendon Surgery in Patients

Transcription

1 ORIGINAL ARTICLE The Incidence of Venous Thromboembolism After Achilles Tendon Surgery in Patients Receiving Thromboprophlaxis İlker Çolak, MD* Deniz Gülabi, MD* Engin Eceviz, MD* Bilgehan H Çevik, MD* Güven Bulut, MD* Halil I Bekler, MD *Dr Lütfi Kırdar Kartal Education and Resarch Hospital, Department of Orthopaedics and Traumatology, Istanbul, Turkey. Department of Orthopaedics and Traumatology, VM Medical Park Kocaeli Hospital, Kocaeli, Turkey. Corresponding author: İlker Çolak, MD, Dr Lütfi Kırdar Kartal Education and Resarch Hospital, Department of Orthopaedics and Traumatology, Cevizli, Şemsi Denizer Cad. E-5 Karayolu Cevizli Mevkii, Kartal Istanbul, 34890, Turkey. ( drilkercolak@hotmail.com) 1

2 ABSTRACT Background: Surgical or non-surgical treatment of an Achilles tendon rupture include a period of immobilization which is a well-documented risk factor for deep venous thrombosis (DVT). DVT is a source of morbidity in orthopaedic surgery, as it can progress to pulmonary embolism (PE). The aim of this study was to investigate the incidence of deep vein thrombosis and pulmonary embolism following surgical treatment of an Achilles tendon rupture. Methods: A retrospective analysis was made of patients who underwent surgical treatment of Achilles tendon rupture at our clinic between January 2006 and November Patient data were collected from the medical record system of our hospital. Results: Of 238 patients with a mean age of 39 years (range 18 to 66 years), 18 (7.5%) were diagnosed with symptomatic DVT. The average body mass index (BMI) of the patients with DVT was 31.8 (range 24 to 33). Of the patients with DVT, 11 were aged > 40 years and 2/3 had BMI 30. PE was diagnosed in 4 patients (1.6%), none of whom had DVT symptoms. Conclusion: Venous thrombosis continues to be a major cause of morbidity and mortality in postoperative patients. Limited data is available for the use of thromboprophylaxis in foot and ankle surgery. In the light of the literature review and results of this study, authors suggest that routine thromboembolism prophylaxis should be considered for patients with Achilles tendon rupture. 2

3 Level of Clinical Evidence: Level III (retrospective study). Key words: achilles tendon rupture, deep-vein thrombosis, pulmonary embolism, immobilization Introduction Achilles tendon (TA) ruptures are common injuries. A study conducted in Finland, reported that the incidence of Achilles tendon ruptures increased from 2.1 ( ) in 1979 to 21.5 ( ) in 2011 in all age groups (1). Consistent with prior publications, the majority of patients (83%) in the current study were male, but the males were seen to be significantly younger (average 44.4 vs 50 years) than their female counterparts at the time of the Achilles tendon rupture (2). Most injuries of the Achilles tendon occur as a result of trauma or athletic activities such as jumping (2,3). Treatment options include non-operative treatment, immobilization, or surgery. In literature, the rates of reported DVT range from 0.43% to 34% and pulmonary embolism rates range from 0% to 3% after surgical and conservative treatment of Achilles tendon rupture (3,4). Many risk factors have been reported for venous thromboembolism (VTE) following surgical treatment of TA ruptures such as age, smoking, immobilization, steroid use, obesity, protein C/S deficiencies, Factor V Leiden mutation, and congestive heart failure (3,5,6). A well-documented risk factor for deep vein thrombosis (DVT) is immobilisation (7) and the treatment for Achilles rupture, whether surgical or non-surgical, inevitably includes a period of immoblisation. 3

4 Furthermore, DVT in the leg is thought to be the source of 90% of pulmonary emboli (PE) (8). Although there is general consensus regarding the use of prophylactic antithrombotic therapy after knee and hip surgery (9), VTE prophylaxis after Achilles tendon rupture is still a controversial issue. A previous study found significantly lower rates of DVT in those with lower limb fractures treated with cast immobilisation and low molecular weight heparin (LMWH) compared to those treated without LMWH (10). Other studies have found no significant difference in treatment with or without LMWH, despite a diagnosis of asymptomatic DVT (11,12). The most recently published antithrombotic guidelines do not recommend prophylaxis of deep vein thrombosis after Achilles tendon injury (9). The aim of this study was to investigate the incidence and risk factors of deep vein thrombosis and pulmonary embolism following surgical treatment of an Achilles tendon rupture in patients received anticoagulants. Methods The study comprised patients who had undergone surgery for Achilles tendon rupture in our orthopaedic department between January 2006 and November Approval for the study was granted by the Local Ethics Committee. Patient data were collected retrospectively from the electronic medical record system at Dr Lütfi Kırdar Kartal Research and Education Hospital. Specific ICD-10 codes were used for data collection (S86.0 Injury of Achilles tendon, I82.49 acute embolism and thrombosis of other specified deep vein of lower extremity and I26 pulmonary embolism). Exclusion criteria were 4

5 existing, previous Achilles tendon rupture, associated fractures and injuries in the lower extremity, previous DVT or pulmonary embolism, Achilles tendon pathology. Patient treatment costs were covered by their health insurance. On physical examination, most of the patients were found to have a palpable gap of the TA associated with a positive Thompson test. Magnetic resonance images of the ankles confirmed Achilles tendon ruptures. Surgical repair was applied to the patients by eleven different surgeons. Most of the patients (64%) were induced under spinal anaesthesia, and a tourniquet was inflated to 300 mm Hg after the foot was elevated for 5 minutes. The tendon was sutured using the Krackow technique, and the paratendon was repaired with continuous sutures. The procedure took approximately minutes. The patients were subsequently immobilized with a below-the-knee plaster cast with the foot in a plantar flexed position and were mobilised the following day on crutches. After 4-6 weeks the patients were recalled for cast renewal and were immobilized with a below-the-knee plaster cast with the ankle in a neutral position and partial weight-bearing with two crutches was encouraged. This patient population received anti-coagulation therapy (enoxaparin, 4000 anti-xa IU /0.4 ml) for 20 days (3 weeks) after surgical repair. Patients were followed up by an orthopaedic surgeon for a minimum of 12 weeks and most attended follow-up examinations at 1, 2, 4, 8 and 12 weeks postoperatively. Physical therapy was recomended after cast removal. Patients who presented with pain, cough and dyspnea that would not be expected of an Achilles tendon rupture and symptoms of DVT underwent diagnostic imaging. A diagnosis within 3 5

6 months of the injury was considered to be symptomatic DVT or PE related to the Achilles tendon rupture. A confirmatory duplex ultrasound was applied to patients clinically diagnosed with DVT (Figure 1) and the patients were then referred to the cardiovascular surgeon. Patients with a suspected PE underwent computed tomography (CT) scans to verify PE (Figure 2). Treatment of a standard regime of anti-coagulant was administered. Arterial blood gases and bleeding profiles were monitored closely. Heparin infusion was later changed to oral warfarin. The plaster cast was removed and replaced by an molded ankle-foot orthosis (MAFO). After 3 weeks of brace therapy, during which time the patient continued full weight-bearing, if the clinical examination revealed no evidence of a palpable defect on the Achilles tendon, a customized anterior Achilles tendon splint was applied and full weight-bearing mobility was encouraged. Concentric and eccentric muscle strengthening exercises were started under the supervision of a physiotherapist for patients who were referred to the physiotherapy department. After 3 months postoperatively, a progressive increase in muscle strengthening and a gradual return to sporting activities were permitted. SPSS for Windows version 15.0 was used for data analysis in this study. Descriptive statistics were used to determine the mean, range and percentage distribution values. Results A total of 241 (13 female, 5.4%) patients with partial or complete Achilles rupture were retrospectively evaluated. A total of 3 were excluded because of previously Achilles rupture 6

7 (n:2) or surgery not related to TA (n:1). When the medical charts of the patients were analysed, most of the Achilles tendon injuries were the result of a sporting or physical activity or falling from height, after a sudden dorsiflexion of the ankle in plantar flexion. All patients were admitted to hospital within 3 weeks of the injury. The mean time from injury to surgery was 6 days (range 1 to 25 days). The average body mass index (BMI) of the patients was 29.8 (range 23.2 to 35). The total 238 patients had a mean age of 39 years (range 18 to 66) and average BMI of 31.8 (range 24 to 33) and 2/3 had BMI 30. Symptomatic DVT was diagnosed in 18 (7.5%) patients, of whom 11 were aged >40 years Proximal DVT was diagnosed in 1 patient, and distal DVT in 17. PE was diagnosed in four patients (1.6%) none of whom had any DVT symptoms. The 18 patients with DVT comprised 16 males and 2 females with a mean age of 41.7 (range 26 to 58) years The patients with PE were males with a mean age of 40.3 (range 28 to 50) years. The average BMI of the patients with PE was 27.4 (range 23.6 to 29.7). The youngest patient was diagnosed with factor V leiden heterozygous mutation and the oldest was a habitual smoker. DVT occurred at mean 18 (range 7-32) days after surgical treatment and PE occurred at mean 35.3 (range 27-47) days. No death occurred in the study. 7

8 Discussion Postoperative deep venous thrombosis (DVT) and pulmonary embolism (PE), which constitute venous thrombosis (VT), continue to be leading causes of morbidity and mortality following surgery. The most common cause of preventable death in hospital in-patients has been reported to be PE. There have been few studies in literature investigating the incidence of DVT and PE after TA rupture repair (Table 2). To the best of our knowledge, only two prospective studies have been published on this topic. The study by Patel et al (3) had the largest sample size and the overall rates of symptomatic DVT and PE after TA rupture were low (0.43% and 0.34%). Makhdom et al (4), Nilsson-Helander et al (13) and Lapidus et al (14) reported higher rates of DVT and PE after TA rupture. In the current study, the rate of symptomatic DVT was 7.5% and PE was 1.6%, which are similar to the results reported by Saragas et al (15) and Healy et al (16). The different rates of DVT and PE in literature may be related to differences in study designs, with some reporting only the rate of symptomatic DVT and others with prospective design reporting the rates of both symptomatic and asymptomatic DVT. Differences can also be seen in the post-treatment procedures in different studies. However, the lack of consensus on the use of venous thromboembolism prophylaxis after TA rupture repair may also be a reason for different rates of DVT and PE. Most studies reported that routine anticoagulation treatment was not used (3,4,15). One survey of senior foot and ankle 8

9 surgeons found no significant difference in DVT prevalence amongst those who never used thromboprophylaxis and those who always used it for elective forefoot, elective midfoot, open elective ankle, elective ankle arthroscopy and ankle trauma surgery (17). In another study, Heyes et al reported that conservative treatment for TA does increase the incidence of symptomatic DVT from the general population (18). Healy et al (16) reported that 1 of 208 patients received aspirin prophylaxis and in a study by Nilsson-Helander et al (13), the surgically treated group received prophylactic treatment. Lapidus et al (14) compared an intervention group of 41 patients administered with Dalteparin and a control group of 42 patients given placebo treatment. It was suggested that Dalteparin treatment did not significantly reduce the risk of thromboembolic complications compared to that of patients given placebo treatment during immobilization after Achilles tendon rupture surgery. In contrast, a retrospective analysis of 2,281 patients by Gritsiouk et al (19) showed that prophylactic low molecular weight heparin was associated with a reduction of VTE in trauma patients. However, Shibuya et al suggested the analysis of risk factors instead of routine pharmacologic thromboprophlaxis (20). The patient population in the current study received anti-coagulation therapy (enoxaparin) for 20 days (3 weeks) routinely. The use of anti-coagulation therapy may have led to the lower incidence rates of DVT and PE compared to some other studies and there was no evaluation of the subclinical DVT range in this patient population. Various risk factors for the development of DVT and PE have been reported in literature. It has 9

10 been reported that major surgery, multiple trauma, fracture of the hip or lower extremity, previous VTE, older age, BMI, cardiac or respiratory failure, prolonged immobility, the presence of central venous lines, estrogens, and a wide variety of inherited and acquired hematological conditions contribute to an increased risk for VTE (3,6,13-15,21). Due to the retrospective nature of this study, there was no evaluation of age, BMI, use of steroids and oral contraceptives, diabetes mellitus or smoking habits. Patient age of >40 years was determined in 63.6% of those with DVT and in 75% of patients with PE. BMI of > 30 was determined in 66.6% of patients with DVT but not in any patient with PE. In the DVT and PE population of the current study, there was no steroid use in any case. Of the patients with DVT, two females were using oral contraceptives. 61% were smokers and 44% had diabetes mellitus. The oldest patient with PE was a habitual smoker and the youngest patient was diagnosed with factor V leiden heterozygous mutation after PE. Makhdom et al reported a greater DVT rate after Achilles rupture in patients older than 40 years, but no significant difference was determined in a comparison of DVT rates between BMI groups (4). In another study reported that older age is a risk factor that statistically significantly associated and clinically relevant for both DVT and PE in foot and ankle trauma (20). Early mobilization and starting physiotherapy may reduce the incidence of DVT and PE. Patel et al reported a very low incidence of DVT and PE, stating that all patients with or without surgery were mobilized with crutches after rupture (3). In a study by Saragas and Ferraro, patients were non-weight-bearing for four weeks with the application of a below-the-knee cast, and it was 10

11 aimed to achieve full weight-bearing in the following 6 weeks with physiotherapy initiated after the cast was removed (15). Similarly, the current study group were non-weight-bearing on the injured extremity for four weeks with a below-the-knee cast. Mobilisation was provided with a three-point crutch gait and physiotherapy was suggested when the cast was removed. The risk of DVT may be reduced by the application of a weight-bearing cast or MAFO, or the use of electrical muscle stimulation through windows in the cast to allow muscle contraction, other physiotherapy techniques, and gentle mobilisation. However, the value of these measures has not been assessed in terms of VTE prophylaxis. There is an urgent need for further randomised, controlled studies of various pharmacological and non-pharmacological prophylactic measures to be able to establish evidence-based guidelines for the prevention of VTE during cast immobilisation of patients with Achilles rupture. The limitations of this study were that it was retrospective in design and it is possible that some symptomatic DVT patients may have been overlooked during the clinical follow up as the DVT symptoms could have been attributed to the normal postoperative course, and that there was no evaluation of asymptomatic VTE. In conclusion, the results of this study showed that age of 40 years is a risk factor for DVT and PE, and BMI is a risk factor for DVT in patients with Achilles tendon rupture. Although VTE prophylaxis was administered to the current study patient population, the incidences of DVT and PE were not low. In the light of the literature review and results of this study, it can be suggested 11

12 that routine VTE prophylaxis should be considered for these patients. Future studies are required to focus on the timing of VTE prophylaxis. Conflict of interests: none Author Contributions İÇ planned study, performed the surgeries, abstracted data from tha medical records to select the patients for the investigation, assessed patient data, and contributed to writing the paper. DG analyzed the patient data, performed the statistical analyses, and contributed to writing the paper. EE performed the surgeries, abstracted data from tha medical records to select the patients for the investigation, and contributed to writing the paper. BHÇ analyzed the patient data, and contributed to writing the paper. GB performed the surgeries, analyzed the data. HİB performed the surgeries and analyzed the paper. References 1. Lantto I, Heikkinen J, Flinkkilä T, et al. Epidemiology of Achilles tendon ruptures: increasing incidence over a 33-year period. Scand J Med Sci Sports 25(1):e133, Raikin SM. Epidemiology of Achilles tendon rupture in the US Available at: External link Accessed Feb 26, Patel A, Ogawa B, Charlton T, et al. Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture. Clin Orthop Relat Res 470:270,

13 4. Makhdom AM, Cota A, Saran N, et al. Incidence of symptomatic deep venous thrombosis after Achilles tendon rupture. J Foot Ankle Surg 52(5):584, Makhdom AM, Garceau S, Dimentberg R. Fatal Pulmonary Embolism following Achilles Tendon Repair: A Case Report and a Review of the Literature. Case Rep Orthop : Mangwani J, Sheikh N, Cichero M, et al. What is the evidence for chemical thromboprophylaxis in foot and ankle surgery? Systematic review of the English literature. Foot (Edinb) 25(3):173, Paavola M, Kannus P, Paakkala T, et al. Long-term prognosis of patients with Achilles tendinopathy. An observational 8-year follow-up study. Am J Sports Med 28:634, Hull RD, Raskob GE, Hirsh J. Prophylaxis of venous thromboembolism. An overview. Chest 89(5 Suppl):374, Geerts WG, Bergqvist D, Pineo GF, et al. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Prevention of venous thromboembolism. Chest 133(suppl 6):381, Kujath P, Spannagel U, Habscheid W. Incidence and prophylaxis of deep venous thrombosis in outpatients with injury of the lower limb. Haemostasis 23(suppl 1):20,

14 11. Jorgensen PS, Warming T, Hansen K, et al. Low molecular weight heparin (Innohep) as thromboprophylaxis in outpatients with a plaster cast: a venografic controlled study. Thromb Res 105:477, Lassen MR, Borris LC, Nakov RL. Use of the low-molecular-weight heparin reviparin to prevent deep-vein thrombosis after leg injury requiring immobilization. N Engl J Med 347:726, Nilsson-Helander K, Thurin A, Karlsson J, et al. High incidence of deep venous thrombosis after Achilles tendon rupture: a prospective study. Knee Surg Sports Traumatol Arthrosc 17(10):1234, Lapidus LJ, Rosfors S, Ponzer S, et al. Prolonged thromboprophylaxis with dalteparin after surgical treatment of achilles tendon rupture: a randomized, placebo-controlled study. J Orthop Trauma 21(1):52, Saragas NP, Ferrao PN. The incidence of venous thromboembolism in patients undergoing surgery for acute Achilles tendon ruptures. Foot Ankle Surg 17(4):263, Healy B, Beasley R, Weatherall M. Venous thromboembolism following prolonged cast immobilisation for injury to the tendo Achillis. J Bone Joint Surg Br 92(5):646, Biant LC, Hill G, Singh D. Antithrombotic prophylaxis in foot and ankle surgery in the UK. British Orthopaedic Foot Surgery Society. J Bone Joint Surg Br 87-B;(suppl 3):375,

15 18. Heyes GJ, Tucker A, Michael AL, et al. Erratum to: the incidence of deep vein thrombosis and pulmonary embolism following cast immobilisation and early functional bracing of Tendo Achilles rupture without thromboprophylaxis. Eur J Trauma Emerg Surg 41(3):277, Gritsiouk Y, Hegsted DA, Schlesinger P, et al. A retrospective analysis of the effectiveness of low molecular weight heparin for venous thromboembolism prophylaxis in trauma patients. Am J Surg 207(5):648, Shibuya N, Frost CH, Campbell JD, et al. Incidence of acute deep vein thrombosis and pulmonary embolism in foot and ankle trauma: analysis of the National Trauma Data Bank. Foot Ankle Surg 51(1):63, Anderson FA Jr, Spencer FA. Risk factors for venous thromboembolism. Review. Circulation 17;107(23 Suppl 1):I9, Figure 1: Dupplex USG image of the patient showing popliteal venous thrombosis. 15

16 Figure 2: Pulmonary CT image of the patient showing bilateral superior and inferior lob pulmonary arterial segments occluded by embolus. 16

17 Table 1: Demographic and clinic characteristics of the patients Parameter Total N=238 (100%) DVT n=18 (7.5%) PE n=4 (1.6%) Age (years) 39 (18-66) 41.7 (26-58) 40.3 (28-50) Gender 13 Female (5.4%) 2 Female (0.8%) 4 Male (1.6%) 225 Male (94.5%) 16 Male (6.7%) Site rupture 141 left (59.2%) 97 right (40.7%) 13 left (5.4%) 5 right (2.1%) 3 left 1 right Age < 40 years 133 (55.8%) 7 (2.9%) 1 (0.4%) Age 40 years 105 (44.1%) 11 (4.6%) 3 (1.2%) BMI < (44.5%) 6 (2.5%) 4 (1.6 %) BMI (55.4%) 12 (5%) - Use of steroids 16 (6.7%) - - Diabetes Mellitus 43 (18%) 8 (3.3%) - Smoking habit 67 (28.1%) 11 (4.6%) 1 (0.4%) Using oral contraceptive 5 (2.1%) 2 (0.8%) - Table 2: Other studies that include incidences of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Authors Study Design Prophylactic anticoagulation Current study Makhdom et al (2013) (7) Patel et al (2012) (6) Saragas et al (2011) Healy et al (2010) Number of patients DVT incidence (%) PE incidence (%) Retrospective Retrospective Retrospective Retrospective Retrospective One patient received aspirin prophylaxis

18 Nilsson- Helander et al (2009) Lapidus et al (2007) Prospective Prospective Surgically treated group (n=49) received 500 ml of Macrodex Intervention group (n=47) received Dalteparin