Introduction. Total contact casting (TCC) is one of the most commonly utilized modalities in the management of diabetic feet. We undertook a retrospective review to determine the prevalence of symptomatic VTE events in patients treated in a weight bearing TCC in our diabetic foot unit, and to formulate guidelines for VTE prophylaxis. Methods. Electronic records were reviewed to identify all patients treated in a TCC between 2014 and 2021. Data collection included patient demographics, comorbidities, period of immobilization in TCC, the incidence of VTE events, and any VTE prophylaxis prescribed during their period in TCC. Results. 549 patients were identified who had at least one episode of TCC. Mean age was 67 years (range 28 to 94 years) and the mean duration in cast was 10.2 weeks (range 0.3–46 weeks). Only 6 patients (1.1%) were prescribed chemical thrombo-prophylaxis during their period in TCC. Mean body mass index (BMI) for these patients was 32.3 (Range 18.4–58.9). Other significant comorbidities: 81% (n-444) of patients had associated cardio-vascular comorbidities; 54 % (n-296) had renal comorbidities including 22% (n-121) having had dialysis and 4.2% (n-23) with renal transplants. Eight of the 549 patients (1.5%) had suffered a VTE event of which only 2 (0.36%) were during the period of immobilization in TCC. One was a symptomatic DVT (0.18%) and the another was an asymptomatic (incidental) finding of pulmonary embolism (PE). There was no mortality related to the VTE episodes. Conclusion. NICE guidelines state that one should “Consider pharmacological VTE prophylaxis for patients with lower limb immobilization”. Our study finds that patients treated in a weight bearing TCC do not require routine pharmacological VTE prophylaxis, in spite of an extended period of lower limb immobilization and significant medical comorbidities

Background. Venous Thrombo-Embolism is a recognized complication of lower limb immobilization. In the neuropathic patient total contact casting (TCC) is used in the management of acute charcot neuroathropathy and/or to off-load neuropathic ulcers, frequently for long time periods. To our knowledge there is no literature stating the prevalence of VTE in patients undergoing TCC. We perceive that neuropathic patients with active charcot have other risk factors for VTE which would predispose them to this condition and would mandate the use of prophylaxis. We report a retrospective case series assessing the prevalence of VTE in the patients being treated with TCCs. Methods. Patients undergoing TCC between 2006 and 2018 were identified using plaster room records. These patients subsequently had clinical letters and radiological reports assessed for details around the TCC episode, past medical history and any VTE events. Results. There were 143 TCC episodes in 104 patients. Average age at cast application was 55 years. Time in cast averaged 45 days (range 5 days – 8 months, median 35 days). 3 out of 4 patients had neuropathy as a consequence of diabetes. One TCC related VTE (0.7% of casting episodes) was documented. This was a proximal DVT confirmed on USS 9 days following cast removal. No patient received VTE prophylaxis while in TCC. Conclusion. Despite these complex patients having a multitude of co-morbidities the prevalence of VTE in the TCC setting remains similar to that of the general population. This may be due to the fact that TCCs permit weight bearing. This case series suggests that, while all patients should be individually VTE risk assessed as for any lower limb immobilization, chemical thromboprophylaxis is not routinely indicated in the context of TCCs

Introduction. Venous thromboembolism (VTE) represents a major cause of morbidity, mortality and financial burden to the NHS. Acquired risk factors are well documented, including immobilisation, lower limb plaster cast and surgery. NICE guidance on VTE prophylaxis within orthopaedics currently excludes operative ankle fracture fixation (ankle ORIF). Aims. Ascertain the local incidence of VTE; compare our local VTE rates with published data from other institutions; review guidelines, scientific literature and other hospitals policies; formulate a local policy for VTE prophylaxis. Method. Retrospective analysis of records of all patients undergoing ankle ORIF in our hospital over a continuous 5 year period, identifying cases of VTE, individual risk factors and surgical duration. Results. 380 patients underwent ankle ORIF; 3 developed VTE; no mortality. VTE incidence 0.79% (0.26%DVT; 0.53%PE). Operative duration 88 +/− 34mins (mean +/− 1S.D); in those with VTE, duration was 35, 90&85min. There is no statistically significant difference (p=0.18) observed between our local and national VTE incidence rates. Operative duration was not a significant factor in those developing VTE. Additional risk factors were identified in one patient with VTE. Discussion. The incidence of heparin induced thrombocytopenia is 0.5%, its associated mortality 10% (i.e. 1:2000). To prevent one fatal PE in foot & ankle surgery, 10,000 must receive VTE prophylaxis. Therefore, heparin associated mortality exceeds VTE associated mortality in foot & ankle surgery. Conclusion. Our local VTE rates are comparable to national rates. Risk of pharmacological prophylaxis exceeds benefit; therefore routine use not justified. Individual risk should be assessed; higher risk patients may benefit

The incidence of venous thromboembolism (VTE) is unknown in elective foot and ankle surgery. In March 2010 we surveyed the current practice in VTE prophylaxis in elective foot and ankle surgery amongst members of the British Orthopaedic Foot and Ankle Society (BOFAS). The response rate was 53%. The total the number of elective foot and ankle operations performed by the surveyed group was 33,500 per annum. The perceived incidence of DVT, PE and fatal PE was 0.6%, 0.1% and 0.02%. In our study the number of patients needed to treat to prevent a single fatal PE is 10,000 although this figure is open to significant bias. The National Institute for Health and Clinical Excellence (NICE) recently published guidelines on reducing the risk of venous thromboembolism in surgical patients. These guidelines cover all surgical inpatients and uses data extrapolated from other groups of patients. We question the applicability of these guidelines to patients undergoing elective foot and ankle surgery. We consider that this data justifies the prospective study of the incidence of VTE in patients undergoing elective foot and ankle surgery, without the use of chemical thromboprophylaxis

We report an audit of 208 patients with a mean age of 39 years (16 to 65) attending the Orthopaedic Assessment Unit at the Wellington Hospital between January 2006 and December 2007 with an injury of the tendo Achillis requiring immobilisation in a cast. Information on assessment of venous thromboembolism (VTE) risk, prophylactic measures and VTE events for all patients was obtained from the medical records. A VTE risk factor was documented in the records of three (1%) patients. One of the 208 patients received aspirin prophylaxis; none received low molecular weight heparin. In all, 13 patients (6.3%, 95% confidence interval 3.4 to 10.5) developed symptomatic VTE during immobilisation in a cast, including six with a distal deep-vein thrombosis (DVT), four with a proximal DVT, and three with a confirmed pulmonary embolus. This incidence of symptomatic VTE is similar to that reported following elective hip replacement. We propose that consideration is given to VTE prophylaxis during prolonged immobilisation of the lower limbs in a cast, to ensure that the same level of protection is provided as for patients undergoing elective hip replacement

Background. Despite the suggestion by Virchow in 1856 that thrombosis was the result of venous stasis, endothelial dysfunction and hypercoagulability there are some fundamental questions which remain to be answered. The published studies fail to provide specific details such as cast type and anatomical location of the thrombosis, but instead focus on the incidence of VTE and which chemical thromboprophylaxis is most effective. Previous studies of VTE in trauma patients have involved small numbers of patients and have not look at the risk medium to long term risk. Most importantly they have not looked at the site of the VTE. This makes interpretation of the link between cast and VTE even more complex. Methodology. We analysed 1479 consecutive trauma cast applications and the incidence of symptomatic VTE in the six months following the injury. The diagonosis, cast type and site of the VTE was recorded. Results. The overall incidence of DVT was 2.5% (2.2% distal and 0.3% proximal), 50% occured inthe first 3 weeks, the rest were between 6–13 weeks. The incidence of PE was 0.7%, there was 1 death due to PE. Achilles tendon injury was a statistically significant risk factor, there were no other conditions with a specific risk. There was no difference between above and below knee cast immobilisation. However all symptomatic DVTs occured in the casted leg. Discussion. This is the first study to look at long term VTE risk and the site of thrombosis, these findings have implications for VTE prophylaxis. It would appear that the risk of developing symptomatic VTE extends beyound the currently advised treatment period. It also suggests that venous stasis and endothelial damage are more important that hypercoagulability in the development of VTE after cast treatment for trauma. We recommend a programme of exercises within the cast to reduce this risk

Nice guidelines recommend VTE prophylaxis to patients in below knee casts following foot and ankle surgery following risk assessment. The guidelines are controversial and BOFAS recommendations reiterate the risk factors but highlight poor evidence to support these guidelines. Implementation has been variable dependent on interpretation. 58 patients who underwent hindfoot procedures and were immobilised in a cast were identified. These patients were under the care of two consultants, one of whom anticoagulates with daily enoxaparin and one who does not, providing a de facto case-control design. The patients were followed up to identify those who subsequently suffered a DVT or PE, and the clinical circumstances. 2 cases of VTE events were noted in 58 patients undergoing foot and ankle surgery. Both were elective cases managed postoperatively in cast and treated with prophylaxic enoxaparin. Both of these presented to hospital with signs of VTE greater than 6 weeks following surgery after cast removal and discontinuation of enoxaparin. No patients were considered high risk according to NICE guidelines. None of the patients who received no thromboprophylaxis had a clinical DVT. Within our study group we found that VTE thromboprophylaxis does not influence clinically evident VTE rates. Patients who developed VTE were not considered high risk by definition of NICE guidelines but only at increased risk due to their immobility. The VTE events were initiated while the patients were receiving thromboprophylaxis. The effectiveness of the guidelines in predicting patients who would benefit from chemoprophylaxis is questionable from this study. NICE guidelines on VTE thromboprophylaxis have been received with some concerns. Although this investigation studied only a relatively small number of patients, it raises issues about the clinical effectiveness of the guidelines in foot and ankle patients

Aims

To our knowledge, there is currently no information available about the rate of venous thromboembolism (VTE) or recommendations regarding chemoprophylaxis for patients whose lower limb is immobilized in a plaster cast. We report a retrospective case series assessing the rate of symptomatic VTE in patients treated with a lower limb cast. Given the complex, heterogeneous nature of this group of patients, with many risk factors for VTE, we hypothesized that the rate of VTE would be higher than in the general population.

Diagnostic and operative codes are routinely collected for every patient admitted to hospital in the English NHS. Data on post-operative complications following foot and ankle surgery have not previously been available in large numbers. Data on symptomatic venous thromboembolism events and mortality within 90 days were extracted for patients undergoing fixation of an ankle fracture, first metatarsal osteotomy, hindfoot fusions and total ankle replacement over a period of 42 months. For ankle fracture surgery (45 949 patients), the rates of deep-vein thrombosis (DVT), pulmonary embolism and mortality were 0.12%, 0.17% and 0.37%, respectively. For first metatarsal osteotomy (33 626 patients), DVT, pulmonary embolism and mortality rates were 0.01%, 0.02% and 0.04%, and for hindfoot fusions (7033 patients) the rates were 0.03%, 0.11% and 0.11%, respectively. The rate of pulmonary embolism in 1633 total ankle replacement patients was 0.06%, and there were no recorded DVTs and no deaths. Statistical analysis could only identify risk factors for venous thromboembolic events of increasing age and multiple comorbidities following fracture surgery.

Venous thromboembolism following foot and ankle surgery is extremely rare, but this subset of fracture patients is at a higher risk. However, there is no evidence that thromboprophylaxis reduces this risk, and these national data suggest that prophylaxis is not required in most of these patients.