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Foot & Ankle: Further Opinion Leading research

and clinical practice
in orthopaedic

Venous thromboembolism following

surgery
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prolonged cast immobilisation for

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injury to the tendo Achillis Sign up to Table of Contents alerts

Open access to the

B Healy, R Beasley, M Weatherall best
musculoskeletal
J Bone Joint Surg [Br] 2010;92-B:646-50. science and
research
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Archive
This paper is an important addition to the literature. It challenges previous assumptions and will make the reader
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reconsider his/her practice.

Some criticise thromboprophylaxis in orthopaedics because they believe that venous thrombosis is an imaginary A global view in
orthopaedics
radiological phenomenon. This paper, only observing symptomatic events, found that 6.3% had a deep-vein thrombosis
Current Issue
(DVT) or pulmonary embolisom (PE). This is a high proportion - greater than that seen after hip replacement. This is Archive
not imaginary. Furthermore, symptomatic events only represent the tip of an iceberg; for every symptomatic DVT or PE
there will probably be three asymptomatic events. It is usually asymptomtic DVTs which embolise and kill.

The recent NICE guidelines1, concerning lower limb plaster casts, recommend: (1.6.3) Consider offering Sign up to Table of Contents alerts

pharmacological VTE prophylaxis to patients with lower limb plaster casts after evaluating the risks (see section 1.1)
and benefits based on clinical discussion with the patient. Offer LMWH (or UFH for patients with renal failure) until
lower limb plaster cast removal. Follow@BoneJointPortal

This advice, to which UK orthopaedic surgeons are expected to adhere, suggests a risk assessment. Some risk factors
are obvious such as a previous history of VTE, varicose veins, obesity and malignancy. Some are occult including rare
coagulopathies such as Leiden factor deficiency (as found in one of the patients in this study after the VTE had been
diagnosed). However, VTE usually occurs sporadically without any obvious risk factor apart from the orthopaedic
intervention and consequent immobility.

The high rate of symptomatic VTE in this study suggests that it is the rupture of the tendo Achillis and its treatment
with prolonged plaster immobilisation and sometimes surgery, which conveys the high risk. If so, routine risk
assessment for these patients would lead to mandatory and universal thromboprophylaxis.

The accumulation of evidence shows that LMWH does reduce the rate of VTE after plaster immobilisation2,3although
its administration for several weeks poses pragmatic issues and risks thrombocytopenia in a very small proportion
risks. An oral agent would be preferable. Aspirin is unlikely to be effective and Warfarin, whether effective or not, is
complicated and risks significant complications. We now have oral agents (Dabigitran and Rivaroxaban) available,
effective and approved for use in hip and knee arthroplasty. Should we not support a randomized trial in the setting of
plaster cast immobilization? If so, given the demonstrable risk and the known benefit of LMWH, the trial would have to
compare one of these drugs with LMWH as it would be unethical to use a placebo. As a simpler and more expeditious
solution, one could extrapolate the results from joint arthroplasty and use these drugs off label if appropriate funding
was available.

The authors of this study should be praised for highlighting the real clinical risk and for providing such a
comprehensive and well-written discussion of the issues.

References
1.http://www.nice.org.uk/nicemedia/live/12695/47195/47195.pdf
2. Ettema HB, Kollen BJ, Verheyen CC, Buller HR.Prevention of venous thromboembolism in patients with
immobilization of the lower limb extremities: a meta-analysis of randomized controlled trials.J Thromb
Haemostas2008;6:1093-8.
3. Testroote M, Stigter WAH, de Visser DC, Janzing HMJ.Low Molecular weight heparin for prevention of venous
thromboembolism in patients with lower-leg immobilization.Cochrane Database of Systematic
Reviews2008;4:CD006681.

http://www.boneandjoint.org.uk/content/furtheropinion/venousthromboembolismfollowingprolongedcastimmobilisationinjurytendo 1/2
4/15/2017 Bone&Joint

Warwick D, MD, RFCS, FRCS(Orth), Reader in Orthopaedics

Southampton University Hospitals, Southampton, United Kingdom

E-mail: davidwarwick@me.com

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http://www.boneandjoint.org.uk/content/furtheropinion/venousthromboembolismfollowingprolongedcastimmobilisationinjurytendo 2/2