Can we use biomarkers of coagulation to predict which patients with foot and ankle injury will develop deep vein thrombosis?

BACKGROUND: Our aim was to determine whether plasma levels of Tissue Factor (TF), Vascular Cell Adhesion Molecule 1 (VCAM-1), Interleukin 6 (IL-6) or D-dimer after foot and ankle injury could predict which patients would develop deep vein thrombosis (DVT). METHODS: Patients aged 18-60 years with acute foot and ankle injury had venous blood sample to measure TF, VCAM-1, IL-6 and D-dimer within 3 days of injury. Patients had bilateral lower limb venous ultrasound to assess for DVT on discharge from clinic. RESULTS: 21 of 77 patients were found to have DVT (27%). There was no statistically significant association between levels of TF, VCAM-1, IL-6 or D-dimer and subsequent development of DVT. CONCLUSION: Tissue Factor (TF), Vascular Cell Adhesion Molecule-1 (VCAM-1), Interleukin-6 (IL-6) and D-dimer levels were not associated with development deep vein thrombosis in patients with acute foot and ankle injury.

Does thromboprophylaxis reduce symptomatic venous thromboembolism in patients with below knee cast treatment for foot and ankle trauma? A systematic review and meta-analysis.

BACKGROUND: Our aim was to determine the evidence for thromboprophylaxis for prevention of symptomatic venous thromboembolism (VTE) in adults with foot or ankle trauma treated with below knee cast or splint. Our secondary aim was to report major bleeding events. METHODS: MEDLINE and EMBASE databases were searched for randomized controlled trials from inception to 1st June 2015. RESULTS: Seven studies were included. All focused on low molecular weight heparin (LMWH). None found a statistically significant symptomatic DVT reduction individually. At meta-analysis LMWH was protective against symptomatic DVT (OR 0.29, 95% CI 0.09-0.95). Symptomatic pulmonary embolism affected 3/692 (0.43%). None were fatal. 86 patients required LMWH thromboprophylaxis to prevent one symptomatic DVT event. The overall incidence of major bleeding was 1 in 886 (0.11%). CONCLUSIONS: Low molecular weight heparin reduces the incidence of symptomatic VTE in adult patients with foot or ankle trauma treated with below knee cast or splint.

The effect of active toe movement (AToM) on calf pump function and deep vein thrombosis in patients with acute foot and ankle trauma treated with cast - A prospective randomized study.

BACKGROUND: Patients with foot and ankle trauma treated with cast are advised to perform toe movements to prevent venous thromboembolism (VTE). Our aim was to determine the effect of active toe movement on asymptomatic deep vein thrombosis (DVT) and venous calf pump function. METHODS: Patients aged 18-60 years with acute foot and ankle trauma requiring below knee non weight bearing cast were randomized to intervention (regular active toe movement) or control groups (n=100). Patients had bilateral lower limb venous ultrasound to assess for DVT on discharge from clinic. Patients requiring chemical thromboprophylaxis were excluded. RESULTS: 78 completed the study. 27% sustained asymptomatic DVT, with no statistically significant difference in calf pump function or DVT incidence between groups. All DVT's occurred in the injured lower limb. CONCLUSION: Active toe movement is not a viable strategy for thromboprophylaxis in patients with acute foot and ankle trauma treated with cast.

A critical evaluation of venous thromboembolism risk assessment models used in patients with lower limb cast immobilisation.

BACKGROUND: There is a recognised link between lower limb cast immobilisation and the development of venous thromboembolism (VTE). Our aim was to assess the diagnostic accuracy of risk assessment models (RAMs) applicable to this patient group. This has not been done before. METHODS: A literature and guideline review identified five RAMs. They were used to retrospectively risk assess a consecutive series of patients who were diagnosed with symptomatic VTE following lower limb injury treated with a cast (Group I). A case-matched cohort who did not suffer symptomatic VTE (Group II) was also retrospectively risk assessed. The RAMs' diagnostic performance indicators were calculated. RESULTS: Groups I and II consisted of 21 patients each. There was no significant difference in the mean age or total number of VTE risk factors between Groups I and II (p=.957 and p=.878 respectively). The Plymouth (2010) RAM achieved the highest accuracy (54.8%). CONCLUSIONS: Each RAM demonstrated significant limitations. Two displayed very limited clinical utility. Three recommended chemical thromboprophylaxis to all patients because they weighted lower limb immobilisation as an absolute risk factor for the development of VTE. Cast immobilisation should not be considered an absolute risk factor when risk assessing patients who all have casts. Prospective evaluation with a larger patient cohort is required.

The Cardiff Arthroplasty Satisfaction Index (CASI). A simple tool for the assessment of outcome following knee arthroplasty.

Our aim was to develop a patient reported outcome measure of satisfaction following total knee arthroplasty (TKA) and assess its correlation with Oxford knee score (OKS), Quality of life (EQ5D) and Visual analogue scale for pain (VAS). 172 patients with minimum 5year follow up post primary total knee arthroplasty completed CASI, OKS, EQ5D and VAS for pain. Receiver-operator curve analysis was performed to identify an OKS threshold of poor satisfaction defined by CASI rarely/never. The CASI showed positive correlation with the OKS, VAS for pain, and EQ5D, (Spearman's rho); 0.779; 0.711; 0.629. A threshold of 20 for the Oxford Knee score had 85% specificity and 85% sensitivity for poor satisfaction on CASI. The CASI is a useful measure of patient satisfaction following TKA.

The effect of lower limb cast immobilization on calf muscle pump function: a simple strategy of exercises can maintain flow.

BACKGROUND: We have investigated the role of the calf muscle pump in casted patients. An audit of venous thromboembolism (VTE) in casted patients showed that the thrombosis occurred in the casted leg; this has not been previously assessed. We postulated that local factors play a major role, and we set out to assess the calf muscle pump in casted patients and to determine whether this can be optimized despite below-knee cast immobilization. METHODS: We measured the flow in the popliteal vein using a validated method of Doppler ultrasound measurement of peak velocity with and without a below-knee plaster cast. RESULTS: We demonstrated that a simple strategy of toe and ankle exercises can maintain venous return despite below-knee cast immobilization. CONCLUSION: This is the first study to examine the effect of the calf muscle pump in the presence of a plaster cast. Major muscle groups such as the flexor hallucis longus and gastrocsoleus extend beyond the field of control of the cast and can still be recruited. CLINICAL RELEVANCE: We recommend that all patients treated with a below-knee cast be given a program of exercises that can be comfortably performed with the cast; this could provide a useful, inexpensive, and safe thromboprophylaxis strategy acting at the site of greatest risk and targeting a major cause of VTE.