Eric B Smith1, Javad Parvizi, James J Purtill. 1. Department of Orthopaedics, Rothman Institute of Orthopaedics at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107, USA.
Abstract
BACKGROUND: This prospective study explores the incidence of preoperative deep venous thrombosis (DVT) in a group of patients with hip and femur fracture who for various reasons experienced a delay of >24 hours from the time of injury until time of surgery. We also evaluated the results of preoperative treatment with inferior vena cava (IVC) filter. METHODS: There were 101 consecutive patients with a mean age of 75.8 years. The mean time to surgery from injury was 3.5 days. All patients were evaluated for signs and symptoms of DVT and underwent Doppler ultrasound before surgery. All patients received preoperative prophylactic anticoagulation. Those patients with DVT underwent IVC filter insertion before surgical intervention. RESULTS: No patient exhibited signs or symptoms of DVT; however, preoperative ultrasound detected DVT in 10 patients. Despite negative ultrasound, two additional patients developed pulmonary embolus preoperatively for an overall incidence of thromboembolic disease of 11.9%. The average delay in surgery was 5.7 days for patients with DVT versus 3.2 days for those without (p = 0.021). The incidence increased each day from 14.5% if surgery was delayed >1 day to 33.3% if surgery was delayed >7 days. Relative risk increased from 2.32 to 3.71 over the same period. There were no postoperative thromboembolic complications or complications related to IVC filter placement in these patients. DISCUSSION: In this prospective study, we observed that patients experiencing a delay in surgical care for an acute hip or femur fracture are at a relatively high risk for development of thromboembolic disease despite prophylactic anticoagulation. There was a direct correlation between the period of delay and the incidence of thromboembolism. Clinical examination in this setting is unreliable as none of these patients had signs or symptoms suggestive of DVT. We suggest that all patients with delayed (>24 hours) surgical intervention undergo preoperative Doppler ultrasound to rule out DVT. Appropriate measures such as placement of an IVC filter and aggressive postoperative anticoagulation should then be implemented for those with DVT and/or pulmonary embolus.
BACKGROUND: This prospective study explores the incidence of preoperative deep venous thrombosis (DVT) in a group of patients with hip and femur fracture who for various reasons experienced a delay of >24 hours from the time of injury until time of surgery. We also evaluated the results of preoperative treatment with inferior vena cava (IVC) filter. METHODS: There were 101 consecutive patients with a mean age of 75.8 years. The mean time to surgery from injury was 3.5 days. All patients were evaluated for signs and symptoms of DVT and underwent Doppler ultrasound before surgery. All patients received preoperative prophylactic anticoagulation. Those patients with DVT underwent IVC filter insertion before surgical intervention. RESULTS: No patient exhibited signs or symptoms of DVT; however, preoperative ultrasound detected DVT in 10 patients. Despite negative ultrasound, two additional patients developed pulmonary embolus preoperatively for an overall incidence of thromboembolic disease of 11.9%. The average delay in surgery was 5.7 days for patients with DVT versus 3.2 days for those without (p = 0.021). The incidence increased each day from 14.5% if surgery was delayed >1 day to 33.3% if surgery was delayed >7 days. Relative risk increased from 2.32 to 3.71 over the same period. There were no postoperative thromboembolic complications or complications related to IVC filter placement in these patients. DISCUSSION: In this prospective study, we observed that patients experiencing a delay in surgical care for an acute hip or femur fracture are at a relatively high risk for development of thromboembolic disease despite prophylactic anticoagulation. There was a direct correlation between the period of delay and the incidence of thromboembolism. Clinical examination in this setting is unreliable as none of these patients had signs or symptoms suggestive of DVT. We suggest that all patients with delayed (>24 hours) surgical intervention undergo preoperative Doppler ultrasound to rule out DVT. Appropriate measures such as placement of an IVC filter and aggressive postoperative anticoagulation should then be implemented for those with DVT and/or pulmonary embolus.