Recommendations from the ICM-VTE: Foot & Ankle
2022; Wolters Kluwer; Volume: 104; Issue: Suppl 1 Linguagem: Inglês
10.2106/jbjs.21.01439
ISSN1535-1386
Tópico(s)Diagnosis and Treatment of Venous Diseases
Resumo1 - Should patients undergoing surgical debridement of diabetic foot ulcers receive routine VTE prophylaxis? Response/Recommendation: There is currently no evidence in the literature to determine if a diabetic patient undergoing ulcer debridement requires venous thromboembolism (VTE) prophylaxis. There is, however, an increased risk for morbidity and mortality in diabetic foot ulcers (DFU) patients who develop VTE. Therefore, it is justified to propose that patients with DFU are given thromboprophylaxis, particularly if they have reduced mobility and other medical comorbidities. This may not be true for all cases of surgical debridement alone of DFU without additional interventions when prolonged limited weight-bearing is not required. Strength of Recommendation: Limited. Delegates vote: Agree 100.00% Disagree 0.0% Abstain 0.00% (Unanimous Strong Consensus). Rationale: There is increasing evidence that diabetes mellitus (DM) is associated with derangements in coagulation and fibrinolysis leading to a tendency to form thrombi1,2. The risk for developing VTE is also elevated in part due to associated co-morbid conditions and frequent hospitalization for acute medical conditions and surgery3-5. DM patients who develop VTE are more likely to suffer a complicated clinical course, including long-term major bleeding complications, recurrent VTE5,6, major adverse limb events and a higher risk of all-cause mortality6. Aside from neuropathy, the tendency for thrombosis places DM patients at risk of developing DFU. Patients with DFU have increased mortality rates compared to non-ulcerated diabetic patients7. Compounded with VTE, DFU patients may also have delayed ulcer healing rates4,8 and longer periods of immobility. Despite many reports of elevated risk of VTE in DM patients, no specific recommendations can be found for managing diabetic patients at risk for VTE. For this review, a search in PubMed revealed 244 papers but none specifically discuss VTE prophylaxis for DFU patients undergoing surgery, nor for DM patients in general. In a review of 2,488 patients with validated VTE in the Worcester Venous Thromboembolism Study, Piazza et al., reported a low rate of thromboprophylaxis among the 476 patients with VTE and DM5. Wang et al., highlighted the impact of a history of VTE on major adverse limb events (MALEs) and concluded that prevention of thrombotic events needed to be emphasized in patients requiring diabetic foot care6. Aside from increased all-cause mortality rates, they showed that a history of VTE was associated with a 1.6-fold increased risk of MALEs and a 1.4-fold higher risk of major amputation. Azlina A. Abbas, Steven M. Raikin 2 - Is routine VTE prophylaxis needed for patients placed in walker boot immobilization? Response/Recommendation: Patients in walker boot immobilization may be at increased risk of development of venous thromboembolism (VTE). Patients should be risk assessed, and VTE prophylaxis offered on an individual basis. Strength of Recommendation: Limited. Delegates vote: Agree 96.30% Disagree 0.0% Abstain 3.70% (Strong Consensus). Rationale: Immobilization of the lower limb in a walker boot can provide an alternative to a cast for post-operative and non-operative management of many foot and ankle-related conditions. Potential benefits include the removal for hygiene purposes, the ability to perform range of motion exercises, and the potential to adjust the fit with resolution of swelling. Furthermore, a boot does not require a clinic visit for definitive removal. A 2017 Cochrane Review, which included eight randomized controlled trials (RCT), assessed the effectiveness of low-molecular-weight heparin (LMWH) for the prevention of VTE in patients with lower limb immobilization9. In patients who received no prophylaxis, the incidence of deep venous thrombosis (DVT) ranged from 4.3% to 40% but was reduced in patients who received prophylaxis. Most of the trials included in this review utilized only cast immobilization, while three studies also included patients immobilized in a brace. The authors concluded there was moderate-quality evidence that LMWH reduced the number of venous thromboembolic events. Another systematic review performed in 2019 found a lower risk of VTE when patients with temporary immobilization of the lower extremity received VTE prophylaxis10. For this recommendation, RCT investigating VTE prophylaxis regimens in patients in boot or brace immobilization were identified. In addition, RCT were also included if they reported the incidence of VTE in patients immobilized in a boot, orthosis, or brace in comparison to a control group in any other form of immobilization, or no immobilization. Four RCT of VTE prophylaxis regimens including patients in orthoses or braces were identified. All of them were included in the previously mentioned systematic review10. In patients requiring immobilization after fracture or achilles tendon rupture, Lassen et al., reported the incidence of DVT identified by venography as 19% in a placebo group compared to 9% in those receiving reviparin (p=0.01)11. Lapidus et al., reported no significant difference in the incidence of DVT identified by phlebography between patients receiving dalteparin or placebo following immobilization after ankle fractures12 or surgery for achilles tendon rupture (ATR)13. Finally, Samama et al., reported an incidence of VTE of 2.3% in patients receiving fondaparinaux compared to 7.9% in those receiving nadroparin14. None of the studies presented sub-group data or analysis of those patients in boot or orthosis immobilization, and in all trials most patients were immobilized in a cast. Six additional RCT reporting the incidence of VTE during immobilization in a boot, brace or orthosis compared to another form of immobilization were identified. Kortekangas et al., investigated patients with ankle fractures treated with an orthosis versus a cast15. There were no symptomatic DVT in the 80 patients treated in an orthosis for three weeks. There were 3 (3.6%) DVT recorded in the 83 patients treated in a cast, although this difference was not statistically significant. Lehtonen et al., randomized patients with ankle fractures to post-operative immobilization in a cast or early mobilization in a functional ankle brace16. Of the fifty patients treated in a cast, symptomatic DVT was identified in two patients (4%) compared to no DVT in the 50 patients in a brace. In ATR, Groetelaers et al., investigated 60 patients randomized to either a cast or an Achillotrain flexible brace following minimally invasive repair17. Symptomatic DVT occurred in two (8%) of patients in the cast group compared to none in the Achillotrain group. Patients in the Achillotrain group were allowed to weight-bear and began mobilization earlier than the cast group. The United Kindom Study of tendo Achilles Rehabilitation (UKSTAR) RCT compared a brace against cast immobilization in ATR managed conservatively in 540 patients18. Symptomatic DVT was recorded in 2% of patients in a functional brace compared to 1% in a plaster (p = 0.51). Aufwerber et al., reported the incidence of asymptomatic DVT on ultrasound imaging in 150 patients following ATR surgery19. DVT was recorded in 29% of patients in a dynamic orthosis, compared to 31% of patients immobilized for two weeks in cast and then transferred into an Aircast boot. Patients in the dynamic orthosis group were permitted to begin weight bearing and mobilization earlier following surgery. The clinical importance of asymptomatic DVT remains uncertain20-22. In a RCT by Lamb et al., 584 patients with ankle sprains were randomized to receive a below-knee cast, Aircast brace, Bledsoe boot or tubular compression bandage. DVT was identified in one patient in every treatment group except for the compression bandage23. None of these six studies identified a statistically significant difference in the incidence of VTE between forms of immobilization. With the exception of the study by Aufwerber et al.19, the incidence of VTE was a secondary outcome. As the search strategy was focused on VTE, it is acknowledged that other trials investigating the use of a brace or orthosis and reporting VTE only as a secondary outcome may not have been captured in the search. However, it is expected that such studies are likely to be similarly underpowered to detect a difference in the incidence of symptomatic DVT. In summary, limited evidence was identified to establish if routine VTE prophylaxis reduces the risk of VTE in walker boot immobilization. All four RCT of VTE prophylaxis combined data for patients in a boot or orthosis with patients in cast immobilization. In six RCT comparing patients immobilized in a boot or orthosis versus those in cast immobilization there were no statistically significant differences in the incidence of VTE. These studies displayed heterogeneity in the type of injury, operative versus non-operative intervention and the type of orthosis. Additional variation, even within individual studies, in weight bearing status and mobilization of the ankle and foot are also likely to affect the incidence of VTE. However, the literature demonstrates that VTE may occur in patients placed in boot or brace immobilization, when the patients are instructed to weight-bear at < 50% early after surgery19. In view of the limitations, future research specifically investigating VTE in patients immobilized in a walker boot is needed. We recommend that patients should be assessed and VTE prophylaxis offered on an individual basis according to patient factors, weight-bearing status and mobilization status. William Fishley, Allison L. Boden, Rajesh Kakwani, Amiethab Aiyer 3 - Does the weight-bearing status of the patient after foot and ankle surgery influence the selection of VTE prophylaxis? Response/Recommendation: Non-weight-bearing restrictions of the lower extremity are an independent risk factor for venous thromboembolic (VTE) events. This risk is mitigated by load-bearing of the operative limb greater than 50%. No additional conclusions can be made regarding the selection of VTE prophylaxis as it relates to non-weight-bearing based on the available literature. Strength of Recommendation: Limited. Delegates vote: Agree 100.00% Disagree 0.0% Abstain 0.00% (Unanimous Strong Consensus). Rationale: A period of non-weight-bearing restrictions after foot and ankle (F&A) surgery is often required to protect the surgical limb and optimize outcomes. Weight-bearing restrictions after F&A surgery commonly coincide with immobilization of the operative limb (e.g., in a plaster cast or orthosis). These postoperative restrictions, though seemingly innocuous, are not without risks. To this end, immobilization of the lower extremity has been identified as a strong contributor to VTE complications24,25. The pathomechanism of immobilization and VTE events is related to the diminished venous return conferred by immobility and static positioning of the limb26,27. The impact, if any, that non-weight-bearing restrictions have on the development of VTE complications is not as clearly understood, and the relevance that non-weight-bearing restrictions should have on post-surgical VTE prophylaxis selection is debated. There is a relative dearth of literature reporting on the association of VTE complications and non-weight-bearing restrictions. The literature by and large has focused on immobilization specifically and non-weight-bearing as an independent factor in VTE complications. However, weight-bearing has been shown to increase venous emptying of the lower extremity and may be of clinical relevance in the development of VTE events28. A level I prospective study evaluated 150 patients that underwent open achilles tendon repair29. Patients were randomized to a protocol consisting of either early full weight-bearing in an orthosis or a conventional postoperative protocol consisting of two weeks of non-weight-bearing in a cast followed by 4 weeks weight-bearing in an orthosis. No patients were prescribed VTE prophylaxis, and all patients were screened for VTE with bilateral doppler ultrasounds two and six weeks after surgery. The authors identified that loading of the limb less than or equal to 50% of the body weight in the first week following surgery was an independent risk factor for developing VTE and conferred 4.3 times higher odds of developing a VTE in the first two weeks after surgery. Notably, there was no association of VTE, and the number of steps taken per day, which indicates that loading of the operative limb is independently relevant to developing VTE complications. A separate study by Barg et al., investigated risk factors for VTE in a series of 665 patients undergoing total ankle replacement over a 9-year period30. Patients were instructed to weight-bear while immobilized in a cast or orthosis starting three to four days after surgery unless they had concomitant osteotomies. All patients were prescribed prophylaxis with low-molecular-weight heparin (LMWH) 5000 IU. Three-point nine percent of patients developed a symptomatic deep venous thrombosis (DVT). Multiple regression analysis identified the absence of full post-operative weight-bearing as an independent risk factor for symptomatic VTE, with an odds ratio of 4.53. A prospective multi-center study by Mizel et al., included 2,733 over the course of a year. Patient demographics, administered medication, orthopaedic procedure and postoperative ordinations including anticoagulation and weight-bearing status was reported by the treating orthopaedic surgeon. Postoperative follow-up averaged 91 days and symptomatic DVT were confirmed by venogram or ultrasonography. Of the six patients that developed DVT, all had been non-weight-bearing corresponding to a relative risk of 1.0 (95% confidence interval [CI] 1.0009 to 1.008, p = 0.014). Two of these 6 patients had received anticoagulation. Furthermore, 4 of the 6 patients with DVT developed non-fatal pulmonary emboli (PE), though whether these received anticoagulation was not specified31. A retrospective analysis of a series of patients over a one-year period at a single hospital was conducted by Thomas and Van Kampen on a series of patients to evaluate risk factors for symptomatic VTE32. The authors reported that 7 of the 381 (1.84%) patients included in their analysis developed DVT, 4 of which developed a PE. Chart review revealed that all patients that had a PE were instructed to be non-weight-bearing for injuries consisting of ankle fractures (2), distal tibia and fibula fracture (1), and achilles rupture (1). None of the patients underwent surgery and no prophylaxis was prescribed. The study was not powered to determine the statistical significance of weight-bearing restrictions on VTE events, but these findings are notable, nonetheless. A prospective descriptive study was performed on a group of 216 patients who underwent various F&A surgeries33. Short leg cast immobilization and non-weight-bearing for at least 4 weeks was required in 130 patients, while 88 patients underwent hallux surgery that did not require immobilization or weight-bearing restrictions. No patients received VTE prophylaxis. Screening by ultrasound at 2 and 6 weeks after surgery revealed an overall incidence of DVT of 5.09% with no clots being identified in the hallux valgus subgroup who were permitted to weight-bear immediately, and 8.46% incidence in the group immobilized in a cast with non-weight-bearing restrictions. These results are descriptive, as the study was not sufficiently powered to determine individuals risk factors; however, these findings do coincide with previous reports that have identified an association between non-weight-bearing restrictions and VTE event. These findings in summation do suggest that non-weight-bearing restrictions are an independent risk factor for VTE events and merit the attention of the surgeon. The literature supporting this conclusion, however, is limited, with the work of Aufwerber et al., representing the only Level I evidence identifying this association. The pathomechanism of non-weight-bearing restrictions on VTE is likely related to the resultant restricted venous return, which does conversely increase with weightbearing. Clinicians should consider non-weight-bearing restrictions when determining patients' risks for VTE events following F&A surgery. This risk may be mitigated by permitting at least partial loading of the limb even when immobilized29. No recommendation regarding the use of additional VTE prophylaxis medications or interventions for patients requiring non-weight-bearing after surgery can be made. Determining the need for chemoprophylaxis based on non-weight-bearing restrictions following surgery has not been independently investigated. It is notable, however, that a recent Cochrane review did investigate LMWH VTE prophylaxis specifically in patients with lower limb immobilization but did not specifically analyze non-weight-bearing restrictions25. From the authors' analysis of 3,680 participants from 8 randomized controlled trials, it was concluded that LMWH prophylaxis did significantly lower incidence of DVT in patients requiring lower extremity immobilization. These results were based on moderate-quality evidence. Investigation regarding the use of VTE prophylaxis in patients undergoing F&A surgery requiring postoperative weight bearing restrictions is needed. Thomas I. Sherman, Paul W. Ackermann 4 - Concerning VTE risk, which surgeries can be considered major, and which surgeries can be considered non-major in foot and ankle surgery? Response/Recommendation: There is insufficient data to characterize foot and ankle surgical procedures as either major or non-major risk with regard to postoperative venous thromboembolic (VTE) event risk. Certain diagnoses, such as achilles rupture, do seem to demonstrate a higher rate of VTE, but this may be independent of surgical or non-surgical management and instead relate to impaired venous return. Patient-specific risk factors are critical towards understanding the risk of VTE after foot and ankle (F&A) surgery, and may include age > 50 years, splint or cast immobilization, Charlson Comorbidity Index (CCI) > 2, varicose veins, history of VTE, hypercoagulability disorder, and inflammatory arthritis. Strength of Recommendation: Limited. Delegates vote: Agree 100.00% Disagree 0.0% Abstain 0.00% (Unanimous Strong Consensus). Rationale: Historically, discussion regarding the incidence of VTE disease in orthopaedic surgery—and the concordant use of chemoprophylaxis to prevent deep venous thrombosis (DVT) and pulmonary embolism (PE) has revolved around VTE risk inherent to a given procedure. Procedures such as total hip arthroplasty (THA) or total knee arthroplasty (TKA), as well as hip fracture surgical fixation, have uniformly high rates of VTE in the absence of preventative measures34. Professional societies such as the American College of Chest Physicians (ACCP) have thus explicitly recommend administering chemoprophylaxis "for patients undergoing major orthopaedic surgery (THA, TKA, hip fracture surgery [HFS])"35. In defining a subset of orthopaedic procedures as major, however, the ACCP guidelines did not conversely define other procedures as minor. They only noted that chemoprophylaxis was unnecessary in "in patients with isolated lower-leg injuries requiring leg immobilization". Indeed, while the word "major" appears 201 times in the 2012 ACCP guidelines, the word "minor" appears only twice, and specifically pertaining to minor bleeding events. The challenges providers face when addressing VTE among F&A patients are manyfold. First, while the rate of VTE is much lower amongst F&A patients than after THA or TKA patients, it is certainly neither zero nor uniform across all patients and procedures36. This makes any risk-benefit analysis of using chemoprophylaxis far more nuanced, as one weighs the risk of DVT and PE against adverse outcomes such as bleeding events, wound ooze, and even heparin-induced thrombocytopenia37. Second, without overwhelming implications of any procedure itself determining use of chemoprophylaxis, patient-specific risk factors play an increasingly important role, undermining a "one size fits all" approach to VTE prevention38,39. Lastly, it may not be a procedure per se that provokes a DVT or PE, but rather the pathologic condition itself (e.g., achilles tendon rupture with gastrocsoleus retraction), often independently of operative versus nonoperative management, as well as the requisite period of non-weight bearing and/or immobilization40,41. The confusion shared by F&A clinicians and patients alike is reflected by the diverse clinical practice guidelines put forth by multiple professional societies pertaining to surgery of the lower extremity, including F&A procedures. As noted, for example, the ACCP does not recommend use of chemoprophylaxis after F&A surgery35. In contrast, the National Institute for Health and Care Excellence (NICE) in the United Kingdom does recommend that surgeons use of chemoprophylaxis after lower extremity procedures other than THA, TKA, or HFS when patients have one or more risk factors, but conflates risk factors such as a prior history of VTE in an individual or first degree relative with more ubiquitous risk factors such as age > 60 years, lower limb procedures lasting > 60 minutes, and body mass index (BMI) > 30 kg/m242 Moreover, the American Orthopaedic Foot & Ankle Society (AOFAS) has stated that there is insufficient data for it to recommend for or against the use of routine VTE prophylaxis after F&A surgery, and that further research is necessary43. Thus, the decision to use chemoprophylaxis after F&A surgery must integrate not only the nature of the procedure, but also patient-specific risk factors, many of which have yet to be defined. Validated risk assessment tools do exist, but have been honed around non-orthopaedic procedures such as general or vascular surgery44,45. Among the most commonly used risk assessment scales is that purported by Caprini, which assigns a point value to each of forty elements that allows clinicians to stratify patients by risk status, with ≥ 5 total points considered "highest risk"46. It does distinguish between minor and major surgery but does so based on whether the time of surgery crosses a threshold of 45 minutes; any surgery of > 45 minutes duration is considered major. In practice, patients aged 41 - 60 years (1 point) undergoing a minor surgical procedure (1 point) who have a BMI > 25 kg/m2 (1 point) would be considered "high-risk" (3 - 4 points), making it difficult to know how to apply this instrument to the F&A population. A recent study by Dashe et al., retrospectively compared the incidence of DVT and PE among 300 orthopaedic patients with pelvic or acetabular fractures, empirically deemed to be at "high-risk", to the incidence among 548 patients with foot and ankle fractures deemed to be at "low-risk"47. It found that those patients with pelvic and acetabular fractures did indeed demonstrate a higher rate of VTE (8% vs. 1.6%, p < 0.0001), but the traditional Caprini score threshold of 5 did not appropriately differentiate those at "highest risk" between the two groups, and the authors instead recommended a threshold of 10 points. Unfortunately, even this latter score threshold loses utility when applied to F&A patients without fractures, because it largely emanates from the 5 points assigned to "hip, pelvis or leg fracture (< 1 month)"46. Complicating matters is the fact that certain specific diagnoses within F&A surgery do seem to correlate with a heightened risk of VTE. Achilles tendon ruptures have been reported to have a rate of DVT ranging from 0.4% to 34%48,49. This reported wide variability emanates largely from whether patients in a given study are routinely screened with ultrasound, or whether only symptomatic patients are imaged. Studies, however, have highlighted rates of symptomatic DVT as high as 23.5% and, most notably, have not necessarily found a difference between operatively versus nonoperatively treated patients41,50,51. Thus, rather than achilles tendon repair being considered a "major surgery", it may be that achilles ruptures as a whole are better identified as a "major diagnosis". Even more confusing, it is not entirely clear that chemoprophylaxis effectively lowers the rate of VTE after achilles rupture based on prospective, randomized study49. Extrapolating the idea that more proximal procedures in the lower extremity have higher rates of VTE than those performed more distally, it intuits that within F&A specifically one might find a progressive increase in the rate of postoperative VTE when moving from the forefoot to the hindfoot/ankle to the lower leg. A study by Hejiboer et al., compared the rate of VTE and adverse bleeding events among two separate, matched cohorts of 5,286 patients undergoing below knee procedures with and without chemoprophylaxis using propensity score matching37. The authors did identify an increase in the rate of VTE as one moved more proximally within the F&A, including the forefoot (0.8%), hindfoot/ankle (1.4%), and lower leg (3.4%) among patients who did not receive chemoprophylaxis. The study also found an analogous increase among patients receiving chemoprophylaxis who underwent procedures to the forefoot (0.2%), hindfoot/ankle (0.4%), and lower leg (1.0%), and was able to demonstrate a 3-fold reduction in the rate of VTE when using chemoprophylaxis but a 2-fold increase in bleeding events. This finding highlights the inherent trade-offs of preventative measures. Ultimately, in F&A surgery, as compared to THA and TKA, patient risk factors play a disproportionate role in precipitating a higher rate of VTE. Risk factors in the literature have included age > 50 years, splint or cast immobilization, achilles tendon ruptures, increased comorbid burden as reflected in a CCI > 2, varicose veins, history of VTE, either in a given individual or first degree relative, a known hypercoagulability disorder, and inflammatory arthritis38,39,52-55. This must be kept firmly in mind when interpreting studies. For example, a recent meta-analysis that incorporated six prospective randomized controlled trials (RCT) comprising 1,600 patients undergoing isolated F&A surgery found a rate of VTE of 8.3% among patients with chemoprophylaxis as compared to 11.7% without (relative risk [RR] 0.72, 95% confidence interval [CI] 0.55 - 0.94, p = 0.02)56. It concluded that, while chemoprophylaxis is efficacious, "event rates are low and symptomatic events are rare". On the other hand, the authors highlight that the average age of patients in all six RCT was < 50 years. Separately, all six studies excluded patients with a prior history of VTE. Both are likely contributing risk factors for VTE after F&A surgery, limiting the ability to extrapolate their findings to broader populations. In summary, there is insufficient data to characterize F&A surgical procedures as either major or non-major as this pertains to the risk of postoperative VTE. Certain diagnoses such as achilles rupture do seem to demonstrate a higher rate of VTE, but patient risk factors are especially critical as compared to patients undergoing THA and TKA or HFS. Large scale, prospective, RCT are necessary to define subpopulations of patients at heightened risk, as well as elucidate the relative utility of various chemoprophylactic strategies. Daniel Guss, Christopher W. DiGiovanni, Steven M. Raikin 5 - Is routine VTE prophylaxis required for patients undergoing forefoot and midfoot surgery who would be allowed to fully weight-bear? Response/Recommendation: The risk of venous thromboembolism (VTE) following forefoot and midfoot is rare, with pulmonary embolism (PE) and even more so, fatal PE being exceedingly rare. The rates appear to be lower in forefoot surgery as opposed to midfoot surgery, while both appear low. We do not recommend routine anticoagulants for VTE prevention following elective a forefoot and midfoot in low-risk patients, especially after immediate weight-bearing. We do encourage further high-quality research into routine VTE chemoprophylaxis. Strength of Recommendation: Limited. Delegates vote: Agree 100.00% Disagree 0.0% Abstain 0.00% (Unanimous Strong Consensus). Rationale: There is limited data to support routine prophylaxis for VTE events in foot and ankle (F&A) surgery patients. This is especially true regarding forefoot and midfoot surgery where patients are often allowed to weight-bear fully. In the field of F&A surgery, there is relatively little data available to guide clinical decision-making regarding VTE prophylaxis, especially in comparison to other fields of orthopaedics. One single surgeon study found only 22 clinically symptomatic VTE in 2,774 patients (0.79%) over the span of 10 years57. Other authors have found a relatively high rate of otherwise asymptomatic VTE in F&A surgery patients (25.4%)58 at 2- and 6-week screening ultrasounds. All of the detected deep venous thromboses (DVT) were distal to the popliteal vein and all patients were undergoing hindfoot or midfoot surgery and were made non-weight-bearing58. There is very little data on the risk of VTE in patients who are undergoing forefoot and midfoot surgery. In our systematic review, we identified 34 potential studies out of 318 reviewed that may discuss the incidence of VTE and prophylaxis in forefoot and midfoot patients who were allowed to weight-bear immediately after surgery. However, only 29 reported on the incidence of VTE after forefoot and midfoot procedures57-85. In a total of 38,105 reported forefoot procedures, 37 patients (0.097%) had a VTE while 7 patients (0.018%) had a PE. Of these patients, 2 (0.005%) had a fatal PE. Regarding midfoot surgery, 750 patients were included, of whic
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