APMA News - July/August 2023 - 24

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DVT/PE Prophylaxis for Podiatric
Surgery and Treatment Requiring
Immobilization-Is it Necessary?
It is not uncommon for a podiatric physician to be
named in a lawsuit when a patient suffers a deep
vein thrombosis or pulmonary embolism (DVT/PE)
following podiatric surgery or treatment requiring
immobilization. Allegations against the physician
commonly include:
* Failure to place the patient on DVT/PE prophylactic
anticoagulation therapy
* Failure to recognize the patient was at high risk
for development of a DVT/PE
* Failure to provide information regarding the
potential for the development of a DVT/PE to a
patient prior to undergoing surgery and obtain
appropriate informed consent
Unfortunately, there is no consensus regarding
when or who DVT/PE pharmacologic and/
or mechanical prophylaxis for podiatric surgery
and treatment requiring immobilization should
be instituted.
The American College of Foot and Ankle
Surgeons (ACFAS) published " Clinical Consensus
Statement: Risk, Prevention, and Diagnosis of
Venous Thromboembolism Disease (VTED) in
Foot and Ankle surgery and Injuries Requiring
Immobilization " (ACFAS Consensus Statement) in
2015. This consensus statement concluded that
routine prophylaxis is not indicated and that the decision
to place a patient on prophylactic anticoagulation
therapy should be based on each individual
risk/benefit ratio.
The American Orthopaedic Foot and Ankle
Society (AOFAS) published a position statement
on " The Use of Venous Thromboembolic Disease
Prophylaxis (VTED) in Foot and Ankle Surgery "
on February 11, 2020. The AOFAS position is that
there is currently insufficient data to recommend
for or against routine venous thromboembolic
disease prophylaxis for patients undergoing foot
and ankle surgery. AOFAS recommends that the
decision to implement anti-thrombotic prophylaxis,
as well as the measures used to do so, should be
based upon a patient-specific risk/benefit analysis
that takes into consideration the patient's risk
for VTED and the potential risks of the proposed
prophylactic measures.
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JULY/AUGUST 2023
The United Kingdom's National Institute of
Clinical Excellence (NICE) recommends use of
chemoprophylaxis following all lower extremity
surgery with one or more of the following
risk factors:
* Greater than 60 years of age
* Lower extremity surgery lasting greater than
60 minutes
* A BMI greater than 30
* A prior history of DVT in the patient or a first
degree relative
While there are no clear answers regarding DVT/
PE prophylaxis, physicians can take steps to reduce
their risk of a lawsuit or defend themselves in the
event of a lawsuit by a patient who suffered a DVT/
PE following foot and ankle surgery or treatment
requiring immobility.
Risk Assessment
First, it is important for the physician to assess
the patient for risk of developing DVT/PE and
determine based upon the physician's medical
judgment whether the patient should receive
mechanical and/or chemical prophylaxis and for
how long.
ACFAS has identified risk factors for venous
thromboembolism disease during management of
foot and ankle conditions. These risk factors are divided
into three categories: patient-specific, related
to the treatment course, and related to the surgery
or injury itself.
Several VTED risk evaluation tools are available,
such as Caprini Risk Scoring, Geneva Score, Wells
Criteria, and others. While these are not specific
to podiatry, most identify a common set of risk
factors and can assist the physician in determining
if the patient is at low-, moderate-, or high-risk for
developing VTED.
Risk/Benefit Analysis
Chemical prophylaxis is not without risk. Risks
include bleeding, increased risk of infection, increased
risk of wound healing complications, drug
interactions, heparin-induced thrombocytopenia,
cost, and no guarantee of protection.
APMA News - July/August 2023

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