Abstract

Most of current literatures advise on thromboprophylaxis with injectable LMWH for trauma patients. Injectable anticoagulants have got inherent problems of pain, bruising and difficulty in administering the drug, which leads to low compliance. Clexane is derived from a pig's intestinal mucosa, hence could be objectionable to certain proportion of patients because of their religious beliefs. Oral anticoagulants have been used as thromboprophylactic agents in hip and knee arthroplasty. However there is not enough literature supporting their use as thromboprophylactic agent in ambulatory trauma patients with ankle fracture being managed non-operatively as out-patient.

This study looks into the efficacy of oral anticoagulant in preventing VTE in ambulatory trauma patients requiring temporary lower limb immobilisation for management of ankle fracture. The end point of this study was symptomatic deep vein thrombosis (either proximal or distal) and pulmonary embolism.

Routine assessment with a VTE assessment risk proforma for all patients with temporary lower limb immobilisation following lower limb injury requiring plaster cast is done in the fracture clinic at this university hospital. These patients are categorised as low or high risk for a venous thromboembolic event depending on their risk factor and accordingly started on prophylactic dose of oral anticoagulant (Rivaroxaban - Factor Xa inhibitor). Before the therapy is started these patients have a routing blood check, which includes a full blood count and urea and electrolyte. Therapy is continued for the duration of immobilisation. Bleeding risk assessment is done using a proforma based on NICE guideline CG92. If there is any concern specialist haematologist advice is sought. A total of 200 consecutive patients who presented to the fracture clinic with ankle fracture, which was managed in plaster cast non-operatively, were included in this study. They were followed up for three months following injury. This was done by checking these patients’ radiology report including ultrasound and CT pulmonary scan (CTPA) test on hospital's electronic system. Fracture of the lateral malleolus which include Weber-A, Weber-B and Weber-C fractures were included in the study. Also included were bimalleolar fractures and isolated medial malleolus fractures. Complex pilon fractures, polytrauma and paediatric patients were excluded from the study.

Only one case of plaster associated isolated distal deep vein (soleal vein) thrombosis was reported in this patient subgroup. There was no incidence of proximal deep vein thrombosis or pulmonary embolism. No significant bleeding event was reported.

Injectable low molecular weight heparin (LMWH) rather than oral anticoagulant has been recommended by most of the studies and guidelines as main thromboprophylactic agent for lower limb trauma patients.

Introduction

Growing evidence in the literature suggests better clinical and functional outcomes and lower re-rupture rates with repair compared to non-operative treatment of ruptured Achilles tendon. There are however, concerns of wound infection, nerve injury and scar tenderness with the standard open and percutaneous techniques of repair. We aim to evaluate clinical and functional outcomes and complications in patients treated with minimally invasive Achillon device.

There is mixed evidence in the literature regarding increasing age, ASA and BMI as risk factors for surgical site infection in orthopaedic surgery. To investigate the matter further, we examined 1055 wounds in 1008 patients in the Department of Trauma and Orthopaedic Surgery at University College London Hospital between 2000 and 2006. All patients with a minimum two-night stay were included. Data was collected by four designated research nurses. The age, height, weight and ASA status of each patient was recorded. All wounds were classified using ASEPSIS. This is a quantitative wound scoring method which is a summation of scores calculated from visual wound characteristics and the clinical consequences of infection.

Our results showed a strong linear association between age and ASEPSIS scores. Single variable regression analysis showed a t value of 3.32 and p value of 0.001. A similar linear association was seen between ASA grading and ASEPSIS scores. Single variable regression analysis showed a t value of 2.75 and p value of 0.006. The association between BMI and ASEPSIS scores was markedly different from that seen with age and ASA. The graph was U-shaped with patients with a BMI of 25-30 having the lowest average ASEPSIS scores. Patients with a lower and a higher BMI had higher average ASEPSIS scores. Single variable regression analysis was not significant since the relationship between BMI and ASEPSIS scores is not linear.

In conclusion, there are clearly defined patient groups who are at increased risk of developing a surgical site infection: older patients, patients with a higher ASA, and patients with both a low and high BMI. These patients should be targeted to reduce overall infection rates. This can be achieved by ensuring adequate antibiotic prophylaxis, having a low threshold to treat suspected infection and arranging regular follow-up.