D. Doppler ultrasound of the leg would be the most appropriate initial intervention given the history provided. While RICE and NSAIDs would be reasonable for a muscle strain, the presentation of new onset calf pain after prolonged exercise in a retired individual raises suspicion for deep vein thrombosis, which should be evaluated with Doppler ultrasound. Plain films and antibiotics are not indicated based on the information given.

1. POST-OPERATIVE COMPLICATIONS
OF SURGERY
DEEP VENOUS THROMBOSIS (DVT)
Agbeko Ocloo FWACS
Department of Surgery
University of Ghana School of Medicine

2. DISCLAIMER
• No Conflict of Interest

3. Deep Vein Thrombosis
• This condition is the most deadly of all
complications in orthopedic surgery
• It is arguably the most preventable
complication
• Awareness?
• Focus of this CPD is to discuss pathophysiology
and prevention.

4. PROBLEM
• Hospital Deaths (most preventable cause)
• In 1989 Sandler D A ; Martin J F: found a death
rate of 10% from Pulmonary Embolism (PE) in
a Sheffield hospital
• 2011 Douglas Kopke et al found the death rate
from PE to be 2% in a large teaching hospital
in the UK

5. Africa
• Danwang C. et al Epidemiology of venous
thromboembolism in Africa: a systematic
review: (Journal of thrombosis and
haemostasis August 2017)
• Included 21 studies. The great majority of the
studies yielded a moderate risk of bias.
• The prevalence of deep vein thrombosis (DVT)
varied between 2.4% and 9.6% in
postoperative patients

6. • Rates of 380 and 448 per 100 000 births per
year in pregnant and postpartum women.
• The prevalence of pulmonary embolism (PE) in
medical patients varied between 0.14% and
61.5%, with a mortality rate of PE between
40% and 69.5%.
• The case-fatality rate after surgery was 60%.
Overall

7. • Surgical patients: 31.7–75% of the patients
were at risk of VTE, and between 34.2% and
96.5% of these received VTE prophylaxis.
• GHANA
• Very little data. Couple of case reports
• KorleBu Teaching Hospital
• Monthly Surgical mortality meetings: PE is still
a common cause of death ( 40% of total
deaths from PE)

8. Increased Awareness World Wide
• NOTABLE CELEBRITIES WHO HAVE SUFFERED
FROM DVT

9. Serena Williams

10. Chris Bosh

11. Nick Cannon

12. Heavy D

13. Dennis Farina (Law & Order)

14. Zsa-Zsa Gabor

15. Nene Leakes ( Real Housewives of
Atlanta)

16. Cardi B

17. ORTHOPEDIC PATIENT
• F. PIOVELLA et al (Journal of Thrombosis and
Haemostasis) Aug 2005
• Deep-vein thrombosis rates after major
orthopedic surgery in Asia. An epidemiological
study based on postoperative screening with
centrally adjudicated bilateral venography
• DVT rate of 40% similar to reports from
western counties

18. Virchow's Triad

19. Hypercoagulable conditions
• Sickle cell disease
• Multiple Myeloma
• Metastatic Bone diseases
• Smoking
• Dehydration
• Sepsis

20. Endothelial Damage
• Reaming of medullary canal
• Bone Cement? Real data but still a risk
• Tourniquets: Some surgeons use it sparingly
• Retractors
• Tissue hypoxia
• Hemorrhage

21. Stasis
• Lower extremity fractures/injuries
• Pelvic and Hip surgeries
• Knee Surgeries
• Lower leg, foot & ankle (1%)

22. Plaster of Paris Casts

24. Intraoperative Stasis

25. Patient positions

26. Popliteal vein compression

27. Femoral vein compression

28. Risk Assessment
• Caprini score and Padua prediction score: not
extensively validated:
• Both the surgical interventions and the
characteristics of the patients are involved in
risk estimation
• The most used risk classification scale is the
one described by Geerts

30. When should prophylactic
anticoagulation begin
• Immediately
• elderly patients with hip fractures presenting
after 48hrs had a DVT rate of 50-75%
• Caution in injured patients with ongoing
bleeding (intra abdominal and intracranial
bleeds)
• Exsanguinating pelvic fractures

31. General Measures
• Same day admission
• Regional anesthesia
• Reduced Operating time
• Fast Track Analgesia
• Active or Passive mobilization: Begin same day
after surgery. Get the patient out of Bed!
• Mean hospital stay 5 days (Caution)
• Adequate hydration. Especially in the elderly
population. (Crystalloids)

32. TED STOCKINGS

33. • Every patient should be wearing this
• No demonstrable difference between calf or
thigh level ones.
• Issues with compliance
• Complications if not used properly

34. Intermittent compression Pumps

35. Hospital Bed Cycle

36. • General measure plus mechanical devices are
adequate prophylaxis for patients with low
risks.
• At the least orthopedic patients should have
TED stockings and on-table compression
pumps

37. Pharmacological Prophylaxis
• Start as soon as possible and continue until
risk fades
• Bleeding: Concerns about bleeding leading to
persistent wound drainage and infection
• Risk/benefit ratio for bleeding after the
pharmacologic prophylaxis is different with
every patient
• Ideally the type of thrombo-prophylaxis
should be customized according to risk.

38. Aspirin
• Anti-platelet aggregator
• Used for prevention of clots in the arterial
circulation
• Previously has not been recommended for
venous thrombosis
• Recent interest in its use for venous
thrombosis

39. Aspirin
• Cheap
• Easy to dose (325mg daily)
• No elaborate tests
• Less wound complications
• ACCP & AAOS are in disagreement

40. • Current surgical care improvement project
measures do not include aspirin as an
appropriate sole option for the prevention of
DVT, but in patients undergoing elective TKA
or who have a contraindication to
pharmacologic prophylaxis and undergo a THA
or HFS, aspirin in conjunction with
compression devices as part of a multimodal
approach would meet these measures.

41. • A Systematic Review on the Use of Aspirin in the
Prevention of Deep Vein Thrombosis in Major
Elective Lower Limb Orthopedic Surgery: An
Update from the Past 3 Years. Dylan AM et al
• The Surgery Journal: Open access journal
published December 2017
• Conclusion Aspirin is an effective and safe
prophylactic against deep vein thrombosis
following major elective lower limb arthroplasty
surgery. DVT rate 0.66% in 43,012 patients

42. Warfarin
• Vitamin K antagonist
• Long history and data on its use
• Gold Standard for the prevention and
treatment of DVT & PE
• Cheap
• ‘YOU KNOW WHERE YOU ARE’ : Dosage can be
adjusted for more anticoagulation or less in
terms of INR (2-4)

43. • Difficult to dose and maintain therapeutic
range. (Anecdotal). Personal solution is to use
the same source for the drug and
same/standard lab tests
• Increased incidence of wound complications
• INR 2.0

44. Unfractionated Heparin
• Available
• Cost?
• Dosing regimen
• Local complication at injection site
• Wound haematoma and drainage is a big
concern
• Difficult to use in the outpatient setting

45. Low Molecular Weight Heparins
• Developed to curb some of the problems with
unfractionated heparins
• No serum monitoring
• Lower incidence of hematomas and wound
complications (unfractionated heparin)
• Convenient daily dosing
• Outpatient use.
• Cost

46. Oral Anticoagulants
• New class of drugs
• Factor Xa Inhibitors & Direct thrombin
inhibitors
• No blood level monitoring
• Convenient once daily dosing and use in the
outpatient setting
• Cost

47. Recommended
• Low Risk: Ambulation + TED Stockings
• Moderate Risk: TED stockings + Compression
Pumps +/- anticoagulant
• High Risk: TED stockings + Compression
Pumps + Anticoagulant

48. Duration for prophylaxis
• Prophylaxis must continue until risk is
low/absent
• ACCP & AAOS recommends minimum
durations and not maximum
• Summary: minimum of 10-14 day (Knee) & 28-
35 days (Hip)
• Maximum recommendations by type of
surgery and other risk factors
• Anecdotal

49. Post Operative Ultrasound
• American Academy of Orthopaedic Surgeons
• Released September 11, 2013
• Avoid performing routine post-operative deep vein
thrombosis ultrasonography screening in patients
who undergo elective hip or knee arthroplasty.
• Since ultrasound is not effective at diagnosing
unsuspected deep vein thrombosis (DVT) and
appropriate alternative screening tests do not exist, if
there is no change in the patient’s clinical status,
routine post-operative screening for DVT after hip or
knee arthroplasty does not change outcomes or clinical
management.

50. Conclusion
• DVT & PE are preventable in the hospital
setting
• All hospital workers should be educated on
prevention and recognition
• There is still a lot of unanswered questions
and further research is needed.
• It doesn’t matter your choice for
anticoagulation, make sure you put the
patient on “Something”.

51. Conclusion
• Incidence of DVT and PE in the subregion is
unacceptable
• Lot more awareness should be raised amongst
health care personnel
• Hospital admission forms should have a
section for assessment of DVT risk and
interventions prescribe
• New studies and Data

52. Question:
• A 61yr-old-male presents to the polyclinic
with pain in the right calf of three days
duration. He is newly retired from public
service and has taken to playing tennis to keep
fit. 5 days prior to presentation he had played
for 3 hrs. and believes he might have strained
his right calf. Examination was unremarkable
except for mild tenderness of the medial
gastroc muscle. Which intervention will be the
most appropriate?

53. Answers
A. Rest, Ice, Compression & Elevation (RICE) and
NSAIDS.
B. Plain X-rays of the leg
C. Prescription for broad spectrum antibiotics
D. Doppler ultrasound of the leg