Incidence and location of deep vein thrombosis of lower extremity following surgery of tibial plateau fracture

INTRODUCTION

Tibial plateau fractures are commonly seen fractures of lower limb. They are difficult to manage since they are mostly associated with soft tissue injuries.

Tibial plateau fracture is common fracture following knee injury, represents 1-2% of adult fractures and 32% of peri-knee fractures.¹ They usually occur as a result of high velocity trauma and are common in young age group.

Tibial plateau is one of the most important weight bearing areas of the body with 80% borne by tibia and remaining by fibula. Any fracture in proximity of the joint is very important since restoring articular congruity is an essential step for functional outcome.

DVT a subset of venous thromboembolism (VTE) is a known and significant cause of morbidity, pulmonary embolism (PE), and even mortality in all hospitalized patients, especially after trauma and lower extremity fracture, which further carries risk of significant morbidity and mortality.^2,3

Tibial plateau fractures are often associated with a poor prognosis because of the associated factors such as cartilage destruction and soft-tissue envelope damage, as well as complications including compartment syndrome, postoperative infection, knee instability or stiffness, and posttraumatic osteoarthritis.^4-7

Such complications result in extended hospitalization and delayed recovery after Tibial plateau fractures. A extended period of extremity elevation and restricted mobility place patients at an increased risk for the development of DVT both preoperatively and postoperatively. Hypercoagulation state, trauma stress, and systemic inflammatory response after injury are early factors that contributed to the occurrence of DVT.⁸

Increased duration of extremity elevation and restricted mobility, which is required to allow the soft tissue envelop safe for surgical interventions aggravates the risk of DVT.

Complete understanding of the related risk factors is critical for prevention of occurrence of DVT, and it is of more clinical significance to distinguish between proximal and distal venous thrombosis, which allows more accurate diagnose and a more aggressive therapy for the proximal DVT. ⁹ The objective of our study is to determine the incidence and risk factors associated with DVT in patients operated for tibia plateau fractures.

METHODS

This study was a prospective observational randomized study performed at MGM medical college and MY hospital, Indore, M.P. during the period from September 2019 to August 2022 after clearance from the scientific and ethical committee of the institute which is one of the biggest tertiary care centres in central India.

Each patient visiting the emergency OPD/ casualty with chief complaint of tibial plateau fractures was evaluated. Primary ATLS protocol was followed and patient was hemodynamically stabilized.

All patient between age 18-70 who had a tibial plateau fracture and are willing for weekly USG venous doppler are included to be a part of the study. All patients with pathological fracture, hyper-coaguable state, preoperative DVT and fracture more than 3 week are excluded from the study.

Patients who fulfilled the inclusion criteria were recruited for the present study after taking pre-informed written consent. All the patients underwent USG Doppler prior to surgery to rule out DVT pre operatively.

All the patients were operated by anterolateral or/and posteromedial plating of proximal tibia depending on the fracture pattern. USG Doppler of the lower limbs was done on day 2, day 7, day 14, day 21, day 28 for screening of external iliac vein, common femoral vein, superficial and deep femoral vein, long saphenous vein, sapheno femoral junction, popliteal vein, short saphenous vein.

The criteria for positivity were based on compressibility, lumen, resting flow, phasic variation, distal augmentation, Valsalva maneuver. DVT involving popliteal vein or proximal to it was defined as proximal DVT while those distal to the popliteal vein will be defined as the distal DVT.

All the data was collected and evaluation was done for determining the risk factors associated with DVT in operated patients of tibial plateau fractures during the first four weeks. All the statistical analysis was done using the SPSS 21.0 software. The sample size was calculated using previous years database of tibial plateau fractures.

RESULTS

A total of 79 patients were included in the study who had tibial plateau fracture.

Out of the total patients included in the study, four patients were diagnosed with DVT post operatively. Three were males and one was female (Table 1).

Out of the total patients diagnosed DVT, two patients had DVT in age 51-60 years and one each in 31-40 years and 41-50 years respectively (Table 2).

All the four patients had high energy trauma. Three patients were operated with open reduction internal fixation and one patient had undergone surgery using MIPPO technique (Table 3).

It was found that all the four patients who had DVT had duration of surgery of more than one hour (Table 4). Two patients who had DVT had preoperative interval from injury to surgery was of three weeks whereas one patient had DVT in preoperative interval one week and two weeks respectively (Table 5).

Table 6 shows association of Schatzker type with DVT which shows that DVT was found in patient with high energy trauma. 50% for type IV, 25% for type V and 25% for type VI.

It was observed that three patient had DVT distal to knee and one patient had DVT proximal to knee (Table 7).

DISCUSSION

Among 79 patients evaluated in the present study, 40.5% (32/79) belonged to 20-30 years age group followed by 32.9% (23/79) for age group 41-50 years, 22.8% (18/79) for age group 31-40 years and least 3.8% (3/79) patients belonged to 51-60 years age group respectively.

The average age of patients was 35.28±10.01. The results of our study were comparable to Li et al and Zhu et al.^8-11 Males showed a higher prevalence i.e., out of 79 patients 64.6% (51) compared to females i.e., 35.4% (28/79). The male to female ratio was found to be 1.82:1.

The results of our study were comparable to Zhu et al and Li et al who stated male preponderance.^8,11 Most of the fractures in our study were due to high energy trauma i.e., 62% (44/79) and secondly by low energy trauma i.e.,38% (35/79). 51.9% of the patient had duration of surgery of <1 hour and the remaining proportion 48.1% had duration >1 hour. All the patient who had DVT had duration of surgery more than 1 hour. In our study Two out of four patients who had DVT had preoperative interval of 2-3 week. Out of 4 patients who developed DVT incidence being 5.06%, 3 were identified below the knee (Distal DVT) and 1 was identified above the knee (Proximal DVT). Incidence of 1.26% for proximal and 3.8% for distal DVT was observed.

The limitations of our study were short sample size, loss to follow up, investigator bias in diagnosing the condition aptly.

CONCLUSION

DVT is a very common complication which are usually silent. It can cause pulmonary thromboembolism which can be threatening and add to morbidity and mortality of the patient. Through our study we conclude that there are 6 risk factors which are strongly associated with DVT-Increased age, male gender, energy of trauma, open reduction increased preop interval and prolonged duration of surgery. These epidemiologic data may be helpful in individual assessment, risk stratification and development of targeted prevention programs.

ACKNOWLEDGEMENTS

Author would like to thanks to all our patients who agreed to be a part of the study. Also, to all our staff members at department and department of radiology at our institute who helped us with the basic management of the patients. We would also like to thank all the staff and doctors of our department who supported us for our work.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

REFERENCES

1. 1. Zhang Y. Clinical epidemiology of orthopedic trauma. 2^nd edi, Thieme. 2012.
2. 2. Lapidus LJ, Rosfors S, Ponzer S, Levander C, Elvin A, Lärfars G et a. Prolonged thromboprophylaxis with dalteparin after surgical treatment of achilles tendon rupture: a randomized, placebo-controlled study. J Orthopaedic Trauma. 2012;21(1):52-7.
3. 3. Lapidus JL, Ponzer S, Elvin A, Levander C, Larfars G, Rosfors S et al. Prolonged thromboprophylaxis with Dalteparin during immobilization after ankle fracture surgery: a randomized placebo-controlled, double-blind study. Acta Orthopaedica. 2007;78(4):528-35.
4. 4. Gaston P, Will EM, Keating JF. Recovery of knee function following fracture of the tibial plateau. J Bone Joint Surg Br Vol. 2005;87(9):1233-6.
5. 5. Gardner MJ, Yacoubian S, Geller D. Prediction of soft-tissue injuries in Schatzker II tibial plateau fractures based on measurements of plain radiographs. J Trauma. 2006;60(2):319-23.
6. 6. Stevens DG, Beharry R, McKee MD. The long-term functional outcome of operatively treated tibial plateau fractures. J Orthop Trauma. 2001;15(5):312-20.
7. 7. Houben PF, Van der Linden ES, Van den Wildenberg FA. Functional and radiological outcome after intra-articular tibial plateau fractures. Injury. 1997;28(7):459-62.
8. 8. Li J, Zhu Y, Chen W, Zhao K, Zhang J, Meng H et al. Incidence and locations of deep venous thrombosis of the lower extremity following surgeries of tibial plateau fractures: a prospective cohort study. J Orthop Surg Res. 2020;15(1):605.
9. 9. Calfon M, Seddighzadeh A, Piazza G, Goldhaber SZ. Deep vein thrombosis in orthopedic surgery. Clin Appl Thromb Hemost. 2009;15(5):512-6.
10. 10. Choufani C, Aguir S, Barbier O. Thromboembolic risk in repatriated patients with traumatic lower-limb injuries. J Med Vasc. 2018;43(6):342-6.
11. 11. Zhu et al. Incidence and locations of preoperative deep venous thrombosis (DVT) of lower extremity following tibial plateau fractures: a prospective cohort study. J Orthop Surg Res. 2021;16:113.