October 2013

Do Patients With Achilles Tendon Ruptures Have An Elevated DVT Risk?

By Brian McCurdy, Senior Editor

Patients who experience Achilles tendon ruptures face a high incidence of deep vein thrombosis (DVT) both before and following surgical treatment, according to a recent study in the Journal of Foot and Ankle Surgery.

   The study consisted of a retrospective chart review of 115 patients. Twenty-seven of those patients with a surgically treated Achilles tendon rupture developed a symptomatic DVT either preoperatively or after surgery, with researchers noting about one-third of those patients had a DVT diagnosis before surgery. Of the 27 patients with DVT, the authors note three had a proximal DVT and 24 had a distal DVT. One patient developed a pulmonary embolism, according to the study. The authors suggest having a high level of suspicion for DVT during the follow-up period and educating patients about the risks of DVT, especially those over 40.

   Bradly Bussewitz, DPM, has not experienced patients developing DVT after Achilles tendon ruptures, something he attributes to “prevention, luck or asymptomatic presentation.” William DeCarbo, DPM, has not had any patients who had DVTs after Achilles ruptures although he has spoken to colleagues who have.

   “Perhaps there is something to this specific injury or the patient positioning surgically that predisposes patients to DVT formation,” speculates Dr. DeCarbo, a fellowship-trained foot and ankle surgeon who is in private practice in Pittsburgh.

   When monitoring patients for DVT, Dr. Bussewitz says the most important keys are a thorough clinical exam and having an appropriate index of suspicion. Following a positive clinical exam, he suggests ordering an urgent ultrasound to confirm or deny the presence of DVT. If the ultrasound is positive, one should initiate a pharmacologic response and appropriate consult, according to Dr. Bussewitz, a fellowship-trained foot and ankle surgeon who practices in Iowa City, Iowa.

   In Dr. DeCarbo’s practice, the incidence of DVT in all patients is low and consistent with previously published rates of 0.22 percent to 3.5 percent with risk factors being a previous DVT, age and extensive reconstructive surgery. For treatment, he will use compression stockings on the non-operative leg. For low-risk patients, he will use EC aspirin 325 mg for 30 days postoperatively. For high-risk patients, he prescribes enoxaparin sodium (Lovenox, Sanofi Aventis) 40 mg SC daily for 21 days postoperatively. Dr. DeCarbo says the vast majority of his patients do not receive prophylaxis.

   Dr. Bussewitz emphasizes that preventing DVT is based on risk stratification, acknowledging there are no strict guidelines regarding foot and ankle DVT prophylaxis. If patients are low risk, he says they receive compressive socks while high risk patients receive sequential compresive devices. Dr. Bussewitz also provides postoperative aspirin, patient education and emphasizes early mobilization. If the patient has additional risks, such as a history of DVT or a hypercoagulable state, he initiates low molecular weight heparin for 21 days following surgical repair.

   “Our most important strategy involves a strong, quick repair, allowing confidence in protected early weightbearing,” says Dr. Bussewitz. Similarly, Dr. DeCarbo supports early mobilization of the operative leg as well as the non-operative leg with or without weightbearing, as well as being active with the upper body.

   Editor’s note: For a related article, see “Current Concepts In Treating Achilles Tendon Ruptures” in the September 2009 issue.

FDA Requires Updated Labeling On Fluoroquinolones Due To Peripheral Neuropathy Risk

By Danielle Chicano, Editorial Associate

The Food and Drug Administration (FDA) recently announced that it is requiring updated labeling and medication guides for all fluoroquinolone antibacterial drugs to warn patients about the potential side effect of peripheral neuropathy.

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