October 2013

Pages: 10 - 13

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.

   The FDA adds that this risk of peripheral neuropathy only occurs with fluoroquinolones taken orally or by injection. According to the FDA, this nerve damage may occur soon after patients use the drug and can be permanent.

   Warren Joseph, DPM, FIDSA, says he is well aware of this new warning and multiple other warnings regarding quinolone antibiotics.

   “Nothing surprises me anymore when it comes to quinolones and adverse effects,” explains Dr. Joseph. “This group of antibiotics is one of the most overused in history and that has led to numerous safety concerns.”

   Although the new warning does not surprise Dr. Joseph, he has not seen peripheral neuropathy develop in patients treated with quinolones. He believes this is either because he has greatly limited his use of quinolones over the past 10 years or because many of his patients with diabetes already have peripheral neuropathy so linking the disease to the drug would be more difficult.

   Aside from their safety issues, quinolones are limited in their efficacy for the treatment of lower extremity infections, says Dr. Joseph, a Fellow of the Infectious Diseases Society of America.

   Quinolones do not have a very reliable activity against gram-positive organisms Staphylococcus and Streptococcus, which cause the majority of lower extremity infections, explains Dr. Joseph. He notes that research has shown quinolones to potentiate the development of both methicillin resistant Staphylococcus aureus (MRSA) along with multi-drug-resistant, gram-negative rods.

   “At our hospital, up to 75 percent of our Escherichia coli (E. coli) are resistant to quinolones at this point,” says Dr. Joseph, who is affiliated with Roxborough Memorial Hospital in Philadelphia. “Frankly, I find very few organisms anymore that these drugs reliably treat.”

   In 2008, the FDA warned that quinolones increase the risk of tendinitis and tendon ruptures. This is the “classic” lower extremity complication from these drugs, explains Dr. Joseph.

   “Numerous quinolones have been pulled off the market for safety concerns over the past 20 years …” he adds. “Physicians use these drugs as if they were as safe as a placebo but clearly they are not.”

Study Says PIPJ Arthrodesis Causes More Second Metatarsal Stress Than Other Hammertoe Procedures

By Brian McCurdy, Senior Editor

A recent study in the Journal of the American Podiatric Medical Association concludes that one of three analyzed techniques for hammertoe and claw toe repair can lead to more post-op stress at the second metatarsal.

   The study evaluated three techniques for the correction of hammertoe and claw toe deformities: the flexor digitorum longus tendon transfer, the flexor digitorum brevis tendon transfer and proximal interphalangeal joint (PIPJ) arthrodesis. The authors used multislice computed tomography and 93 tomographic images of the foot from a healthy 36-year-old man.

   The study noted that the proximal interphalangeal joint arthrodesis showed a significantly higher increase in traction and compressive stresses and strain at the medial aspect of the shaft of the second metatarsal bone in comparison to the flexor digitorum longus tendon transfer and flexor digitorum brevis tendon transfer. The authors conclude that the flexor digitorum longus tendon transfer and flexor digitorum brevis tendon transfer have a biomechanical advantage over the PIPJ arthrodesis for hammertoe or claw toe deformities.

   For hammertoe and claw toe, Lawrence DiDomenico, DPM, FACFAS, most often performs a flexor digitorum longus tendon transfer. He cites several advantages to this procedure. With the flexor digitorum longus tendon transfer, there is no bone resection, joint instability, shortening or rotation of the toe, according to Dr. DiDomenico, the Director of the Reconstructive Rearfoot and Ankle Surgical Fellowship within the Ankle and Foot Care Centers in Ohio, and the Kent State University College of Podiatric Medicine.

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