Authors: Mansoor Ali Khan  ( Department of Orthopedics, The Indus Hospital, Karachi, Pakistan )
Sateesh Pal  ( Department of Orthopedics, The Indus Hospital, Karachi, Pakistan )
Muhammad Amin Chinoy  ( Department of Orthopedics, The Indus Hospital, Karachi, Pakistan )
Syed Kamran Ahmed  ( Department of Orthopedics, The Indus Hospital, Karachi, Pakistan )

Objective: To find out the frequency of deep vein thrombosis in hip fracture patients.
Methods: The prospective, cross-sectional study Was conducted at Indus Hospital, Karachi, from November 2016 to September 2017, and comprised patients with hip fractures who were scanned for the presence of deep vein thrombosis on both lower limbs preoperatively at the time of presentation and postoperatively on post-op day 3 and day 28. No thrombo-prophylaxis was provided to the patients. Risk factors for deep vein thrombosis were also assessed. Data was analysed using SPSS 21.
Results: Of the 109 patients, 50(46%) were male and 59(64%) were females. The overall mean age was 64.59 ± 9.82 years. Deep vein thrombosis was found in 4(3.66%) patients; 2(50%) preoperatively and 2(50%) in the early postoperative period. No deep vein thrombosis was found in any patient on postop day 28.
Conclusion: The frequency of deep vein thrombosis in Pakistani geriatric patients with hip fractures was found to be low compared to the western population.
Keywords: Hip fracture, Complications, Mortality. (JPMA 69: S-21; 2019) 

Introduction

Deep vein thrombosis (DVT ) is a medical condition characterised by formation of thrombi within the deep veins of the body.¹ It is a common complication in orthopaedic surgery that can lead to life-threatening pulmonary embolism (PE) since DVT is usually present in more than 90% of PE cases. Studies revealed that venous function was significantly reduced after surgical procedure involving proximal femur which correlated with the occurrence of DVT.²
DVT and resulting PE are the major causes of mortality and morbidity in elderly patients who have undergone a hip fracture surgery.³ A combination of  old age, lower limb trauma, hospitalisation, immobility and orthopaedic surgery puts hip fracture patients at a high DVT risk.⁴ Pharmacological thromboprophylaxis is not routinely used in Asian patients because postsurgical DVT is thought to be low in incidence. However, in a multinational and multi-ethnic study on Asian population, Piovella et al. concluded that the incidence of DVT in the absence of thromboprophylaxis after arthroplasty and hip fracture surgery is equivalent to that in Western countries.⁵ DV T diagnosis should be established by special
investigations as symptoms and signs are non-specific and may be entirely lacking.⁶ Though contrast venography is considered standard method for DVT diagnosis, its widespread use is hampered mainly due to the invasive nature of the test, cost issues, limited availability, and the side effects associated with the use of the contrast material.⁷ Doppler ultrasound has a sensitivity of 100% and a specificity of 97%. It is a safe, effective and quick technique for diagnosing venous thrombosis in patients. It is well accepted by both patients and staff and is without any inherent risk, but it can be operator-dependent.⁸
Though much work has been done on DVT following arthroplasty, there is comparatively less literature about DVT and its consequences in the setting of hip fractures.⁹ Although major orthopaedic surgery is inclusive of total hip replacement (THR), total knee replacement (TKR) and hip fracture surgery, majority of the literature has done  very little evaluation of hip fracture surgery ¹⁰ Though routine chemoprophylaxis is provided to all patients of major trauma in Western countries, its routine use in the Asian population is still lacking because only a few reports are available on this topic from Asian countries, and majority of them report low incidence of DVT compared to Western countries.¹¹A study done in India in 2006 reported 8.6% incidence of venous thromboembolism in THR patients, 6.8% in hip fracture surgery group and none in TKR. Overall incidence of venous thromboembolism was 6.12%.¹² A study done in Singapore reported 8% incidence of DVT after total hip arthroplasty (THA)¹³ Another study done in India reported 43.2% incidence of DVT in THA patients who had received thromboprophylaxis and 60% incidence of DVT in those who did not receive thromboprophylaxis. Overall incidence of DVT in THA patients was reported as 52.1%.¹⁴ The current study was planned to assess the frequency of pre-operative and postoperative incidence of DVT inpatients with hip fractures.

Subjects and Methods


The prospective, cross-sectional study Was conducted at Indus Hospital, Karachi, from November 2016 to September 2017, and comprised patients with hip fractures who were scanned for the presence of DVT on both lower limbs preopeatively at the time of presentation and postoperatively on post-op day 3 and day 28. Those included were patents aged 50-80 years of either gender with duration of fracture less than 15 days. Approval was obtained from the institutional ethics review board, and informed consent was taken from all the subjects. Those who declined to participate were excluded. Those included were scanned for the presence of DVT with the help of Doppler ultrasound by an experienced radiologist. No thromboprophylaxis was provided to the patients during study period. Risk factors for DVT were also as se ssed. Data was analysed using SPSS21.

Results

Of the 109 patients, 50(46%) were male and 59(54%) were females. The overall mean age was 64.59 ± 9.82 years (Table 1).



Deep vein thrombosis was found in 4(3.66%) patients; 2(50%) preoperatively and 2(50%) on post-op day 3 (Tables 2-3).







Mean duration of surgery post-fracture was 7.66 ± 3.43 days. Majority of fractures were femur intertrochanteric fractures 60(55%). All 4(3.66%) patients with DVT had proximal DVT in the affected lower limb. All were asymptomatic and no patient developed signs and symptoms of PE.

Discussion

DVT is a major health problem in Western countries necessitating the use of thromboprophylaxis. Not many studies are available regarding incidence of DVT i Pakistani patients which results in uncertainty regarding the use of thromboprophylaxis in our patients. The available data on DVT incidence in Asian patients is limited due to the lack of clinical trials which makes use of  thromboprophylaxis controversial.¹⁵ Interestingly, community surveys have found that Asian people living in the United States appear to have comparatively lower DVT rates and PE than Americans of European origin, suggesting that genetic and cultural traits may contribute to thrombosis.16 Cho et al. found 2.6% incidence of pre-operative DVT in patients with hip fractures in Korean population.³ In most studies on DVT in hip fracture patients, no preoperative
screening investigations were done, so preoperative DVT was not assessed separately. Therefore, those studies were not able to identify whether DVT was pre-existing or a development following surgical trauma. The current study scanned all the hip fracture patients for DVT before the surgery, and those who did not have DVT on pre-operative assessment were scanned further for post-operative DVT assessment. Doppler ultrasound was used for screening of DVT before and after hip surgery. Doppler ultrasound is a safe, effective and quick technique for diagnosing venous thrombosi in patients.⁸ Use of chemo-thromboprophylaxis is effective in preventing DVT, but is associated with the risk of major bleedin g complications, so th e use of chemo - thromboprophylaxis should be selective. Gent et al. found bleeding complications in 4% hip fracture patients during treatment with orgaran and aspirin.¹⁷ The current study did not use any mechanical or chemoprophylaxis for DVT. The frequency of DVT was 3.66% which is relatively low compared to that observed in Western population. In our study, the frequency of DVT was found to be higher in the injured limb than the non-injured limb, higher incidence of proximal DVT than distal DVT, and higher in patients suffering intertrochanteric femoral fracture than the femoral neck fracture. The duration of fracture was greater among patients with DVT, which suggests that immobility increases the risk of DVT. However, the differences were not statistically significant. Both of our post-operative DVT cases occurred during the early post-operative period (within 1 week of surgery). This correlates with the findings that DVT is much more common in the early postoperative period compared to the late rehabilitation period. Preventive measures to reduce venous thromboembolic complications in orthopaedic surgery is a commo practice in Western countries, but it is highly controversial in Pakistan as available reports show low incidence of DVT. However, thromboprophylaxis for our patients wit risk factors for DVT should be considered individually. Large-scale multi-centric study on the incidence of DVT in hip fractures in Asian countries is needed to confirm
the findings of the current study.

Conclusion

The frequency of DVT in Pakistani geriatric patients with hip fractures both pre-operatively and post-operatively was found to be low compared to Western population. Thromboprophylaxis for patients with risk factors for DVT can be considered individually.

Disclaimer: None.
Conflict of Interest: None.
Source of Funding: None.

References

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