It's my pleasure to reintroduce Dr. Seth J. Baum to the PRESENT community, who brought his editorial series, Bridging the gab Between Podiatry and General Medicine, to us about a year ago. A perfect topic for Dr. Baum, as he has been instrumental in bringing the allopathic and complementary forms of cardiology together.

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I am a Preventive Cardiologist and Clinical Lipidologist; although for the first half of my career, I practiced solely interventional cardiology and electrophysiology. My charge now is to discuss six medical maladies that bridge the worlds of Podiatric and General Medicine. There are many subjects I could have chosen as my starting point. I have opted for Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE), not just because these disorders possess a powerful personal significance for me, but also because they are so often misdiagnosed. Read the full article.

Please share your thoughts and experiences with DVT and PE.

  This discussion is extremely important for podiatrists to become familiar with. In my practice as I see more patients with foot problems assosciated with more medical morbidities,such as diabetes,arthritis,vascular disease,etc, the need for hyper vigilance of DVT and PE is acute.I have had a number of cases where patients are treated for their foot problem and part of the treatment is immobilization of some kind. If they are not already on an anti-coagulant then we will empirically place them on ASA,or lovenox until we can get in touch with the PCP to review which method is better for that particular patient. As Podiatrists become more involved as part of the medical team taking care of complex cases,the more important it is that we develop an even higher index of suspicion  ( HIS ) when patients present with the symptoms that might suggest either DVT or PE.
Tim Shea DPM
Concord,California

In my practice, I generally initiate DVT prophylaxis following my large reconstructive cases where i anticipate the patients will be non-weight baring and will be largely sedentary in the post operative period.  This is especially true if the patient presents with any significant risk factors for the development of DVT.  Also, all of my patients are educated on potential signs and symptoms of the development of  DVT so that i can follow with a wary eye.  In those instances in which patients call in complaining of calf pain or other DVT-like symptoms, we bring them in rapidly and get them scanned to evaluate for the possibility of clot.

I agree with the previous comments, a cliniican must  maintain a high level of clinical suspicion to avoid this potential outcome.

Please comment on  venous  Doppler  exam versus d-dimer test for DVT.

I agree that DVT diagnosis requires a high index of suspicion.  Increasingly, I'm placing more patients on anticoagulants (Fragmin is my drug of choice) for 10 days postop.  A couple of years ago I had a patient 3days s/p Brostrum repair who called me complaining of increasing calf pain and shortness of breath.  I immediately sent him to the ER.  He had not only a calf DVT but also a saddle PE that may have killed him had we not intervened immediately.  Thrombolytics were used successfully and he did OK (unfortunately his incision dehisced and healed after some local wound care).  I did not have him on anticoagulants postop.  It only takes one of these scary episodes to prove you need a high level of suspicion. 

I don't use D-dimer at all for DVT diagnosis.  It's only useful if negative.  D-dimer has a high rate of false positives, and if it is positive you still need to order the venous duplex ultrasound. 

My question is about length of anticoagulation.  As I mentioned above I generally anticoagulate for 10 days postop.  It this long enough though?  Here's an abstract in the British Medical Journal about DVT in middle-age women.  This study came out with some interesting data.  See below the abstract for the article.  One of the things I found interesting was looking at the relative risk for "other orthopedic surgery" which much of our surgery would be included in.  The relative risk was 57.3 in the first 6 weeks, then down to 5.6 7-12 weeks postop.  Should we be prophylaxing for 6 weeks?  Anyone know of any other studies that might support this?  I can only imagine the medication cost to put a patient on Fragmin for 6 weeks.According to epocrates Fragmin costs $359 for 10 days. Food for thought!

BMJ 2009;339:b4583

ABSTRACT
Objective To examine the duration and magnitude of increased risk of venous thromboembolism after different
types of surgery.
Design Prospective cohort study (Million Women Study). Setting Questionnaire data from the Million Women Study
linked with hospital admission and death records. Participants 947 454 middle aged women in the United Kingdom recruited in 1996-2001 and followed by record linkage to routinely collected NHS data on hospital
admissions and deaths. During follow-up 239 614 admissions were for surgery; 5419 women were admitted,
and a further 270 died, from venous thromboembolism. Main outcome measures Adjusted relative risks and
standardised incidence rates for hospital admission or death from venous thromboembolism (pulmonary
embolism or deep vein thrombosis), by time since and type of surgery.
Results Compared with not having surgery, women were 70 times more likely to be admitted with venous
thromboembolism in the first six weeks after an inpatient operation (relative risk 69.1, 95% confidence interval
63.1 to 75.6) and 10 times more likely after a day case operation (9.6, 8.0 to 11.5). The risks were lower but still
substantially increased 7-12 weeks after surgery (19.6, 16.6 to 23.1 and 5.5, 4.3 to 7.0, respectively). This pattern
of risk was similar for pulmonary embolism (n=2487) and deep venous thrombosis (n=3529). The postoperative
risks of venous thromboembolism varied considerably by surgery type, with highest relative risks after inpatient
surgery for hip or knee replacement and for cancer— 1-6 weeks after surgery the relative risks were,
respectively, 220.6 (187.8 to 259.2) and 91.6 (73.9 to113.4).
Conclusion The risk of deep vein thrombosis and pulmonary embolism after surgery is substantially
increased in the first 12 postoperative weeks, and varies considerably by type of surgery. An estimated 1 in 140
middle aged women undergoing inpatient surgery in the UK will be admitted with venous thromboembolism
during the 12 weeks after surgery (1 in 45 after hip or knee replacement and 1 in 85 after surgery for cancer),
compared with 1 in 815 after day case surgery and only 1in 6200 women during a 12 week period without surgery.

During my research, I came across this intresting research study,  in the "American College of chest physicians."

http://chestjournal.chestpubs.org/content/135/4/917.full

Background: The Agency for Healthcare Research and Quality ranks prevention of venous thromboembolism (VTE) as a top priority for patient safety; however, no guidelines or population-based research exist to guide management for podiatric surgery patients. The objective of our study was to determine the incidence and risk factors for postprocedure VTE in podiatric surgery.

Methods: A 5-year retrospective analysis of patients undergoing podiatric surgery in a large not-for-profit health maintenance organization serving > 485,000 members in the Pacific Northwest from 1999 to 2004.

Results: We identified 16,804 surgical procedures in 7,264 patients and detected 22 symptomatic postprocedure VTEs. The overall incidence of postprocedure VTE was 0.30%. Three risk factors were significantly and independently associated with VTE in podiatric surgery: prior VTE (incidence, 4.6%; relative risk, 23.0; p < 0.001), use of hormone replacement therapy or oral contraceptives (incidence, 0.55%; relative risk, 4.2; p = 0.01), and obesity (incidence, 0.48%; relative risk, 3.0; p = 0.02).

Conclusions: We identified a low overall risk of VTE in podiatric surgery, suggesting that routine prophylaxis is not warranted. However, for patients with a history of VTE, periprocedure prophylaxis is suggested based on the level of risk. For podiatry surgery patients with two or more risk factors for VTE, periprocedure prophylaxis should be considered. Until a prospective study is completed testing recommendations, guidelines and care decisions for podiatric surgery patients will continue to be based on retrospective data, expert consensus, and clinical judgment.

Great addition to this discussion, Ali!  I didn't know of this study.  It really does point to the fact that we need a good prospective trial to answer this question.

I largely don't relay on D-Dimer as others have posted;  the test it is nonspecific and can remain elevated for a number of conditions in addition to (and unrelated to) the development of a DVT.  If there is a clinical suspicion for DVT, i feel it is most appropriate to get the scan.  The key is to maintain a high index of suspicion in those patients who may have pre-existing risk factors (previous history, BCP usage, sendarty life style, etc), or among those who demonstrate perioperative risk factors (such as immobilization, endothelial injury).

The reality is that it probably does not happen all that often following podiatric surgery (at least that is what the few studies would suggest --which illustrates the need for larger, better studies), but despite this minimal risk, it is a realistic complication that we have to be ready to assess and manage in our patients.  If you're not looking for it...you won't find it.

As for the length of time, i've found myself prophylaxing for 10-14 days.  For some reason, two weeks seems like a nice round number that i've sort of find myself tap-dancing around.  Generally speaking by this point, even my most sedentary patient can manage to be up and about and moving --regardless of the nature of the reconstruction-- which presumably lessens their further risk for the development of DVT.

I tend to fall in line with both Ryan and Jarrod.  I prophylax my patients with 10 days of Fragmin post-op if they meet the American College of Cardiology risk standard for DVT.  I will also prophylactic dose patient those I feel are a "higher" risk even though they may not have "risk assessments". 

As usual, I will check with the PCP/Cardiologist regarding their comfort level with dosing regimens for Fragmin, but  I can say, that I too, have never had a DVT issue, and I hope that I don't!

But for those of you that do FIND that DVT, get the patient into the hospital ASAP and get the PCP on the phone.  Start Heparin and go to sleep knowing that you saved a life.

Excellent article by Dr. Baum. Certainly he shares my observations over many years in dealing with "limb salvage/multiple morbidity" patients. Unfortunately, as Dr. Baum personally experienced, many healthy patients are at risk for for a potentially fatal PE. There also has been an increased observation of fatal PE in the medical-legal arena. Retrospective orthopedic/podiatric studies state that many of our patients are NOT at risk for DVT. I feel these observations are not accurate and reports such as those by Dr. Baum will raise awareness.

GRP

Excellent comments all around, from start to finish. I have copied Dr. Baum's comments and have recommended him as a speaker for several upcoming conference. Podiatrists NEED to hear his message. 

This condition has followed me throughout my career - personally and professionally.

Residency:  
I will never forget the patient. Grey hair, grey beard. Pelvic fracture. I was on call. First year podiatric intern. On a general surgery rotation with Yale surgical residents. Frankly, they are as frightened as I am. That makes me even more frightened.

The thin man is writhing up out of his bed, completely raising his torso up out of his bed in pain and gasping for air. It is the nurse who tells me and the second year resident what we are dealing with. "It is a PE. G..damn it! It is a PE."

She barks out the order for what is needed next. I learn that night to trust in nurses for the first three months of a residency program (and maybe the fourth if you are slow. St. Elsewhere wasn't fiction after all.) The patient survived thanks to the nurse. The two of us, the Yalie and I, were heaps of sweat and frayed nerves by dawn. We lived to tell the tale but it took its toll.

Personally:
Years later by mom had a PE after waiting by my dad's bedside for 2 weeks as he lay dying. She literally did not move except to go to the bathroom. The doctors there did not order a VQ scan until I arrived and pointed out that she was laboring to breath.

A Patient:
Is it a PE or is it a DVT? You have to work it up all the same. You hope for a DVT, of course. Sedentary, often. Will it resolve with warm compresses and ASA? Most of all do you have labored breathing? And then bring in the big guns of blood tests and VQ scans and you have your answers and then do not lose time in treating or else you may lose a life. In this case, although it appeared to be a PE, it failed the VQ scan, the definitive test of the time, and so we were NOTdealing with a PE. We all sighed a breath of relief. At least one patient had escaped this difficult diagnosis.

My best advice on a PE is to never let it fool you, one way or the other. Don't assume that it IS a PE or that it ISN"T a PE. Keep digging utill you know definitively that it is or isn't. If you don't heed my advice, you will be burned, my friend.