Approach to management & prevalence of Deep venous thrombosis in periarticular knee fractures

Deep venous thrombosis is characterized by presence of thrombus within deep veins of the extremity.1,2 If not recognized timely, deep venous thrombi can embolize to pulmonary arterial circulation subsequently lodging in a lung which can be life threatening within few hours of onset. Hence early diagnosis is only preventive & therapeutic measure needed for its management. Complex periarticular knee fractures due to high energy trauma lead to endothelial injury and subsequent manipulation fulfill Virchow’s triad namely venous stasis, endothelial damage and hypercoagulability important in thrombus formation3,4.

 

Previous studies done in view of Indian perspective on this topic is lacking due to the non-availability of published Indian data.5 The disease is very elusive in terms of its recognition. DVT is the most common serious complication seen postoperatively early after total hip and knee arthroplasty.6,7As a consequence pulmonary embolism which is a life threatening catastrophe may occur. Lower limb fractures and surgeries, amongst them, total hip & knee arthroplasty, have a high risk of developing DVT as a potential complication8,9. Age above 50 years, long period of immobilization, previous H/o stroke, previous history of venous Thromboembolism, pregnancy and puerperium are other risk factors for DVT. 6,10

 

In Asian population incidence of DVT is reported upto 63%.11 Limited studies are there which include only post traumatic patients to determine incidence of DVT in Indian populations.12,13

 

Clinical signs such as pain, edema, local tenderness, skin changes (including redness, pigmentation, cyanosis), and positive Homan's sign are suggestive of DVT. The disease is very elusive both in terms of its recognition and management, the clinical diagnosis being inaccurate in up to 50% of cases5.

 

Colour Doppler Ultarssonography is the most noninvasive, safe, inexpensive accurate & widely available diagnosic modality as compared to MRI venography and hence it was selected as diagnostic tool for our study.

The study was conducted in the department of Orthopedics, NIMS Hospital, Jaipur from January 2023 to December 2024

 

The study was a non-analytical cohort study.

 

6.1 Inclusion criteria

1.      All patients getting admitted for surgeries for trauma around the knee at NIMS Hospital.

2.      All patients admitted for periarticular knee trauma & managed conservatively.

3.      Minimum age criteria was 18 years and above.

 

6.2 Exclusion criteria

1.      Patients with history of bleeding tendencies.

2.      All known cases of hypercoaguable states.

3.      Patient not willing to be part of study.

4.      Patient already diagnosed as having DVT.

5.      Non trauma surgeries such as knee arthroplasty & Arthroscopy.

A detailed clinical history, clinical and radiological examination was carried out in all 65 patients.

 

HISTORY

A detailed history of trauma/mode of injury

Past History: any previous history of DVT, or any other risk factors such as smoking, contraceptive pills, H/O cardiac disease/ stroke, long immobilization, bleeding disorders was excluded.

 

Local Examination

Calf swelling, Neurovascular status of limb, any wound, erythema/blisters.

Homan sign i.e. pain on passive calf strtetching were assessed

 

Investigations done:

Venous Doppler B/L lower limb was carried out in all patients fitting inclusion criteria.

 

Preoperative assessment for DVT was done in patients by Doppler ultrasonography. The assessment included examination of the bilateral common femoral, popliteal, anterior tibial and posterior tibial vein for their flow/velocity, diameter, presence of thrombosis & compressibility.

 

A diagnosis of DVT was made in case of visualization of thrombus, absence of flow, lack of compressibility or lack of augmentation. However colour doppler ultrasosonography of deep venous thrombosis relies on loss of vein compressibility as a primary criteria for diagnosis of DVT.

 

A repeat Doppler study was performed at 3 months in every patient diagnosed with DVT to look for evidence of reacanalisation. In patients diagnosed with DVT, LMWH 0.6 mg OD was administered along with warfarin 5mg per day with regular monitoring of APTT& PT/INR.

Table 1: Age interval in the study group

 

Majority of subjects in the study groups belong to the 50-70(48%) year age group and considerable amount of subjects in the 20-40 (31%) years age group

 

Table 2: Co-morbid illness in our study group

 

Comorbid illness	n	%
Diabetes	11	17%
Hypertension	19	24%
Smoking	3	4%

 

 

 

 

 

 

Out of 65 patients with fractures around knee, 11 patients had associated Diabetes Mellitus,19 patients had Hypertension and 3 patients had H/o chronic smoking

 

Table 3: Prevalence of Venous Thromboembolism (VTE) in our study group

 

DVT was diagnosed in 7 out of 65 patients i.e. 10.7% of patients.

 

Table 4 – Comparison of DVT in surgical v/s conservative management

 

Out of 7 cases diagnosed with DVT 5 were being managed conservatively and 2 were diagnosed in postoperative period.

 

Table 5: Number of DVT cases at initial & 2 weeks

 

5 cases were positive after the first Doppler ultrasound. They might have developed DVT within initial 24 hrs as the first Doppler was done with 48 hrs. Additional 2 cases were positive on the 2^nd Doppler at 2 weeks interval.

 

Table 5: Comparison of clinical & subclinical DVT

 

In patients diagnosed with DVT, clinical signs of DVT was present in 4 cases i.e. 57%. Most reliable sign is Calf pain which directly correlates with DVT.

 

Table 6: Comparison between proximal and distal DVT among patients with DVT

 

Among the patients with DVT, 3 cases had proximal DVT and rest of 4 cases   had distal DVT. Proximal DVT is defined as DVT involving popliteal vein and above while Distal DVT involves calf veins.

 

This correlation suggests high incidence of distal DVT as compared to proximal DVT

 

Table 8: Distribution of fractures included in study

 

Distal femur fractures (43%) included were distal shaft 1/3, supracondylar & intercondylar femur fractures while proximal tibia fractures (52%) included were condylar fractures and proximal shaft fractures upto 1/3 tibia.

Floating knee injuries were 5%.

 

Table 7: Age vs management of fracture

Age Interval	Management of Fracture
	Conservative		Operative
	n	%	n	%
< 20	1	5%	0	0.00%
20 – 30	5	25%	6	13%
30 – 40	3	15%	6	13%
40 – 50	1	5%	4	9%
50 – 60	4	20%	13	29%
60 – 70	2	10%	12	27%
>= 70	4	20%	4	9%
TOTAL	20	100%	45	100%

 

 

 

 

 

 

 

 

 

 

 

 

 

Conservative managed cases were 20 (31%) & operated cases were 45(69%).

 

Table 9: Distribution of Fractures and DVT cases

 

Proximal Tibia fractures had maximum no. of DVT cases (72%).

DVT after lower limb trauma results from injury to vascular endothelium, any subsequent manipulation and prolonged immobility further lead to events accelerating thrombus formation.

 

65 patients were included in the study with periarticular knee fractures and floating knee injury as per inclusion criteria. All patients underwent Doppler ultrasound within 24-48 hrs of admission and repeat Doppler was done 2 weeks after the first Doppler.

 

5 cases were positive after the first Doppler ultrasound. These cases were followed up as it was not clear at what stage they developed DVT. Two of these had no clinical symptoms prior to admission in hospital. They might have developed DVT within initial 24 hrs as the first Doppler was done with 48 hrs. Additional 2 cases were positive on the 2nd Doppler at 2 weeks interval. While the 1st Doppler may have picked up pre-existing DVT, repeat picks up all those which have developed during the course of the treatment. 

Among the patients with DVT, 3 cases i.e. 43% of diagnosed cases had proximal DVT and rest 4 cases i.e. 57% cases had distal DVT. This might also suggest that there are high chances of progression of thrombus to proximal veins during the course. 

 

Doppler evidence of DVT were found in 7 (10.7%) patients, The incidence of DVT in our study was lower in comparison of Li etal14 & Zhang et al.15

 

Of these 7 patients 4 (57%) had clinical signs of DVT while only 3 (43%) were subclinical. This is in correlation with other studies.12

 

Most persistent feature was edema in all patients having clinical features. 9 patients had clinical features but no evidence of DVT on Doppler.

 

In our study, amongst the 7 patients who developed DVT, 5 cases were being treated conservatively (71%) and 2 cases were being treated operatively (29%). While amongst the normal patients, maximum patients were treated operatively. This data is statistically significant (p value <0.05). This suggests conservatively managed cases had a higher incidence of DVT as compared to operative cases probably as postsurgical cases are mobilized by Non weight bearing ambulation almost the next day. Since the most number cases of DVT were present in the above 50 yr. age groups, maximum number of conservative cases were also in the same age group as compared to other groups where operative intervention is used most commonly.

 

2 patients developed DVT in post operative period. One patient had tourniquet applied in intraoperative period while in other tourniquet was not applied since the number of cases is low, we can’t establish any significant corelation between tourniquet application and incidence of DVT in post operative patients.

 

Out of diagnosed 7 patients with DVT  5 (71%) patients were above 50 years age group, only 2 (29%) patients belong in 20-40 year age group. This suggests that the incidence of DVT increases with age as suggested by some other studies (Sharma et al12, Kapoor et al16)

 

Road traffic accidents was most common mode of injury (68%). Patients coming after Road traffic accidents had high energy trauma.

 

In our study we included a variety of fractures around the knee joint. Out of those variety, proximal Tibia fractures were more common (52%) while distal femoral fractures were (43%). Approx. 5% of cases were of floating knee injury.

 

We have found higher incidence of DVT in proximal tibial fractures (72%). The risk of DVT appears to increase with the proximity of the fracture to the knee, tibial plateau fractures have higher risk.15 One of the possible reasons could be as most of the trauma around the knee resulted from high energy and hence greater soft tissue damage leading to a higher incidence of DVT.

 

In our study out of 65 patients, majority of them belong to the 50-70 year age group (48%) and considerable amount of subjects in the 20-40 years age group (31%) probably because it is the most common age group suffering from Road traffic accidents. Out of 65 subjects, 35 were male and 30 were female. But a significant statistical correlation could not be made out for association between gender and incidence of DVT.

 

1 patient expired in our study. This was a post traumatic # proximal tibia with established DVT and died because of pulmonary embolism.

 

Patients with established DVT were kept on LMWH 0.6 mg once a day along with warfarin 5 mg along once a day along with PT/INR & APTT monitoring at time of discharge of DVT and they were kept on follow up for 3-6 months

 

Patients who developed DVT were followed upto 3 month until there was no sign of DVT on Doppler. Except one patient who expired in our study, rest all of the patients recovered. Edema lasted for 3 months.

 

Chemoprophylaxis was not given to any patients in our study, only patients diagnosed with DVT received LMWH as empirical treatment.

This study was done to study the prevalence of DVT in patients presenting to this hospital with periarticular fractures around knee. The study also showed that conservatively treated cases shows statistically significant more risk for DVT than operated cases.

 

The prevalence of DVT & pulmonary embolism in this study highlights the importance of high index of suspicion for both DVT and Pulmonary emobilism and need for both mechanical and chemoprophylaxis in these cases.

 

In our study, 43% cases of diagnosed DVT were clinically asymptomatic as compared to 57% of clinically symptomatic cases.

 

Among the operative cases, use of tourniquet with DVT was assessed. But since the number of patients were too less, no adequate correlation can be made out.

 

Limitations of study were non inclusion of all lower limb fractures & small sample size.

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