Strategies in Trauma and Limb Reconstruction

Register      Login

VOLUME 15 , ISSUE 3 ( September-December, 2020 ) > List of Articles

Original Article

Thromboprophylaxis in Intramedullary Limb Lengthening Surgery

Alexios D Iliadis, Anna Timms, Sharron Fugazzotto, Penina Edel, Simon Britten, Jonathan Wright, David Goodier, Peter Calder

Keywords : Complication, Cosmetic limb lengthening, Internal lengthening nail, Intramedullary lengthening, Limb lengthening, PRECICE

Citation Information : Iliadis AD, Timms A, Fugazzotto S, Edel P, Britten S, Wright J, Goodier D, Calder P. Thromboprophylaxis in Intramedullary Limb Lengthening Surgery. 2020; 15 (3):151-156.

DOI: 10.5005/jp-journals-10080-1505

License: CC BY-NC-SA 4.0

Published Online: 01-12-2020

Copyright Statement:  Copyright © 2020; Jaypee Brothers Medical Publishers (P) Ltd.


Aim: The use of intramedullary lengthening devices is becoming increasingly popular. There are limited data regarding the incidence of venous thromboembolism following intramedullary lengthening surgery and no reports or guidance for current practice on use of thromboprophylaxis. Following a case of post-operative deep vein thrombosis in our institution, we felt that it is important to assess best practice. We conducted a national survey to collect data that would describe current practice and help develop consensus for treatment. Materials and methods: We identified surgeons across the UK that perform adult intramedullary limb lengthening through the British Limb Reconstruction Society membership and a Precise Users database. Surgeons were contacted and asked to respond to an online survey. Responses to thromboprophylaxis regimes employed in their practice and cases of venous thromboembolism were collated. Results: 24 out of 54 surgeons identified responded with a total of 454 cases of adult intramedullary lengthening (352 femoral and 102 tibial nails) performed over a five year period (January 2015–January 2020). Only one case of deep venous thrombosis (DVT) following femoral lengthening was reported. There is wide variability in practice both in terms of thromboprophylaxis risk assessment, choice of medications and duration of treatment. The vast majority of surgeons (85%) felt that there was insufficient evidence available to guide their practice. Conclusions: Intramedullary lengthening is a surgical treatment growing in popularity. There are limited data available to guide decision-making regarding aspects of treatment such as thromboprophylaxis. This is reflected in the wide variation in practice reported in this study. There are both a need and a desire to gather data that will allow us to come to a consensus and to guide safe practice. Clinical significance: Venous thromboembolism is a potential complication of lower limb lengthening surgery. We report on national incidence and current practices of thromboprophylaxis to allow for informed decision-making and help develop consensus for best practice.

PDF Share
  1. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft-tissue preservation. Clin Orthop Relat Res 1989;238:249–281.
  2. Ilizarov GA. Transosseous Osteosynthesis – Theoretical and Clinical Aspects and the Regeneration and Growth of Tissue. New York: Springer-Verlag; 1992.
  3. Calder PR, Laubscher M, Goodier WD. The role of the intramedullary implant in limb lengthening. Injury 2017;48 (Suppl 1):S52–S58. DOI: 10.1016/j.injury.2017.04.028.
  4. Paley D. PRECICE intramedullary limb lengthening system. Expert Rev Med Devices 2015;12(3):231–249. DOI: 10.1586/17434440.2015.1005604.
  5. Flevas DA, Megaloikonomos PD, Dimopoulos L, et al. Thromboembolism prophylaxis in orthopaedics: an update. EFORT Open Rev 2018;3(4):136–148. DOI: 10.1302/2058-5241.3.170018.
  6. Lapidus LJ, Ponzer S, Pettersson H, et al. Symptomatic venous thromboembolism and mortality in orthopaedic surgery – an observational study of 45,968 consecutive procedures. BMC Musculoskelet Disord 2013;14:177. DOI: 10.1186/1471-2474-14-177.
  9. Roberts DJ, Panagiotidou A, Sewell M, et al. The incidence of deep vein thrombosis and pulmonary embolism with the elective use of external fixators. Strategies Trauma Limb Reconstr 2015;10(2):67–71. DOI: 10.1007/s11751-015-0219-1.
  10. Wagner P, Burghardt RD, Green SA, et al. PRECICE® magnetically-driven, telescopic, intramedullary lengthening nail: pre-clinical testing and first 30 patients. SICOT J 2017;3:19. DOI: 10.1051/sicotj/2016048.
  11. Paley D, Debiparshad K, Balci H, et al. Stature Lengthening Using the PRECICE Intramedullary Lengthening Nail. Tech Orthopaed 2015;30(3):167–182. DOI: 10.1097/BTO.0000000000000140.
  12. Paley D, Harris M, Debiparshad K, et al. Limb lengthening by implantable limb lengthening devices. Tech Orthopaed 2014 Jun;29(2):72–85. DOI: 10.1097/BTO.0000000000000072.
  13. Calder PR, McKay JE, Timms AJ, et al. Femoral lengthening using the Precice intramedullary limb-lengthening system: outcome comparison following antegrade and retrograde nails. Bone Joint J 2019;101-B(9):1168–1176. DOI: 10.1302/0301-620X.101B9.BJJ-2018-1271.R1.
  15. Anderson FA Jr, Spencer FA. Risk factors for venous thromboembolism. Circulation 2003;107(Suppl 1):I9–I16. DOI: 10.1161/01.CIR.0000078469.07362.E6.
  16. Patterson JT, Morshed S. Chemoprophylaxis for venous thromboembolism in operative treatment of fractures of the tibia and distal bones: a systematic review and meta-analysis. J Orthop Trauma 2017;31(9):453–460. DOI: 10.1097/BOT.0000000000000873.
  17. Abelseth G, Buckley RE, Pineo GE, et al. Incidence of deep-vein thrombosis in patients with fractures of the lower extremity distal to the hip. J Orthop Trauma 1996;10(4):230–235. DOI: 10.1097/00005131-199605000-00002.
  18. Wang H, Kandemir U, Liu P, et al. Perioperative incidence and locations of deep vein thrombosis following specific isolated lower extremity fractures. Injury 2018;49(7):1353–1357. DOI: 10.1016/j.injury.2018.05.018.
  19. Boyd RA, DiCarlo L, Mandema JW. Direct oral anticoagulants vs. enoxaparin for prevention of venous thromboembolism following orthopedic surgery: a dose-response meta-analysis. Clin Transl Sci 2017;10(4):260–270. DOI: 10.1111/cts.12471.
  20. Maratea D, Fadda S, Trippoli S, et al. Prevention of venous thromboembolism after major orthopedic surgery: indirect comparison of three new oral anticoagulants. J Thromb Haemost 2011;9(9):1868–1870. DOI: 10.1111/j.1538-7836.2011.04421.x.
  21. Dong Y, Wang Y, Ma RL, et al. Efficacy and safety of direct oral anticoagulants versus low-molecular-weight heparin in patients with cancer: a systematic review and meta-analysis. J Thromb Thrombolysis 2019;48(3):400–412. DOI: 10.1007/s11239-019-01871-4.
  22. Kwok CS, Pradhan S, Yeong JK‐Y, et al. Relative effects of two different enoxaparin regimens as comparators against newer oral anticoagulants. Meta‐analysis and adjusted indirect comparison. Chest 2013;144(2):593–600. DOI: 10.1378/chest.12-2634.
  23. Duran A, Sengupta N, Diamantopoulos A, et al. Cost effectiveness of rivaroxaban versus enoxaparin for prevention of post-surgical venous thromboembolism from a U.S. payer's perspective. Pharmacoeconomics 2012;30(2):87–101. DOI: 10.2165/11599370-000000000-00000.
  24. O’Donnell M, Weitz JI. Thromboprophylaxis in surgical patients. Can J Surg 2003;46(2):129–135.
  25. Tasker A, Harbord R, Bannister GC. Meta-analysis of low molecular weight heparin versus placebo in patients undergoing total hip replacement and post-operative morbidity and mortality since their introduction. Hip Int 2010;20(1):64–74. DOI: 10.1177/112070001002000110.
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.