Altered venous function and deep venous thrombosis following proximal femoral fracture
Introduction
Proximal femoral fracture is common in the elderly population [1]. This large group of patients is at high risk for the development of deep venous thrombosis (DVT) [2] with incidences of up to 91% having been recorded [3]. The prevalence of fatal pulmonary embolism following hip fracture has been reported up to 7.5% [4] compared with less than 1% following elective hip arthroplasty [5]. In contrast to the elective hip arthroplasty patient, the hip fracture patient is a decade older, undergoes the double assault of traumatic fracture and surgical intervention, and endures a longer immobilisation in the pre- and early postoperative period. Hip fracture patients following surgery have a recorded in-patient mortality of 12% [6] and 1 year mortality of 22% [7].
All of Virchow's triad of factors (altered coagulation, venous stasis and vessel wall damage) have been implicated in the aetiology of DVT after hip surgery [4]. This study was designed to determine the effect of surgery for proximal femoral fracture on the venous haemodynamics of both legs by using the Belfast strain gauge plethysmograph [8], [9], [10], [11], [12], [13], [19] to record venous indices in the 1st week after surgery and again at review at 6 weeks postoperation. The association of altered venous function and the development of venographically identified deep venous thrombosis was also investigated.
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Patients and methods
All patients admitted to a single Belfast fracture unit during a 12-month period were assessed for inclusion in this investigation. Exclusion criteria involved a previous history of deep venous thrombosis or pulmonary embolus, known active malignancy, coexistent lower limb or pelvic injury at the time of hip fracture, gross obesity, presence of a clinically large thigh haematoma, evidence of ascites or clinically apparent abdominal distension. Informed consent from the patient and immediate
Results
Two hundred and sixty-two patients were assessed for inclusion. Twenty were excluded due to history of thromboembolic disease, 12 because of known malignancy, eight because of gross obesity, three because of associated pelvic or ipsilateral femoral shaft fracture, two because of bilateral proximal femoral fractures, and 38 because of failure to gain consent to be included. These exclusions resulted in 179 patients being entered to the study.
The mean age of the patients was 82 years and the male
Discussion
This demonstration of maximal depression of venous function in the first 3–5 days postoperatively is supported by several authors [14], [15], [16], [17] who also found the effect to be maximal in the 1st postoperative week. A number of factors may contribute to the impaired venous function in the 1st week following hip surgery, including pain [18], [19], relative immobility [6], lower limb swelling [20], wound haematoma or oedema, and altered coagulation as a consequence of injury and surgery
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