Blood thinners in high-risk patients- continue or discontinue prior to elective foot surgery

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mandrew

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Based on my current research there seems to be no gold standard with regards to elective foot surgery and patients who are on Plavix, aspirin, etc. If you have a patient with a history of DVT and atrial fib who is currently on these meds should they be instructed to simply continue them without interruption for an outpatient hammertoe or hallux valgus repair with an ankle tourniquet? Isn't the risk of a blood clot a bigger concern than post operative bleeding with regards to this type of forefoot surgery? Thanks for your replies.
 
mandrew said:
Based on my current research there seems to be no gold standard with regards to elective foot surgery and patients who are on Plavix, aspirin, etc. If you have a patient with a history of DVT and atrial fib who is currently on these meds should they be instructed to simply continue them without interruption for an outpatient hammertoe or hallux valgus repair with an ankle tourniquet? Isn't the risk of a blood clot a bigger concern than post operative bleeding with regards to this type of forefoot surgery? Thanks for your replies.
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1729795883405.png
 
jamanetwork.com

Perioperative Management of Patients Taking Direct Oral Anticoagulants

This narrative review investigates the use of direct oral anticoagulants to treat patients undergoing surgical and nonsurgical procedures and the most effective management strategies for these medications based on the type of procedure, including elective, emergent, urgent, or semiurgent.
jamanetwork.com jamanetwork.com

1729796181046.png
 
1. Don’t use a tourniquet, not necessary. Use cautery to help dissect, retractors to put pressure against skin bleeders

2. Don’t do surgery on these patients.
 
wakaflocka88 said:
1. Don’t use a tourniquet, not necessary. Use cautery to help dissect, retractors to put pressure against skin bleeders

2. Don’t do surgery on these patients.
Click to expand...
I can see it not being necessary on the anticoagulated, but do you just do standard surgeries on healthy patients no tourniquet? Do you just rely on cautery and cleaning the site?
 
Weirdy said:
jamanetwork.com

Perioperative Management of Patients Taking Direct Oral Anticoagulants

This narrative review investigates the use of direct oral anticoagulants to treat patients undergoing surgical and nonsurgical procedures and the most effective management strategies for these medications based on the type of procedure, including elective, emergent, urgent, or semiurgent.
jamanetwork.com jamanetwork.com

View attachment 394069
Click to expand...

What about Plavix and aspirin in the high risk patient with low bleeding risk?
 
IMO They won't bleed out from a foot/ankle incision. Keep the thinners going. Never had an issue.

Also, as above, don't use tourniquet, especially if hx of blood clots.
 
mandrew said:
Both of these articles gave no definitive answer
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Judgement call. Read between the lines dude. Low % risk regardless. Can stop a day before and restart after surgery. Talk to PCP. Talk to the Heme/Onc. Get a PT/INR if worried and pass it on to their main team managing all that. Why do I need to spell everything out and search it for you?

Here's even more literature for you to read between the lines.

1729803999090.png



journals.lww.com

Preoperative and Postoperative Therapeutic Anticoagulation... : JAAOS - Journal of the American Academy of Orthopaedic Surgeons

c surgery patients receiving perioperative therapeutic anticoagulation. Methods: A systematic review and meta-analysis was performed in concordance with the Preferred Reporting Items for Systematic Review and Meta Analysis 2020 guidelines. PubMed was queried for articles related to therapeutic...
journals.lww.com journals.lww.com
1729804036485.png
 
wakaflocka88 said:
1. Don’t use a tourniquet, not necessary. Use cautery to help dissect, retractors to put pressure against skin bleeders

2. Don’t do surgery on these patients.
Click to expand...
Ding ding ding. ^^

The only surgery you should be doing on ppl with anticoag is non-elective I&Ds or source-control amps or (big, displaced) trauma surgery that can't be avoided. (fwiw, asa81 is not a 'blood thinner')

Some post-CABG guy doesn't need a hammertoe or neuroma... a CVA or severe CAD lady does not need 2nd met fx ORIF or ankle scope. Just does not need it. Unnecessary risk. You will put the patients at risk and PCPs/anesthesia will think you're simple. Find other ppl to do elective surgery on. Sorry.

Homo sapien said:
I can see it not being necessary on the anticoagulated, but do you just do standard surgeries on healthy patients no tourniquet? Do you just rely on cautery and cleaning the site?
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I do it all the time. They don't bleed to death. Ditto for most of the well-trained ppl who post on here... bunions, Achilles, fibula ORIF etc etc without tourniquet inflated. For amps and I&D, it should be a given not to inflate tourniquet.

I do inflate cuff for maybe 15 or 30min sometimes for the joint prep/position for midfoot/hindfoot fusions or the fracture reduction, etc. If you use cuff, always let cuff down before closing skin (lets you see if you missed any sizable bleeders, lets out the hematoma/edema).
But yeah, 90% of the surgery we do can be done fine without tourniquet inflated (have one on) with just good dissection and cautery and tying bigger vessels and epi lido 1:200k (only lasts for about an hour, though).

And yeah, I do realize most programs train you to do cuff up from before incision to after last suture even for Austins, but that's simply garbage.
 
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Feli said:
And yeah, I do realize most programs train you to do cuff up from before incision to after last suture even for Austins, but that's simply garbage.
Click to expand...
Yeah that’s dumb. You should always deflate the tourniquet while closing. In my DPM aacfas aabpm pgy4 opinion…
 
If they cant stop their blood thinners they are not going to get an elective surgery from me. They are almost certainly not a good systemic candidate.

Diabetic emergency patients especially with stents I never stop them.

Outside of an amputation or I&D cutting on a patient with a high INR is not fun. I would argue the work will be subpar in many cases. Nothing worse than a blood bath and running the suction full blast with 20 laps soaked on the back table.

If trauma came in I would consult hospitalist/cardiology to see risk/benefits. If its an emergency and cant stop them or the risk is too high then you gotta do it wet.

For post surgery preventative (Especially forefoot) I tell just about everyone 1 aspirin a day. I dont think that actually does anything but so far I havent had any (known) issues with a DVT a decade out of school.

Patients in a cast, Achilles tendon, and ankle surgery get anticoagulated with Plavix or xarelto. Im not messing with Coumadin.

BUt youre right there really isnt a strong consensus.
 
Also use a tourniquet and not have to deal with blood and drop it before you leave the room. Works everytine
 
DYK343 said:
If they cant stop their blood thinners they are not going to get an elective surgery from me. They are almost certainly not a good systemic candidate.

Diabetic emergency patients especially with stents I never stop them.

Outside of an amputation or I&D cutting on a patient with a high INR is not fun. I would argue the work will be subpar in many cases. Nothing worse than a blood bath and running the suction full blast with 20 laps soaked on the back table.

If trauma came in I would consult hospitalist/cardiology to see risk/benefits. If its an emergency and cant stop them or the risk is too high then you gotta do it wet.

For post surgery preventative (Especially forefoot) I tell just about everyone 1 aspirin a day. I dont think that actually does anything but so far I havent had any (known) issues with a DVT a decade out of school.

Patients in a cast, Achilles tendon, and ankle surgery get anticoagulated with Plavix or xarelto. Im not messing with Coumadin.

BUt youre right there really isnt a strong consensus.
Click to expand...
Wait you are doing Xarelto?? Or having PCP. Take a full aspirin and relax everything will be fine.
 
Homo sapien said:
I can see it not being necessary on the anticoagulated, but do you just do standard surgeries on healthy patients no tourniquet? Do you just rely on cautery and cleaning the site?
Click to expand...

Yes, almost all my elective forefoot and rearfoot I do not use a tourniquet. However, I will still put a thigh cuff on just in case I need it. Majority of times I do a simple calf esmarch tourniquet before resorting to the thigh, and it does not need to be super tight. Try it.

Ankle tourniquets are dumb IMO. Gets in the way. Simple high ankle/calf esmarch better.

Cautery and weitlaners make a big difference in putting pressure against small bleeders. I just bovie straight down to bone to open a joint once cleared and eliminates small intra capsular bleeders. I use it to peel off periosteum. Great for Brostrom cases as there’s always freaking bleeders when knifing the sucker open.


Without a tourniquet you will notice how much less pain they have afterwards. I can’t recall the last time i had to refill a Norco 5, I only prescribe 15 tablets post op, 0.25% marcaine before and after incisions always. The skin is easier to close without that reactive engorgement of blood rushing back down.

One can even argue this may result in lower chances of delayed and/or non unions, wound issues, etc etc
 
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Cant help but feel electing to not use a tq for elective cases is unecessary fist bumping culture. Inflate the tq, know where you're going, meticulous nick and spread dissection, buzz the traversing smallvessels or mobilize and retract bigger ones, avoid unnecessary dissection, keep periosteal stripping to the absolute minimum, close in layers, dress it and let the tq down. I've literally never had an issue with that. The key to minimizing post op pain is precise dissection and most importantly IMO keep periosteal stripping to a minimum. Periosteum is LOADED with nerve fibers.
 
air bud said:
Wait you are doing Xarelto?? Or having PCP. Take a full aspirin and relax everything will be fine.
Click to expand...
Plavix more common to Rx. Achilles, ankle, casting.

ASA alone is insufficient IMO.

BUt there is no good consensus in literature for foot/ankle. Most data is based off knee/hip. I will admit its been a few years since I have really dived deep into DVT prophylaxis articles.
 
forums.studentdoctor.net

Anticoagulation protocols

To break away from all the posts speaking about the profession and its flaws I would like to start a discussion on anticoagulation protocols. If anyone is willing to share I am interested in hearing what everyone’s personal protocols are. I recently had an ambulatory patient develop a PE and I...
forums.studentdoctor.net forums.studentdoctor.net

We covered some of that already as well
 
Do whatever your local Ortho do
 
My Ortho and many many many other Ortho full aspirin. But think about it, by prescribing aspirin only there's minimal risks with it you're going to certainly get some benefits. If something happens you have already basically acknowledged the risk and attempted to mitigate that risk and you're not going to get in trouble because oh you should have prescribed plavix instead of a full aspirin. Now you get a DVT when the patient's on nothing then it's harder for you to explain.
 
air bud said:
My Ortho and many many many other Ortho full aspirin. But think about it, by prescribing aspirin only there's minimal risks with it you're going to certainly get some benefits. If something happens you have already basically acknowledged the risk and attempted to mitigate that risk and you're not going to get in trouble because oh you should have prescribed plavix instead of a full aspirin. Now you get a DVT when the patient's on nothing then it's harder for you to explain.
Click to expand...
Aspirin for CYA 100% agree. I do the same.
 
MortonExtension said:
i would do xarelto. also would try my best to avoid sx, elective case after all.
Click to expand...

Thumbs up.

So this patient already had a lapidus done elsewhere. Its fused in 35 degrees of IM and its a non-union. The patient can't walk. Their cardiologist wants them to work on their heart health and they say they can't walk or do anything because of unrelenting foot pain. Your partner who only does Austin's has already seen them, diagnosed them with a non-union and placed them on your surgery and told them you'll revise it. The cardiologist has already generously provided the patient with a cardiac clearance indicating to begin xarelto 24 hours after surgery.

I'm being ridiculous - except that I actually got the above patient.

The problem with foot surgery is that a lot of what we do technically fits the definition of immobilization except that the overall rate of DVT after foot surgery is trivial. We also treat potentially a lot of smokers and obese people. This thread to me attempts to describe the intersection of appropriate medicine, but also the intersection of the medicolegal with the medical system system. None of us are lawyers and my suspicion is none of us have actually spoken to a lawyer who has participated in a DVT lawsuit ie. how was it argued, decided.

I personally don't believe that your risk will be mitigated if you provide aspirin to a patient who has true DVT risk factors and develops a DVT while on aspirin. The opposing expert witness will presumably argue you under treated the patient. She had risk factors doctor, why didn't you use a real anticoagulant like Xarelto etc.

How many people are actually performing a DVT risk assessment with a patient in which they go through a list of actual DVT risk factors - provide a score for the patient and then spell out their decision making in a note? I did this in residency and I will tell you that tons of your patients will then hit lots of low level risk factors and yet they presumably shouldn't be on a true blood thinner because its just overall isn't needed based on the occurrence data. Its all very dissatisfying to me. I think we need to be specific in our language when we walk about it and avoid being cavalier.
 
heybrother said:
Thumbs up.

So this patient already had a lapidus done elsewhere. Its fused in 35 degrees of IM and its a non-union. The patient can't walk. Their cardiologist wants them to work on their heart health and they say they can't walk or do anything because of unrelenting foot pain. Your partner who only does Austin's has already seen them, diagnosed them with a non-union and placed them on your surgery and told them you'll revise it. The cardiologist has already generously provided the patient with a cardiac clearance indicating to begin xarelto 24 hours after surgery.

I'm being ridiculous - except that I actually got the above patient.

The problem with foot surgery is that a lot of what we do technically fits the definition of immobilization except that the overall rate of DVT after foot surgery is trivial. We also treat potentially a lot of smokers and obese people. This thread to me attempts to describe the intersection of appropriate medicine, but also the intersection of the medicolegal with the medical system system. None of us are lawyers and my suspicion is none of us have actually spoken to a lawyer who has participated in a DVT lawsuit ie. how was it argued, decided.

I personally don't believe that your risk will be mitigated if you provide aspirin to a patient who has true DVT risk factors and develops a DVT while on aspirin. The opposing expert witness will presumably argue you under treated the patient. She had risk factors doctor, why didn't you use a real anticoagulant like Xarelto etc.

How many people are actually performing a DVT risk assessment with a patient in which they go through a list of actual DVT risk factors - provide a score for the patient and then spell out their decision making in a note? I did this in residency and I will tell you that tons of your patients will then hit lots of low level risk factors and yet they presumably shouldn't be on a true blood thinner because its just overall isn't needed based on the occurrence data. Its all very dissatisfying to me. I think we need to be specific in our language when we walk about it and avoid being cavalier.
Click to expand...
Have they tried swimming
 
PODIATRYCRAZE said:
Very inspiring. Can you please mention whether or not your job required ABFAS? Or did ABPM work just as well?
Click to expand...

heybrother said:
Thumbs up.

So this patient already had a lapidus done elsewhere. Its fused in 35 degrees of IM and its a non-union. The patient can't walk. Their cardiologist wants them to work on their heart health and they say they can't walk or do anything because of unrelenting foot pain. Your partner who only does Austin's has already seen them, diagnosed them with a non-union and placed them on your surgery and told them you'll revise it. The cardiologist has already generously provided the patient with a cardiac clearance indicating to begin xarelto 24 hours after surgery.

I'm being ridiculous - except that I actually got the above patient.

The problem with foot surgery is that a lot of what we do technically fits the definition of immobilization except that the overall rate of DVT after foot surgery is trivial. We also treat potentially a lot of smokers and obese people. This thread to me attempts to describe the intersection of appropriate medicine, but also the intersection of the medicolegal with the medical system system. None of us are lawyers and my suspicion is none of us have actually spoken to a lawyer who has participated in a DVT lawsuit ie. how was it argued, decided.

I personally don't believe that your risk will be mitigated if you provide aspirin to a patient who has true DVT risk factors and develops a DVT while on aspirin. The opposing expert witness will presumably argue you under treated the patient. She had risk factors doctor, why didn't you use a real anticoagulant like Xarelto etc.

How many people are actually performing a DVT risk assessment with a patient in which they go through a list of actual DVT risk factors - provide a score for the patient and then spell out their decision making in a note? I did this in residency and I will tell you that tons of your patients will then hit lots of low level risk factors and yet they presumably shouldn't be on a true blood thinner because its just overall isn't needed based on the occurrence data. Its all very dissatisfying to me. I think we need to be specific in our language when we walk about it and avoid being cavalier.
Click to expand...
Sounds like many I've seen come in for 2nd opinion with a certain double plate fixation..
 
wakaflocka88 said:
Yes, almost all my elective forefoot and rearfoot I do not use a tourniquet. However, I will still put a thigh cuff on just in case I need it. Majority of times I do a simple calf esmarch tourniquet before resorting to the thigh, and it does not need to be super tight. Try it.

Ankle tourniquets are dumb IMO. Gets in the way. Simple high ankle/calf esmarch better.

Cautery and weitlaners make a big difference in putting pressure against small bleeders. I just bovie straight down to bone to open a joint once cleared and eliminates small intra capsular bleeders. I use it to peel off periosteum. Great for Brostrom cases as there’s always freaking bleeders when knifing the sucker open.


Without a tourniquet you will notice how much less pain they have afterwards. I can’t recall the last time i had to refill a Norco 5, I only prescribe 15 tablets post op, 0.25% marcaine before and after incisions always. The skin is easier to close without that reactive engorgement of blood rushing back down.

One can even argue this may result in lower chances of delayed and/or non unions, wound issues, etc etc
Click to expand...
I need to try that esmarch idea
 
Flip-flop-flerpity said:
Cant help but feel electing to not use a tq for elective cases is unecessary fist bumping culture. Inflate the tq, know where you're going, meticulous nick and spread dissection, ..
Click to expand...
Put a cuff on your own ankle for even 10min at even 200 or 225mmhg... you'll understand. Thigh tourniquet at 300+ setting? You wont make it even one minute (main reason those ppl always need gen anesth). If you like your ankle, then simply ask anesthesia... very impactful. It makes a big difference in pain.

Cuff also causes all 3 of triad: injury (crush vessels), stasis (obviously), and hypercoaguble state (pain + more anesthesia meds).

Other benefits are post op pain, edema, seeing vessels to avoid them (basically color anatomy... versus everything's white-ish with cuff up). You can do much better dissection without cuff inflated.

They're useful for some procedures and parts of others, but the way most DPMs use tourniquets is not necessary. If ortho does THA or humerus ORIF and vasc surg does carotid or fistula without tourniquet, I'd think we can at least do hammertoes, Haglund, ankle scope , most bunions without it? (Yes I use cuff briefly on calc osteotomy or hindfoot fusions or parts of things that just bleed a lot... or pts who just do for whatever reason).
 
Last edited:
Feli said:
Put a cuff on your own ankle for even 10min at even 200 or 225mmhg... you'll understand. Thigh tourniquet at 300+ setting? You wont make it even one minute (main reason those ppl always need gen anesth). If you like your ankle, then simply ask anesthesia... very impactful. It makes a big difference in pain.

Cuff also causes all 3 of triad: injury (crush vessels), stasis (obviously), and hypercoaguble state (pain + more anesthesia meds).

Other benefits are post op pain, edema, seeing vessels to avoid them (basically color anatomy... versus everything's white-ish with cuff up). You can do much better dissection without cuff inflated.

They're useful for some procedures and parts of others, but the way most DPMs use tourniquets is not necessary. If ortho does THA or humerus ORIF and vasc surg does carotid or fistula without tourniquet, I'd think we can at least do hammertoes, Haglund, ankle scope , most bunions without it? (Yes I use cuff briefly on calc osteotomy or hindfoot fusions or parts of things that just bleed a lot... or pts who just do for whatever reason).
Click to expand...
Yes, surgery hurts. Where is a ortho going to put a tq for a THA? Around the abdomen? Where is vascular going to put a tq for a carotid? Around a patients neck? All I am saying is that for elective cases it makes the procedure quicker and reduces anesthesia time and not using one for elective cases comes across as sort of bragging right. I have yet to meet an ortho or plastics guy who doesn't routinely use them for hand or wrist procedures, and that's the analogous structure to a foot or ankle.
 
I use calf tourniquet for elective cases all the time. I only operated wet once for a patient with cancer and DVT. But again I really shouldn't operate on that patient anyway. Surgery reimbursement is already as low as it is for private practice, so I chose to operate on healthier patients with better payors. If I have to think twice about tourniquet use and their DVT/wound healing risk, then that's not a surgical candidate for me. They can see somebody else, and I can see them back in the hospital for the complications (already happened multiple times).

I sometimes even use calf tourniquet on TMAs. Confirmed with my vascular colleagues that it wouldn't harm any of their revasc work and I shouldn't worry about it.
It's on for 15 min max, but significantly reduced my OR time. No need to stop and bovie/tie vessels. Make the cut, tie the ones you see, let it down and then bovie for patch work. They healed fine.

Again, turnover is key. Less anesthesia time is probably more important. I really can't justify spending more than 2 hours for any foot and ankle cases these days.
 
Flip-flop-flerpity said:
Yes, surgery hurts. Where is a ortho going to put a tq for a THA? Around the abdomen? Where is vascular going to put a tq for a carotid? Around a patients neck? All I am saying is that for elective cases it makes the procedure quicker and reduces anesthesia time and not using one for elective cases comes across as sort of bragging right. I have yet to meet an ortho or plastics guy who doesn't routinely use them for hand or wrist procedures, and that's the analogous structure to a foot or ankle.
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I have no one to brag to, I operate as a lone wolf. Just for me personally, my post op pain issues, bone healing and wound healing have not been a problem at all. Surf it adds some time and I will still inflate the thigh cuff to 250 if I’m doing a triple so I can cut and prep joints quickly.

Also helps me visualize what is a vessel versus a sensory nerve.
 
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