Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Boston, MA, USA.
Clin Orthop Relat Res. 2018 Oct;476(10):2052-2061. doi: 10.1097/CORR.0000000000000463.
Previous studies have shown that venous thromboembolism (VTE) is a complication associated with neoplastic disease and major orthopaedic surgery. However, many potential risk factors remain undefined.
QUESTIONS/PURPOSES: (1) What proportion of patients develop symptomatic VTE after surgery for long bone metastases? (2) What factors are associated with the development of symptomatic VTE among patients receiving surgery for long bone metastases? (3) Is there an association between the development of symptomatic VTE and 1-year survival among patients undergoing surgery for long bone metastases? (4) Does chemoprophylaxis increase the risk of wound complications among patients undergoing surgery for long bone metastases?
A retrospective study identified 682 patients undergoing surgical treatment of long bone metastases between 2002 and 2013 at the Massachusetts General Hospital and Brigham and Women's Hospital. We included patients 18 years of age or older who had a surgical procedure for impending or pathologic metastatic long bone fracture. We considered the humerus, radius, ulna, femur, tibia, and fibula as long bones; metastatic disease was defined as metastases from solid organs, multiple myeloma, or lymphoma. In general, we used 40 mg enoxaparin daily for lower extremity surgery and 325 mg aspirin daily for lower or upper extremity surgery. The primary outcome was a VTE defined as any symptomatic pulmonary embolism (PE) or symptomatic deep vein thrombosis (DVT; proximal and distal) within 90 days of surgery as determined by chart review. The tertiary outcome was defined as any documented wound complication that might be attributable to chemoprophylaxis within 90 days of surgery. At followup after 90 days and 1 year, respectively, 4% (25 of 682) and 8% (53 of 682) were lost to followup. Statistical analysis was performed using multivariable logistic and Cox regression and Kaplan-Meier.
Overall, 6% (44 of 682) of patients had symptomatic VTE; 22 patients sustained a DVT, and 22 developed a PE. After controlling for relevant confounding variables, higher preoperative hemoglobin level was independently associated (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.60-0.93; p = 0.011) with decreased symptomatic VTE risk, the presence of symptomatic VTE was associated with a worse 1-year survival rate (VTE: 27% [95% CI, 14%-40%] and non-VTE: 39% [95% CI, 35%-43%]; p = 0.041), and no association was found between wound complications and the use of chemoprophylaxis (OR, 3.29; 95% CI, 0.43-25.17; p = 0.252).
The risk of symptomatic 90-day VTE is high in patients undergoing surgery for long bone metastases. Further study would be needed to determine the VTE prevention strategy that best balances risks and benefits to address this complication.
Level III, therapeutic study.
先前的研究表明，静脉血栓栓塞症（VTE）是与肿瘤疾病和大型骨科手术相关的并发症。然而，许多潜在的风险因素仍未得到明确。
问题/目的：（1）接受长骨转移手术的患者中有多大比例会发生有症状的 VTE？（2）哪些因素与接受长骨转移手术的患者发生有症状的 VTE 有关？（3）在接受长骨转移手术的患者中，有症状的 VTE 的发生与 1 年生存率之间是否存在关联？（4）化学预防是否会增加接受长骨转移手术患者的伤口并发症风险？
一项回顾性研究在马萨诸塞州综合医院和布莱根妇女医院确定了 2002 年至 2013 年间接受长骨转移手术治疗的 682 名患者。我们纳入了年龄在 18 岁或以上、即将发生或病理性转移性长骨骨折的手术患者。我们将肱骨、桡骨、尺骨、股骨、胫骨和腓骨视为长骨；转移性疾病定义为来自实体器官、多发性骨髓瘤或淋巴瘤的转移。一般来说，我们在下肢手术中使用每天 40 毫克依诺肝素，在上肢或下肢手术中使用每天 325 毫克阿司匹林。主要结局是通过图表审查确定的手术后 90 天内任何有症状的肺栓塞（PE）或有症状的深静脉血栓形成（DVT；近端和远端）定义为 VTE。次要结局定义为手术后 90 天内任何可能与化学预防有关的有记录的伤口并发症。分别在 90 天和 1 年的随访中，4%（682 例中有 25 例）和 8%（682 例中有 53 例）患者失访。使用多变量逻辑回归和 Cox 回归以及 Kaplan-Meier 进行统计分析。
总体而言，6%（44/682）的患者发生有症状的 VTE；22 例患者发生 DVT，22 例患者发生 PE。在控制了相关混杂变量后，较高的术前血红蛋白水平与较低的有症状 VTE 风险独立相关（比值比[OR]，0.75；95%置信区间[CI]，0.60-0.93；p = 0.011），有症状 VTE 的存在与 1 年生存率下降相关（VTE：27%[95%CI，14%-40%]和非 VTE：39%[95%CI，35%-43%]；p = 0.041），并且未发现伤口并发症与使用化学预防之间存在关联（OR，3.29；95%CI，0.43-25.17；p = 0.252）。
接受长骨转移手术的患者发生有症状的 90 天 VTE 的风险很高。需要进一步研究以确定最佳的 VTE 预防策略，以平衡风险和收益，以解决这一并发症。
III 级，治疗性研究。
