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High Risk of Venous Thromboembolism After Surgery for Long Bone Metastases

A Retrospective Study of 682 Patients

Groot, Olivier Q., BSc; Ogink, Paul T., MD; Janssen, Stein J., MD; Paulino Pereira, Nuno Rui, MD; Lozano-Calderon, Santiago, MD, PhD; Raskin, Kevin, MD; Hornicek, Francis, MD, PhD; Schwab, Joseph H., MD, MS

Clinical Orthopaedics and Related Research®: October 2018 - Volume 476 - Issue 10 - p 2052–2061
doi: 10.1097/CORR.0000000000000463

Background 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?

Methods 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.

Results 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).

Conclusions 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 of Evidence Level III, therapeutic study.

Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Boston, MA, USA

O. Q. Groot, Massachusetts General Hospital, 55 Fruit Street, Room 3.946, Yawkey Building, Boston, MA 02114, USA, email:

Each author certifies that neither he, nor any member of his immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his institution waived approval for this investigation and that all investigations were conducted in conformity with ethical principles of research.

Received February 22, 2018

Accepted July 31, 2018

© 2018 Lippincott Williams & Wilkins LWW
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