It is not uncommon for a podiatric physician to be named in a lawsuit when a patient suffers a DVT/PE following podiatric surgery or treatment requiring immobilization. Allegations against the physician commonly include:

• Failure to place the patient on DVT/PE prophylactic anticoagulation therapy
• Failure to recognize the patient was at high risk for development of a DVT/PE
• Failure to provide information regarding the potential for the development of a DVT/PE to a patient prior to undergoing surgery and obtain appropriate informed consent

Unfortunately, there is no consensus regarding when or who DVT/PE pharmacologic and/or mechanical prophylaxis for podiatric surgery and treatment requiring immobilization should be instituted. 

The American College of Foot and Ankle Surgeons (ACFAS) published “Clinical Consensus Statement: Risk, Prevention, and Diagnosis of Venous Thromboembolism Disease (VTED) in Foot and Ankle surgery and Injuries Requiring Immobilization” (ACFAS Consensus Statement) in 2015. This consensus statement concluded that routine prophylaxis is not indicated and that the decision to place a patient on prophylactic anticoagulation therapy should be based on each individual risk/benefit ratio.

The American Orthopaedic Foot and Ankle Society (AOFAS) published a position statement on “The Use of Venous Thromboembolic Disease Prophylaxis in Foot and Ankle Surgery” on February 11, 2020. The AOFAS position is that there is currently insufficient data to recommend for or against routine venous thromboembolic disease prophylaxis for patients undergoing foot and ankle surgery. They recommend that the decision to implement anti-thrombotic prophylaxis, as well as the measures used to do so, should be based upon a patient specific risk/benefit analysis that takes into consideration the patient’s risk for VTED and the potential risks of the proposed prophylactic measures.

The United Kingdom’s National Institute of Clinical Excellence (NICE) recommends use of chemoprophylaxis following all lower extremity surgery with one or more for the following risk factors:

• Greater than 60 years of age
• Lower extremity surgery lasting greater than 60 minutes
• A BMI greater than 30
• A prior history of DVT in the patient or a first degree relative

While there are no clear answers regarding DVT/PE prophylaxis, physicians can take steps to reduce their risk of a lawsuit or defend themselves in the event of a lawsuit by a patient who suffered a DVT/PE following foot and ankle surgery or treatment requiring immobility.

Risk Assessment
First, it is important for the physician to assess the patient for risk of developing DVT/PE and determine based upon his or her medical judgement whether the patient should receive mechanical and/or chemical prophylaxis and for how long.

The ACFAS has identified risk factors for venous thromboembolism disease during management of foot and ankle conditions. These risk factors are divided into three categories: patient-specific, related to the treatment course, and related to the surgery or injury itself. See Table 1 on page 4 of this ACFAS article.

There are also several VTED risk evaluation tools available such as Caprini Risk Scoring, Geneva Score, Wells Criteria, and others. While these are not specific to podiatry, most identify a common set of risk factors and can assist the physician in determining if the patient is low, moderate, or high risk for developing VTED. 

Risk/Benefit Analysis
Chemical prophylaxis is not without risk. Risks include bleeding, increased risk of infection, increased risk of wound healing complications, drug interactions, heparin-induced thrombocytopenia, cost, and no guarantee of protection.

The final decision regarding use and method(s) of prophylaxis adopted should be agreed upon by both the physician and patient after a discussion of the potential benefits and harms as they relate to the individual. If there is uncertainty regarding the prophylaxis of a patient, it would be prudent to refer the patient to an appropriate specialist for an opinion.

Informed Consent
The discussion of the potential risks and benefits of prophylaxis should take place during the preoperative visit or in the immediate post-injury setting. The risk of developing DVT/PE should be specifically included on the informed consent form regardless of whether prophylaxis is instituted. It is possible for a patient who is at low risk for developing DVT/PE or for a patient who receives prophylaxis to develop a DVT/PE.

Patient Education
Patients undergoing surgery or treatment requiring immobilization and their caregivers should receive education regarding signs and symptoms of DVT/PE and what to do if they should develop signs and symptoms. Also it is a good idea to provide the patient with a written handout with the signs and symptoms of DVT/PE so they can review it at home.

Patient Monitoring
Monitor the patient for signs and symptoms of DVT/PE during each post-operative visit and promptly refer the patient for additional testing if the patient exhibits any signs or symptoms.

Documentation
Even if you provide excellent care of your patient, there is always a possibility for a bad outcome. Should a patient develop a DVT/PE and a lawsuit ensues, your medical record can be a valuable defense. Your contemporaneous documentation should reflect:

• That you considered the patient’s risk for developing a DVT/PE
• That you considered the risks and benefits of prophylaxis for that patient
• Your rationale for your decision to prophylax or not to prophylax
• That you obtained the patient’s informed consent
• That you educated the patient on the signs and symptoms of DVT/PE
• That you monitored the patient for signs and symptoms of DVT/PE and promptly and appropriately referred the patient for further workup if signs and symptoms were present

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The information contained on the PICA Blog does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only. We encourage all blog visitors to consult with their personal attorneys for legal advice, as specific legal requirements may vary from state to state. Links or references to organizations, websites, or other information is for reference use only and do not constitute the rendering of legal, financial, or other professional advice or recommendations. All information contained on the blog is subject to change.