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The Incidence of Thromboembolic Events in Surgically Treated Ankle Fracture
Stéphane Pelet, MD, PhD1; Marie-Eve Roger, MD2; Etienne L. Belzile, MD, FRCS(C)2; Marc Bouchard, MD, FRCS(C)2
1 Division of Orthopaedic Surgery, CHA-Pavillon Enfant-Jésus, 1401, 18ème Rue, QC G1J 1Z4, Canada. E-mail address: stephane.pelet.ortho@gmail.com
2 Division of Orthopaedic Surgery, CHUQ-Hotel Dieu de Quebec, 11, côte du Palais, QC G1R 2J6, Canada
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Investigation performed at CHAUQ-Hospital Enfant-Jésus and CHUQ-Hospitals Saint-François d'Assises and Hotel-Dieu, Québec City, Canada

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Mar 21;94(6):502-506. doi: 10.2106/JBJS.J.01190
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Thromboembolic events occur following musculoskeletal injury, and some have serious sequelae, including death. The purpose of this study was to determine the incidence of thromboembolic events and its relationship with risk factors in ambulatory patients with ankle fracture requiring open reduction and internal fixation.


We conducted a retrospective chart review of 2478 patients who underwent open reduction and internal fixation of an ankle fracture at any one of three university hospitals between January 1, 1997, and April 30, 2005. One thousand five hundred and forty patients meeting the inclusion criteria and with complete records (minimum follow-up, six months) were identified. The median age of the patients at the time of surgery was forty-six years, and there was an equal proportion of male and female patients. Fracture types included 45% unimalleolar fractures, 31% bimalleolar, and 24% trimalleolar. Charts were reviewed to identify thromboembolic events, risk factors (neoplasia, hormone use, pregnancy, blood dyscrasia, history of a previous thromboembolic event, a current history of smoking, obesity, dyslipidemia, atherosclerotic vascular disease, or paralysis), and use of thromboprophylactic agents. A thromboembolic event was defined as symptomatic when deep venous thrombosis was confirmed with use of Doppler ultrasonography or when pulmonary embolism was confirmed with use of ventilation and perfusion scintigraphy or helical computed tomography.


The incidence of thromboembolic events was 2.99% (forty-six patients), with 2.66% (forty-one patients) involving a deep venous thrombosis and 0.32% (five patients) involving a nonfatal pulmonary embolism. There were no fatal pulmonary emboli recorded. The incidence did not differ among hospitals. Of the 1540 patients, 16.43% received thromboprophylaxis during their hospital stay and for six weeks (for the 10.78% taking low-molecular-weight heparin) or three months (for the 5.65% taking warfarin) after discharge without significantly modifying the incidence of thromboembolic events (2.56% vs. 2.37%, relative risk = 0.91). However patients with one or more risk factors had a greater risk of a thromboembolic event than did patients with no risk factors (3.59% vs. 2.38%, respectively; relative risk = 0.66). The use of thromboprophylaxis had no apparent impact on the occurrence of thromboembolic events in patients who did or did not have risk factors (3.68% vs. 3.55%, respectively; relative risk = 0.96). No significant correlation could be identified between the occurrence of thromboembolic events and fracture types, age, or sex.


Clinically detectable thromboembolic events after surgical treatment of ankle fractures are uncommon and do not appear to be influenced by the use of thromboprophylaxis. Patients with risk factors appear to be at higher risk for these events, but there is a need for prospective studies to determine the efficacy of thromboprophylaxis after surgical treatment of ankle fractures.

Level of Evidence: 

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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