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EXPERT OPINION
Year : 2021  |  Volume : 7  |  Issue : 1  |  Page : 64-67

Expert opinion: Using of antiplatelet agents in surgery with external fixators


Mangioni Hospital, Lecco, Italy

Date of Submission04-May-2021
Date of Acceptance17-May-2021
Date of Web Publication30-Jun-2021

Correspondence Address:
Maurizio A Catagni
Mangioni Hospital, Lecco
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2455-3719.320061

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How to cite this article:
Catagni MA, Pili D. Expert opinion: Using of antiplatelet agents in surgery with external fixators. J Limb Lengthen Reconstr 2021;7:64-7

How to cite this URL:
Catagni MA, Pili D. Expert opinion: Using of antiplatelet agents in surgery with external fixators. J Limb Lengthen Reconstr [serial online] 2021 [cited 2021 Dec 8];7:64-7. Available from: https://www.jlimblengthrecon.org/text.asp?2021/7/1/64/320061




  Introduction Top


Who remembers Calcitonin?

In the 1970s, a drug called Calcitonin was put on the market. Today I read, on Wikipedia “Calcitonin is a hormone consisting of a polypeptide of 32 amino acids that is produced, in humans, by the parafollicular cells of the thyroid gland (also known as C cells, from clear: due to their poor colorability under the microscope optic compared to thyrocytes), from the K cells of the respiratory epithelium and in many other animals from the Last pharyngeal body (gland associated with the last branchial arch).

The main function of calcitonin is to lower the concentration of calcium in the blood (Ca2+), counteracting the effects of the parathyroid hormone parathyroid hormone (PTH). This calcium regulation mechanism has been found in fish, reptiles, birds and mammals. Unlike animal studies, its importance in humans has not been well defined, as it is not clear how relevant its function is in regulating normal calcium homeostasis compared to other molecules.

The hormone calcitonin also acts in the kidney, stimulating the tubular elimination of calcium. It was used in the treatment of osteoporosis and other osteometabolic pathologies. The role in these pathologies has however been extensively re-evaluated, in fact to date calcitonin has no established therapeutic indication. In recent studies, an increase in the incidence of osteosarcoma has also been observed in patients on previous chronic therapy with calcitonin. ”.

I remember very well that this drug was prescribed in industrial quantities by orthopaedists to fight osteoporosis and even in the bone metastases of malignant tumours and then also in Paget's disease. Then the drug disappeared because, after years and years, the scientific evidence that had been highlighted in many publications, had not been reflected in the clinical results of the patients undergoing treatment. The companies that made the drug, however, made huge profits for many years. But the works that demonstrated the effectiveness of the drug, how and by whom were they made? I leave the answer to the intelligence of my reader.

I also remember a drug that was most popular for the treatment of sciatica that was promoted to health care doctors as the cure-all for sciatica for an elusive anti-neuritic power, such Cronassial, which disappeared from circulation after many years because we realized that it was useless. In the 70s, hyaluronic acid for joint infiltrations was marketed with an advertising campaign that guaranteed miraculous results but. then it was removed from the free handbook and disappeared for many years until its relatively recent rebirth as “high density”. I challenge any of my colleagues to demonstrate real efficacy in patients other than as a placebo effect lubricant!

This is a premise for what I want to demonstrate, with certain clinical results, on the real need to use antiplatelet agents during surgical treatments with external fixators.

Post-surgical Deep Vein Thrombosis (DVT)

According to several clinical studies, DVT develops in approximately 40-60% of patients undergoing limb surgery. Basically, whether a prophylaxis with anti-platelet aggregates is done or not but, it seems, the patients on prophylaxis show less evident clinical symptoms. That is, DVT exists but is not clinically diagnosed. Now, we are talking about the risk of pulmonary embolism and, according to my clinical experience as an orthopaedic surgeon, all the pulmonary embolisms that I have detected in surgical practice, were of patients operated on for prostheses with previous respiratory problems and advanced age and who, in any case, were under treatment with LMWH.

There is no comparative study between serious risk of DVT in patients undergoing surgical treatment with circular fixators and heparin prophylaxis and other patients with the same surgical treatments but without LMWH prophylaxis.

In the following presentation, I present a series of patients, treated mainly with circular fixator surgery where antiplatelet prophylaxis has never been applied but one.

This work represents the control cases and I hope that some other author will be able, with patients with similar treatments, to evaluate the difference in terms of DVT.

Why don't we give antiplatelet prophylaxis in fixator surgery?

  1. An antiplatelet treatment produces, as everyone knows, a greater ease of uncontrolled bleeding, with the formation of haematoma at in the surgical sites. This does not only increase blood loss but also increased the risk of surgical sites infection. The skin is under tension due to uncontrolled hematoma.

    A parenthesis: how many times have I seen in cases of joints arthroplasty surgery make an aggressive antiplatelet prophylaxis and then, during the surgery, have the need to administer tranexamic acid (TXA) which, by definition, is a coagulant and antifibrinolytic!!!. The use TXA and antiplatelets therapy contradict each other.
  2. In addition, any antiplatelet agent prevents the organization of the clot which is crucial for the formation of callus both in fractures and for new bone formation in lengthening. These eventualities have been found in numerous cases of patients treated with LMWH or with non-steroidal anti-inflammatory drugs, which have essentially the same negative mechanism in the formation of callus (which, remember, is a process of organizing hematoma and vascular neoformation).
  3. In addition, treatment with external fixators allows immediate mobilization, within a few hours of surgery with the possibility of partial load in the treatment of the lower limbs.


We remind you that the recommendation of those who advocate treatment with Heparin is to administer it until functional recovery and, therefore, substantially for those who recover function within a few hours, there would be no indication. In common practice, the administration of heparin is extended to cases in which there is not even a minute of reduction in function, even in ankle sprains in which patients, with braces, walk immediately. The reason is to be found in the so-called “defensive medicine” where the risk of a complaint by the patient is extremely high (due to a large number of lawyers and a large number of doctors ready to report the colleague for unlikely damage from failure to administer heparin!). The judge, called upon to settle the dispute, tends to agree with the patient, based on medical reports which in turn draw strength from the numerous publications that recommend the use of heparins in surgery. All of us were contacted many years ago by various pharmaceutical companies who, with the excuse of scientific experimentation, gave doses to the hospital convincing them of the need for administration and then, based on the results we shared, they could affirm that with the treatment there was no risk of DVT. But no one has, honestly and really checked that the results were “driven”, so that the therapy has subtly become “necessary”, with a great economic waste and with the damage that anticoagulant therapies actually produce (haemorrhages, non-consolidation of fractures and new bone formation during lengthening and increased risk of infections in the surgical scar). It being understood that the use of heparin is absolutely useful in cases of discoagulopathies and pulmonary embolisms, the clinical evidence of my results requires a proper rethink on the subject.


  Material Top


From 2015 to 2019 we performed 1748 operations at the Mangioni Hospital in Lecco, all with balanced general anaesthesia, of which 623 where it was applied in a circular external fixator, in a hybrid conformation, i.e. the stabilization of the bone was 90% consisting of conical half pin with a diameter of 6 mm in adults and 5 mm in children, made of titanium or steel coated with hydroxy apatite. Steel-only counts were about 15%, in adult bones.

The post-operative treatment of all patients subjected to the application of fixators was to allow the almost immediate mobilization of the treated segment, with the possibility, in the lower limbs, of partial load with crutches (from 15 to 30 kg, measured with the aid of scales). Pain-relieving treatment was limited to 24 hours after surgery, using morphine in elastomer, followed by paracetamol from the second post-operative day, for a period of 2-3 days.

The remaining operations were 783 removal of internal fixation devices or removal of external fixators, 248 operations on the foot, hand and knee (without fixators), 94 tendon transpositions (EPA, TP)

Specifically, the pathologies of external fixators were the following:

623 long bone surgeries with at least one osteotomy (19 femur lengthening, 17 bilateral femur lengthening, 53 femur and leg lengthening, 23 leg lengthening, 42 bilateral leg lengthening, 14 bilateral humerus lengthening, 5 unilateral humerus lengthening, 5 monofocal ankle arthrodesis, corrections knee dislocation with femur and leg assembly, 16 forearm deformities, 68 femur deformities, 16 femur and leg deformities, 19 bilateral leg deformities, 134 leg deformities, 19 foot deformities, 7 iliac crest regenerated grafts, 36 leg osteitis with antibiotic beads, 22 femur osteitis with antibiotic beads, 3 humerus osteitis with antibiotic beads, 3 forearm pseudarthrosis resection and bifocal, 6 femur pseudarthrosis resection and bifocal, 8 femur pseudarthrosis revision and monofocal, 23 pseudarthrosis leg resection and bifocal, 19 pseudarthrosis leg resection and 34 revision leg pseudarthrosis and iliac crest grafts, 1 humerus pseudarthrosis resection and bifocal, 10 humerus pseudarthrosis resection, grafts and monofocal, 1 knee prosthesis removal and arthrodesis with leg lengthening.

LMWH was never administered in all the patients (1748) but 1.

Patients were discharged on the second or third post-surgical day, after careful clinical and radiological control; subsequent checks after 2-4 weeks.

During the checks, the necessary radiographs were performed, and the status of the treated segment was clinically assessed.

No oedema of the segment has ever been observed, except in rare cases of patients where, due to repeated surgical treatments already performed previously, a venous return deficit was already present. Also in these cases, by stimulating walking, the oedema resolved on its own and disappeared before the removal of the fixator.

In only one case we administered LMWH in an ankle arthrodesis, since the patient, already operated on in other locations, had reported “thrombophilia”. In the same patient, the consolidation of the arthrodesis failed due to a lack of callus formation. In a subsequent surgery, a new revision was performed to favour tibio talar arthrodesis, LMWH was not administered, and the consolidation of the arthrodesis took place quickly.
Figure 1: Post traumatic ankle arthritis

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Figure 2: One month after

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  Conclusion Top


In our experience, based on the evidence, we did not find any clinical complications of DVT in any of our patients treated with circular fixators. Since 90% of our patients were resident in locations other than our hometown. Our patient evaluated by their family doctor. The family doctor ordered doppler study to rule out DVT. The family doctor does not know the type of treatment in progress, despite the clear indications of the prescription of our discharge. The minimal oedema of the limb was the reason to order the Doppler study. The study always with come back with negative results. This study was performed in about 10% of patients who had had lower limb surgery.

Therefore, according to our experience, specifically in the treatment of long bones with external fixators, the treatment with LMWH heparin is not only useless but, as far as bone consolidation is concerned, also harmful. From an economic point of view, considering the average price of a dose of fractionated heparin is about 4 euros per dose, in the 5 years of treatment of our patients, considering 20 days of treatment (in clinical practice some surgeons administer heparin for the whole maintenance time of the fixers, up to even 1 year!), about 140,000 euros were saved.

The present report represents a control group that should be compared with a group of similar diseases treated with administration of fractionated heparin.

In the near future, a further series of patients is planned in which, in addition to the clinic, the instrumental research of possible DVT with Doppler study will also be presented.




    Figures

  [Figure 1], [Figure 2]



 

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