Lower limb immobilization is associated with high risk of complications, i.e. venous thromboembolism (VTE) and failed healing. Pharmacoprophylaxis of VTE is in leg-immobilized patients, however, low- or non-effective and associated with adverse events. Thus, there is a need for novel treatments. This study aims to demonstrate in leg immobilized patients who have suffered an ankle fracture (1000 patients) or an Achilles tendon rupture (400 patients) that adjuvant intermittent pneumatic compression (IPC) therapy, which targets impaired vascular flow, compared to treatment-as-usual with plaster cast, reduces VTE incidence and improves healing.
The proposed intervention, intermittent pneumatic compression (IPC) is an evidence-based prevention for VTE in hospitalized patients and used in daily practice. IPC is, however, not currently used on outpatients and it is currently unknown if it reduces the risk of VTE during long term leg-immobilization. Plaster cast and orthosis treatments are currently used in daily practice on Achilles tendon ruptures and ankle fractures. At present there is no consensus about using VTE prophylaxis in leg-immobilized patients. Since pharmacoprophylaxis has shown low- or no VTE preventive effects in leg-immobilization, is not recommended by some guidelines. Furthermore, since all patients will undergo clinical examinations and have DVT-screening performed with compression Doppler ultrasound (CDU) removal of leg immobilization this will comprise an extra security for the included patients to detect a VTE. If a VTE is detected clinical guidelines will be followed by initiating chemical VTE-treatment.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
PREVENTION
Masking
DOUBLE
Enrollment
1,400
This IPC-system delivers sequential circumferential compression. The IPC device is mobile and should therefore not restrict patient mobilization, but can be taken off if the patient wants to mobilize independently.
Karolinska University Hospital
Stockholm, Sweden
RECRUITINGVenous Thromboembolic Events (VTE)
The primary outcome is VTE defined as symptomatic Deep venous Thrombosis (DVT) or asymptomatic DVTs,or symptomatic pulmonary embolism
Time frame: Up til the time of removal of leg immobilization, approx. 6-8 weeks
Patient reported Outcome - ATRS
symptoms will be assessed using the reliable and valid score; the Achilles tendon Total Rupture Score (ATRS)
Time frame: 6 months and 1 year
Patient reported Outcome - FAOS
symptoms will be assessed using the reliable and valid score; the Foot and Ankle Outcome Score (FAOS)
Time frame: 6 months and 1 year
Patient reported Outcome - OMAS
symptoms will be assessed using the reliable and valid score; the Olerud-Molander Ankle Score (OMAS)
Time frame: 6 months and 1 year
Patient reported Outcome - EQ-5D-5L
symptoms will be assessed using the reliable and valid score; EuroQol Group's questionnaire (EQ-5D-5L).
Time frame: 6 months and 1 year
Functional outcome - muscular endurance tests (heel-rise)
Patient leg function will be measured by a validated endurance test (i.e. the heel-rise test) at 1 year post-injury.
Time frame: 1 year
Callus production
Microdialysis followed by quantification of procollagens will assess callus production in Achilles tendon healing.
Time frame: 6 weeks
VTE-preventive mechanisms
VTE-preventive mechanisms will be analyzed at the 6 week visit by assessments of profibrinolysis and coagulation factors as well as by blood-flow quantification .
Time frame: 6 weeks
Incidence of VTE in patients using low molecular weight heparin(LMWH) with or without adjvant IPC
Efficacy of LMWH with and without the use of IPC as to prevent VTE will be studied in order to confirm the efficency of a commonly used drug for VTE prophylaxis.
Time frame: 6-8 weeks
Patient mortality
Mortality of patients included will be recorded and investigated for cause of death. If the cause of death is VTE, this will be reported. The overall mortality rate in this study is expected to be low. Mortality will be investigated via patient journals at one year after study inclusion, and at 2 years via national mortality register.
Time frame: 1year and 2 years
Health economic analyses
Together with Karolinska Institutet, LIME, the trial treatment effects will involve a within-trial evaluation of cost effectiveness integrated into a decision-analytic model of longer run costs and health effects
Time frame: 2 years
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