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Andrew H. Felcher, MD; Richard A. Mularski, MD, MSHS, MCR, FCCP; David M. Mosen, PhD, MPH; Steven E. Laxson, DPM
Author and Funding Information

From the Northwest Permanente Medical Group (Drs Felcher, Mularski, and Laxson); and Center for Health Research (Drs Mularski and Mosen), Kaiser Permanente Northwest.

Correspondence to: Richard A. Mularski, MD, MSHS, MCR, FCCP , Kaiser Permanente Center for Health Research, 3800 N Interstate Ave, WIN1060, Portland, OR 97227; e-mail: richard.a.mularski@kpchr.org


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(1):243. doi:10.1378/chest.09-2129
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To the Editor:

We appreciate the opportunity to respond to Drs Budny and Rogers’ comments on our recent article in CHEST (April 2009).1 Although we agree that podiatrists and orthopedists may perform the same foot and ankle procedures, our intent was to describe the risk of venous thromboembolism (VTE) in patients under the care of a typical podiatrist doing common podiatric procedures in a common podiatric practice. Our database included more than 16,000 procedures done by all of the podiatrists in a large medical group over 5 years and reflects the variety of procedures performed by the vast majority of podiatrists, hence the title of our article. We did not exclude any particular foot or ankle surgeries; thus, the forefoot proportion is representative of the practice in podiatrists. Likewise, the podiatric distinction clarifies the confusion regarding incidence computation in the studies referenced in our article. Only one study estimated the incidence of VTE seen by podiatrists, whereas six studies explored VTE in foot/ankle surgery performed by orthopedists.2 Although we agree there is merit in either approaching VTE risk by surgical specialty experience or by specific procedures or anatomic regions, we chose to elucidate risk in a large general podiatrist practice.

By the same token, we chose not to exclude any of the procedures done in a typical podiatrist’s practice, including injections and percutaneous drainages. While a proportion of the 16,804 surgical procedures identified in our study involved foot injections (Current Procedural Terminology [CPT] 20550) or drainage of a joint/bursa/cyst (CPT 20605 and 20600), incidence rates are computed at the patient level (n = 7,264 in our full study population), thus many patients had multiple procedures that included both these and more extensive surgeries. In performing a sensitivity analysis adjusting for injection/drainage procedures, we find three patients with symptomatic postprocedure VTE who received both these procedures and more invasive surgeries. Adjusting our sample to include only those who had a more invasive procedure, we find the pool reduced to 5,621 individuals, and we continue to compute low adjusted incidence rates of VTE at 0.39% overall (0.21% for deep vein thrombosis only; 0.18% for pulmonary embolism only). Incidence rates remain in the low risk strata, and our conclusion that VTE prophylaxis is not indicated for routine podiatric procedures in patients without any additional risk factors for VTE remains valid, even after adjusting for injections/drainage. As we note in our paper, definitive decisions about VTE prophylaxis should be made on an individual patient basis; in this we agree with Drs Budny and Rogers.

Felcher AH, Mularski RA, Mosen DM, Kimes TM, DeLoughery TG, Laxson SE. Incidence and risk factors for venous thromboembolic disease in podiatric surgery. Chest. 2009;1354:917-922. [CrossRef] [PubMed]
 
Slaybaugh RS, Beasley BD, Massa EG. Deep venous thrombosis risk assessment, incidence, and prophylaxis in foot and ankle surgery. Clin Podiatr Med Surg. 2003;202:269-289. [CrossRef] [PubMed]
 

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References

Felcher AH, Mularski RA, Mosen DM, Kimes TM, DeLoughery TG, Laxson SE. Incidence and risk factors for venous thromboembolic disease in podiatric surgery. Chest. 2009;1354:917-922. [CrossRef] [PubMed]
 
Slaybaugh RS, Beasley BD, Massa EG. Deep venous thrombosis risk assessment, incidence, and prophylaxis in foot and ankle surgery. Clin Podiatr Med Surg. 2003;202:269-289. [CrossRef] [PubMed]
 
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