Javascript is currently disabled in your browser. When javascript is disabled, some functions of this website will not work.

Open access for scientific and medical research

From submission to the first editing decision.

From editor acceptance to publication.

The above percentage of manuscripts have been rejected in the past 12 months.

Open access to peer-reviewed scientific and medical journals.

Dove Medical Press is a member of OAI.

Batch reprints for the pharmaceutical industry.

We provide real benefits for authors, including fast processing of papers.

Register your specific details and specific drugs of interest, and we will match the information you provide with articles in our extensive database and send you a PDF copy via email in a timely manner.

Back to Journal »International Journal of General Medicine» Volume 14

ECG non-specific ST segment and T wave (NS-STT) are associated with increased incidence of deep vein thrombosis in patients with lower limb fractures under 75 years of age during the perioperative period

Authors: Ren C, Li Min, Ma Tao, Xu Yongbao, Li Zhong, Xue Hezhong, Wang Qiang, Lu Yi, Sun Li, Zhang Kun

Published on November 23, 2021, the 2021 volume: 14 pages 8631-8641

DOI https://doi.org/10.2147/IJGM.S335243

Single anonymous peer review

Editor approved for publication: Dr. Scott Fraser

Chengren,* Mingli,* Ma Teng, Xu Yibo, Zhong Li, Xue Hanzhong, Wang Qian, Yao Lu, Sun Liang, Zhang Kun, Department of Orthopedics and Traumatology, Honghui Hospital of Xi’an Jiaotong University, Xi’an, Anshi, Shaanxi Province, People’s Republic of China*These The author made equal contributions to this work [protected] Purpose: This study aims to investigate the clinical correlation between non-specific ST segment or T wave (NS-STT) changes and perioperative deep vein thrombosis (DVT) in patients with lower limb fractures. Methods: From February 2016 to November 2018, 1469 patients with lower limb fractures were continuously screened in Xi'an Honghui Hospital, and the patients were included in this retrospective study according to the inclusion and exclusion criteria. After collecting the ECG baseline, the patients were divided into NS-STT group and non-NS-STT group. After comparing demographic and clinical characteristics, a multivariate logistic regression model was used to determine the effect of changes in NS-STT on perioperative DVT. All analyses were performed using R and EmpowerStats software. Results: A total of 968 patients were included in this study. Ninety-seven patients (10.02%) showed NS-STT changes on the ECG upon admission. A total of 303 patients (31.30%) developed perioperative DVT of the lower limbs. Univariate analysis showed that NS-STT segment changes were significantly correlated with perioperative DVT (OR = 3.45, 95% CI: 2.25–5.30, P <0.0001). In addition, age ≥ 50 (P <0.0001), female (OR = 1.50, 95% CI: 1.14–1.97, P = 0.0038), hypertension (OR = 1.54, 95% CI: 1.08–2.20, P = 0.0161) blood transfusion (OR = 1.78, 95% CI: 1.34–2.37, P <0.0001), joint prosthesis (OR = 3.26, 95% CI: 2.21–4.81, P <0.0001), blood loss ≥ 300 mL (OR = 320.12, 95 % CI: 1.50–3.01, P <0.0001) is associated with perioperative lower extremity DVT. We identified confounding factors such as age, gender, classification of internal implants, operation time, blood loss, and fluid infusion. After adjusting for potential confounding factors, changes in NS-STT were associated with perioperative DVT (OR = 2.13, 95% CI: 1.33–3.42; P = 0.0017). Sensitivity analysis shows that the results are stable. Conclusion: The changes of ECG NS-STT in patients with lower limb fractures under 75 years of age are correlated with a 2.13-fold increase in the incidence of DVT during the perioperative period. In clinical practice, surgeons should pay more attention to these patients. Keywords: non-specific ST segment and T wave, NS-STT, electrocardiogram, DVT, lower limb fracture, logistic regression

Deep vein thrombosis (DVT) is an important complication of patients with lower limb fractures. However, previous studies paid more attention to thrombosis after fracture, and ignored thrombosis after surgery. In patients with lower limb fractures, the incidence of postoperative deep vein thrombosis is often higher than the preoperative data. 1 The incidence of postoperative deep vein thrombosis can reach 61.3%. 2 It was also found that 28% of patients will develop new deep vein thrombosis after surgery. In a recent study, most of the thrombosis was preoperative DVT and continued until postoperative. 3

Perioperative deep vein thrombosis can affect the recovery and recovery process. It is worth noting that the newly formed thrombus is loosely attached to the vein wall, which can easily fall off and cause pulmonary embolism. In addition, leg swelling, skin changes, pain, chronic ulcers, etc. will affect the patient's psychology. Therefore, perioperative DVT has a higher risk of shedding during functional exercise, which should be paid attention to.

The causes of DVT during perioperative period of lower limb fractures are usually multi-factors. Most of the factors are related to surgery, including blood loss and operation time. 1 Although perioperative DVT caused by surgery has received more and more attention in recent years, few researchers worry about the influence of preoperative factors on perioperative DVT.

Traditionally, ST segment or T wave changes on the ECG are known predictors of cardiovascular mortality. 4 However, the physiological non-specific ST segment or T wave (NS-STT) is also very common, and the ECG can be seen in any lead. Most clinicians believe that in asymptomatic patients, isolated, mild, or NS-STT abnormalities are incidental, usually transient, and benign. 5 In fact, it is reported that changes in NS-STT are related to inflammatory diseases. 6 Inflammation is involved in thrombosis, thrombotic tissue, and vein repass. The link between inflammation and DVT has been established. 7-9 In addition, the relationship between arrhythmia, inflammation and blood coagulation was established very early. 10 Therefore, evidence suggests that physiological NS-STT may be related to thrombosis.

As far as we know, no previous work or report has considered the impact of NS-STT changes on perioperative thrombosis. This study aimed to explore the clinical correlation between the changes of NS-S TT and perioperative DVT in patients with lower limb fractures.

The clinical and surgical data of the reviewed cases come from the original medical records. The ethics committee of Xi'an Honghui Hospital approved this retrospective study (No. 2014026). Because the patient's identity remains anonymous, and because of the observational nature of the study, the requirement for informed consent was waived, as reported elsewhere. 11,12 All human-related procedures are in compliance with the 1964 Helsinki Declaration and subsequent amendments.

From February 2016 to November 2018, Xi'an Honghui Hospital consecutively admitted 1469 patients with lower limb fractures. The inclusion criteria are as follows: 1). Age ≥18 years old; 2) new lower limb fractures undergoing surgical treatment; 3) availability of electrocardiogram; 4) completion of hospital admission and perioperative ultrasound examination. We excluded patients with coronary heart disease symptoms (n = 28), age> 75 years (n = 320), and patients undergoing closed reduction and internal fixation (n = 153). The remaining 968 cases formed the final population.

Upon admission, the nurse records personal electrocardiogram electrical signals. Professional physicians report more than 50,000 cases each year and report the results of electrocardiogram. Their reports are independent and undisturbed. Two well-trained doctors analyze each ECG to maintain consistency and resolve differences through discussion. Unresolved differences are discussed with a third senior doctor. The criteria for NS-STT changes include slight ST segment straightening, actual ST segment depression or elevation, T wave flattening, biphasic T wave or T wave inversion. According to these criteria, a total of 97 patients experienced NS-STT changes after fracture.

We define perioperative DVT as thrombosis that occurs before or after surgery, which is found to be defective by ultrasound. Ultrasound is used to diagnose DVT. Three well-trained operators use bedside machines to perform vascular ultrasound examinations. The diagnostic criterion for fresh thrombosis is the presence of a persistent cavity filling defect. 13 All patients underwent the first examination of both lower limbs upon admission.

When the nurse collects the ECG and blood samples on admission, the surgeon uses the Thromboembolic Risk Assessment Score to assess the thromboembolic risk of each patient. 14 For patients with no contraindications, low molecular weight heparin (LMWH; 3800 IU/0.4 mL, once a day; according to the guidelines in CHEST 2012.15, subcutaneous injection of Fraxiparine, Glaxo Wellcome, GlaxoSmithKline) to prevent DVT anticoagulant therapy was stopped 12 hours before surgery and recovered 24 hours after surgery. In addition, we use a mechanical pressure pump (20 minutes, twice a day) to promote blood return. For patients without thrombosis, continue subcutaneous injection of LMWH. For thrombus In patients who develop, the vascular surgeon prescribes a DVT treatment plan and subcutaneously injects LMWH (3800 IU/0.4 mL, twice a day; Fraxiparine, Glaxo Wellcome Production, GlaxoSmithKline). If necessary, we use an inferior vena cava filter before the operation To prevent fatal pulmonary embolism. After the operation, the anticoagulation strategy is continued. On the 3rd to 5th day after the operation, the patient is subjected to a second ultrasound examination of the lower extremities.

First, we compared the data distribution of each covariate between the NS-STT group and the non-NS-STT group, using t test or Kruskal-Wallis rank sum test for continuous variables, and c2 test for categorical data. Secondly, univariate and subgroup analysis and multivariate logistic regression model were used to investigate whether the changes of ECG NS-STT and other covariates have independent effects on the occurrence of lower extremity DVT during the perioperative period of lower extremity fractures. Third, we explored the relationship between NS-STT changes in the ECG of patients with lower limb fractures and DVT during the perioperative period through smoothing graphs, and adjusted for potential confounding factors. All analyses were performed using R (http://www.R-project.org) and EmpowerStats software (www.empowerstats.com, X&Y Solutions, Inc. Boston, MA).

Among the 968 patients included in the study, 97 (10.02%) had NS-STT changes on their ECG at admission. Demographic and clinical characteristics, including comorbidities, factors related to injury and surgery are shown in Table 1. The average age of the NS-STT group was 65.05±8.41, while the average age of the non-NS-STT group was 47.93±15.34 (P <0.001). In terms of fracture types, there were more femoral fractures in the NS-STT group than in the non-NS-STT group. Among the comorbidities, there were more hypertensive patients in the NS-STT group, and more damage in the non-NS-STT group. In addition, in the factors related to surgery, the operation time and blood loss of the NS-STT group were more than those of the non-NS-STT group. Nevertheless, there were fewer patients in the NS-STT group who used tourniquets. More patients in the NS-STT group used intramedullary nails and joint prostheses. Table 1 Demographic and clinical characteristics​​

Table 1 Demographic and clinical characteristics​​

In this study, a total of 303 patients (31.30%) developed perioperative lower limb DVT. Univariate regression analysis showed that changes in the ST-T segment of ECG were significantly correlated with perioperative DVT (OR = 3.45, 95% CI: 2.25-5.30, P <0.0001). In addition, age ≥50 years, female, high blood pressure, blood transfusion, joint prosthesis, blood loss ≥300 mL may also be associated with perioperative deep vein thrombosis of the lower extremities (Table 2). Table 2 Single factor analysis of the impact of risk factors on perioperative DVT

Table 2 Single factor analysis of the impact of risk factors on perioperative DVT

Table 3 shows the subgroup analysis of DVT risk factors during perioperative period. Among these factors, the results of different subgroups are comparable. Table 3 Subgroup analysis of potential risk factors leading to perioperative DVT

Table 3 Subgroup analysis of potential risk factors leading to perioperative DVT

At the beginning of the analysis, we identified two confounding factors for age and internal implant classification. To identify other important confounding factors, we explored potential factors. Since age, operation time, blood loss, and fluid infusion are continuous variables, a smooth curve fit between these factors during perioperative DVT is drawn, as shown in Figure 1. As for the curve relationship with perioperative DVT, these factors are taken into account the following adjustment factors. In addition, we also explored the relationship with changes in NS-STT, and we found that gender (reference male, female (OR = 4.05, 95% CI: 2.54-6.44, P <0.0001)) is an important factor. Therefore, we have identified the factors that need to be controlled. Figure 1 The curve correlation between age (A), operation time (B), blood loss (C) and fluid infusion (D) and perioperative DVT.

Figure 1 The curve correlation between age (A), operation time (B), blood loss (C) and fluid infusion (D) and perioperative DVT.

After adjusting for potential confounding factors, the independent influence of NS-STT changes on perioperative DVT was confirmed, as shown in Table 4. In models I to IV, the results are close to each other. In addition, in order to explore the stability of the results, we continue to complete the sensitivity analysis. When the subgroups are divided one by one according to the above-identified factors, the results of the different subgroups are very close. Therefore, changes in NS-STT were associated with perioperative DVT (OR = 2.13, 95% CI 1.33–3.42; P = 0.0017). Table 4 The relationship between changes in ECG NS-STT and perioperative DVT

Table 4 The relationship between changes in ECG NS-STT and perioperative DVT

In this study, we found that changes in ECG NT-STT were associated with a 2.13-fold increase in the perioperative DVT incidence of patients with lower limb fractures under 75 years of age. In clinical practice, when patients with lower limb fractures under 75 years of age have changes in NT-STT when they are admitted to the hospital, the surgeon should pay more attention to the prevention of perioperative DVT. As we all know, this is the first correlation analysis to clarify the relationship between ECG characteristics and thrombosis.

So far, studies have investigated many risk factors that lead to DVT in the perioperative period after lower extremity fractures. It is now clear that in addition to Virchow's triad (blood flow disturbance, hypercoagulable state, and vessel wall changes), inflammation also plays a vital role in triggering DVT. 8 Changes in ST and T waves may represent heart disease or normal variation. In addition to being prevalent in middle-aged men, women, and blacks, NS-STT abnormalities are also related to benign factors, such as food intake, posture, emotional stressors, hyperventilation, electrolyte disturbances, and antiarrhythmic or psychotropic drugs use. 16-28 In addition, inflammation may also be related to NS-STT on the ECG. 6 Therefore, we explored the relationship between perioperative DVT and changes in NS-STT on the ECG.

In the included patients, we only limited the newly-occurring lower limb fractures undergoing surgical treatment to control the baseline of the included patients and avoid the confounding factors of delayed fractures and conservative treatment. In addition, we have identified two key factors. As we know, ST and T wave changes are closely related to coronary heart disease. 29,30 This is a powerful confounding factor for our results. We excluded patients with symptoms of coronary heart disease and patients older than 75 years in this study. The proportion of fracture patients with coronary heart disease who are older than 75 years old is close to 40% (127/320). Therefore, we excluded patients with pathological ST and T wave changes, and most of the remaining patients had physiological NS-STT. In addition, the reset method (open reduction or closed reduction) is another confounding factor. 31,32 Since most patients underwent open surgery, we excluded patients who underwent closed reduction and internal fixation. In terms of demographics and clinical characteristics, the age, operation time, and blood loss of the NS-STT group were higher than those of the non-NS-STT group. In addition, the proportion of women, femoral fractures, hypertension, and combined injuries in the NS-STT group was higher than that in the non-NS-STT group, but the NS-STT group had a lower proportion of tourniquets. These characteristics are different in the two groups.

The average age of the NS-STT group was 65.05 years. The age is close to the limit of the elderly. In previous studies, advanced age has been associated with high blood pressure, 33 related injuries, 34 and hip fractures. 35 A higher incidence of hip fractures means a lower rate of tourniquet use. Therefore, age is a key factor in control. In the subgroup ≥60 years of age, changes in ECG NT-STT were associated with perioperative DVT. There is no correlation in the subgroup of age <60 years. We believe that the reason is that there are fewer samples in the subgroup of ages <60 years. In addition, we also found that 72.16% of women in the NS-STT group, 39.04% in the non-NS-STT group, gender is related to changes in ECG NS-STT. In previous studies, women 36 associated with hip fractures have been identified. Therefore, gender is another confounding factor. In the subgroup, males (OR = 4.14) and females (OR = 2.83) were more closely related to changes in NT-STT and perioperative DVT.

In subgroup analysis and sensitivity analysis, the results of different subgroups are close to each other. Therefore, we finally found that patients with NS-STT changes on the ECG were associated with a 2.13-fold increase in the incidence of perioperative DVT in patients with lower limb fractures under 75 years of age. In clinical practice, when patients with NS-STT changes are admitted to the hospital, the surgeon should pay more attention to the formation of DVT in the lower limbs and do more ultrasound screening.

Although our analysis shows that changes in NS-STT at admission are associated with perioperative DVT, this study has several limitations that should be noted. First of all, this result is applicable to patients under the age of 75 and does not include a diagnosis of coronary heart disease, so this conclusion cannot be adopted for patients over 75 years of age or patients with coronary heart disease. Secondly, there are too many reasons for NS-STT changes: including functional and physiological changes, myocardial ischemia, any cardiomyopathy, myocarditis, pericarditis, post-heart surgery, pulmonary embolism or endogenous lung disease, fever, anemia, acidosis or alkalinity Poisoning, electrolyte or other metabolic abnormalities, endocrine abnormalities, endogenous catecholamines, acute abdomen, cerebrovascular accidents. We believe that inflammation is the key link between NS-STT changes and perioperative DVT, but the evidence is insufficient. This relationship needs to be studied in the future. Third, due to the limitations of retrospective studies, this study may have proposed possible selection bias and sample size from a single center.

The changes in ECG NS-STT of patients with lower limb fractures under 75 years of age are related to a 2.13-fold increase in the incidence of DVT during the perioperative period. In clinical practice, surgeons should pay more attention to these patients.

NS-STT, non-specific ST segment or T wave; DVT, deep vein thrombosis.

Due to data privacy, the data set generated and/or analyzed during the current research period is not publicly available, but can be obtained from the corresponding author upon reasonable request.

This study was approved by the Ethics Committee of Xi'an Honghui Hospital (No. 2014026).

All authors who have contributed to data analysis, drafting, or revision of the article agree to the journal to which the article will be submitted, finally approve the version to be published, and agree to be responsible for all aspects of the work.

This research was funded by the Shaanxi Provincial Social Development Foundation with grant numbers 2017ZDXM-SF-009 and 2019ZDLSF01-09.

The author said that he did not violate his rights.

1. Zhang B, Wang Ping, Fei C, et al. Perioperative deep vein thrombosis in patients with lower limb fractures: an observational study. Clinical application of thrombus Hemost. 2020; 26: 1076029620930272.

2. Terao M, Ozaki T, Sato T. Diagnosis of deep vein thrombosis after proximal femoral fracture: a comparative study of ultrasound and venography. J Orthop Sc. 2006;11(2):146-153. doi:10.1007/s00776-005-0997-2

3. Fu Ying, Liu Ping, Xu Xu, etc. Deep vein thrombosis of lower limbs after femoral neck fracture: a retrospective observational study. J Orthopedic surgery. 2020;28(1):2309499019901172. doi:10.1177/2309499019901172

4. Mozos I, Caraba A. ECG predictor of cardiovascular mortality. Dis mark. 2015; 2015: 727401. doi:10.1155/2015/727401

5. Badheka AO, Rathod A, Marzouka GR, etc. Isolated non-specific ST segment and T wave abnormalities in the US cross-sectional population and mortality rate (from NHANES III). This is J Cardiol. 2012;110(4):521–525. doi:10.1016/j.amjcard.2012.04.023

6. Geraldino-Pardilla L, Gartshteyn Y, Piña P, etc. Compared with rheumatoid arthritis, patients with systemic lupus erythematosus have non-specific ST-T and QTc abnormalities. Lupus scientific medicine. 2016; 3(1): e000168. doi:10.1136/lupus-2016-000168

7. Colling M, Tourdot B, Kanthi Y. Inflammation, infection and venous thromboembolism. Circ Res. 2021;128(12):2017-2036. doi:10.1161/CIRCRESAHA.121.318225

8. Borgel D, Bianchini E, Lasne D, etc. Deep vein thrombosis inflammation: treatment goal? hematology. 2019; 24(1): 742–750. doi:10.1080/16078454.2019.1687144

9. Alipanahzadeh H, Ghulamreza R, Shokouhian M, etc. Deep vein thrombosis: a less noticed complication in hematological malignancies and immune system diseases. J Thrombolysis. 2020;50(2):318-329. doi:10.1007/s11239-019-02005-6

10. Culić V. Inflammation, coagulation, weather and arrhythmia: is there a connection? . International Heart Journal. 2014;176(1):289-293. doi:10.1016/j.ijcard.2014.06.078

11. Moreno G, Rodríguez A, Reyes L, etc. Corticosteroid therapy in critically ill patients with severe influenza pneumonia: a propensity score matching study. Intensive care medicine. 2018; 44(9): 1470–1482. doi:10.1007/s00134-018-5332-4

12. Hong J, Tong Y, He J, et al. The relationship between tumor molecular subtype, clinical stage, and axillary pathological response in breast cancer patients with complete pathological remission after neoadjuvant chemotherapy: potential impact on axillary surgery downgrading. The Adv Med Oncol. 2021; 13: 1758835921996673. doi:10.1177/1758835921996673

13. Mantoni M. Extremity vein ultrasound. Euro radio. 2001;11(9):1557–1562. doi:10.1007/s003300101016

14. Greenfield LJ, Proctor MC, Rodriguez JL, etc. Prevention of post-traumatic thromboembolism. J trauma. 1997;42(1):100–103. doi:10.1097/00005373-199701000-00017

15. Kearon C, Akl EA, Comerota AJ, etc. Antithrombotic treatment of VTE disease: Antithrombotic treatment and prevention of thrombosis, 9th edition: Evidence-based clinical practice guidelines of the American College of Chest Physicians. Chest. 2012;141(2 Suppl):e419S–e496S. doi:10.1378/chest.11-2301

16. Kumar A, Lloyd-Jones D. Clinical significance of minor non-specific ST segment and T wave abnormalities in asymptomatic subjects: a systematic review. Cardiol Rev. 2007;15(3):133-142. doi:10.1097/01.crd.0000249382.65955.14

17. Greenland P, Xie X, Liu K, et al. The influence of minor ECG ST segment and/or T wave abnormalities on cardiovascular mortality during long-term follow-up. This is J Cardiol. 2003;91(9):1068-1074. doi:10.1016/S0002-9149(03)00150-4

18. Battelle A, Hayden S, Tyrol H, etc. An ECG predictor of coronary heart disease. Arch intern doctor. 1971;128(6):929-937. doi:10.1001/archinte.1971.00310240083010

19. Miall W, Del Campo E, Fodor J, etc. Longitudinal study of heart disease in rural Jamaica. I. Prevalence, with special reference to ECG results. Bull World Health Organization. 1972;46(4):429-441.

20. Strogatz D, Tyroler H, Watkins L, etc. ECG abnormalities and mortality in middle-aged black and white men in Evans County, Georgia. J chronic disease. 1987;40(2):149-155. doi:10.1016/0021-9681(87)90066-X

21. Sutherland S, Gazes P, Keil J, etc. ECG abnormalities and 30-year mortality in white and black men in the Charleston Heart Study. cycle. 1993;88(6):2685-2692. doi:10.1161/01.CIR.88.6.2685

22. Rose G, Baxter P, Reid D, etc. The prevalence and prognosis of middle-aged men's electrocardiogram examination results. Br Heart J. 1978;40(6):636-643. doi:10.1136/hrt.40.6.636

23. Higgins I, Kannel W, Dawber T. ECG in epidemiological research: reproducibility, validity and international comparison. Br J Prev Soc Med. 1965; 19: 53-68. doi:10.1136/jech.19.2.53

24. Ostrander L, Brandt R, Kjelsberg M, etc. Electrocardiogram results of an adult population in the entire natural community of Tecumseh, Michigan. cycle. 1965; 31(6): 888-898. doi:10.1161/01.CIR.31.6.888

25. The electrocardiogram of Cullen K, Murphy B, Cumpston G. Busselton. Aust NZJ Psychiatry. 1974; 4(4): 325-330. doi:10.1111/j.1445-5994.1974.tb03199.x

26. Ostör E, Schnohr P, Jensen G, etc. ECG results in the Copenhagen City Heart Study and its association with mortality. Eur Heart J. 1981;2(4):317-328. doi:10.1093/oxfordjournals.eurheartj.a061212

27. Reunanen A, Aromaa A, Pyörälä K, etc. Coronary Heart Disease Research by Social Insurance Institutions. Baseline data and 5 years of mortality experience. Acta Med Scand Suppl. 1983; 673: 1-120.

28. Kumar A, Prineas R, Arnold A, etc. The prevalence, prognosis, and impact of isolated minor non-specific ST segment and T wave abnormalities in the elderly: a cardiovascular health study. cycle. 2008;118(25):2790-2796. doi:10.1161/CIRCULATIONAHA.108.772541

29. Farhan HL, Hassan KS, Al-Belushi A, etc. The diagnostic value of aVL lead ECG T wave inversion for coronary artery disease in patients with chronic stable angina pectoris[J]. Oman Medical Journal 2010; 25(2): 124-127. doi:10.5001/omj.2010.33

30. Birnbaum Y, Wilson JM, Fiol M, etc. Electrocardiogram diagnosis and classification of acute coronary syndromes[J]. Ann non-invasive electrocardiogram. 2014;19(1):4-14. doi:10.1111/anec.12130

31. Jupiter D, Saenz F, Mileski W, etc. Acute deep vein thrombosis and pulmonary embolism of foot and ankle trauma in the National Trauma Database: update and reanalysis. J Foot and Ankle Surgery. 2019;58(6):1152–1162. doi:10.1053/j.jfas.2019.03.011

32. Weinraub G, Newport I, Kim B, etc. The result of open reduction and internal fixation by a podiatric surgeon for ankle fracture (ORIF). J Foot and Ankle Surgery. 2021; 60(5): 960–963. doi:10.1053/j.jfas.2021.04.004

33. Wen J, Su M. A randomized trial of Tai Chi for preventing hypertension and hyperlipidemia in middle-aged and elderly people. Int J Environ Res Public Health. 2021;18(10):5480. doi:10.3390/ijerph18105480

34. Almegbel F, Altaibi I, Alhusain F, etc. Menstrual prevalence, risk factors, and consequent injury of falls among Saudi elderly living in Riyadh, Saudi Arabia: a cross-sectional study. BMJ Open. 2018; 8(1): e019063. doi:10.1136/bmjopen-2017-019063

35. Prestmo A, Hagen G, Sletvold O, etc. Comprehensive elderly care for patients with hip fracture: a prospective, randomized, controlled trial. Lancet. 2015;385(9978):1623-1633.

36. George J, Sharma V, Farooque K, etc. The injury mechanism of hip fracture in India. Hip pelvis. 2021;33(2):62-70. doi:10.5371/hp.2021.33.2.62

This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and include the Creative Commons Attribution-Non-commercial (unported, v3.0) license. By accessing the work, you hereby accept the terms. The use of the work for non-commercial purposes is permitted without any further permission from Dove Medical Press Limited, provided that the work has an appropriate attribution. For permission to use this work for commercial purposes, please refer to paragraphs 4.2 and 5 of our terms.

Contact Us• Privacy Policy• Associations and Partners• Testimonials• Terms and Conditions• Recommend this site• Top

Contact Us• Privacy Policy

© Copyright 2021 • Dove Press Ltd • Software development of maffey.com • Web design of Adhesion

The views expressed in all articles published here are those of specific authors and do not necessarily reflect the views of Dove Medical Press Ltd or any of its employees.

Dove Medical Press is part of Taylor & Francis Group, the academic publishing department of Informa PLC. Copyright 2017 Informa PLC. all rights reserved. This website is owned and operated by Informa PLC ("Informa"), and its registered office address is 5 Howick Place, London SW1P 1WG. Registered in England and Wales. Number 3099067. UK VAT group: GB 365 4626 36

In order to provide our website visitors and registered users with services that suit their personal preferences, we use cookies to analyze visitor traffic and personalize content. You can understand our use of cookies by reading our privacy policy. We also retain data about visitors and registered users for internal purposes and to share information with our business partners. By reading our privacy policy, you can understand which of your data we retain, how to process it, with whom to share it, and your right to delete data.

If you agree to our use of cookies and the content of our privacy policy, please click "Accept".