Changes in LPIA D-dimer levels after total hip or knee arthroplasty relevant to deep-vein thrombosis diagnosed by bilateral ascending venography

Estimated glomerular filtration rate versus creatinine clearance to determine anticoagulant dosage after lower-limb orthopedic surgery

BACKGROUND

Anticoagulation is recommended for thromboprophylaxis after lower-limb orthopedic surgery. The suggested dosage is based on creatinine clearance (CCr) in the labels. However, most facilities only provide estimated glomerular filtration rate (eGFR) as laboratory data. Because the eGFR equation adjusts for a body surface area (BSA) of 1.73 m2, it may overestimate renal function in patients with a small BSA. This retrospective study aimed to determine whether different renal function estimation formulas affect the incidences of venous thromboembolism (VTE) and bleeding when determining anticoagulant dosages.

METHODS

This study included patients who underwent lower-limb orthopedic surgery and received anticoagulants (edoxaban, enoxaparin, and fondaparinux) between 2017 and 2020 at Yaizu City Hospital. Anticoagulant dosing was evaluated using CCr, eGFR, and de-indexed eGFR (without correction for BSA), and the incidences of VTE and bleeding were compared among these formulas.

RESULTS

The median values for BSA, CCr, eGFR, and de-indexed eGFR were 1.40 m2, 56.0 mL/min, 73.0 mL/min/1.73m2, and 60.9 mL/min, respectively. There was no significant difference in the VTE incidence among these formulas. However, when dose reduction or contraindication threshold was determined by eGFR vs. CCr, the bleeding incidence was significantly higher in the group that was overdosed by CCr (6.0% vs. 25.7%, p < 0.05). Similarly, using de-indexed eGFR vs. CCr, the bleeding incidence was significantly higher in the group that was overdosed by CCr (7.5% vs. 28.6%, p < 0.05).

CONCLUSIONS

In orthopedic surgery, anticoagulant dosages should be based on CCr for patients with a small BSA to avoid bleeding risks.

Incidence of deep venous thrombosis in patients with hemophilia undergoing bilateral simultaneous total knee arthroplasty: a retrospective cohort study

BACKGROUND

Hemophilic arthropathy usually affects the knees bilaterally. In order to reduce costs and improve rehabilitation, bilateral simultaneous total knee arthroplasty (TKA) can be performed. However, pharmacological prophylaxis for deep venous thrombosis (DVT) remains controversial in patients with severe hemophilia. The purpose of this study was to establish the incidence of DVT in severe hemophilia A patients undergoing bilateral simultaneous TKA without pharmacological thromboprophylaxis.

METHODS

Consecutive patients with severe hemophilia A undergoing bilateral simultaneous TKA at a single center between January 2015 and December 2020 were retrospectively reviewed. All patients received a modified coagulation factor substitution regimen. Tranexamic acid (TXA) was used for hemostasis in all patients during surgery. All patients followed a standardized postoperative protocol with routine mechanical thromboprophylaxis, and none received anticoagulation. D-dimer was measured preoperatively, on the day of the operation and on postoperative days 1, 7 and 14. Ultrasound (US) of the lower extremities was performed before (within 3 days of hospitalization) and after surgery (days 3 and 14) to detect asymptomatic DVT. Patients were followed up until 2 years after surgery for the development of symptomatic DVT or pulmonary embolism (PE).

RESULTS

38 male patients with severe hemophilia A underwent 76 simultaneous TKAs. Mean (± standard deviation) age at the time of operation was 41.7 (± 17.1) years. Overall, 47.3% of patients had D-dimer concentrations above the threshold 10 µg/mL on day 7 and 39.5% on day 14. However, none of the patients had DVT detected on postoperative US, nor developed symptomatic DVT or PE during the 2-year follow-up.

CONCLUSIONS

The risk of DVT in patients with severe hemophilia A after bilateral simultaneous TKA is relatively low, and routine pharmacological thromboprophylaxis may not be needed.

Utility of D-dimer in total joint arthroplasty

As the number of patients receiving total joint replacements continues to rise, considerable attention has been directed towards the early detection and prevention of postoperative complications. While D-dimer has long been studied as a diagnostic tool in venous thromboembolism (VTE), this assay has recently received considerable attention in the diagnosis of periprosthetic joint infection (PJI). D-dimer values are substantially elevated in the acute postoperative period after total joint arthroplasty, with levels often exceeding the standard institutional cutoff for VTE (500 µg/L). The utility of D-dimer in detecting VTE after total joint replacement is currently limited, and more research to assess its value in the setting of contemporary prophylaxis protocols is warranted. Recent literature supports D-dimer as a good to excellent biomarker for the diagnosis of chronic PJI, especially when using serum sample technique. Providers should exercise caution when interpreting D-dimer levels in patients with inflammatory and hypercoagulability disorders, as the diagnostic value is decreased. The updated 2018 Musculoskeletal Infection Society criteria, which includes D-dimer levels > 860 µg/L as a minor criterion, may be the most accurate for diagnosing chronic PJI to date. Larger prospective trials with transparent lab testing protocols are needed to establish best assay practices and optimal cutoff values for D-dimer in the diagnosis of PJI. This review summarizes the most current literature on the value of D-dimer in total joint arthroplasty and elucidates areas for future progress.

Incidence of venous thromboembolism and hemorrhage in Chinese patients after pulmonary lobectomy: mechanical prophylaxis or mechanical prophylaxis combined with pharmacological prophylaxis: a randomized controlled trial

Background

Venous thromboembolism (VTE) and postoperative bleeding are important complications of lung resection surgery. We investigated the preventive effect of mechanical prophylaxis versus pharmacological prophylaxis after lobectomy, and evaluated the effect of both on the incidence of hemorrhagic events.

Methods

A prospective study of 424 lobectomies with moderate to high risk of VTE (Caprini risk score <5) in a single center was performed from April 2020 to March 2021. Patients were 1:1 randomly allocated to mechanical prophylaxis or to the low-molecular-weight heparin (LMWH)-combination-prophylaxis. The incidence of postoperative thrombotic and bleeding events and relevant factors of the two groups were analyzed.

Results

A total of 410 participants, with 202 and 208 in the mechanical prophylaxis and LMWH-combination-prophylaxis groups respectively, were selected for analysis. Both groups had similar baseline and clinical characteristics. There were no cases of VTE or major bleeding during the study, but the incidence rate of minor bleeding in the LMWH-combination-prophylaxis group was significantly higher than mechanical prophylaxis group [odds ratio (OR) 0.035, 95% confidence interval (CI): 0.011–0.113].

Conclusions

A case-by-case risk assessment of VTE and hemorrhage remains necessary to determine the most appropriate method of thrombosis prophylaxis for patients undergoing pulmonary surgery. Mechanical prophylaxis may be preferable for lung cancer patients with moderate to high risk of VTE (Caprini risk score <5) undergoing lobectomy.

Trial Registration

Chinese Clinical Trial Registry ChiCTR2100051073.

Comparison of Intravenous and Periarticular Administration of Corticosteroids in Total Knee Arthroplasty: A Prospective, Randomized Controlled Study

BACKGROUND

Corticosteroids are widely used in total knee arthroplasty (TKA) to relieve postoperative pain and prevent postoperative nausea. The aim of this prospective, randomized controlled study was to compare the effects of intravenous and periarticular administration of corticosteroids on pain control, prevention of postoperative nausea, and inflammation and thromboembolism markers following TKA.

METHODS

One hundred patients undergoing TKA were randomly allocated to either the intravenous administration or periarticular injection group. The intravenous administration group received 10 mg dexamethasone 1 hour before and 24 hours after the surgical procedure, as well as a periarticular injection placebo during the procedure. The periarticular injection group received a 40-mg injection of triamcinolone acetonide during the surgical procedure, as well as an intravenous administration placebo 1 hour before and 24 hours after the procedure. Postoperative pain scores at rest and during walking and nausea scores were recorded according to the 0-to-10 Numerical Rating Scale. Interleukin-6 (IL-6), C-reactive protein (CRP), and prothrombin fragment 1.2 (PF1.2) were measured preoperatively and postoperatively.

RESULTS

Pain scores at rest and during walking 24 hours postoperatively were significantly lower in the periarticular injection group than in the intravenous administration group. Nausea scores showed no significant difference between groups. IL-6 at 24 and 48 hours postoperatively also showed no significant difference between groups. CRP at 24 and 48 hours postoperatively was significantly lower in the intravenous administration group than in the periarticular injection group. In contrast, CRP at 1 week postoperatively was significantly higher in the intravenous administration group than in the periarticular injection group. The mean PF1.2 was significantly lower in the intravenous administration group than in the periarticular injection group at 4 hours postoperatively. Two cases of deep venous thrombosis in each group were detected with use of ultrasonographic examination.

CONCLUSIONS

Periarticular injection of corticosteroids showed a better pain-control effect at 24 hours postoperatively than did intravenous administration, whereas the antiemetic effect was similar between treatments. Although intravenous administration had a better anti-thromboembolic effect than periarticular injection, the incidence of deep venous thrombosis was low in both groups.

LEVEL OF EVIDENCE

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

D-dimer-based screening for early diagnosis of venous thromboembolism after hepatectomy

PURPOSE

The aim of this study was to evaluate the clinical utility of a novel diagnostic algorithm based on serum D-dimer levels for venous thromboembolism (VTE) after hepatectomy.

METHODS

We retrospectively analyzed 742 consecutive patients who underwent hepatectomy in our hospital from 2009 to 2019. From 2015, we routinely measured serum D-dimer level postoperatively and computed tomography was performed when D-dimer level was ≥ 20 μg/mL.

RESULTS

VTE was diagnosed in 26 patients and pulmonary embolism (PE) was diagnosed in 18 patients. Multivariate analysis revealed that resected liver weight ≥ 120 g is a significant predictor of VTE (P = 0.011). The incidence of VTE from 2015 to 2019 was greater than that from 2009 to 2014 (5.0% versus 2.1%, P = 0.044). The number of low-risk PE patients between 2015 and 2019 was significantly greater than that between 2009 and 2014 (P = 0.013). There was no in-hospital mortality of patients with PE from 2015 to 2019.

CONCLUSION

Patients who undergo hepatectomy are at high risk for VTE, especially when the resected liver weight is high. The proposed diagnostic algorithm based on serum D-dimer levels for VTE after hepatectomy can be useful for early diagnosis.

Prevalence and Risk Factors of Preoperative Deep Vein Thrombosis in Patients with End-Stage Knee Osteoarthritis

BACKGROUND

The purpose of this study is to determine the prevalence and the risk factors of DVT in end-stage OA patients.

METHODS

From March 2015 to June 2017, 521 patients with knee degenerative osteoarthritis undergoing knee arthroplasty were enrolled; 458 patients (87.9%) were admitted for primary total knee arthroplasty and 63 patients (12.1%) were admitted for unicompartmental knee arthroplasty. Parameters were compared using χ² or t-test for both the groups. Binary logistic regression analysis was used to determine risk factors.

RESULTS

The incidence of preoperative DVT was 6.7% (n = 35). Age in preoperative DVT group was significantly more than the non-DVT group (72.54 ± 6.53 vs. 68.65 ± 7.35, P = 0.002). Preoperative D-dimer >0.5 μg/mL (P < 0.001) was also associated with preoperative DVT in knee osteoarthritis patients. The incidence increased with age significantly (2.17% in <65 years, 6.86% in ≥65 <75 years, and 12.26% in ≥75 years) (P = 0.008). Thus, age (P = 0.041, OR 1.075, 95% CI [1.002-1.110]) and D-dimer >0.5 μg/mL (P < 0.001, OR 4.441, 95% CI [1.942-10.153]) were the independent risk factors for preoperative DVT in knee osteoarthritis patients.

CONCLUSIONS

The incidence of DVT in end-stage osteoarthritis was 6.7%. The results suggest that older people aged over 75 and D-dimer > 0.5 μg/mL were risk factors for DVT among patients admitted to the hospital for total knee arthroplasty. Instrumental screening should be encouraged, especially in subgroups at higher risk for preoperative DVT.

D-dimer monitoring combined with ultrasonography improves screening for asymptomatic venous thromboembolism in acute spinal cord injury

Objective: We compared screening methods for asymptomatic venous thromboembolism (VTE) in patients with acute spine and spinal cord injuries (SCI). Patients were screened by D-dimer monitoring alone (DS group) or by D-dimer monitoring combined with ultrasonography (DUS group).Design: Prospective cohort study.Setting: One department of a university hospital in Japan.Participants: 114 patients treated for acute SCI between 2011 and 2017.Interventions: N/A.Outcome Measures: D-dimers were measured upon admission and 1, 3, 5, 7, and 14 days thereafter. DUS-group patients also underwent an ultrasound 7 days after admission. If ultrasonography indicated deep venous thrombosis (DVT), or if D-dimer levels increased to ≥ 10 µg/mL, the patient was assessed for VTE, including DVT or pulmonary embolism (PE), by contrast venography. We analyzed the incidence of VTE detected in the DS and DUS groups.Results: In the DS group, D-dimers were elevated (≥ 10 µg/mL) in 15 of 70 patients (21.4%), and 9 of the 15 had asymptomatic VTE (12.9%, DVT 11.4%, PE 5.7%). In the DUS group, one patient developed VTE on day 4, and D-dimers were elevated in 13 of 43 patients (30.2%), ultrasonography indicated DVT in 12 patients (27.9%), and asymptomatic VTE was diagnosed in 12 patients (27.9%, DVT 27.9%, PE 4.7%). The DUS group had a higher incidence of DVT (P = 0.002) and VTE (P = 0.042) than the DS group.Conclusions: Combined D-dimer and ultrasound screening in patients with acute SCI improved the detection of VTE, including PE, compared with D-dimer screening alone.

Plasma D-dimer is not useful in the prediction of deep vein thrombosis after total knee arthroplasty in patients using rivaroxaban for thromboprophylaxis

Background

Venous thromboembolism (VTE) is a serious complication following total joint replacement. The use of rivaroxaban, a highly selective and direct factor Xa inhibitor, has been used widely as a safe and efficacious way to prevent VTE after total joint replacements. However, little is known about the diagnostic efficacy of plasma D-dimer test on deep vein thrombosis (DVT) in patients using rivaroxaban for thromboprophylaxis. The study is aimed to investigate the trend and the diagnostic efficacy of D-dimer test on DVT in patients with primary total knee arthroplasty (TKA) using rivaroxaban for thromboprophylaxis.

Methods

Two hundred TKA patients using rivaroxaban postoperatively as chemical prophylaxis were reviewed. D-dimer levels were checked at 4 h after the surgery and on postoperative days 1 and 4. Venography was used to document the presence of DVT. The Mann-Whitney U test was used to detect the differences in the D-dimer levels at different time points in patients with and without DVT, followed by Bonferroni corrections for p values. Receiver operating characteristics (ROC) curves were constructed to determine the best cutoff values of the D-dimer test at each time point after the surgery.

Results

Twenty-nine of the 200 patients were found to have deep vein thrombosis by venography, resulting in an incidence of 14.5%. All patients with DVTs occurred in the distal calf veins, and only one patient was symptomatic. We found significant differences in D-dimer concentration between patients with and without DVT at postoperative day 4. The best cutoff value determined by receiver operating characteristics analysis was 3.8 mg/L at postoperative day 4, with an AUC equal to 63.5%, and a sensitivity, specificity, PPV, and NPV of 58.6, 76, 29.3, and 91.5%, respectively.

Conclusions

Rivaroxaban was effective on reducing DVT in patients undergoing TKA. Because all the DVTs occurred in the leg veins, decreased thrombus volume and size might result in poor accuracy of plasma D-dimer test in prediction or diagnosis of postoperative DVT.

D-dimer predicts pulmonary embolism after low-risk spine surgery

Introduction

Pulmonary embolism (PE) is a risk of mortality following spine surgery. Many studies have demonstrated that deep venous thrombosis (DVT) may affect and actually advance to PE, but few studies have shown how venous thromboembolism (VTE), including PE and DVT, affect blood markers after spine surgery. In this study, we examined changes in blood markers with PE or DVT after low-risk spine surgery, namely cervical laminoplasty or lumbar laminectomy.

Methods

Seventy-two spine surgery patients were studied. A 16-row multidetector computed tomography was performed before and 3 d after the surgery. Patients with a history of cerebral vascular accident or arterial thrombotic episode or pre-surgical asymptomatic PE or DVT were excluded. Plasma levels of soluble fibrin monomer complex, D-dimer, plasminogen activator inhibitor type-1 (PAI-1), and white blood cell and platelet counts were measured preoperatively and postoperatively at days 1, 3, and 7.

Results

No patient developed symptomatic post-surgical VTE. Six patients with asymptomatic PE and six with asymptomatic DVT were detected post-surgery, including one patient with both. D-dimer postoperatively at days 3 and 7 was significantly higher in the post-op PE group than in the no-PE group. PAI-1 preoperatively was significantly higher in the DVT and VTE groups than in the no-DVT and no-VTE groups.

Conclusions

Elevated D-dimer at postoperative days 3 and 7 is a predictive factor for the early diagnosis of PE after spine surgery. Moreover, elevated PAI-1 preoperatively is a predictive factor for the early diagnosis of DVT and VTE. Consequently, PE may occur through a pathway other than DVT.

Elevated d-Dimer Is Not Predictive of Symptomatic Deep Venous Thrombosis After Total Joint Arthroplasty

BACKGROUND

Serum d-dimer is a common screening test for symptomatic deep venous thrombosis (DVT) after total joint arthroplasty. This study characterized the longitudinal resolution of d-dimer measurements after total hip and knee arthroplasty (THA/TKA) over a 6-week period. The authors hypothesized that serum d-dimer would not return to baseline or be below the institutional threshold for a positive test at 6 weeks after uncomplicated total joint arthroplasty, suggesting that quantitative d-dimer has limited clinical utility for postoperative DVT screening.

METHODS

An institutional review board-approved retrospective cohort study was conducted with consecutive patients between January 2013 and June 2015. A total of 177 adult patients aged 40-88 years who underwent a primary hip or knee arthroplasty with a Charlson Comorbidity Index <3 were included in the study. Serum d-dimer was measured at preoperative, perioperative, and postoperative 2- and 6-week time points.

RESULTS

d-dimer measurements peaked 2 weeks postoperatively for both TKA and THA. At the 6-week time point, the peak serum d-dimer measurement resolved by 54.3% and 76.6% for TKA and THA, respectively. At 6 weeks after operation, 92% of THA patient and 100% of TKA patients had serum d-dimer measurements higher than the institutional threshold (0.40 μg/mL) for a "positive" quantitative test. No symptomatic DVTs were reported for the THA and TKA cohorts during the study period.

CONCLUSION

The results suggest that serum d-dimer is an ineffective screening test for the diagnosis of symptomatic DVT in the acute postoperative period. The authors propose that extravascular fibrinolysis, a process essential for wound healing, has a crucial role in the prolonged elevation of serum d-dimer in the postoperative period.

Comparison of Continuous Epidural Analgesia, Patient-Controlled Analgesia with Morphine, and Continuous Three-in-One Femoral Nerve Block on Postoperative Outcomes after Total Hip Arthroplasty

Background

Postoperative pain relief can be achieved with various modalities. However, there are only few reports that have analyzed postoperative analgesic techniques in total hip arthroplasty patients. The aim of this retrospective study was to compare the postoperative outcomes of three different analgesic techniques after total hip arthroplasty.

Methods

We retrospectively reviewed the influence of three analgesic techniques on postoperative rehabilitation after total hip arthroplasty in 90 patients divided into three groups (n = 30 patients per group). Postoperative analgesia consisted of continuous epidural analgesia (Epi group), patient-controlled analgesia with morphine (PCA group), or a continuous femoral nerve block (CFNB group). We measured the following parameters relating to postoperative outcome: visual analog scale scores, the use of supplemental analgesia, side effects, length of the hospital stay, plasma D-dimer levels, and the Harris hip score.

Results

Each group had low pain scores with no significant differences between the groups. The PCA group had a lower frequency of supplemental analgesia use compared to the Epi and CFNB groups. Side effects (nausea/vomiting, inappetence) and day 7 D-dimer levels were significantly lower in the CFNB group (p < 0.05). There were no significant differences between the groups in terms of the length of the hospital stay or the Harris hip score.

Conclusions

Although there were no clinically significant differences in outcomes between the three groups, the CFNB provided good pain relief which was equal to that of the other analgesics with fewer side effects and lower D-dimer levels in hospitalized patients following total hip arthroplasty.

D-dimer testing cannot rule out thromboembolism after major lower extremity arthroplasties and thromboprophylaxis treatment

PURPOSE

Our previous study showed, for the first time, that a guideline-recommended thromboprophylactic strategy reduced the prevalence of venous thromboembolism (VTE) including venous thromboembolism and pulmonary embolism after arthroplasties of the major lower extremities, such as total hip arthroplasty (THA) or total or partial knee arthroplasty (TPKA), to 4.4 %. In this retrospective study, we examined the diagnostic value of D-dimer for VTE and try to confirm the low prevalence of VTE after THA or TPKA.

METHODS

This was a retrospective study including 380 procedures of 361 patients who underwent elective 129 TPKA or 251 THA, as well as multidetector computed tomography (MDCT) on postoperative day 7 with D-timer testing to screen for VTE. In 303 of 380 procedures, D-timer testing was performed on the same day as MDCT. The antithrombotic prophylaxes included medical and mechanical therapy and early ambulation.

RESULTS

The prevalence of VTE was 4.5 % (17 cases) (95 % confidence interval 2.4-6.6 %). The D-dimer level was significantly greater in patients with VTE than in those without (13.4 ± 11.1 vs 10.1 ± 6.5 μg/mL). At the lowest cut-off value of 4.0 μg/mL, D-dimer testing ruled out VTE in only 26 of 303 cases with 1 (6 %) false negative result.

CONCLUSIONS

The low incidence of postoperative VTE with the strict anticoagulation strategy was confirmed in this validation study. D-dimer testing is not useful for excluding VTE postoperatively in patients who undergo THA or TPKA.

Risk factors for deep vein thrombosis after orthopedic surgery and the diagnostic value of D-dimer

BACKGROUND

This study was prospectively designed to determine the risk factors of deep vein thrombosis (DVT) in patients who underwent different surgeries, and to evaluate the efficacy and accuracy of plasma D-dimer level as a screening test.

METHODS

From June 2013 to June 2014, 360 consecutive patients undergoing orthopedic surgery were evaluated. All patients underwent ultrasonography preoperatively and on postoperative day 7. Plasma D-dimer levels were estimated by latex immunoturbidimetry on the day of surgery and on postoperative days 1, 3, and 7.

RESULTS

Of the 360 patients in this study, 339 patients completed the analysis. Among them, DVT was confirmed in 28 (8.26%) patients based on ultrasonographic findings. Multivariate logistic analysis revealed that body mass index was an independent risk factor for developing DVT (P = 0.018) and D-dimer levels on postoperative days 1 and 7 were independently correlated with the development of DVT (P = 0.019 and P < 0.001, respectively). The receiver operating characteristic curve analysis determined that the area under the curve was largest (0.752) when using D-dimer level on postoperative day 7 as diagnostic index, and the sensitivity and specificity were 71.4% and 81.7% at the cut-off value of 6.17 μg/mL, respectively. The elevated D-dimer levels followed the same tendency toward a double-peaked distribution with peaks at days 1 and 7 postoperatively.

CONCLUSION

D-dimer level was a useful screening test to exclude DVT, and the cut-off values of D-dimer determined in this study will provide a reference for the absence of DVT to a certain extent.

Prospective study of deep vein thrombosis in patients with spinal cord injury not receiving anticoagulant therapy

STUDY DESIGN

Prospective cross-sectional study.

OBJECTIVES

To investigate the timing of deep vein thrombosis (DVT) onset secondary to spinal cord injury without anticoagulant therapies.

SETTING

Spinal Cord Injury Center in Hokkaido, Japan.

METHODS

Between November 2012 and June 2013, patients with spinal cord injury who were admitted to our hospital within 1 day after the injury and treated surgically within 24 h underwent a neurological examination, leg vein ultrasonography and D-dimer test 1, 3, 7, 14 and 28 days after surgery. All patients received treatment with intermittent pneumatic compression and elastic stockings, but without any anticoagulant.

RESULTS

DVT developed in 12 patients (11 men and 1 women), with a mean age of 62.2 years (range, 41-80 years; mean age of total sample, 63.2 years (range, 25-78 years)), all distal to the popliteal vein. DVT occurred more often with a more severe paralysis (66.3%, AIS A and B). The median (± standard error) length of time from the operation to DVT detection was 7.5±2.2 days. The mean D-dimer level upon DVT detection was 14.6±11.8 μg ml(-1), with no significant differences between those who developed DVT and those who did not at any of the time points.

CONCLUSION

These results suggest that DVT can develop at the very-acute stage of spinal cord injury and the incidence increases with a more severe paralysis. DVT detection was more reliable with ultrasonography, which should be used with DVT-preventive measures, beginning immediately after the injury, for the management of patients with spinal cord injury.

Enhanced pre-operative thrombolytic status is associated with the incidence of deep venous thrombosis in patients undergoing total knee arthroplasty

Background

Deep venous thrombosis (DVT), which is often associated with pulmonary embolism (PE), is a serious complication after total knee arthroplasty (TKA). In the present study, we examined the overall thrombotic and thrombolytic status using Global Thrombosis Test (GTT) in non-anticoagulated blood of patients undergoing TKA to develop the predictable marker for the incidence of DVT.

Methods

DVT was diagnosed using doppler ultrasonography a day after the surgery in 31 patients with osteoarthritis (n = 24), rheumatoid arthritis (n = 6) and ankylosing spondylitis (n = 1) by the well-trained operator. We measured overall thrombotic and thrombolytic status using GTT and other biomarkers, which is associated with blood coagulation and fibrinolysis, before and immediately after the surgery.

Results

Newly-generated DVT during the operation was detected in 11 of 31 patients (35.4%) 1 day after TKA. There were no differences in markers of coagulation (PT and APTT), platelet activity (platelet aggregation-induced by ADP and collagen) and fibrinolysis (FDP and D-dimer) between non-DVT and DVT group both before and after the surgery. Both Pre- and Post-operative GTT-occlusion times (OT), an index of platelet reactivity, were tended to be shorter, but not significant, in DVT group compared with non-DVT group. Pre-operative GTT-lysis time (LT), an index of thrombolytic activity, was significantly shorter in DVT group compared with non-DVT group, while there were no differences in post-operative value of this index between DVT group and non-DVT group, suggesting overall thrombolytic activity was enhanced in DVT group before surgery.

Conclusions

Our data suggest that enhancement of pre-operative thrombolytic activity assessed by GTT may be a predictable marker for the incidence of DVT after TKA.

Postoperative plasma D-dimer value for predicting deep venous thrombosis following hip arthroplasty with nadroparin prophylaxis

The aim of the study was to assess the value of D-dimer as an event predicitor for deep vein thrombosis (DVT) in patients given low molecular weight heparin (LMWH) after total hip arthroplasty (THA). Plasma D-dimer levels were obtained preoperatively and at days 1, 3, and 7 postoperatively in 83 consecutive patients undergoing THA treated with nadroparin prophylaxis plus intermittent pneumatic compression. Unilateral ascending venography was performed at postoperative day 7 or 8. There was a significant difference between the D-dimer levels in the DVT group (28 patients) and non-DVT group (55 patients) on each day (P<0.01). ROC analysis showed the AUC on postoperative days 1, 3 and 7 was 0.706, 0.712 and 0.772 respectively. The D-dimer concentration on postoperative day 1, day 3 or day 7 is of moderate predicting value of DVT in patients undergoing THA, treated with nadroparin prophylaxis plus intermittent pneumatic compression.

Recent Korean perspective of deep vein thrombosis after total knee arthroplasty

This prospective study was performed on 311 consecutive knees in 227 patients for total knee arthroplasty. The aim was to assess the recent incidence of deep vein thrombosis (DVT) after total knee arthroplasty without chemoprophylaxis in Koreans, the efficacy of plasma d-dimer levels as a screening test, and the associated risk factors. Deep vein thrombosis was found in 79 knees (26.60%). There were 9 cases (3.03%) of proximal DVT, 70 cases (23.57%) of distal DVT, and no symptomatic pulmonary embolism. Although this cohort had limited number of patients by a single surgeon, there is still low incidence of proximal DVT in Koreans with rare pulmonary embolism occurrence compared with those of the Western. High postoperative d-dimer levels were correlative, but no appropriate cutoff value was found. Obesity was a significant associated risk factor.

Early ambulation after total knee arthroplasty prevents patients with osteoarthritis and rheumatoid arthritis from developing postoperative higher levels of D-dimer

This study aimed to clarify the therapeutic effects of postoperative ambulation after total knee arthroplasty (TKA) on deep venous thrombosis (DVT) in patients with osteoarthritis (OA) and rheumatoid arthritis (RA) after TKA. Subjects of this study were thirty-seven inpatients (21 inpatients: OA, 16 inpatients: RA) undergoing TKA (32 female and 5 male). Subjects were divided into two groups, deep venous thrombosis (DVT) group (n=25) and non-DVT group (N group, n=12). The cutoff value was 10.0 microg/ml plasma D-dimer level measured on 7(th) postoperative day. The N group was below the cutoff value. Another cutoff value divided into two groups, ambulatory group (n=26) and non-ambulatory group (n=11). Ambulatory group was the date of ambulation beginning below 7(th) day. Statistical analysis confirmed that all subjects showed a significant correlation to the date of ambulation. Postoperative ambulation beginning had strong association with the level of D-dimer (r=0.71). Group comparison showed that the non-ambulatory group had significant higher values of D-dimer than ambulatory group (P=0.022). Typical case supported these results. Postoperative early ambulation within a week after TKA kept patients with OA and RA after TKA lower level of D-dimer.

Deep vein thrombosis after total hip arthroplasty in Korean patients and D-dimer as a screening tool

INTRODUCTION

This prospective study was designed to confirm risk factors and to assess the incidence of deep vein thrombosis after total hip and surface replacement arthroplasty in Korean patients not receiving anticoagulation prophylaxis and to determine efficacy of plasma D-dimer levels as a screening test.

MATERIALS AND METHODS

From May 2003 to August 2004, 221 consecutive patients undergoing unilateral total hip arthroplasty and hip resurfacing were evaluated. All patients underwent ultrasonography preoperatively and venography and/or ultrasonography on postoperative day 7. Plasma D-dimer levels were estimated by latex immuno-assay preoperatively and on days 3 and 7 postoperatively.

RESULTS

Of the 221 patients in our cohort, 23 developed deep vein thrombosis (10.4%). Age (r = 0.245, P < 0.001) and gender (r = 0.155, P = 0.021) significantly correlated with deep vein thrombosis. Rise in incidence paralleled increase in age (X(2) = 32.860, P < 0.001). D-dimer levels on postoperative days 3 (gamma = 0.364, P < 0.001) and 7 (gamma = 0.470, P < 0.001) were significantly correlated to the development of DVT.

CONCLUSION

While incidence of deep vein thrombosis in Korean population after THA was lower than that in the West; it increased with age, and in female gender. Significant correlation was found between D-dimer levels and the development of deep vein thrombosis.

The value of D-dimer in the detection of early deep-vein thrombosis after total knee arthroplasty in Asian patients: a cohort study

Background and purpose

The relationship of D-dimer and deep-vein thrombosis (DVT) after total knee arthroplasty (TKA) remains controversial. The purpose of this study was to assess the value of D-dimer in the detection of early DVT after TKA.

Methods

The measurements of plasma D-dimer level were obtained preoperatively and at day 7 postoperatively in 78 patients undergoing TKA. Ascending venography was performed in 7 to 10 days after surgery. The plasma D-dimer levels were correlated statistically with the venographic DVT.

Results

Venographic DVT was identified in 40% of patients. High plasma D-dimer level >2.0 μg/ml was found in 68% of patients with DVT and 45% without DVT (P < 0.05). Therefore, high D-dimer level greater than 2.0 μg/ml showed 68% sensitivity, 55% specificity, 60% accuracy, 50% positive predictive rate and 72% negative predictive rate in the detection of early DVT after TKA.

Conclusion

High plasma D-dimer level is a moderately sensitive, but less specific marker in the detection of early of DVT after TKA. Measurement of serum D-dimer alone is not accurate enough to detect DVT after TKA. Venography is recommended in patients with elevated D-dimer and clinically suspected but asymptomatic DVT after TKA.

Disease-specific screening for deep venous thrombosis and pulmonary thromboembolism using plasma D-dimer values after total knee arthroplasty

We prospectively evaluated the disease-specific features of the early postoperative plasma D: -dimer value and the relationship with deep venous thrombosis and/or pulmonary thromboembolism (DVT/PE) in 95 patients following total knee arthroplasty. Patients in whom DVT/PE was highly suspected were diagnosed by high-resolution multi-detector row computed tomography scanning (MDCT). Forty-nine knees in 46 patients with rheumatoid arthritis (RA, 24 knees) or osteoarthritis (OA, 25 knees) were finally recruited. DVT/PE was detected in 28 (57.1%) of the 49 cases examined by diagnostic MDCT: 12 (50.0%) of the 24 cases of RA, and 16 (64.0%) of the 25 cases of OA. Of these, PE was found in 11 cases (39.2%), but none of them showed clinical symptomatic signs of dyspnea or chest pain. In both RA and OA cases, there were statistically significant differences in the D: -dimer value on postoperative day 3 (P = 0.027) and after day 28 (P = 0.037) between the groups with and without DVT/PE. In OA cases, there were significant differences between the two groups on postoperative days 1 (P = 0.034), 3 (P = 0.020), 5 (P = 0.005), and 7 (P = 0.045), respectively. At the baseline, perioperative D: -dimer levels in the RA group without DVT/PE were higher than in the OA group. However, multivariate logistic regression analysis showed that RA was not a significant risk factor of DVT/PE in comparison with OA. In conclusion, individual evaluation of the D: -dimer level between RA and OA should provide a more precise predictive indicator of early postoperative DVT/PE.

D-Dimer in the diagnosis of deep vein thrombosis following total hip and knee replacement: a prospective study

INTRODUCTION

The merit of using D-dimer estimations in patients following total hip and knee replacement has been previously questioned. A survey of radiology protocols in 70 hospitals ascertained that the test continues to be mandatory in 51 prior to formal radiological investigation of suspected deep vein thrombosis (DVT) in this patient population.

PATIENTS AND METHODS

In this study, D-dimer levels were measured pre-operatively and during the first 7 days following primary total hip and knee replacement to estimate the range of normal values in these patients.

RESULTS

All 78 patients were ultrasonographically shown to be clear of DVT. D-Dimer levels were significantly raised in all patients at all measurements during the first week. Levels after total knee replacement were higher than after total hip replacement. Comparison was made with an age-matched group who had a proven DVT. There was no difference in D-dimer levels between patients with or without a DVT.

CONCLUSIONS

The use of this test in this patient group is a waste of resource and merely delays appropriate radiological investigation and treatment.

Predictive indicators of deep venous thrombosis and pulmonary arterial thromboembolism in 54 subjects after total knee arthroplasty using multislice computed tomography in logistic regression models

PURPOSE

To determine predictors of deep venous thrombosis (DVT) in the lower extremities and pulmonary arterial thromboembolism (PE) after total knee arthroplasty (TKA), we evaluated the incidence of these events using multislice computed tomography (CT).

METHODS

54 subjects (10 males, 53-81 years old, the first consecutive 25 receiving anticoagulant therapy) underwent enhanced multislice CT (MSCT) before and one week after TKA.

RESULTS

DVT, PE, and both were detected in twelve, twelve, and three subjects, respectively, one week after TKA. Hemoglobin and alveolar-arterial oxygen gradient (AaDO2) on the day after TKA, and total amount of operative bleeding (TAOB) were significantly higher in subjects with DVT or PE (P<0.05). In a logistic model for predicting DVT or PE, hemoglobin and AaDO2 levels on the day after TKA and TAOB were associated with an increased incidence of DVT or PE (relative risks 3.51, 1.19 and 1.01 (P<0.05), respectively). From box and whisker plots, we speculated the significant border to predict DVT or PE as 10.5 g/dl for hemoglobin, 34 Torr for AaDO2, and 1280 ml for TAOB. These factors also predicted DVT or PE (relative risks 5.08 (hemoglobin more than 10.5), 6.25 (AaDO2 more than 34 Torr), and 4.95 (TAOB more than 1280 ml) (P<0.05)).

CONCLUSIONS

The incidence of DVT or PE one week after TKA was 39% by MSCT. High levels of TAOB, hemoglobin and AaDO2 on the day after TKA may be predictive indicators of DVT or PE one week after TKA.

Usefulness of arterial blood gas analysis and D-dimer measurement in the assessment of pulmonary embolism after orthopedic surgery

BACKGROUND

Deep venous thrombosis (DVT) and pulmonary embolism (PE) after spinal or lower extremity surgery are well recognized as common complications. Since 1995 we have investigated the incidence of PE after orthopedic surgery using ventilation-perfusion (V/Q) lung scans, and the prevalence of PE was about 10%. With a view to detecting early-stage PE by simple examinations, we evaluated the use of both the blood gas analysis and the D-dimer measurement after spinal or lower extremity surgery.

METHODS

Altogether, 85 patients who underwent spinal or lower extremity surgery were eligible for the study. Pneumatic sequential leg compression devices (PSLCDs) were utilized continuously both intra- and postoperatively. Arterial blood gas analysis and D-dimer measurement were performed pre- and postoperatively on days 3 and 7. We set lung scan criteria as follows: postoperative decrease in Pa(O2) (deltaPa(O2) by > or = 10 torr (group G), postoperative D-dimer of > or = 1 microg/ml (group D), or both. Patients with the criteria went on to undergo lung scans, and PE was diagnosed by the existence of any mismatch between ventilation-perfusion (V/Q) lung scans.

RESULTS

A total of 44 (51.8%) patients met the lung scan criteria and underwent perfusion lung scans, 10 (11.7%) of whom were diagnosed as PE. In groups G and D, about 30% showed PE. Moreover, six (85.7%) of the seven patients with both criteria showed a significant increase (83.7%) in the prevalence of PE.

CONCLUSIONS

Patients with the above criteria showed a high prevalence of PE. Moreover, 10 (11.7%) of the 85 patients were diagnosed as having PE, which corresponded to the prevalence in our former studies where lung scans were performed in all patients. The blood gas analysis and the D-dimer measurement may be utilized as the first screening examinations.

Surveillance biologique après chirurgie orthopédique. Quel apport au diagnostic des complications infectieuses et thromboemboliques ?

OBJECTIVES

To determine the modification in postoperative D-dimer level as a function of the surgical act and to assess the relevance of this measure for diagnosing thromboembolism.

METHOD

A cohort of 179 patients was followed: group 1 comprised 128 patients undergoing lower limb arthroplasty, group 2 comprised 29 patients undergoing lower limb surgery without implant, and group 3 comprised 22 patients undergoing spinal or upper limb surgery. D-dimer level was systematically measured on admission and then once a week for 4 weeks. Doppler ultrasonography was performed on clinical suspicion of deep vein thrombosis. D-dimer levels were compared between patients with and without deep vein thrombosis.

RESULTS

D-dimer levels were constantly elevated postsurgery (2- to 6-fold above normal) and returned to normal by week 4 in groups 2 and 3 but remained elevated in group 1 (3-fold above normal). Deep vein thrombosis was suspected in 45 cases and confirmed by Doppler ultrasonography in 10 cases. D-dimer level was not significantly different between patients with deep vein thrombosis and those without.

DISCUSSION AND CONCLUSIONS

In the postoperative period, measurement of D-dimer level does not aid in diagnosing thromboembolism since its constant high level obviates any negative predictive value.

Variation in the diagnostic performance of D-dimer for suspected deep vein thrombosis

BACKGROUND

Numerous studies have evaluated the accuracy of D-dimer in diagnosing suspected deep vein thrombosis (DVT), but results are conflicting.

AIM

To overview estimates of the diagnostic accuracy of D-dimer and identify causes of variation.

DESIGN

Systematic review, meta-analysis and meta-regression.

METHODS

We searched Medline, EMBASE, CINAHL, Web of Science, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, Database of Reviews of Effectiveness, the ACP Journal Club, citation lists, and contacted manufacturers. We selected studies that compared D-dimer to a reference standard in patients with suspected DVT. Data were analysed by random effects meta-analysis and meta-regression.

RESULTS

We included 97 studies reporting 198 assays in 99 different patient groups. Overall estimated sensitivity and specificity of D-dimer were 90.5% and 54.7%, but both estimates were subject to significant heterogeneity (p < 0.001). Meta-regression identified that some heterogeneity was explained by study setting, exclusion criteria, whether recruitment was consecutive or the study prospective, whether D-dimer and the reference standard were measured blind, and whether the D-dimer threshold was determined a priori. Sensitivity and specificity also varied between ELISA (94% and 45% respectively), latex (89% and 55%) and whole blood agglutination assays (87% and 68%). Sensitivity was higher for proximal than distal DVT. Specificity was dependent upon whether clinical probability of DVT was high (specificity 51%), intermediate (67%) or low (78%).

DISCUSSION

D-dimer has good sensitivity, but poor specificity, for DVT. Estimates are subject to substantial heterogeneity from various sources. D-dimer specificity appears to be strongly dependent upon the pre-test clinical probability of DVT.

Pilot study on the use of tourniquet: a risk factor for pulmonary thromboembolism after total knee arthroplasty?

The risk of pulmonary thromboembolism (PTE) after total knee arthroplasty (TKA) with tourniquet is still controversial. In this study, we determined whether plasma D-dimer could be used as a marker of PTE, and whether intraoperative use of tourniquet is a risk factor for symptomatic PTE after TKA. We divided 86 patients (12 males and 74 females) who underwent primary TKA into four groups based on (i) operation method (unilateral/bilateral) and (ii) use of pneumatic tourniquet during surgery (with/without). Plasma D-dimer values were measured preoperatively and on Day 1 postoperatively. "D1-value" was defined as the difference between postoperative and preoperative plasma D-dimer levels. We determined the cutoff level of "D1-value" for symptomatic PTE, monitored by O(2) saturation (SAT) and lung scintigraphy. "D1-values" for patients with PTE symptoms were higher than those without symptoms (p<0.001). Furthermore, "D1-values" for TKA without tourniquet procedures were significantly lower than those with tourniquet both in unilateral (p=0.003) and bilateral groups (p=0.004). At a cutoff level of >or=8.6 mug/mL, the sensitivity, specificity, and positive and negative predictive values were 100%, 82.5%, 30.0% and 100% for symptomatic PTE, respectively. The results of our pilot study showed that elevated plasma "D1 value" is a sensitive marker for detection of PTE. Further studies will be needed, in order to evaluate the risk of tourniquet, and to reduce PTE after TKA.

Deep venous thrombosis during neoadjuvant chemotherapy in a patient with osteosarcoma: a case report

A 29-year-old man with an osteosarcoma of the left distal femur developed asymptomatic deep venous thrombosis (DVT) during neoadjuvant chemotherapy. The thrombotic event occurred in the left common iliac vein and was revealed by pelvic computed tomography (CT). We successfully performed a limb salvage operation with placement of a permanent inferior vena cava filter. The thrombus spontaneously regressed without thrombolytic therapy after surgery. We should consider DVT in patients with musculoskeletal sarcomas who are under long-term hospitalization and immobilization associated with not only surgery but also chemotherapy. To screen for both metastasis and DVT, we recommend contrast-enhanced whole-body CT, including scans of the pelvis.