Evaluating the effectiveness of a deep-vein thrombosis prophylaxis protocol in orthopaedics and traumatology

Clinical Risk Factors and Perioperative Hematological Characteristics of Early Postoperative Symptomatic Deep Vein Thrombosis in Posterior Lumbar Spinal Surgery

STUDY DESIGN

A retrospective analysis (2015-2019) of data collected from patients who underwent posterior lumbar spinal surgery.

OBJECTIVE

This study aims to identify the incidence, perioperative hematological characteristics, potential prognostic indicators, and risk factors of deep venous thrombosis (DVT) in the lower limbs after posterior lumbar spinal surgery. Eliminating risk factors or taking measures against patients at risk may reduce the incidence of DVT.

SUMMARY OF BACKGROUND DATA

Deep venous thromboses have been extensively studied in other reconstructive surgeries. Present literatures provide limited evidence for determining the prognostic and risk factors for this complication after spinal surgery.

METHODS

Patients who underwent posterior lumbar spinal surgery with internal fixation in the Spine Surgery Center of Peking Union Medical College Hospital (PUMCH) were evaluated. The patient demographics, the number of operative segments, the hematological and biochemical parameters on baseline and postoperative day 1, and the presence of DVTs were obtained from all patients. The diagnosis of DVT was established by venous ultrasound when symptomatic. A multivariate logistic regression test was subsequently performed to determine the prognostic indicators and risk factors for DVT.

RESULTS

A total of 2053 patients who received lumbar spine procedures were qualified and included. Patients were followed up for 12 weeks. Early symptomatic DVT occurred in 58 individuals (2.39%; 95% confidence interval [CI], 0.4-0.7%). Advanced age, higher preoperative serum D-dimer level, and lower serum potassium level were recognized as independent risk factors for symptomatic DVT.

CONCLUSION

Multiple independent risk factors were identified for early symptomatic DVT after posterior lumbar spine surgery. Postoperative prophylactic anti-coagulation treatment might be warranted for patients with high D-dimer or low potassium levels before the procedure.Level of Evidence: 4.

Deep Vein Thrombosis and Pulmonary Embolism Considerations in Orthopedic Surgery

Patients undergoing orthopedic surgery have an increased risk for deep venous thrombosis (DVT) and pulmonary embolism (PE). These complications are considered detrimental, as they cause major postoperative morbidity and mortality and lead to a substantial health care burden. Because of the high incidence and serious nature of these complications, it is essential for orthopedic surgeons to have a comprehensive knowledge of the risk factors, diagnosis, and treatment of acute DVT and PE. Perioperative management of orthopedic patients to prevent postoperative DVT and PE and optimize postoperative outcomes is also discussed in this review.

Duplex Ultrasonography Has Limited Utility in Detection of Postoperative DVT After Primary Total Joint Arthroplasty

BACKGROUND

Duplex ultrasound is routinely used to evaluate suspected deep venous thrombosis after total joint arthroplasty. When there is a clinical suspicion for a pulmonary embolism, a chest angiogram (chest CTA) is concomitantly obtained.

QUESTIONS/PURPOSES

Two questions were addressed: First, for the population of patients who receive duplex ultrasound after total joint arthroplasty, what is the rate of positive results? Second, for these patients, how many of these also undergo chest CTA for clinical suspicion of pulmonary embolus and how many of these tests are positive? Furthermore, what is the correlation between duplex ultrasound results and chest CTA results?

METHODS

A retrospective chart review was conducted of total joint replacement patients in 2011 at a single institution. Inclusion criteria were adult patients who underwent a postoperative duplex ultrasonography for clinical suspicion of deep venous thrombosis (DVT). Demographic data, result of duplex scan, clinical indications for obtaining the duplex scan, and DVT prophylaxis used were recorded. Additionally, if a chest CTA was obtained for clinical suspicion for pulmonary embolus, results and clinical indication for obtaining the test were recorded. The rate of positive results for duplex ultrasonography and chest CTA was computed and correlated based on clinical indications.

RESULTS

Two hundred ninety-five patients underwent duplex ultrasonography of which only 0.7% were positive for a DVT. One hundred three patients underwent a chest CTA for clinical suspicion of a pulmonary embolism (PE) of which 26 revealed a pulmonary embolus, none of which had a positive duplex ultrasound.

CONCLUSION

Postoperative duplex scans have a low rate of positive results. A substantial number of patients with negative duplex results subsequently underwent chest CTA for clinical suspicion for which a pulmonary embolus was found, presumably resulting from a DVT despite negative duplex ultrasound result. A negative duplex ultrasonography should not rule out the presence of a DVT which can embolize to the lungs and thus should not preclude further workup when clinical suspicion exists for a pulmonary embolus.

Incidence and Fate of "Symptomatic" Venous Thromboembolism After Knee Arthroplasty Without Pharmacologic Prophylaxis in an Asian Population

BACKGROUND

As the possibility of developing complications after an "asymptomatic" venous thromboembolism (VTE) after total knee arthroplasty (TKA) has been reported very low, "symptomatic" VTEs seem to be the real concern among orthopedic surgeons. Therefore, the purpose of this study was to determine the incidence of "symptomatic" VTEs and the fate of "symptomatic" VTEs after anticoagulation therapy and assess whether routine pharmacologic prophylaxis is necessary in TKA patients.

METHODS

We retrospectively reviewed 2891 consecutive TKAs in 1933 patients. Graduated compression stockings and intermittent pneumatic calf compression devices were used for VTE prophylaxis. The incidence of symptomatic VTE was investigated until 6 months postoperatively. Patients with VTE underwent anticoagulation therapy and followed up to evaluate range of motion, knee society score, Western Ontario and McMaster Universities index scores, and the presence of any complications (mean follow-up period, 3.6 years).

RESULTS

Fifty-three (1.83%) of the 2891 TKAs had suggestive symptoms and/or sign of VTE. Of these 53 cases, 26 (0.90%) were diagnosed as symptomatic VTE, which comprised 10 (0.35%) symptomatic deep venous thromboses, 11 (0.38%) symptomatic pulmonary embolisms (PEs), 5 (0.17%) symptomatic deep venous thromboses combined with PEs, and no fatal PE. There was no significant difference in range of motion, knee society score, and Western Ontario and McMaster Universities index scores between the groups with or without symptomatic VTE. When treated properly after the diagnosis of symptomatic VTE, no specific complications were identified.

CONCLUSION

Symptomatic VTEs are rare in patients who undergo TKAs with mechanical prophylaxis only. Patients with symptomatic VTEs after TKA can be treated without significant sequelae once they are properly treated with anticoagulation after the diagnosis.