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Ultrasound compared with venography for deep venous thrombosis surveillance following total joint arthroplasty
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The Journal of Arthroplasty Vol. 12 No. 2 February 1997
scan in 1.0% (26/2,592). It occurred in 0.58% (15/2,592) of the hospitalized patients and in 0.54% (11/2037) of the patients with venograms (only 3 of these 11 had a positive venogram). There was one fatality in the hospital due to a myocardial infarction. After discharge, late PE occurred in 0.42% (11/2,592) of the patients. One of 0.04% (1/2,592) of these late PE was fatal. Of the deven patients with a late PE, ten had venograms in the hospital and all ten were negative for Deep Venous Thrombosis. Conclusions: The observed incidence of thromboembolism after primary THA in this large group of patients is amongst the lowest reported in the literature. The surgery- was performed under hypotensive epidural anesthesia and in an expedient manner by three experienced, senior surgeons. Duration of surgery, obstruction of femoral venous flow, and blood loss were all kept to a minimum. While the incidence of thromboemboism after primary THA is quite low, PE can still occur in 1.0% (26/2,592) of the patients in spite of a negative venogram. The origin of these clots is most likely intrapelvic, where venography and Doppler ultrasound can not identify them.
PAPER# 44 INTERMITTENT PNEUMATIC COMPRESSION PROTECTION FOR PROXIMAL DEEP VENOUS THROMBOSIS FOLLOWING TOTAL HIP REPLACEMENT Steven T. Woolson, MD, Menlo Park, CA The efficacy of intermittent pneumatic compression (IPC) prophylaxis in preventmg proximal deep venous thrombosis was determined in a consecutive series of patients who underwent primary or revision total hip replacement (THR). 289 patients who were 40 years old or more had 242 primary and 80 revision THR using intraoperative and postoperative IPC using thigh-high sequential compression sleeves and elastic stockings as the only form of prophylaxis. Venous ultrasonography of the proximal veins was performed to determine the presence of thrombosis at an average of 5 days postoperatively. The prevalence of proximal thrombosis in the 289 patients 0 2 2 procedures) was 6% and no patient had a clinically-detected pulmonary embolus. The prevalence of proximal thrombosis was 4% after 233 procedures performed under regional anesthesia and 11% after the 89 procedures performed under general anesthesia (p=0.02). Patients who were less than 75 years-old had a 3% prevalence of proximal thrombosis versus 16% for those patients who were older than 75 years (p<0.000l). No patient in this series had a significant bleeding complication. Mechanical prophylaxis using 1PC combined with regional anesthesia is highly effective in the prevention of proximal thrombosis after THR. The prevalence of proximal thrombosis using 1PC was similar to the reported prevalences for several large series of THR patients who were treated with either low-dose warfarin or low-molecular-weightheparm, but with no risk of major postoperative bleeding.
PAPER# 45 *PNEUMATIC COMPRESSION ENHANCEMENT OF VENOUS FLOW IN TOTAL HIP AND KNEE ARTHROPLASTY: A COMPARISON OF DEVICES Geoffrey H. Westrich, MD, New York,NY, Lawrence M. Spect, MD, Nigel E. Sharrock, MD, Russell E. Windsor, MD, Thomas P. Sculco, MD, Steven B. Haas, MD, Ednardo A. Salvati, MD, Paul M. Pellicci, MD, John Trombtey, MD, Margaret Peterson, PhD Purpose: A crossover study was performed to evaluate the hemodynamic effect of several pneumatic compression devices as well as active dorsi-plantarflexion in ten total hip arthroplasty (THA) and ten total knee arthroplasty (TKA) patients. Methods: Using the AcusoncE 128XP/10 color ultrasound system with a 5 Megahertz linear array probe, both peak venous velocity and venous volume were assessed above and below the greater saphenons-common femoral vein junction. The study was conducted in the recovery room, after the hemodynamic status of each patient was optimized. A randomization table was utilized to determine the
* D e n o t e s t h a t s o m e t h i n g of v a l u e w a s r e c e i v e d . Presenters are boldfaced.
order of the test conditions. The pneumatic compression devices evaluated induded: two foot pumps, a foot-calf pump, a calf pump, and three calf-thigh pumps. Statistical analysis included both analysis of variance and analysis of variance with covariance, such as the baseline measurements and the order in which the devices were tested. Bonferroni corrected differences were also determined. Results: In the THA patients below the greater saphenous-common femoral vein junction, the increase in peak venous velocity for each test condition was as follows: foot pumps AV lmpulse/E 53%, PlexiPulse T M 64%; foot-calf p u m p PIexiPulse T M 212%; calf pump VenaFlow/E 268%, three calf-thigh pumps FlowtrontE 126%, Kendall SCDT M 110%, Jobst Athromhic PumWE 207%; and active dorsi-plantar flexion 217%. The response in TKA was similar with the following increases in peak venous velocity: foot pumps AV ImpulsetE 29%, PlexiPulse T M 65%; foot-calf pump PlexiPulse T M 221%; calf pump VenaFlow/E 302%, three calf-thigh pumps FlovctroncE 87%, Kendall SCDT M 116%, Josbst Athromhic PumWE 263%; and active dorsi-plantar flexion 175%. All the devices augmented venous volume; however, in both the THA and TKA cohorts, the greatest effect was observed with calf-thigh compression. Conclusions: The greatest effect of these devices was observed in the deep venous system. In both the cohorts of patients, impulse pneumatic compression with a rapid inflation time produced the greatest increase in peak venous velocity, while sequential compression of the calf and thigh demonstrated the greatest increase in venous volume. It is noteworthy teat the greatest enhancement in peak venous velocity was obtained with an impulse calf compression device. In THA or other high risk patients where isolated proximal thrombosis may occur without calf thrombosis as a precursor, a pneumatic compression device that has increased peak venous velocity at the common femoral vein may provide better prophylaxis. Since patient and nursing compliance is so essential to the success of mechanical prophylaxis for thromboembolic disease, the more simple devices that are easier to apply and less cumbersome, appear to have a greater likelihood of success.
PAPER#46 ULTRASOUND COMPARED WITH VENOGRAPHY FOR DEEP VENOUS THROMBOSIS SURVEILLANCE FOLLOWING TOTAL JOINT ARTHROPLASTY William J. Ciccone, II, MD, Hershey, PA, Preston S. Fox, MD, Marsha Neumyer, BS, RVT, Deborah Rubens, MD, Vincent D. Pellegrini, Jr., MD Purpose: Deep venous thrombosis (DVT) remains the most frequent and potentially lethal complication following total joint arthroplasty. In the past, long hospital stays allowed for adequate prophylaxis against thromboembolie disease (TED) in a controlled inpatient setting. However, in these cost conscious times, postoperative hospitalization has been decreasing. It is in this period teat various DVT surveillance modahiies are employed in order to allow selective treatment for TED and limit the unnecessary use of anticoagulants. While venography is the "gold standard", duplex ultrasound is performed more commonly due to its low morbidity and noninvasive nature. The purpose of this study was to establish the validity of duplex ultrasound surveillance for DVT in asymptomatic postoperative total joint patients. Methods: Data were obtained from two University medical centers both with certified vascular labs and teaching programs in radiology and orthopaedics to obtain 202 patients who underwent either primary or revision totat joint arthroplasty. All patients were given contemporary DVT prophyla~ds with warfarin or low molecular weight heparin. Ascending contrast venography and duplex ultrasound complemented with doppler color flow imaging were performed on all asymptomatic patients prior to discharge. Results: Color flow duplex doppler ultrasound and ascending contrast venography were performed on 342 lower extremities from 202 postoperative patients. Total hip replacement patients had 202 extremities studied while 140 extremlties were studied following total knee replacement. A total of 55 DVT were identified by venography (prevalence 28%), three proximal thigh thrombi and 52 in the catL Color flow duplex doppler was able to correctly identify 2/3 thigh thrombi (sensitMty 67%) and 5/52 calf thrombi (sensitivity 10%). There were two false positive ultrasound examinations involving a sintle proximal and distal thrombna. When compared to venography, ultrasound displayed a sensitivity of 67%, a specificity of 99.7%, and an accuracy of 99% for the detection of thigh thrombi and a sensitivity of 10% a specificity of 99.7% and an accuracyof 86% for calf thromhi. Conclusions: The poor sensitivity of duplex ultrasonography to detect asymptomatic DVT following total joint replacement make it a poor surveillance tool. Until improved noninvasive modalities are developed we feel that venography is the most appropriate method of DVT surveillance because of its ability to identify both proximal and distal thrombi.
The Journal of Arthroplasty Vol. 12 No. 2 February 1997
scan in 1.0% (26/2,592). It occurred in 0.58% (15/2,592) of the hospitalized patients and in 0.54% (11/2037) of the patients with venograms (only 3 of these 11 had a positive venogram). There was one fatality in the hospital due to a myocardial infarction. After discharge, late PE occurred in 0.42% (11/2,592) of the patients. One of 0.04% (1/2,592) of these late PE was fatal. Of the deven patients with a late PE, ten had venograms in the hospital and all ten were negative for Deep Venous Thrombosis. Conclusions: The observed incidence of thromboembolism after primary THA in this large group of patients is amongst the lowest reported in the literature. The surgery- was performed under hypotensive epidural anesthesia and in an expedient manner by three experienced, senior surgeons. Duration of surgery, obstruction of femoral venous flow, and blood loss were all kept to a minimum. While the incidence of thromboemboism after primary THA is quite low, PE can still occur in 1.0% (26/2,592) of the patients in spite of a negative venogram. The origin of these clots is most likely intrapelvic, where venography and Doppler ultrasound can not identify them.
PAPER# 44 INTERMITTENT PNEUMATIC COMPRESSION PROTECTION FOR PROXIMAL DEEP VENOUS THROMBOSIS FOLLOWING TOTAL HIP REPLACEMENT Steven T. Woolson, MD, Menlo Park, CA The efficacy of intermittent pneumatic compression (IPC) prophylaxis in preventmg proximal deep venous thrombosis was determined in a consecutive series of patients who underwent primary or revision total hip replacement (THR). 289 patients who were 40 years old or more had 242 primary and 80 revision THR using intraoperative and postoperative IPC using thigh-high sequential compression sleeves and elastic stockings as the only form of prophylaxis. Venous ultrasonography of the proximal veins was performed to determine the presence of thrombosis at an average of 5 days postoperatively. The prevalence of proximal thrombosis in the 289 patients 0 2 2 procedures) was 6% and no patient had a clinically-detected pulmonary embolus. The prevalence of proximal thrombosis was 4% after 233 procedures performed under regional anesthesia and 11% after the 89 procedures performed under general anesthesia (p=0.02). Patients who were less than 75 years-old had a 3% prevalence of proximal thrombosis versus 16% for those patients who were older than 75 years (p<0.000l). No patient in this series had a significant bleeding complication. Mechanical prophylaxis using 1PC combined with regional anesthesia is highly effective in the prevention of proximal thrombosis after THR. The prevalence of proximal thrombosis using 1PC was similar to the reported prevalences for several large series of THR patients who were treated with either low-dose warfarin or low-molecular-weightheparm, but with no risk of major postoperative bleeding.
PAPER# 45 *PNEUMATIC COMPRESSION ENHANCEMENT OF VENOUS FLOW IN TOTAL HIP AND KNEE ARTHROPLASTY: A COMPARISON OF DEVICES Geoffrey H. Westrich, MD, New York,NY, Lawrence M. Spect, MD, Nigel E. Sharrock, MD, Russell E. Windsor, MD, Thomas P. Sculco, MD, Steven B. Haas, MD, Ednardo A. Salvati, MD, Paul M. Pellicci, MD, John Trombtey, MD, Margaret Peterson, PhD Purpose: A crossover study was performed to evaluate the hemodynamic effect of several pneumatic compression devices as well as active dorsi-plantarflexion in ten total hip arthroplasty (THA) and ten total knee arthroplasty (TKA) patients. Methods: Using the AcusoncE 128XP/10 color ultrasound system with a 5 Megahertz linear array probe, both peak venous velocity and venous volume were assessed above and below the greater saphenons-common femoral vein junction. The study was conducted in the recovery room, after the hemodynamic status of each patient was optimized. A randomization table was utilized to determine the
* D e n o t e s t h a t s o m e t h i n g of v a l u e w a s r e c e i v e d . Presenters are boldfaced.
order of the test conditions. The pneumatic compression devices evaluated induded: two foot pumps, a foot-calf pump, a calf pump, and three calf-thigh pumps. Statistical analysis included both analysis of variance and analysis of variance with covariance, such as the baseline measurements and the order in which the devices were tested. Bonferroni corrected differences were also determined. Results: In the THA patients below the greater saphenous-common femoral vein junction, the increase in peak venous velocity for each test condition was as follows: foot pumps AV lmpulse/E 53%, PlexiPulse T M 64%; foot-calf p u m p PIexiPulse T M 212%; calf pump VenaFlow/E 268%, three calf-thigh pumps FlowtrontE 126%, Kendall SCDT M 110%, Jobst Athromhic PumWE 207%; and active dorsi-plantar flexion 217%. The response in TKA was similar with the following increases in peak venous velocity: foot pumps AV ImpulsetE 29%, PlexiPulse T M 65%; foot-calf pump PlexiPulse T M 221%; calf pump VenaFlow/E 302%, three calf-thigh pumps FlovctroncE 87%, Kendall SCDT M 116%, Josbst Athromhic PumWE 263%; and active dorsi-plantar flexion 175%. All the devices augmented venous volume; however, in both the THA and TKA cohorts, the greatest effect was observed with calf-thigh compression. Conclusions: The greatest effect of these devices was observed in the deep venous system. In both the cohorts of patients, impulse pneumatic compression with a rapid inflation time produced the greatest increase in peak venous velocity, while sequential compression of the calf and thigh demonstrated the greatest increase in venous volume. It is noteworthy teat the greatest enhancement in peak venous velocity was obtained with an impulse calf compression device. In THA or other high risk patients where isolated proximal thrombosis may occur without calf thrombosis as a precursor, a pneumatic compression device that has increased peak venous velocity at the common femoral vein may provide better prophylaxis. Since patient and nursing compliance is so essential to the success of mechanical prophylaxis for thromboembolic disease, the more simple devices that are easier to apply and less cumbersome, appear to have a greater likelihood of success.
PAPER#46 ULTRASOUND COMPARED WITH VENOGRAPHY FOR DEEP VENOUS THROMBOSIS SURVEILLANCE FOLLOWING TOTAL JOINT ARTHROPLASTY William J. Ciccone, II, MD, Hershey, PA, Preston S. Fox, MD, Marsha Neumyer, BS, RVT, Deborah Rubens, MD, Vincent D. Pellegrini, Jr., MD Purpose: Deep venous thrombosis (DVT) remains the most frequent and potentially lethal complication following total joint arthroplasty. In the past, long hospital stays allowed for adequate prophylaxis against thromboembolie disease (TED) in a controlled inpatient setting. However, in these cost conscious times, postoperative hospitalization has been decreasing. It is in this period teat various DVT surveillance modahiies are employed in order to allow selective treatment for TED and limit the unnecessary use of anticoagulants. While venography is the "gold standard", duplex ultrasound is performed more commonly due to its low morbidity and noninvasive nature. The purpose of this study was to establish the validity of duplex ultrasound surveillance for DVT in asymptomatic postoperative total joint patients. Methods: Data were obtained from two University medical centers both with certified vascular labs and teaching programs in radiology and orthopaedics to obtain 202 patients who underwent either primary or revision totat joint arthroplasty. All patients were given contemporary DVT prophyla~ds with warfarin or low molecular weight heparin. Ascending contrast venography and duplex ultrasound complemented with doppler color flow imaging were performed on all asymptomatic patients prior to discharge. Results: Color flow duplex doppler ultrasound and ascending contrast venography were performed on 342 lower extremities from 202 postoperative patients. Total hip replacement patients had 202 extremities studied while 140 extremlties were studied following total knee replacement. A total of 55 DVT were identified by venography (prevalence 28%), three proximal thigh thrombi and 52 in the catL Color flow duplex doppler was able to correctly identify 2/3 thigh thrombi (sensitMty 67%) and 5/52 calf thrombi (sensitivity 10%). There were two false positive ultrasound examinations involving a sintle proximal and distal thrombna. When compared to venography, ultrasound displayed a sensitivity of 67%, a specificity of 99.7%, and an accuracy of 99% for the detection of thigh thrombi and a sensitivity of 10% a specificity of 99.7% and an accuracyof 86% for calf thromhi. Conclusions: The poor sensitivity of duplex ultrasonography to detect asymptomatic DVT following total joint replacement make it a poor surveillance tool. Until improved noninvasive modalities are developed we feel that venography is the most appropriate method of DVT surveillance because of its ability to identify both proximal and distal thrombi.