Routine Preoperative Venous Doppler Screening Is Not Effective in Preventing Thromboembolic Events After Total Joint Arthroplasty

• Updated on: 2018-04-03
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Routine Preoperative Venous Doppler Screening Is Not Effective in Preventing Thromboembolic Events After Total Joint Arthroplasty
Morteza Meftah, MD; Peter B. White, BA; Ahmed Siddiqi, DO; Vinayak S. Perake, MD; Ira H. Kirschenbaum, MD
Orthopedics. 2018;41(2):e202-e206
Abstract
Abstract
Despite advances in thromboprophylaxis, the relationship between preexisting deep venous thromboses (DVTs) and postoperative thromboembolic complications is not fully established. The aim of this study was to assess the utility of selective and nonselective preoperative lower extremity venous Doppler screening protocols as tools in reducing the incidence of thromboembolic events (DVT/pulmonary embolism [PE]) after total joint arthroplasty. In the 2-year period from August 2013 to August 2015, a total of 455 consecutive elective primary total joint arthroplasties were identified from the authors' database. During the first year, a selective preoperative Doppler ultrasound screening protocol (only patients with a history of DVT/PE) was used for 182 patients, 31 of whom had preoperative ultrasound scans. The following year, a nonselective screening protocol was used for 273 consecutive patients, all of whom had preoperative Doppler ultrasound scans. All patients were followed for a minimum of 3 months postoperatively for postoperative Doppler ultrasound scans, emergency department visits, and readmissions related to DVT/PE. Preoperatively, there was no difference between the selective and nonselective cohorts regarding preoperative DVTs (3 and 1, respectively; P=.307); all patients were known to have prior DVT. Postoperative thromboembolic events were found in 4 (2.6%) of the patients in the selective cohort and 2 (0.7%) of the patients in the nonselective cohort (P=.196). Use of a nonselective preoperative Doppler ultrasound screening protocol did not improve the identification of preoperative DVTs or reduce postoperative thromboembolic complications. [Orthopedics. 2018; 41(2):e202–e206.]
Full Text
Abstract
Despite advances in thromboprophylaxis, the relationship between preexisting deep venous thromboses (DVTs) and postoperative thromboembolic complications is not fully established. The aim of this study was to assess the utility of selective and nonselective preoperative lower extremity venous Doppler screening protocols as tools in reducing the incidence of thromboembolic events (DVT/pulmonary embolism [PE]) after total joint arthroplasty. In the 2-year period from August 2013 to August 2015, a total of 455 consecutive elective primary total joint arthroplasties were identified from the authors' database. During the first year, a selective preoperative Doppler ultrasound screening protocol (only patients with a history of DVT/PE) was used for 182 patients, 31 of whom had preoperative ultrasound scans. The following year, a nonselective screening protocol was used for 273 consecutive patients, all of whom had preoperative Doppler ultrasound scans. All patients were followed for a minimum of 3 months postoperatively for postoperative Doppler ultrasound scans, emergency department visits, and readmissions related to DVT/PE. Preoperatively, there was no difference between the selective and nonselective cohorts regarding preoperative DVTs (3 and 1, respectively; P=.307); all patients were known to have prior DVT. Postoperative thromboembolic events were found in 4 (2.6%) of the patients in the selective cohort and 2 (0.7%) of the patients in the nonselective cohort (P=.196). Use of a nonselective preoperative Doppler ultrasound screening protocol did not improve the identification of preoperative DVTs or reduce postoperative thromboembolic complications. [Orthopedics. 2018; 41(2):e202–e206.]
Deep venous thrombosis (DVT), or venous thromboembolism (VTE), is a well-known acute complication after total joint arthroplasty (TJA) that can lead to a potentially life-threatening pulmonary embolism (PE). 1–3 Based on the American College of Chest Physicians guidelines, orthopedics, particularly total hip and knee arthroplasty, has the highest risk for DVT. 3 Despite advances in thromboprophylaxis, the reported incidence of symptomatic DVTs and PEs following TJA is as high as 3%. 4
Asymptomatic DVTs existing prior to TJA may ultimately lead to postoperative thromboembolic complications. Therefore, identifying preoperative asymptomatic DVTs by noninvasive ultrasound may potentially reduce postoperative VTE complications. 5–9 However, guidelines regarding routine preoperative ultrasound screening prior to TJA have not been established. Furthermore, the few clinical studies that have evaluated the usefulness of preoperative Doppler ultrasound scans have had little consistency regarding the prevalence of preoperative VTEs. 10–16
The purpose of this study was to determine the utility and the cost of selective and nonselective preoperative lower extremity venous Doppler ultrasound screening protocols in identifying preexisting DVTs and reducing the incidence of thromboembolic events (DVT/PE) after TJA.
Materials and Methods
This study received institutional review board approval. In the 2-year period from August 2013 to August 2015, all consecutive elective primary TJAs were identified from the authors' prospective database. All TJAs had been performed by the 2 senior authors (M.M., I.H.K.) using similar techniques. Patients who underwent surgery for femur fracture, revision, or simultaneous bilateral TJA were excluded. The total cohort was composed of 455 primary TJAs (353 total knee arthroplasties [TKAs] and 102 total hip arthroplasties [THAs]). The cohort had a mean age of 59.1±5.7 years (range, 46.7–82.6 years) and a mean body mass index of 33.9±7.4 kg/m2 (range, 17.7–52 kg/m2).
Hypotensive epidural anesthesia was used in all cases. All patients received a similar multimodal pain protocol. 17 Thromboprophylaxis was determined based on the American Society of Anesthesiologists Physical Classification System. Patients who were classified as I or II (without a prior history of DVT/PE) were determined to be at low risk for DVT and received 325 mg of aspirin twice a day. Patients who were classified as III or IV (with a prior history of DVT/PE or had a history of a hypercoagulopathy) were considered to be at high risk and received low-molecular-weight heparin injections (Lovenox; Sanofi Aventis, Bridgewater, New York). All primary THAs were performed using a noncemented implant (Accolade II; Stryker, Mahwah, New Jersey). All primary TKAs were performed with a cemented, posterior-stabilized implant (Triathlon PS; Stryker). A tourniquet was used only during cementation.
During the study, there were 2 protocols regarding preoperative ultrasound screening. Throughout the first year, August 2013 to August 2014, a selective preoperative ultrasound screening protocol was used for 182 primary TJAs. Patients were selected to have a preoperative Doppler ultrasound scan if they reported a previous history of a DVT or PE, or if they presented with swelling and a history of peripheral vascular disease. With this protocol, 31 (17%) had a preoperative Doppler ultrasound scan, whereas 151 (83%) did not.
In the second year of the study, August 2014 to August 2015, a nonselective preoperative Doppler ultrasound protocol was used for 273 consecutive TJAs. This was based on the recommendation of the internal medicine team at the authors' institution to detect DVTs prior to any orthopedic procedures. During this period, all patients had a preoperative Doppler ultrasound scan regardless of history. There were no significant differences between the 2 groups regarding demographic criteria, including age, type of surgery (TKA vs THA), and DVT prophylaxis (Table 1 ).
Table 1:
Demographics of the 2 Groups
All patients were followed for a minimum of 3 months postoperatively, and no patients were lost to follow-up. All patients who had postoperative Doppler ultrasound scans, emergency department visits, or readmissions related to DVT or PE were identified. Patients were indicated for a postoperative Doppler ultrasound scan in the emergency department if they had clinical symptoms of a DVT, including swelling, pain, tenderness, increased warmth, or erythema in the calf. 1 Patients who had clinical findings suggestive of a PE underwent a computed tomography angiography scan. All Doppler ultrasound scans and computed tomography scans were evaluated by 1 radiologist.
All statistical analyses were performed using STATA version 14.0 software (Stata-Corp, College Station, Texas). Differences between categorical and continuous variables were assessed with chi-square and Fisher's exact tests and t tests, respectively. Descriptive statistics are reported as means with standard deviations for continuous variables and as frequencies with percentages for categorical variables. A cursory cost analysis was also performed on the 2 protocols using the 2016 Medicare reimbursement fee schedule for unilateral in-patient Doppler ultrasound ($156.11 per Doppler ultrasound scan). 18
Results
In the selective preoperative ultrasound cohort, 3 (9.6%) of the 31 patients who underwent a preoperative Doppler ultrasound scan were found to have a positive result (1.6% overall). All 3 patients had a preoperative history of DVTs, and 1 of the patients underwent placement of an inferior vena cava filter prior to undergoing TKA. In the nonselective cohort, only 1 (0.4%) patient, who also had a history of preoperative DVTs, was found to have a positive result on preoperative Doppler ultrasound scan. An additional patient from this group also had a positive result for a DVT in the superficial femoral vein; however, for other reasons, this patient did not undergo surgery. There was no difference in the overall incidence of preoperative DVTs between the 2 cohorts (P=.307).
Postoperatively, 50 (27.4%) Doppler ultrasound scans were performed for the selective screening cohort and 25 (9.2%) were performed for the nonselective cohort. Postoperatively, thromboembolic events were found in 4 (2.6%) of the patients in the selective protocol cohort and 2 (0.7%) of the patients in the nonselective cohort, which was not statistically significant (P=.196). All 6 cases were diagnosed with a positive result on Doppler ultrasound scan or computed tomography scan during the hospital stay on postoperative day 1 or 2. None of these 6 patients had a positive result on preoperative ultrasound scan.
The cost of preoperative Doppler ultrasound screening was $4839.41 for the selective cohort (31 cases) vs $42,618.03 for the nonselective cohort (273 cases).
Discussion
Despite advances in thromboprophylaxis, thromboembolic complications remain among the most preventable yet lethal complications after TKA or THA. The reported incidence of postoperative thromboembolic complications has varied from 0.07% to 15%, 19–25 with recent studies suggesting 3%. 4 To further reduce the incidence of postoperative complications, some have suggested that preoperative Doppler screening may be useful to identify patients at risk for a postoperative DVT. 5–9
This study had several limitations. First, despite the large cohort of patients, the rates of both preoperative and postoperative thromboembolic complications were low, limiting the power of the study. However, the authors were able to show that there was no clear benefit to preoperative Doppler ultrasound scan for all patients without any selection protocols. Second, the diagnosis of DVT by Doppler ultrasound scan is operator dependent and may be subject to variability, although the accuracy of Doppler ultrasound scan for identifying DVT is high. 9 Third, no other coagulation studies (ie, D-Dimer) were performed. Finally, the authors used Medicare reimbursement fee to analyze cost. However, it is difficult to properly assess the true cost of ultrasound and related operative expenses (ie, radiology reports), and the authors' analysis likely underestimated the actual cost. Strengths of this study included a prospective cohort analysis, the exclusion of nonelective (fracture) cases, and use of a single institution's data.
With the 2 screening protocols used in this study, the authors found low incidences of preexisting DVTs, consistent with previous reports in the literature. 12 Despite some reports of higher incidences of preoperative DVTs, 12 most studies on the topic have reported incidence rates between 0.2% and 4.0% 11–16,26 (Table 2 ). Chumas et al 26 performed nonselective screening on 93 consecutive patients and reported an incidence rate of 4.3% for preexisting DVT. Hartford et al 13 similarly found an incidence of 2.1% for patients undergoing both hip and knee arthroplasty. As others have suggested, 27 and many previous studies have found, 26 the routine use of nonselective Doppler ultrasound scan may have little clinical value. However, the findings of this study suggest that selective screening based on history can be useful in identifying preexisting DVTs.
Table 2:
Findings of Published Studies on Preoperative Screening for Deep Venous Thrombosis
Multiple studies and the 2012 American College of Chest Physicians Evidence-Based Clinical Practice Guidelines have reported that routine duplex ultrasound screening is unnecessary after TJA if effective chemical prophylaxis has been used. 28–30 Additionally, although aspirin has recently gained momentum as an agent for VTE prophylaxis, its use for high-risk patients with a history of VTE, with malignancy, with a prothrombotic condition, or requiring anticoagulation for preexisting conditions has yet to be evaluated. 31 To the authors' knowledge, the current study is the first to evaluate the utility and cost of selective preoperative screening for higher-risk patients in an effort to appropriately risk stratify patients and choose suitable agents for chemoprophylaxis. Patients were risk stratified preoperatively based on their medical history for further intervention, such as placement of an inferior vena cava filter, or initiation of a more potent thromboprophylaxis agent.
In this study, there was a lack of a relationship between preexisting DVT/positive findings on Doppler ultrasound scan and postoperative thromboembolic complications. The authors believe that the selective preoperative Doppler ultrasound scan is more appropriate for patients at a higher risk for postoperative thromboembolisms, rather than all, and certainly more cost-effective. Therefore, they have discontinued the nonselective preoperative Doppler ultrasound screening at their institution.
Conclusion
In this study, the incidence of preexisting DVTs was extremely low. Preoperative Doppler ultrasound scans in the nonselective screening protocol were not helpful in reducing postoperative thromboembolisms. Moreover, selective screening was a cost-efficient alternative to non-selective, routine screening. Additionally, selective preoperative screening of higher-risk individuals may help risk stratify patients for medical optimization prior to arthroplasty procedures.
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Table 1