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Diagnosis of Deep Venous Thrombosis after Total Knee Arthroplasty: A Comparison of Ultrasound and Venography Studies.  [PDF]
Ching-Jen Wang,Chung-Cheng Huang,Pao-Chu Yu,Han-Hsiang Chen
Chang Gung Medical Journal , 2004,
Abstract: Background: A prospective clinical study was performed to compare the diagnostic accuracybetween ultrasound and venography of deep venous thrombosis (DVT)after total knee arthroplasty (TKA).Methods: This series consisted of 55 patients (43 women and 12 men) with an averageage of 61 (range, 51-81) years who underwent TKA. No pharmaceutical prophylaxisfor DVT was administered. Ultrasound and venographic studieswere performed to detect DVT within 5 to 7 days postoperatively.Results: The incidence of DVT was 36% (20 of 55) by clinical examination, 42% (23of 55) by ultrasound study, and 58% (32 of 55) with venography. The differencein number of cases of DVT determined between ultrasound and venographystudy was marginally significant statistically ( p = 0.082). When thevenographic results were used as the baseline reference, the sensitivity andspecificity of the ultrasound study in the diagnosis of DVT after TKA were87% and 63%, respectively.Conclusion: Ultrasound is a reasonably good alternative to venography in the diagnosis ofDVT after TKA. Ultrasound is non-invasive, safe, and convenient.Ultrasound can be used as the initial screening test for clinically suspectedDVT to be followed by venography in cases of equivocal results of the ultrasoundstudy and in patients with negative ultrasound results but clinicallyevident DVT.
Clinical Significance of Muscular Deep-vein Thrombosis after Total Knee Arthroplasty  [PDF]
Ching-Jen Wang,Jun-Wen Wang,Lin-Hsiu Weng,Chung-Cheng Huang
Chang Gung Medical Journal , 2007,
Abstract: Background: The definition of gastrocneumus and soleus deep-vein thrombosis (DVT)remains controversial. The purpose of this study was to evaluate the clinicalsignificance of muscular deep-vein thrombosis after total knee arthroplasty(TKA).Methods: This study consisted of 359 consecutive patients undergoing TKA evaluatedfor DVT by ascending venography. Venographies were performed 5 to 7days after surgery. Those patients showing positive DVT underwent a follow-up venographic study at 3 months. The evaluation parameters includedclinical symptoms, late DVT, thrombus propagation and pulmonaryembolism. The data from patients with isolated muscular DVT were comparedstatistically with those patients with DVT of the leg veins and combinedDVT.Results: Of 359 patients, 175 (49%) developed venographic DVT including 160 withdistal and 15 with proximal DVT. Of the 160 cases with distal DVT, 83(52%) involved the gastroneumus and soleus muscular veins. Of these 83cases, 38 (46%) were isolated muscular DVT and 45 (54%) involved muscularbranches and major leg veins including the anterior and posterior tibialand peroneal veins. Patients with isolated muscular DVT showed comparablerates of clinical symptoms, late DVT, thrombus propagation and no pulmonaryembolism compared with patients with DVT in the major leg veins(p = 0.874, 0.398 and 1.000) and patients with combined DVT (p = 0.155,0.592 and 1.000).Conclusion: The clinical significance of isolated muscular DVT is comparable to that ofthe major leg veins and combined DVT. Muscular DVT in the calf is considereda significant clinical entity and should be treated accordingly.
The value of D-dimer in the detection of early deep-vein thrombosis after total knee arthroplasty in Asian patients: a cohort study
Chung-Jen Chen, Ching-Jen Wang, Chung-Cheng Huang
Thrombosis Journal , 2008, DOI: 10.1186/1477-9560-6-5
Abstract: 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.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.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.Recent studies have shown that the incidence of deep-vein thrombosis (DVT) after total knee arthroplasty (TKA) in Asian patients is as high as that of the Western countries [1-9]. Pharmaceutical prophylaxis significantly lowered the incidence of DVT, but none of currently available modalities showed total prevention of DVT [3]. Deep-vein thrombosis after TKA is sometimes difficult to diagnose because more than half of DVT cases after TKA are asymptomatic [3], which might cause propagation of the clots leading to pulmonary embolism [7]. Therefore, the effective management of DVT relies on the early detection of DVT. Venographic study is considered the gold standard in the diagnosis of DVT of the lower extremity. Venography, however, is an invasive procedure that can incur certain risks and is expensive [3]. As a result, patients often refuse venography and orthopedic surgeons thus are reluctant to recommend the procedure. Ultrasonography is a reasonable alternative, but the sensitivity of ultrasound in detecting calf DV
Comparison of Clinical Results in Deep Vein Thrombosis of Total Knee Arthroplasty with Rivaroxaban and Dalteparin Sodium  [PDF]
Su Chan Lee, Chang Hyun Nam, Hye Sun Ahn, Seung Hyun Hwang, Nong Kyum Ahn, Ha Young Park
Open Journal of Orthopedics (OJO) , 2015, DOI: 10.4236/ojo.2015.52003
Abstract: This study was intended to investigate into the incidence rates of deep vein thrombosis (DVT) in patients who used prophylactic antithrombotic medications after total knee arthroplasty (TKA), and to compare clinical results in groups treated with Rivaroxaban versus Dalteparin sodium as prophylactic antithrombotic medications. This prospective study was performed in 300 patients who underwent TKA between November 2011 and December 2012. The prophylactic therapy was given to 150 patients in Rivaroxaban group and Dalteparin sodium group, respectively. In addition, intermittent compression pump and stocking were used in all the groups immediately after TKA. In order to determine the incidence of DVT, color Doppler ultrasonography, D-dimer, and clinical symptom examination were conducted. There were 17 cases (11.3%) of DVT in Rivaroxaban group and 18 cases (12.0%) of DVT in Dalteparin sodium group after TKA, and no significant difference was seen between both groups. Between patients with DVT and those without DVT after TKA at 4 days in both groups, there was a significant difference in the swelling indices. Moreover, a significant difference was observed in the evaluation of bruise. The early signs of DVT after TKA are unknown, however, some initial clinical signs such as swelling have been observed. After using the said prophylactic drugs, the lower incidence of DVT was seen, and there was no difference between the types of drugs. Pharmacological therapy (either Rivaroxaban or Dalteparin sodium) after TKA is considered effective for DVT prevention. There is also a need to consider constant monitoring of clinical symptoms.
Routine chemoprophylaxis for deep venous thrombosis in Indian patients: Is it really justified?  [cached]
Mavalankar Ashutosh,Majmundar Darshan,Rani Shubha
Indian Journal of Orthopaedics , 2007,
Abstract: Background: Venous thromboembolism (VTE), which consists of deep vein thrombosis (DVT) and pulmonary embolism, is a potentially fatal disease. According to the Western literature, DVT of lower limb veins is one of the most common complications following total hip and knee arthroplasty and surgeries for lower limb fractures. Very few studies have been published from India on the subject and very little is known about the true incidence of the condition. The issue has acquired greater significance in Indian subjects in recent times as there is a manifold increase in the number of joint replacement surgeries and surgeries for lower limb fractures. There are no clear guidelines regarding the prophylaxis for VTE for Indian patients. Materials and Methods: We carried out a prospective study to determine the incidence of DVT. Present study included 125 patients undergoing total knee and hip joint arthroplasty and surgeries for fractures of the lower limb over a three-year period. All the patients underwent duplex ultrasonography between the seventh and 14 th postoperative day. No mechanical or chemical form of DVT prophylaxis was used. Results: Only nine patients (7.2%) showed sonographic evidence of DVT and the majority of them resolved without treatment. There was no case of pulmonary embolism. Conclusion: DVT following total joint arthroplasty and surgery for lower limb fractures in Indian patients is not as common as reported in the Western literature. A high level of suspicion and close clinical monitoring is mandatory, routine chemoprophylaxis is perhaps not justified in every patient undergoing lower limb surgery in our opinion. More trials involving a larger number of patients and at multi centers, in future, would be required to confirm the findings of our study.
Thromboprophylaxis for Hip and Knee Arthroplasty: Current Managements and Review of the Literature  [PDF]
Ismail Hakki Korucu, Faik Turkmen, Burkay Kacira, Onur Bilge, Alper Kilicaslan, Serdar Toker
World Journal of Cardiovascular Diseases (WJCD) , 2014, DOI: 10.4236/wjcd.2014.412071
Abstract: Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) are major surgical procedures which can cause high morbidity and even mortality. Among these complications is venous thrombo embolism (VTE) comprising deep vien thrombosis (DVT) and pulmonary embolism (PE). Therefore, after these operations, thromboprophylaxis is routinely used. However, it has some complications such as bleeding, adverse effect of chemical agents for using prevention of DVT. Anti-thrombotic prophylaxis includes: low molecular weight heparin (LMWH), fondaparinux, apixaban, dabigatran, rivaroxaban, low dose unfractionated heparin (LDUH), adjusted dose vitamin K antagonist (VKA), aspirin, or mechanical thromboprophylaxis devices. All over the World, orthopaedic surgeons consider a balance between thromboprophylaxis and bleeding. However, it has been still controversy about optimum prophylaxis for DVT. In this current paper, we aimed to review the literature under light of the current studies.
IgG-class anti-PF4/heparin antibodies and symptomatic DVT in orthopedic surgery patients receiving different anti-thromboembolic prophylaxis therapeutics
Satoru Motokawa, Takafumi Torigoshi, Yumi Maeda, Kazushige Maeda, Yuka Jiuchi, Takayuki Yamaguchi, Shinsuke Someya, Hiroyuki Shindo, Kiyoshi Migita
BMC Musculoskeletal Disorders , 2011, DOI: 10.1186/1471-2474-12-22
Abstract: A prospective observational study was performed for 374 Japanese patients undergoing THA or TKA to determine the incidence of VTE. IgG-class anti-PF4/heparin antibodies were measured using IgG-specific EIA before and after the operation.In the clinical outcome, the incidence of symptomatic deep vein thrombosis (DVT) was 15.0% (56/374, TKA; 35, THA; 21) and pulmonary emboli (PE) were not observed. The total seroconversion incidence of IgG-class PF4/heparin antibodies was 19.8% (74/374). The seroconversion incidence of IgG-class PF4/heparin antibodies was higher in patients receiving UFH (32.7%) compared to those receiving LMWH (9.5%) or fondaparinux (14.8%). Furthermore, the seroconversion incidence was significantly higher in patients undergoing TKA compared to those undergoing THA. Based on multivariate analysis, seroconversion of the IgG-class PF4/heparin antibodies was independent a risk factor for symptomatic DVT.Our findings show that the seroconversion of IgG-class anti-PF4/heparin antibodies differed with various anti-thrombotic prophylaxis therapeutics and was associated with the risk of DVT in a subset of patients undergoing total joint arthroplasty (TKA and THA).Venous thromboembolism (VTE) is a serious complication of major orthopedic surgery including total hip arthroplasty (THA) and total knee arthroplasty (TKA) [1]. The incidence of postoperative deep vein thrombosis (DVT) is 45-57% after THA and 41-85% after TKA if prophylaxis is not used [2]. Consequently, pharmacological thromboprophylaxis is recommended and widely used in patients undergoing orthopedic surgery [3]. Although, low-dose unfractionated heparin (UFH) has been used as a thromboprophylactic agent, enoxaparin and fondaparinux have recently been approved for thromboprophylaxis in patients after TKA or THA in Japan [4,5]. LMWHs is an important tool in DVT management, offering advantages over UFH, considering the reduced risk for HIT [6], a prothrombotic adverse drug reaction caused by platel
Combined pharmacological and mechanical prophylaxis for DVT following hip and knee arthroplasty
B. Moretti,V. Patella,V. Pesce,C. Simone,M. Ciccone,M. De Nicolò
Journal of Orthopaedics and Traumatology , 2002, DOI: 10.1007/s101950200042
Abstract: Intermittent pneumatic compression (IPC) is an attractive method for prophylaxis of deep venous thromboembolism (DVT) because there is no risk of haemorrhagic complications. However, IPC has not been studied as thoroughly as other methods in orthopaedic and traumatologic surgery. We monitored 328 patients undergoing total hip or knee arthroplasty (THA, TKA) treated with combined pharmacological and mechanical prophylaxis or with pharmacological prophylaxis alone, with pre- and postoperative colour Doppler ultrasound. Prevalences of DVT after THA (4.0%) and TKA (3.2%) were similar, even if the absolute prevalence was lower in the groups given combined prophylaxis. IPC has an important role in preventing postoperative DVTin these patients and reduces the progression from post-thrombotic syndrome (PTS) to DVT.
The Efficacy and Safety of Rivaroxaban for Venous Thromboembolism Prophylaxis after Total Hip and Total Knee Arthroplasty  [PDF]
Robert D. Russell,William R. Hotchkiss,Justin R. Knight,Michael H. Huo
Thrombosis , 2013, DOI: 10.1155/2013/762310
Abstract: Venous thromboembolism (VTE) is a common complication after total hip and total knee arthroplasty. Currently used methods of VTE prophylaxis after these procedures have important limitations, including parenteral administration, and unpredictable plasma levels requiring frequent monitoring and dose adjustment leading to decreased patient compliance with recommended guidelines. New oral anticoagulants have been demonstrated in clinical trials to be equally efficacious to enoxaparin and allow for fixed dosing without the need for monitoring. Rivaroxaban is one of the new oral anticoagulants and is a direct factor Xa inhibitor that has demonstrated superior efficacy to that of enoxaparin. However, the data also suggest that rivaroxaban has an increased risk of bleeding compared to enoxaparin. This paper reviews the available data on the efficacy and safety of rivaroxaban for VTE prophylaxis after total hip and total knee arthroplasty. 1. Introduction Venous thromboembolism (VTE) is a common complication after total hip arthroplasty (THA) and total knee arthroplasty (TKA). Without anticoagulant prophylaxis, symptomatic deep venous thrombosis (DVT) occurs in approximately 15%–30% of the patients undergoing THA and TKA [1, 2]. Patients undergoing TKA are at higher risk for developing DVT; however, the rate of symptomatic DVT is higher after THA [1, 3, 4]. With evolving surgical technique, and methods of preventing VTE, the rate of VTE has decreased over time [1]. Using currently accepted methods of VTE prophylaxis, the rate of symptomatic DVT is approximately 1%–3%, and the rate of pulmonary embolism (PE) is approximately 0.2%–1.1% [2, 5–8]. The efficacy of VTE prophylaxis must be weighed against the risk of bleeding complications for the patients. The most commonly used VTE chemoprophylaxes after THA and TKA are low-molecular-weight heparin (LMWH), adjusted-dose warfarin with a targeted INR of 2-3, fondaparinux, or aspirin [2]. Current VTE prophylaxis regimens have significant shortcomings. Warfarin has a slow onset of action and has a narrow therapeutic window requiring frequent monitoring. Patients taking warfarin have only a 33% compliance rate and are frequently outside the targeted INR range increasing the risk of both bleeding and VTE [9, 10]. Low-molecular-weight heparin (LMWH) and fondaparinux must be administered parenterally, which requires time and cost. Patients are less compliant with administration of these drugs due to these barriers. One study reported only 75% continued the medication after discharge [9]. However, both warfarin and LMWH have
A Case of Rectus Sheath Hematoma Due to Anticoagulants after Total Knee Arthroplasty  [PDF]
Wataru Shishikura, Hideyuki Aoki, Takashi Nakamura, Yoshiyasu Miyazaki, Takashi Saito, Ryo Takamatsu, Katsunori Fukutake, Kazuaki Tsuchiya
Open Journal of Orthopedics (OJO) , 2016, DOI: 10.4236/ojo.2016.66020
Abstract: Background: Hematoma in the rectus sheath is not common but if happens it will become major bleeding. Sometimes anticoaglation of deep vein thrombosis (DVT) causes the hematoma in the rectus sheath. Case Report: A 74-year-old female patient after total knee arthroplasty (TKA) due to osteoarthritis. Postoperation, residual DVT was noted in the right soleus vein on ultrasonography of the veins of the lower limbs. Anticoaglation was started 7.5 mg/day Arixtra for treatment of DVT. Anticoaglation was administered throughout rehabilitation, and abdominal pain developed on postoperative day 9. Since respiratory distress developed on day 10, then thoracoabdominal contrast CT was performed. Although no PE was observed, a hematoma was detected in the rectus sheath, and it perforated into the abdominal cavity. The hemoglobin level was reduced by about 4 g/dL, and the patient was admitted to the ICU. Surgical treatment was not performed, anticoagulant treatment was discontinued, and conservative treatment was administered. During management in the ICU, a total of 24 units of red blood cells were transfused. Conclusions: Rectus sheath hematoma should be in mind of surgeons during differential diagnosis of acute abdominal pain especially in patients receiving anticoagulants. Early recognition can be of great importance for patients’ recovery, preventing from severe complications. Management is usually supportive although surgical intervention in some patients should be considered.
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