Ultrasound screening for distal vein thrombosis is not beneficial after major orthopedic surgery.

Summary

Ultrasound screening for deep vein thrombosis (DVT) after orthopedic surgery revealed thrombosis in up to 30% of patients, but the clinical impact of screening for distal thrombosis has not been established.

Three hundred and forty six patients after hip or knee replacement and postoperative standard prophylaxis of 10 days low molecular weight heparin (LMWH) were randomized to receive either prolonged prophylaxis with LMWH or postoperative ultrasound screening for proximal and distal thrombosis. All thrombosis found in screening was treated. Patients with a negative screening test did not receive any heparin after day 10. The cumulative rate of proximal thrombosis and symptomatic pulmonary embolism until day 35 postoperatively was determined.

In 174 screening patients, ultrasound found 55 cases of distal (31.6%) and 9 cases of proximal (5.1%) in-hospital thrombosis. In 108 screening patients without thrombosis at discharge 7 new distal (6.5%) and 6 new proximal (5.6%) thrombotic events occurred by day 35. In 163 patients with prolonged prophylaxis, 33 cases of distal (20.2%) and 7 cases of proximal (4,3%) thrombotic events occurred by day 35. The cumulative rate of proximal events was 8,7% in the screening group and 4.3% in the prophylaxis group (p=0.12).

In conclusion, ultrasound screening for thrombosis does not reduce the rate of proximal thrombosis and symptomatic pulmonary embolism 35 days after hip or knee replacement surgery.

Keywords

Ultrasound screening - venous thromboembolism - orthopedic surgery - prophylaxis

• References

• 1 Grady-Benson JC, Oishi CS, Hanson PB. et al. Routine postoperative duplex ultrasonography screening and monitoring for the detection of deep vein thrombosis. A survey of 110 total hip arthroplasties. Clin Orthop 1994; 307: 130-41.
• 2 Barnes CL, Nelson CL, Nix ML. et al. Duplex scanning versus venography as a screening examination in total hip arthroplasty patients. Clin Orthop 1991; 271: 180-9.
• 3 Robinson KS, Anderson DR, Gross M. et al Ultrasonographic screening before hospital discharge for deep venous thrombosis after arthroplasty: the post-arthroplasty screening study. A randomized, controlled trial. Ann Intern Med 1997; 127 (06) 439-45.
• 4 Hull RD, Pineo GF, Francis C. et al Low-molecular-weight heparin prophylaxis using dalteparin extended out-of-hospital vs in-hospital warfarin/out-of-hospital placebo in hip arthroplasty patients: a double-blind, random-ized comparison. North American Fragmin Trial Investigators. Arch Intern Med 2000; 160 (14) 2208-15.
• 5 Barnes RW, Nix ML, Barnes CL. et al Perioperative asymptomatic venous thrombosis: role of duplex scanning versus venography. J Vasc Surg 1989; 9 (02) 251-60.
• 6 Delis KT, Hunt N, Strachan RK. et al Incidence, natural history and risk factors of deep vein thrombosis in elective knee arthros-copy. Thromb Haemost 2001; 86 (03) 817-21.
• 7 Ohgi S, Tachibana M, Ikebuchi M. et al Pulmonary embolism in patients with isolated soleal vein thrombosis. Angiology 1998; 49 (09) 759-64.
• 8 Solis MM, Ranval TJ, Nix ML. et al Is anticoagulation indicated for asymptomatic postoperative calf vein thrombosis?. J Vasc Surg 1992; 16 (03) 414-8. discussion 418-9.
• 9 Schwarz T, Schmidt B, Schellong SM. Interobserver agreement of complete compression ultrasound for clinically suspected deep vein thrombosis. Clin Appl Thromb Hemost 2002; 8 (01) 45-9.
• 10 Planes A, Vochelle N, Darmon JY. et al Risk of deep-venous thrombosis after hospital discharge in patients having undergone total hip replacement: double-blind randomised comparison of enoxaparin versus placebo. Lancet 1996; 348 9022 224-8.
• 11 Bergqvist D, Benoni G, Bjorgell O. et al Low-molecular-weight heparin (enoxaparin) as prophylaxis against venous thromboembolism after total hip replacement. N Engl J Med 1996; 335 (10) 696-700.
• 12 Dahl OE, Andreassen G, Aspelin T. et al Prolonged thromboprophylaxis following hip replacement surgery—results of a double-blind, prospective, randomised, placebo-controlled study with dalteparin (Fragmin). Thromb Haemost 1997; 77 (01) 26-31.
• 13 Lassen MR, Borris LC, Anderson BS. et al Efficacy and safety of prolonged thrombo-prophylaxis with a low molecular weight heparin (dalteparin) after total hip arthroplasty–the Danish Prolonged Prophylaxis (DaPP) Study. Thromb Res 1998; 89 (06) 281-7.
• 14 Dahl OE, Aspelin T, Arnesen H. et al Increased activation of coagulation and formation of late deep venous thrombosis following discontinuation of thromboprophylaxis after hip replacement surgery. Thromb Res 1995; 80 (04) 299-306.
• 15 Kearon C, Julian JA, Newman TE. et al Noninvasive diagnosis of deep venous thrombosis. McMaster Diagnostic Imaging Practice Guidelines Initiative. Ann Intern Med 1998; 128 (08) 663-77.
• 16 Schellong SM, Schwarz T, Halbritter K. et al Complete compression ultrasonography of the leg veins as a single test for the diagnosis of deep vein thrombosis. Thromb Haemost 2003; 89 (02) 228-34.
• 17 Turpie AG, Levine MN, Hirsh J. et al A ran-domized controlled trial of a low-molecular-weight heparin (enoxaparin) to prevent deep-vein thrombosis in patients undergoing elective hip surgery. N Engl J Med 1986; 315 (15) 925-9.
• 18 Turpie AG, Bauer KA, Eriksson I B. et al Fondaparinux vs enoxaparin for the prevention of venous thromboembolism in major orthopedic surgery: a meta-analysis of 4 ran-domized double-blind studies. Arch Intern Med 2002; 162 (16) 1833-40.
• 19 Verlato F, Bruchi O, Prandoni P. et al The value of ultrasound screening for proximal vein thrombosis after total hip arthroplasty–a prospective cohort study. Thromb Haemost 2001; 86 (02) 534-7.