J Knee Surg 2020; 33(12): 1232-1237
DOI: 10.1055/s-0039-1693417
Original Article

Characterization of Pulmonary Emboli in Total Joint Arthroplasty Patients Compared to General Medical Patients

Nathaniel A. Jové
1   Department of Orthopaedic Surgery, Detroit Medical Center/Providence Hospital Orthopaedic Surgery Residency Program, Detroit, Michigan
2   Department of Orthopaedic Surgery, Providence Hospital and Medical Center, Southfield, Michigan
,
Sam Samaan
3   Department of Radiology, Providence Hospital and Medical Center, Southfield, Michigan
,
Natalie M. Pizzimenti
4   Department of Research, The MORE Foundation, Novi, Michigan
,
Denis Lincoln
3   Department of Radiology, Providence Hospital and Medical Center, Southfield, Michigan
,
David C. Markel
1   Department of Orthopaedic Surgery, Detroit Medical Center/Providence Hospital Orthopaedic Surgery Residency Program, Detroit, Michigan
2   Department of Orthopaedic Surgery, Providence Hospital and Medical Center, Southfield, Michigan
› Author Affiliations

Abstract

Pulmonary emboli (PEs) occur in medical and postoperative total joint arthroplasty (TJA) patients. These are different patient populations, yet both undergo identical diagnosis and treatment regardless of PEs size and quantity. To date, there has been no analysis of the location, size, and quantity of emboli that occur postoperatively in TJA compared with general medical patients. We hypothesized TJA patients would have different size and distribution of PEs per event compared with medical patients. A retrospective chart review was conducted of patients who underwent total hip or knee arthroplasty in comparison to general medical patients at our institution from 2006 to 2011 with a PE diagnosis. Medical co-morbidities, sex, age, procedure, postoperative day, size, and location of PE using spiral computed tomography were recorded using a novel mapping scheme. Embolus size was defined based on blockage level in the pulmonary arterial tree. Of the 4,178 TJA patients reviewed, 51 were diagnosed with a PE. A total of 67% of TJA patients were women, yet women represented 90% (n = 46) of TJA PE patients (p < 0.0001). Medical patients had an equal distribution of men and women with PEs. Orthopaedic patients averaged more (4.0 vs. 2.2, p < 0.0001) and smaller PEs compared with medical patients (p < 0.0001). In conclusion, women undergoing TJA had significantly higher risk of developing PE compared with male arthroplasty or medical patients. Differences were observed in size and distribution of PEs between medical and TJA patients, which suggest a different nature of embolic phenomenon.



Publication History

Received: 30 November 2018

Accepted: 19 May 2019

Article published online:
09 July 2019

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 
  • References

  • 1 Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89 (04) 780-785
  • 2 Arcelus JI, Caprini JA, Traverso CI. Venous thromboembolism after hospital discharge. Semin Thromb Hemost 1993; 19 (Suppl. 01) 142-146
  • 3 Coventry MB, Nolan DR, Beckenbaugh RD. “Delayed” prophylactic anticoagulation: a study of results and complications in 2,012 total hip arthroplasties. J Bone Joint Surg Am 1973; 55 (07) 1487-1492
  • 4 Hirsh J, Levine M. Prevention of venous thrombosis in patients undergoing major orthopaedic surgical procedures. Br J Clin Pract Suppl 1989; 65: 2-8
  • 5 Lieberman JR, Geerts WH. Prevention of venous thromboembolism after total hip and knee arthroplasty. J Bone Joint Surg Am 1994; 76 (08) 1239-1250
  • 6 Clagett GP, Anderson Jr FA, Levine MN, Salzman EW, Wheeler HB. Prevention of venous thromboembolism. Chest 1992; 102 (4, Suppl) 391S-407S
  • 7 Kakkar VV, Howe CT, Flanc C, Clarke MB. Natural history of postoperative deep-vein thrombosis. Lancet 1969; 2 (7614): 230-232
  • 8 Leyvraz PF, Bachmann F, Hoek J. et al. Prevention of deep vein thrombosis after hip replacement: randomised comparison between unfractionated heparin and low molecular weight heparin. BMJ 1991; 303 (6802): 543-548
  • 9 Wroblewski BM, Siney PD, White R. Fatal pulmonary embolism after total hip arthroplasty. seasonal variation. Clin Orthop Relat Res 1992; (276) 222-224
  • 10 Wolf LD, Hozack WJ, Rothman RH. Pulmonary embolism in total joint arthroplasty. Clin Orthop Relat Res 1993; (288) 219-233
  • 11 Carson JL, Kelley MA, Duff A. et al. The clinical course of pulmonary embolism. N Engl J Med 1992; 326 (19) 1240-1245
  • 12 Heit JA, O'Fallon WM, Petterson TM. et al. Relative impact of risk factors for deep vein thrombosis and pulmonary embolism: a population-based study. Arch Intern Med 2002; 162 (11) 1245-1248
  • 13 Heit JA, Silverstein MD, Mohr DN, Petterson TM, O'Fallon WM, Melton III LJ. Predictors of survival after deep vein thrombosis and pulmonary embolism: a population-based, cohort study. Arch Intern Med 1999; 159 (05) 445-453
  • 14 Silverstein MD, Heit JA, Mohr DN, Petterson TM, O'Fallon WM, Melton III LJ. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med 1998; 158 (06) 585-593
  • 15 Pulido L, Grossman S, Smith EB. et al. Clinical presentation of pulmonary embolus after total joint arthroplasty: do size and location of embolus matter?. Am J Orthop 2010; 39 (04) 185-189
  • 16 Kearon C, Akl EA, Comerota AJ. et al. Antithrombotic therapy for VTE disease. Chest 2016; 149 (02) 315-352
  • 17 Sekhri V, Mehta N, Rawat N, Lehrman SG, Aronow WS. Management of massive and nonmassive pulmonary embolism. Arch Med Sci 2012; 8 (06) 957-969
  • 18 Konstantinides S. Should thrombolytic therapy be used in patients with pulmonary embolism?. Am J Cardiovasc Drugs 2004; 4 (02) 69-74
  • 19 Ramakrishnan N. Thrombolysis is not warranted in submassive pulmonary embolism: a systematic review and meta-analysis. Crit Care Resusc 2007; 9 (04) 357-363
  • 20 Burge AJ, Freeman KD, Klapper PJ, Haramati LB. Increased diagnosis of pulmonary embolism without a corresponding decline in mortality during the CT era. Clin Radiol 2008; 63 (04) 381-386
  • 21 DeMonaco NA, Dang Q, Kapoor WN, Ragni MV. Pulmonary embolism incidence is increasing with use of spiral computed tomography. Am J Med 2008; 121 (07) 611-617