Routine Duplex Ultrasound Screening after TKA is Not Necessary

Abstract

We determined if negative ultrasound screening at the time of acute care hospital discharge or 2 weeks post operatively would reliably identify patients without deep venous thrombosis, thus allowing discontinuation of warfarin chemoprophylaxis. Patients undergoing primary TKA (1344) were treated with adjusted-dose warfarin (target prothrombin time, 15-18 seconds; internationalized normalization ratio, 1.4-1.7) until screening and then aspirin (325 mg po bid) until 6 weeks postoperatively. Deep venous thrombosis as determined by ultrasound was the measured outcome. From 1994 to 1997, 525 patients underwent screening ultrasound before discharge (usually postoperative Day 3): 12 (2.3%) patients with proximal deep venous thrombosis and three (0.6%) patients with distal deep venous thrombosis were identified. From 1997 to 2001, 819 patients underwent ultrasound screening at Day 14 postoperatively: 10 (1.2%) patients with proximal deep venous thrombosis and 29 (3.6%) patients with distal deep venous thromboses were identified. There was no difference in proximal deep venous thrombosis detection, but there was a difference in distal deep venous thrombosis detection. We no longer screen asymptomatic patients with ultrasound for deep venous thrombosis after TKA.

High Incidence of Complications From Enoxaparin Treatment After Arthroplasty

“…The presence of PE was established by spiral computed tomography or ventilation-perfusion (V/Q) scan, which were obtained if clinical symptoms warranted. No type of screening for thromboembolism was performed [14]. Patients were excluded if they had impaired renal function, defined as a creatinine of 1.6 mg/dL or greater, or if they had a history of hepatic dysfunction before surgery.…”

Duplex Ultrasonography Has Limited Utility in Detection of Postoperative DVT After Primary Total Joint Arthroplasty

“…They advocated that a negative duplex ultrasound should not preclude further workup and evaluation in symptomatic patients [6]. Similarly, Iorio et al found that in patients undergoing total knee replacements, routine use of duplex ultrasonography was of limited clinical benefit and recommended that this diagnostic modality only be employed when high clinical suspicion exists [11]. Unay et al reported in a proposed protocol for DVT prophylaxis that out of a group of 1326 patients undergoing a wide range of orthopedic procedures including arthroplasty (217 patients), trauma, arthroscopy, and congenital and acquired deformities, 58 (4.4%) met predefined criteria (pain, swelling, patchy/venous appearance, tenderness, temp increase, pain) for ordering a Doppler ultrasound, and only six of those were positive [21].…”