Copyright © 2006 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Clifford W. Colwell Jr, MD*,
Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La Jolla, California
Posted November 2006
In a comparison of screening protocols for deep venous
thrombosis, all eight orthopaedic surgeons participating in the study followed
a consensus clinical pathway, which included 2364 patients who underwent
primary total hip or knee arthroplasty from 1994 to 2001. In this protocol, one
cohort underwent noninvasive compression venous ultrasonography prior to
discharge and the other cohort underwent the same screening two weeks after the
operation. The data showed that the timing of the two screening protocols did
not significantly affect the overall rate of detection of deep venous
thrombosis or pulmonary embolism. The authors therefore do not recommend the use
of noninvasive venous ultrasonography as a postoperative prophylactic method of
screening for asymptomatic deep venous thrombosis.
These findings are similar to those found by the review
panel for The American College of Chest Physicians (ACCP) guidelines, which
included three orthopaedic surgeons at the time of the initial evaluation and ten
orthopaedic consultants prior to publication. These recommendations were based
on the randomized prospective studies1,2.
It would have been interesting if the authors had performed
an additional duplex ultrasound test at twenty-eight to thirty-five days after
hip surgery, since the median time to diagnosis is seventeen days3. Dahl
et al. reported that the average time to symptomatic deep venous thrombosis in patients
who underwent total hip arthroplasty was twenty-seven days4. Venographic
data also suggest that a significantly higher incidence of deep venous
thrombosis occurs if the prophylaxis is not continued beyond the two-week
protocol instituted in this paper5,6. These results hold true for
total hip arthroplasty but have not been confirmed in total knee replacement
studies3,7. It also would have been interesting if the authors had
presented their own institutional data on the efficacy of duplex ultrasonography
compared with venography, with respect to sensitivity, specificity, and
accuracy. Have they in fact studied their data from duplex ultrasonography
compared with that from the known venographic modality?
In addition, the authors' protocol recommended the use of
aspirin at the time of discontinuing the use of warfarin. It would be
interesting to know whether or not this protocol had been compared with one in
which aspirin was not used. The use of aspirin as prophylaxis against deep
venous thrombosis has been extremely controversial. Prospective randomized
studies establishing its efficacy have not been performed or reported, despite its
wide prescription by North American orthopaedic surgeons.
*The author did not receive any outside funding or grants in
support of his research for or preparation of this work. Neither he nor a
member of his immediate family received payments or other benefits or a
commitment or agreement to provide such benefits from a commercial entity. No
commercial entity paid or directed, or agreed to pay or direct, any benefits to
any research fund, foundation, division, center, clinical practice, or other
charitable or nonprofit organization with which the author, or a member of his
immediate family, is affiliated or associated.
References
1. Schmidt B, Michler R, Klein M, Faulmann G, Weber C, Schellong S. Ultrasound screening for distal vein thrombosis is not beneficial after major orthopedic surgery. A randomized controlled trial. Thromb Haemost. 2003;90:949-54.
2. Berry DJ. Surveillance for venous thromboembolic disease after total knee arthroplasty. Clin Orthop Relat Res. 2001;392:257-66.
3. White RH, Romano PS, Zhou H, Rodrigo J, Bargar W. Incidence and time course of thromboembolic outcomes following total hip or knee arthroplasty. Arch Intern Med. 1998;158:1525-31.
4. Dahl OE, Gudmundsen TE, Haukeland L. Late occurring clinical deep vein thrombosis in joint-operated patients. Acta Orthop Scand. 2000;71:47-50.
5. Comp PC, Spiro TE, Friedman RJ, Whitsett TL, Johnson GJ, Gardiner GA, Jr., Landon GC, Jove M. Enoxaparin Clinical Trial Group. Prolonged enoxaparin therapy to prevent venous thromboembolism after primary hip or knee replacement. J Bone Joint Surg Am. 2001;83:336-45.
6. Lassen MR, Borris LC, Anderson BS, Jensen HP, Skejo Bro HP, Andersen G, Petersen AO, Siem P, Horlyck E, Jensen BV, Thomsen PB, Hansen BR, Erin-Madsen J, Moller JC, Rotwitt L, Christensen F, Nielsen JB, Jorgensen PS, Paaske B, Torholm C, Hvidt P, Jensen NK, Nielsen AB, Appelquist E, Tjalve E, et al. Efficacy and safety of prolonged thromboprophylaxis with a low molecular weight heparin (dalteparin) after total hip arthroplasty--the Danish Prolonged Prophylaxis (DaPP) Study. Thromb Res. 1998;89:281-7.
7. Eikelboom JW, Quinlan DJ, Douketis JD. Extended-duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta-analysis of the randomised trials. Lancet. 2001;358:9-15.
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