DEEP

VEIN

THROMBOSIS AN

M.

D.

STRINGER,

C. A.

AFTER

INCIDENCE

STEADMAN,

The incidence

of venous

STUDY

A.

From

ELECTIVE

R. HEDGES,

King’s

thromboembolism

312

E. M.

College

after

IN

SURGERY

PATIENTS

THOMAS,

Hospital,

elective

KNEE

T. R.

MORLEY,

V.

London

knee

surgery

has previously

been

exclusively in patients receiving total knee replacements, in whom the risk of a deep vein approximately 60%. We report the results of ipsilateral ascending venography in 312 patients wide variety of elective knee operations under tourniquet ischaemia, none of whom received prophylaxis Total

against thromboembolism. knee replacement was confirmed

to carry

a high risk with ipsilateral

and symptomatic pulmonary embolism in 1.9%. By contrast, arthroscopy of venous thrombosis (4.2%). Meniscectomy, arthrotomy, patellectomy, all high-risk procedures, particularly in patients over 40 years of age, thrombosis rates thromboembolism

of 25% in all

V. KAKKAR

deep

studied

almost

thrombosis is undergoing a any specific

vein thrombosis

in 56.4%

was’associated with a low incidence synovectomy and arthrodesis were and were associated with deep vein

to 67%. patients

On the basis of these findings, we advise over 40 years of age undergoing elective

original

observations

prophylaxis against venous knee surgery other than

arthroscopy.

After

Sevitt

and

Gallagher’s

patients

injured

in 1959,

venous

on

thromboembolism

has

been recognised as a major cause of morbidity and mortality in both emergency and elective orthopaedic surgery. Total hip replacement is associated with a 51% incidence ofdeep vein thrombosis (DVT) in the operated limb (Stamatakis et al. 1977) and pulmonary embolism (PE) this

remains operation

Relatively have ment, 59%

little and

surgery

the largest (Johnson, is known

the

few

dealt almost where the (Stulberg

of the risks

studies

that

exclusively incidence

et al.

We undertook

single cause of mortality Green and Charnley involved

have

with of DVT

after

been

total was

after 1977). knee

performed

knee replaceapproximately

1984). a prospective

study

to determine

the

incidence

of DVT

PATIENTS of 323

A total knee entered

into

the day Patients

A. R. Hedges, E. M. Thomas,

MRCP, FRCS, Surgical Computer Technician

FRCS, FRCS,

Research

Fellow

for the

before were

study.

FRCSE, Surgical Research Fellow Consultant Orthopaedic Surgeon

T. R. Morley, FRCS, Consultant Orthopaedic Surgeon V. V. Kakkar, FRCS, FRCSE, DirectorofThrombosis Research Unit and Professor of Surgical Sciences Thrombosis Research Unit and Department of Orthopaedic Surgery, King’s College Hospital, Denmark Hill, London SE5 8RX, England. Correspondence

©

should

be

sent

to Mr

M.

1989 British Editorial Society of Bone 0301 -620X/89/3062 $2.00 J Bone Joint Surg [Br] 1989:71-B:492-7.

492

D.

Stringer.

and

Joint

Surgery

were

together dage

METHODS undergoing

elective

conditions

All patients

were

and gave questioned

were

interviewed

informed about

on

consent. a previous

or PE, previous surgery or trauma to the and the use oforal contraceptives. They for evidence oflower limb venous disease or venous ulceration) and their weight recorded. postoperative

No

specific venous

prophylactic thromboembo-

employed. was

under exsanguinated

general or epidural anaesthesia, by elevation alone, Esmarch

bandage or by a graduated to the surgeon’s preference. quet was 500 mmHg.

of elective

under tourniquet before the necessity

patients

At operation, the limb

variety

non-malignant

operation specifically

history of DVT limb concerned, were examined (varicose veins

lism

AND

consecutive

operations

and height were measures against M. D. Stringer, C. A. Steadman,

a wide

following

operations on the knee performed ischaemia. Such a study is essential for prophylaxis can be defined.

then applied The duration with

or plaster). Ascending

the

type

compression device according A pneumatic thigh tourniand inflated to of the operation

of postoperative

venography THE

JOURNAL

was OF BONE

a pressure of was recorded dressing

performed AND

JOINT

(banon

the

SURGERY

DEEP

VEIN

THROMBOSIS

AFTER

ELECTIVE

KNEE

SURGERY

493

operated limb seven to 10 days postoperatively. The technique has been described in detail elsewhere (Kakkar 1969) and enables visualisation of calf, popliteal, femoral and iliac veins. Thrombi confined to the calf were classified as ‘minor’ if less than 5 cm in length and ‘major’ if more extensive. Popliteal and femoral thrombi were classified as ‘proximal’ DVTs (Fig. I). Any patient with symptoms suggestive of pulmonary embolism had a radio-isotope ventilation-perfusion lung scan. Pulmonary segmental normal

emboli or larger

were diagnosed perfusion defect

on

the basis accompanied

of

a by

chi-squared U-test.

test,

ventilation.

Statistical Student’s 1-test

analysis and the

was by the Mann-Whitney

RESULTS Of the 323 patients entered into the study, 1 1 were subsequently withdrawn: two were allergic to iodinecontaining contrast media, venography was unsuccessful in two, two other patients were too ill to be transferred for

venography,

Thus from

performed replacement

Postoperative placement teal DVT.

Table

after a total knee rea major calf and popli-

I. Clinical

details

of 312 patients

investigated

Total

Age

(years)

Sex

(male

Mean

: female)

obesity

Clinical

history

(per

(W/H2)

Previous

surgery

Varicose

veins

Venous On *

VOL.

71-B,

No.

contraceptive

See

3, MAY

limb to limb

ulcers

Table

1989

pill III

in age was

(151),

included synovial

arthrotomy for removal of loose bodies or biopsy (45 patients), arthrodesis (6), patellec(4) and

and

miscellaneous

synovectomy

(58).

(3).

The

Clinical

incidence

of 28.2%.

thrombi

>5

after

elective

knee

knee

Of these,

cm

in

length

44 (50%) and

a

latter

and

surgery

Open meniscectomy (n=151)

Miscellaneous (n=58)

64.5

32.6

32.9

34.8

± 9.8

24.5(n

± 12.9

37:11 =

38)

22.4(n

± 1 1.3

128:23 =

21 )

23.5(n

6.3

1.4

± 16.9

43:15 =

1 12)

24. I(n

5.3

7.4

14.9

26.9

11.1

26.9

28.3

14.2

27.8

17.3

0

6.7

0

9.4

0

1.4

0

0

6.3

1.3

6.9

were

further

Arthroscopy (n=48)

31 to same

to participate. ranging Analysis

in four operative categories : total knee (55 patients), arthroscopy (48), open menis-

cent)

DVT/PE Trauma

refused 90 female) available.

arthroplasty (n=55)

14:41

index

patients male: were

group

operative

details of the patients are given in Tables I and II. Most of the total knee arthroplasties (42 of 55) were of the Attenborough semi-constrained type. In all, 88 DVTs were diagnosed, giving an overall

1

venogram demonstrating

five

(222 years

cectomy

tomy

Fig.

and

312 patients 15 to 87

=

46)

major 11

calf

(12.5%)

494

M. D. STRINGER,

C. A. STEADMAN,

A. R. HEDGES,

E. M. THOMAS,

T. R. MORLEY,

V. V. KAKKAR

Iliac

Femoral

Popliteal

Calf

Minor 33 (37.5%)

Major 44 (50%)

Proximal

4-

6 (6.8%) Fig.

Distribution

Table

of 88

II. Operative

details

DVTs

in the

operated

of 312 patients Total

Method (Esmarch bandage)

of exsanguination : elevation/ (per cent)

Duration (minutes)

dressing plaster) (per

cent)

Days in bed (median) See

2

limbs

investigated

of 312

patients

after

elective

after

elective

knee

surgery

knee

knee

surgery.

Open

arthroplasty (n=55)

Arthroscopy (n=48)

meniscectomy (n=151)

Miscellaneous* (n = 58)

67.4:32.6

38.7:61.3

85.1:14.9

59:41

85 ± 13

35 ± 13

48 ± 16

57 ± 29

87.2:

86.2:13.8

28.9:71.1

34:66

1

5

4

of operation

Postoperative (Bandage:

S

5 (5.7%)

Table

Table

12.8

9 III

III.

elective

Incidence

knee

of deep

vein

thrombosis

(DVT)

and

Incidence, Operation Total

Total knee

arthroplasty

Arthroscopy Open

meniscectomy

Miscellaneous Arthrotomy Arthrodesis Patellectomy Synovectomy

pulmonary

embolism

(PE)

after

surgery

number

Calf DVI

55

31(56.4)

48

2(4.2)

151

number

and

(per cent)

Proximal

DYT

PE

5(9.1)

1(1.8)

0

0

37(24.5)

3(2)

0

58

18(3/)

3(5.2)

2(3.4)

45 6 4 3

11(24) 4(66.7) 2(50) 1(33.3)

1(2.2) 2(33.3) 0 0

0 1(16.7) 1(25) 0

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

DEEP

[/

Total

knee

arthroplasty

VEIN

THROMBOSIS

AFTER

Arthroscopy

I

Meniscectomy

(151)

E

Miscellaneous

(58)

KNEE

(48)

of DVT

and

that

(weight in in metres), history of

duration

of surgery,

duration

of postoperative

type

of postoperative

dressing,

immobility

(Table

and

II).

Only the age of the patient and the duration of the operation were significantly different between those patients who developed a DVT and those with normal venograms. For the series as a whole, those patients who

11-30

31-50

51-70 Age

Incidence

of DVT

after

>70

51 . 1 minutes

in years

Fig.

knee

there surgery

related

were

factors groups.

to age.

thrombi

teal and/or no patients

femoral veins with isolated

Three

patients

pulmonary two

extending

(1%)

embolism of them

popliteal

and

proximally

into

the

(Fig. 2). There were, popliteal or femoral

suffered

symptomatic had major calf proximal extension

non-fatal thrombi, into the

; all three

also

had

femoral

veins.

None

of the PEs

(Fig.

popli-

however, thrombi.

occurred

at

venograms were performed in 20 consecutive patients; DVTs were detected in five of their operated limbs, and one of these patients had a minor calf thrombosis in the contralateral limb. We observed no significant complications

from Table

four desis

operative groups. and patellectomy

cedures

ascending III shows

with

contrast, boembolic

an

venography the incidence Total knee all appear

incidence was

arthroscopy complications.

rate

throughout the ofDVT in each

study. of the

greater

than

50%.

In

Among ment,

of4O

the following 71-B,

No.

3. MAY

in both

groups

was

with no significant operative group and pre-operative 1989

those

with

similar

at 58.5

difference. for the series

factors

were

and as a

assessed

between

age

these

these

two

knee replacement a postoperative

DVTs

undergoing difference

rheumatoid

proximal

anticoagulation three months. by anticoagulation

under 30 40 years

or PE had

a mean

total the

arthritis

DVTs

with Major

in

were

knee risk and

treated

replaceof DVT those

with

by

full

heparin followed by Warfarin for calf DVTs were generally managed and minor calf thromboses by elastic

compression stockings alone. One meniscectomy patient developed a haemarthrosis in the operated knee following anticoagulation which was therefore discontinued.

DISCUSSION

It is well

recognised

thrombosis of those

techniques undergoing

respectively Within each

However,

10% for patients for patients over

proximal

with

of

the results from the groups alone, since

differences

those patients there was no

between

DVT was 4.2% and 24.5% respectively, which is significantly different (p