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Clinical Orthopaedics and Related Research®

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01-03-2014 | Clinical Research

Symptomatic Pulmonary Embolus After Joint Arthroplasty: Stratification of Risk Factors

Authors: Javad Parvizi, MD, Ronald Huang, MD, Ibrahim J. Raphael, MD, William V. Arnold, MD, PhD, Richard H. Rothman, MD, PhD

Published in: Clinical Orthopaedics and Related Research® | Issue 3/2014

Abstract

Background

Prophylaxis for pulmonary embolism (PE) after total joint arthroplasty (TJA) presents the clinical dilemma of balancing the risk of postoperative thrombotic risk and anticoagulation-related complications such as bleeding, hematoma formation, and infection. Risk stratification of patients undergoing TJA is needed to tailor prophylaxis based on thrombotic and bleeding risk.

Questions/purposes

The purpose of this study was to identify the preoperative comorbidities that were associated with an increased risk of symptomatic PE after joint arthroplasty in a large group of patients who had TJAs and who were treated with either aspirin or warfarin.

Methods

We conducted a retrospective study of 26,391 primary and revision TJAs performed at our institution between January 2000 and April 2011. A total of 24,567 patients received warfarin prophylaxis for 6 weeks (targeted international normalized ratio of 1.5–2.0) and 1824 patients received 325 mg aspirin twice daily. Symptomatic patients with decreased oxygen saturation were evaluated for PE using either a ventilation/perfusion scan or multidetector CT scan. Symptomatic PEs occurring in patients within 90 days postoperatively identified with CT or ventilation/perfusion scans were considered complications related to surgery, and fatal PEs were those that occurred in patients who died during the hospital admission owing to cardiopulmonary failure after PE. Using a logistic regression analysis, a nomogram was created to predict postoperative symptomatic PE risk.

Results

Risk of postoperative symptomatic PE after primary and revision TJAs was 1.1%. Risk of postoperative fatal PE was 0.02%. Elevated BMI (p < 0.035), procedures on the knee (p < 0.006), higher Charlson Comorbidity Index (p < 0.015), chronic obstructive pulmonary disorder (p = 0.006), atrial fibrillation (p < 0.001), anemia (p < 0.001), presence of deep vein thrombosis (p < 0.001), and depression (p = 0.012) were independent risk factors for symptomatic PE. Based on these risk factors and derived scoring criteria, patients can be classified into low- (0.35%), medium- (1.4%), and high- (9.3%) risk categories.

Conclusions

Patients who are obese, undergo knee procedures, have an elevated Charlson Comorbidity Index, chronic obstructive pulmonary disease, atrial fibrillation, anemia, depression, or postoperative deep vein thrombosis are at greater risk of having a postoperative PE develop. These risk factors should be considered when deciding on postoperative anticoagulation prophylaxis.

Level of Evidence

Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

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Title: Symptomatic Pulmonary Embolus After Joint Arthroplasty: Stratification of Risk Factors
Authors: Javad Parvizi, MD
Ronald Huang, MD
Ibrahim J. Raphael, MD
William V. Arnold, MD, PhD
Richard H. Rothman, MD, PhD
Publication date: 01-03-2014
Publisher: Springer US
Published in: Clinical Orthopaedics and Related Research® / Issue 3/2014
Print ISSN: 0009-921X
Electronic ISSN: 1528-1132
DOI: https://doi.org/10.1007/s11999-013-3358-z

At a glance: The STEP trials

Springer Medicine

Symptomatic Pulmonary Embolus After Joint Arthroplasty: Stratification of Risk Factors

Abstract

Background

Questions/purposes

Methods

Results

Conclusions

Level of Evidence

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Questions/purposes

Methods

Results

Conclusions

Level of Evidence

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