Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-014-3216-x
KNEE
Incidence of deep venous thrombosis in Chinese patients undergoing arthroscopic knee surgery for cruciate ligament reconstruction Jiang‑tao Dong · Xin Wang · Xiao‑qian Men · Xiao‑feng Wang · Xiao‑zuo Zheng · Shi‑jun Gao
Received: 17 January 2014 / Accepted: 28 July 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose This study investigated the incidence of deep venous thrombosis (DVT) in patients undergoing arthroscopic cruciate ligament surgery. Methods A total of 282 patients were examined by color Doppler ultrasound preoperatively and 3 and 7 days postoperatively. Results DVT was present in 34 of 282 patients (12.1 %); of these, 11 (32.6 %) underwent reconstruction of the anterior cruciate ligament (ACL), alone or in conjunction with the medial or lateral collateral ligament (MCL or LCL, respectively; 17.6 %); eight (23.5 %) of the posterior cruciate ligament (PCL); four (11.8 %) of the PCL–MCL/LCL; and five (14.7 %) of the ACL–MCL. In patients with tourniquets applied for 120 min, the incidence of DVT was 5.6, 12.8, and 17.4 %, respectively. Conclusion The incidence of DVT in normal patients undergoing ACL surgery was 12.1 %. A higher incidence was observed among cases of multiligament reconstruction, especially those involving the PCL, as well as in patients with tourniquets applied for more than 2 h. Based on these findings, prophylactic measures for DVT may be considered after arthroscopic knee surgery in order to decrease the incidence of DVT if specific risk factors are present. Levels of evidence IV.
Introduction The high incidence of venous thromboembolism (VTE)— which includes deep venous thrombosis (DVT) and pulmonary embolism (PE)—in patients undergoing total hip or knee replacement is widely acknowledged and has prompted the development of comprehensive anticoagulation management guidelines [7, 10, 23] by the medical profession. With new technological developments in arthroscopic procedures in recent years, VTE is becoming an ever-increasing concern, although there is limited and conflicting data on its prevalence and effective management. For instance, an incidence between 1.5 and 17.9 % [3, 5, 6, 8, 16, 29, 30] has been reported, and anticoagulation treatment is not usually prescribed by clinicians after arthroscopic surgery [10, 11, 29]. The American College of Chest Physicians does not recommend the use of anticoagulants unless other risk factors are present [1]; nonetheless, DVT is especially a problem for patients undergoing ligament reconstruction, with several reported fatalities from PE following arthroscopy [9, 18]. Due to the lack of reports about different cruciate ligament reconstruction operations and the service time of tourniquet, this study will focus on their influences on DVT occurrence rates to provide a reference for day-to-day clinical work.
Keywords Arthroscopic knee surgery · Cruciate ligament reconstruction · Deep venous thrombosis
Materials and methods Inclusion and exclusion criteria
Jiang-tao Dong and Xin Wang have contributed equally to this work. J. Dong · X. Wang · X. Men · X. Wang · X. Zheng · S. Gao (*) Department of Orthopaedics, Third Hospital of Hebei Medical University, Shijiazhuang 050051, China e-mail: [email protected]
Between 2009 and 2011, 282 patients were enrolled in the study who had undergone reconstruction of the anterior cruciate ligament (ACL), ACL combined with medial and/or lateral collateral ligament (MCL and/or LCL, respectively),
13
Table 1 General information on patients in this study
ACL anterior cruciate ligament, BMI body mass index, LCL lateral collateral ligament, MCL medial collateral ligament, PCL posterior cruciate ligament
Knee Surg Sports Traumatol Arthrosc Groups Tourniquet time (min) 120 Surgery type ACL ACL + MCL/LCL PCL PCL + MCL/LCL ACL + PCL Total
Number
BMI (kg/m2)
Gender (M/F)
90 94 98
33.1 35.6 34.2
64/26 56/38 65/33
23.4 22.4 22.6
152 47 46 17 20
34.9 37.4 32.5 33.1 32.5
91/61 36/11 29/17 13/4 16/4
22.6 24.5 21.1 25.2 26.5
282
34.7
185/97
22.8
posterior cruciate ligament (PCL), PCL combined with MCL and/or LCL, or ACL combined with MCL. The surgical procedure involved arthroscopic-assisted reduction of avulsion fractures of the tibial insertion of the ligament. Patients undergoing open reduction surgery for the fracture were excluded, as were patients older than 45 years with a body mass index (BMI) >30 kg/m2, who had preexisting conditions or were positive for DVT risk factors such as diabetes, oral contraceptive use, malignancy, cardiac insufficiency, a history of varicosities, or were receiving anticoagulant treatment prior to the surgery. General patient information The mean age (±standard deviation) of patients was 34.7 ± 10.1 years (185 male, 97 female), and mean BMI (±standard deviation) was 22.8 ± 2.9 kg/m2. Table 1 lists the type of surgery performed and no differences were found in the number, age, gender distribution, and BMI between groups. Diagnostic methods and standards Diagnoses were based on results from the color Doppler ultrasound. The first ultrasound was performed on patients within 24 h of admission to the hospital, and the second and third ultrasounds were performed 3 days preoperatively and 7 days postoperatively, respectively. In cases where DVT symptoms such as pain or swelling of the lower limbs were detected after the operation, an additional ultrasound was performed on the patient. Only one technician was responsible for taking all duplex ultrasound images and another independent radiologist read all of the images. Both deep and superficial venous thrombosis were studied through duplex ultrasound images, which is two dimensional with color flow to reach the veins in the affected leg. A venous Doppler analysis was also performed. Each vein was evaluated for intraluminal echoes and examined
13
Age (years)
Table 2 DVT incidence in relation to tourniquet application time and type of surgical procedure Number DVT (%) Tourniquet time (min) 120 98 Surgical procedure ACL 152 ACL + MCL/LCL 47 PCL 46 PCL + MCL/LCL 17 ACL + PCL
20
Relative risk (95 % CI)
5 (5.6 %) 1.00a 12 (12.8 %) 2.487 (0.839–7.371) 17 (17.4 %) 3.567 (1.258–10.117)* 11 (7.2 %) 6 (12.8 %) 8 (17.4 %) 4 (23.5 %)
1.00a 1.876 (0.654–5.381) 2.699 (1.041–7.180)* 3.944 (1.099–14.152)*
5 (25.0 %) 4.273 (1.308–13.956)*
ACL anterior cruciate ligament, CI confidence interval, DVT deep venous thrombosis, LCL lateral collateral ligament, MCL medial collateral ligament, PCL posterior cruciate ligament * Significant relative risk compared to the reference group a
Reference group
for DVT according to the following criteria: complete noncompressibility of a vein, absence of venous flow, or the presence of an echogenic thrombus mass in the normally anechoic vein. The Ethics Review Committee of Hebei Medical University approved this study and written consent was obtained from all of the participants. The IRB approval ID number is L200918—1. Surgical procedures and postoperative care All patients received either spinal or general anesthesia in the supine position during the surgery. After a knee examination was performed, a thigh tourniquet was used on the operated leg; this was deflated for procedures lasting longer than 120 min, and re-inflated 10 min later if necessary. For PCL or ACL reconstruction, the single-bundle technique combined with allograft or auto-hamstring tendon reconstruction was performed by the same surgeon. No
Knee Surg Sports Traumatol Arthrosc
anticoagulant drugs were provided to the patient postoperatively; instead, ice was applied with a compressive wrap for 20 min every 3–4 h for the first 24–48 h after the surgery to reduce swelling. Isotonic, progressively restrictive exercises for the quadriceps and hamstrings were begun 24 h after the operation. A non-weight-bearing hinged knee brace was provided during the hospital stay that allowed 30°–90° of motion. Statistical analysis Comparisons between different types of surgery and tourniquet application times were performed using a chi-square test. The relative risk of DVT was calculated using the lowest value for tourniquet time (i.e.,
KNEE
Incidence of deep venous thrombosis in Chinese patients undergoing arthroscopic knee surgery for cruciate ligament reconstruction Jiang‑tao Dong · Xin Wang · Xiao‑qian Men · Xiao‑feng Wang · Xiao‑zuo Zheng · Shi‑jun Gao
Received: 17 January 2014 / Accepted: 28 July 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose This study investigated the incidence of deep venous thrombosis (DVT) in patients undergoing arthroscopic cruciate ligament surgery. Methods A total of 282 patients were examined by color Doppler ultrasound preoperatively and 3 and 7 days postoperatively. Results DVT was present in 34 of 282 patients (12.1 %); of these, 11 (32.6 %) underwent reconstruction of the anterior cruciate ligament (ACL), alone or in conjunction with the medial or lateral collateral ligament (MCL or LCL, respectively; 17.6 %); eight (23.5 %) of the posterior cruciate ligament (PCL); four (11.8 %) of the PCL–MCL/LCL; and five (14.7 %) of the ACL–MCL. In patients with tourniquets applied for 120 min, the incidence of DVT was 5.6, 12.8, and 17.4 %, respectively. Conclusion The incidence of DVT in normal patients undergoing ACL surgery was 12.1 %. A higher incidence was observed among cases of multiligament reconstruction, especially those involving the PCL, as well as in patients with tourniquets applied for more than 2 h. Based on these findings, prophylactic measures for DVT may be considered after arthroscopic knee surgery in order to decrease the incidence of DVT if specific risk factors are present. Levels of evidence IV.
Introduction The high incidence of venous thromboembolism (VTE)— which includes deep venous thrombosis (DVT) and pulmonary embolism (PE)—in patients undergoing total hip or knee replacement is widely acknowledged and has prompted the development of comprehensive anticoagulation management guidelines [7, 10, 23] by the medical profession. With new technological developments in arthroscopic procedures in recent years, VTE is becoming an ever-increasing concern, although there is limited and conflicting data on its prevalence and effective management. For instance, an incidence between 1.5 and 17.9 % [3, 5, 6, 8, 16, 29, 30] has been reported, and anticoagulation treatment is not usually prescribed by clinicians after arthroscopic surgery [10, 11, 29]. The American College of Chest Physicians does not recommend the use of anticoagulants unless other risk factors are present [1]; nonetheless, DVT is especially a problem for patients undergoing ligament reconstruction, with several reported fatalities from PE following arthroscopy [9, 18]. Due to the lack of reports about different cruciate ligament reconstruction operations and the service time of tourniquet, this study will focus on their influences on DVT occurrence rates to provide a reference for day-to-day clinical work.
Keywords Arthroscopic knee surgery · Cruciate ligament reconstruction · Deep venous thrombosis
Materials and methods Inclusion and exclusion criteria
Jiang-tao Dong and Xin Wang have contributed equally to this work. J. Dong · X. Wang · X. Men · X. Wang · X. Zheng · S. Gao (*) Department of Orthopaedics, Third Hospital of Hebei Medical University, Shijiazhuang 050051, China e-mail: [email protected]
Between 2009 and 2011, 282 patients were enrolled in the study who had undergone reconstruction of the anterior cruciate ligament (ACL), ACL combined with medial and/or lateral collateral ligament (MCL and/or LCL, respectively),
13
Table 1 General information on patients in this study
ACL anterior cruciate ligament, BMI body mass index, LCL lateral collateral ligament, MCL medial collateral ligament, PCL posterior cruciate ligament
Knee Surg Sports Traumatol Arthrosc Groups Tourniquet time (min) 120 Surgery type ACL ACL + MCL/LCL PCL PCL + MCL/LCL ACL + PCL Total
Number
BMI (kg/m2)
Gender (M/F)
90 94 98
33.1 35.6 34.2
64/26 56/38 65/33
23.4 22.4 22.6
152 47 46 17 20
34.9 37.4 32.5 33.1 32.5
91/61 36/11 29/17 13/4 16/4
22.6 24.5 21.1 25.2 26.5
282
34.7
185/97
22.8
posterior cruciate ligament (PCL), PCL combined with MCL and/or LCL, or ACL combined with MCL. The surgical procedure involved arthroscopic-assisted reduction of avulsion fractures of the tibial insertion of the ligament. Patients undergoing open reduction surgery for the fracture were excluded, as were patients older than 45 years with a body mass index (BMI) >30 kg/m2, who had preexisting conditions or were positive for DVT risk factors such as diabetes, oral contraceptive use, malignancy, cardiac insufficiency, a history of varicosities, or were receiving anticoagulant treatment prior to the surgery. General patient information The mean age (±standard deviation) of patients was 34.7 ± 10.1 years (185 male, 97 female), and mean BMI (±standard deviation) was 22.8 ± 2.9 kg/m2. Table 1 lists the type of surgery performed and no differences were found in the number, age, gender distribution, and BMI between groups. Diagnostic methods and standards Diagnoses were based on results from the color Doppler ultrasound. The first ultrasound was performed on patients within 24 h of admission to the hospital, and the second and third ultrasounds were performed 3 days preoperatively and 7 days postoperatively, respectively. In cases where DVT symptoms such as pain or swelling of the lower limbs were detected after the operation, an additional ultrasound was performed on the patient. Only one technician was responsible for taking all duplex ultrasound images and another independent radiologist read all of the images. Both deep and superficial venous thrombosis were studied through duplex ultrasound images, which is two dimensional with color flow to reach the veins in the affected leg. A venous Doppler analysis was also performed. Each vein was evaluated for intraluminal echoes and examined
13
Age (years)
Table 2 DVT incidence in relation to tourniquet application time and type of surgical procedure Number DVT (%) Tourniquet time (min) 120 98 Surgical procedure ACL 152 ACL + MCL/LCL 47 PCL 46 PCL + MCL/LCL 17 ACL + PCL
20
Relative risk (95 % CI)
5 (5.6 %) 1.00a 12 (12.8 %) 2.487 (0.839–7.371) 17 (17.4 %) 3.567 (1.258–10.117)* 11 (7.2 %) 6 (12.8 %) 8 (17.4 %) 4 (23.5 %)
1.00a 1.876 (0.654–5.381) 2.699 (1.041–7.180)* 3.944 (1.099–14.152)*
5 (25.0 %) 4.273 (1.308–13.956)*
ACL anterior cruciate ligament, CI confidence interval, DVT deep venous thrombosis, LCL lateral collateral ligament, MCL medial collateral ligament, PCL posterior cruciate ligament * Significant relative risk compared to the reference group a
Reference group
for DVT according to the following criteria: complete noncompressibility of a vein, absence of venous flow, or the presence of an echogenic thrombus mass in the normally anechoic vein. The Ethics Review Committee of Hebei Medical University approved this study and written consent was obtained from all of the participants. The IRB approval ID number is L200918—1. Surgical procedures and postoperative care All patients received either spinal or general anesthesia in the supine position during the surgery. After a knee examination was performed, a thigh tourniquet was used on the operated leg; this was deflated for procedures lasting longer than 120 min, and re-inflated 10 min later if necessary. For PCL or ACL reconstruction, the single-bundle technique combined with allograft or auto-hamstring tendon reconstruction was performed by the same surgeon. No
Knee Surg Sports Traumatol Arthrosc
anticoagulant drugs were provided to the patient postoperatively; instead, ice was applied with a compressive wrap for 20 min every 3–4 h for the first 24–48 h after the surgery to reduce swelling. Isotonic, progressively restrictive exercises for the quadriceps and hamstrings were begun 24 h after the operation. A non-weight-bearing hinged knee brace was provided during the hospital stay that allowed 30°–90° of motion. Statistical analysis Comparisons between different types of surgery and tourniquet application times were performed using a chi-square test. The relative risk of DVT was calculated using the lowest value for tourniquet time (i.e.,
