Deep Vein Thrombosis In Orthopedic Surgery: Deep Vein Thrombosis In Orthopedic Surgery Dr Zameer Ali orthopaedics 1 Slide 2: 2 THE PRESENCE OF THROMBUS WITHIN A DEEP VEIN OF THE EXTREMITY IS TERMED DEEP VENOUS THROMBOSIS DVT IS A COMMON CLINICAL PROBLEM THAT COMPLICATES MANY MEDICAL AND SURGICAL DISORDERS Overview: Overview Venous thrombosis is an important cause of morbidity and mortality One out of four patients hospitalised for medical conditions is known to develop VTE Responsible for 300,000–600,000 hospitalisations in the USA alone each year PE is potentially the most serious complication of VTE Thrombus Migration Embolus Int Angiol 1997; 16: 3 – 38. Pathology: 4 Pathology Virchow’s Triad Hypercoagulability Endothelial injury Venous flow disturbance (stasis or turbulence) DVT in India – An Under Recognised Condition: DVT in India – An Under Recognised Condition Incidence of DVT in Indian patients is as common as elsewhere 41.4% of the DVT patients were asymptomatic Because of the silent nature of the disease and low autopsy rates, prevalence and mortality rates of VTE remain elusive *Ind J. Surg 2003; 65 (2):159-62, Ind J. Ortho # Ind J. Orth o; 37 (2) two thirds with symptomatic VTE manifest deep vein thrombosis (DVT) Why lack of Data in Indian Setting ?: Why lack of Data in Indian Setting ? Autopsy data are the basis for most estimates of the frequency of death due to pulmonary embolism. But unfortunately such data is not available in India, thus masking the prevalence of VTE in India The true incidence of postoperative DVT and its pattern of distribution in Asian and Indian patients in not well highlighted There has not been a systematic study to detect the incidence of DVT prophylaxis in India Arch Intern Med . 1991; 151:933-938 Indian Journal of Surgery 2003; 65(2):159-16 Ind Jour of Crit Care Med 2003; 7(2):105 How will Indian data help DVT Patients?: How will Indian data help DVT Patients? Arch Intern Med . 1991; 151:933-938 It would help create an awareness on the serious aspects of DVT care Western data do not obviously reveal the burden of disease in an Indian setting Awareness of disease would generate interest in the disease Interest on the disease would leverage appropriate action towards DVT prophylaxis Reduction in the incidence of DVT among Indian patients Risk FACTORS FOR DVT AND PUL. EMBOLISM (Hirish J, Dalen Guyatt ACCP chest 2001) : 8 Risk FACTORS FOR DVT AND PUL. EMBOLISM (Hirish J, Dalen Guyatt ACCP chest 2001) Trauma History of DVT Age > 40 Prolonged Immobility CVA CHF Surgery (especially orthopedic or pelvic) Fracture of LE or pelvis Venous catheters Pregnancy or recent delivery Obesity Estrogen Therapy Inflammatory disorders (vasculitis, IBD, SLE) Cancer Genetic/acquired thrombophilia Slide 9: 9 DVT In Orthopaedic DVT is one of one of the most common complication of total hip arthroplasty The use of cemented implants has been found to promote the occurrence of DVT as well. ( kops chan Wfi j bone joint surg am 2002) Significance of Deep Vein Thrombosis lies in its ability to cause pulmonary thrombo embolism (especially in cases of proximal Deep Vein Thrombosis – 2 to 3 %) and chronic venous insufficiency ( thomas dp whitherj bone joint surg 2000 ) Slide 10: 10 Calf thrombi (distal venous thrombosis) carry a low risk of embolisation and chronic venous insufficiency at later stages However without prophylaxis, calf thrombi are more likely to propagate proximally which substantially increases the risk of pulmonary embolism Slide 11: 11 A study by Kim and Suh in 1988 found that 10% of 146 Korean patients who underwent non cemented Total Hip Arthroplasty had Deep Vein Thrombosis (J Bone Joint Surg Am, 1988) Atichartakarn et al did not find any cases of Deep Vein Thrombosis in study of 19 Thai Total Hip Arthroplasty patients (Arch Intern Med, 1988) Slide 12: operation Asian patient Western patient THR 17% 45-57 TKR 43 40-84 HFS 24 36-60 Jbjs 2002vol 39(7) Results from Indian Orthopedic Patients: In J Orth. 2003; 37(2) Incidence of DVT in Indian patients is as common as elsewhere 41.4% of the DVT patients were asymptomatic NO LMWH LMWH I* LMWH II + LMWH III # THR 42.8% 23.1% 27.1% 7.1% TKR 72.7% 50.0% 36.4% 18.2% IT NF 71.4% 45.1% 0% 4.9% Total 60.0% 43.2% 34.4% 7.8% Results from Indian Orthopedic Patients Multicentric study : Orthopedic Surgery: Multicentric study : Orthopedic Surgery In one of the first observations of it’s kind in the country, St Johns Hospital, Bangalore; recorded an incidence of 28% for DVT. (1997-98) Patients with recent surgery has a 22-fold increased risk of VTE In the absence of prophylaxis, about 50% of hip replacement patients and over 60% of knee replacement patients develop DVT In J Orth. 2003; 37(2) Risk of Deep Vein Thrombosis after major Orthopaedic surgery: 15 Risk of Deep Vein Thrombosis after major Orthopaedic surgery The highest risk of occurrence of DVT has been reported to be on the fourth postoperative day and second highest on 13TH day The highest risk of fatal pulmonary embolism occurs in second week and risk is supposed to remain there until approximately 3 months after surgery Slide 16: 16 The incidence of Deep Vein Thrombosis in non operated leg is about 20% (Hirish H Dalen J Guyatt g 2000 ACCP) After performing Total Hip Arthroplasty without prophylaxis the incidence of Deep Vein Thrombosis is 40% to 70% Proximal Deep Vein Thrombosis is 10 % to 20 % Clinical DVT is 1% to 2 % Non fatal symptomatic pulmonary embolism is 1% to to 2 % fatal pulmonary embolism is 0.1% to 1 % Slide 17: 17 Although the incidence of Deep Vein Thrombosis is very high that of proximal Deep Vein Thrombosis is low and that of fatal pulmonary embolism is very rare ( Bertina Pm Piletich hennekens CH JAMA 1997) Slide 18: 18 Sex: The male-to-female ratio is 1.2:1. Age: DVT usually affects individuals older than 40 years. Slide 19: 19 DVT of the lower extremity usually begins in the deep veins of the calf around the valve cusps or within the soleal plexus. A minority of cases arise primarily in the ileofemoral system as a result of direct vessel wall injury, as seen with hip surgery or catheter-induced DVT. Signs of DVT: 20 Signs of DVT Tenderness along the course of vein Warmth or erythema of skin can be present Clinical signs and symptoms of pulmonary embolism as the primary manifestation occur in 10% of patients with confirmed DVT. HOMAN’S SIGN: 21 HOMAN’S SIGN Pain occurs on dorsiflexion of the foot Another study states Homan sign as unreliable with its presence in only 8-30 % cases of symptomatic patients harboring DVT Moses’ sign: 22 Moses’ sign Tenderness elicited by squeezing or presenting firmly on sole of foot or calf Phlegmasia cerulea dolens: Phlegmasia cerulea dolens Patients with venous thrombosis may have variable discoloration of the lower extremity. The most common abnormal hue is reddish purple from venous engorgement and obstruction. In rare cases, the leg is cyanotic from massive ileofemoral venous obstruction. This ischemic form of venous occlusion was originally described as phlegmasia cerulea dolens or painful blue inflammation. The leg is usually markedly edematous, painful, and cyanotic. Petechiae are often present. 23 Slide 24: 24 Slide 25: 25 Stulberg et al found that symptoms for DVT are not reliable in diagnosing DVT Following conditions may mimic deep vein thrombosis - Abcesses bakers cyst Cellulitis Claudication musculoskeltal injury venous stasis Investigations: 26 Investigations D- dimer Contrast venography Duplex ultrasonography Impedance plethysmography MRI Nuclear medicine imaging studies Duplex ultrasonography: 27 Duplex ultrasonography Technological advances in ultrasonography have permitted the combination of real-time ultrasonographic imaging with Doppler flow studies (duplex ultrasonography). Slide 28: 28 Sensitivity of duplex ultrasonography for proximal vein Deep Vein Thrombosis is 97% but only 73% for calf vein Deep Vein Thrombosis. Slide 29: 29 The primary disadvantage of duplex ultrasonography is its inherent inaccuracy in the diagnosis of calf vein thrombosis. Venous thrombi proximal to the inguinal ligament are also difficult to visualize. Nonoccluding thrombi may be difficult to detect. Impedance plethysmography: 30 Impedance plethysmography Plethysmography is derived from the Greek word meaning "to increase." This procedure is based on recording changes in blood volume of an extremity, which are directly related to venous outflow. Slide 31: 31 Standardized graphs are used to discriminate normal IPG study results from abnormal results. Contrast venography: 32 Contrast venography For many reasons, including allergic reactions, contrast-induced Deep Vein Thrombosis noninvasive studies have essentially replaced venography as the initial diagnostic test of choice. D-dimer: 33 D-dimer Recent interest has focused on the use of D-dimer in the diagnostic approach to Deep Vein Thrombosis D-dimer has high sensitivity but low specificity D-Dimer levels remain elevated in Deep Vein Thrombosis for about 7 days. Slide 34: 34 D-Dimer results should be used as follows: A negative D-dimer assay rules out Deep Vein Thrombosis in patients with low-to-moderate risk All patients with a positive D-dimer assay and all patients with a moderate-to-high risk of Deep Vein Thrombosis require a diagnostic study (duplex ultrasonography). MRI: 35 MRI MRI is the diagnostic test of choice for suspected iliac vein or inferior vena caval thrombosis. In suspected calf vein thrombosis, MRI is more sensitive than any other noninvasive study. Preventive strategies: Preventive strategies Mechanical Early ambulation Sequential compression devices (inflatable stockings worn on legs) Vena Cava (main abdominal and chest vein) filters: small wire cages in vena cava to prevent PE Chemical Heparin: ‘blood thinner’ anticoagulant Coumadin: daily pill anticoagulant 36 : We are conducting a study in deptt. of orthopedics in st Stephens to look for prevalence of DVT in peri articular hip and knee fractures and surgeries from Nov 2008 Till now we have studied 35 patients in our study and 3 patients have been diagnosed to be having deep venous thrombosis in post operative period and have been put on treatment 37 STASTICS: STASTICS DIAGNOSIS MALE FEMALE NOF # 5 9 IT # 7 12 TIBIAL PLATEAU # 1 RH ARTHRITIS 1 Slide 39: Out of 35 pat. Studied, 22 were females and 13 were males 9 females were in age group of 50 –70 years and had fracture NOF and had been operated in form of hemiarthroplasty 12 females in age group of 40- 60 years had inter trochanteric fracture and had undergone DHS 1 Female had Rh arthritis knee and treated by TKR 39 Slide 40: 7 males had IT # and were treated by DHS 5 males had # NOF and were treated by hemiarthroplasty 1 male had tibial plateau # and was treated by cancellous screw fixation Slide 41: 8males in age group 40 /60 had intertrochanteric fracture treated in form of dynamic hip screws 3males were in age group 60 –80 years and had neck of femur fracture and were operated in form of hemiarthroplasty 1 male patient was operated in form of total hip replacement 41 Results : Results 2 females with fracture NOF who were diagnosed to be having DVT all had DVT IN POPLITEAL VEIN AND there were no clinical signs or symptoms persistent with DVT One female who was having #nof was diagnosed to have DVT in pre op and hence surgery was deferred and patient was put on treatment All were diagnosed with venous Doppler/d Dimer All 3 patients had D DIMER values in range of 800- 2000ng/dl Slide 43: As of now now no conclusion can be made as number of patients in study are less But we had no evident clinical case of pul embolism 3 patients had dvt and that too were diagnosed on venous doppler and d dimer reports as there were no clinical signs and symptoms 43 Sushila devi NOF # OPPOSITE LEG DVT: Sushila devi NOF # OPPOSITE LEG DVT DOPPLER IMAGE SHOWING POPLITEAL VEIN BLOCKAGE: DOPPLER IMAGE SHOWING POPLITEAL VEIN BLOCKAGE Slide 47: Thanks……..