FEATURES OF THROMBOEMBOLIC COMPLIATIONS AFTER KNEE JOINT REPLACEMENT
Vlasova I.V., Vlasov S.V., Milyukov A.Yu., Tsuryupa V.N.
Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia
One of the main tasks in orthopedics
and traumatology is treatment of diseases and damages of big joints, with knee
osteoarthrosis deformans, which consists almost a quarter of them (24.7 %). It
causes the primary disability in 31.2 % of all pathologic states of the
locomotor system [1, 2]. Endoprosthesis replacement is a highly efficient
technique normalizing the function of an injured joint and correcting the pain
syndrome [1].
As any extensive orthopedic surgery, knee joint replacement (KJR) can
cause some complications [3]. Deep venous thrombosis (DVT) is one of them. High
invasiveness of the intervention, blood loss, use of bone cement, and high
comorbidity according to data of the normogram and ASA (the classification of
the objective status of American Society of Anesthesiologists) are the promoting
factors of clot formation. Besides, the features of a surgical intervention, i.e.
forced attitude of the extremity during surgery (flexion), results in temporary
disorder of venous outflow from the extremity. All above-mentioned factors
determine the high risk of DVT in KJR, which 1.5-2 times higher than the risk
in hip replacement [4].
The rate of thrombotic complications
of KJR is quite variable in various clinics, and varies within 9-64 % according
to the studies. Thromboembolic complications worsen the treatment outcomes,
lengthen the hospital stay, increase the financial costs and can cause
pulmonary embolism [1-5]. The use of various measures for prevention is
directed to decrease in complications [3-7]. Therefore, the problem of timely
and qualitative diagnostics of DVT in patients after KJR is important.
Ultrasonic duplex scanning (DS) with
color doppler mapping is widely used in clinics [8-12]. Sensitivity and
specificity of the technique for diagnosis of proximal thrombosis is high and
reaches 98-100 %. The deep veins of the leg are difficult to examine. The
sensitivity of DS in identification of venous thrombosis of the leg varies from
60 to 90 % according to various data.
The difficulties of examination of
the veins of the leg are mainly determined by their anatomical features. Deep
veins of the leg are the paired posterior tibial veins (PTV) and the anterior
tibial veins (ATV) (which form the popliteal vein), fibular veins (FV) and
sural veins. The number of the veins varies from 2 to 4 around the same-name
artery. Also the system of anastomoses of all veins of the leg and between the
superficial and deep venous network is quite developed and variable. Sural
veins (SV) present the high interest too. They are the muscular venous sinuses
in the thickness of sural and soleus muscles, which play the important role in
pathogenesis of chronic venous insufficiency [13, 14]. The diameter of SV is
quite variable: from big (> 1 cm) to small (Fig. 1). However proper scanning
in various planes with use of color and energetic mapping, and B-flow mode
allow achieving the visualization of the veins of the leg in approximately 90 %
of cases [15].
Figure 1. Muscular venous
sinuses of the leg in longitudinal and transverse scanning of gastrocnemius
muscle.
The objective of the study was identification of
the features of the thrombotic process and the protocol for examining the
patients after total KJR.
MATERIALS AND METHODS
The examination included 570 patients
after total knee joint replacement in 2014-2017 in the Regional Clinical Center
of Miners’ Health Protection. There were 442 women and 128 men. The mean age was 64 (47-79).
The study was conducted according to World
Medical Association Declaration of Helsinki – Ethical Principles for Medical
Research Involving Human Subjects, 2013, and the Rules for clinical practice in
the Russian Federation (the Order by the Russian Health Ministry, June 19,
2003) with the written consent for participation in the study and approval from
the local ethical committee of the center (the protocol No.3, February 15,
2018). Low molecular weight heparin (fraxiparine, 0.3 mg/day, clexane, 0.2
mg/day) was prescribed for prevention of thrombotic complications for all
patients 10-12 hours after surgery. Aspirin and trental were used from the
second day. Non-specific prevention included the use of compression knitwear.
The physical rehabilitation with remedial gymnastics and early activation of
the patients were conducted. Warfarin was prescribed with the dosage of 5
mg/day.
DS of magistral vessels of the lower
extremities was conducted with the expert ultrasonic system MyLab Class (Esaote,
Italy). For exclusion of the thrombotic process, the examination was conducted
before the surgery and on the days 2-3 after KJR. If any thrombotic
complications were found, the examination was repeated each 2-3 days.
The patients were examined in horizontal
supine position. Considering the impossibility of changing the position, the
popliteal veins were examined with slight flexion of the extremity in the knee
joint and abduction of the extremity to the outside. The major problems
appeared in scanning of the veins of the leg. During the first day after
surgery, all patients demonstrated the evident edema of soft tissues in the periarticular
region and in the leg. In some cases, edema compressed the veins and caused the
impossibility of their visualization. Besides, many patients (mainly, the
women) had the excessive body weight. Thick subcutaneous fat tissue in the legs
impeded the visualization too.
The techniques promoting the venous
visualization were used for negotiating these problems. The extremity was
positioned with support to the foot (or the heel) with slight flexion in the
knee joint. At that, the maximal relaxation of the leg muscles was achieved. In
this position, the proper transverse sliding scanning with use of intensive
compression with the transducer for each centimeter of sliding was carried out.
The transducer was moved from the popliteal region downwards along the
posteriomedial or posteriolateral surface of the leg. The medial and lateral sural
veins and proximal PTV were visualized. Then proper scanning along the medial
surface from the ankle joint to the popliteal region was conducted. Therefore,
PTV and SV were examined in the muscles at the level of the middle and upper
one-third. FV were visualized with this approach in some patients, but FV compression
could not be full in all cases due to high deepness of the muscles. For this
reason, the study with color mapping did not lead to full staining of the
veins, resulting in a possibility of a false positive result. Therefore, the
examination of FV was repeated from the lateral approach. The best
visualization of FV was achieved in transverse scanning along the lateral
surface of the leg at the level of the middle one-third. During the compression
tests, it was efficient to use the back pressure by the hand to the leg muscles
from the opposite site. The final decision on venous patency was made on the
basis of transverse scanning, when the venous lumen and a degree of its
compression were evident.
The strict adherence to the algorithm gives the satisfactory
visualization of all veins of the leg in most cases.
RESULTS
The thrombotic complications were identified in 103 patients (18 %) (the table).
Table. Distribution of patients according to location of venous thrombosis
Incidence of thrombosis |
Amount of patients |
% |
All leg veins and popliteal vein |
4 |
3.9 |
Posterior tibial, fibular and sural veins |
6 |
5.8 |
Posterior tibial and sural veins |
10 |
9.7 |
Posterior tibial and fibular veins |
2 |
0.3 |
Posterior tibial veins |
24 |
23.3 |
Isolated thrombosis of sural veins |
57 |
55 |
The thrombotic process was limited by the veins of the leg in almost all cases. Thrombosis extended to the popliteal veins in 4 cases only. The thrombotic process was extensive, with affection of PTV, FV and SV, in 6 patients (Fig. 2).
Figure 2. Occlusive masses in fibular veins in extensive
thrombosis of leg veins
Therefore, DVT with
significant disorder of outflow from the leg was found in only 9.7 % of all
thrombosis (10 patients).
DVT was not extensive in
all other cases. In thrombosis of only PTV (24 patients) and in combination of
thrombosis of PTV and SV (10 patients), the feature was a lesion of one of the
paired veins or non-occlusive pattern of the process. The veins were often clotted
in the middle and proximal one-third of the leg with normal patency in the
distal one-third. Satisfactory outflow was from the leg in the paired patent
veins and in the anastomoses with other veins of the leg.
A half of all cases of DVT included
thrombosis of only muscular venous sinuses. DS showed some hypoechogenous or isoechoic
spindle-shaped structures, with absence of compression, without blood flow
inside or with weak parietal flow in distal compression. The thrombotic process
was limited by sinuses, without extension to SV entries (Fig. 3).
Figure 3. Occlusive thrombosis of sural veins
SV thrombosis was without any
clinical manifestations, and without pain in compression by the transducer
during the examination.
Active anticoagulant therapy was
prescribed (fraxiparine, 0.6-0.9 mg/day, clexane, 0.4 mg/day) with shift to
warfarin (5 mg) and achievement of the targeted value of INR of 2-3, with
continuation of therapy up to 3-6 months at the outhospital stage. The compression knit-wear was used.
Over the time, DS did not show any
progression of the process in any cases. Some signs of repatency were
identified by the end of the week in all cases of thrombosis of PTV and FV. The
blood flow in the distal part of the leg in the region of perforants recovered
with the highest rate.
The time course in isolated
thrombosis of SV showed two variants. In most cases, the vein decreased in the
diameter due to retraction of a clot, but the occlusive process was persistent
during the whole period of hospital stay. In rare cases, the process of
repatency in view of slight parietal blood flow appeared in distal compression
of the leg (Fig. 4).
Figure 4. Initiation of recanalization in sural veins
The dynamic observation was continued after hospital discharge. DS was repeated one month later. Ascendant thrombosis was not identified in any cases. The process of repatency in PTV and FV was active. Some residual events such as incomplete compression of the vein and valvular insufficiency were found. Venous obliteration happened in SV thrombosis. One month later, it was impossible to differentiate the vein from the surrounding tissue in most cases.
DISCUSSION
KJR is associated with high risk of
thrombotic complications. DVT was identified in 18 % of the operated patients.
Despite of the limited amount of cases of DVT, 90 % of the cases had the
limited pattern. A half of cases of thrombosis located in only muscular venous
sinuses, without distribution to the magistral veins. SV thrombosis can be the
beginning of extensive thrombotic process that we could observe on the regular
basis, for example in critically ill patients with polytrauma and long term
immobilization. Therefore, it is not acceptable to ignore these measurements
despite of their local pattern.
Timely therapy after identification
of the thrombotic process resulted in active venous recanalization, without
cases of progression of the complication.
The outflow from SV highly depends on
normal activity of the muscular-venous pump. The velocity of blood though SV is
very slow at rest, and the possibility of stasis with clot formation is high.
Long term intrasurgical flexion of the extremity disorders the venous outflow,
and SV are most vulnerable. It explains the fact of lesion of SV in 77 of 103
(74.7 %) cases.
Monitoring of thrombotic
complications in extensive orthopedic operations is common during almost 20
years in our clinic. The analysis of complications in 2008-2009 has shown the
high rate of venous thrombosis in the lower extremities. It resulted in necessity
of analyzing the causes. The arresting bleeding tourniquet for prevention of
intrasurgical blood loss was shown as one of the provoking factors of clotting
in KJR. Refusal from the tourniquet and the decrease in time of surgery
decreased the amount of thrombotic complications from 19 to 9.5 % [11]. However
the protocol of the ultrasonic examination included only the magistral veins of
the leg (PTV, ATV, FV). The accumulated experience and the use of high
resolution ultrasonic scanners caused the revision and clarification of the
examination volume. Obligatory examination of all veins, which are available for
visualization (including muscular venous sinuses resulted in almost two-fold
increase in the rate of thrombotic complications as compared to achieved 9.5 %,
but determined the true picture of postsurgical condition of the venous system
[16].
Ultrasonic diagnosis specialists often do not conduct the full volume of
examination of the veins of the leg. It is associated with difficulty of
identification of all deep veins that is determined by various variants of
connection and significant increase in time of estimation. The studies showed
that DS protocol for estimation of muscular and fibular veins could decrease
the amount of false-negative outcomes in DVT by 64 and 15 % correspondingly [8,
16].
CONCLUSION
1. Thrombotic complications in KJR
were identified in 18 % of cases. A half of the cases were local thrombosis of
muscular venous sinuses of the leg that were possibly associated with specific
position of the extremity during surgery, resulting in temporary disorder of
venous outflow from the leg.
2. The feature of thrombotic
complications of KJR is the process limited by the veins of the leg, non-severe
pattern of thrombosis, preservation of sufficient outflow from the leg through
passable paired veins in most cases, active recanalization of the veins in timely
therapy.
3. The examination protocol with duplex scanning for patients after KJR
should include the examination of muscular venous sinuses and fibular veins.
Information about financing and conflict of interests
The study was conducted without
sponsorship.
The authors declare the absence clear and potential conflicts of
interests relating to publication of this article.
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