Disputed Use of Routine Ultrasound Screening in Total Knee Arthroplasty Patients

Editor’s note: The following letter is in response to an article published in the February 2018 issue of AAOS Now titled “Preventing VTE After Elective TJA.” Letters to the editor are encouraged; please send correspondence to aaoscomm@aaos.org.

I applaud author Antonia F. Chen, MD, MBA, for denouncing the use of routine ultrasound screening (US) of primary total joint arthroplasty (TJA) patients because it neither reduces the rate of symptomatic pulmonary embolism (PE) nor prevents the overzealous anticoagulation of superficial thromboses.

However, I disagree with her statement that “the use of mechanical compression with or without pharmacologic intervention is encouraged. Studies have not shown whether these strategies affect rare, but critical, medical concerns such as mortality (i.e., fatal PE) or symptomatic deep vein thrombosis (DVT) or PE.”

My concern is that multimodal problem-solving instituted through integrated clinical pathways to combat venous thromboembolism will be diminished in the readers’ minds. Our randomized, controlled trial that multimodal problem-solving, implemented through a robust integrated clinical pathway, demonstrated 100 percent prevention of DVT in low-risk total knee arthroplasty (TKA) patients. We used a tourniquet-less surgical technique, aspirin twice daily, and a mechanical compression device (MCD). In our group, 80 percent compliance with the MCD was achieved for at least three weeks after surgery.

For the past five years, in more than 1,000 consecutive low-risk DVT TKA cases, the rate remains at zero percent. Extended MCD use was provided in all cases. US was never utilized outside of the study patients. Therefore, I both agree and disagree with Dr. Chen: Do not use routine US surveillance, but always rely on extended use of MCDs in low-risk TKA patients who are also protected with at least four weeks of twice-a-day low-dose aspirin, tourniquet-less technique, and rapid mobilization. Avoid the cost and complications too frequently associated with stronger anticoagulants and treatment obligated by findings from routine US screening.

References

  1. Snyder MA: Eliminate adverse events with integrated clinical pathways. AAOS Now. March 2018. Available at: https://www.aaos.org/AAOSNow/2018/Mar/Clinical/clinical01/. Accessed September 10, 2019.
  2. Snyder MA, Sympson AN, Scheuerman CM, et al: Efficacy in deep vein thrombosis prevention with extended mechanical compression device therapy and prophylactic aspirin following total knee arthroplasty. J Arthroplasty 2017;32:1478-82.
  3. Parvizi J, Huang R, Rezapoor M, et al: Individualized risk model for venous thromboembolism after total joint arthroplasty. J Arthroplasty 2016;31:s180-6.
  4. Parvizi J, Huang R, Restrepo C, et al: Low-dose aspirin is effective chemoprophylaxis against clinically important venous thromboembolism following total joint arthroplasty. J Bone Joint Surg Am 2017;99:91-8.

Mark A. Snyder, MD, FAOA, is medical director of the Orthopaedic Center of Excellence at the Good Samaritan Hospital in Ohio. He can be reached at markasnydermd@gmail.com.

Advertisements


Advertisement