Are There Clinical Meaning on Asymptomatic Pulmonary Embolism After Total Knee Arthroplasty?

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1 Are There Clinical Meaning on Asymptomatic Pulmonary Embolism After Total Knee Arthroplasty? * 1,2 ATSUSHI SATO, MD, PhD, * 1,2 Takayuki Koya, * 2,3 Hiroshi Takagi, * 2 Jun Oike,, * 2 Saki Yagura, * 2 Takayuki Okumo, * 2 Naoki Okuma, * 2 Shin Kato, * 2 Masahiko Maekawa, * 2 Fumiyoshi Kawashima, * 2 Soshi Asai, * 1,3 Yushi Hoshino and * 1,3 Kazunari Tomita. * 1 Department of Orthopedic Surgery, Showa University Koto Toyosu Hospital, Tokyo. * 2 Department of Orthopedic Surgery, Showa University Fujigaoka Hospital, Yokohama. * 3 Department of Orthopedic Surgery, Showa University School of Medicine, Tokyo.

2 Atsushi Sato, MD, PhD I have no financial conflicts to disclose.

3 Abstract Total knee arthroplasty (TKA) is one of the most successful surgeries to relieve pain and dysfunction caused by severe arthritis. However, it is still debated that there is a necessity on anticoagulant for Deep vein thrombosis (DVT) and pulmonary embolism (PE) after TKA. Therefore, we prospectively investigated the incidence of DVT/PE after primary TKA by contrast enhanced computed tomography (CE-CT) and venous ultrasonography (US) in Japanese Patients. (Methods) One hundred and fourteen patients who underwent primary TKA from January 2015 to June 2016 were applied. The mean age was 75.0 years and average BMI was There were 105 cases of osteoarthritis and 7 of rheumatoid arthritis. A single knee surgery team performed all operations with cemented type prostheses. There were 47 cases of one-staged bilateral TKA and 67 of unilateral TKA. CE-CT and venous US were performed at the 4th day after surgery. These images were read by a single senior radiologist team. (Results) CE-CT was performed in 90 patients (78.9%) and US was in all patients. The incidence of DVT was 63 patients (55.2%) and asymptomatic PE was 11 patients (9.6%). Then we compared the incidence between one-staged bilateral TKA group and Unilateral group. DVT was 30 (63.8%) and 33 (49.2%) respectively. Asymptomatic PE was eight (17.0%) and three (4.4%) respectively, and there was significant difference on the incidence between two groups. (Conclusion) We prospectively investigated 114 patients for DVT/PE after primary TKA using CE- CT and venous US. There was significant difference on the incidence of asymptomatic PE between one-staged bilateral TKA group and Unilateral group. Thus, using CE-CT should be taken into account to investigate asymptomatic PE at least for the patients who undertake bilateral TKA.

4 Patients Patients and Methods Primary TKA 114 patients (161 TKAs) from Jan 2015 to June All were of Japanese ethnicity. One-staged Bil. TKA 47, Uni. TKA 67. Patients demographics are in Table 1. Surgical procedures General anesthesia with femoral nerve block. Cemented type prostheses. A pneumatic tourniquet was applied.

5 Thromboprophylaxis Protocol Physical prophylaxis Weight bearing gait ex ROM ex. IPC GCS Contrast enhanced CT Venous ultrasonography Exclusion criteria for CE-CT Renal dysfunction (egfr<50 ml/min/1.73m 2 ) History of bronchial asthma Allergy for contrast medium TKA POD Edoxaban Chemical prophylaxis DVT/PE ( ) Continue chemical thromboprophylaxis DVT (+) Continuous heparin administration and warfarin PE (+) UCG, Consultation with cardiologist to treat for PE IPC: intermittent pneumatic compression GCS: graduated compression stockings

6 List of Investigation The rate of conducted contrast enhanced CT and venous US. The rate of DVT/PE after primary TKA The difference of the DVT/PE rate between bilateral and unilateral TKA.

7 Results 1

8 Results 2 There was no statistical difference in patients demographics between the two groups.

9 Results 3

10 Discussion 1 The incidence of DVT after primary TKA in Japanese. Piovella Fq et al. DVT (58.1%) in Asian patients Western countries. J Thromb Haemost Kanchanabat B. et al. Symptomatic DVT 42.5% (venography), 9.5% (ultrasonography) in Asian patients < Western. Systematic review and meta-analysis Br J Surg.2011 Lee WS. et al. Overall DVT 40.4%, symptomatic DVT 1.9% in Asians. Meta-analysis Clin Orthop Relat Res.2013 Our study showed high incidence (55.2%) of DVT in Japanese patients by careful examination. It can suggest that the incidence of DVT is equivalent to the Western.

11 Discussion 2 The incidence of PE after primary TKA in Japanese. Guidelines PE 1% (fatal PE 0.1%) after primary TKA. Allen C. et al. PE 3.5% by computer tomography pulmonary angiography (CTPA). Review N Z Med J Goel R. et al. Symptomatic PE 1.0% (Aspirin use) -2.2% (Warfarin use). Bone Joint J Our study showed high incidence (9.6%) of asymptomatic PE. It was very effective to detect asymptomatic PE by CE-CT, but it is debatable that it is necessary for all patients to be applied the exam.

12 Discussion 3 The incidence of DVT/PE compared between bilateral TKA and unilateral TKA Levy YD et al. DVT 6(10.9%), PE 2(3.6%) in bilateral TKA vs. DVT 9(3.1%), PE 0% in unilateral TKA. J Arthroplasty Yeager AM et al. PE 1.87% bilateral TKA vs. 0.61% unilateral TKA (p<0.001) J Arthroplasty Goel R. et al. Risk of PE 204% higher Simultaneous bilateral TKA relative to unilateral TKA. Bone Joint J In this study, higher incidence of asymptomatic PE in bilateral TKA (17.0% vs 4.4% unilateral TKA) was also detected by CE-CT. We have to consider CE-CT at least for bilateral TKA patients.

13 Limitation We could not perform CE-CT in all patients and not follow up all detected DVT/PE by image procedures.

14 Conclusion We prospectively investigated the incidence of DVT and PE after primary TKA using contrast enhanced CT and venous US in Japanese patients. Our study shows that the incidence of DVT is 55.2% and 9.6% of PE. There was significant difference in the incidence of asymptomatic PE between bilateral TKA (17.0%) and unilateral TKA (4.4%).