Duplex Ultrasonography for the Detection of Deep Vein Thrombi After Total Hip or Knee Arthroplasty

Abstract

The usefulness of real-time duplex ultrasonography (DU) as a screening test for deep vein thrombosis (DVT) in high-risk patients remains uncertain. To determine the sensitivity and specificity of DU for the detection of DVT, the authors prospectively studied 178 consecutive patients after total hip (n=113) or total knee (n = 66) arthroplasty. The deep veins from the inguinal ligament to the ankle were examined first by continuous wave and then by pulsed Doppler signals as needed with real-time gray-scale ultrasound imaging using the criteria of vein noncompressibility to define DVT. Ascending contrast venography was performed within twelve hours after DU studies. Venograms and DU were interpreted independently. DU was attempted on 177 lower extremities (2 patients refused) but was judged adequate for interpretation for only 145 (82%). Venography could not be performed for 28 lower extremities and was technically inadequate for 8 studies. The primary analysis included 119 examinations for which adequate DU and ascending venograms were interpreted. DU was positive in 17 of 27 lower extremities with DVT (23 calf, 4 proximal) diagnosed by venography (sensitivity = .63; 95% confidence interval [CI] = .42 to .81), and DU was negative in 85 of 92 lower extremities with normal venograms (specificity = .92; 95% CI = .85 to .97). A secondary analysis of 81 prospectively collected anatomically complete DU studies demonstrated a sensitivity of .80 (95% CI = .56 to .94) and a specificity of .90 (95% CI = .80 to .96). The authors conclude that real-time DU is not sensitive for the detection of venographically demonstrable calf DVT in the operated-on lower extremity following total hip or knee arthroplasty. Real-time DU is specific for the diagnosis of DVT following total hip or knee arthroplasty.

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References

Moser KM : Venous thromboembolism: State of the art. Am Rev Respir Dis 141:235-249, 1990.

Kalebo P. , Anthmyr BA , Eriksson BI , et al: Phlebographic findings in venous thrombosis following total hip replacement. Acta Radiol 31:259-263, 1990.

Barnes RW , Nix ML , Barnes CL , et al: Perioperative asymptomatic venous thrombosis: Role of duplex scanning versus venography. J Vasc Surg 9:251-260, 1989.

Paiement G. , Wessinger JJ , Waltman AC , et al: Surveillance of deep-vein thrombosis in asymptomatic total hip replacement patients with impedance phlebography. Am J Surg , 155:400-404, 1988.

Harris WH , Athanasoulis CA , Waltman AC , et al: Prophylaxis of deep-vein thrombosis after total hip replacement: Dextran and external pneumatic compression compared with 1.2 or 0.3 grams of aspirin daily. J Bone Joint Surg AM 67:57-62, 1985.

Turpie Agg , Levine MN , Hirsh J. , et al: A randomized controlled trial of a low molecular weight heparin (Enoxaparin) to prevent deep-vein thrombosis in patients undergoing elective hip surgery. N Engl J Med 315:925-929, 1986.

Francis CW , Marder VJ , Evarts M. , et al: Two-step warfarin therapy. JAMA 249:374-378, 1983.

McLachlin JA , Richards T. , Paterson JC : An evaluation of clinical signs in the diagnosis of venous thrombosis. Arch Arug 85:738-744, 1962.

Cranley JJ , Canos AJ , Sull WJ : The diagnosis of deep venous thrombosis: Fallibility of clinical signs and symptoms. Arch Surg 111:34-36, 1976.

10.

Albrechtsson U. , Olsson CG : Thrombotic side effects of lower limb venography . Lancet 1:723-724, 1976.

11.

Thomas ML , MacDonald LM : Complications of ascending phlebography of the leg. Br Med J 2:317-318, 1978.

12.

Levine MN , Hirsh J. , Gent M. , et al: Prevention of deep vein thrombosis after elective hip surgery . Ann Intern Med 114:545-551, 1991.

13.

Lensing AW , Prandoni P. , Brandies D. , et al: Detection of deep-vein thrombosis by real-time B-mode ultrasonography . N Engl J Med 320:342-345, 1989.

14.

O'Leary DH , Kane RA , Chase BM : A prospective study of the efficacy of B-scan sonography in the detection of deep venous thrombosis in the lower extremities. J Clin Ultrasound 16:1-8, 1988.

15.

Appelman PT , DeJong TE , Lampmann LE : Deep venous thrombosis of the leg: U.S. findings . Radiology 163:743-746, 1987.

16.

Vogel P. , Laing FC , Jeffrey RB , et al: Deep venous thrombosis of the lower extremity: U.S. evaluation . Radiology 163:747-751, 1987.

17.

Cronan JJ , Dorfman GS , Scala FH , et al: Deep venous thrombosis: U.S. assessment using vein compression . Radiology 162:191-194, 1987.

18.

Borris LC , Christiansen HM , Lassen MR , et al: Comparison of real-time B-mode ultrasonography and bilateral ascending phlebography for detection of postoperative deep vein thrombosis following elective hip surgery. Thromb Haemost 61:363-365, 1989.

19.

Flinn WR , Sandager GP , Cerullo LJ , et al: Duplex venous scanning for the prospective surveillance of perioperative venous thrombosis. Arch Surg 124:901-905, 1989.

20.

Monreal M. , Montserral E. , Salvador R. , et al: Real-time ultrasound for diagnosis of symptomatic venous thrombosis and for screening of patients at risk: Correlation with ascending conventional venography. Angiology 40:527-533, 1989.

21.

Comerota AJ , Katz ML , Greenwald LL , et al: Venous duplex imaging: Should it replace hemodynamic tests for deep venous thrombosis? J Vasc Surg 11:53-61, 1990.

22.

Talbot SR : Use of real-time imaging in identifying deep venous obstruction: A preliminary report. Bruit 6:41-46, 1982.

23.

Talbot SR : B-mode evaluation of peripheral veins. Semin Ultrasound CT MR 9:295-319, 1988.

24.

Rabinov K. , Paulin S. : Roentgen diagnosis of venous thrombosis in the leg. Arch Surg 104:134-144, 1972.

25.

Feinstein AR : Clinical Epidemiology, The Architecture of Clinical Research, Philadelphia: WB Saunders, 1985, pp 434-437.

26.

Lentner C. : Geigy Scientific Tables, vol. 2, Basle, Switzerland: Ciba-Geigy Limited , 1982, pp 89-102.

27.

Kakkar VV , Howe CT , Flame C. , et al: Natural history of postoperative deep vein thrombosis. Lancet 2:230-232, 1969.

28.

Lagerstedt CI , Olsson CG , Fagher BD , et al: Need for long-term anticoagulant treatment in symptomatic calf-vein thrombosis. Lancet 2:515-518, 1985.

29.

Polak JF , Cutler BJ , O'Leary DH: Deep veins of the calf: Assessment with color Doppler flow imaging . Radiology 171:481-485, 1989.

30.

Sumner DS , Londrey GL , Spadone DP , et al: Study of deep venous thrombosis in high-risk patients using color flow Doppler. In: Venous Disorders, ed. by Bergan JJ, YAO JST. Philadelphia: WB Saunders, 1991, pp 63-76.

31.

Rose SC , Zweibel WJ , Nelson BD , et al: Symptomatic lower extremity deep venous thrombosis: Accuracy, limitations, and role of color duplex flow imaging in Diagnosis. Radiology 175:639-644, 1990.

32.

Dee SK , Kakkar VV : Can colour coded duplex sonography reliably replace venography in the diagnosis of acute deep vein thrombosis? Thromb Haemostas 65: 804, 1991.

33.

Hyers TM , Hull RD , Weg JG : Antithrombotic therapy for venous thromboembolic disease. Chest 95 (Suppl):37S-51S, 1989.