Is Impedance Plethysmography a Safe Test After Total Joint Replacement?

Abstract

Screening for deep venous thrombosis (DVT) following total joint replacement (TJR) has been recommended as an adjunct to DVT prophylaxis. This study evaluates a structured protocol utilizing impedance plethysmography (IPG) as the primary screening modality. Over a 12-month period all patients undergoing TJR of the lower extremities had an IPG 3 to 5 days after surgery. Patients received primary DVT prophylaxis with warfarin. Minimal follow up of 6 weeks was obtained on all patients.

Three-hundred three TJRs were performed. The IPG appeared normal in 220 of 303 patients (73%), obviating further testing. During follow-up, two patients had thromboembolic disease (TED). Of the 83 seemingly abnormal IPGs, 81 were false positive compared to venous ultrasound, with significantly more after knee surgery (p < 0.001). There was one confirmed DVT in the abnormal IPG group and one patient died 2 weeks after discharge with an autopsy-proven pulmonary embolism. There was a low overall rate of TED (1.3%); three fourths of patients with TED presented 2-4 weeks after discharge.

These results indicate that it is clinically safe to discharge patients who have had a normal-appearing postoperative IPG. However, the large number of false-positive results reduces the utility of the test, particularly after knee replacement. While IPG is safe and cheaper than venous ultrasound, prophylaxis extended beyond the of hospitalization may obviate the need for screening.

Get full access to this article

View all access options for this article.

References

1. Anderson FA , Wheeler HB , et al: A population based perspective of the hospital incidence and case-fatality rates of deep-vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med 151:933-938, 1991.

2. Mohr DN , Silverstein MD , Murtaugh PA , et al: Prophylactic agents for venous thrombosis in elective hip surgery. Arch Int Med 153:2221-2228, 1993.

3. D'Ambrosia R , Colwell CW , Fitzgerald RH , et al: New advances in the prophylaxis of venous thromboembolism in joint replacement. Orthopedics 17 (suppl):3-27, 1994.

4. Ricci MA : Deep venous thrombosis in orthopedic patients: Current techniques in the precise diagnosis. Orthop Review 8:29-40, 1984.

5. Oster G Tuden R , Colditz G : A cost-effective analysis of prophylaxis against deep-vein thrombosis in major orthopedic surgery. JAMA 257:203-208, 1987.

6. Paiement GD , Wessinger SJ Hughes R et al: Routine use of adjusted low-dose warfarin to prevent venous thromboembolism after total hip replacement. J Bone Joint Surg 75-A:893-898, 1993.

7. Paiement GD , Wessinger SJ Harris WH : Surveillance of deep vein thrombosis in asymptomatic total hip replacement patients: Impedance plethysmography and fibrinogen scanning versus roentgenographic phleborrhaphy. Am J Surg 155:400-404, 1988.

8. Paiement GD , Bell D , Wessinger SJ , et al: The Otto Aufranc Award paper. New advances in the prevention, diagnosis, and cost effectiveness of venous thromboembolic disease in patients with total hip replacement. Hip 7:94-119, 1987.

9. Barnes RW , Nix ML , Barnes CL , et al: Perioperative asymptomatic venous thrombosis: Role of duplex scanning vs venography. J Vasc Surg 9:351-360, 1983.

10.

10. Mavor GE , Galloway J : The iliofemoral venous segment as a source of pulmonary emboli. Lancet 1:871 874, 1967.

11.

11. Stamatakis JD , Kakkar W . Sagar S et al: Femoral vein thrombosis and total hip replacement. Br Med J 2:223-225, 1977.

12.

12. Paiement GD , Wessinger , Harris WH : Cost-effectiveness of prophylaxis in total hip replacement. Am J Surg 161:519-524, 1991.

13.

13. Anderson FA , Wheeler HB : Physician practices in the management of venous thromboembolism: A community-wide survey. J Vasc Surg 15:707-714, 1992.

14.

14. Hull RD , van Aken WG , Hirsh J et al: Impedance plethysmography using the occlusive cuff technique in the diagnosis of venous thrombosis. Circulation 53:696-700, 1976.

15.

15. Hull RD , Hirsh J Powers P et al: Impedance plethysmography: The relationship between venous filling and sensitivity and specificity for proximal vein thrombosis. Circulation 58:898-902, 1978.

16.

16. Hull RD , Hirsh J Carter CJ et al: Diagnostic efficacy of impedance plethysmography for clinically suspected deep-vein thrombosis: A randomized trial. Ann Int Med 102:21-28, 1985.

17.

17. Taylor DW , Hull RD , Sackett DL , et al: Simplification of the sequential impedance plethysmograph technique without loss of accuracy. Thromb Res 15:561 565, 1980.

18.

18. Shackford SR , Moser KM : Deep venous thrombosis and pulmonary embolism in trauma patients. J Int Care Med 3:87-98, 1988.

19.

19. Mallory TH , Vaughn BK , Lombardi AV , et al: Impedance plethysmography for surveillance of deep vein thrombosis following early discharge of total joint replacement patients. Orthopedics 13:1347 1351, 1990.

20.

20. Andersen FA Jr , Wheeler HB , Grady-Benson JC , et al: Developments in thromboembolic disease in orthopedics. J Bone Joint Surg 76-A (suppl):4-35, 1994.

21.

21. Frank WH , Mallory TH , Danyi J The use of impedance plethysmography and aspirin prophylaxis in total joint replacement. Ortho Transactions 6:438-438, 1983.

22.

22. Ginsberg JS Wells PS , Hirsh J , et al: Re-evaluation of the sensitivity of impedance plethysmography in the diagnosis of proximal deep venous thrombosis. Arch Int Med 154:1930-1933, 1994.

23.

23. Anderson DR , Lensing AWA , Hirsh J et al: Limitations of impedance plethysmography in the diagnosis of clinically suspected deep venous thrombosis. Ann Int Med 118:25-30, 1993.

24.

24. Solis MM , Ranval TJ , Nix ML , et al: Is anticoagulation indicated for asymptomatic postoperative calf vein thrombosis? J Vasc Surg 16:414-418, 1992.

25.

25. Bergqvist D , Benoni G Bjorgell O , et al: Low-molecular-weight heparin (enoxaparin) as prophylaxis against venous thromboembolism after total hip replacement. N Engl J Med 335:696-700, 1996.

26.

26. Hull RD , Raskob GE , Pineo GF , et al: Subcutaneous low-molecular-weight heparin vs warfarin for prophylaxis of deep vein thrombosis after hip or knee implantation. An economic perspective. Arch Int Med 157:298-303, 1997.