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Late Deep Venous Thrombosis and Delayed Weightbearing After Total Hip Arthroplasty

Buehler, Knute O., MD*; D'Lima, Darryl D., MD*; Petersilge, William J., MD**; Colwell, Clifford W. Jr., MD*; Walker, Richard H., MD*

Clinical Orthopaedics and Related Research®: April 1999 - Volume 361 - Issue - p 123-130
Section II: Original Articles: Spine
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One hundred ninety-nine patients who underwent primary total hip arthroplasty and used in hospital pneumatic compression stockings and aspirin as thromboembolic prophylaxis were screened for deep venous thrombosis using duplex ultrasonography on the fourth postoperative day. Of the initial 98 patients, 21 underwent noncemented arthroplasty, maintained touchdown weightbearing for 6 weeks after surgery, and then began progressive partial weightbearing. Of the subsequent 101 patients, 28 underwent noncemented arthroplasty and began progressive weightbearing immediately after surgery. All other patients underwent hybrid arthroplasty and began weightbearing to tolerance immediately after surgery. After duplex screening examination, patients with proximal deep venous thrombosis were given anticoagulation therapy, and patients with negative study results were observed clinically. The relative risk of proximal deep venous thrombosis after noncemented arthroplasty using delayed weightbearing was compared with that after noncemented arthroplasty using immediate progressive weightbearing. of patients with noncemented arthroplasty, the prevalence of proximal deep venous thrombosis was significantly lower in those using progressive weightbearing immediately after surgery (none) than in those using delayed weightbearing rehabilitation (19%). This study showed that patients undergoing noncemented total hip arthroplasty with delayed weightbearing rehabilitation risk greater potential for deep venous thrombosis after hospital discharge. This study suggests consideration for continued thromboembolic prophylaxis or routine deep venous thrombosis surveillance, or both measures, after hospital discharge, unless more rapid progression of weightbearing is allowed.

From the *Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA; and the **Department of Orthopaedics, Case Western Reserve University, Cleveland, OH.

Reprint requests to Richard H. Walker, MD, Division of Orthopaedic Surgery, Scripps Clinic, 10666 North Torrey Pines Road, La Jolla, CA 92037.

Received: March 16; 1998.

Revised: August 14, 1998.

Accepted: November 5, 1998.

Venous thromboembolic disease is a well recognized complication after total hip arthroplasty.13,26 However, risk factors for the development of postoperative venous thromboembolic disease are not fully defined.

Use of noncemented total hip arthroplasty in the treatment of younger patients with coxarthrosis has been well described.4,9,19,20 The incidence of deep venous thrombosis after noncemented total hip arthroplasty has been reported from several centers,5,11,25 although without addressing the relative risk regarding noncemented or cemented prosthetic fixation or regarding postoperative rehabilitation protocols. Concern for an association between extremity disuse or immobilization and increased risk of deep venous thrombosis has been raised7,12,18 but has not been studied regarding total hip arthroplasty rehabilitation protocols. Protected weightbearing during the initial weeks after noncemented total hip arthroplasty has been advocated for the purpose of optimizing bony ingrowth fixation,3,4,10 although immediate weightbearing has been shown to have no detrimental effect on clinical or radiographic outcome.17

The purpose of this study was threefold: to compare the prevalence of proximal deep venous thrombosis (1) in patients after noncemented total hip arthroplasty using delayed weightbearing rehabilitation with that of patients after noncemented arthroplasty using immediate progressive weightbearing; (2) in patients after noncemented total hip arthroplasty using delayed weightbearing rehabilitation with that of patients after hybrid arthroplasty using immediate full weightbearing; and (3) in patients after noncemented arthroplasty using immediate progressive weightbearing rehabilitation with that of patients after hybrid arthroplasty using immediate full weightbearing.

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PATIENTS AND METHODS

One hundred ninety-nine patients who underwent primary total hip arthroplasty and had no history of thromboembolic disease were screened for postoperative deep venous thrombosis using duplex ultrasonography on the fourth postoperative day. All patients used pneumatic compression stockings and aspirin during hospitalization as prophylaxis against venous thromboembolic disease.

Patients with proximal deep venous thrombosis detected by duplex screening examination were treated with therapeutic anticoagulation using unfractionated heparin and warfarin for 12 weeks after surgery. Patients with a negative result of duplex screening examination were administered no additional prophylaxis against thromboembolic disease and were observed clinically for 12 months after surgery. For subsequent symptomatic manifestation of deep venous thrombosis (painful or progressive calf or thigh swelling) or pulmonary embolism (dyspnea, pleuritic pain, tachypnea, tachycardia, fever, hemoptysis), duplex ultrasonography was performed for confirmation of deep venous thrombosis. Confirmation of the presence of proximal deep venous thrombosis warranted therapeutic anticoagulation with unfractionated heparin and warfarin.

Duplex ultrasonography was performed as described in a previous report from this institution.6 The reliability of duplex ultrasonography in detecting proximal deep venous thrombosis after total hip arthroplasty at the authors' institution, as determined by direct comparison with venography, previously was confirmed and reported.6

The study population of 199 patients consisted of two consecutive cohorts (Cohort THA1 and Cohort THA2). Cohort THA1 consisted of 98 patients, including 21 patients with noncemented arthroplasty (Group NC1) and 77 patients with hybrid arthroplasty (Group HY1, cemented femoral component, noncemented acetabular component). Cohort THA2 consisted of 101 patients, including 28 patients with noncemented arthroplasty (Group NC2) and 73 patients with hybrid arthroplasty (Group HY2). Noncemented or hybrid total hip arthroplasty was selected after an informed consent discussion between the patient and surgeon regarding implant fixation alternatives; noncemented arthroplasty generally was done in patients younger than 65 years of age. Demographic data regarding gender, age, and weight of the patients are given in Table 1.

TABLE 1

TABLE 1

All procedures were performed by one surgeon (RHW) using a standardized anesthetic (general endotracheal hypotensive), patient position (lateral decubitus), approach (posterolateral), perioperative thromboembolic prophylaxis regimen (described), and postoperative physical therapy protocol throughout the study period. Before surgery, no patient in the study had a history of deep venous thrombosis or pulmonary embolism. Patients undergoing endoprosthetic hip arthroplasty, arthroplasty for fracture, or arthroplasty involving neoplastic or infections conditions and patients with active neoplastic process or history of venous thromboembolic disease were excluded from the study. Patients undergoing primary total hip arthroplasty and participating in randomized pharmacologic thromboembolic prophylaxis investigations during the period of this study also were excluded from the study. This study reports a consecutive series of patients using pneumatic compression stockings and aspirin for thromboembolic prophylaxis after primary total hip arthroplasty.

In Cohort THA1, patients with noncemented arthroplasty (Group NC1) were instructed to maintain touchdown weightbearing for 6 weeks after surgery and progressive partial weightbearing for the ensuing 6 weeks, thereby beginning full weightbearing 12 weeks after surgery. In Cohort THA2, patients with noncemented arthroplasty (Group NC2) were instructed in progressive weightbearing for 12 weeks after surgery at increments of 11 kg (25 lb) every 2 weeks, thereby attaining full weightbearing approximately 12 weeks after surgery. Throughout the study, patients with hybrid arthroplasty (Groups HY1 and HY2) were allowed weightbearing, as tolerated, immediately after surgery.

Patients were interviewed and examined 2 weeks, 6 weeks, 12 weeks, and 12 months after surgery for manifestation of deep venous thrombosis or pulmonary embolism. Statistical analysis was performed using the chi square test with Yates' correction.

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RESULTS

Demographic data are presented in Table 1. As a result of the selection criteria, the patients in the noncemented arthroplasty groups (Groups NC1 and NC2) were younger than the patients in the hybrid arthroplasty groups (Groups HY1 and HY2). Patients in Groups NC1 and NC2 were predominately male, whereas patients in Groups HY1 and HY2 were predominantly female. There were no differences with regard to gender, age, or weight when comparing patients in noncemented groups (Groups NC1 with NC2) and patients in hybrid groups (Group HY1 with HY2).

The prevalence of proximal deep venous thrombosis on duplex screening examination on the fourth postoperative day is given in Table 2. There was no significant difference between concomitant noncemented and hybrid groups in Cohort THA1 (Groups NC1 and HY1) and in Cohort THA2 (Groups NC2 and HY2). There was no significant difference between noncemented groups (Group NC1, 5%; Group NC2, none) or hybrid groups (Group HY1, 14%; Group HY2, 8%).

TABLE 2

TABLE 2

The prevalence of proximal deep venous thrombosis manifesting clinically after negative result of duplex screening examination is given in Table 3. In Cohort THA1, there was a significant difference in posthospitalization symptomatic proximal deep venous thrombosis between patients in the noncemented (touchdown weightbearing for 6 weeks) and hybrid (weightbearing as tolerated) groups (Group NC1, 15%; Group HY1, none; p = 0.01). In Cohort THA2, this difference between patients in the noncemented (progressive weightbearing) and hybrid (weightbearing as tolerated) groups was eliminated (Group NC2, none; Group HY2, 3%; p > 0.10).

TABLE 3

TABLE 3

Symptomatic proximal deep venous thrombosis presented between 3 and 8 weeks after surgery in male patients with osteoarthritis and weight between 75 and 89 kg. Three of these five patients also had symptomatic pulmonary embolism.

The overall prevalence of proximal deep venous thrombosis detected on duplex screening examination and on clinical followup for 12 months after surgery is given in Table 4. There was a significant difference in the overall prevalence of patients treated for proximal deep venous thrombosis in noncemented Group NC1 (19%) compared with Group NC2 (none; p = 0.03). Perioperative management of Groups NC1 and NC2 differed with regard to the postoperative protocol for weightbearing. Patients in Group NC1 remained touchdown weightbearing for 6 weeks after surgery and progressive weightbearing thereafter; patients in Group NC2 initiated progressive weightbearing immediately after surgery.

TABLE 4

TABLE 4

There were no complications related to duplex ultrasonography examinations or anticoagulation therapy.

To address the threefold purpose of the study: (1) when comparing patients after noncemented total hip arthroplasty using delayed weightbearing with patients after noncemented arthroplasty using immediate progressive weightbearing (groups with no difference in gender, age, or weight), the study showed a significantly higher overall incidence of proximal deep venous thrombosis in patients after noncemented arthroplasty using delayed weightbearing; (2) when comparing patients after noncemented arthroplasty using delayed weightbearing with patients after hybrid arthroplasty using immediate full weightbearing, the study showed no difference in outcome of duplex screening examination results but a significantly higher incidence of symptomatic posthospitalization deep venous thrombosis in patients after noncemented arthroplasty using delayed weightbearing; and (3) when comparing patients after noncemented arthroplasty using immediate progressive weightbearing with patients after hybrid arthroplasty using immediate full weightbearing, the study showed no difference in proximal deep venous thrombosis revealed by inhospital duplex screening examination or by posthospitalization clinical followup.

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DISCUSSION

Thromboembolic disease is a well recognized and significant concern after total hip arthroplasty, warranting measures of prophylaxis against deep venous thrombosis.13,23,26 The efficacy of sequential compression stocking prophylaxis, the method of primary prevention of deep venous thrombosis used in this study, has been substantiated.14,28 The usefulness and cost effectiveness of duplex ultrasonography screening, the method of secondary prevention of deep venous thrombosis used in this study, also has been substantiated.1,6,15

Several authors previously established the reliability of duplex ultrasonography, compared with venography, for detection of proximal deep venous thrombosis after total hip arthroplasty.21,22,24,27 A previous study6 at the authors' institution reported duplex screening of 102 lower extremities in 51 patients after total hip arthroplasty, showing no false positive or false negative examination results (100% sensitivity, 100% specificity, 100% accuracy) on direct comparison with venography. These data, supported by reports in the literature, were deemed sufficient to validate the reliability of duplex ultrasonography for detection of deep venous thrombosis at the authors' institution and to allow initiation of the use of duplex ultrasonography as a screening tool for deep venous thrombosis after total hip arthroplasty.

This study showed no significant difference in the incidence of inhospital proximal deep venous thrombosis between patients after noncemented total hip arthroplasty and patients after hybrid total hip arthroplasty. However, this study showed that patients with noncemented arthroplasty and delayed weightbearing had a significantly higher prevalence of later clinical manifestation (3 to 8 weeks after surgery) of proximal deep venous thrombosis than did patients with hybrid arthroplasty and immediate full weight-bearing. This study also showed that patients with noncemented arthroplasty and delayed weightbearing had a significantly higher prevalence of proximal deep venous thrombosis than did patients with noncemented arthroplasty and immediate progressive weightbearing. No other study has documented similar data indicating a higher risk for late presentation of proximal deep venous thrombosis in patients after noncemented total hip arthroplasty.

The use of noncemented primary total hip arthroplasty in the treatment of younger patients with coxarthrosis has been well supported.4,9,19,20 Protected weightbearing during the initial weeks after noncemented total hip arthroplasty has been advocated.3,4,10 Pilliar et al,16 Haddad et al,8 and Brunski2 have discussed restriction of relative motion at the prosthesis-bone interface as a condition for initial bone ingrowth in animal models. Cameron3 described a theoretical benefit of allowing maturation of the bone ingrowth process before subjecting the bone-prosthesis interface to the load of weightbearing. As such, clinical recommendations for rehabilitation protocols after noncemented total hip arthroplasty have incorporated varying degrees and duration of limited weightbearing. Harris10 recommended using two crutches for 12 weeks postoperatively. Engh et al4 recommended using two crutches and touchdown weightbearing for 6 weeks after surgery, followed by use of one crutch for 4 weeks, followed by use of a cane for 4 weeks. Harris10 also advocated using two crutches for 6 weeks after surgery, with gradual reduction of crutch support thereafter; this was the protocol practiced in the current study for Group NC1. However, Rao et al17 compared patients after noncemented total hip arthroplasty and immediate weightbearing with patients after noncemented arthroplasty and 10% weightbearing for 6 weeks and found no difference in clinical or radiographic outcomes at the 2-year followup.

A correlation between extremity immobilization or disuse and the development of deep venous thrombosis has been reported, resulting in the promotion of mechanical and pharmacologic measures against deep venous thrombosis in such a setting.7,12,18 In these studies, despite adjunctive prophylactic modalities, deep venous thrombosis in association with limited extremity use remained a concern, although thrombosis occurred at a decreased rate with prophylaxis. Previous studies have examined the incidence of deep venous thrombosis specifically after noncemented total hip arthroplasty.5,11,25 Kim and Suh11 evaluated 146 consecutive patients undergoing noncemented total hip arthroplasty and found a 10% incidence of deep venous thrombosis when examined by venogram. Francis et al,5 in a retrospective, randomized study comparing the efficacy of two thromboprophylactic modalities, found no venographically documented deep venous thrombosis in patients with noncemented total hip arthroplasty. Wittman et al,25 in a retrospective study of 490 patients who underwent noncemented total hip arthroplasty, found a 2% incidence of clinical manifestation of deep venous thrombosis. These studies did not compare the effect of methods of component fixation (noncemented versus cemented) and of methods of postoperative rehabilitation (rapidity or weightbearing) on the risk of thromboembolic disease.

This study indicates that method of fixation does not affect incidence of proximal deep venous thrombosis when rapidity of weightbearing is similar. However, this study also indicates that delayed weightbearing after total hip arthroplasty increases the risk of proximal deep venous thrombosis after hospital discharge. Patients who underwent noncemented arthroplasty, were younger (Group NC1: mean age, 53 years), and used delayed weightbearing rehabilitation when compared with patients who underwent hybrid arthroplasty, were older (Group HY1: mean age, 71 years), and used immediate weightbearing had no difference in the rate of asymptomatic proximal deep venous thrombosis on duplex screening examination before hospital discharge but had a significantly higher rate of symptomatic proximal deep venous thrombosis after hospital discharge. This higher rate of symptomatic proximal deep venous thrombosis for patients with noncemented arthroplasty was not seen in patients using an immediate progressive weightbearing rehabilitation protocol.

This retrospective study showed an increased risk of posthospitalization proximal deep venous thrombosis after noncemented total hip arthroplasty when using a delayed weightbearing rehabilitation protocol. These data indicate the need for a randomized prospective study to evaluate the relative risk of posthospitalization deep venous thrombosis associated with limited weightbearing after noncemented total hip arthroplasty. Until such a study is completed, these findings warrant consideration for posthospitalization management after noncemented total hip arthroplasty that includes: (1) continued thromboembolic prophylaxis; (2) continued routine deep venous thrombosis surveillance; or (3) a combination of these measures, unless more rapid progression of weightbearing (as with Group NC2 in this study) is allowed.

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