CT Pulmonary Angiography After Total Joint Arthroplasty: Overdiagnosis and Iatrogenic Harm?
CT pulmonary angiography (CTPA) has become widely adopted to detect pulmonary embolism (PE) after total joint arthroplasty (TJA). CTPA is a sensitive tool, which has the ability to detect emboli that may be clinically insignificant. This may lead to iatrogenic harm from overtreatment.
The purpose of this study was to assess changing prevalence, mortality, treatment complications, and resource consumption associated with PE after TJA before and after the introduction of CTPA.
The Nationwide Inpatient Sample was used to identify 2,335,248 patients undergoing TJA from 1993 to 1998 before the introduction of CTPA and 6,321,671 patients from 1999 to 2008 after the introduction of CTPA. Bivariate and multivariate regression analysis was performed to compare changing prevalence of PE, mortality, potential treatment complications of anticoagulation, length of stay, and total charges before and after the introduction of CTPA in patients with PE.
In-hospital diagnosis of PE after TJA increased (p < 0.001) from an average of 0.27% to 0.37% after the introduction of CTPA. All-cause mortality in patients with a diagnosis of PE decreased (p < 0.001) from 11.5% to 4.6% (odds ratio, 2.3; 95% confidence interval, 2.1–2.6) after the introduction of CTPA. Overall, PE was associated with increased (p < 0.001) risks for hematoma/seroma, postoperative infection, gastrointestinal bleed, and drug-related thrombocytopenia, although the prevalence of these complications has decreased after 1998 (p < 0.001). Length of stay doubled for patients with PE (both before and after CTPA) and total charges increased over 69% in both study periods for these patients.
Adoption of CTPA appears to be associated with an increase in the diagnosis of PE after TJA and an associated decrease in case-fatality. Although CTPA may improve our ability to diagnose PE and possibly reduce mortality, the observed decrease in case-fatality could also be explained by the overdiagnosis of clinically unimportant emboli. The diagnosis of PE was strongly associated with potential iatrogenic harm from anticoagulation and increased length of stay and hospital charges in this study, emphasizing the importance of further investigation to define the role of CTPA in the diagnosis and treatment of PE after TJA.
Level of Evidence
Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
- Auer RC, Schulman AR, Tuorto S, Gonen M, Gonsalves J, Schwartz L, Ginsberg MS, Fong Y. Use of helical CT is associated with an increased incidence of postoperative pulmonary emboli in cancer patients with no change in the number of fatal pulmonary emboli. J Am Coll Surg. 2009;208:871–878; discussion 878–880. CrossRef
- Bjornara BT, Gudmundsen TE, Dahl OE. Frequency and timing of clinical venous thromboembolism after major joint surgery. J Bone Joint Surg Br. 2006;88:386–391.
- Bozic KJ, Kurtz SM, Lau E, Ong K, Chiu V, Vail TP, Rubash HE, Berry DJ. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res. 2010;468:45–51. CrossRef
- Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009;91:128–133. CrossRef
- Butt AJ, McCarthy T, Kelly IP, Glynn T, McCoy G. Sciatic nerve palsy secondary to postoperative haematoma in primary total hip replacement. J Bone Joint Surg Br. 2005;87:1465–1467.
- Colwell CW, Berkowitz SD, Lieberman JR, Comp PC, Ginsberg JS, Paiement G, McElhattan J, Roth AW, Francis CW, EXULT B Study Group. Oral direct thrombin inhibitor ximelagatran compared with warfarin for the prevention of venous thromboembolism after total knee arthroplasty. J Bone Joint Surg Am. 2005;87:2169–2177 CrossRef
- Decousus H, Leizorovicz A, Parent F, Page Y, Tardy B, Girard P, Laporte S, Faivre R, Charbonnier B, Barral FG, Huet Y, Simonneau G. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prevention du Risque d’Embolie Pulmonaire par Interruption Cave Study Group. N Engl J Med. 1998;338:409–415. CrossRef
- Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45:613–619. CrossRef
- Donohoo JH, Mayo-Smith WW, Pezzullo JA, Egglin TK. Utilization patterns and diagnostic yield of 3421 consecutive multidetector row computed tomography pulmonary angiograms in a busy emergency department. J Comput Assist Tomogr. 2008;32:421–425. CrossRef
- Douketis JD, Eikelboom JW, Quinlan DJ, Willan AR, Crowther MA. Short-duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta-analysis of prospective studies investigating symptomatic outcomes. Arch Intern Med. 2002;162:1465–1471. CrossRef
- Francis CW, Berkowitz SD, Comp PC, Lieberman JR, Ginsberg JS, Paiement G, Peters GR, Roth AW, McElhattan J, Colwell CW Jr, EXULT A Study Group. Comparison of ximelagatran with warfarin for the prevention of venous thromboembolism after total knee replacement. N Engl J Med. 2003;349:1703–1712. CrossRef
- Freedman KB, Brookenthal KR, Fitzgerald RH Jr, Williams S, Lonner JH. A meta-analysis of thromboembolic prophylaxis following elective total hip arthroplasty. J Bone Joint Surg Am. 2000;82:929–938.
- Fujita S, Hirota S, Oda T, Kato Y, Tsukamoto Y, Fuji T. Deep venous thrombosis after total hip or total knee arthroplasty in patients in Japan. Clin Orthop Relat Res. 2000;375:168–174. CrossRef
- Galat DD, McGovern SC, Hanssen AD, Larson DR, Harrington JR, Clarke HD. Early return to surgery for evacuation of a postoperative hematoma after primary total knee arthroplasty. J Bone Joint Surg Am. 2008;90:2331–2336. CrossRef
- HCUP. Introduction to the HCUP Nationwide Inpatient Sample (NIS) 2005. Rockville, MD, USA: Agency for Healthcare Quality and Research (AHRQ); 2007.
- Howie C, Hughes H, Watts AC. Venous thromboembolism associated with hip and knee replacement over a ten-year period: a population-based study. J Bone Joint Surg Br. 2005;87:1675–1680.
- Keays AC, Mason M, Keays SL, Newcombe PA. The effect of anticoagulation on the restoration of range of motion after total knee arthroplasty: enoxaparin versus aspirin. J Arthroplasty. 2003;18:180–185. CrossRef
- Kim YH, Kim JS. Incidence and natural history of deep-vein thrombosis after total knee arthroplasty. A prospective, randomised study. J Bone Joint Surg Br. 2002;84:566–570. CrossRef
- Kim YH, Oh SH, Kim JS. Incidence and natural history of deep-vein thrombosis after total hip arthroplasty. A prospective and randomised clinical study. J Bone Joint Surg Br. 2003;85:661–665. CrossRef
- Lawton RL, Morrey BF, Narr BJ. Validity of index of suspicion for pulmonary embolism after hip arthroplasty. Clin Orthop Relat Res. 2003;415:180–192. CrossRef
- Neviaser AS, Chang C, Lyman S, Della Valle AG, Haas SB. High incidence of complications from enoxaparin treatment after arthroplasty. Clin Orthop Relat Res. 2010;468:115–119. CrossRef
- Oster G, Ollendorf DA, Vera-Llonch M, Hagiwara M, Berger A, Edelsberg J. Economic consequences of venous thromboembolism following major orthopedic surgery. Ann Pharmacother. 2004;38:377–382. CrossRef
- Park B, Messina L, Dargon P, Huang W, Ciocca R, Anderson FA. Recent trends in clinical outcomes and resource utilization for pulmonary embolism in the United States: findings from the nationwide inpatient sample. Chest. 2009;136:983–990. CrossRef
- Parvizi J, Ghanem E, Joshi A, Sharkey PF, Hozack WJ, Rothman RH. Does ‘excessive’ anticoagulation predispose to periprosthetic infection? J Arthroplasty. 2007;22:24–28. CrossRef
- Patel VP, Walsh M, Sehgal B, Preston C, DeWal H, Di Cesare PE. Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. J Bone Joint Surg Am. 2007;89:33–38. CrossRef
- Sanchez-Ballester J, Smith M, Hassan K, Kershaw S, Elsworth CS, Jacobs L. Wound infection in the management of hip fractures: a comparison between low-molecular weight heparin and mechanical prophylaxis. Acta Orthop Belg. 2005;71:55–59.
- Warwick D, Friedman RJ, Agnelli G, Gil-Garay E, Johnson K, FitzGerald G, Turibio FM. Insufficient duration of venous thromboembolism prophylaxis after total hip or knee replacement when compared with the time course of thromboembolic events: findings from the Global Orthopaedic Registry. J Bone Joint Surg Br. 2007;89:799–807.
- Weir ID, Drescher F, Cousin D, Fraser ET, Lee R, Berman L, Strauss E, Wang Y, Fine JM. Trends in use and yield of chest computed tomography with angiography for diagnosis of pulmonary embolism in a Connecticut hospital emergency department. Conn Med. 2010;74:5–9.
- Welch HG, Black WC. Overdiagnosis in cancer. J Natl Cancer Inst. 2010;102:605–613. CrossRef
- Westrich GH, Haas SB, Mosca P, Peterson M. Meta-analysis of thromboembolic prophylaxis after total knee arthroplasty. J Bone Joint Surg Br. 2000;82:795–800. CrossRef
- White RH, Romano PS, Zhou H, Rodrigo J, Bargar W. Incidence and time course of thromboembolic outcomes following total hip or knee arthroplasty. Arch Intern Med. 1998;158:1525–1531. CrossRef
- Wiener RS, Schwartz LM, Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med. 2011;171:831–837. CrossRef
- Witt DM, Delate T, Clark NP, Martell C, Tran T, Crowther MA, Garcia DA, Ageno W, Hylek EM, Warfarin Associated Research Projects and other EnDeavors (WARPED) Consortium. Outcomes and predictors of very stable INR control during chronic anticoagulation therapy. Blood. 2009;114:952–956. CrossRef
- Wittram C, Meehan MJ, Halpern EF, Shepard JA, McLoud TC, Thrall JH. Trends in thoracic radiology over a decade at a large academic medical center. J Thorac Imaging. 2004;19:164–170. CrossRef
- CT Pulmonary Angiography After Total Joint Arthroplasty: Overdiagnosis and Iatrogenic Harm?
Clinical Orthopaedics and Related Research®
Volume 471, Issue 9 , pp 2737-2742
- Cover Date
- Print ISSN
- Online ISSN
- Springer US
- Additional Links
- Industry Sectors