HSS Journal

, 2:148 | Cite as

Effect on Deep Venous Thrombosis with Flexion during Total Knee Arthroplasty

  • Geoffrey H. Westrich
  • Raz Winiarsky
  • Michael Betsy
  • Lena Maun
  • Thomas P. Sculco


This study investigates the relationship between intraoperative extreme flexion and tibia-femoral dislocation during total knee arthroplasty on the prevalence of postoperative deep venous thrombosis. Knees were randomized into two groups. The control group underwent the procedure according to normal protocol, which kept the knee in extreme flexion and maintained dislocation for the duration of the exposure, whereas the variable group underwent the procedure modified to minimize the total amount of time the knee was hyperflexed and dislocated. Venograms were positive in 42% (39/92) of the control knees and 38% (30/79) of the modified group (p = 0.6). Proximal deep venous thrombosis were found in 12% (11/92) of the control knees and in 16% (13/79) of the modified knees (p = 0.4). No statistical difference could be detected between the two techniques in regards to the incidence of deep venous thrombosis.

Key words

total knee arthroplasty deep venous thrombosis flexion tibial femoral dislocation venography 


  1. 1.
    Antiplatelet Trialists' Collaboration (1994) Collaborative overview of randomized trials of antiplatelet therapy—III: reduction in venous thrombosis and pulmonary embolism by antiplatelet prophylaxis among surgical and medical patients. Br Med J 308:235–246Google Scholar
  2. 2.
    Borow M, Goldson HJ (1983) Prevention of postoperative deep venous thrombosis and pulmonary emboli with combined modalities. Am Surgeon 49:599–605PubMedGoogle Scholar
  3. 3.
    Bradley JG, Krugener GH, Jager HJ (1993) The effectiveness of intermittent plantar venous compression in prevention of deep venous thrombosis after total hip arthroplasty. J Arthroplast 8:57–61CrossRefGoogle Scholar
  4. 4.
    Cohen SH, Ehrlick GE, Kauffman MS, Cope C (1973) Thrombophlebitis following knee surgery. J Bone Jt Surg 55-A:106–112Google Scholar
  5. 5.
    Colwell CW Jr, Spiro TE, Trowbridge AA, Stephens JW, Gardiner GA Jr, Ritter MA (1995) Efficacy and safety of enoxaparin versus unfractionated heparin for prevention of deep venous thrombosis after elective knee arthroplasty. Enoxaparin Clinical Trial Group. Clin Orthop Relat Res 321:19–27PubMedGoogle Scholar
  6. 6.
    Comerota AJ, Katz ML, White JV (1992) Why does prophylaxis with external pneumatic compression for deep vein thrombosis fail? Am J Surg 164:265–268PubMedCrossRefGoogle Scholar
  7. 7.
    Coventry MB, Nolan DR, Beckenbaugh RD (1973) “Delayed” prophylactic anticoagulation: a study of results and complications in 2,012 total hip arthroplasties. J Bone Jt Surg 55:1487–1492Google Scholar
  8. 8.
    DeLee JC, Rockwood CA Jr (1980) The use of aspirin in thromboembolic disease. J Bone Jt Surg 62-A:149–152Google Scholar
  9. 9.
    Doouss T (1976) The clinical significance of venous thrombosis of the calf. Br J Surg 63:377–378PubMedCrossRefGoogle Scholar
  10. 10.
    Evarts CM (1992) Prevention of venous thromboembolism. Clin Ortop 222:98–104Google Scholar
  11. 11.
    Fitzgerald RH, Spiro TE, Trowbridge AA, Gardiner GA, Whitsett TL, O'Connell MB, Ohar JA, Young TR (2001) Prevention of venous thromboembolic disease following primary total knee arthroplasty. J Bone Jt Surg 83-A(6):900–906Google Scholar
  12. 12.
    Fordyce MJF, Ling RSM (1992) A venous foot pump reduces thrombosis after total hip replacement. J Bone Jt Surg 74-B:45–49Google Scholar
  13. 13.
    Gianchino A (1988) Relationship between deep-vein thrombosis in the calf and fatal pulmonary embolism. Can J Surg 31:129–130Google Scholar
  14. 14.
    Gold EW (1988) Prophylaxis of deep venous thromboembolism. Orthopedics 11:1197–1201PubMedGoogle Scholar
  15. 15.
    Grady-Benson JC, Oishi CS, Hannson PB, Colwell CW Jr, Otis SM, Walker RJ (1994) Postoperative surveillance for deep venous thrombosis with duplex ultrasound after total knee arthroplasty. J Bone Jt Surg 76-A(11):1649–1657Google Scholar
  16. 16.
    Guyer RD, Booth RE Jr, Rothman RH (1982) The detection and prevention of pulmonary embolism in total hip replacement. A study comparing aspirin and low-dose warfarin. J Bone Jt Surg 64-A:1040–1044Google Scholar
  17. 17.
    Haas SB, Insall JN, Scuderi GR, Windsor RE, Ghelman B (1990) Pneumatic sequential-compression boots compared with aspirin prophylaxis of deep-vein thrombosis after total knee arthroplasty. J Bone Jt Surg 72-A:27–31Google Scholar
  18. 18.
    Haas SB (1999) Postoperative complications of deep vein thrombosis: prevention and treatment. In: Lotke PA, Garino J (eds) Revision total knee arthroplasty. Lippincott-Raven, Philadelphia, pp 437–446Google Scholar
  19. 19.
    Harris WH, Salzman EW, Athanasoulis CA, Waltman AC, Baum S, DeSanctis RW (1974) Comparison of warfarin, low-molecular-weight dextran, aspirin, and subcutaneous heparin in prevention of venous thromboembolism following total hip replacement. J Bone Jt Surg 56-A:1552–1562Google Scholar
  20. 20.
    Harris WH, Athanasoulis C, Waltman AC, Salzman EW (1976) Cuff-impedance phlebotomy and 1251fibrinogen scanning versus roentgenographic phlebotomy for diagnosis of thromboembolism following hip surgery: a preliminary report. J Bone Jt Surg 58-A:939–944Google Scholar
  21. 21.
    Harris WH, Athanasoulis CA, Waltman AC, Salzman EW (1982) High and low-dose aspirin prophylaxis against venous thromboembolic disease in total hip replacement. J Bone Jt Surg 64-A:63–66Google Scholar
  22. 22.
    Harris WH, McKusick K, Athanasoulis CA, Waltman AC, Strauss HW (1984) Detection of pulmonary emboli after total hip replacement using serial C15O2 pulmonary scans. J Bone Jt Surg 66-A:1388–1393Google Scholar
  23. 23.
    Harris WH, Athanasoulis CA, Waltman AC, Salzman EW (1985) Prophylaxis of deep-vein thrombosis after total hip replacement. Dextran and external pneumatic compression compared with 1.2 or 0.3 gram of aspirin daily. J Bone Jt Surg 67-A:57–62Google Scholar
  24. 24.
    Hartman JT, Pugh JL, Smith RD, Robertson WW Jr, Yost RP, Janssen HF (1982) Cyclic sequential compression of the lower limb in prevention of deep venous thrombosis. J Bone Jt Surg 64-A:1059–1062Google Scholar
  25. 25.
    Hull R, Delmore TJ, Hirsh J, Gent M, Armstrong P, Lofthouse R et al (1979) Effectiveness of intermittent pulsatile elastic stockings for the prevention of calf and thigh vein thrombosis in patients undergoing elective knee surgery. Thromb Res 16:37–45PubMedCrossRefGoogle Scholar
  26. 26.
    Hull RD, Raskob GE (1986) Current concepts review. Prophylaxis of venous thromboembolic disease following hip and knee surgery. J Bone Jt Surg 68-A:146–150Google Scholar
  27. 27.
    Insall JN, Haas SB (1993) Complications of total knee arthroplasty. In: Insall JN (ed) Surgery of the knee. Churchill Livingstone, New York, pp 891–894Google Scholar
  28. 28.
    Irving GA, Noakes TD (1985) The protective role of local hypothermia in tourniquet-induced ischaemia of muscle. J Bone Jt Surg Br 67(2):297–301Google Scholar
  29. 29.
    Kakkar VV, Howe CT, Flanc C, Clarke MB (1969) Natural history of postoperative deep-vein thrombosis. Lancet 2:230–232PubMedCrossRefGoogle Scholar
  30. 30.
    Lotke PA (1989) Thromboembolic disease: a critical review. Bull Am Acad Orthop Surg 37:20–21Google Scholar
  31. 31.
    Lotke PA, Ecker ML, Alavi A, Berkowitz H (1984) Indications for the treatment of deep venous thrombosis following total knee replacement. J Bone Jt Surg 66-A:202–208Google Scholar
  32. 32.
    Lotke PA, Wong RY, Ecker ML (1986) Asymptomatic pulmonary embolism after total knee replacement. Orthop Trans 10:490Google Scholar
  33. 33.
    Lotke PA, Palevsky H, Keenan AM, Meranze S, Steinberg ME, Ecker ML et al (1996) Aspirin and warfarin for thromboembolic disease after total joint arthroplasty. Clin Ortop 324:251–258CrossRefGoogle Scholar
  34. 34.
    McCardel BR, Lachiewicz PF, Jones K (1990) Aspirin prophylaxis and surveillance of pulmonary embolism and deep vein thrombosis in total hip arthroplasty. J Arthroplast 5:181–185CrossRefGoogle Scholar
  35. 35.
    McKenna R, Bachmann F, Kaushal SP, Galante JO (1976) Thromboembolic disease in patients undergoing total knee replacement. J Bone Jt Surg 58-A:928–932Google Scholar
  36. 36.
    McKenna R, Galante J, Bachmann F, Wallace DL, Kaushal SP, Meredith P (1980) Prevention of venous thromboembolism after total knee replacement by high-dose aspirin or intermittent calf and thigh compression. Br Med J 280:514–517PubMedCrossRefGoogle Scholar
  37. 37.
    Modig J, Borg T, Karlström G, Maripuu K, Sahlstedt B (1983) Thromboembolism after total hip replacement: role of epidural and general anesthesia. Anesth Analg 62:174–180PubMedCrossRefGoogle Scholar
  38. 38.
    Morrey BF, Adams RA, Ilsrtup DM, Bryan RS (1987) Complications and mortality associated with bilateral or unilateral total knee arthroplasty. J Bone Jt Surg 69-A:484–488Google Scholar
  39. 39.
    Moser KM, Le Moine JR (1981) Is embolic risk conditioned by location of deep venous thrombosis? Ann Intern Med 94:574–580Google Scholar
  40. 40.
    Paiement G, Wessinger SJ, Waltman AC, Harris WH (1987) Low-dose warfarin versus external pneumatic compression for prophylaxis against venous thromboembolism following total hip replacement. J Arthroplast 2:23–26CrossRefGoogle Scholar
  41. 41.
    Paiement GD, Bell D, Wessinger SJ et al (1987) New advances in prevention, diagnosis, and cost effectiveness of venous thromboembolic disease in patients with total hip replacement. The hip, proceedings of the fourteenth open scientific meeting of the Hip Society. C.V. Mosby, St. Louis, pp 94–119Google Scholar
  42. 42.
    Paiement GD, Beisaw NE, Lotke PA, Elia E, Wessinger S, Harris W (1989) Advances in the prevention of venous thromboembolic disease after hip and knee surgery. Orthop Rev 18:1–20Google Scholar
  43. 43.
    Paiement GD, Beisaw NE, Harris WH, Wessinger SJ, Wyman EM (1990) Advances in prevention of venous thromboembolic disease after elective hip surgery. Instr Course Lect 39:413–421PubMedGoogle Scholar
  44. 44.
    Roberts TS, Nelson CL, Barnes CL et al (1989) Low dose dextran 40 in reconstructive hip surgery patients. Orthopedics 12:789–801Google Scholar
  45. 45.
    Santori FS, Vitullo A, Stopponi M, Santori N, Ghera S (1994) Prophylaxis against deep-vein thrombosis in total hip replacement. Comparison of heparin and foot impulse pump. J Bone Jt Surg 76-B:579–583Google Scholar
  46. 46.
    Sharrock NE, Brien WW, Salvati EA, Mineo R, Garvin K, Sculco TP (1990) The effect of intravenous fixed-dose heparin during total hip arthroplasty on the incidence of deep-vein thrombosis. A randomized double-blind trial in patients operated on with epidural anesthesia and controlled hypotension. J Bone Jt Surg 72-A:1456–1461Google Scholar
  47. 47.
    Sharrock NE, Haas SB, Hargett MJ, Urquhart B, Insall JN, Scuderi G (1991) Effects of epidural anesthesia on the incidence deep-vein thrombosis after total knee arthroplasty. J Bone Jt Surg 73-A:502–506Google Scholar
  48. 48.
    Sikorski JM, Hampson WG, Staddon GE (1981) The natural history and aetiology of deep vein thrombosis after total hip replacement. J Bone Jt Surg 63-B:171–177Google Scholar
  49. 49.
    Stranks GJ, MacKenzie NA, Grover ML, Fail T (1992) The A-V impulse system reduces deep-vein thrombosis and swelling after hemiarthroplasty for hip fractures. J Bone Jt Surg 74-B:775–778Google Scholar
  50. 50.
    Stringer MD, Steadman CA, Hedges AR, Thomas EM, Morley TR, Kakkar VV (1989) Deep vein thrombosis after elective knee surgery: an incidence study in 312 patients. J Bone Jt Surg 71-B:492–497Google Scholar
  51. 51.
    Stulberg BN, Dorr LD, Ranawat CS, Schneider R (1982) Aspirin prophylaxis for pulmonary embolism following total hip arthroplasty: an incidence study. Clin Ortop 168:119–123Google Scholar
  52. 52.
    Westrich GH, Sculco TP (1996) Prophylaxis against deep vein thrombosis after total knee arthroplasty. Pneumatic plantar compression and aspirin compared to aspirin alone. J Bone Jt Surg 78-A(6):826Google Scholar
  53. 53.
    Westrich GH, Menezes A, Sharrock N, Sculco TP (1999) Thromboembolic disease prophylaxis in total knee arthroplasty using intraoperative heparin and postoperative pneumatic foot compression. J Arthroplast 14(6):651–656CrossRefGoogle Scholar
  54. 54.
    Wilson NV, Das SK, Kakkar VV, Maurice HD, Smibert JG, Thomas EM et al (1992) Thrombo-embolic prophylaxis in total knee replacement. Evaluation of the A-V impulse system. J Bone Jt Surg 74–78Google Scholar
  55. 55.
    Westrich GH, Allen ML, Tarantino SJ, Ghelman B, Schneider R, Laskin RS et al (1998) Ultrasound screening for deep venous thrombosis after total knee arthroplasty. 2-year reassessment. Clin Orthop Relat Res 356:125–133PubMedCrossRefGoogle Scholar
  56. 56.
    Abdel-Salam A, Eyres KS (1995) Effects of tourniquet during total knee arthroplasty. A prospective randomised study. J Bone Jt Surg Br 77(2):250–253Google Scholar
  57. 57.
    Harvey EJ, Leclerc J, Brooks CE, Burke DL, Anders MJ, Lifeso RM et al (1997) Effect of tourniquet use on blood loss and incidence of deep vein thrombosis in total knee arthroplasty. J Arthroplast 12:291–296CrossRefGoogle Scholar
  58. 58.
    Wakankar HM, Nicholl JE, Koka R, D'Arcy JC (1999) The tourniquet in total knee arthroplasty. A prospective, randomised study [see comments]. J Bone Jt Surg Br 81(1):30–33CrossRefGoogle Scholar
  59. 59.
    Irvine GB, Chan RN (1986) Arterial calcification and tourniquets. Lancet 2(8517):1217PubMedCrossRefGoogle Scholar
  60. 60.
    Wascher DC, Dvirnak PC, DeCoster TA (1997) Knee dislocation: initial assessment and implications for treatment. J Orthop Trauma 11(7):525–529PubMedCrossRefGoogle Scholar
  61. 61.
    Westrich GW, Allen ML, Tarantino S, Ghelman B, Schneider R, Laskin RS, Haas SB, Sculco TP (1998) Ultrasound screening for deep venous thrombosis after total knee arthroplasty. Clin Orthop Relat Res 336:125–133CrossRefGoogle Scholar

Copyright information

© Hospital for Special Surgery 2006

Authors and Affiliations

  • Geoffrey H. Westrich
    • 1
    • 2
  • Raz Winiarsky
    • 2
  • Michael Betsy
    • 3
  • Lena Maun
    • 2
  • Thomas P. Sculco
    • 1
    • 2
  1. 1.Department of Orthopedic SurgeryCornell University Medical CenterNew YorkUSA
  2. 2.Hospital for Special SurgeryNew YorkUSA
  3. 3.Dartmouth Medical SchoolHanoverUSA

Personalised recommendations