Clinical Orthopaedics and Related Research®

, Volume 470, Issue 2, pp 497–502 | Cite as

Overdiagnosis of Pulmonary Embolism: Evaluation of a Hypoxia Algorithm Designed to Avoid This Catastrophic Problem

  • Brian S. Winters
  • Mark Solarz
  • Christina L. JacovidesEmail author
  • James J. Purtill
  • Richard H. Rothman
  • Javad Parvizi
Symposium: Papers Presented at the Annual Meetings of The Hip Society



We observed a substantial increase in the incidence of pulmonary embolism (PE) after total joint arthroplasty (TJA) when multidetector computerized tomography (MDCT) replaced ventilation-perfusion (V/Q) scans as the diagnostic modality of choice. We questioned whether this resulted from the detection of clinically unimportant PE with the more sensitive MDCT and in 2007 instituted a hypoxia protocol to enhance the detection of PE.


We determined whether this new hypoxia protocol increased the specificity of our workups for suspected clinically important PE in the immediate postoperative period without affecting patient morbidity and mortality.

Patients and Methods

We compared the frequency of MDCT, V/Q scan and total investigations, incidence of PE, and overall mortality rates in the 3 years prior (January 2003 to December 2006) and 2 years after (January 2007 to November 2009) the implementation of the algorithm.


After instituting the protocol, we observed a trend toward a decrease in the number of patients worked up for PE (4.6 to 4.0 per 100 TJAs, 13.5% decrease). At the same time, there was an increase in the percent of positive findings of PE per workup for PE (23–33 positive PEs per 100 patients, 40.5% increase). All-cause mortality rates decreased for the 30-day period (3.1 to 1.4 per 1000 TJAs, 53.5% decrease) and the 90-day period (5.0 to 2.6 per 1000 TJAs, 48.3% decrease).


With the implementation of this algorithm, the specificity of our management of postoperative hypoxia and suspected clinically important PE improved without affecting patient morbidity or mortality.


Pulmonary Embolism Total Joint Arthroplasty Protocol Change Pulmonary Embolism Diagnosis Transient Hypoxia 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Austin L, Pulido L, Ropiak R, Porat M, Parvizi J, Rothman RH. Hypoxemia after total joint arthroplasty: a problem on the rise. J Arthroplasty. 2008;23:1016–1021.PubMedCrossRefGoogle Scholar
  2. 2.
    Carrier M, Righini M, Wells PS, Perrier A, Anderson DR, Rodger MA, Pleasance S, Le Gal G. Subsegmental pulmonary embolism diagnosed by computed tomography: incidence and clinical implications. A systematic review and meta-analysis of the management outcome studies. J Thromb Haemost. 2010;8:1716–1722.PubMedCrossRefGoogle Scholar
  3. 3.
    Cheely R, McCartney WH, Perry JR, Delany DJ, Bustad L, Wynia VH, Griggs TR. The role of noninvasive tests versus pulmonary angiography in the diagnosis of pulmonary embolism. Am J Med. 1981;70:17–22.PubMedCrossRefGoogle Scholar
  4. 4.
    Dalen JE, Alpert JS. Natural history of pulmonary embolism. Prog Cardiovasc Dis. 1975;17:259–270.PubMedCrossRefGoogle Scholar
  5. 5.
    Della Valle CJ, Jazrawi LM, Idjadi J, Hiebert RN, Stuchin SA, Steiger DJ, Di Cesare PE. Anticoagulant treatment of thromboembolism with intravenous heparin therapy in the early postoperative period following total joint arthroplasty. J Bone Joint Surg Am. 2000;82:207–212.PubMedGoogle Scholar
  6. 6.
    Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999;353:1386–1389.PubMedCrossRefGoogle Scholar
  7. 7.
    Lawton RL, Morrey BF. The use of heparin in patients in whom a pulmonary embolism is suspected after total hip arthroplasty. J Bone Joint Surg Am. 1999;81:1063–1072.PubMedGoogle Scholar
  8. 8.
    Le Gal G, Righini M, Parent F, van Strijen M, Couturaud F. Diagnosis and management of subsegmental pulmonary embolism. J Thromb Haemost. 2006;4:724–731.PubMedCrossRefGoogle Scholar
  9. 9.
    Oser RF, Zuckerman DA, Gutierrez FR, Brink JA. Anatomic distribution of pulmonary emboli at pulmonary angiography: implications for cross-sectional imaging. Radiology. 1996;199:31–35.PubMedGoogle Scholar
  10. 10.
    Parvizi J, Smith EB, Pulido L, Mamelak J, Morrison WB, Purtill JJ, Rothman RH. The rise in the incidence of pulmonary embolus after joint arthroplasty: is modern imaging to blame? Clin Orthop Relat Res. 2007;463:107–113.PubMedGoogle Scholar
  11. 11.
    Patel S, Kazerooni EA, Cascade PN. Pulmonary embolism: optimization of small pulmonary artery visualization at multi-detector row CT. Radiology. 2003;227:455–460.PubMedCrossRefGoogle Scholar
  12. 12.
    Patterson BM, Marchand R, Ranawat C. Complications of heparin therapy after total joint arthroplasty. J Bone Joint Surg Am. 1989;71:1130–1134.PubMedGoogle Scholar
  13. 13.
    Prologo JD, Gilkeson RC, Diaz M, Cummings M. The effect of single-detector CT versus MDCT on clinical outcomes in patients with suspected acute pulmonary embolism and negative results on CT pulmonary angiography. AJR Am J Roentgenol. 2005;184:1231–1235.PubMedGoogle Scholar
  14. 14.
    Remy-Jardin M, Pistolesi M, Goodman LR, Gefter WB, Gottschalk A, Mayo JR, Sostman HD. Management of suspected acute pulmonary embolism in the era of CT angiography: a statement from the Fleischner Society. Radiology. 2007;245:315–329.PubMedCrossRefGoogle Scholar
  15. 15.
    Schoepf UJ, Holzknecht N, Helmberger TK, Crispin A, Hong C, Becker CR, Reiser MF. Subsegmental pulmonary emboli: improved detection with thin-collimation multi-detector row spiral CT. Radiology. 2002;222:483–490.PubMedCrossRefGoogle Scholar
  16. 16.
    Storto ML, Di Credico A, Guido F, Larici AR, Bonomo L. Incidental detection of pulmonary emboli on routine MDCT of the chest. AJR Am J Roentgenol. 2005;184:264–267.PubMedGoogle Scholar
  17. 17.
    Strashun AM. A reduced role of V/Q scintigraphy in the diagnosis of acute pulmonary embolism. J Nucl Med. 2007;48:1405–1407.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2011

Authors and Affiliations

  • Brian S. Winters
    • 1
  • Mark Solarz
    • 1
  • Christina L. Jacovides
    • 1
    Email author
  • James J. Purtill
    • 1
  • Richard H. Rothman
    • 1
  • Javad Parvizi
    • 1
  1. 1.The Rothman Institute of Orthopedics at Thomas Jefferson University HospitalPhiladelphiaUSA

Personalised recommendations