Pulmonary Findings on Computed Tomography in Asymptomatic Total Joint Arthroplasty Patients

Abstract

An increase in the diagnosis of pulmonary embolus (PE) in the early postoperative period has been attributed to the use of multidetector 64-slice computed tomographic (CT) scans. It was suspected that this finding was the result of marrow or fat emboli that are commonly associated with arthroplasty rather than a true venous thromboembolic phenomenon. The purpose of this study was to determine the baseline pulmonary findings in asymptomatic patients after total joint arthroplasty (TJA). Over a 1-year period, an institutional review board-approved prospective study of 20 asymptomatic patients using a multidetector 64-slice CT scanner was performed. Overall, 15 TKAs and 5 total hip arthroplasties were included for analysis. All of the CT scans were negative for PE. There were no signs of microemboli or fat emboli on any scan. No patient went on to develop a PE at 2 years postoperatively. Despite the fact that emboli are created during TJA, if emboli are seen on a CT scan postoperatively, they should be assumed to be real events with clinical sequelae. If pulmonary symptoms develop postoperatively, they should not simply be assumed to be the result of fat or marrow embolism.

Keywords

asymptomatic - pulmonary embolism - total knee arthroplasty

• References

• 1 Freedman KB, Brookenthal KR, Fitzgerald Jr RH, Williams S, Lonner JH. A meta-analysis of thromboembolic prophylaxis following elective total hip arthroplasty. J Bone Joint Surg Am 2000; 82-A (7) 929-938
• 2 Westrich GH, Haas SB, Mosca P, Peterson M. Meta-analysis of thromboembolic prophylaxis after total knee arthroplasty. J Bone Joint Surg Br 2000; 82 (6) 795-800
• 3 Dalen JE, Alpert JS. Natural history of pulmonary embolism. Prog Cardiovasc Dis 1975; 17 (4) 259-270
• 4 Stein PD, Henry JW. Clinical characteristics of patients with acute pulmonary embolism stratified according to their presenting syndromes. Chest 1997; 112 (4) 974-979
• 5 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 (7) 1016-1021
• 6 Gandhi R, Salonen D, Geerts WH, Khanna M, McSweeney S, Mahomed NN. A pilot study of computed tomography-detected asymptomatic pulmonary filling defects after hip and knee arthroplasties. J Arthroplasty 2012; 27 (5) 730-735
• 7 Wiener RS, Schwartz LM, Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med 2011; 171 (9) 831-837
• 8 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 (4) 983-990
• 9 Parvizi J, Smith EB, Pulido L , et al. The rise in the incidence of pulmonary embolus after joint arthroplasty: is modern imaging to blame?. Clin Orthop Relat Res 2007; 463 (463) 107-113
• 10 Koessler MJ, Fabiani R, Hamer H, Pitto RP. The clinical relevance of embolic events detected by transesophageal echocardiography during cemented total hip arthroplasty: a randomized clinical trial. Anesth Analg 2001; 92 (1) 49-55
• 11 Lafont ND, Kostucki WM, Marchand PH, Michaux MN, Boogaerts JG. Embolism detected by transoesophageal echocardiography during hip arthroplasty. Can J Anaesth 1994; 41 (9) 850-853
• 12 Christie J, Burnett R, Potts HR, Pell AC. Echocardiography of transatrial embolism during cemented and uncemented hemiarthroplasty of the hip. J Bone Joint Surg Br 1994; 76 (3) 409-412
• 13 Murphy P, Edelist G, Byrick RJ, Kay JC, Mullen JB. Relationship of fat embolism to haemodynamic and echocardiographic changes during cemented arthroplasty. Can J Anaesth 1997; 44 (12) 1293-1300
• 14 Byrick RJ, Mullen JB, Mazer CD, Guest CB. Transpulmonary systemic fat embolism. Studies in mongrel dogs after cemented arthroplasty. Am J Respir Crit Care Med 1994; 150 (5 Pt 1): 1416-1422
• 15 Heinrich H, Kremer P, Winter H, Wörsdorfer O, Ahnefeld FW, Wilder-Smith O. Embolic events during total hip replacement. An echocardiographic study. Acta Orthop Belg 1988; 54 (1) 12-17
• 16 Pitto RP, Koessler M, Draenert K. The John Charnley Award. Prophylaxis of fat and bone marrow embolism in cemented total hip arthroplasty. Clin Orthop Relat Res 1998; (355) 23-34
• 17 Ereth MH, Weber JG, Abel MD , et al. Cemented versus noncemented total hip arthroplasty—embolism, hemodynamics, and intrapulmonary shunting. Mayo Clin Proc 1992; 67 (11) 1066-1074
• 18 Lafont ND, Kalonji MK, Barre J, Guillaume C, Boogaerts JG. Clinical features and echocardiography of embolism during cemented hip arthroplasty. Can J Anaesth 1997; 44 (2) 112-117
• 19 Caillouette JT, Anzel SH. Fat embolism syndrome following the intramedullary alignment guide in total knee arthroplasty. Clin Orthop Relat Res 1990; (251) 198-199
• 20 Orsini EC, Byrick RJ, Mullen JB, Kay JC, Waddell JP. Cardiopulmonary function and pulmonary microemboli during arthroplasty using cemented or non-cemented components. The role of intramedullary pressure. J Bone Joint Surg Am 1987; 69 (6) 822-832
• 21 Pitto RP, Schramm M, Hohmann D, Kössler M. Relevance of the drainage along the linea aspera for the reduction of fat embolism during cemented total hip arthroplasty. A prospective, randomized clinical trial. Arch Orthop Trauma Surg 1999; 119 (3–4) 146-150