The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 7

Scientific Articles | July 01, 2007

Prevalence of Pulmonary Embolism After Total Elbow Arthroplasty

Scott F.M. Duncan, MD, MPH¹; John W. Sperling, MD, MS²; Bernard F. Morrey, MD²

¹ Department of Orthopedic Surgery, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054. E-mail address: duncan.scott@mayo.edu
² Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905

View Disclosures and Other Information

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (Zimmer) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.

Investigation performed at the Departments of Orthopedic Surgery, Mayo Clinic, Scottsdale, Arizona, and Mayo Clinic, Rochester, Minnesota

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2007 Jul 01;89(7):1452-1453. doi: 10.2106/JBJS.F.01328

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Abstract

Background: Although numerous articles have addressed the risk of pulmonary embolism following total knee and total hip arthroplasty, we were unable to find comparable information for the risk following elbow arthroplasty. We therefore sought to determine the prevalence of pulmonary embolism after total elbow arthroplasty.

Methods: We conducted a retrospective review of the medical records of consecutive patients who had undergone primary elbow arthroplasty (816 procedures) or revision total elbow arthroplasty (260 procedures) at our tertiary-care academic medical institution between June 1981 and June 2001. Our purpose was to identify all patients in whom a pulmonary embolism developed after the surgery.

Results: Three patients had a pulmonary embolism and one died as a result of the complication during the twenty-year study period. Because of a low index of suspicion, the presenting symptoms of the pulmonary embolus were originally attributed to other causes of respiratory distress in two of the three patients.

Conclusions: These findings suggest that pulmonary embolism after total elbow arthroplasty is a rare but potentially fatal complication. Surgeons should consider this diagnosis when a patient exhibits respiratory distress after total elbow arthroplasty.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Pulmonary embolism is a well-recognized complication of total hip and knee arthroplasty, and others have defined the risk factors, provided prevalence data (1.79% to 2.27%), and determined the probability of death from a pulmonary embolism (0.05% to 0.22%) in this patient group^1-4. We found five articles on pulmonary embolism after shoulder arthroplasty^5-9, with only one providing prevalence data (0.173%). However, we found no reports on pulmonary embolism after total elbow arthroplasty. We therefore sought to determine its prevalence by reviewing a large sample of patients who had undergone either primary or revision elbow arthroplasty at the Mayo Clinic.

Materials and Methods

Materials and Methods | Results | Discussion | References

Between June 1981 and June 2001, 1076 prosthetic elbow arthroplasties (816 primary and 260 revision) were performed at our institution. Three patients (two women and one man) sustained a postoperative pulmonary embolism that was confirmed either with computed tomography or at autopsy. Patients were identified from the computerized joint-replacement database of our department of orthopaedic surgery, which, since 1969, has been used to prospectively follow all patients who have had a total joint arthroplasty. Any complications that occur during hospitalization or during the course of long-term clinical follow-up are recorded in the registry database. Furthermore, patients are contacted annually by database personnel according to a protocol to determine their status and to record any complications or other problems. Our institutional review board granted approval for us to conduct this research.

Perioperatively, we followed a standard prophylactic protocol, which included use of thromboembolic disease stockings and use of sequential compression devices on every patient. Postoperatively, we encouraged walking. No formal prophylaxis with anticoagulation medication was used in this series.

Results

Materials and Methods | Results | Discussion | References

In this study of 1076 total elbow arthroplasties, the overall prevalence of overt pulmonary embolism was 0.25% for primary arthroplasties (two of 816 patients) and 0.38% for revision arthroplasties (one of 260 patients). One (0.1%) of the 1076 patients died as a result of pulmonary embolism. None of the three patients with pulmonary embolism had a history of deep-vein thrombosis or a previous pulmonary embolism. The time to diagnosis of the pulmonary embolism ranged from the day of surgery to the third postoperative day. Neither of the two patients who had a primary arthroplasty had had prior elbow surgery.

All three patients presented with symptoms on the first, second, or third postoperative day, and the symptoms in two patients were initially attributed to other causes. The possibility of a pulmonary embolism was not considered initially in these two patients, which delayed definitive diagnosis and treatment.

Case Reports

Case 1. A forty-three-year-old woman with a history of juvenile rheumatoid arthritis underwent a total elbow arthroplasty. On the first postoperative day, she had shortness of breath and was diagnosed with atelectasis and respiratory distress. She subsequently went into respiratory arrest and died that same day. At autopsy, she was found to have had a massive pulmonary embolism.Case 2. A thirty-nine-year-old woman underwent total elbow arthroplasty on the right side because of rheumatoid arthritis. Shortness of breath developed on the third postoperative day. She was initially diagnosed with bronchitis. Later that day, a computed tomography scan was performed because of increasing shortness of breath, and a pulmonary embolism was diagnosed. She was treated with warfarin sodium for six months.Case 3. A fifty-seven-year-old man underwent a revision total elbow arthroplasty on the right side. The humeral component was inserted with the addition of an impaction cancellous graft and the ulnar component, with a strut graft. Two days after the surgery, shortness of breath developed and the patient was diagnosed with a possible pulmonary embolism. Ultrasound examination of the upper and lower extremities revealed no clot. On the third postoperative day, a computed tomography scan of the lung showed a pulmonary embolism. The patient was treated for three months with warfarin and survived.

Case 2. A thirty-nine-year-old woman underwent total elbow arthroplasty on the right side because of rheumatoid arthritis. Shortness of breath developed on the third postoperative day. She was initially diagnosed with bronchitis. Later that day, a computed tomography scan was performed because of increasing shortness of breath, and a pulmonary embolism was diagnosed. She was treated with warfarin sodium for six months.

Case 3. A fifty-seven-year-old man underwent a revision total elbow arthroplasty on the right side. The humeral component was inserted with the addition of an impaction cancellous graft and the ulnar component, with a strut graft. Two days after the surgery, shortness of breath developed and the patient was diagnosed with a possible pulmonary embolism. Ultrasound examination of the upper and lower extremities revealed no clot. On the third postoperative day, a computed tomography scan of the lung showed a pulmonary embolism. The patient was treated for three months with warfarin and survived.

Discussion

Materials and Methods | Results | Discussion | References

Although there has been extensive research on pulmonary embolism after total hip and knee arthroplasty, there is little information on this complication after total elbow arthroplasty. Our review indicates that the prevalence of pulmonary embolism after elbow arthroplasty is low. However, the fact that one of the three patients had a fatal event is sobering.

Our findings raise serious concerns about the potential misinterpretation of early symptoms of pulmonary embolism and the resulting delay in diagnosis. The symptoms of pulmonary embolism were initially attributed to other causes in two of our patients. Furthermore, the upper and lower-extremity ultrasound study in one patient failed to demonstrate a deep venous thrombosis. This lack of findings raises the additional concern that the clot could have originated in the pelvis or elsewhere rather than in the upper extremity. Thus, surgeons should be aware of these other potential sources of venous thrombosis after total elbow arthroplasty.

Our study demonstrated that pulmonary embolism is a rare but potentially fatal complication of total elbow arthroplasty. Surgeons should consider this possibility in any patient in whom respiratory difficulty develops after an upper-extremity arthroplasty. ?

References

Materials and Methods | Results | Discussion | References

Bjornara BT, Gudmundsen TE, Dahl OE. Frequency and timing of clinical venous thromboembolism after major joint surgery. J Bone Joint Surg Br.2006;88: 386-91.88386 2006 [PubMed][CrossRef]

Pellegrini VD Jr, Donaldson CT, Farber DC, Lehman EB, Evarts CM. Prevention of readmission for venous thromboembolic disease after total hip arthroplasty. Clin Orthop Relat Res.2005;441: 56-62.44156 2005 [PubMed][CrossRef]

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: 1675-80.871675 2005 [PubMed][CrossRef]

O'Reilly RF, Burgess IA, Zicat B. The prevalence of venous thromboembolism after hip and knee replacement surgery. Med J Aust.2005;182: 154-9.182154 2005 [PubMed]

Lyman S, Sherman S, Carter TI, Bach PB, Mandl LA, Marx RG. Prevalence and risk factors for symptomatic thromboembolic events after shoulder arthroplasty. Clin Orthop Relat Res.2006;448: 152-6.448152 2006 [PubMed][CrossRef]

Rockwood CA Jr, Wirth MA, Blair S. Warning: pulmonary embolism can occur after elective shoulder surgery — report of two cases and survey of the members of the American Shoulder and Elbow Surgeons. J Shoulder Elbow Surg.2003;12: 628-30.12628 2003 [PubMed][CrossRef]

Sperling JW, Cofield RH. Pulmonary embolism following shoulder arthroplasty. J Bone Joint Surg Am.2002;84: 1939-41.841939 2002 [PubMed]

Saleem A, Markel DC. Fatal pulmonary embolus after shoulder arthroplasty. J Arthroplasty.2001;16: 400-3.16400 2001 [PubMed][CrossRef]

Arcand M, Burkhead WZ Jr, Zeman C. Pulmonary embolism caused by thrombosis of the axillary vein after shoulder arthroplasty. J Shoulder Elbow Surg.1997;6: 486-90.6486 1997 [PubMed][CrossRef]

Topics

pulmonary embolism ; arthroplasty ; elbow replacement arthroplasty

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These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

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Scott F.M. Duncan, M.D.

Posted on October 03, 2007

Dr. Duncan et al. respond to Dr. Mereddy et al.

Mayo Clinic, Rochester, MN

We would like to thank Dr. Mereddy for his inquiries regarding our article(1). In response to his first question the third patient did not have any co-morbidities (unlike the first two). As mentioned in the article(1), our intra-operative protocol is to have TED hose and SCDs on all patients undergoing elbow arthroplasty. During the post-operative period, patients are placed on heparin or low-molecular weight heparin only if they have a history of previous deep venous thrombosis or if they are slow to mobilize in the post operative period. Our answer to the third question is a definitive â€œyesâ€. Since we wrote this paper, all patients undergoing total elbow arthroplasty are now counseled about the potential risk of DVT and PE as part of our consent process.

Reference:

1. Duncan SFM, Sperling JW, Morrey BF. Prevalence of pulmonary embolism after total elbow arthroplasty. J Bone Joint Surg Am. 2007;89:1452-1453.

Praveen K Mereddy

Posted on August 08, 2007

Prevalence of Pulmonary Embolism After Total Elbow Arthroplasty

Wirral University Teaching Hospital, UK

To The Editor:

We read this article(1) with great interest and appreciate the effort by the authors. However, the article raised a number of questions that we would like to pose to the authors and the readers of the Journal:

In their series, the prevalence of PE was 0.32%(3 out of 1076) and the prevalence of fatal PE was 0.1%. Two patients who had PE had a diagnosis of rheumatoid arthritis. A diagnosis of rheumatoid arthritis is a risk factor for thromboembolism(2). Did the third patient have any co- morbidities?

Would the authors recommend thromboprophylaxis to prevent DVT/PE in all patients undergoing total elbow arthroplasty or only in the high risk group such as patients with rheumatoid arthritis?

Do the authors warn candidates for total elbow arthroplasty about the risk of PE/Fatal PE in their informed consent?

The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

References:

1. Duncan SFM, Sperling JW, Morrey BF. Prevalence of pulmonary embolism after total elbow arthroplasty. J Bone Joint Surg Am. 2007;89:1452-1453.

2. Hanslow SS, Grujic L, Slater HK, Chen D. Thromboembolic disease after foot and ankle surgery.Foot Ankle Int. 2006 Sep;27(9):693-5.

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Scott F.M. Duncan, John W. Sperling, Bernard F. Morrey; Prevalence of Pulmonary Embolism After Total Elbow Arthroplasty. The Journal of Bone & Joint Surgery. 2007 Jul;89(7):1452-1453.

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