Abstract
Background Elevated plasma levels of D-dimer have been found to be a useful screening tool in the diagnosis of deep venous thrombosis (DVT) in the general population. In the postoperative setting however their role is less clear.
In approximately 73% of NHS trusts D-dimer is a prerequisite test prior to radiological imaging to diagnose DVT.
This study evaluates the effectiveness of D-dimer as a screening tool for DVT in the postoperative period following total hip and knee arthroplasty.
Method Plasma D-dimer levels were measured pre operatively and on post-operative days 1, 3, 5, and 7 in 78 patients undergoing primary total hip or knee arthroplasty. On day 7 patients underwent bilateral duplex ultrasound scanning in order to confirm the absence of DVT.
All patients wore pneumatic foot pumps for DVT prophylaxis. Chemical thromboprophylaxis was not used. All patients were under the care of one surgeon with the same postoperative regimen.
Results D-dimer levels in the post-operative period were characterized by a double peak, on days 1 and 7. Mean day 1 value 3.63 (sd=2.72, range 0.60–14.34), mean day 7 value 2.83 (sd=1.58, range 1.10–10.30). Mean values on days 3 and 5 were 2.52 (sd=2.26, range 0.50–11.85) and 2.45 (sd=1.41, range 0.91–5.05)
Comparing D-dimer levels between hip and knee arthroplasty we found that both groups displayed the same trend in post-operative D-dimer levels (i.e. peaks at days 1 and 7); however levels were significantly higher following knee replacement (At day 7 p< 0.005)
We compared D-dimer levels of these patients with a second group of 43 patients who had a confirmed DVT following hip or knee arthroplasty. The mean D-dimer level in this group was 2.20 (sd=0.98 or range 0.80 – 4.46). This group was subdivided into two groups, those with D-dimer samples before (and including) day 7 and those after. We found a significant difference between the groups (p=0.01). Mean ≤ day 7 = 2.70. Mean > day 7 = 1.97.
The group of patients with Confirmed DVT on or before day 7 were compared with those free of clot. There was no significant difference found between the D-dimer levels of the two groups. (p=0.37)
Conclusion The D-dimer level is never normal (< 0.4mg/l), in the week following total hip or knee replacement and so cannot exclude a DVT. The level it rises to is indistinguishable form that seen in the population with a DVT and so cannot identify those patients in whom further investigation is warranted. Requesting a D-dimer test in this population wastes time and resources and is of no benefit.
Editoral Secretary Mr Peter Howard. Correspondence should be addressed to BHS at the Royal College of Surgeons, 35 - 43 Lincoln’s Inn Fields, London WC2A 3PN.
