Elsevier

The Knee

Volume 28, January 2021, Pages 266-272
The Knee

Predictive value of lower extremity color doppler ultrasonography before knee arthroplasty on a postoperative cardiovascular event

https://doi.org/10.1016/j.knee.2020.12.014Get rights and content

Abstract

Background

The study intended to determine the presence of lower limb arterial calcification (LLAC) in lower extremity color Doppler ultrasonography (CDUS) before primary total knee arthroplasty (TKA) and its relation with cardiovascular events (CVE) during knee arthroplasty and the postoperative period, as well as to investigate its effect on surgical risk estimation.

Methods

We designed this study as a retrospective cohort study. The study comprised 467 patients who met the inclusion criteria and had surgery for a primary gonarthrosis diagnosis between January 2005 and December 2015 were included. In the study group, patients with arterial calcification in the lower extremity CDUS were included; however, those reported not to have it were included in the control group. The research data were obtained from preoperative anesthesia records and patient medical records.

Results

72% of the sample had preoperative cardiovascular comorbidity. There was no difference between the groups in terms of comorbidities, except for congestive heart failure (CHF) and peripheral artery disease (PAD). The groups did not differ in terms of ASA scores, either. Both pre- and post-operative CVEs, i.e., ischemic heart disease, dysrhythmia, and CHF, were statistically high in the study group. In terms of postoperative mortality, there was no statistical difference between the groups.

Conclusion

The study demonstrates that the presence of LLAC in CDUS is associated with increased risk of perioperative cardiovascular events (CVEs). Ultrasonographic detection of LLAC may give some idea the surgeon about the requirement for additional preoperative cardiac examinations.

Introduction

Total knee arthroplasty (TKA) is not a risk-free procedure, although it is a confirmed and quite successful intervention for moderate to severe arthritis of the knee [1]. Studies report that acute myocardial infarction (MI) is the most common cause of death after elective TKA [2], [3]. Therefore, in preoperative patient assessment, cardiovascular risk assessment is extremely important. Clinical indicators of the patient, the functional capacity of the patient, and the risk factors of the surgery are closely related to a cardiovascular event (CVE).

The primary causes of perioperative and postoperative cardiac morbidity and mortality increase include increase in the elderly population, the number of patients who underwent surgery, the number of high-risk patients and surgical procedures, and the increase in cardiovascular risk factors. Cardiac state may have a wide range of responses from systemic problems caused by tissue damage depending on the size and duration of surgery, neuroendocrine changes, stress responses emerging as tachycardia and hypertension because of surgical stress to MI, and heart failure.

A study of perioperative ischemia assessment reported that 6.9% of patients undergoing non-cardiac surgery and with known risk of cardiovascular disease developed major adverse cardiac event (MACE) in the postoperative period [4]. It is necessary to identify the risk factors of the patient that increase the risk of perioperative unwanted cardiac events and take the necessary measures. Certain preoperative clinical risk factors are defined; however, they are unavailable in at least half of all patients suffering from postoperative MI. This confirms that the preoperative risk classification of patients clearly requires additional development [5], [6]. In this manner, during and after the patient’s non-cardiac surgery, cardiac risk can be minimized.

In this context, this study aimed to detect any presence of lower limb arterial calcification (LLAC) in patients undergoing primary TKA using lower extremity color doppler ultrasonography (CDUS) before the arthroplasty procedure and to determine its relation with pre- and post-operative CVEs such as angina, MI, newly-developed heart failure and cardiovascular death during and after arthroplasty of the knee, which is a noncardiac surgery, and to investigate its effect on surgical risk estimation.

Section snippets

Materials and methods

The research was designed as a retrospective cohort study after the approval of the local ethics committee No: 18-KAEK-067. The study universe comprised patients diagnosed with gonarthrosis and performed TKA upon their admission to the Orthopedics and Traumatology Clinic of the university hospital between 2005 and 2015; however, the sample of the study included those patients who underwent elective primary knee arthroplasty with preoperative CDUS of the lower extremities. Patients with

Results

In this study, 40.2% of the sample had arterial changes, which included changes from arterial calcification wall to monophasic flow in the primary vascular structures of the lower extremities.

There was no difference between the study and control groups in terms of quantitative variables such as age, height, weight, and BMI (p > 0.05); however, when examined as a group of patients including solely those with monophasic and biphasic flow patterns, patients in this group were reported to have

Discussion

In studies, postoperative MI was identified as the leading cause of death after total joint arthroplasty (TJA) [2], [3]; therefore, in preoperative patient assessment, cardiovascular risk assessment is extremely important. Common risk factors that can cause cardiovascular complications after TJA include bilateral or revision arthroplasty, increased age, underlying heart disease, and arrhythmia history [5], [6], [7], [8].

Studies demonstrated that the presence of LLAC is associated with the risk

Conclusions

As per the results of our study, the presence of LLAC in arterial doppler ultrasound of the lower extremities is associated with increased risk of perioperative cardiovascular events. The ultrasonographic detection of arterial calcification in the lower extremity may give some idea to the surgeon that further preoperative cardiac examination may be required.

The fact that our study was conducted in a limited regional study area, retrospective data collection and the arterial doppler

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

This study was submitted as a doctoral thesis on 16 November 2018. We would like to extend our gratitude to Tokat Gaziosmanpaşa University Orthopedics and Traumatology Department and Cardiology Department for their cooperation.

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