Pulmonary Embolism in Orthopaedic Patients: Diagnosis and Treatment

Venous thromboembolism (VTE) is a spectrum that includes deep venous thrombosis (DVT) and pulmonary embolism (PE). Patients who undergo major lower extremity orthopaedic procedures such as hip and knee arthroplasty, lower extremity fracture repair, and treatment of trauma are among the highest risk for the development of VTE. For postoperative orthopaedic patients, symptomatic presentation with VTE is typically delayed and has been estimated at 17 days for hip arthroplasty and 7 days for knee arthroplasty. A high level of clinical suspicion is needed when patients present with symptoms. Diagnosis can never be made on clinical assessment, but must be based on objective testing. Spiral computed tomography (CT), ventilation–perfusion lung scan, compression ultrasound, and D-dimer testing all contribute to the diagnostic evaluation for PE. Specific algorithms are reviewed to assist in the choice of testing for individual clinical presentations. Low-molecular-weight heparin is currently the treatment of choice for VTE and many patients can be safely treated at home. The duration of warfarin therapy for surgical patients can be as short as 3 months. Long-term complications of VTE include risk of recurrent VTE, postthrombotic syndrome, and chronic thromboembolic pulmonary hypertension.