Anti-clotting therapy may be used too often following orthopaedic surgery or trauma

Men and women who undergo joint replacement procedures, as well as those who have significant fractures, tend to be at an increased risk of developing pulmonary emboli (PE), blood clots that travel to the lungs where they may cause serious complications and even death. Patients are often aggressively treated with anticoagulants, or blood thinners, to help prevent the clots from forming, but a study published in the September 2012 issue of the Journal of the American Academy of Orthopaedic Surgeons indicates that some blood clots being identified by today's sensitive testing methods may not require aggressive treatments.

"If these clots break away from the wall of the blood vessel and travel to the lungs; this is called pulmonary emboli," said Paul Tornetta, MD, lead author of the study.

"Some recent studies have shown that while the incidence of diagnosis of pulmonary embolism is increasing, there is not a corresponding increase in mortality," Dr. Tornetta added. "What this suggests is that not all clots have the same clinical relevance - that is, they may not require the same aggressive level of blood thinners for treatment - and that increasingly sensitive tests may be picking up small, relatively insignificant clots that would not necessarily require treatment."

Risks of Treatment

Aggressive treatment of PE typically includes the use of anticoagulants to prevent blood clot propagation. However, orthopaedic patients also are at an increased risk for postoperative bleeding and blood thinner usage can increase that risk.

Accurately identifying blood clots that need treatment, as well as those that are not likely to cause complications, could help physicians reduce patient risks and improve outcomes. Currently, though, there are no standard guidelines for differentiating between clots that require treatment and those that do not. "Because these patients are at increased risk for both clot formation and bleeding events, they can pose a unique dilemma which can be very challenging to treat," Dr. Tornetta noted.

In addition to the increased PE risks associated with some orthopaedic procedures or injuries, other factors also can increase a patient's chances of developing one of these conditions, including:

Older age
Use of oral contraceptives
Having a personal or family history of PE
Undergoing extensive or prolonged surgical procedures
Undergoing a lengthy period of immobilization following surgery or trauma

Identifying Clots and Diagnosing PE

Many patients with PE have specific symptoms, including:

Sudden shortness of breathHowever, many orthopaedic patients with potentially dangerous clots do not have symptoms. For these patients, other methods of diagnosis must be used, including blood tests and imaging studies. The most common and popular imaging test is the computerized tomography pulmonary angiogram (CTPA), a very sensitive test that is capable of identifying potentially serious clots that could otherwise go undetected. But, because the CTPA is so sensitive, it may also identify much smaller clots which could resolve without use of anticoagulants.