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Original Article http://dx.doi.org/10.3349/ymj.2015.56.1.

139
pISSN: 0513-5796, eISSN: 1976-2437
Yonsei Med J 56(1):139-145, 2015

Incidence of Deep Vein Thrombosis after Major Lower Limb


Orthopedic Surgery: Analysis of a Nationwide Claim Registry
Seung Yeol Lee,1* Du Hyun Ro,2* Chin Youb Chung,2 Kyoung Min Lee,2
Soon-Sun Kwon,3 Ki Hyuk Sung,4 and Moon Seok Park2
Department of Orthopaedic Surgery, Ewha Womans University Mokdong Hospital, Seoul;
1

2
Department of Orthopaedic Surgery, 3Biomedical Research Institute, Seoul National University Bundang Hospital, Seongnam;
4
Department of Orthopaedic Surgery, Myongji Hospital, Goyang, Korea.

Received: January 28, 2014 Purpose: We aimed to evaluate the nationwide incidence and risk factors for symp-
Revised: April 5, 2014 tomatic deep vein thrombosis (DVT) after major lower limb orthopedic surgeries.
Accepted: April 15, 2014 Materials and Methods: The Korean Health Insurance Review and Assessment
Corresponding author: Dr. Moon Seok Park,
Service database was used to retrospectively identify International Classification of
Department of Orthopedic Surgery,
Seoul National University Bundang Hospital,
Disease-10 codes for DVT and operation codes representing hip arthroplasty, knee
82 Gumi-ro 173beon-gil, Bundang-gu, arthroplasty, and hip fracture surgeries. The age- and gender-adjusted annual inci-
Seongnam 463-707, Korea. dence of DVT, rates of major lower limb orthopedic surgeries, and the postoperative
Tel: 82-31-787-7203, Fax: 82-31-787-4056 incidence of DVT according to the surgical procedure were assessed. Results: The
E-mail: pmsmed@gmail.com
age- and gender-adjusted annual incidence of DVT was 70.67 per 100000 persons/
year. Compared to patients aged <49 years, the relative risk of DVT was five times
*Seung Yeol Lee and Du Hyun Ro contributed
equally to this work. higher in patients aged 50‒69 and 10 times higher in patients aged >70 years
(p<0.001). Females showed a greater relative risk for DVT than males (1.08;
∙ The authors have no financial conflicts of p<0.001). The incidence of postoperative DVT, according to the type of surgery, was
interest. significantly greater for knee replacement arthroplasty than for other forms of sur-
gery (p<0.002). The relative risk of postoperative DVT was higher in females in
knee replacement arthroplasty (1.47) and hip fracture surgery (2.25) groups, al-
though relatively lower in those who underwent hip replacement arthroplasty (0.97).
Conclusion: Among major lower limb surgeries, advanced age, female gender, and
undergoing a knee replacement arthroplasty were found to be risk factors for devel-
oping postoperative DVT. These findings further emphasize the need for orthopedic
surgeons to consider the development of DVT after surgery in high-risk patients.

Key Words: Deep vein thrombosis, incidence, hip arthroplasty, knee arthroplasty,
hip fracture surgery

© Copyright:
INTRODUCTION
Yonsei University College of Medicine 2015
This is an Open Access article distributed under the Deep vein thrombosis (DVT) is a major medical problem characterized by throm-
terms of the Creative Commons Attribution Non-
Commercial License (http://creativecommons.org/ bi formation in the deep venous system and can result in a fatal pulmonary embo-
licenses/by-nc/3.0) which permits unrestricted non-
commercial use, distribution, and reproduction in any
lism (PE). DVT occurs most commonly in the legs, although thrombi can also
medium, provided the original work is properly cited. form in the veins of the arms as well.1 In the United States, DVT and PE result in

Yonsei Med J http://www.eymj.org Volume 56 Number 1 January 2015 139


Seung Yeol Lee, et al.

up to 600000 hospitalizations a year, and nearly 50000 indi- is obliged to enroll in the government-operated National
viduals die annually as a result of PE.2 Health Insurance (NHI) program, which is the only public
Hip arthroplasty, knee arthroplasty, and hip fracture ortho- medical insurance system. There are no exceptions for unem-
pedic surgeries are strongly associated with a risk of develop- ployed or part-time workers. Patients typically pay approxi-
ing DVT.2-4 The incidence of asymptomatic DVT after a ma- mately 30% of the medical cost, and hospitals or clinics sub-
jor orthopedic surgery without prophylaxis reportedly ranges mit claims, with details on diagnostic codes, demographic
from 30% to 80%,2,5,6 whereas the incidence of symptomatic and medication data, operation codes, and operative re-
DVT reportedly ranges from 0.5% to 4%.4,7 Although the cords, to the NHI for the remainder of the medical cost. Im-
incidence of asymptomatic DVT is greater than that of symp- portantly, the HIRA database contains claim records from
tomatic DVT, the clinical importance of asymptomatic DVT all medical facilities in Korea. The remaining 3% of popu-
remains unclear.8,9 Indeed, asymptomatic DVT rarely causes lation not insured by the NHI program are either covered by
symptomatic PE and most asymptomatic DVT cases include the Medical Aid Program of Korea or are illegal residents;
isolated DVT of the calf that is usually detected by venogra- claims from these patients are also reviewed by the HIRA.
phy.10 However, estimates indicate that 40‒50% of untreated Therefore, a nationwide study was possible given that every
symptomatic DVT patients will develop a PE within 3 claim record, along with its diagnostic code, is electronically
months and 10% of symptomatic PE cases will die within 1 collected via the HIRA database. According to the HIRA da-
hour of onset.10,11 Therefore, as the objective of DVT pre- tabase, 99.9% of Koreans were registered in 2009.
vention is to prevent fatal PE, elucidating the incidence of
symptomatic DVT, as a surrogate marker for PE, is of criti- Data collection
cal importance. We identified DVT cases using the International Classifica-
Hip and knee arthroplasties rank high among the most suc- tion of Diseases (ICD-10) system. The codes for DVT were
cessful surgeries performed in the orthopedic field, and ap- I80.2 [DVT, not otherwise specified (NOS)] and I80.3 (em-
proximately 1 million arthroplastic surgeries are performed bolism or thrombosis of the lower extremity, NOS). Major
annually in the United States or Europe.12,13 Although, ortho- orthopedic procedures of the lower limbs were identified
pedic surgeons are encouraged to consider the development using the HIRA operation code classification system. Hip
of DVT, there are no nationwide reports on the incidence of arthroplasty, knee arthroplasty, and hip fracture surgeries
symptomatic DVT after major orthopedic surgery. In the pres- were considered as major lower limb orthopedic proce-
ent study, we aimed to use a national claim registry to evalu- dures. Hip replacement arthroplasty included total hip re-
ate the incidence and risks factor for the development of placement arthroplasty, revision total hip replacement ar-
symptomatic DVT after major lower limb orthopedic surgery. throplasty, and bipolar hemiarthroplasty. Knee replacement
We also attempted to evaluate whether the incidence of post- arthroplasty consisted of total knee arthroplasty, revision to-
operative DVT varies among major orthopedic operations. tal knee arthroplasty, unicompartmental knee replacement
arthroplasty, and revision for unicompartmental knee re-
placement arthroplasty. Hip fracture surgery included closed
MATERIALS AND METHODS reduction of the femur, open reduction of the femur, and ex-
ternal fixator application for the femur and the pelvic bone.
The present study was exempt from Institutional Review Postoperative DVT was considered in cases where the DVT
Board review because it did not involve human subjects. codes were claimed within 4 weeks postoperatively.

Data source and study population Incidence of DVT and the rates of major orthopedic
We investigated the incidence of DVT from 2007 to 2011 surgeries
using a nationwide database maintained by the Korean Demographic data (e.g., gender and age) were obtained
Health Insurance Review and Assessment Service (HIRA). from the HIRA database. We divided the subjects into 10-
The HIRA is a non-profit agency that is responsible for re- year age groups. The crude annual incidence of DVT was
viewing medical fees, as well as evaluating the appropriate- calculated using the number of patients with DVT and the
ness of health care services provided to health insurance total Korean population for the respective year. The annual
beneficiaries. Approximately 97% of the Korean population incidence of DVT according to age was also calculated. As

140 Yonsei Med J http://www.eymj.org Volume 56 Number 1 January 2015


DVT after Major Lower Limb Orthopedic Surgery

Table 1. The Annual Nationwide Population of South Korea


2007 2008 2009 2010 2011
Male 24,944,131 25,102,682 25,241,212 25,379,265 25,536,889
Female 24,728,257 24,898,375 25,049,559 25,201,926 25,371,756
Total 49,672,388 50,001,057 50,290,771 50,581,191 50,908,645

there were differences in the population size for each year Table 2. Relative Risk of Deep Vein Thrombosis (DVT) Ac-
with regard to age and gender, the age- and gender-adjusted cording to Age, Year, and Gender. Old Age and Female Gen-
der Were Risk Factors for Developing DVT
annual incidence of DVT was also calculated, after adjust-
RR (95% CI) p value
ing with the 2009 population.
Age group
The age- and gender-adjusted rates of major orthopedic 0‒49 1
surgeries in the South Korean population from 2007 to 2011 50‒69 5.12 (5.11‒5.13) <0.001
were calculated. The data for knee replacement arthroplasty ≥70 10.68 (10.67‒10.70) <0.001
was evaluated from 2008 to 2011. The postoperative inci- Gender
dence of DVT according to the surgical procedure was also Male 1
assessed. Female 1.08 (1.07‒1.09) <0.001
RR, relative risk; CI, confidence interval.
Statistical analysis
350
The surgery rate per 100000 persons/year and the 95% con-
Annual incidence of DVT per 105 per year

fidence intervals were calculated on the basis of the Poisson 300

distribution for the observed number of DVT cases. The 250


relative risk of DVT between genders for the different sur-
200
geries was assessed using the ratio of these rates, along with
95% confidence intervals. Data were analyzed using SPSS 150
Statistics, version 20.0, for Windows (IBM Co., Chicago,
100
IL, USA). All statistics were two-tailed and all p-values less
than 0.05 were considered statistically significant. 50

0
0–49 50–69 ≥70
RESULTS Age group
Fig. 1. The age- and gender-adjusted annual rate of major lower limb ortho-
pedic surgeries in the South Korean population. DVT, deep vein thrombosis.
The population of South Korea in 2007 was approximately
50,000,000 and increased annually until 2011. The popula- 120
HRA
tion comprised a greater number of males than females (Ta-
Number of surgery per 105 persons/year

HFS
100 KRA
ble 1).
When adjusted for age and gender, the overall annual in- 80
cidence of DVT was 70.67 per 100000 persons/year, and
this value annually increased during the 5-year period of 60

the study. DVT incidence also increased with age (Fig. 1).
40
Indeed, when compared to patients aged <49 years, the rel-
ative risk of DVT was five times higher in patients aged 20
50‒69 years and 10 times higher in patients aged >70 years
0
(p<0.001). Interestingly, females showed a greater relative 2007 2008 2009 2010 2011
risk for DVT than males (p<0.001) (Table 2). Year
From 2007 to 2011, 89710 hip replacement arthroplasties Fig. 2. Annual change in surgery number per 100000 persons/year. The
number of all of the major lower limb orthopedic surgeries performed in-
and 75328 hip fracture surgeries were performed, whereas creased annually over the 5 years examined. HRA, hip replacement arthro-
180611 knee replacement arthroplasties were performed plasty; KRA, knee replacement arthroplasty; HFS, hip fracture surgery.

Yonsei Med J http://www.eymj.org Volume 56 Number 1 January 2015 141


Seung Yeol Lee, et al.

from 2008 to 2011. The annual number of the major ortho-


Hip replacement arthroplastry
700 pedic surgeries increased over the 5 years of evaluation (Fig.
2). The relative risk for major lower limb orthopedic surgery
600
Number of surgery per 105 persons/year

Male was higher in females than in males. The relative risk for hip
Female replacement arthroplasty and hip fracture surgery in females
500
was 1.54 [95% confidence interval (CI), 1.38‒1.70] and 1.66
400 (95% CI, 1.47‒1.85), respectively. Females were also more
likely to require knee replacement arthroplasty than males
300
(relative risk, 7.45; 95% CI, 6.90‒8.00) (Fig. 3).
200 The overall incidences of DVT in patients undergoing
hip replacement arthroplasty, knee replacement arthroplas-
100
ty, and hip fracture surgery were 0.15%, 0.22%, and 0.16%,
0 respectively. Furthermore, the relative risk of DVT after a
20–29 30–39 40–49 50–59 60–69 70–79 Over 80 major lower limb orthopedic surgery increased with age.
Age group
A Compared with the patients aged 20‒49 years, the relative
risk in the older age groups increased from 1.2- to 2.8-fold.
Knee replacement arthroplastry
1200 The incidence of postoperative DVT according to the type
Male of surgery was significantly higher for knee replacement ar-
Number of surgery per 105 persons/year

1000 Female throplasty, compared to those for hip replacement arthro-


plasty and hip fracture surgery (p<0.002) (Table 3, Fig. 4).
800
The relative risk for DVT was higher in females than in
males for knee replacement arthroplasty (relative risk, 1.47)
600
and hip fracture surgery (relative risk, 2.25) groups. How-
ever, for hip replacement arthroplasty, the relative risk in fe-
400
males (relative risk, 0.97) was similar to that in males.
200

DISCUSSION
0
20–29 30–39 40–49 50–59 60–69 70–79 Over 80
Age group
B This study is the first nationwide investigation of DVT after
Hip fracture surgery
major lower limb orthopedic surgery. The age- and gender-
600
adjusted annual incidence of DVT was 70.67 per 100000
persons/year, and this value showed an annual increase
Number of surgery per 105 persons/year

500
Male over the 5-year period examined. Additionally, the inci-
Female
dences of postoperative DVT for hip replacement arthro-
400
plasty, knee replacement arthroplasty, and hip fracture sur-
300
geries were 0.15%, 0.22%, and 0.16%, respectively.
The definition of postoperative DVT varies among stud-
200 ies in the literature. DVT has been reported to occur up to 3
months postoperatively.14,15 However, most thromboembol-
100 ic events after elective orthopedic surgery are reported to
develop during the first postoperative week.16,17 In patients
0 who develop DVT after 4 weeks postoperatively, the causal
0–9 10–19 20–29 30–39 40–49 50–59 60–69 70–79 Over 80
relationship between surgery and DVT is not clear. There-
Age group
C fore, we defined postoperative DVT as DVT that developed
Fig. 3. The number of surgery per 100000 persons/year according to type of
surgery and age. (A) Hip replacement arthroplasty, (B) knee replacement
within 4 weeks postoperatively.
arthroplasty, and (C) hip fracture surgery. The age- and gender-adjusted nationwide annual inci-

142 Yonsei Med J http://www.eymj.org Volume 56 Number 1 January 2015


DVT after Major Lower Limb Orthopedic Surgery

Table 3. Annual Number of Postoperative Deep Vein Thrombosis (DVT) in Each Age Group According to the Major Lower
Limb and Orthopedic Surgery Performed
HRA KRA Hip Fx
Total Total Total
20‒49 50‒69 ≥70 20‒49 50‒69 ≥70 20‒49 50‒69 ≥70
(95% CI) (95% CI) (95% CI)
Postoperative DVT
14 42 76 132 2 202 188 392 6 23 89 118
case
Operation case 11406 28288 49917 89710 1414 93950 85142 180611 8473 18799 44237 75328
0.15 0.22 0.16
Incidence rate (%) 0.12 0.15 0.15 0.14 0.22 0.22 0.07 0.12 0.20
(0.12‒0.17) (0.20‒0.24) (0.13‒0.19)
Relative risk 1 1.21 1.24 1 1.52 1.56 1 1.73 2.8
HRA, hip replacement arthroplasty; KRA, knee replacement arthroplasty; Hip Fx, surgery for hip fracture; CI, confidence interval.

dences of DVT in the present study are comparable, or 0.30


slightly lower, than those of previous reports from Western

Incidence of postoperative DVT (%)


0.25
populations.18,19 Interracial differences,20 genetic factors, and
a Western lifestyle may affect the incidence of DVT. In- 0.20
deed, the adoption of a Westernized lifestyle, the aging pop-
ulation of South Korea, and the development of new diag- 0.15

nostic tools may have contributed to the annual increases in 0.10


the incidence of DVT in the current study. However, re-
search is lacking on these issues and future investigations 0.05

regarding ethnic, genetic, and lifestyle factors are required.


0.00
Old age is a well-known risk factor for DVT, which was HRA KRA HFS
also confirmed in our study.18,21,22 Moreover, elderly indi- Type of surgery

viduals are more likely to require a major operation or may Fig. 4. The incidence of postoperative deep vein thrombosis (DVT) accord-
ing to the type of orthopedic surgery. The incidence of postoperative DVT
be immobilized due to medical problems. Our current find- was significantly higher for knee replacement than that for hip replace-
ings also showed that females are at a greater risk for DVT ment and hip fracture surgery. HRA, hip replacement arthroplasty; KRA,
knee replacement arthroplasty; HFS, hip fracture surgery.
and postoperative DVT; no consensus has been reached re-
garding differences in the incidence of DVT according to Interestingly, we found that knee replacement arthroplasty
gender in previous studies.19,23,24 cases showed the highest incidence of postoperative DVT.
Orthopedic surgery is a well-known risk factor for DVT. Previous Asian studies of major orthopedic surgeries, fol-
The release of thromboplastin from the dissected soft tissue lowed by venography, have shown similar results.6,26 Al-
and reamed bone, as well as venous stasis during surgery and though these previous investigations focused on the inci-
postoperative immobility, are responsible for high rates of dence of postoperative asymptomatic DVT, whereas we
DVT.13 The rate of all of the major lower limb orthopedic evaluated symptomatic DVT, it is important to note that the
surgeries that were evaluated in this study increased annually, highest rate of proximal DVT was also observed in knee re-
and this trend is similar to those reported in previous stud- placement arthroplasty patients.6 Given that proximal DVT
ies.12,25 As mentioned above, an aging population and eco- is associated with a higher risk of embolization, compared
nomic growth may have contributed to increases in the rate to distal DVT,27 the incidence of DVT after knee replace-
of major orthopedic surgeries. Furthermore, both kneeling ment surgery should be considered very carefully. Overall,
and squatting are strong risk factors for degenerative arthritis as the rate of major orthopedic surgeries increases, the inci-
of the knee. Koreans commonly kneel or squat throughout dence of postoperative DVT will also likely increase.
their daily activities. This cultural characteristic greatly in- Several limitations of the current study should be consid-
creases the likelihood of needing a surgery, and therefore, ered. First, the data were retrieved according to diagnostic
maintaining knee flexion (which enables kneeling and squat- codes and not on an individual patient basis. Therefore, we
ting) may be an important factor when deciding to undergo could not evaluate whether the DVT cases were recurrent in
surgery in Koreans.12 the same patient and year. The cause of arthroplasty, which

Yonsei Med J http://www.eymj.org Volume 56 Number 1 January 2015 143


Seung Yeol Lee, et al.

varies between patients and might affect the incidence of 6. Piovella F, Wang CJ, Lu H, Lee K, Lee LH, Lee WC, et al. Deep-
DVT, could also not be evaluated. In addition, cases of bi- vein thrombosis rates after major orthopedic surgery in Asia. An
epidemiological study based on postoperative screening with cen-
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lieve that the current diagnosis-based results, compared to 2005;3:2664-70.
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monary embolism following hip and knee arthroplasty among pa-
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the number of times the patient had presented. Second, the JAMA 2012;307:294-303.
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sen MR, et al. Prevention of venous thromboembolism: American
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Physicians guidelines for venous thromboembolism prevention in
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