Plasma D-dimer is not useful in the prediction of deep vein thrombosis after total knee arthroplasty in patients using rivaroxaban for thromboprophylaxis

Abstract

Background: Venous thromboembolism (VTE) is a serious complication following total joint replacement. The use of rivaroxaban, a highly selective and direct factor Xa inhibitor, has been used widely as a safe and efficacious way to prevent VTE after total joint replacements. However, little is known about the diagnostic efficacy of plasma D-dimer test on deep vein thrombosis (DVT) in patients using rivaroxaban for thromboprophylaxis. The study is aimed to investigate the trend and the diagnostic efficacy of D-dimer test on DVT in patients with primary total knee arthroplasty (TKA) using rivaroxaban for thromboprophylaxis.

Methods: Two hundred TKA patients using rivaroxaban postoperatively as chemical prophylaxis were reviewed. D-dimer levels were checked at 4 h after the surgery and on postoperative days 1 and 4. Venography was used to document the presence of DVT. The Mann-Whitney U test was used to detect the differences in the D-dimer levels at different time points in patients with and without DVT, followed by Bonferroni corrections for p values. Receiver operating characteristics (ROC) curves were constructed to determine the best cutoff values of the D-dimer test at each time point after the surgery.

Results: Twenty-nine of the 200 patients were found to have deep vein thrombosis by venography, resulting in an incidence of 14.5%. All patients with DVTs occurred in the distal calf veins, and only one patient was symptomatic. We found significant differences in D-dimer concentration between patients with and without DVT at postoperative day 4. The best cutoff value determined by receiver operating characteristics analysis was 3.8 mg/L at postoperative day 4, with an AUC equal to 63.5%, and a sensitivity, specificity, PPV, and NPV of 58.6, 76, 29.3, and 91.5%, respectively.

Conclusions: Rivaroxaban was effective on reducing DVT in patients undergoing TKA. Because all the DVTs occurred in the leg veins, decreased thrombus volume and size might result in poor accuracy of plasma D-dimer test in prediction or diagnosis of postoperative DVT.

Keywords: D-dimer; Deep vein thrombosis; Rivaroxaban; Thromboprophylaxis; Total knee arthroplasty; Venous thromboembolism.

Fig. 1

Longitudinal changes of the D-dimer levels after TKA. The D-dimer levels reached a peak value at 4 h after the surgery and decreased gradually on POD1 and POD4 in both DVT (+) and DVT (−) groups. The D-dimer levels were significantly higher in patients with DVT than in patients without DVT on POD4

Fig. 2

Receiver operating characteristics (ROC) curves for plasma D-dimer in the diagnosis of DVT. The AUCs of plasma D-dimer at 4 h after surgery, POD1, and POD4 were 0.547 (p = 0.42), 0.58 (p = 0.17), and 0.635 (p = 0.02), respectively. AUC, area under curve