132 – Concerning VTE risk, which surgeries can be considered major, and which surgeries can be considered non-major in hand surgery?

132 – Concerning VTE risk, which surgeries can be considered major, and which surgeries can be considered non-major in hand surgery?

Jacob E. Tulipan, Pedro Beredjiklian.

Response/Recommendation: Surgeries involving general anesthesia for >90 minutes, surgeries requiring bed rest or limited ambulation postoperatively, and surgeries involving replantation or free vascularized tissue transfer should be considered major in Hand Surgery.

Strength of Recommendation: Consensus.

Rationale: Risk factors for venous thromboembolism (VTE) following hand surgery are poorly studied.  This is partly due to the very low incidence of these adverse events, which was determined to be 0.0018% by Hastie et al., in a sample of 3,357 consecutive upper extremity surgeries1.  As a result, it is extremely challenging to stratify procedures into high- or low-risk categories for VTE.

Some studies of VTE risk following surgical procedures have included hand and wrist surgery in their samples.  A study by Keller et al., of VTE following endoprosthesis surgeries included 183,420 upper extremity surgeries and reported a 0.4% incidence of VTE (2.69 times lower than that of lower extremity endoprosthesis surgery), but this study did not differentiate between hand, wrist, elbow, and shoulder procedures2.  Similarly, studies investigating VTE prophylaxis following free tissue transfer have included upper extremity tissue transfers.  Ricci et al., recommended subcutaneous heparin VTE prophylaxis following upper extremity free flaps, but based this recommendation on expert opinion given the lack of available evidence3.  A National Surgical Quality Improvement Program (NSQIP) database study of VTE following plastic surgery analyzed 19,276 plastic surgery cases performed under general anesthesia and found a VTE incidence of 1.3% in cases lasting over 5 hours.  In cases lasting less than 5 hours, VTE incidence was less than 0.36%.  There were no hand surgical procedures that resulted in >2 VTE within this sample, although the total number of hand surgical cases that were complicated by VTE was not reported4.  Consensus guidelines from the British Society for Surgery of the Hand (BSSH) currently recommend mechanical VTE prophylaxis for cases under general anesthesia lasting >90 minutes and/or in patients with at least one VTE risk factor and recommend the consideration of pharmacological prophylaxis in patients undergoing >90 minutes of general anesthesia with more than one risk factor, or prolonged immobility5.

Given the lack of evidence differentiating high- and low-risk hand surgeries, further study in this topic is needed, and current recommendations are based on a consensus of opinion among experts.


1.         Hastie GR, Pederson A, Redfern D. Venous thromboembolism incidence in upper limb orthopedic surgery: do these procedures increase venous thromboembolism risk? J Shoulder Elbow Surg. 2014;23(10):1481-1484. doi:10.1016/j.jse.2014.01.044

2.         Keller K, Hobohm L, Engelhardt M. Risk of venous thromboembolism after endoprosthetic surgeries: lower versus upper extremity endoprosthetic surgeries. Heart Vessels. 2019;34(5):815-823. doi:10.1007/s00380-018-1305-3

3.         Ricci JA, Crawford K, Ho OA, Lee BT, Patel KM, Iorio ML. Practical Guidelines for Venous Thromboembolism Prophylaxis in Free Tissue Transfer. Plast Reconstr Surg. 2016;138(5):1120-1131. doi:10.1097/PRS.0000000000002629

4.         Mlodinow AS, Khavanin N, Ver Halen JP, Rambachan A, Gutowski KA, Kim JYS. Increased anaesthesia duration increases venous thromboembolism risk in plastic surgery: A 6-year analysis of over 19,000 cases using the NSQIP dataset. J Plast Surg Hand Surg. 2015;49(4):191-197. doi:10.3109/2000656X.2014.981267

5.         Roberts DC, Warwick DJ. Updated recommendations for venous thromboembolism prophylaxis in hand, wrist and elbow surgery. J Hand Surg Eur Vol. 2019;44(10):1107-1108. doi:10.1177/1753193419871665

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