153 – Concerning VTE risk, which surgeries can be considered major, and which surgeries can be considered non-major in shoulder and elbow surgery?

Alexander Rondon, Brian C. Werner, Surena Namdari.

Response/Recommendation: Shoulder arthroscopy, non-fracture-related shoulder arthroplasty, and all elbow procedures can be considered non-major venous thromboembolism (VTE) risk. Fracture-related shoulder procedures can be considered major VTE risk.

Strength of Recommendation: Limited.

Rationale: VTE following shoulder and elbow surgery are rare events. One study reported for all upper extremity deep venous thromboses (DVT) to represent 1% to 4% of all DVT¹. In the shoulder, surgeries can be divided into arthroscopic, non-fracture shoulder arthroplasty, and fracture-related surgeries. In the elbow, surgeries can be divided into arthroscopy, fracture-related, and arthroplasty. With respect to these surgeries, several studies have reported VTE rates, however, a majority of this information comes from a collection of level 3 and level 4 evidence along with registry studies.

In shoulder arthroscopy, VTE rates are low with reported rates ranging from 0.011% to 0.38%^2–6. Kuremsky et al., in a retrospective study of 2,872 patients undergoing shoulder arthroscopy reported VTE rate of 0.24%². Jameson et al., in a registry study out of the United Kingdom, reported 0.011% VTE rate in a retrospective review of 65,302 shoulder arthroscopy cases³. Similarly, Brislin et al., reported VTE rate of 0.38% in a consecutive series of 263 arthroscopic rotator cuff repairs (RCR)⁴. These VTE rates following arthroscopic RCR were similar to rates reported by Hoxie et al., (0.26%)⁵. Additionally, open instability surgeries also comprise higher VTE risk than their arthroscopic counterparts. Goodloe et al., in a registry study compared arthroscopic Bankart repair, open Bankart repair, and Latarjet-Bristow procedure with reported VTE rates of 0.1% , 0.0%, and 0.8%, respectively⁷. Thus, shoulder arthroscopy procedures can be considered non-major concerning VTE risk.

In shoulder arthroplasty, a distinction must be made between non-fracture indications for primary shoulder arthroplasty (glenohumeral arthritis or rotator cuff arthropathy) and arthroplasty for fracture. For non-fracture arthroplasty, VTE rates have ranged from 0.16% to as high as 13%^3,8–11. Sperling and Cofield in a 20-year respective review of 2,885 shoulder arthroplasties reported 0.17% VTE rate¹². In a UK registry study, Jameson et al., reported VTE rate of 0.16% for 10,229 shoulder arthroplasties³. Other registry studies have reported similar rates with Lyman et al., reporting 0.68% VTE rate (69 DVT, 32 PE) in 13,759 shoulder arthroplasties⁹, Lovy et al., also reported 0.35% VTE rate (20 VTE) in 5,801 total shoulder arthroplasty (TSA)¹¹, and Young et al., reported a pulmonary embolism (PE) rate of 0.25% in 422,372 TSA⁸.  Furthermore, Kirsch et al., in a retrospective review of 2,141 primary arthroplasty patients receiving aspirin 81 mg as chemoprophylaxis report a VTE rate of 0.56%¹⁰. Willis et al., in an observational trial of 100 consecutive patients reported VTE rate of 13%, however, all patients were screened irrespective of symptoms¹³. These findings suggest that reported VTE rates may be underrepresented. Tashjian et al., present higher symptomatic VTE rates of 2.6% (14/533) (5 DVT and 12 PE) in single-institution retrospective review¹⁴. Primary shoulder arthroplasty for non-fracture indications can be considered non-major concerning symptomatic VTE risk.

For proximal humerus fracture related surgery, VTE rates can be delineated between open reduction internal fixation (ORIF) and arthroplasty. In fracture related arthroplasty, reported VTE rates are higher than non-fracture-related arthroplasty with reported rates ranging from 0.51% to as high as 5.1%^3,15,16. Jameson et al., reported 0.51% VTE rate in 4,696 hemiarthroplasties performed for fracture³. Farng et al., in a retrospective California registry study of 10,244 primary shoulder arthroplasties reported 1.0% VTE rate in fracture arthroplasty in comparison to 0.4% for non-fracture arthroplasty¹⁵. Furthermore, Navarro et al., demonstrated trends towards higher VTE rates for traumatic indications in comparison to elective surgery regardless of procedure type (1.71% vs. 0.80%, p=0.055)¹⁷. Hoxie et al., reported PE rate of 5.1% (7/137) in consecutive series of 137 arthroplasties for fracture¹⁶. For proximal humerus ORIF, Nayar et al., in another registry study reported VTE rate of 3.0% and also reported a 0.36% VTE for fractures around distal humerus/ elbow¹⁸. Thus, proximal humerus fracture surgery can be considered major concerning VTE risk.

For elbow surgery, the limited literature with respect to VTE risk. Intravia et al., in a retrospective review of 560 consecutive elbow arthroscopies reports no incidence of VTE¹⁹. For elbow arthroplasty, Duncan et al., report a 0.28% PE rate in a retrospective review of 816 consecutive total elbow arthroplasties (TEA) and 260 revision elbow arthroplasty cases over a 20-year period²⁰. Similarly, Krenek et al., in a California registry study of 1,625 patients undergoing TEA report a 0.25% PE rate²¹. Thus, elbow procedures can be considered non-major concerning VTE risk.

References:

1.         Kommareddy A, Zaroukian MH, Hassouna HI. Upper extremity deep venous thrombosis. Semin Thromb Hemost. 2002;28(1):89-99. doi:10.1055/s-2002-20567

2.         Kuremsky MA, Cain EL, Fleischli JE. Thromboembolic phenomena after arthroscopic shoulder surgery. Arthroscopy. 2011;27(12):1614-1619. doi:10.1016/j.arthro.2011.06.026

3.         Jameson SS, James P, Howcroft DWJ, et al. Venous thromboembolic events are rare after shoulder surgery: analysis of a national database. J Shoulder Elbow Surg. 2011;20(5):764-770. doi:10.1016/j.jse.2010.11.034

4.         Brislin KJ, Field LD, Savoie FH. Complications after arthroscopic rotator cuff repair. Arthroscopy. 2007;23(2):124-128. doi:10.1016/j.arthro.2006.09.001

5.         Hoxie SC, Sperling JW, Cofield RH. Pulmonary embolism following rotator cuff repair. Int J Shoulder Surg. 2008;2(3):49-51. doi:10.4103/0973-6042.42576

6.         Randelli P, Castagna A, Cabitza F, Cabitza P, Arrigoni P, Denti M. Infectious and thromboembolic complications of arthroscopic shoulder surgery. J Shoulder Elbow Surg. 2010;19(1):97-101. doi:10.1016/j.jse.2009.04.009

7.         Goodloe JB, Traven SA, Johnson CA, Woolf SK, Nutting JT, Slone HS. Increased Risk of Short-Term Complications and Venous Thromboembolism in Latarjet-Bristow Procedures Compared With Bankart Repairs. Arthroscopy. 2021;37(3):806-813. doi:10.1016/j.arthro.2020.10.039

8.         Young BL, Menendez ME, Baker DK, Ponce BA. Factors associated with in-hospital pulmonary embolism after shoulder arthroplasty. J Shoulder Elbow Surg. 2015;24(10):e271-278. doi:10.1016/j.jse.2015.04.002

9.         Lyman S, Sherman S, Carter TI, Bach PB, Mandl LA, Marx RG. Prevalence and risk factors for symptomatic thromboembolic events after shoulder arthroplasty. Clin Orthop Relat Res. 2006;448:152-156. doi:10.1097/01.blo.0000194679.87258.6e

10.       Kirsch JM, Gutman M, Patel M, et al. Low-dose aspirin and the rate of symptomatic venous thromboembolic complications following primary shoulder arthroplasty. J Shoulder Elbow Surg. 2021;30(7):1613-1618. doi:10.1016/j.jse.2020.09.030

11.       Lovy AJ, Keswani A, Beck C, Dowdell JE, Parsons BO. Risk factors for and timing of adverse events after total shoulder arthroplasty. J Shoulder Elbow Surg. 2017;26(6):1003-1010. doi:10.1016/j.jse.2016.10.019

12.       Sperling JW, Cofield RH. Pulmonary embolism following shoulder arthroplasty. J Bone Joint Surg Am. 2002;84(11):1939-1941. doi:10.2106/00004623-200211000-00005

13.       Willis AA, Warren RF, Craig EV, et al. Deep vein thrombosis after reconstructive shoulder arthroplasty: a prospective observational study. J Shoulder Elbow Surg. 2009;18(1):100-106. doi:10.1016/j.jse.2008.07.011

14.       Tashjian RZ, Lilly DT, Isaacson AM, et al. Incidence of and Risk Factors for Symptomatic Venous Thromboembolism After Shoulder Arthroplasty. Am J Orthop (Belle Mead NJ). 2016;45(6):E379-E385.

15.       Farng E, Zingmond D, Krenek L, Soohoo NF. Factors predicting complication rates after primary shoulder arthroplasty. J Shoulder Elbow Surg. 2011;20(4):557-563. doi:10.1016/j.jse.2010.11.005

16.       Hoxie SC, Sperling JW, Cofield RH. Pulmonary embolism after operative treatment of proximal humeral fractures. J Shoulder Elbow Surg. 2007;16(6):782-783. doi:10.1016/j.jse.2006.12.004

17.       Navarro RA, Inacio MCS, Burke MF, Costouros JG, Yian EH. Risk of thromboembolism in shoulder arthroplasty: effect of implant type and traumatic indication. Clin Orthop Relat Res. 2013;471(5):1576-1581. doi:10.1007/s11999-013-2829-6

18.       Nayar SK, Kuwabara AM, Flores JM, Osgood GM, LaPorte DM, Shafiq B. Venous Thromboembolism in Upper Extremity Fractures. J Hand Surg Asian Pac Vol. 2018;23(3):320-329. doi:10.1142/S2424835518500303

19.       Intravia J, Acevedo DC, Chung W-LJ, Mirzayan R. Complications of Elbow Arthroscopy in a Community-Based Practice. Arthroscopy. 2020;36(5):1283-1290. doi:10.1016/j.arthro.2019.11.108

20.       Duncan SFM, Sperling JW, Morrey BF. Prevalence of pulmonary embolism after total elbow arthroplasty. J Bone Joint Surg Am. 2007;89(7):1452-1453. doi:10.2106/JBJS.F.01328

21.       Krenek L, Farng E, Zingmond D, SooHoo NF. Complication and revision rates following total elbow arthroplasty. J Hand Surg Am. 2011;36(1):68-73. doi:10.1016/j.jhsa.2010.09.036