Augustus Demanes, Ashley Blom, Setor Kunutsor, Kristen Combs, Ronald Navarro.
Response/Recommendation: Given the minimally increased risk of clinically significant thromboembolic events following shoulder arthroplasty, it is unlikely that the benefits of chemical deep venous thrombosis (DVT) prophylaxis outweigh the risks. There is insufficient evidence to support or recommend against using aspirin (ASA) as venous thromboembolism (VTE) prophylaxis in upper extremity surgery. The bleeding risks associated with low-molecular-weight heparin (LMWH) and direct oral anticoagulants (DOAC) outweigh the benefits in patients without substantial risk factors for VTE.
Strength of Recommendation: Limited.
Rationale: While extensive studies have allowed for the recommendation that chemical DVT prophylaxis be used following lower extremity arthroplasty, lack of data has precluded such recommendations from being made for shoulder arthroplasty1–6.
Available literature reports wide variability in the incidence of VTE events following shoulder arthroplasty, with estimates ranging from 0.2%-16%1–16. However, these studies varied significantly in how VTE events were identified. Patients in some studies underwent routine surveillance with DVT ultrasound or computer tomography (CT) scans throughout their postoperative course and all positive findings were included as VTE events. Other studies were retrospective reviews which only included clinically significant VTE events1–16. Unsurprisingly, the incidence estimates in studies that only considered clinically significant VTE events were much closer to the lower end of that range, with most reporting an incidence of <1% and one study reporting a weighted average of 0.68%1. A recent meta-analysis of 19 studies reported a pooled 3-month incidence of 0.85%7. It should also be considered that the underlying rate of VTE events in the general population (i.e., those not necessarily undergoing procedures) has been reported at 0.5%2.
Our recommendation is limited due to the lack of randomized control trials (RCT) addressing this question3. Studies have shown very low rates of clinically significant VTE events following shoulder arthroplasty in patients who take ASA or other VTE prophylaxis postoperatively1–15. The rate also appears to be low even in patients who underwent shoulder arthroplasty and had no chemical DVT prophylaxis postoperatively8. Given that no RCT have been completed on the topic, one might best follow the recommendation that an overall VTE risk of over 3% is required to outweigh the bleeding risk from pharmacological prophylaxis using LMWH5. Major bleeding has been postulated to occur in 2.5 per 1,000 patients prescribed LMWH, with an even higher risk of minor bleeding. Other complications reported to be associated with DVT prophylaxis include heparin-induced thrombocytopenia, skin reactions, thrombocytosis, electrolyte imbalances such as hyperkalemia and osteoporosis5.
When deciding to prescribe anticoagulation following shoulder arthroplasty, several patient-specific factors must be considered which have been shown to alter the incidence of VTE and include older age and principal diagnosis of fracture, history of VTE, cardiac arrhythmia, presence of a metastatic tumor, coagulopathy, congestive heart failure, anemia, urinary tract infection, sleep apnea, fluid & electrolyte balance, alcohol abuse, and obesity2,4–13. Furthermore, outpatient shoulder arthroplasty has been shown to be associated with reduced risk of VTE7. Importantly, statistically similar rates of VTE events have been shown between hemiarthroplasty, reverse total shoulder arthroplasty (RTSA), and anatomic total shoulder arthroplasty (TSA) in some studies while others have shown a trend toward lower rates for anatomic TSA indicating another area where further research is warranted7,8.
As the clinical decision to initiate VTE prophylaxis is a complex process, until RCT have been undertaken better delineate the risk/benefit profile of VTE prophylaxis in the setting of shoulder arthroplasty, decision making should be individualized and tailored to each patient’s preference and risk factors.
1. Aibinder WR, Sanchez-Sotelo J. Venous Thromboembolism Prophylaxis in Shoulder Surgery. Orthop Clin North Am. 2018;49(2):257-263. doi:10.1016/j.ocl.2017.11.012
2. Day JS, Ramsey ML, Lau E, Williams GR. Risk of venous thromboembolism after shoulder arthroplasty in the Medicare population. J Shoulder Elbow Surg. 2015;24(1):98-105. doi:10.1016/j.jse.2014.09.025
3. Kolz JM, Aibinder WR, Adams RA, Cofield RH, Sperling JW. Symptomatic Thromboembolic Complications After Shoulder Arthroplasty: An Update. J Bone Joint Surg Am. 2019;101(20):1845-1851. doi:10.2106/JBJS.18.01200
4. Saleh HE, Pennings AL, ElMaraghy AW. Venous thromboembolism after shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg. 2013;22(10):1440-1448. doi:10.1016/j.jse.2013.05.013
5. Kadhum M, Elniel AR, Furniss D. Is venous thromboembolism prophylaxis beneficial in upper limb major joint replacement surgery? A systematic review. Shoulder Elbow. 2021;13(2):119-130. doi:10.1177/1758573219896279
6. Dattani R, Smith CD, Patel VR. The venous thromboembolic complications of shoulder and elbow surgery: a systematic review. Bone Joint J. 2013;95-B(1):70-74. doi:10.1302/0301-620X.95B1.29854
7. Kunutsor SK, Barrett MC, Whitehouse MR, Blom AW. Venous thromboembolism following 672,495 primary total shoulder and elbow replacements: Meta-analyses of incidence, temporal trends and potential risk factors. Thromb Res. 2020;189:13-23. doi:10.1016/j.thromres.2020.02.018
8. 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
9. Kirsch JM, Gutman M, Patel M, et al. Low-dose aspirin and the rate of symptomatic venous thromboembolic complications following primary shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2021;30(7):1613-1618. doi:10.1016/j.jse.2020.09.030
10. Wronka KS, Pritchard M, Sinha A. Incidence of symptomatic venous thrombo-embolism following shoulder surgery. Int Orthop. 2014;38(7):1415-1418. doi:10.1007/s00264-014-2329-7
11. 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
12. Lung BE, Kanjiya S, Bisogno M, Komatsu DE, Wang ED. Risk factors for venous thromboembolism in total shoulder arthroplasty. JSES Open Access. 2019;3(3):183-188. doi:10.1016/j.jses.2019.07.003
13. Heyer JH, Parker RL, Lynch T, Parry T, Neviaser AS. Rate of venous thromboembolism after surgical treatment of proximal humerus fractures. Arch Orthop Trauma Surg. 2021;141(3):403-409. doi:10.1007/s00402-020-03505-4
14. 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
15. Rapp CM, Shields EJ, Wiater BP, Wiater JM. Venous Thromboembolism After Shoulder Arthoplasty and Arthroscopy. J Am Acad Orthop Surg. 2019;27(8):265-274. doi:10.5435/JAAOS-D-17-00763
16. 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