158 – Should routine VTE prophylaxis be administered to patients undergoing rotator cuff repair?

Brian C. Werner, Gerald R. Williams.

Response/Recommendation: The incidence of venous thromboembolism (VTE) after arthroscopic rotator cuff repair (RCR) is very low. Although the current literature has identified several risk factors for VTE after arthroscopic RCR, there is limited evidence supporting the efficacy of routine VTE prophylaxis postoperatively. In the absence of any literature to guide a recommendation, it is our consensus opinion that patients undergoing RCR should have intraoperative mechanical compression and early mobilization. Patients should also be risk-stratified and if considered high-risk due to other medical conditions, consideration should be given to adding VTE chemoprophylaxis.

Strength of Recommendation: Limited.

Rationale: The incidence of VTE following arthroscopic shoulder surgery and RCR has been reported in several studies to be exceeding low, well below 1% in all but one study, but likely elevated compared to the general non-surgical population1–6. Although individual studies report differing findings likely due to the low incidence of VTE6, several risk factors for VTE after RCR have been established, including diabetes mellitus, heart disease, rheumatoid arthritis, and high altitude4,7.

One retrospective study evaluated 39,825 RCR, including 31,615 performed arthroscopically, and reported an overall VTE rate of 0.3% that occurred at a mean of 11.5 days postoperatively8. The authors identified the following risk factors for postoperative VTE: male sex, body mass index > 30 kg/m2, American Society of Anesthesiologists score III or IV, duration of surgery > 80 minutes, bleeding disorder, and dyspnea. While the authors did not specifically evaluate prophylaxis strategies, the risk factors identified could be used to identify higher-risk patients that could be considered for more aggressive prophylaxis. Alyea, et al., published a retrospective case-control study of 914 patients who underwent arthroscopic RCR, of which 484 had intraoperative compression boots and early mobilization and 430 had the same measures with the addition of 81 mg/day aspirin9. The overall VTE rates were very low, and there were no differences in VTE rates between groups, leading the authors to conclude that the use of intraoperative mechanical prophylaxis and early mobilization is a sufficient method of VTE prophylaxis after arthroscopic RCR for most patients.

References:

1.         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

2.         Imberti D, Ivaldo N, Murena L, et al. Venous thromboembolism in patients undergoing shoulder surgery: findings from the RECOS Registry. Thromb Res. 2014;134(2):273-277. doi:10.1016/j.thromres.2014.05.014

3.         Takahashi H, Yamamoto N, Nagamoto H, Sano H, Tanaka M, Itoi E. Venous thromboembolism after elective shoulder surgery: a prospective cohort study of 175 patients. J Shoulder Elbow Surg. 2014;23(5):605-612. doi:10.1016/j.jse.2014.01.054

4.         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

5.         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

6.         Schick CW, Westermann RW, Gao Y, ACESS Group, Wolf BR. Thromboembolism Following Shoulder Arthroscopy: A Retrospective Review. Orthop J Sports Med. 2014;2(11):2325967114559506. doi:10.1177/2325967114559506

7.         Cancienne JM, Burrus MT, Diduch DR, Werner BC. High altitude is an independent risk factor for venous thromboembolism following arthroscopic rotator cuff repair: a matched case-control study in Medicare patients. J Shoulder Elbow Surg. 2017;26(1):7-13. doi:10.1016/j.jse.2016.06.005

8.         Sager B, Ahn J, Tran J, Khazzam M. Timing and Risk Factors for Venous Thromboembolism After Rotator Cuff Repair in the 30-Day Perioperative Period. Arthroscopy. 2019;35(11):3011-3018. doi:10.1016/j.arthro.2019.05.045

9.         Alyea E, Gaston T, Austin LS, et al. The Effectiveness of Aspirin for Venous Thromboembolism Prophylaxis for Patients Undergoing Arthroscopic Rotator Cuff Repair. Orthopedics. 2019;42(2):e187-e192. doi:10.3928/01477447-20181227-05