Filippo Randelli, Alberto Fioruzzi.
Response/Recommendation: In the absence of any literature to guide a recommendation, it is our consensus opinion that patients undergoing ligament reconstruction for elbow instability 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 venous thromboembolism (VTE) chemoprophylaxis.
Strength of Recommendation: Consensus.
Rationale: Controversies remain whether or not the patients undergoing ligament reconstruction surgery for elbow instability1–3 should be routinely administered VTE prophylaxis.
A recent comprehensive literature review about all upper limb orthopaedic surgery suggests a VTE rate as low as 0.26% to 0.64%4. Nevertheless, the incidence of VTE risk has not been defined in ligament reconstruction around the elbow. There are available only retrospective studies or case reports5,6. A recent systematic review1 on the outcome and complications of lateral ulnar collateral ligament reconstruction of the elbow for posterolateral rotatory instability has shown an incidence of deep venous thrombosis (DVT) of 0.60%. Sanchez-Sotelo et al.6, reported only one case of DVT, with an incidence of 2%, in 44 patients undergoing ligament repair for posterolateral rotatory instability of the elbow. Furthermore, the VTE prophylaxis was not even cited in the post-operative management. Hannon et al.5, reported a case report of DVT in an 18-year-old male baseball pitcher after ulnar collateral ligament reconstruction surgery. The VTE prophylaxis was not performed, and the patient developed an extensive clot throughout his calf and lower thigh and minor pulmonary emboli four months from the index surgery.
Several studies4,7–9 examined the prevalence of VTE in upper limb surgery and highlighted that patients should be stratified regarding the risk factor profile. Different national scientific associations have done indications for the prophylaxis dividing the patients in “low-risk” and “high-risk”10–12. Although it is recognized that upper limb surgery is associated with an increased risk of VTE, especially under certain circumstances, current literature lacks robust data evaluating the need for routine prophylaxis for patients undergoing ligament reconstruction around the elbow.
Surgeons should routinely assess the risk for each patient to identify the higher-risk subject that may benefit from VTE prophylaxis.
References:
1. Badhrinarayanan S, Desai A, Watson JJ, White CHR, Phadnis J. Indications, Outcomes, and Complications of Lateral Ulnar Collateral Ligament Reconstruction of the Elbow for Chronic Posterolateral Rotatory Instability: A Systematic Review. Am J Sports Med. 2021;49(3):830-837. doi:10.1177/0363546520927412
2. Thomas SJ, Paul RW, Rosen AB, et al. Return-to-Play and Competitive Outcomes After Ulnar Collateral Ligament Reconstruction Among Baseball Players: A Systematic Review. Orthop J Sports Med. 2020;8(12):2325967120966310. doi:10.1177/2325967120966310
3. Torres SJ, Limpisvasti O. Ulnar Collateral Ligament Repair of the Elbow-Biomechanics, Indications, and Outcomes. Curr Rev Musculoskelet Med. 2021;14(2):168-173. doi:10.1007/s12178-021-09698-4
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. Hannon J, Garrison C, Conway J. Residents case report: deep vein thrombosis in a high school baseball pitcher following ulnar collateral ligament (ucl) reconstruction. Int J Sports Phys Ther. 2013;8(4):472-481.
6. Sanchez-Sotelo J, Morrey BF, O’Driscoll SW. Ligamentous repair and reconstruction for posterolateral rotatory instability of the elbow. J Bone Joint Surg Br. 2005;87(1):54-61.
7. Anakwe RE, Middleton SD, Beresford-Cleary N, McEachan JE, Talwalkar SC. Preventing venous thromboembolism in elective upper limb surgery. J Shoulder Elbow Surg. 2013;22(3):432-438. doi:10.1016/j.jse.2012.10.033
8. 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
9. Roberts DC, Warwick DJ. Venous thromboembolism following elbow, wrist and hand surgery: a review of the literature and prophylaxis guidelines. J Hand Surg Eur Vol. 2014;39(3):306-312. doi:10.1177/1753193412469131
10. Randelli F, Romanini E, Biggi F, et al. II Italian intersociety consensus statement on antithrombotic prophylaxis in orthopaedics and traumatology: arthroscopy, traumatology, leg immobilization, minor orthopaedic procedures and spine surgery. J Orthop Traumatol. 2013;14(1):1-13. doi:10.1007/s10195-012-0214-y
11. Scottish Intercollegiate Guidelines Network. Prevention and Management of Venous Thromboembolism: A National Clinical Guideline. SIGN; 2010.
12. National Guideline Centre (UK). Venous Thromboembolism in over 16s: Reducing the Risk of Hospital-Acquired Deep Vein Thrombosis or Pulmonary Embolism. National Institute for Health and Care Excellence (UK); 2018. Accessed September 27, 2021. http://www.ncbi.nlm.nih.gov/books/NBK493720/