Luis Becker, Juan Del Castillo, Matthias Pumberger, Nicolás Cancela.
Response/Recommendation: Routine venous thromboembolism (VTE) prophylaxis in patients undergoing upper extremity osteosynthesis under local or regional anesthesia is not needed. VTE prophylaxis should be considered in patients at high risk of VTE and those undergoing surgery under general anesthesia that lasts over 90 minutes.
Strength of recommendation: Limited.
Rationale: Upper-extremity deep vein thrombosis (UEDVT) has a very low overall incidence of 0.4 to 1 in 10,000 persons1–4. Upper extremity thrombosis is divided into primary (20%) and secondary (80%) causes. Among these, idiopathic thrombosis, effort-related thrombosis (Paget-Schroetter syndrome), or venous thoracic-outlet syndrome due to compression of the subclavian vein resulting from abnormalities of one or more structures at the costoclavicular junction represents the cause of primary thrombosis. The more common secondary thrombosis of the upper extremity results from catheter- or pacemaker-associated thrombosis, cancer-associated thrombosis, hormone-induced coagulation abnormalities, and surgery or trauma to the upper extremity2,5. Pulmonary embolism (PE), post-thrombotic syndrome, and thrombosis recurrence have been described as serious complications associated with UEDVT2,5,6. However, UEDVT has a significantly lower risk of PE compared to lower extremity venous thrombosis6–9. UEDVT occur more frequently in association with central catheters and in association with malignancies and are less associated with immobilization3,4,9. Very few studies report the incidence of deep venous thrombosis due to upper extremity osteosynthesis. In a report by Levy et al., among 300 patients with UEDVT, 31% of patients had developed thrombosis of upper extremity as a result of surgery or trauma7. In another study comprising of 3,357 patients undergoing upper extremity orthopedic procedures, only six patients (0.0018%) developed postoperative VTE, and five out of six patients had a strong history of prior VTE10. Calotta et al., analyzing registry 24,494 patients in a registry database reported an incidence of 0.3% of upper extremity DVT in patients undergoing open reduction and internal fixation of distal radius fractures11. The risk factors identified for upper extremity deep venous thrombosis (DVT) in the latter study were history of congestive heart failure and use of estrogen11. In another study by Mino et al., on 1,857 patients undergoing general surgery, the incidence of postoperative thrombosis of the upper extremity was 1.13%, with all, but one, patient developing the DVT in association with central catheter12. In contrast, Blom et al., reporting on an association between upper extremity surgery and UEDVT in two patients in a subcohort of 179 patients out of the MEGA study selected due to UEDVT, resulting in the odds ratio of 11.8 compared to a control cohort of 2,398 patients, in which three patients underwent upper extremity surgery within three months before index date13,14. In addition, Hoxie et al., reported an occurrence of pulmonary embolism in 5.6% of surgically treated patients with a proximal humerus fracture (4 hemiarthroplasty, 3 open reduction internal fixation [ORIF])15. In contrast, Widmer et al., found no thromboembolic events in 50 patients, receiving VTE prophylaxis, after proximal humerus fracture16. In addition to the aforementioned studies, there are sporadic case reports of the occurrence of UEDVT and PE and upper extremity fracture or osteosynthesis17–23. Two reviews around the topic of the need for thromboprophylaxis of upper limb surgery were identified. The article by Roberts and Warwick summarizes the literature and guidelines regarding prophylaxis for thrombosis in hand, wrist, and elbow surgery24,25. They recommend risk assessment for DVT in patients with prolonged elbow or forearm surgery and found that history of active cancer or cancer treatment, age over 60 years, admission to intensive care unit, dehydration, history of VTE, obesity, history of one or more significant medical co-morbidities, family history of VTE, use of hormone replacement therapy or estrogen-containing contraceptives, varicose veins with phlebitis to be predisposing factors for upper extremity VTE. The authors recommended that VTE prophylaxis be considered for patients at high-risk population and patients undergoing upper extremity osteosynthesis under local or regional anesthesia were considered to be at low-risk24,25. The other review article by Anakwe et al., also discussed the topic of thromboprophylaxis in patients undergoing elective upper extremity osteosynthesis26. They also recommended an approach that involved risk assessment and administration of chemoprophylaxis for high-risk patients and mechanical prophylaxis for others, unless contraindicated26. Evidence on which form of mechanical or chemical thromboprophylaxis should be chosen in case of upper limb osteosynthesis does not exist. However, some organizational guidelines have been proposed. The National Institute for Health and Care Excellence (NICE) Guidelines has produced guidelines that are stated below27:
- 1.11.15 Be aware that VTE prophylaxis is generally not needed if giving local or regional anaesthetic for upper limb surgery. .
- 1.11.16 Consider VTE prophylaxis for people undergoing upper limb surgery if the person’s total time under general anaesthetic is over 90 minutes or where their operation is likely to make it difficult for them to mobilize. .
The British Society for Surgery of the Hand (BSSH) has also proposed guidelines that are stated below (Table1)28:
Table1. BSSH recommendations for prophylaxis in hand, wrist, and elbow surgery
|Low||LA, regional anaesthesia or <90 minutes GA||No prophylaxis|
|Moderate||>90 minutes GA (including elbow arthroplasty) and/or 1 risk factor||Mechanical prophylaxis until mobile|
|High||>90 minutes GA and >1 risk factor, prolonged post-operative immobility, or tumour surgery||Mechanical prophylaxis and consider pharmacological prophylaxis until mobile|
The evidence for the use of thromboprophylaxis in upper extremity osteosynthesis is limited. There is scarce but consistent evidence that VTE prophylaxis in patients undergoing upper extremity osteosynthesis under local or regional anesthesia is not necessary. Instead, chemoprophylaxis should be reserved for patients undergoing upper extremity osteosynthesis under long general anesthesia (> 90 minutes), those at high-risk VTE (as discussed above), and patients who are likely to have difficulty with mobilization. The potential benefits of chemoprophylaxis should always be weighed against the bleeding risk.
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