Ryan W. Paul, Anya Hall, Pawel Chodór, Jacek Kruczyński, Fotios P. Tjoumakaris.

Response/Recommendation: Currently, there is no data to suggest that routine thromboprophylaxis should be performed in patients undergoing arthroscopic shoulder stabilization in normative risk patients. Given the low risk of complications, intermittent pneumatic compression (IPC) devices should be used. Venous thromboembolism (VTE) pharmacological prophylaxis may be considered in patients undergoing stabilization surgery with the Latarjet/Bristow procedure.

Strength of Recommendation: Consensus.

Rationale: Symptomatic VTE rates are higher after shoulder arthroplasty (0.24%-2.60%) than after shoulder arthroscopy (0.01%-0.38%)^1–3. The range of VTE incidence is heavily affected by differences in surgical procedures, as operation severity and length have been associated with VTE development in shoulder arthroscopy^4–7. Some shoulder stabilization procedures are longer and involve significantly more tissue repair, potentially leading to higher risk of developing a post-operative VTE⁸. The Latarjet-Bristow procedure (132 minutes) specifically lasts longer than other shoulder stabilization procedures such as open and arthroscopic Bankart repair (91 and 82 minutes, respectively)⁴.

Two large cohort studies agree that Latarjet-Bristow patients are much more likely to develop VTE than Bankart patients (Table 2). Bokshan et al.⁴, compared 30-day complication rates in 2,864 patients who underwent arthroscopic Bankart, open Bankart, or Latarjet-Bristow procedures between 2005-2014 from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Within 30 days post-operatively 3 (1.8%) Latarjet-Bristow patients had a deep venous thrombosis (DVT), while 2 (0.1%) arthroscopic Bankart repair patients had a DVT, 1 (0.04%) arthroscopic Bankart repair patient had a pulmonary embolism (PE), and no open Bankart repair patients had a VTE. Goodloe et al.⁵, also utilized the ACS NSQIP database to evaluate 30-day complications rates among these three surgical procedures, with a larger cohort of 7,233 patients (471 Latarjet-Bristow, 798 open Bankart repair, 5,964 arthroscopic Bankart repair). Latarjet-Bristow patients had a low rate of developing DVT (0.8%) in this study, though still significantly higher than arthroscopic Bankart (0.1%) and open Bankart repair (0%). A multivariate analysis found that patients who undergo Latarjet surgery are 7.8 (95% confidence interval [CI]: 2.2-27.7) times more likely to develop a VTE than patients undergoing Bankart surgery.

Despite the increased incidence of VTE after Latarjet surgery, no studies were identified that evaluate VTE prophylaxis after shoulder stabilization procedures. Therefore, the closest recommendations for shoulder stabilization are those for shoulder arthroscopy as a whole. Takahashi et al.⁹, reported the DVT preventive measures utilized in their prospective study cohort. Where 99% of the shoulder arthroscopy cases featured IPC devices for the lower extremities, with the remaining 1% using elastic stocking for the lower extremity and no patients receiving low-molecular-weight heparin (LMWH) or aspirin. Randelli et al.¹⁰, showed that pharmacological thromboprophylaxis is not utilized for the majority of arthroscopic shoulder surgery patients, with only 2,410 out of 9,385 (25.7%) patients being provided thromboprophylaxis.

Despite these limitations, surgeons should be aware that Latarjet surgery patients are at an increased risk for developing a VTE compared to open or arthroscopic Bankart surgery patients. Clinicians should consider providing VTE prophylaxis for Latarjet surgery patients who meet other risk factors for VTE. Risk factors for VTE include advanced age, major surgery, history of thromboembolic events, and clotting disorders, as defined by Caprini et al.¹¹. It should be noted that the majority of patients included in these analyses who underwent Latarjet/Bristow, did so with an open technique, and may not fit into a cohort of arthroscopically treated patients.

Table 2.          Details about the nine included studies with results specific to VTE and the JBI critical appraisal tools scores.

Study	Study design (LOE)	Purpose	Surgical Procedure	Sample size	VTE-specific results	JBI Quality Score
Bokshan et al.4, 2017.	cohort study (3)	Compare incidence of complications between arthroscopic Bankart, open Bankart, and Latarjet-Bristow.	410 open Bankart, 163 Latarjet-Bristow, 2291 arthroscopic Bankart	2,864	3 DVT for Latarjet (1.8%), no DVT for open Bankart, and 2 DVT (0.1%) and 1 PE (0.04%) for arthroscopic Bankart.	8.5
Goodloe et al.5, 2021.	Cohort study (3)	Compare incidence of complications between arthroscopic Bankart, open Bankart, and Latarjet-Bristow, and identify risk factors for VTE.	5964 arthroscopic Bankart, 798 open Bankart, 471 Latarjet	7,233	DVT: 0.1% rate for arthroscopic Bankart, none for open Bankart, 0.8% for Latarjet (p<0.001). PE: 0.1% for arthroscopic Bankart, none of open Bankart, 0.2% for Latarjet (p=0.280). Multivariate analysis shows Latarjet surgery increases odds of DVT by 7.84 relative to arthroscopic Bankart (p=0.001).	8.5
Shields et al.6, 2014.	Cohort study (3)	To stratify risk of post-op morbidity and determine risk factors.	Stabilization	114	No DVT for 114 stabilization patients.	8.5
Takahashi et al.9, 2014.	Prospective cohort study (1)	Determine incidence of VTE after elective shoulder arthroscopy.	Bankart repair	17 anterior instability patients	1 out of 17 Bankart repair patients had a DVT. Table 3 – a 66-years old male with hypertension had an asymptomatic DVT 2 days post-op in contralateral soleus.	9
Randelli et al.10, 2010.	Surgeon survey with case series (3)	Determine rate of infection and DVT in shoulder arthroscopy, and association with prophylaxis.	Stabilization	9,385 shoulder arthroscopy patients. Unclear how many are stabilization.	Of 6 total DVT, only one was in a stabilization patient.	7
Kuremsky et al.12, 2011.	case series (4)	Review a series of patients who experienced thromboembolic events after shoulder arthroscopy.	Case 3 – Rotator cuff repair, biceps tenodesis, and pancapsular plication with multidirectional instability. Case 5 – Arthroscopic surgery with capsular repair for anterior instability.	1,908 shoulder arthroscopy patients. Unclear how many stabilizations.	Case 3 – She was diagnosed with a DVT in the subclavian and axillary veins and prescribed warfarin. While still taking this drug, she had a second clot diagnosed on ultrasound in her jugular vein, 4 months after surgery. Workup showed a protein C deficiency. Her shoulder underwent a slow and incomplete recovery due to pain and inconsistent rehabilitation, in part complicated by these concurrent medical issues. Case 5 – Four weeks after surgery, an ipsilateral subclavian vein DVT and PE developed. He was treated with warfarin and eventually had an uneventful recovery with respect to his shoulder. Workup for a hypercoagulable state was negative.	9
Hariri et al.13, 2009.	case report (5)	Report a case of pulmonary embolism after posterior capsuloplasty.	Posterior capsuloplasty	1 posterior instability patient	On post-operative day 10, a chest X-ray demonstrated left pleural effusion and a left triangular opacity compatible with the diagnosis of PE. This diagnosis was confirmed with an angiography scan showing bilateral multifocal PE.	5
Burkhart14, 1990.	case report (5)	Report a case of DVT after anterior shoulder stabilization.	Stabilization	1 anterior instability patient	On post-operative day 3, a complete thrombosis of the basilic vein and the innominate vein was identified. The DVT was treated initially with heparin, then with 3 months of warfarin. After discontinuing the warfarin, he had a recurrence of the thrombophlebitis, which necessitated reinstitution of anticoagulation. The swelling and tenderness have resolved, but the patient remains on a regimen of warfarin at 19 months postoperatively. Patient was discovered to have Hodgkin’s disease (stage 1A).	7
Watanabe et al.15, 2019.	case report (5)	Report a case of DVT and subsequent PE after labrum repair.	Labrum repair	1 anterior instability patient	On post-operative day 6, the patient developed tachycardia and oxygen desaturation with elevated serum D-Dimer. Enhanced CT demonstrated thrombi obstructing bilateral pulmonary arteries as well as the subclavian through basilar vein of the affected arm. A diagnosis of PE caused by upper extremity DVT was reached. Treatment started with oxygen therapy and intravenous heparin administration, which later was replaced by oral anticoagulant. The patient’s symptoms improve seven days after the start of anticoagulation therapy. Anticoagulant was continued for an additional 3 months to obtain further improvement.	8

JBI Quality Scores range from 0-11 for cohort studies, 0-10 for case series, and 0-8 for case reports.

VTE=Venous thromboembolism; JBI=Joanna-Briggs Institute; LOE=Level of evidence, DVT=Deep venous thrombosis, PE=Pulmonary embolism; CT=Computer tomography.

JBI Quality Scores range from 0-11 for cohort studies, 0-10 for case series, and 0-8 for case reports.

JBI=Joanna-Briggs Institute; 1=yes; 0.5=unclear; 0=no; N/A=Not applicable.

References:

1.         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

2.         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

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.         Bokshan SL, DeFroda SF, Owens BD. Comparison of 30-Day Morbidity and Mortality After Arthroscopic Bankart, Open Bankart, and Latarjet-Bristow Procedures: A Review of 2864 Cases. Orthop J Sports Med. 2017;5(7):2325967117713163. doi:10.1177/2325967117713163

5.         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

6.         Shields E, Iannuzzi JC, Thorsness R, Noyes K, Voloshin I. Postoperative Morbidity by Procedure and Patient Factors Influencing Major Complications Within 30 Days Following Shoulder Surgery. Orthop J Sports Med. 2014;2(10):2325967114553164. doi:10.1177/2325967114553164

7.         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

8.         Griesser MJ, Harris JD, McCoy BW, et al. Complications and re-operations after Bristow-Latarjet shoulder stabilization: a systematic review. J Shoulder Elbow Surg. 2013;22(2):286-292. doi:10.1016/j.jse.2012.09.009

9.         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

10.       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

11.       Caprini JA, Arcelus JI, Hasty JH, Tamhane AC, Fabrega F. Clinical assessment of venous thromboembolic risk in surgical patients. Semin Thromb Hemost. 1991;17 Suppl 3:304-312.

12.       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

13.       Hariri A, Nourissat G, Dumontier C, Doursounian L. Pulmonary embolism following thrombosis of the brachial vein after shoulder arthroscopy. A case report. Orthop Traumatol Surg Res. 2009;95(5):377-379. doi:10.1016/j.otsr.2009.03.016

14.       Burkhart SS. Deep venous thrombosis after shoulder arthroscopy. Arthroscopy. 1990;6(1):61-63. doi:10.1016/0749-8063(90)90100-r

15.       Watanabe H, Nagase Y, Tamai K, Tanaka S. Pulmonary embolism associated with upper extremity deep venous thrombosis after shoulder arthroscopy: A case report. J Orthop Sci. 2019;24(4):746-749. doi:10.1016/j.jos.2017.01.008