Darren Roberts, David Warwick.

Response/Recommendation: No universal risk stratification for venous thromboembolism (VTE) exists with respect to the upper extremity except during hand, wrist, and elbow orthopaedic surgery. It is deemed appropriate that personal and procedural-based risk factors should be considered for all patients. Those upper limb operations under local or regional anesthetic without heavy sedation are at very low-risk for VTE and therefore detailed risk assessment is not indicated.

Strength of Recommendation: Limited.

Rationale: There are no risk assessment tools for stratifying the requirement for thromboprophylaxis prior to upper limb surgery even for shoulder procedures¹. Guidelines have been formulated for higher-risk procedures in the lower limb, e.g., hip, and knee arthroplasty, but given the lower risk in the upper limb (even considering shoulder arthroplasty) these guidelines are not directly transferrable. Generalized rather than specific risk stratification tools have been created to help guide whether a patient is at higher risk of deep venous thrombosis (DVT), but there is a paucity of evidence to support these risks when considering upper limb surgery, in particular the risk of developing upper extremity VTE^2–5.

Evidence with respect to upper limb surgery postulates that obesity is correlated with an increased risk of VTE following total elbow arthroplasty⁶. American Society of Anesthesiologists (ASA) score 3-4, hypoalbuminemia and dehydration are associated with a risk of VTE after humeral fracture fixation in elderly patients. Furthermore, hypoalbuminemia is also associated with an increased risk of VTE following shoulder arthroplasty, as is inflammatory arthritis, diabetes and ischemic heart disease^7,8. Risk stratification tools should therefore incorporate those factors which have shown to increase the risk of developing VTE.

Risk stratification is therefore dependent on both patient and procedural-based factors. National guidelines in certain countries have been formulated to identify patients at higher risk of developing VTE. The British Society for the Surgery of the Hand (BSSH) have created a detailed set of guidelines based on risk stratification tools from across the globe and from the evidence of VTE following hand, wrist, and elbow surgery in the literature⁹. As there have been no reported cases of VTE following wide-awake local or regional anaesthetic, thromboprophylaxis is deemed not to be indicated². Therefore, assessment tools to stratify risk can be tailored accordingly.

There are no such guidelines following proximal humeral or shoulder procedures, despite numerous studies documenting the VTE risk and identifying the need for guidance for VTE prophylaxis^10,11. Several studies have proposed that all patients should receive mechanical prophylaxis after shoulder surgery, with chemical prophylaxis reserved for those at high-risk for VTE^7,10. To determine the level of risk, however, requires a risk stratification tool tailored for use in shoulder surgery, which has not been currently formulated.

References:

1.         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

2.         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

3.         Bryll J, Płomiński J. Venous thromboembolism prophylaxis in arthroscopic surgery. Ortop Traumatol Rehabil. 2013;15(6):517-529. doi:10.5604/15093492.1091508

4.         Pannucci CJ, Barta RJ, Portschy PR, et al. Assessment of postoperative venous thromboembolism risk in plastic surgery patients using the 2005 and 2010 Caprini Risk score. Plast Reconstr Surg. 2012;130(2):343-353. doi:10.1097/PRS.0b013e3182589e49

5.         Venclauskas L, Llau JV, Jenny J-Y, Kjaersgaard-Andersen P, Jans Ø, ESA VTE Guidelines Task Force. European guidelines on perioperative venous thromboembolism prophylaxis: Day surgery and fast-track surgery. Eur J Anaesthesiol. 2018;35(2):134-138. doi:10.1097/EJA.0000000000000706

6.         Griffin JW, Werner BC, Gwathmey FW, Chhabra AB. Obesity is associated with increased postoperative complications after total elbow arthroplasty. J Shoulder Elbow Surg. 2015;24(10):1594-1601. doi:10.1016/j.jse.2015.06.016

7.         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

8.         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

9.         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

10.       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

11.       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