Mohammad S. Abdelaal, Nestor Moreno Moreu.
Response/Recommendation: Patients undergoing removal of hardware from the upper extremity are at extremely low risk of VTE. Thus, routine use of VTE prophylaxis in these patients is not required. The use of aspirin as a VTE prophylaxis may be considered for those at high risk of VTE.
Strength of Recommendation: Consensus.
Rationale: Although upper extremity deep venous thromboses (UEDVT) is a rare complication after upper extremity surgery, it can have serious consequences1. During the past decade, some studies have reported an increased risk of UEDVT in patients undergoing elective orthopaedic procedures of the upper extremity2,3. This finding has generated questions regarding the role of prophylactic agents for patients undergoing elective upper extremity surgery. Several studies demonstrate that upper limb surgery can be associated with thrombosis in the upper and lower limbs4. Basat et al,5, documented a case report of deep venous thrombosis (DVT) of brachial vein that lead to massive pulmonary thromboembolism after surgical treatment of an ulnar pseudoarthrosis 4 months after prior internal fixation. The surgery lasted 110 minutes including 85 minutes under tourniquet. They suggested the use of a low molecular weight heparin prophylaxis after upper extremity surgeries necessitating long-term immobilization. However, the operation also included autologous iliac crest bone graft harvesting. Many case studies reported on UEDVT events after conservative treatment of clavicular fracture6–9 and humeral shaft fracture and10. Pearsall et al.11, reported a case of internal jugular vein thrombosis after a case of humerus nonunion treatment including metal removal , iliac bone graft and replating of the humerus shaft.
Importantly, the reported cases confirm that upper and lower extremity DVT can occur in relation to upper limb surgery. However, these studies do not provide any evidence that upper limb surgery confers any additional risk of thromboembolism to the patient over that resulting from individual patient-related factors. These events cause symptoms for a relatively small number of patients, but rates of asymptomatic disease may be higher. As yet, the true extent of this as a problem is undefined, which makes risk assessment and management difficult.
The risk of complications following a UEDVT, including post-thrombotic syndrome and pulmonary embolism (PE), is substantially higher compared with a DVT of the lower extremity1,12. Risk factors for UEDVT include malignancy, age older than 60 years, dehydration, known thrombophilia, obesity, history of DVT, oral contraceptive or hormonal therapy, varicose veins with phlebitis, multiple comorbidities, and pregnancy13–15. Further, Hastie et al., assessed the VTE incidence in 3357 upper limb procedures and found that the most striking common factor in the patients who sustained UEVTE events was the strong family or personal history of DVT or PE3.
Surgery resulting in reduced mobility is a recognized risk factor for VTE16. The exact degree to which mobility needs to be reduced has not been established, although one study found reduced mobility for 3 days or more was associated with an increased risk of symptomatic lower limb DVT17. Recently, Lv et al.18, reported a case of PE after an external and internal fixation procedure of distal radius and ulna with DVT in bilateral posterior tibial veins. However, the procedure was prolonged (4 hours), an iliac graft was harvested, and they described that the patient was reluctant to move out of bed for 3 days because of pain. Although the majority of the cases of hardware removal from upper limb might seem straightforward with low risk of complications, in certain situations the removal procedures can become challenging. Certain factors such as prolonged surgical time, excessive bone manipulation, and the use of tourniquet can put patients at higher risk of complications after surgery19.
There is no consensus regarding the role and efficacy of prophylactic measures in preventing UEDVT after hardware removal surgery. In general, the existing guidance for VTE prophylaxis for elective upper limb surgery is unclear, and contradicting recommendations are unhelpful.
The American Academy of Orthopaedic Surgeons and the American College of Chest Physicians20 do not offer specific guidelines regarding the use of prophylactic agents after elective orthopaedic procedures of the upper extremity. Guidelines from the United Kingdom National Institute for Clinical Excellence (NICE)14 recommend VTE prophylaxis in major orthopaedic procedures and interpret this as hip and knee arthroplasty surgeries and upper limb surgery lasting longer than 90 minutes. Scottish Intercollegiate Guidelines Network (SIGN) VTE guidelines recommended that this should include the total procedure time, including the time to administer an anesthetic.21 There is no evidence for the specific timings chosen, and for this reason, separate guidelines produced by SIGN refer only to ‘‘prolonged immobility’’ associated with orthopaedic procedures or plaster immobilization.
The existing guidelines are consistent in that they recommend an assessment of risk for each patient. This must be the standard of care and should form part of the consent process during which the risk of bleeding and VTE are considered4. In addition, it is recommended that mechanical prophylaxis(including fitted compression hosiery, intermittent pneumatic compression devices, and foot pumps) be routinely offered to patients undergoing elective upper limb surgery on admission and continued until discharge, unless there is a specific contraindication20. Chemical prophylaxis (e.g., aspirin, unfractionated heparin (UH), low-molecular-weight heparin (LMWH) , factor Xa inhibitors, thrombin inhibitors or warfarin) can be considered when patients are judged to have an increased VTE risk on the basis of their individual patient-related factors balanced against the risk of bleeding4. However, there is likely no need for chemical prophylaxis if such patients are able to quickly return to their prior level of mobility. For those who cannot, chemical prophylaxis is suggested with no recommendation regarding length of use after surgery.4 With all forms of chemical prophylaxis, the risk of bleeding must be weighed carefully before beginning therapy. No evidence exists regarding the length of use; however, the authors recommend at least 2 weeks if chemical prophylaxis is given because the risk of DVT is highest in the first 2 weeks following surgery.
In conclusion, there is no evidence to suggest that elective hardware removal from the upper limb confers an additional VTE risk in itself. The quality of this evidence is poor, and further research should be undertaken to examine the extent of the problem and any specific risks associated with these procedures. Due to the paucity of studies evaluating the efficacy of prophylaxis for UEDVT after implant removal, specific recommendations cannot be made regarding the choice of VTE prophylaxis and the length of use after these surgeries. It seems reasonable to adopt a multimodal approach that involves all patients receiving mechanical prophylaxis, with chemical prophylaxis reserved for those who are at high risk for VTE.
1. Sindhu KK, Cohen B, Blood T, Gil JA, Owens B. Upper Extremity Deep Venous Thrombosis Prophylaxis After Elective Upper Extremity Surgery. Orthopedics. 2018;41(1):21-27. doi:10.3928/01477447-20170824-04
2. 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
3. Hastie GR, Pederson A, Redfern D. Venous thromboembolism incidence in upper limb orthopedic surgery: do these procedures increase venous thromboembolism risk? Journal of Shoulder and Elbow Surgery. 2014;23(10):1481-1484. doi:10.1016/j.jse.2014.01.044
4. 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
5. Basat HC, Kalem M, Binnet MS, Demirtaş M. Pulmonary thromboembolism after surgical treatment of ulnar pseudoarthrosis: a case report. Acta Orthop Traumatol Turc. 2011;45(4):284-287. doi:10.3944/AOTT.2011.2426
6. Jones RE, McCann PA, Clark DA, Sarangi P. Upper limb deep vein thrombosis: a potentially fatal complication of a clavicle fracture. Ann R Coll Surg Engl. 2010;92(5):W36-38. doi:10.1308/147870810X12699662980358
7. Peivandi MT, Nazemian Z. Clavicular fracture and upper-extremity deep venous thrombosis. Orthopedics. 2011;34(3):227. doi:10.3928/01477447-20110124-28
8. Ranke H, Märdian S, Haas NP, Baecker H. [Thrombosis of the subclavian vein after conservative treatment of a clavicular fracture: A rare complication]. Unfallchirurg. 2016;119(3):255-258. doi:10.1007/s00113-015-0091-y
9. Adla DN, Ali A, Shahane SA. Upper-extremity deep-vein thrombosis following a clavicular fracture. Eur J Orthop Surg Traumatol. 2004;14(3):177-179. doi:10.1007/s00590-004-0151-4
10. Sawyer GA, Hayda R. Upper-extremity deep venous thrombosis following humeral shaft fracture. Orthopedics. 2011;34(2):141. doi:10.3928/01477447-20101221-27
11. Pearsall AW, Stokes DA, Russell GV. Internal jugular deep venous thrombosis after surgical treatment of a humeral nonunion: a case report and review of the literature. Journal of Shoulder and Elbow Surgery. 2004;13(4):459-462. doi:10.1016/j.jse.2004.01.015
12. Spaniolas K, Velmahos GC, Wicky S, et al. Is upper extremity deep venous thrombosis underdiagnosed in trauma patients? Am Surg. 2008;74(2):124-128.
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16. Bosson J-L, Pouchain D, Bergmann J-F, ETAPE Study Group. A prospective observational study of a cohort of outpatients with an acute medical event and reduced mobility: incidence of symptomatic thromboembolism and description of thromboprophylaxis practices. J Intern Med. 2006;260(2):168-176. doi:10.1111/j.1365-2796.2006.01678.x
17. Motykie GD, Caprini JA, Arcelus JI, et al. Risk factor assessment in the management of patients with suspected deep venous thrombosis. Int Angiol. 2000;19(1):47-51.
18. Lv B, Xue F, Shen Y-C, Hu F-B, Pan M-M. Pulmonary thromboembolism after distal ulna and radius fractures surgery: A case report and a literature review. World J Clin Cases. 2021;9(1):197-203. doi:10.12998/wjcc.v9.i1.197
19. McLendon K, Goyal A, Bansal P, Attia M. Deep Venous Thrombosis Risk Factors. In: StatPearls. StatPearls Publishing; 2021. Accessed July 11, 2021. http://www.ncbi.nlm.nih.gov/books/NBK470215/
20. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e278S-e325S. doi:10.1378/chest.11-2404
21. Prevention and management of venous thromboembolism. SIGN. Accessed June 28, 2021. https://testing36.scot.nhs.uk