Shoulder joint replacement arthroplasty - pulmonary embolism in hospital

Factors associated with in-hospital pulmonary embolism after shoulder arthroplasty.

These authors used the Nationwide Inpatient Sample to gather a sample of 422,372 patients having shoulder arthroplasty between 2002 and 2011. This population was divided into 2 groups: those who experienced perioperative PE (0.25%) and those who did not.

The top 4 independent predictors for PE were primary diagnosis of proximal humerus fracture, deficiency anemia, congestive heart failure, and chronic lung disease. Other pertinent risk factors included increasing age, obesity, fluid and electrolyte abnormalities, undergoing total shoulder arthroplasty rather than hemiarthroplasty, and subsequent days of postoperative care. Individuals having pulmonary emboli had a death rate of 5% in comparison to 0.1% in those without.

Comment: An often asked question is whether thromboembolic prophylaxis shoulder be used after shoulder joint replacement arthroplasty. While these authors identified a number of risk factors as summarized in the table below, they were unable to include some of the most important identified risk factors for pulmonary embolism: prior history of pulmonary embolism or deep venous thrombosis, cancer, smoking, and supplemental estrogen.

The use of preoperative prophylactic anticoagulation for shoulder arthroplasty cannot be taken lightly because of the increased risk of hematoma, would drainage, infection, swelling, pain, and stiffness. Based on an understanding of each patient's factors, the surgeon must balance the risks of thromboembolism versus the risks of anticoagulation.

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Preventing thromboembolic disease after shoulder arthroplasty

Risk of venous thromboembolism after shoulder arthroplasty in the Medicare population

These authors used Medicare claims data to determine the national incidence of symptomatic venous thromboembolism (VTE) after 130,258 shoulder arthroplasty during the index surgical admission and after discharge. Data were compared to 2,509,530 lower extremity arthroplasties.

VTE complications occurred in 0.53% of shoulder arthroplasties and 1.2% of lower extremity arthroplasties.  The risk of these complications were increased with fractures, a history of VTE, cardiac arrhythmia, presence of a metastatic tumor, coagulopathy, congestive heart failure, alcohol abuse, and obesity.

The authors recommend the use of mechanical prophylaxis combined with aspirin for shoulder arthroplasty patients who are not at increased risk of VTE. Chemoprophylaxis with agents other than aspirin may be warranted in patients with a demonstrated risk of VTE.

Comment: These results can be compared to those in previous post shown here. Our practice is consistent with the recommendations of these authors for routine cases. The situation becomes more complex in patients with prior history of VTE, who have artificial heart valves, atrial fibrillation, hyper coagulable states, and other risk factors. In these cases the care team must balance the risk of VTE agains that of bleeding and discuss the options with the patient. If patients are placed on anticoagulants, post operative motion may need to be restricted and the wound observed closely for bleeding.

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Shoulder joint replacement and blood clots - pulmonary emboli and venous thrombosis

Venous thromboembolism after shoulder arthroplasty: a systematic review

The authors of this article conducted a literature review of 14 articles reporting at least 1 case of deep vein thrombosis or pulmonary embolism after shoulder arthroplasty. The reported incidence these complications ranged from 0.2% to 16.0%. Risk factors for these complications included a history of VTE, thrombophilia, major surgery, advanced age, current malignant disease, immobility, and bed confinement. They were unable to find clear guidance for prophylaxis. 

Comment - It is important to differentiate venous clots from pulmonary emboli. Many studies lump these two together as "venous thromboembolism".  Preventing pulmonary emboli is the target. The most important risk factor is a history of a previous pulmonary embolism. Also high on the list are know hypercoagulable states such as Factor V Leiden and antiphospholipid syndrome or antiphospholipid antibody syndrome.

All our patients have sequential compression devices (SCDs) applied in the operating room before surgery and continued until they are ambulatory. Patients are out of bed within 24 hours of their surgery and are encouraged to actively move their legs while in bed.

In our shoulder arthroplasty practice, we do not use routine medical prophylaxis, such as unfractionated or fractionated heparin or low molecular weight heparin (e.g. Lovenox, Fondaparinux) except in high risk cases because of the increased risk of bleeding into the wound.

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Pulmonary embolism, thromboembolic prophylaxis and shoulder arthroplasty

National organizations have developed guidelines for the prevention of blood clots after hip and knee surgery The guidelines from the American Academy of Orthopaedic Surgeons can be found here.

The risk of pulmonary embolism after shoulder arthroplasty is much less than after hip and knee surgery, probably because the patient can be up and walking around immediately after the procedure.

Our practice is to screen patients for conditions that predispose them to a high risk of blood clots and for other reasons for them to take anticoagulants, such as coumadin, including past history of pulmonary emboli. In the absence of specific indications for medical thrombophrophylaxis, we use early ambulation and compressive stockings and sequential pressure devices to reduce the risk of blood clots. We avoid anticoagulants if possible to reduce the risk of bleeding at the site of our shoulder surgery.

It is a question of balancing one risk versus another for each patient.

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Shoulder arthritis articles from July issue of the JSES - cementing, loosening, venous thromboembolism, resurfacing, revision arthroplasty, hemophilia, arthritis in Korea,

The July issue of JSES has several articles of interest.
The first is a study in cadavers: Bone cement penetration pattern and primary stability testing in keeled and pegged glenoid components points out that the more osteoporotic the bone of the glenoid, the more cement can be pressurized into it. While this result is intuitive (porous bone accepts more cement), it has some important implications. As we've show previously, more cement generates more heat as it sets up and more heat can kill bone and dead bone can contribute to loosening of the component. From the figures in this article, it appears that the authors vigorously reamed the bone of the glenoid, perhaps removing much of the firmer cortical bone that lies at the joint surface. We strive to preserve as much of this bone as possible in all cases, but especially in those with soft bone.

A second issue is that these authors state that they tested "primary" stability of the component. But rather than studying the common failure mode: the 'rocking horse', they used direct pull-out, which is a mechanism that is not possible in the living shoulder.

Further, in these 'stability' tests, they found that the components were pulled out of the cement mantle. As the examples below of the many loose glenoids I've retrieved show, this is not the mode of failure in living patients. Instead, glenoid components fail in the clinical situation at the cement-bone interface because the bone around the cement gives way.

Finally, there is a lot to be said about cement technique. The authors state that they used "3rd generation" cementing technique.  Cementing in a cadaver without bleeding is quite different than cementing in a living, bleeding bone. Cement pressurization is easier in cylindrical holes for a pegged component rather than an irregular keel hole. Placing cement on the surface of the bone beneath the prosthesis may offer greater 'initial' stability in cadavers, but this thin layer of cement is subject to fatigue cracking in the living patient.

The bottom line is that even though this is a well-done cadaver study, the clinical application of such cadaver studies must be made cautiously.

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Next an article entitled, The prevalence of shoulder osteoarthritis in the elderly Korean population: association with risk factors and function, showed that in Korea the risk of OA increased with age and with the co-existence of knee arthritis.

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Our UK colleagues found that Venous thromboembolic events are rare after shoulder surgery: analysis of a national database. Specifically after total shoulder replacement, the rates of deep venous thrombosis, pulmonary embolism, and death within 90 days were, respectively, 0%, 0.2%, and 0.22%. These rates were not changed by the implementation of thromboembolic prophylaxis. As a result the authors suggest that such prophylaxis may not be necessary.

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Long-term results and patient satisfaction after shoulder resurfacing provided a minimum of 20 year or until death followup on 61 patients having either hemi resurfacing or total resurfacing procedures.  The satisfaction rate was reported to be high; 7 patients were lost to followup. Twelve of the 41 total resurfacing prostheses showed radiolucent lines but only three had revision surgery for glenoid component loosening.

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Results of revision from hemiarthroplasty to total shoulder arthroplasty utilizing modular component systems pointed out that it is often possible to revise a painful modular humeral hemiarthroplasty to a total shoulder by removing the humeral head aspect of the humeral component, inserting a glenoid component, and then replacing the humeral head component.

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Finally, Shoulder arthroplasty in hemophilic arthropathy demonstrated that satisfactory results could be obtained with this complex condition, but that the support of a hematologist was recommended.

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