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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Shoulder arthroplasty and thromboembolism

Risk of Thromboembolism in Shoulder Arthroplasty: Effect of Implant Type and Traumatic Indication

These authors performed a retrospective database review of symptomatic thromboembolic (VTE) events and mortality within 90 days of shoulder arthroplasty in a large (30-hospital) integrated healthcare system over a 5-year period, from January 2005 to December 2009. They compared the likelihood of these events and death in patients undergoing reverse shoulder arthroplasties (RSAs), total shoulder arthroplasties (TSAs), and hemiarthroplasties (HAs), and compared the likelihood of these events and death in patients who underwent elective shoulder arthroplasties with those who underwent shoulder arthroplasty in the setting of acute trauma.

In the 2574 eligible shoulder arthroplasties identified during the study period, VTE developed in 1.01% of patients (deep vein thrombosis 0.51% and pulmonary embolism 0.54%).   VTE occurred more frequently in patients having surgery for traumatic indications than after elective surgery (1.71% versus 0.80%; p = 0.055). A higher likelihood of 90-day mortality was observed in trauma patients compared with elective (odds ratio = 7.4; 95% CI, 2.4-25.2).

These data are helpful in consideration of the use of  pharmacologic VTE prophylaxis in the perioperative treatment of patients undergoing shoulder arthroplasty. One one hand, such prophylaxis may reduce the risk of thromboembolic complications, but on the other it may increase the risk of wound complications and hematomas.

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Blood clots after total joints - thromboembolic prophylaxis - conflict of interest - JBJS

The JBJS recently published an article by Lee et al entitled: Conflict of Interest in the Assessment of Thromboprophylaxis After Total Joint Arthroplasty: A Systematic Review. Although problems with deep venous thrombosis and pulmonary emboli are not common after shoulder surgery, they do occur. As mentioned in a previous post, it is a question of balancing the risk of blood clots versus the risk of bleeding.

The article by Lee et al takes a look at the recent published evidence regarding thromboprophylaxis with special regard to the relationship between industrial funding and the results of the study. 52 of the 71 articles were funded by industry. They found a significant association was observed between the funding source and qualitative conclusions. Only two (3.8%) of the fifty-two industry-sponsored studies had unfavorable conclusions, whereas three (21.4%) of the fourteen non-industry-sponsored studies indicated that, depending on the clinical scenario, the modality examined was neither effective nor safe.

They concluded that most studies on thromboprophylaxis after total joint arthroplasty are sponsored by industry and that  qualitative conclusions in those studies are favorable to the use of the sponsored prophylactic agent.

The lesson here is clear. Identifying conflict of interest is essential to the interpretation of the results of studies. As we have pointed out in previous posts, it is unfortunate that uncovering this critical information can be difficult. 

Our position is that a discussion of all conflicts of interest and their possible effects on study design, results and conclusions should be a part of the "limitations" paragraph of the Discussion section of each paper.

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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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