Risks of anticoagulation after shoulder arthroplasty

Therapeutic postoperative anticoagulation is a risk factor for wound complications, infection, and revision after shoulder arthroplasty

These authors examined the relationship between postoperative therapeutic anticoagulation, wound complications, infection, and revision using a national insurance database from 2007 to 2016

Those with a prescription for a therapeutic anticoagulant within 2 weeks of surgery were identified and compared with controls without postoperative therapeutic anticoagulant prescriptions.

A total of 17,272 patients were included, including 684 patients who received therapeutic anticoagulation and 16,588 controls.

Patients receiving therapeutic anticoagulation had increased risk of wound complications at 3 months (odds ratio [OR] 3.0, 95% confidence interval [CI] 2.0-4.6, P < .0001) and 6 months (OR 2.5, 95% CI 1.7-3.8, P < .0001).

Patients receiving therapeutic anticoagulation also experienced increased rates of wound infection at 3 months (OR 1.5, 95% CI 1.1-2.0, P ..007) and 6 months (OR 1.8, 95% CI 1.4-2.3, P <.0001).

Finally, patients receiving therapeutic anticoagulation experienced increased rates of revision surgery at 6 months (OR 1.8, 95% CI 1.3-2.5, P . .0003) and within 9 years (OR 1.5, 95% CI 1.1-2.0, P . .007).

Comment: The risks of anticoagulation are undeniable. We have found this program to be effective
(1) to ask the patient's cardiologist for each patient with atrial fibrillation if anticoagulation is really necessary - often it turns out not to be,
(2) to be meticulous about hemostasis,
(3) to use thrombogenic agents at the time of surgery (e.g. topical tranexamic acid, thrombin+gelfoam, etc),
(4) to close the wound with staples to allow drainage,
(5) to use a dressing with suction (see illustration below),
(5) to delay range of motion exercises until it is obvious that bleeding is under control, and
(6) to ask the patient and family to notify us promptly of increased swelling, pain or drainage.

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Shoulder surgery and the Marlboro Man

Tobacco use is associated with increased rates of infection and revision surgery after primary superior labrum anterior and posterior repair.

These authors used the PearlDiver Patient Records Database, a for-fee insurance-based database of patient records, to explore the relationship between tobacco use and the adverse outcomes of arthroscopic superior labrum anterior and posterior (SLAP) repairs. The cohort of primary SLAP repairs was then divided into tobacco use and non–tobacco use cohorts using ICD-9 code 305.1 (tobacco use disorder). It is not known how accurate this coding is and how it reflects the different uses of tobacco (inhaled, chewed, etc).

They found that the incidences of revision SLAP repair or revision to a biceps tenodesis (P = .023) and postoperative infection (P = .034) were significantly higher in patients who used tobacco versus matched controls.

They suggest that tobacco’s negative effects on poor wound healing and the development of postoperative infection may results from a combination of factors. "On a cellular level, tobacco use reduces cutaneous blood flow, impairing soft tissue oxygenation, resulting in increased anaerobic metabolism in healing tissues. Simultaneously, thrombi are generated as a result of increased platelet aggregation, which compounds an already hypoxic environment, leading to decreased healing potential. This reduced perfusion impairs the delivery of critical lymphocytes to areas undergoing healing or prone to infection. Furthermore, systemic nicotine has been shown to have a negative immunomodulatory effect on T-cell function, resulting in cells that are more susceptible to infectious pathogens. Finally, and perhaps most specific to tendon healing required for a successful SLAP repair, the synthesis of collagen has been shown to be greatly impeded in smokers, leading to impaired wound and soft-tissue healing."

Comment: The same factors that impair success in SLAP repairs must apply to the healing of rotator cuff repairs, Bankart repairs and subscapularis healing in In addition to its effect on healing (see this link), tobacco use is also associated with increased pain (another cause of 'surgical failure')  as shown here and here .

The prior post also emphasizes the risk.

There is another association of importance than may account for some of the surgical failures in smokers, and that is the observation that smokers tend to take more risks than non-smokers (see this post). Here is a compelling quote from that article.

"The fact that smoking is bad for people’s health has become common knowledge, yet a substantial amount of people still smoke. Previous studies that sought to better understand this phenomenon have found that smoking is associated with the tendency to take risk in other areas of life as well. The current paper explores factors that may underlie this tendency. An experimental analysis shows that smokers are more easily tempted by immediate high rewards compared to nonsmokers. Thus the salience of risky alternatives that produce large rewards most of the time can direct smokers to make bad choices even in an abstract situation such as the Iowa Gambling Task. These findings suggest that the risk taking behavior associated with smoking is not related to the mere pursuit of rewards but rather reflects a tendency to yield to immediate temptation."

Now here's a quiz. This paper comes from Virginia. Can you name the top five tobacco producing states in order? The answer can be found here.

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