Recommendations from the ICM-VTE: Shoulder & Elbow
2022; Wolters Kluwer; Volume: 104; Issue: Suppl 1 Linguagem: Inglês
10.2106/jbjs.21.01258
ISSN1535-1386
Tópico(s)Shoulder and Clavicle Injuries
ResumoQuestion: 1 - Concerning VTE risk, which surgeries can be considered major, and which surgeries can be considered non-major in shoulder and elbow surgery? Response/Recommendation: Shoulder arthroscopy, non-fracture related shoulder arthroplasty, and all elbow procedures can be considered non-major venous thromboembolism (VTE) risk. Fracture related shoulder procedures can be considered major VTE risk. Strength of Recommendation: Limited. Delegates vote: Agree 93.94% Disagree 6.06% Abstain 0.00% (Strong Consensus) Rationale: VTE following shoulder and elbow surgery are rare events. One study reported for all upper extremity deep venous thromboses (DVT) to represent 1% to 4% of all DVT1. In the shoulder, surgeries can be divided into arthroscopic, non-fracture shoulder arthroplasty, and fracture related surgeries. In the elbow, surgeries can be divided into arthroscopy, fracture related, and arthroplasty. With respect to these surgeries, several studies have reported VTE rates, however, a majority of this information comes from a collection of level 3 and level 4 evidence along with registry studies. In shoulder arthroscopy, VTE rates are low with reported rates ranging from 0.011% to 0.38%2-6. Kuremsky et al., in a retrospective study of 2,872 patients undergoing shoulder arthroscopy reported VTE rate of 0.24%2. Jameson et al., in a registry study out of the United Kingdom reported 0.011% VTE rate in a retrospective review of 65,302 shoulder arthroscopy cases3. Similarly, Brislin et al., reported VTE rate of 0.38% in a consecutive series of 263 arthroscopic rotator cuff repairs (RCR)4. These VTE rates following arthroscopic RCR were similar to rates reported by Hoxie et al., (0.26%)5. Additionally, open instability surgeries also comprise higher VTE risk than their arthroscopic counterparts. Goodloe et al., in a registry study compared arthroscopic Bankart repair, open Bankart repair, and Latarjet-Bristow procedure with reported VTE rates of 0.1%, 0.0%, and 0.8%, respectively7. Thus, shoulder arthroscopy procedures can be considered non-major concerning VTE risk. In shoulder arthroplasty, a distinction must be made between non-fracture indications for primary shoulder arthroplasty (glenohumeral arthritis or rotator cuff arthropathy) and arthroplasty for fracture. For non-fracture arthroplasty, VTE rates have ranged from 0.16% to as high as 13%3,8-11. Sperling and Cofield in a 20-year respective review of 2,885 shoulder arthroplasties reported 0.17% VTE rate12. In a UK registry study, Jameson et al., reported VTE rate of 0.16% for 10,229 shoulder arthroplasties3. Other registry studies have reported similar rates with Lyman et al., reporting 0.68% VTE rate (69 DVT, 32 PE) in 13,759 shoulder arthroplasties9, Lovy et al., also reported 0.35% VTE rate (20 VTE) in 5,801 total shoulder arthroplasty (TSA)11, and Young et al., reported a pulmonary embolism (PE) rate of 0.25% in 422,372 TSA8. Furthermore, Kirsch et al., in a retrospective review of 2,141 primary arthroplasty patients receiving aspirin 81 mg as chemoprophylaxis report a VTE rate of 0.56%10. Willis et al., in an observational trial of 100 consecutive patients reported VTE rate of 13%, however, all patients were screened irrespective of symptoms13. These findings suggest that reported VTE rates may be underrepresented. Tashjian et al., present higher symptomatic VTE rates of 2.6% (14/533) (5 DVT and 12 PE) in single institution retrospective review14. Primary shoulder arthroplasty for non-fracture indications can be considered non-major concerning symptomatic VTE risk. For proximal humerus fracture related surgery, VTE rates can be delineated between open reduction internal fixation (ORIF) and arthroplasty. In fracture related arthroplasty, reported VTE rates are higher than non-fracture related arthroplasty with reported rates ranging from 0.51% to as high as 5.1%3,15,16. Jameson et al., reported 0.51% VTE rate in 4,696 hemiarthroplasties performed for fracture3. Farng et al., in a retrospective California registry study of 10,244 primary shoulder arthroplasties reported 1.0% VTE rate in fracture arthroplasty in comparison to 0.4% for non-fracture arthroplasty15. Furthermore, Navarro et al., demonstrated trends towards higher VTE rates for traumatic indications in comparison to elective surgery regardless of procedure type (1.71% vs. 0.80%, p=0.055)17. Hoxie et al., reported PE rate of 5.1% (7/137) in consecutive series of 137 arthroplasty for fracture16. For proximal humerus ORIF, Nayar et al., in another registry study reported VTE rate of 3.0% and also reported a 0.36% VTE for fractures around distal humerus/ elbow18. Thus, proximal humerus fracture surgery can be considered major concerning VTE risk. For elbow surgery, the limited literature with respect to VTE risk. Intravia et al., in a retrospective review of 560 consecutive elbow arthroscopies reports no incidence of VTE19. For elbow arthroplasty, Duncan et al., report a 0.28% PE rate in a retrospective review of 816 consecutive total elbow arthroplasties (TEA) and 260 revision elbow arthroplasty cases over 20-year period20. Similarly, Krenek et al., in a California registry study of 1,625 patients undergoing TEA report a 0.25% PE rate21. Thus, elbow procedures can be considered non-major concerning VTE risk. Alexander J. Rondon, Brian C. Werner, Surena Namdari Question: 2 - Does immobilization of the upper extremity influence the VTE prophylaxis protocol? Response/Recommendation: No studies have directly answered the question of whether immobilization of the upper extremity influences the venous thromboembolism (VTE) prophylaxis protocol. There is insufficient evidence to support any alteration in VTE prophylaxis protocol based on need for immobilization of the upper extremity. Strength of Recommendation: Limited. Delegates vote: Agree 100.00% Disagree 0.00% Abstain 0.00% (Strong Consensus) Rationale: The Guidelines in Emergency Medicine Network (GEMNet) posed a similar question in 2013, asking "in patients with isolated upper extremity injury, does the use of temporary immobilization via plaster cast/sling increase the risk of subsequent venous thromboembolic events during short-term follow-up?"22. Only four papers met their inclusion criteria23-26, of which three were retrospective cohort studies and one was a case-control study. All four studies were small and none were designed to directly test the association between temporary upper extremity immobilization and VTE or associated prophylaxis protocols. They determined from this limited evidence that there was no evidence to suggest a significant risk of VTE in ambulatory patients with temporary upper extremity immobilization. In the United Kingdom, the 2018 the National Institute for Health and Care Excellence (NICE) guidelines for reducing the risk of hospital-acquired VTE makes two recommendations. First, that VTE prophylaxis is generally not required if upper limb surgery is taking place under local or regional anaesthesia; and second, that VTE prophylaxis should be considered if the duration of upper limb surgery under general anaesthesia will exceed 90 minutes or if the operation will make it more difficult for the patient to mobilize afterwards27,28. Again, the recommendation does not include immobilization of the upper limb as a factor in the decision-making process. A 2013 consensus statement from Italy provided limited recommendations for VTE prophylaxis in patients undergoing upper limb surgery. They recognized that VTE is a rare complication of upper extremity surgery and non-joint replacement surgery of the shoulder but recommended pharmacological prophylaxis with low-molecular-weight heparin (LMWH) in patients undergoing shoulder joint replacement surgery. They also suggested pharmacological prophylaxis with LMWH should be considered in non-prosthetic surgery patients who have risk factors for VTE for a minimum of seven days and prolonged if a patient will be confined to bed for an extended period. Similar recommendations were made for shoulder arthroscopy. In circumstances of upper limb fracture, VTE prophylaxis was recommended only in circumstances of bed confinement, poorly mobile patients with VTE risk factors, and crush injuries – with prophylaxis for 30 days or until mobility out of bed is restored. For elbow and wrist arthroscopy, VTE prophylaxis was not advised, but they recognized that this is an area that has not been studied29. Richard L Donovan, Antoon van Raebroeckx, Michael R. Whitehouse Question: 3 - Is there a risk stratification method for VTE of the upper extremity? 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. Delegates vote: Agree 100.00% Disagree 0.00% Abstain 0.00% (Strong Consensus) Rationale: There are no risk assessment tools for stratifying the requirement for thromboprophylaxis prior to upper limb surgery even for shoulder procedures30. 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 VTE31-34. Evidence with respect to upper limb surgery postulates that obesity is correlated with an increased risk of VTE following total elbow arthroplasty35. American Society of Anesthesiologist (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 disease36,37. 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 literature38. As there have been no reported cases of VTE following wide-awake local or regional anaesthetic, thromboprophylaxis is deemed not to be indicated31. 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 prophylaxis39,40. Several studies have proposed that all patients should receive mechanical prophylaxis after shoulder surgery, with chemical prophylaxis reserved for those at high-risk for VTE36,39. To determine the level of risk, however, requires a risk stratification tool tailored for the use in the shoulder surgery, which has not been currently formulated. Darren C. Roberts, David J. Warwick Question: 4 - Should routine VTE prophylaxis be administered to patients undergoing upper extremity immobilization, such as casting? Response/Recommendation: While there are no official guidelines recommending routine venous thromboembolism (VTE) prophylaxis for patients undergoing upper extremity immobilization, the risk of upper extremity VTE is still present. Given that VTE prophylaxis for high-risk patients undergoing various lower limb or spinal orthopaedic procedures is recommended, VTE prophylaxis in high-risk patients undergoing upper extremity immobilization may be beneficial. However, evidence is inconclusive and further research must be done. Strength of Recommendation: Limited. Delegates vote: Agree 90.91% Disagree 9.09% Abstain 0.00% (Strong Consensus) Rationale: At this point in time there are no official guidelines recommending routine VTE prophylaxis for patients undergoing upper extremity immobilization. This immobilization can include a cast, splint, or other orthopaedic intervention for stability. VTE involves the formation of a blood clot within the venous system, often in the deep veins of the leg or pelvis41,42. Other terminology associated with a VTE may include a deep venous thrombosis (DVT) or pulmonary embolism (PE), with both being potentially dangerous complications resulting in elevated mortality. Risk factors for VTE include major surgery, trauma, malignancy, and immobilization43,44. Although less common than in the lower extremity, an estimated 1% to 4% of VTE involve the upper extremity45. Multiple case reports from orthopaedic literature discuss this potential for upper extremity VTE following orthopaedic injury46-48. Further morbidity or mortality may arise from these upper extremity VTE with 9% to 14% of these VTE progressing to a PE49. Therefore, it is important to recognize high-risk patients for upper extremity VTE and provide appropriate prophylaxis. "High-risk" patients include an elevated age, or presence of comorbidities including hypertension treated with medication, and wound infection as these have been shown to increase the risk of DVT50. Despite the lack of evidence surrounding upper extremity VTE prophylaxis, there have been multiple studies focused on VTE prophylaxis in other orthopaedic procedures. These include hip and knee arthroplasty, as well as spinal surgery. The American Academy of Surgeons (AAOS) and the American College of Chest Physicians (ACCP) have created guidelines specifically covering prophylaxis following hip and knee arthroplasty51-53. Between these guidelines, there is no conclusive universal recommendation for which specific chemoprophylaxis to provide, the timeline of administration, and the scenarios for which chemoprophylaxis should be withheld. For example, patients undergoing knee arthroscopy with minimal risk factors are recommended to have no chemoprophylaxis. Alternative measures include early mobilization/ambulation, mechanical compression, transcutaneous nerve stimulation, and adequate hydration54-56. European guidelines demonstrating that hydration and early ambulation are especially promising for low-risk patients undergoing day surgeries57. For specific instances of upper extremity VTE in patients with immobilization in a cast or splint as a risk factor, a case-control study highlighted a patient cohort of 10 individuals with plaster immobilization. Three out of ten patients demonstrated upper extremity VTE within 3-months of immobilization [odds ratio [OR] 7.6 (2.0-29.9)]58. Another case report demonstrated upper extremity VTE in a patient with distal humeral shaft fracture treated with a coaptation splint59. Four days post immobilization, the patient presented with increasing forearm pain and swelling. Ultrasound later confirmed the presence of a right brachial vein thrombus. This patient was not on any prophylaxis at the time, requiring a brief hospitalization and home-discharge on warfarin. It is important to note that inherent in these case reports is the individual variability seen when placing different types of immobilizations. This adds further uncertainty to guidelines when assessing the need for VTE prophylaxis. The 2018 published guidelines by the National Institute for Health and Care Excellence (NICE) stated that for upper limb orthopaedic surgery: 1) VTE prophylaxis is generally not needed if giving local or regional anesthetic for upper limb surgery. 2) VTE prophylaxis may be considered for people undergoing upper limb surgery if the person's total time under general anesthesia is over 90 minutes or the operation will likely make the patient more difficult to mobilize themselves60. Considering the known risk factor of immobilization with the development of VTE, the case reports found in orthopaedic literature, and the 2018 guidelines published by NICE, it is appropriate to recognize the possible need for VTE prophylaxis for upper extremity immobilization, especially in patients with predisposing comorbidities or other risk factors. Further research will need to be conducted to assess whether the type and duration of immobilization impacts the risk of VTE as well as which form of prophylaxis is best standard of care for each situation. Kenneth A. Egol, Garret Esper and Ariana Meltzer-Bruhn Question: 5 - Is there a role for administration of aspirin as a VTE prophylaxis in patients undergoing upper limb surgery? Response/Recommendation: There is insufficient evidence to support or recommend against using aspirin as venous thromboembolism (VTE) prophylaxis in upper extremity surgery. It may be most beneficial for high-risk patients undergoing more complex reconstructive surgery. Strength of the Recommendation: Limited. Delegates vote: Agree 93.94% Disagree 6.06% Abstain 0.00% (Strong Consensus) Rationale: There is a paucity of literature regarding venous thromboembolic (VTE) prophylaxis in upper limb surgery61,62. In general, the risk of VTE following upper limb surgical procedures is considered low62-65. Most of the clinical guidelines do not recommended or mention VTE prophylaxis following upper limb procedures the American Academy of Orthopaedic Surgeons (AAOS), the American College of Chest Physicians (ACCP), the European Society of Anaesthesia (ESA)61,62,66. Nonetheless, The National Institute for Health and Care Excellence (NICE) and the British Society for Surgery of the Hand (BSSH) have described a set of risk factors and prophylaxis indications for VTE following upper extremity surgery67,68. There are recommendations that only longer duration surgeries (more than 90 minutes of general anesthesia) of the upper should be considered for chemical thromboprophylaxis when associated with another personal intrinsic risk factor67,68. There are few studies directly investigating aspirin (ASA) as a VTE chemoprophylactic agent after upper limb surgery. Most studies analyzing upper limb postoperative VTE prophylaxis are retrospective series with no uniform pattern of prophylaxis. Regarding rotator cuff repair, the only direct comparative study between aspirin 81 mg/daily vs. no chemoprophylaxis is a retrospective case-control study carried out on 914 patients69. Both groups received mechanical prophylaxis. Low rates of symptomatic VTE were found, with no differences between the ASA (0.93%) and non-ASA groups (0.66%). For shoulder arthroplasty, Kirsch et al., reported a rate of 0.63% for symptomatic VTE after 2,394 primary shoulder arthroplasties treated with 81 mg ASA daily for 6 weeks postoperatively70. One large series of upper limb procedures, with nearly 50% of patients without prophylaxis, found a similar rate of symptomatic VTE of 0.53%71. For proximal humeral fractures, one study on 163 patients treated for proximal humerus fracture without chemical prophylaxis (only mechanical prophylaxis) found a rate of symptomatic VTE of 3.3%72. Alberto D. Delgado-Martinez, Laura López-Cuquerella, Ryan M. Cox, Sommer Hammoud Question: 6 - Should routine VTE prophylaxis be administered to patients undergoing upper extremity osteosynthesis? Response/Recommendation: Routine venous thromboembolism (VTE) prophylaxis in patients undergoing upper extremity osteosynthesis under local or regional anesthesia is not needed. VTE prophylaxis should be considered in patients at high risk of VTE and those undergoing surgery under general anesthesia that lasts over 90 minutes. Strength of recommendation: Limited. Delegates vote: Agree 100.00% Disagree 0.00% Abstain 0.00% (Strong Consensus) Rationales: Upper-extremity deep vein thrombosis (UEDVT) has a very low overall incidence of 0.4 to 1 in 10,000 persons73-76. Upper extremity thrombosis is divided into primary (20%) and secondary (80%) causes. Among these, idiopathic thrombosis, effort-related thrombosis (Paget-Schroetter syndrome), or venous thoracic-outlet syndrome due to compression of the subclavian vein resulting from abnormalities of one or more structures at the costoclavicular junction represents the cause of primary thrombosis. The more common secondary thrombosis of the upper extremity results from catheter- or pacemaker-associated thrombosis, cancer-associated thrombosis, hormone-induced coagulation abnormalities, and surgery or trauma to the upper extremity74,77. Pulmonary embolism (PE), post-thrombotic syndrome, and thrombosis recurrence have been described as serious complications associated with UEDVT74,77,78. However, UEDVT has a significantly lower risk of PE compared to lower extremity venous thrombosis78-81. UEDVT occur more frequently in association with central catheters and in association with malignancies and are less associated with immobilization75,76,81. Very few studies report the incidence of deep venous thrombosis due to upper extremity osteosynthesis. In a report by Levy et al., among 300 patients with UEDVT, 31% of patients had developed thrombosis of upper extremity as a result of surgery or trauma79. In another study comprising of 3,357 patients undergoing upper extremity orthopedic procedures, only six patients (0.0018%) developed postoperative VTE, and five out of six patients had a strong history of prior VTE82. Calotta et al., analyzing registry 24,494 patients in a registry database reported an incidence of 0.3% of upper extremity DVT in patients undergoing open reduction and internal fixation of distal radius fractures83. The risk factors identified for upper extremity deep venous thrombosis (DVT) in the latter study were history of congestive heart failure and use of estrogen83. In another study by Mino et al., on 1,857 patients undergoing general surgery, the incidence of postoperative thrombosis of the upper extremity was 1.13%, with all, but one, patient developing the DVT in association with central catheter84. In contrast, Blom et al., reporting on an association between upper extremity surgery and UEDVT in two patients in a sub cohort of 179 patients out of the MEGA study selected due to UEDVT, resulting in the odds ratio of 11.8 compared to control cohort of 2398 patients, in which three patients underwent upper extremity surgery within three months before index date85,86. In addition, Hoxie et al., reported an occurrence of pulmonary embolism in 5.6% of surgically treated patients with a proximal humerus fracture (4 hemiarthroplasty, 3 open reduction internal fixation [ORIF])87. In contrast, Widmer et al., found no thromboembolic events in 50 patients, receiving VTE prophylaxis, after proximal humerus fracture88. In addition to the aforementioned studies, there are sporadic case reports of the occurrence of UEDVT and PE and upper extremity fracture or osteosynthesis89-95. Two reviews around the topic of the need for thromboprophylaxis of upper limb surgery were identified. The article by Roberts and Warwick summarizes the literature and guidelines regarding prophylaxis for thrombosis in hand, wrist, and elbow surgery96,97. They recommend risk assessment for DVT in patients with prolonged elbow or forearm surgery and found that history of active cancer or cancer treatment, age over 60 years, admission to intensive care unit, dehydration, history of VTE, obesity, history of one or more significant medical co-morbidities, family history of VTE, use of hormone replacement therapy or estrogen-containing contraceptives, varicose veins with phlebitis to be predisposing factors for upper extremity VTE. The authors recommended that VTE prophylaxis be considered for patients at high-risk population and patients undergoing upper extremity osteosynthesis under local or regional anesthesia were considered to be at low-risk96,97. The other review article by Anakwe et al., also discussed the topic thromboprophylaxis in patients undergoing elective upper extremity osteosynthesis98. They also recommended an approach that involved risk assessment and administration of chemoprophylaxis for high-risk patients and mechanical prophylaxis for others, unless contraindicated98. Evidence on which form of mechanical or chemical thromboprophylaxis should be chosen in case of upper limb osteosynthesis does not exist. However, some organizational guidelines have been proposed. The National Institute for Health and Care Excellence (NICE) Guidelines has produced guidelines that are stated below99: 1.11.15 Be aware that VTE prophylaxis is generally not needed if giving local or regional anaesthetic for upper limb surgery. [2018]. 1.11.16 Consider VTE prophylaxis for people undergoing upper limb surgery if the person's total time under general anaesthetic is over 90 minutes or where their operation is likely to make it difficult for them to mobilize. [2018]. The British society for Surgery of the Hand (BSSH) has also proposed guidelines that are stated below (Table I)100: TABLE I - BSSH recommendations for prophylaxis in hand, wrist, and elbow surgery Risk Example Recommendation Low LA, regional anaesthesia or 90 minutes GA (including elbow arthroplasty) and/or 1 risk factor Mechanical prophylaxis until mobile High >90 minutes GA and >1 risk factor, prolonged post-operative immobility, or tumour surgery Mechanical prophylaxis and consider pharmacological prophylaxis until mobile The evidence for the use of thromboprophylaxis in upper extremity osteosynthesis is limited. There is scarce but consistent evidence that VTE prophylaxis in patients undergoing upper extremity osteosynthesis under local or regional anesthesia is not necessary. Instead, chemoprophylaxis should be reserved for patients undergoing upper extremity osteosynthesis under long general anesthesia (> 90 minutes), those at high-risk VTE (as discussed above), and patients who are likely to have difficulty with mobilization. The potential benefits of chemoprophylaxis should always be weighed against the bleeding risk. Luis Becker, Juan M. Del Castillo, Matthias Pumberger, Nicolás Cancela Question: 7 - Should routine chemical VTE prophylaxis be administered to patients undergoing shoulder arthroplasty? Response/Recommendation: Given the minimally increased risk of clinically significant thromboembolic events following shoulder arthroplasty, it is unlikely that the benefits of chemical deep venous thrombosis (DVT) prophylaxis outweigh the risks. There is insufficient evidence to support or recommend against using aspirin (ASA) as venous thromboembolism (VTE) prophylaxis in upper extremity surgery. The bleeding risks associated with low-molecular-weight heparin (LMWH) and direct oral anticoagulants (DOAC) outweigh the benefits in patients without substantial risk factors for VTE. Strength of Recommendation: Limited. Delegates vote: Agree 96.97% Disagree 3.03% Abstain 0.00% (Strong Consensus) Rationale: While extensive studies have allowed for the recommendation that chemical DVT prophylaxis be used following lower extremity arthroplasty, lack of data has precluded such recommendations from being made for shoulder arthroplasty101-106. Available literature reports wide variability in the incidence of VTE events following shoulder arthroplasty, with estimates ranging from 0.2%-16%101-116. However, these studies varied significantly in how VTE events were identified. Patients in some studies underwent routine surveillance with DVT ultrasound or computer tomography (CT) scans throughout their postoperative course and all positive findings were included as VTE events. Other studies were retrospective reviews which only included clinically significant VTE events101-116. Unsurprisingly, the incidence estimates in studies that only considered clinically significant VTE events were much closer to the lower end of that range, with most reporting an incidence of <1% and one study reporting a weighted average of 0.68%101. A recent meta-analysis of 19 studies reported a pooled 3-month incidence of 0.85%107. It should also be considered that the underlying rate of VTE events in the general population (i.e., those not necessarily undergoing procedures) has been reported at 0.5%102. Our recommendation is limited due to the lack of randomized control trials (RCT) addressing this question103. Studies have shown very low rates of clinically significant VTE events following shoulder arthroplasty in patients who take ASA or other VTE prophylaxis postoperatively101-115. The rate also appears to be low even in patients who underwent shoulder arthroplasty and had no chemical DVT prophylaxis postoperatively108. Given that no RCT have been completed on the topic, one might best follow the recommendation that an overall VTE risk of over 3% is required to outweigh the bleeding risk from pharmacological prophylaxis using LMWH5. Major bleeding has been postulated to occur in 2.5 per 1,000 patients prescribed LMWH, with an even higher risk of minor bleeding. Other complications reported to be associated with DVT prophylaxis include heparin-induced thrombocytopenia, skin reactions, thrombocytosis, electrolyte imbalances such as hyperkalemia and osteoporosis105. When deciding to prescribe anticoagulation following shoulder arthroplasty, several patient specific factors must be considered
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