Recommendations from the ICM-VTE: Shoulder & Elbow

Abstract

Question: 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 to the does not immobilization of the upper limb as a in the from limited for VTE prophylaxis in patients undergoing upper limb They that VTE is a rare of upper extremity surgery and surgery of the shoulder prophylaxis with in patients undergoing shoulder They also prophylaxis with should be considered in surgery patients have risk for VTE for a of and if a will be to for an were made for shoulder In of upper limb VTE prophylaxis was in of patients with VTE risk and with prophylaxis for or out of is For elbow and arthroscopy, VTE prophylaxis was not that this is an that not Question: 3 - there a risk for VTE of the upper Response/Recommendation: No risk for venous thromboembolism (VTE) with respect to the upper extremity during and elbow is that and risk should be considered for all upper limb under local or regional are for VTE and risk is not Strength of Recommendation: Limited. Delegates vote: Agree 100.00% Disagree 0.00% Abstain 0.00% (Strong Consensus) Rationale: There are no risk for the for to upper limb surgery for shoulder Guidelines have for higher risk procedures in the and arthroplasty, the risk in the upper limb shoulder these guidelines are not directly than risk have to whether a is higher risk of deep venous there is a of evidence to support these upper limb surgery, in the risk of upper extremity with respect to upper limb surgery that is with an risk of VTE following total elbow of and are associated with a risk of VTE fracture fixation in Furthermore, is also associated with an risk of VTE following shoulder arthroplasty, as is and should which have to increase the risk of is on and National guidelines in have to patients higher risk of The for the of the have a of guidelines based on risk from the and from the evidence of VTE following and elbow surgery in the there have no reported cases of VTE following local or regional is not to be to risk can be There are no guidelines following proximal or shoulder studies the VTE risk and the need for for VTE studies have that all patients should prophylaxis shoulder surgery, with prophylaxis for for the level of risk, however, a risk for the use in the shoulder surgery, which not C. J. Question: 4 - VTE prophylaxis be to patients undergoing upper extremity as Response/Recommendation: there are no guidelines venous thromboembolism (VTE) prophylaxis for patients undergoing upper extremity the risk of upper extremity VTE is that VTE prophylaxis for patients undergoing limb or procedures is VTE prophylaxis in patients undergoing upper extremity immobilization may be evidence is and must be Strength of Recommendation: Limited. Delegates vote: Agree Disagree Abstain 0.00% (Strong Consensus) Rationale: this in there are no guidelines VTE prophylaxis for patients undergoing upper extremity immobilization. immobilization can a or for VTE the of a the venous in the deep of the or Other associated with a VTE may a deep venous (DVT) or pulmonary embolism with in for VTE major surgery, and than in the an 1% to 4% of VTE the upper reports from literature this for upper extremity VTE following or may from these upper extremity VTE with to of these VTE to a it is to patients for upper extremity VTE and patients an or of with and as these have to increase the risk of the of evidence upper extremity VTE there have studies on VTE prophylaxis in These and arthroplasty, as as The of and the of have guidelines prophylaxis following and these there is no for which chemoprophylaxis to the of and the for which chemoprophylaxis should be For patients undergoing arthroscopy with risk are to have no and guidelines that and are for patients undergoing For of upper extremity VTE in patients with immobilization in a or as a risk a case-control study a cohort of with plaster immobilization. out of patients demonstrated upper extremity VTE of immobilization report demonstrated upper extremity VTE in a with distal fracture with a the with and the of a was not on any prophylaxis the a and on is to that in these reports is the of to guidelines the need for VTE The 2018 guidelines by the National Institute for Health and Care Excellence (NICE) that for upper limb VTE prophylaxis is generally not if local or regional for upper limb VTE prophylaxis may be considered for undergoing upper limb surgery if the total under general is over 90 minutes or the operation will make the more difficult to the risk of immobilization with the of the reports in and the 2018 guidelines by it is to the need for VTE prophylaxis for upper extremity in patients with or risk will need to be to whether the type and duration of immobilization the risk of VTE as as which of prophylaxis is of for and Question: - there a for of aspirin as a VTE prophylaxis in patients undergoing upper limb surgery? Response/Recommendation: There is insufficient evidence to support or aspirin as venous thromboembolism (VTE) prophylaxis in upper extremity may be for patients undergoing more Strength of the Recommendation: Limited. Delegates vote: Agree 93.94% Disagree 6.06% Abstain 0.00% (Strong Consensus) Rationale: There is a of literature venous thromboembolic (VTE) prophylaxis in upper limb In the risk of VTE following upper limb procedures is considered of the guidelines not or VTE prophylaxis following upper limb procedures the of the of the of The National Institute for Health and Care Excellence (NICE) and the for of the have a of risk and prophylaxis indications for VTE following upper extremity There are that duration surgeries than 90 minutes of general of the upper should be considered for associated with another risk There are studies directly aspirin as a VTE upper limb studies upper limb VTE prophylaxis are retrospective series with no of rotator cuff repair, the study between aspirin 81 vs. no chemoprophylaxis is a retrospective case-control study out on rates of symptomatic VTE were with no between the and For shoulder arthroplasty, Kirsch et al., reported a rate of for symptomatic VTE primary shoulder arthroplasties with 81 mg for One series of upper limb with of patients a similar rate of symptomatic VTE of For proximal one study on patients for proximal humerus fracture prophylaxis a rate of symptomatic VTE of Question: - VTE prophylaxis be to patients undergoing upper extremity Response/Recommendation: venous thromboembolism (VTE) prophylaxis in patients undergoing upper extremity under local or regional is not VTE prophylaxis should be considered in patients high risk of VTE and undergoing surgery under general that over 90 Strength of Limited. Delegates vote: Agree 100.00% Disagree 0.00% Abstain 0.00% (Strong Consensus) deep a low incidence of to 1 in extremity is divided into primary and or venous to of the from of one or more the the of primary The more of the upper extremity from or and surgery or to the upper embolism and have as associated with a risk of PE compared to extremity venous more in association with and in association with and are associated with studies report the incidence of deep venous to upper extremity In a report by et al., patients with of patients of upper extremity as a of surgery or In another study of patients undergoing upper extremity patients and out of patients a of et al., registry patients in a registry reported an incidence of of upper extremity DVT in patients undergoing open reduction and internal fixation of distal The risk for upper extremity deep venous (DVT) in the study were of and use of In another study by et al., on patients undergoing general surgery, the incidence of of the upper extremity was with the DVT in association with In et al., reporting on an association between upper extremity surgery and in two patients in a cohort of patients out of the study to in the of compared to cohort of in which three patients upper extremity surgery three In Hoxie et al., reported an of pulmonary embolism in of patients with a proximal humerus fracture 3 open reduction internal fixation In et al., no thromboembolic events in receiving VTE proximal humerus In to the there are reports of the of and PE and upper extremity fracture or around the of the need for of upper limb surgery were The by and the literature and guidelines prophylaxis for in and elbow They risk for DVT in patients with elbow or surgery and that of or over to of of one or more significant of use of or with to be for upper extremity The that VTE prophylaxis be considered for patients and patients undergoing upper extremity under local or regional were considered to be The review by et al., also the in patients undergoing elective upper extremity They also an that risk and of chemoprophylaxis for patients and prophylaxis for on which of or should be in of upper limb does not guidelines have The National Institute for Health and Care Excellence (NICE) Guidelines guidelines that are that VTE prophylaxis is generally not if local or regional for upper limb VTE prophylaxis for undergoing upper limb surgery if the total under general is over 90 minutes or their operation is to make it difficult for to The for of the also guidelines that are - for prophylaxis in and elbow surgery regional anaesthesia or minutes No prophylaxis minutes elbow 1 risk prophylaxis minutes and risk or surgery prophylaxis and prophylaxis The evidence for the use of in upper extremity is There is evidence that VTE prophylaxis in patients undergoing upper extremity under local or regional is not chemoprophylaxis should be for patients undergoing upper extremity under general 90 VTE and patients are to have with The of chemoprophylaxis should be the risk. Question: - VTE prophylaxis be to patients undergoing shoulder Response/Recommendation: the risk of significant thromboembolic events following shoulder arthroplasty, it is that the of deep venous (DVT) prophylaxis the There is insufficient evidence to support or aspirin as venous thromboembolism (VTE) prophylaxis in upper extremity The associated with and the in patients risk for Strength of Recommendation: Limited. Delegates vote: Agree Disagree Abstain 0.00% (Strong Consensus) Rationale: studies have for the that DVT prophylaxis be following extremity arthroplasty, of from made for shoulder literature reports in the incidence of VTE events following shoulder arthroplasty, with ranging from these studies in VTE events were in studies with DVT or their and all findings were as VTE events. Other studies were retrospective which significant VTE the incidence in studies that considered significant VTE events were to the of that with reporting an incidence of and one study reporting a of of studies reported a incidence of should also be considered that the rate of VTE events in the general not undergoing reported is limited to the of this have low rates of significant VTE events following shoulder arthroplasty in patients or VTE prophylaxis The rate also to be low in patients shoulder arthroplasty and no DVT prophylaxis that no have on the one the that an VTE risk of over is required to the risk from prophylaxis to in patients with an higher risk of Other reported to be associated with DVT prophylaxis as and to following shoulder arthroplasty, several must be considered which have to the incidence of VTE and and of of of a and Furthermore, shoulder arthroplasty to be associated with risk of similar rates of VTE events have between total shoulder arthroplasty and total shoulder arthroplasty in studies have a rates for another is the to VTE prophylaxis is a have the of VTE prophylaxis in the of shoulder arthroplasty, should be and to and risk C. Navarro Question: - VTE prophylaxis be to patients undergoing rotator cuff Response/Recommendation: The incidence of venous thromboembolism (VTE) arthroscopic rotator cuff is the literature several risk for VTE arthroscopic there is limited evidence the of VTE prophylaxis In the of any literature to a it is that patients undergoing RCR should have and should also be and if considered to should be to VTE Strength of Recommendation: Limited. Delegates vote: Agree Disagree 0.00% Abstain (Strong Consensus) Rationale: The incidence of VTE following arthroscopic shoulder surgery and RCR reported in several studies to be 1% in all one study, compared to the general studies report findings to the low incidence of several risk for VTE RCR have arthritis and high One retrospective study performed and reported an VTE rate of that a of The the following risk for of or duration of surgery and the not prophylaxis the risk be to higher risk patients that be considered for more et al., a retrospective case-control study of patients arthroscopic of which and and the with the of 81 The VTE rates were and there were no in VTE rates between the to that the use of prophylaxis and is a of VTE prophylaxis arthroscopic RCR for Brian C. Werner, Question: - VTE prophylaxis be to patients undergoing arthroscopic procedures of the Response/Recommendation: there is no to suggest that should be performed in patients undergoing arthroscopic shoulder in risk the low risk of should be thromboembolism (VTE) prophylaxis may be considered in patients undergoing surgery with the Strength of Recommendation: Delegates vote: Agree Disagree Abstain (Strong Consensus) Rationale: VTE rates are higher shoulder arthroplasty than shoulder arthroscopy The of VTE incidence is by in as operation and have associated with VTE in shoulder shoulder procedures are and more repair, to higher risk of a The Latarjet-Bristow procedure than shoulder procedures as open and arthroscopic Bankart and cohort studies that Latarjet-Bristow patients are more to VTE than Bankart patients et compared rates in patients arthroscopic open or Latarjet-Bristow procedures between from the of National 3 Latarjet-Bristow patients a deep venous 2 arthroscopic Bankart patients a DVT, 1 arthroscopic Bankart a pulmonary embolism and no open Bankart patients a Goodloe et also the to rates these three with a cohort of patients open Bankart repair, arthroscopic Bankart Latarjet-Bristow patients a low rate of DVT in this study, higher than arthroscopic Bankart and open Bankart that patients surgery are more to a VTE than patients undergoing Bankart - the studies with to VTE and the et cohort study incidence of between arthroscopic open and open arthroscopic Bankart 3 DVT for no DVT for open and 2 DVT and 1 PE for arthroscopic Goodloe et study incidence of between arthroscopic open and and risk for arthroscopic open rate for arthroscopic none for open for for arthroscopic none of open for surgery of DVT by to arthroscopic Bankart et study risk of and risk No DVT for et cohort study incidence of VTE elective shoulder Bankart instability patients 1 out of Bankart patients a 3 - a with an DVT 2 in et with series rate of and DVT in shoulder arthroscopy, and association with shoulder arthroscopy are total DVT, one was in a Kuremsky et 137 series a series of patients thromboembolic events shoulder 3 cuff repair, and with - surgery with for shoulder arthroscopy 3 - was with a DVT in the and and taking this a on in 4 a shoulder a and to and an in by these - surgery, an DVT and PE was with and an with respect to for a was et report a of pulmonary embolism 1 instability a demonstrated and a with the of was with an report a of DVT shoulder 1 instability a of the and the was The DVT was with with 3 of the a of the which of The and have the on a of was to have et report a of DVT and subsequent PE 1 instability the and with demonstrated pulmonary as as the of the of PE by upper extremity DVT was with and which was by The the of was for an 3 to from for cohort for and for of venous the incidence of VTE surgery, no studies were that VTE prophylaxis shoulder the for shoulder are for shoulder arthroscopy as a et reported the DVT in their study of the shoulder arthroscopy cases for the with the 1% for the extremity and no patients receiving or et that is not for the majority of arthroscopic shoulder surgery with out of patients these should be that surgery patients are an risk for a VTE compared to open or arthroscopic Bankart surgery should VTE prophylaxis for surgery patients risk for for VTE major surgery, of thromboembolic and as by et should be that the majority of patients in these with an open and may not into a cohort of Question: - VTE prophylaxis be to patients undergoing elbow Response/Recommendation: There is no to a the need for venous thromboembolism (VTE) prophylaxis for patients undergoing elbow arthroplasty and are low risk that should be Strength of Recommendation: Delegates vote: Agree Disagree 6.06% Abstain (Strong Consensus) Rationale: studies reported on cases of VTE following One in whether VTE prophylaxis is in upper limb major The VTE incidence in the four was from to The total of VTE events was of pulmonary embolism deep venous (DVT) and the 2 to VTE was reported in one which one from three cases of No were VTE risk were not in any of the four studies. VTE prophylaxis were reported by one study, which and the use of The of VTE prophylaxis on risk reduction or rates have not reported and no have made between patients undergoing with or Surena Namdari Question: - VTE prophylaxis be to patients undergoing around the Response/Recommendation: In the of any literature to a it is that patients undergoing for elbow instability should have and should also be if considered to should be to venous thromboembolism (VTE) Strength of Recommendation: Delegates vote: Agree 93.94% Disagree 6.06% Abstain 0.00% (Strong Consensus) Rationale: whether or not the patients undergoing surgery for elbow should be VTE literature review all upper limb surgery a VTE rate as low as to the incidence of VTE risk not in around the There are retrospective studies or on the and of of the elbow for instability an incidence of deep venous (DVT) of et reported one of DVT, with an incidence of in patients undergoing for instability of the Furthermore, the VTE prophylaxis was not in the et reported a report of DVT in an The VTE prophylaxis was not and the an and and pulmonary four from the the of VTE in upper limb surgery and that patients should be the risk have indications for the prophylaxis the patients in and it is that upper limb surgery is associated with an risk of under literature the need for prophylaxis for patients undergoing around the should the risk for to the that may from VTE Question: 12 - are the if of upper extremity Response/Recommendation: of the and of an upper extremity deep venous (DVT) are as and more as venous and are more concerning for Strength of Recommendation: Limited. Delegates vote: Agree 100.00% Disagree 0.00% Abstain 0.00% (Strong Consensus) Rationale: extremity DVT is not as as extremity DVT and of all DVT They are divided into primary DVT, with no or and or DVT, which are associated with venous or is a type of primary DVT in with In this and of the shoulder a in the They present a of with and of the of the and of upper extremity DVT are and and that may be more of an upper extremity DVT and venous to the of the of the with the be to of the or with and a In cases with a more proximal as or patients may upper extremity or and There were four studies that the and of patients with an upper extremity et al., patients with an upper extremity DVT in a over a was present in all patients with and 4 with in the extremity. In a retrospective review of 90 patients with of the internal or patients in the extremity and with The series was a retrospective review of a DVT with patients of which patients an upper extremity DVT, were associated with venous and were They that patients with an upper extremity DVT were more to have extremity and to have extremity or than patients with a extremity et al., the use of for the of patients with an upper extremity They the to be and The were and of the and of upper extremity DVT are an findings as and more as or or extremity should to out upper extremity Surena Namdari Question: - is the of DVT of the upper Response/Recommendation: with deep venous (DVT) of the upper extremity should the for patients with DVT of the extremity. These and and and or and should be for 3 and 3 if the is or to risk and risk is The use of or should be to cases for Strength of Recommendation: Limited. Delegates vote: Agree 93.94% Disagree 6.06% Abstain 0.00% (Strong Consensus) Rationale: extremity DVT of the and and for to of the total of venous thromboembolic There are no in patients with upper extremity DVT and are based on evidence from in patients with limb venous thromboembolism The risk of pulmonary embolism (PE) was reported to be than in patients with limb DVT as as the for of studies to patients have reported on the and of with No in rates was between of with and and with guidelines on suggest over for patients with upper extremity DVT and suggest to in patients with with of the and the and with of by the is with the of this as a

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