Published 4/24/2019

Risk of Venous Thromboembolism After Shoulder Surgery

How physicians and patients can work together to help mitigate complications 

ROSEMONT, Illinois (April 24, 2019) — A new review article published in the April 15 issue of the Journal of the American Academy of Orthopaedic Surgeons examines risk factors, prevention and current treatment recommendations for venous thromboembolism (VTE) after shoulder surgery. VTE is a potentially life-threatening disease that includes deep vein thrombosis (DVT), a condition in which a blood clot forms most often in the deep veins of the body and pulmonary embolism (PE), a complication in which the blood clot travels through the bloodstream and blocks flow to the lungs.
“As the rate of shoulder surgery continues to rise, so too will the prevalence of patients who can develop venous thromboembolism,” said lead study author and orthopaedic surgeon Catherine Rapp, MD. “Fortunately, recent studies offer more guidance on the management of VTE after shoulder surgery. While VTE after total hip and knee arthroplasty has been well-studied, historically, the literature regarding VTE after shoulder surgery has been lacking. This review aims to summarize the available evidence and recommendations regarding VTE after shoulder surgery.”

Dr. Rapp and her co-authors reviewed general literature that reported a wide range of VTE rates after shoulder surgery, including:
  • Symptomatic VTE rates are higher after shoulder replacement (range, 0.24% to 2.6%) than after arthroscopy (range, 0.01% to 0.38%).
    • Specifically, DVT rates are higher after shoulder replacement (range, 0.09% to 1.69%) than after arthroscopy (range, 0.01% to 0.38%) as are PE rates (range 0% to 3% versus 0% to 0.21%).
  • Asymptomatic DVT rates after shoulder replacement were significantly higher than after arthroscopy at 13% versus 5.7%.
  • While most VTE events occur within the first postoperative week, they can occur up to three months after surgery.
Authors suggest that while VTE can be challenging to diagnose, there are indications for this condition: limb swelling, redness, pain, or a warm, solid, elevated area of tissue or fluid inside or under the skin. If a physician sees a need for concern, an ultrasonography is appropriate. A CT scan and MRI are the most common alternative diagnostic options. Additionally, although the clinical significance of an asymptomatic DVT is unknown, knowledge of the rates and risk factors may assist in developing prevention strategies.
The standardized guidelines for VTE prevention after shoulder surgery are lacking, according to the literature review authors, despite potentially significant long-term risks. Low-risk measures, such as early mobilization and sequential perioperative compression devices (a method used to improve blood flow), should be utilized in all patients when feasible. And higher risk strategies, such as pharmacologic prophylaxis (blood thinners) should be tailored on an individual basis.
“Patients should be aware of their risk for VTE after shoulder surgery and have an open conversation with their doctor about how to reduce their risk,” explained Dr. Rapp. “These factors may include but are not limited to patients with expected significant reduction in mobility, active cancer or cancer treatment, age 60 years or older, obesity, significant medical comorbidities such as diabetes and heart disease, and personal or family history of VTE. Patients should also pay attention to symptoms after surgery and weigh risks and benefits of treatment options with their physician.”
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From the Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI.
Dr. J. M. Wiater or an immediate family member has received royalties from Smith & Nephew; is a member of a speakers’ bureau or has made paid presentations on behalf of Zimmer Biomet; serves as a paid consultant to Catalyst OrthoScience; has stock or stock options held in Catalyst OrthoScience, Coracoid Solutions, Hoolux Medical, and Mprink; and has received research or institutional support from Zimmer Biomet and DJ Orthopaedics. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Rapp, Dr. Shields, and Dr. B. P. Wiater. J Am Acad Orthop Surg 2018; 00:1-10 DOI: 10.5435/JAAOS-D-17-00763 Copyright 2018 by the American Academy of Orthopaedic Surgeons.

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Lauren Riley