Venous thromboembolism prophylaxis may be necessary
after traumatic shoulder arthroplasty, according to a study conducted by
shoulder specialists at Southern California Permanente Medical Group.
The study will be presented at the 2011 Congress of the
European Society for Surgery of the Shoulder and the Elbow in Lyon, France.
Ronald A. Navarro, MD, and colleagues wanted to find out
if patients should be given prophylactic anticoagulants after shoulder
arthroplasty to prevent venous thromboembolism (VTE).
The risk of DVT or PE [pulmonary embolism] may far
outweigh the effects of anticoagulants in some shoulder arthroplasty
subsets, Navarro said.
Navarro and his team began their study to see if
the effect of traumatic indication, meaning arthroplasties that were done
because of trauma, would have a higher incidence of symptomatic VTE,
which would necessitate the use of anticoagulants postoperatively.
The researchers conducted a retrospective study of 2,574
patients, with a mean age of 72.3 years, who underwent shoulder arthroplasties
between 2005 and 2009. They excluded patients who had a previous history of a
VTE or anticoagulant use. Inclusion criteria were patients who had elective or
traumatic total, hemi- or reverse shoulder arthroplasties.
The investigators used an ICD-9-CM algorithm to screen
for 90-day symptomatic postoperative VTE events. They also reviewed
postoperative anticoagulant use, radiographs, ultrasounds and patient charts to
find VTE events.
Higher incidence of VTE
The overall incidence of VTE in the 2,574 arthroplasties
was 1.01%. There was no statistically significant difference by year, gender or
operative side. The major finding of note, according to Navarro, was that the
rate of VTE in trauma patients doubled that of elective patients. In the 586
trauma patients it was 1.71%, compared to 0.8% in the 1,988 elective patients.
In assessing only elective cases, reverse shoulder
arthroplasty patients had a higher rate of VTEs at 1.89% compared to total
shoulder arthroplasties at 0.97% and hemiarthroplaties at 0.15%. Similarly,
elective reverse shoulder arthroplasties had a higher incidence of PE than
elective hemiarthroplasty or total arthroplasty. No significant difference in
the rate of deep venous thrombosis was found when comparing the three elective
groups. The traumatic hemiarthroplasty group had a higher incidence of VTE and
PE than elective hemiarthroplasty group.
Overall, VTE incidence was low in the entire study
population, Navarro said. Should you prophylax a shoulder
arthroplasty with anticoagulants just like we do in total hip and knee
replacements, right after you do the surgery? If it is a traumatic indication,
maybe we should. Postoperative VTE prophylaxis can be supported in traumatic
hemiarthroplasty and in reverse shoulder arthroplasty patients, as this data
suggests higher VTE incidence in both of these subset populations.
Navarro wants to further study the populations as his
groups shoulder registry increases enrollment to see if the trends
If we keep finding the same things, [then] we
would suggest more strongly the need for VTE prophylaxis in those
populations, Navarro said. by Renee Blisard
- Navarro RA, Inacio MCS, Burke MF, et al. Effect of traumatic
indication and implant type on symptomatic VTE rates in shoulder arthroplasty.
Scheduled to be presented at the 2011 Congress of the European Society of the
Shoulder and the Elbow. Sept. 14-17. Lyon, France.
- Ronald A. Navarro, MD, can be reached at the Department of
Orthopedic Surgery, Kaiser Permanente South Bay, 25825 S. Vermont Ave.,
Harbor City, CA 90710; email: email@example.com.
- Disclosure: Navarro and his co-authors have no relevant
It would be useful to understand the frequency of lower
extremity trauma or other surgery performed in patients having prosthetic
management of a proximal humeral fracture. Were these polytrauma cases? Were
they in the hospital longer (length of stay analysis as a comorbidity factor)
or recumbent for a longer period of time? Most patients with reverse total
shoulder arthroplasty (TSA) are a decade older with more comorbidities than
patients who have anatomic TSA or a hemiarthroplasty (HA). It may not be the
nature of the type of shoulder replacement, but rather, the nature of the
patient population. This is important to consider as the risk stratification to
anticoagulate would be focused on patient characteristics rather than what type
of prosthetic was placed.
The study performed is useful in that is represents a
large population of patients in a captured health care environment allowing for
accurate and comprehensive data collection of this population after surgery.
It, therefore, provides some important baseline information of the frequency of
VTE in this population. It does not, unfortunately, separate out patient risk
factors from the type of surgery performed. I am assuming that the body of this
paper does not address this data and that the abstract reflects the entire
content of the paper.
Joseph Iannotti, MD, PhD
Orthopedics Today Shoulder & Elbow Section
The Cleveland Clinic
Disclosure: Iannotti has
no relevant financial disclosures.