Risk of venous thromboembolism after shoulder arthroplasty in the Medicare population

Venous thromboembolism prophylaxis in shoulder surgery: a break-even cost-effectiveness study

BACKGROUND

Venous thromboembolism (VTE) is a serious complication following orthopedic shoulder surgery; however, research is limited involving the break-even cost-effectiveness of VTE prophylaxis. The purpose of this study was to determine whether the cost of aspirin and enoxaparin would break even for VTE prevention in patients following shoulder surgery.

METHODS

A drug retail database was used to obtain the lowest price for a course of aspirin (81 mg) and enoxaparin (40 mg) to perform a break-even cost analysis. Our institutional purchasing records were then searched to estimate the cost of treating a symptomatic VTE. The TriNetX national database was queried to establish a rate of VTE after shoulder surgery. A break-even cost analysis was performed by determining the absolute risk reduction (ARR). This value was used to calculate the number of patients who are treated to prevent a single VTE while breaking even on cost. Sensitivity analyses were performed for drugs that did not break even at the database-derived VTE rates.

RESULTS

Full medication courses of aspirin and enoxaparin were found to cost $1.18 and $125.37, respectively. The cost of treating a symptomatic VTE was determined to be $9407.00. Data from the TriNetX database showed rates of symptomatic VTE following shoulder arthroplasty, hemiarthroplasty, and arthroscopic rotator cuff repair of 1.60%, 1.50%, and 0.68%, respectively. Aspirin broke even on cost for all procedures if the initial rate decreased by an ARR of 0.01% (number needed to treat, 7972). Similarly, enoxaparin broke even for shoulder arthroplasty and hemiarthroplasty if the initial rate of VTE decreased by an ARR of 1.33% (number needed to treat, 75). Enoxaparin did not break even at the initial VTE rate for arthroscopic rotator cuff repair; however, sensitivity analysis found enoxaparin would break even if the drug could be obtained at a cost of ≤$60.00. Enoxaparin broke even if the cost of treating a symptomatic VTE was ≥$20,000.00.

CONCLUSIONS

The cost of a 3-week course of twice-daily aspirin or once-daily enoxaparin breaks even for VTE prophylaxis following shoulder arthroplasty and hemiarthroplasty if these drugs reduce the VTE rate by a calculated ARR. Given the lower rate of VTE observed for patients undergoing arthroscopic rotator cuff repair, only the 3-week course of aspirin broke even under these conditions. Once-daily enoxaparin did not break even at current market rate. Further research is needed to help determine optimal VTE prophylaxis after shoulder surgery.

Total shoulder arthroplasty in patients with factor V Leiden

BACKGROUND

Anatomic and reverse total shoulder arthroplasty (TSA) are effective treatment options for end-stage glenohumeral osteoarthritis. However, consideration for pre-existing conditions must be taken into account. Factor V Leiden (FVL), the most common inherited thrombophilia, is one such condition that predisposes to a prothrombotic state and may affect perioperative and longer-term outcomes following TSA.

METHODS

Adult patients undergoing primary TSA for osteoarthritis indication were identified in the 2010 through October 2021 PearlDiver M157 database. Patients with or without FVL were matched at a 1:4 ratio based on age, sex, and Elixhauser Comorbidity Index. Ninety-day adverse events and 5-year revision rates were assessed and compared with multivariable logistic regression and rank-log tests, respectively. Finally, the relative use and bleeding/clotting outcomes were assessed based on venous thromboembolic (VTE) prophylactic agents used, with categories defined as (1) warfarin, heparin, or direct oral anticoagulant (DOAC) or (2) aspirin/no prescription found.

RESULTS

Of 104,258 TSA patients, FVL was identified for 283 (0.27%). Based on matching, 1081 patients without FVL and 272 patients with FVL were selected. Multivariable analyses demonstrated that those with FVL displayed independently greater odds ratios (ORs) of deep vein thrombosis (DVT, OR = 9.50, P < .0001), pulmonary embolism (PE, OR = 10.10, P < .0001), and pneumonia (OR = 2.43, P = .0019). Further, these events contributed to the increased odds of aggregated minor (OR = 1.95, P = .0001), serious (OR = 6.38, P < .0001), and all (OR = 3.51, P < .0001) adverse events. All other individual 90-day adverse events, as well as 5-year revision rates, were not different between the study groups. When compared to matched patients without FVL on the same anticoagulant agents, FVL patients on warfarin, heparin, or DOAC agents demonstrated lesser odds of 90-day DVT and PE (OR = 4.25, P < .0001, and OR = 2.54, P = .0065) than those on aspirin/no prescription found (OR = 7.64 and OR = 21.95, P < .0001 for both). Interestingly, those on VTE prophylactic agents were not at greater odds of bleeding complications (hematoma or transfusion).

DISCUSSION AND CONCLUSIONS

TSA patients with FVL present a difficult challenge to shoulder reconstruction surgeons. The current study highlights the strong risk of VTE that was reduced but still significantly elevated for those with stronger classes of VTE chemoprophylaxis. Acknowledging this risk is important for surgical planning and patient counseling, but also noted was the reassurance of similar 5-year revision rates for those with vs. without FVL.

Introducing A Day-Case Shoulder Arthroplasty Pathway In The UK - How We Did It

Background

As the demand for elective orthopaedics grows, day-case arthroplasty is gaining popularity. The aim of this study was to create a safe and reproducible pathway for day-case shoulder arthroplasty (DCSA) based upon a literature review and discussion with the local multidisciplinary team (MDT).

Methods

A literature review was performed using OVID MEDLINE and Embase databases reporting 90-day complication and admission rates following DCSA. Minimum follow-up was 30 days. Day-case was defined as discharge on the same day of surgery.

Results

The literature review revealed a mean 90-day complication rate of 7.7% [range, 0-15.9%] and mean 90-day readmission rate of 2.5% [range 0-9.3%]. A pilot protocol was devised based upon the literature review and consisted of 5 phases: (1) pre-operative assessment, (2) intra-operative phase, (3) post-operative phase, (4) follow-up, and (5) readmission protocol. This was presented, discussed, amended, and ultimately ratified by the local MDT. In May 2021 the unit successfully completed its first day-case shoulder arthroplasty.

Discussion

This study proposes a safe and reproducible pathway for DCSA. Patient selection, well-defined protocols and communication within the MDT are important factors to achieve this. Further studies with extended follow-up will be needed to gauge long-term success within our unit.

Trends in Venous Thromboembolism After Shoulder Arthroplasty in the United States: Analysis Following the 2009 American Academy of Orthopaedic Surgeons Clinical Practical Guidelines

BACKGROUND

In 2009, the American Academy of Orthopaedic Surgeons released a consensus recommending venous thromboembolism (VTE) prophylaxis after total shoulder arthroplasty (TSA). The purpose of this study was to examine the (1) change in incidence of 90-day VTE, deep vein thrombosis (DVT), and pulmonary embolism; (2) change in utilization of chemoprophylaxis; and (3) change in the economic burden associated with VTE after TSA from 2010 to 2019.

METHODS

Using the PearlDiver database, national data from 2010 to 2019 were used to identify patients who underwent primary TSA for osteoarthritis and/or rotator cuff arthropathy. Exclusions entailed liver pathology, coagulopathy, or those on prior prescribed blood thinners before TSA. Multivariable regression was used controlling for age and Charlson Comorbidity Index for all years with 2010 as the reference year.

RESULTS

From 2010 to 2019, there was a reduction in VTE rates from 0.89% in 2010 to 0.78% in 2019. Regarding implant type, there was no notable change in incidence of VTE, DVT, and pulmonary embolism within 90 days after anatomic TSA. Notable reductions were observed in both VTE and DVT after reverse TSA from 2010 to 2019. Prescribed chemical VTE prophylaxis utilization after TSA markedly increased from 4.41% in 2010 to 11.70% utilization in 2019. The utilization of aspirin markedly increased from 17.27% in 2010 to 65.17% in 2019. Among anticoagulants, the utilization of direct factor Xa inhibitors increased from 0.0% utilization in 2010 to 66.09% utilization in 2019. The added reimbursements associated with VTE after TSA markedly decreased from $14,122 in 2010 to $4,348 in 2019.

CONCLUSION

The incidence and economic burden associated with VTE after TSA have markedly declined following the 2010 American Academy of Orthopaedic Surgeons clinical practice guidelines. This reduction can be attributed to both an increase in VTE prevention through increased utilization of prescribed chemoprophylaxis and improvement in VTE treatment strategies.

LEVEL OF EVIDENCE

Therapeutic, III.

The Impact of Hypoalbuminemia on Postoperative Complications in Patients Undergoing Shoulder Arthroplasty: A Meta-Analysis

OBJECTIVES

The objective of this meta-analysis was to investigate the association between hypoalbuminemia and postoperative complications in patients undergoing shoulder arthroplasty.

METHODS

This meta-analysis study was registered in PROSPERO (CRD42023442466) and adhered to the PRISMA guidelines. Studies focused on shoulder arthroplasty that compared hypoalbuminemia and normal albumin levels were included. A systematic literature search was conducted in PubMed, EMBASE, Scopus, and the Cochrane Collaboration database. Seven comparative studies were included, and odds ratios with a 95% confidence interval were calculated for the dichotomous variables. A fixed-effect model was used when there was no statistical evidence of heterogeneity, and a random-effect model was used when significant heterogeneity was observed. Review Manager 5.4 software was used for data analysis.

RESULTS

The meta-analysis included a total of 20,290 patients from seven studies. Hypoalbuminemia was significantly associated with a higher risk of readmissions (OR 2.92, 95%CI 1.74 to 4.91), reoperations (OR 3.23, 95%CI 1.98 to 5.27), an increase in hospital stay duration (MD 1.59, 95%CI 0.86 to 2.32), and complications such as death (OR 5.75, 95% CI 2.98 to 11.08; studies = 4), thromboembolic events (OR 2.43, 95% CI 1.46 to 4.06; studies = 4), cardiac events (OR 2.78, 95% CI 1.07 to 7.24; studies = 3), pulmonary infections (OR 3.09, 95% CI 1.54 to 6.20; studies = 3), systemic infections (OR 2.19, 95% CI 1.51 to 3.16; studies = 3), and transfusions (OR 3.16, 95% CI 2.23 to 4.48; studies = 2). However, there was no significant association between hypoalbuminemia and renal complications, surgical site infections, urinary tract infections, wound problems, or cardiovascular events.

CONCLUSION

This meta-analysis provides strong evidence that hypoalbuminemia is associated with a higher risk of postoperative complications in patients undergoing shoulder arthroplasty.

Venous Thromboembolism After Total Shoulder Arthroplasty: A Database Study of 31,918 Cases

INTRODUCTION

Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), is a rare but serious complication of total shoulder arthroplasty (TSA). Owing to limited evidence, Clinical Practice Guideline recommendations for VTE chemoprophylaxis after TSA rely heavily on the risk stratification of individual patients. The objectives of this study were to identify the prevalence and risk factors independently associated with VTE, PE, and DVT in the 30-day postoperative period after TSA.

METHODS

A retrospective case-control study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database by querying the Current Procedural Terminology code for total shoulder arthroplasty from 2011 to 2020. The initial query resulted in 33,089 patients. After applying exclusion criteria for age younger than 50 years, emergency surgery, and open wound or infection, a final cohort of 31,918 patients who underwent TSA were included. The primary outcome was venous thromboembolism, and secondary outcome variables were PE and DVT. A bivariate screen was done for explanatory variables associated with our outcome variables, and variables with P < 0.1 in the bivariate screen were included in a multivariable logistic regression model.

RESULTS

Of the 31,918 patients in our cohort, 183 patients (0.573%) developed VTE, 92 patients (0.29%) developed PE, and 104 patients (0.326%) developed DVT during the 30-day postoperative period. Multivariable logistic regression analysis showed that older age, higher body mass index, longer surgical time, and longer hospital length of stay were associated with VTE and PE and that hypertension and shorter hospital length of stay were associated with DVT.

DISCUSSION

The prevalence of VTE after TSA is low. Older patients, patients with higher body mass index, and patients with longer surgical durations are at higher risk for VTE after TSA. Our findings are relevant for preoperative risk stratification and the decision for chemoprophylaxis.

LEVEL OF EVIDENCE

Level III Prognostic.

Incidence, characteristics, and risk factors of venous thromboembolism in shoulder arthroplasty-a systematic review

PURPOSE

The purpose of this study was to investigate the incidence, characteristics, and risk factors for venous thromboembolism (VTE) in patients who underwent shoulder arthroplasty (SA) through systematic review.

METHODS

A search of studies was conducted using the databases for PubMed, EMBASE, Scopus, Ovid, MEDLINE, and Cochrane Library according to the guidelines for PRISMA (Preferred Reporting Items for Systematic Meta-Analyses). Quality assessment was performed using the Methodological Index for Nonrandomized Studies (MINORS).

RESULTS

Nine studies (12,566 shoulders) were finally eligible and the mean MINORS score was 13.2 (ranges, 9-18). The overall incidence of VTE was 0.81% (78/9681) including 0.54% (52/9681) for deep vein thrombosis (DVT) and 0.33% (42/12,566) for pulmonary embolism (PE). There were no significant differences in the incidences according to the type of arthroplasty. DVT was detected at an average of 18.8 days after index surgery, and PE was detected at an average of 12.7 days after index surgery. The risk factors for VTE included age older than 70 years, higher BMI, raised Charlson Comorbidity Index, history of DVT, asthma, cardiac arrhythmia, diabetes, lower haemoglobin level, use of general endotracheal anaesthesia without interscalene nerve block, traumatic indication, longer operative time, and revision SA. The mortality rate was 4.1% (2/49) for VTE and 8.3% (2/24) for PE.

CONCLUSION

Despite the fact that the overall incidence of VTE following SA was as low as 0.81%, shoulder surgeons should consider the potential for this serious complication in high-risk patients. Further well-designed large-scale studies are necessary to clarify the consensus for VTE after SA including risk factors, treatment, and prophylaxis.

Few UK vascular centres offer a fully NICE-compliant supervised exercise programme: a national audit

INTRODUCTION

To determine the current (pre-COVID-19) provision of supervised exercise training (SET) for patients with peripheral arterial disease (PAD) in UK Vascular Centres.

METHODS

Hospital Trusts delivering vascular care to patients with PAD were identified from the National Vascular Registry and asked to complete an online questionnaire on their provisions for SET. If a centre offered SET, they were asked questions to determine whether the programme was compliant with NICE guidelines and the difficulties they faced delivering the service. If centres did not offer SET, they were asked what obstacles prevented them implement SET.

RESULTS

Of the 78 UK vascular centres, 59 (76%) responded and were included in the audit. Of these, 27 (46%) were able to offer SET but only 21 (36%) could offer it to all their patients with PAD. Only four (6.8%) offered SET that was fully compliant with current NICE guidelines. Reasons identified included insufficient funding, lack of resource and poor patient compliance.

CONCLUSIONS

The benefits of SET are well established yet the availability of the service in the UK is poor. The reasons for this are readily identified but have not yet been overcome. Research on novel methods of delivering supervised exercise that mitigates existing barriers, such as home exercise with remote monitoring, should be prioritised to facilitate optimal management for our patients with PAD.

Reverse total shoulder arthroplasty in patients 80 years and older: a national database analysis of complications and mortality

BACKGROUND

Although reverse total shoulder arthroplasty (RSA) is considered a safe surgical option in elderly patients, large-scale analyses of complications and mortality after RSA in patients 80 years and older are scarce. The goals of the current study were to identify revision, complication, and early mortality rates after RSA in patients 80 years and older and compare these to younger patients.

METHODS

The PearlDiver Database, which contains services rendered to Medicare, Medicaid, and commercial insurance patients, was queried for patients undergoing RSA using International Classification of Diseases, Ninth/Tenth Revision (ICD-9/ICD-10) procedure codes. Patients were separated into 2 groups based on their age: 80 years and older and <80 years of age. The incidence of revision arthroplasty, medical, and surgical complications after RSA were extracted. Multivariate regression was used to compare revision arthroplasty and complication rates between groups. Statistical significance was set at P <.05.

RESULTS

A total of 29,430 cases of RSA were included, with 486 cases in patients 80 years and older (median age, 80 years; age range, 2 years). Patients 80 years and older had 1- and 2-year revision rates of 3.9% and 5.1%, compared with the younger cohort at 3.0% and 3.1%, respectively. In patients 80 years and older, there were higher rates of deep venous thrombosis (DVT) (odds ratio [OR] 2.87, 95% CI 1.5-4.97), urinary tract infection (OR 1.42, 95% CI 1.01-1.94), acute renal failure (OR 2.18, 95% CI 1.44-3.17), and pneumonia (OR 1.75, 95% CI 1.09-2.68) within 90 days postoperatively. Ninety-day surgical complications were similar between the cohorts; however, younger patients experienced higher rates of dislocation, stiffness, periprosthetic fracture, and implant complications 1 year postoperatively. Patients 80 years and older had a significantly higher 90-day mortality rate at 2.7% compared with 1.5% in younger patients (P = .002).

CONCLUSIONS

RSA is a generally safe procedure even in patients 80 years and older, with low complication and revision rates. Patients 80 years and older had higher early mortality and medical complication rates, including DVT, renal failure, and pneumonia than patients <80 years of age. However, patients 80 years and older had lower rates of dislocation, periprosthetic fracture, and implant-related complication at 1 year postoperatively.

Vascular Complications in Sports Surgery: Diagnosis and Management

Orthopedic sports surgery of the knee and shoulder is generally considered to be safe and effective. Vascular complications can occur during or after arthroscopy of either joint. A thorough understanding of anatomy, particularly when placing portals in non-routine locations, is extremely important. Prompt recognition of any vascular complication is of significant importance. This review will discuss the potential vascular complications for both knee and shoulder sports surgery, review the relevant anatomy, and discuss the treatment and expected outcome of each.

Venous thromboembolism complications in shoulder surgery: current concepts

Venous thromboembolism (VTE) is a rare yet known complication of shoulder surgery. Concerning shoulder arthroplasty, reported rates of VTE range from 0.2% to 16%. Unlike many lower extremity procedures, particularly total hip and knee arthroplasty, chemical prophylactic guidelines for VTE in shoulder surgeries have not been established. Some argue that doing so is unnecessary. On the contrary, mechanical prophylaxis is nearly universally accepted in shoulder surgery, particularly for more lengthy procedures. With limited VTE incidence in shoulder surgery, treatment is anecdotally derived from the hip and knee arthroplasty literature. Recent studies have successfully identified risk factors for VTE related to the patient and to the surgery itself. Awareness of these risk factors by the surgeon and declaration of these factors to the patient should be discussed as part of the informed consent process. Further investigational studies and larger patient cohorts will be necessary to optimise VTE prevention in shoulder surgeries.

Low-dose aspirin and the rate of symptomatic venous thromboembolic complications following primary shoulder arthroplasty

BACKGROUND

Venous thromboembolism (VTE) events are infrequent but potentially catastrophic complications following orthopedic surgery. There is currently a paucity of evidence regarding the role of chemoprophylaxis with low-dose aspirin (acetylsalicylic acid [ASA]) after shoulder arthroplasty.

METHODS

We conducted a retrospective review of prospectively collected complications occurring within 90 days of 2394 primary shoulder arthroplasties performed over a 3-year period at a single institution. Patients preoperatively underwent risk stratification into medically high risk, moderate risk, or low risk as part of a standardized navigated-care pathway. For chemoprophylaxis, 81 mg of ASA (low dose) was routinely used once daily for 6 weeks unless alternative medications were deemed necessary by the medical team. Baseline demographic information, medical comorbidities, and postoperative VTE prophylaxis, as well as rates of clinically symptomatic VTE, were assessed.

RESULTS

Symptomatic VTE occurred after 0.63% of primary shoulder arthroplasties (15 of 2394). There were 9 patients with deep vein thromboses and 6 with pulmonary embolisms. Eighty-one milligrams of ASA was used in 2141 patients (89.4%), resulting in an overall VTE rate of 0.56%. Medically high-risk patients were significantly more likely to have a VTE (P = .018). Patients with a history of deep vein thrombosis, asthma, and cardiac arrhythmia were significantly more likely to have a VTE (P < .05). Complications occurred in 4 patients (0.19%) associated with low-dose ASA and 1 patient (0.63%) associated with a novel oral anticoagulant medication.

CONCLUSION

Routine use of low-dose ASA results in a very low risk of VTE and medication-associated complications following primary shoulder arthroplasty. Preoperative medical risk stratification can potentially identify patients at high risk of postoperative VTE.

Is venous thromboembolism prophylaxis beneficial in upper limb major joint replacement surgery? A systematic review

BACKGROUND

Upper limb arthroplasty is an increasingly used treatment modality for end-stage joint disease of the shoulder, elbow and wrist. Whilst complications have been reported, the risk of venous thromboembolism has received less attention when compared to the lower limb. Guidance to aid clinical decision-making remains limited. This review aims to ascertain whether venous thromboembolism prophylaxis is beneficial after upper limb major joint replacement surgery.

METHODS

A systematic review was performed in April 2019, utilising EMBASE, MEDLINE, Cochrane and Google Scholar. All clinical studies reporting venous thromboembolism incidence and risk reduction (after prophylaxis) in upper limb joint replacement were included.

RESULTS

Twenty-four observational studies were identified. The reported incidence of venous thromboembolism ranged from 0.2% to 16% (weighted mean 0.68%) and 0.2% to 0.8% (weighted mean 0.49%) in shoulder and elbow arthroplasty, respectively. No records for wrist arthroplasty were found. In the literature, baseline venous thromboembolism risk of patients without an operation is reported as 0.5%.

DISCUSSION

There is a lack of good quality evidence regarding the risks and benefits of venous thromboembolism prophylaxis in upper limb major joint replacement surgery. We recommend further research, ideally formal randomised controlled trials to guide recommendations. Although venous thromboembolism is rare in upper limb surgery, surgeons should remain vigilant to this possibility.

High risk of venous thromboembolism after orthopedic surgery in patients with thrombophilia

OBJECTIVE

This study aimed at evaluating the effect of thrombophilia on the risk of venous thromboembolism (VTE) in patients undergoing any type of orthopedic surgery.

BACKGROUND

Patients undergoing orthopedic surgery are at high risk for VTE. Although patients with thrombophilia have an increased risk of VTE, it is currently unclear whether there is a synergetic effect in patients with thrombophilia who undergo orthopedic surgery.

METHODS

Data from a large population-based case-control study (the Multiple Environmental and Genetic Assessment [MEGA] of risk factors for venous thrombosis study) were used. Odds ratios (ORs) with 95% confidence intervals (CIs), adjusted for age, sex, and body mass index (BMI) (ORadj) were calculated for patients undergoing any orthopedic intervention.

RESULTS

Of 4721 cases and 5638 controls, 263 cases and 94 controls underwent orthopedic surgery. Patients who had any orthopedic intervention in the year before the index date were at higher risk of VTE (ORadj 3.7; 95% CI, 2.9-4.8) than those who did not undergo any orthopedic surgery. There was an additionally increased risk in patients with factor V Leiden (OR 17.5, 95% CI, 4.1-73.6), non-O blood group (OR 11.2; 95% CI, 3.4-34.0), or elevated plasma levels of factor VIII (OR 18.6; 95% CI, 7.4-46.9) all relative to patients without these defects, not undergoing orthopedic surgery.

CONCLUSIONS

Patients with factor V Leiden, high levels of factor VIII, or blood group non-O were found to have a high risk of VTE after orthopedic surgery. Identification of these patients may enable individualized thromboprophylactic treatment to efficiently reduce VTE risk.

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

BACKGROUND

The purpose of the present study was to examine the relationship between postoperative therapeutic anticoagulation, wound complications, infection, and revision.

METHODS

Using a national insurance database from 2007 to 2016, patients who underwent shoulder arthroplasty with an indication for postoperative therapeutic anticoagulation in the case of atrial fibrillation or acute postoperative venous thromboembolism were identified. Those with a prescription for a therapeutic anticoagulant within 2 weeks of surgery were identified and compared with controls without postoperative therapeutic anticoagulant prescriptions. Wound complications and postoperative infection at 3 and 6 months, and revision shoulder arthroplasty at 6 months and all time points were then compared in the database using a multivariable logistic regression analysis.

RESULTS

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

CONCLUSIONS

Wound complications and revision rates in patients undergoing shoulder arthroplasty who require postoperative therapeutic anticoagulation are significantly elevated compared with controls.

Postoperative Venous Thromboembolism and other Complications after Anatomic Total Shoulder Arthroplasty in Patients With a History of Prostate or Breast Cancer

INTRODUCTION

As cancer treatments continue to improve the overall survival rates, more patients with a history of cancer will present for anatomic total shoulder arthroplasty (TSA). Therefore, it is essential for orthopaedic surgeons to understand the differences in care required by this growing subpopulation. Although the current research suggests that good outcomes can be predicted when appropriately optimized patients with cancer undergo lower extremity total joint arthroplasty, similar studies for TSA are lacking. The primary study question was to examine whether a history of cancer was associated with an increased rate of venous thromboembolism (VTE) after TSA. Secondarily, we sought to examine any association between a history of prostate and breast cancer and surgical or medical complications after TSA.

METHODS

Using a national insurance database, male patients with a history of prostate cancer and female patients with a history of breast cancer undergoing anatomic TSA for primary osteoarthritis were identified and compared with control subjects matched 3:1 based on age, sex, diabetes mellitus, and tobacco use. Patients with a history of VTE and patients who underwent reverse TSA or hemiarthroplasty were excluded.

RESULTS

Female patients with a history of breast cancer and male patients with a history of prostate cancer undergoing TSA had significantly higher incidences of acute VTE (including deep venous thrombosis and pulmonary embolism) compared with matched control subjects (female patients: odds ratio, 1.41; 95% confidence interval, 1.10 to 1.81; P = 0.024 and male patients: odds ratio, 1.37; 95% confidence interval, 1.05 to 1.79; P = 0.023). No significant differences were noted in the incidences of any other complications assessed.

CONCLUSION

Although a personal history of these malignancies does represent a statistically significant risk factor for acute VTE after anatomic TSA, the overall VTE rate remains modest and acceptable. The rates of other surgical and medical complications are not significantly increased in patients with a history of these cancers after TSA compared with control subjects.

Symptomatic Thromboembolic Complications After Shoulder Arthroplasty: An Update

BACKGROUND

Venous thromboembolism (VTE) complications, including deep vein thrombosis and pulmonary embolism, are dreaded complications of orthopaedic surgical procedures that can result in substantial morbidity and mortality. There is a paucity of data examining risk factors for VTE in shoulder arthroplasty. The purpose of the present study was to review the rate of symptomatic VTE, determine patient and operative risk factors for VTE, and report on complications associated with VTE following shoulder arthroplasty.

METHODS

Over a 16-year period, 5,906 patients underwent primary anatomic total shoulder arthroplasty, reverse total shoulder arthroplasty, or hemiarthroplasty. Symptomatic VTE events were identified in 24 shoulders within 90 days of surgery. Patient records were reviewed for surgical indication, patient and operative risk factors, and management of VTE.

RESULTS

The rate of symptomatic VTE following shoulder arthroplasty was 0.41%. There were no deaths resulting from VTE events. Compared with patients who did not have VTE, those with symptomatic VTE events were found to be older (74.75 versus 68.51 years; p = 0.0028) and more likely to have had arthroplasty for a traumatic indication (3.31% versus 0.33%; p < 0.001). Age of >70 years and arthroplasty for a traumatic indication were found to be independent risk factors on multivariate nominal logistic regression analysis, whereas body mass index, sex, operative time, and type of arthroplasty performed were not found to be independent risk factors. There were 11 readmissions resulting directly from the VTE events, and patients diagnosed with VTE as inpatients had longer hospital stays than outpatients (13.71 versus 1.94 days; p = 0.0002).

CONCLUSIONS

The risk of VTE following shoulder arthroplasty is low, and routine use of pharmacologic VTE prophylaxis may not be necessary. However, VTE complications can lead to substantial morbidity, longer hospital stays, readmission to the hospital, and further complications. Therefore, patients with multiple risk factors for VTE such as prior history of VTE, active malignancy, age of >70 years, or arthroplasty for traumatic indications should be considered for pharmacologic VTE prophylaxis.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for venous thromboembolism in total shoulder arthroplasty

Background

Although venous thromboembolism (VTE) has been studied in lower-extremity arthroplasty, there are few guidelines regarding established risk factors for VTE in total shoulder arthroplasty (TSA). With literature suggesting the VTE rate may be as high as 13%, VTE prevention and risk factors should be considered in preoperative planning.

Methods

All TSAs from 2011 through 2016 were queried from the National Surgical Quality Improvement Program database. Age, sex, body mass index, American Society of Anesthesiologists class, ethnicity, functional status, comorbidities, discharge destination, surgical indication, length of stay, and operative time were compared between patients with and without 30-day postoperative VTE. Pearson χ² and t tests were used to assess baseline categorical and continuous variables, respectively. Multivariate logistic regression analysis was conducted to determine associated independent risk factors for VTE.

Results

The analysis included 13,299 patients; VTE developed in 83 patients (0.62%). Patients with VTE were older (72 years vs. 69 years) and had a longer hospital stay (3.5 days vs. 1.9 days). Compared with patients with no VTE, patients with VTE were more likely to undergo TSA for proximal humeral fractures, to be discharged to a rehabilitative center, to have a preoperative albumin level lower than 3.5 g/dL, to undergo non-elective surgery, to have an American Society of Anesthesiologists class of 3 or greater, to have a surgical-site infection develop, and ultimately to need a shoulder reoperation (all P < .05). Multivariate logistic regression analysis revealed that hypoalbuminemia (albumin level < 3.5 g/dL), an increased length of stay, and African American ethnicity were independent risk factors for VTE development.

Conclusion

Patients with hypoalbuminemia, an increased length of stay, and African American ethnicity are at an increased risk of VTE after shoulder arthroplasty. A high index of suspicion is warranted for elderly patients with fractures who may need preoperative medical optimization.

The Application of Medicare Data for Musculoskeletal Research in the United States: A Systematic Review

INTRODUCTION

Musculoskeletal conditions disproportionately affect the lives of aging adults. We aimed to examine the literature using Medicare claims data in the United States for musculoskeletal surgical procedures.

METHODS

Following the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, we searched the PubMed and Medline databases for peer-reviewed articles published between 1990 and 2015. We included the studies that (1) reported primary Medicare claims data use, (2) involved musculoskeletal surgery, and (3) were original peer-reviewed studies. We abstracted the types of surgical procedure and aims, and evaluated outcomes, and strengths and weaknesses of each included article. We assessed the quality of included articles with Newcastle Ottawa Assessment Scale.

RESULTS

The literature search returned 3,233 articles, of which 119 met our inclusion criteria. These studies focused on different outcomes: epidemiology and treatment variation (26), cost of care (15), hospital-level analyses (30), health outcomes (31), the validity and accuracy of Medicare claims data (4), disparities in health care (10), and policy evaluation (3).

DISCUSSION

Medicare claims data provide a unique way for researchers to study a nationally representative patient population longitudinally. A significant limitation of using claims data has been a lack of granularity on defining severity of a condition.

LEVEL OF EVIDENCE

Therapeutic level III.

Preoperative indications for total shoulder arthroplasty predict adverse postoperative complications

BACKGROUND

Although studies have shown improved pain, function, and patient satisfaction after total shoulder arthroplasty (TSA), preoperative factors predicting poor outcomes are unexplored. Comparison of postoperative complications between osteoarthritis (OA), cuff arthropathy (CA), and fracture patients is important for identifying at-risk patients.

METHODS

Primary TSAs from 2014 to 2016 with preoperative OA, CA, and proximal humerus fractures as indications were queried from the National Surgical Quality Improvement Program database. Short-interval postoperative complications were compared using multivariate binary logistic regression, and postoperative time to discharge between groups was analyzed using univariate analysis of variance with Tukey comparison. Statistical significance was defined as P < .05 using SPSS software version 23.0 (IBM Corp., Armonk, NY, USA).

RESULTS

Of 9684 TSA cases, the primary indication was OA in 6571 patients, CA in 725 patients, and fractures in 646 patients. Compared with fractures, OA patients had statistically significant lower risk of dislocation, readmission, return to operating room, nonhome discharge, surgical site infection, perioperative bleeding requiring transfusion, and pulmonary embolism (all P < .05). Statistically significant lower risk of dislocation, nonhome discharge, and transfusion was also found between CA and fracture patients (all P < .03). However, in comparing CA vs. OA as preoperative indications, only postoperative venous thromboembolism (odds ratio, 4.5; P = .01) and surgical site infection (odds ratio, 3.7; P = .007) were significant. Mean differences in discharge time were significant between both OA and CA groups compared with fractures (P < .001), but there was no significance between OA and CA (P = .116).

CONCLUSION

Proximal humerus fracture is a risk factor for increased postoperative complications compared with OA and CA. With new outcomes-based reimbursement models, nonroutine discharge and increased discharge time should be considered in arthroplasty planning.

Venous Thromboembolism After Shoulder Arthoplasty and Arthroscopy

Venous thromboembolism (VTE) in the orthopaedic literature largely focuses on lower extremity trauma and arthroplasty, with relatively few investigations of VTE after shoulder surgery. Because the rate of shoulder surgery, especially arthroplasty, continues to expand, it is important for practicing surgeons to understand the magnitude of risk, potential consequences, and prevention methods with regard to VTE. VTE after shoulder surgery has been a topic of increasing interest over the past decade, and the purpose of this review is to examine the recent literature on pathophysiology, risk factors, incidence, diagnosis, sequelae, prevention, treatment, and current recommendations regarding VTE after shoulder surgery.

The Effectiveness of Aspirin for Venous Thromboembolism Prophylaxis for Patients Undergoing Arthroscopic Rotator Cuff Repair

Venous thromboembolic disease (VTED) is a rare complication following arthroscopic rotator cuff repair (RCR). The American Academy of Orthopaedic Surgeons and the American College of Chest Physicians have no prophylaxis guidelines specific to shoulder arthroscopy, yet many surgeons prescribe aspirin following RCR. The purpose of this study was to evaluate the effectiveness of aspirin and mechanical prophylaxis compared with mechanical prophylaxis alone in preventing VTED following RCR. A total of 914 patients underwent RCR between January 2010 and January 2015. A retrospective case-control study was performed. The control group (n=484) consisted of patients treated with compression boots and early mobilization. The study group (n=430) used compression boots, early mobilization, and 81 mg/d of aspirin. The primary outcome was symptomatic VTED, including deep venous thrombosis (DVT) and pulmonary embolism (PE). A total of 7 VTED events occurred during the study period: 6 DVTs and 1 PE; 1 patient experienced both DVT and PE. The percentage of patients with VTED, DVT, and PE was 0.66%, 0.66%, and 0.11%, respectively. There was no significant difference for DVT or PE between the 2 groups. The incidence of DVT and PE was 0.62% and 0.00%, respectively, for the control group (no aspirin) and 0.70% and 0.23%, respectively, for the study group (aspirin). Aspirin does not lead to a clinically significant reduction in either DVT or PE rate in patients undergoing RCR. The authors conclude that the use of mechanical prophylaxis and early mobilization is a sufficient method of VTED prophylaxis in this low-risk population. [Orthopedics. 2019; 42(2):e187-e192.].

A higher altitude is an independent risk factor for venous thromboembolisms following total shoulder arthroplasty

Introduction

High altitudes lead to physiological changes that may predispose to venous thromboembolisms (VTE) including deep vein thrombosis (DVT) and pulmonary embolism (PE). No prior study has evaluated if there is also a higher risk of VTEs after total shoulder arthroplasties (TSAs) performed at higher elevations compared to lower elevations. The purpose of this study was to identify if undergoing TSA at a higher altitude center (>4000 feet above sea level) is an independent risk factor for a postoperative VTE.

Methods

A retrospective review was performed from 2005 to 2014 using the Medicare Standard Analytical Files of the Pearl Diver database (Pearl Diver Technologies, West Conshohocken, PA, USA). The inclusion criteria for the study group consisted of all patients in the database undergoing primary TSAs at an altitude above 4000 feet. Patients were queried using the International Classification of Disease 9th revision codes (ICD-9). All patients undergoing primary TSA were queried using ICD-9 procedure code 81.80. Patients were filtered using the zip codes of the hospitals where the procedure occurred and were separated into high (>4,000 ft) and low (<100 ft) altitudes. Patients undergoing TSA in altitudes <100 ft represented the control group. Patients with a history of VTE, DVT, PE, and coagulation disorders were excluded from the study. Patients in the study group were randomly matched 1:1 according to age, gender, and comorbidities. Two mutually exclusive cohorts were formed and rates of VTE, DVT, and PE were analyzed and compared. Statistical analysis was performed using the programming language R (University of Auckland, New Zealand). An alpha value less than 0.05 was considered statistically significant.

Results

In the first 30 postoperative days, patients undergoing TSA at a higher altitude experienced a significantly higher rate of PEs (odds ratio [OR], 39.5; P = <0.001) when compared to similar patients at lower altitudes. This trend was also present for PE (OR, 2.02; P < 0.03) at 90 days postoperatively.

Conclusion

TSAs performed at higher altitudes (>4000 feet) have a higher rate of acute postoperative PEs in the first 30 days and 90 days postoperatively when compared to matched patients receiving the same surgery at a lower altitude (<100 feet). TSA patients at high altitude should be counseled on these increased risks.

Thromboembolism prophylaxis in orthopaedics: an update

Venous thromboembolism (VTE) is a serious complication during and after hospitalization, yet is a preventable cause of in-hospital death.

Without VTE prophylaxis, the overall VTE incidence in medical and general surgery hospitalized patients is in the range of 10% to 40%, while it ranges up to 40% to 60% in major orthopaedic surgery. With routine VTE prophylaxis, fatal pulmonary embolism is uncommon in orthopaedic patients and the rates of symptomatic VTE within three months are in the range of 1.3% to 10%.

VTE prophylaxis methods are divided into mechanical and pharmacological. The former include mobilization, graduated compression stockings, intermittent pneumatic compression device and venous foot pumps; the latter include aspirin, unfractionated heparin, low molecular weight heparin (LMWH), adjusted dose vitamin K antagonists, synthetic pentasaccharid factor Xa inhibitor (fondaparinux) and newer oral anticoagulants. LMWH seems to be more efficient overall compared with the other available agents. We remain sceptical about the use of aspirin as a sole method of prophylaxis in total hip and knee replacement and hip fracture surgery, while controversy still exists regarding the use of VTE prophylaxis in knee arthroscopy, lower leg injuries and upper extremity surgery.

Cite this article: EFORT Open Rev 2018;3:136-148. DOI: 10.1302/2058-5241.3.170018

Venous Thromboembolism Prophylaxis in Shoulder Surgery

The incidence of venous thromboembolic events (VTEs) complicating shoulder surgery is difficult to estimate. Case reports, retrospective studies, prospective studies, and systematic reviews vary in terms of separating symptomatic versus asymptomatic VTEs, those occurring in the upper versus lower extremities, and those leading to pulmonary embolism. Reported rates vary between 0.02% and 13%. Arthroplasty is associated with a higher incidence than arthroscopy. Surgery for fracture presents increased risk. Mechanical prophylaxis using compression devices could be considered given its favorable risk-benefit profile. Chemical prophylaxis should be considered for high-risk patients. Evidence-based criteria cannot be obtained from current literature on VTEs after shoulder surgery.

Upper Extremity Deep Venous Thrombosis Prophylaxis After Elective Upper Extremity Surgery

Historically, upper extremity deep venous thromboses (DVTs) have been rare; however, their incidence has increased as awareness has increased. Patients who develop upper extremity DVTs often have multiple comorbidities. However, in the past decade, studies have found a small risk of upper extremity DVTs associated with orthopedic procedures involving the upper extremity. The risk of complications following a DVT, including postthrombotic syndrome and pulmonary embolism, is substantially higher with a DVT of the upper extremity compared with a DVT of the lower extremity. Furthermore, there is no consensus regarding the role and efficacy of prophylactic measures in preventing upper extremity DVT after upper extremity surgery. This article discusses the use of prophylactic agents after elective upper extremity surgery, with an emphasis on the efficacy of commonly used interventions. [Orthopedics. 2018; 41(1):21-27.].

The Effects of Patient Obesity on Early Postoperative Complications After Shoulder Arthroscopy

PURPOSE

To report the prevalence of obesity in shoulder arthroscopy, determine a body mass index (BMI) threshold most predictive of complication within 30 days, and evaluate obesity as an independent risk factor for medical and surgical complications.

METHODS

Using the National Surgical Quality Improvement Program database, we reviewed all patients who underwent shoulder arthroscopy during 2011 to 2013. Receiver operating characteristic and Youden coefficient were calculated to find an optimal BMI cutoff to predict complications within 30 days of surgery. A case-control matched analysis was then performed by stratifying patient BMI by this cutoff and matching patients one to one according to age, sex, type of shoulder arthroscopy, American Society of Anesthesiology rating, surgical setting, and 8 comorbidities. Operating time, complications, and readmissions were also compared.

RESULTS

Of the 15,589 patients who underwent shoulder arthroscopy, 6,684 (43%) were classified as obese when using the optimal cutoff point of BMI = 30 according to the Youden coefficient. Obese patients had a higher risk of superficial site infection than nonobese patients (0.3% vs 0.0%; odds ratio [OR]: 6.00; 95% confidence interval [CI], 1.3 to 26.8; P = .015). Obese patients did not have significantly increased risk for overall early postoperative complication (1.2% compared with nonobese 0.8%; OR: 1.54; 95% CI, 1.0 to 2.4), readmissions (OR: 0.85; 95% CI, 0.5 to 1.5), or increased operating time (P = .068).

CONCLUSIONS

Up to 43% of patients undergoing shoulder arthroscopy can be classified as obese, but early perioperative complications are uncommon. Higher patient BMI is associated with increased risk of superficial site infection but not an overall risk for complication, readmission, or increased operating time.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Tranexamic acid decreases blood loss in total shoulder arthroplasty and reverse total shoulder arthroplasty

BACKGROUND

Efficacy of tranexamic acid (TXA) remains unproven in the setting of shoulder arthroplasty. The purpose of this study was to determine the effects of TXA on perioperative blood loss and drain output in patients undergoing primary total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA).

METHODS

We conducted a retrospective comparison of 77 TSAs and 94 RTSAs performed in 168 patients. TXA was administered intravenously in 35 TSA and 42 RTSA patients. Changes in hemoglobin (Hgb), hematocrit (Hct), drain output, and total blood loss were reviewed with univariate analysis and additional multivariate regression examining the cofactors of age, body mass index, American Society of Anesthesiologists status, and gender of each patient.

RESULTS

Use of TXA in TSA led to a significant decrease in total blood loss (679 mL vs. 910 mL; P < .001), change in Hgb (1.8 mg/dL vs. 2.6 mg/dL; P < .001), and drop in Hct (5.2 vs. 7.0; P < .001). Similarly, RTSA also had significantly less total blood loss with the use of TXA (791 mL vs. 959 mL; P < .001), change in Hgb (2.3 mg/dL vs. 2.9 mg/dL; P < .001), and change in Hct (6.4 vs. 8.3; P < .001). TXA also significantly decreased drain output in both TSA (99 mL vs. 235 mL; P < .001) and RTSA (180 mL vs. 370 mL; P < .001).

CONCLUSIONS

Use of TXA perioperatively among patients undergoing primary shoulder arthroplasty can decrease perioperative blood loss, change in Hgb and Hct, and postoperative drain output.

Heart failure and risk of venous thromboembolism: a systematic review and meta-analysis

BACKGROUND

Venous thromboembolism is a major global health problem that is often secondary to other clinical situations. Many studies have investigated the association between venous thromboembolism and heart failure, but have yielded inconsistent findings. We aimed to quantify the absolute and relative risks (RR) for venous thromboembolism in patients with heart failure after hospital admission. We also assessed rates of venous thromboembolism in patients in different settings.

METHODS

In this systematic review and meta-analysis, we searched for studies investigating the risk of venous thromboembolism in patients in hospital with heart failure. We searched for studies published between Jan 1, 1955, and March 31, 2015, in PubMed, Embase, Evidence-Based Medicine Reviews, Allied and Complementary Medicine Database, Ovid HealthSTAR, Global Health, Ovid Nursing Database, Web of Science, CINAHL Plus, ProQuest Central, Conference Papers Index, BIOSIS Previews, and ClinicalTrials.gov. All cohort studies and subgroup analyses of randomised controlled trials (RCTs) were eligible for inclusion if they reported venous thromboembolism rates (number of events per follow-up period) or RR estimates. We extracted data from published reports and contacted the corresponding authors of records with insufficient quantitative data. RRs and 95% CIs were pooled using a random-effects model. This study is registered with PROSPERO, number CRD42014015504.

FINDINGS

Of 8673 records identified, we included 71 studies with data from 88 cohorts in our analysis, with 59 cohorts included in the assessment of venous thromboembolism rates and 46 cohorts included in the meta-analysis of heart failure and risk of venous thromboembolism. Venous thromboembolism rates varied widely in patients in hospital with heart failure from different settings. The overall median symptomatic venous thromboembolism rate was 2·48% (IQR 0·84-5·61); rates was were 3·73% (1·05-7·31) for patients who did not receive thromboprophylaxis and 1·47% (0·64-3·54) for those who did. Overall, patients with heart failure in hospital had an RR of 1·51 (1·36-1·68) for venous thromboembolism. The overall I(2) statistic was 96·1% and there was no evidence of publication bias (Egger's test, p=0·46).

INTERPRETATION

Heart failure is a common independent risk factor for venous thromboembolism. Thromoboprophylaxis should be considered in clinical practice for high-risk patients.

FUNDING

National Natural Science Foundation.

Superobesity (body mass index >50 kg/m2) and complications after total shoulder arthroplasty: an incremental effect of increasing body mass index

BACKGROUND

The prevalence of obesity in the United States continues to increase. Attention has recently turned to an emerging population of extremely overweight patients, termed superobese and defined as those with body mass index (BMI) ≥50 kg/m(2). The goal of this study was to use a national database to evaluate postoperative complication rates after total shoulder arthroplasty (TSA) in superobese patients and to compare patients of different BMI classes.

METHODS

Patients who underwent TSA or reverse TSA were identified in the PearlDiver database by International Classification of Diseases, Ninth Revision (ICD-9) codes. These patients were then divided into nonobese, obese, morbidly obese, and superobese cohorts by ICD-9 codes. Postoperative complications were assessed and compared between cohorts.

RESULTS

From 2005 to 2012, 144,239 unique patients who underwent TSA or reverse TSA were identified, including 105,661 nonobese patients, 23,864 obese patients, 13,759 morbidly obese patients, and 955 superobese patients. Superobese patients had a significantly higher rate of infection, dislocation, component loosening, revision shoulder arthroplasty, venous thromboembolism, and medical complications after shoulder arthroplasty compared with nonobese controls.

CONCLUSIONS

Obesity is associated with significantly increased rates of numerous complications after TSA, including infection, dislocation, component loosening, revision surgery, venous thromboembolism, and medical complications, compared with nonobese controls. Superobesity (BMI > 50 kg/m(2)) is associated with significantly increased rates of several complications compared with even obese and morbidly obese patients, including infection, component loosening, venous thromboembolism, and medical complications.