The venous thromboembolic complications of shoulder and elbow surgery

Venous Thromboembolism Chemical Prophylaxis in Patients Undergoing Shoulder Arthroscopy

» Venous thromboembolism (VTE) after shoulder arthroscopy is rare (0.01%-0.38%) but impacts a significant number of patients because of the high procedure volume.» Studies found no significant benefit in reducing VTE risk with aspirin or low-molecular-weight heparins.» Current guidelines for thromboprophylaxis in shoulder arthroscopy lack consensus and need patient-specific considerations.» Further research is required to develop evidence-based thromboprophylaxis guidelines for shoulder arthroscopy.

While the Incidence of Venous Thromboembolism After Shoulder Arthroscopy Is Low, the Risk Factors Are a Body Mass Index Greater than 30 and Hypertension

Purpose

This study aims to determine the overall incidence of venous thromboembolism (VTE) following shoulder arthroscopy and to define potential risk factors associated with its development that may help define guidelines for the use of thromboprophylaxis.

Methods

A systematic review was performed using PubMed, Embase, Web of Science, CINAHL, and Cochrane databases per PRISMA guidelines. The search terms consisted of variations of "Venous Thromboembolism" and "Shoulder Arthroscopy." Information regarding arthroscopy indication, risk factors, outcomes, and patient demographics was recorded and analyzed, and pooled odds ratios were reported for each variable.

Results

Six hundred eighty-five articles were identified in the initial search, and 35 articles reported DVT, PE, or VTE incidence following shoulder arthroscopy. Seventeen nonoverlapping articles with a unique patient population incidence rates. Four articles were then used for subgroup meta-analysis. The incidence rate of VTE was 0.24%, ranging from 0.01% to 5.7%. BMI >30 (OR = 1.46; 95% CI = [1.22, 1.74]; I2 = 0%) and hypertension (OR = 1.64; 95% CI = [1.03, 2.6]; I2 = 75%) were significant risk factors (P < .05) for developing VTE following shoulder arthroscopy. Diabetes (OR = 1.2; 95% CI = [0.97, 1.48]; I2 = 0%), insulin-dependent diabetes (OR = 5.58; 95% CI = [0.12, 260.19]; I2 = 85%), smoking (OR = 1.04; 95% CI = [0.79, 1.37]; I2 = 12%), male sex (OR = 0.95; 95% CI = [0.49, 1.85]; I2 = 86%) and age over 65 (OR = 4.3; 95% CI = [0.25, 72.83]; I2 = 85%) were not associated with higher VTE risk.

Conclusion

The VTE incidence following shoulder arthroscopy is low at 0.24%. Patients with BMI >30 and hypertension are at a higher risk for VTE after shoulder arthroscopy.

Level of Evidence

Level IV, systematic review and meta-analysis of Level I-IV studies.

Complications of Lateral Decubitus Positioning During Orthopaedic Surgery

» Lateral decubitus positioning is a nonanatomical position used for multiple orthopaedic procedures to obtain adequate surgical exposure.» Unique ophthalmologic, musculoskeletal, neurovascular, and hemodynamic complications may arise inadvertently from positioning.» Orthopaedic surgeons should be aware of the possible complications that may manifest from placing patients in the lateral decubitus position to adequately prevent and to properly manage them.

Venous thromboembolism after arthroscopic shoulder surgery: a systematic review

PURPOSE

To summarize the incidence, risk factors, diagnosis methods, prophylaxis methods, and treatment of venous thromboembolism (VTE) following arthroscopic shoulder surgery.

METHODS

Literature on VTE after arthroscopic shoulder surgeries was summarized, and all primary full-text articles reporting at least 1 case of deep vein thrombosis (DVT) or pulmonary embolism (PE) after arthroscopic shoulder surgeries were included. Articles were critically appraised and systematically analyzed to determine the incidence, risk factors, diagnosis, prophylaxis, and management of VTE following arthroscopic shoulder surgeries.

RESULTS

This study included 42 articles in which the incidence of VTE ranges from 0 to 5.71% and the overall incidence was 0.26%. Most VTE events took place between the operation day and the 14th day after the operation (35/51). Possible risk factors included advanced age (> 70 years), obesity (BMI ≥ 30 kg/m²), diabetes mellitus, thrombophilia, history of VTE, prolonged operation time, hormone use, and immobilization after surgery. The most common prophylaxis method was mechanical prophylaxis (13/15). No statistical difference was detected when chemoprophylaxis was applied. The management included heparinization followed by oral warfarin, warfarin alone and rivaroxaban, a direct oral anticoagulant.

CONCLUSION

Based on the included studies, the incidence rate of VTE after arthroscopic shoulder surgeries is relatively low. The risk factors for VTE are still unclear. CT/CTA and ultrasound were the mainstream diagnosis methods for PE and DVT, respectively. Current evidence shows that chemical prophylaxis did not deliver significant benefits, since none of the existing studies reported statistically different results. High-quality studies focusing on the prophylaxis and management of VTE population undergoing arthroscopic shoulder surgeries should be done in the future.

Is Routine Screening Using Duplex Ultrasonography for Deep Vein Thrombosis Necessary after Shoulder Arthroplasty?

The aims of this study were to examine the incidence, risk factors, and outcomes of deep vein thrombosis (DVT) after shoulder arthroplasty in Korean patients. A total of 265 patients who underwent shoulder arthroplasty were included. The mean age of the patients was 74.6 years, and there were 195 females and 70 males. Clinical data including patient demographics, blood tests, and previous and current medical history were investigated. For screening of DVT, duplex ultrasonography of the operative arm was performed 2 to 5 days after surgery. Of the 265 patients, 10 patients (3.8%) were diagnosed with DVT using postoperative duplex ultrasonography. There were no cases of pulmonary embolism. There were no significant differences between the DVT and no DVT groups regarding all clinical data, except for the Charlson comorbidity index (CCI), which was significantly higher in the DVT group than in the no DVT group (5.0 vs. 4.1; p = 0.029). All patients had asymptomatic DVT that showed complete resolution after administration of antithrombotic agents or close observation without medications. The overall incidence of DVT was 3.8% during a period of 3 months after shoulder arthroplasty in Korean patients, and most cases were asymptomatic. Routine screening for DVT using duplex ultrasonography after shoulder arthroplasty may not be necessary except in patients with high CCI.

Systems Biology Approach for Personalized Hemostasis Correction

The correction of blood coagulation impairments of a bleeding or thrombotic nature employs standard protocols where the type of drug, its dose and the administration regime are stated. However, for a group of patients, such an approach may be ineffective, and personalized therapy adjustment is needed. Laboratory hemostasis tests are used to control the efficacy of therapy, which is expensive and time-consuming. Computer simulations may become an inexpensive and fast alternative to real blood tests. In this work, we propose a procedure to numerically define the individual hemostasis profile of a patient and estimate the anticoagulant efficacy of low-molecular-weight heparin (LMWH) based on the computer simulation of global hemostasis assays. We enrolled a group of 12 patients receiving LMWH therapy and performed routine coagulation assays (activated partial thromboplastin time and prothrombin time) and global hemostasis assays (thrombodynamics and thrombodynamics-4d) and measured anti-Xa activity, fibrinogen, prothrombin and antithrombin levels, creatinine clearance, lipid profiles and clinical blood counts. Blood samples were acquired 3, 6 and 12 h after LMWH administration. We developed a personalized pharmacokinetic model of LMWH and coupled it with the mechanism-driven blood coagulation model, which described the spatial dynamics of fibrin and thrombin propagation. We found that LMWH clearance was significantly lower in the group with high total cholesterol levels. We generated an individual patient's hemostasis profile based on the results of routine coagulation assays. We propose a method to simulate the results of global hemostasis assays in the case of an individual response to LMWH therapy, which can potentially help with hemostasis corrections based on the output of global tests.

Venothromboembolism following shoulder arthroscopy: a systematic review

Background

Venous thromboembolic events (VTEs) following orthopedic surgery may lead to serious morbidity and mortality. Fortunately, VTEs following upper extremity procedures are uncommon. However, the true incidence is likely underreported. The aim of this study is to provide a systematic review, excluding large database studies, to report on the incidence of VTEs following shoulder arthroscopic procedures.

Methods

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review of multiple databases was performed. A comprehensive search of several databases from inception to September 1, 2021, limited to English language and excluding animal studies, was designed and conducted. Studies were screened by 2 independent reviewers. A decision to exclude studies from large surgical or insurance claim databases was made to minimize the risk of including overlapping data points in this systematic review.

Results

Thirteen studies met inclusion and exclusion criteria and form part of this systematic review. A total of 32,407 patients were included in this study. Among these patients, the deep vein thrombosis, pulmonary embolism, and overall VTE rates were 0.15%, 0.08%, and 0.21%, respectively. Among the patients specified to have undergone arthroscopic rotator cuff repair, the rate of deep vein thrombosis, pulmonary embolism, and overall VTE was 0.71%, 0.37%, and 1.04%, respectively.

Conclusion

While symptomatic VTEs are rare following shoulder arthroscopic procedures, surgeons must be aware that they still account for a certain number of postoperative complications. Factors such as operative time, open procedures, obesity, and altitude may increase the risk of postoperative VTE although conflicting data exist. Current literature supports the idea that chemical antithrombotic prophylaxis likely provides no significant advantage over early mobilization in reducing VTEs following shoulder arthroscopy in low-risk patients.

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.

Incidence and Prevention of Thromboembolic Complications for Sports and Arthroscopic-related Surgery: Evidence-based Recommendations

The incidence of thromboembolic events following arthroscopic surgery is relatively rare. Despite this, these are important complications to be aware of, as arthroscopic procedures are performed in high frequency each year and can lead to a substantial burden within health care. Over the past several decades, pharmacologic antithrombotic prevention strategies following knee arthroscopy have been extensively studied; however, their efficacy remains controversial, and there is a lack of consensus regarding a standard prevention protocol, with the exception of the established benefits of early mobilization. Several surgical and medical risk factors have been established and are important to consider as they specifically relate to each individual patient's risk of thromboembolic disease. Based on the best available evidence, chemical thromboprophylaxis appears to be unnecessary among healthy patients but may be beneficial for higher risk patients, especially those with a prior history of venous thromboembolism. A standard screening tool for risk factors in arthroscopy patients may be a cost-effective and safe solution for implementing preventative efforts.

The Relationship of Staged, Bilateral Arthroscopic Primary Rotator Cuff Repair Timing and Postoperative Complications

BACKGROUND

Although previous studies have reported acceptable clinical outcomes after simultaneous, single-stage bilateral and staged bilateral rotator cuff repair (RCR), few studies have been adequately powered to compare postoperative complication rates at various time intervals between procedures.

PURPOSE

To examine the relationship between the timing of bilateral arthroscopic RCR and complications.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Patients from the Medicare data set within the PearlDiver database who underwent bilateral RCR between 2005 and 2014 were identified. These patients were then stratified by time between surgeries into cohorts: (1) single stage, (2) <3 months, (3) 3 to 6 months, (4) 6 to 9 months, (5) 9 months to 1 year, and (6) 1 to 2 years. Surgical and medical complications of these cohorts were compared with those of a control cohort of patients who underwent bilateral RCR >2 years apart using a regression analysis.

RESULTS

A total of 11,079 patients who underwent bilateral RCR were identified. Patients who underwent single-stage bilateral arthroscopic RCR experienced higher rates of revision RCR (odds ratio [OR], 2.1; P < .0001), reverse total shoulder arthroplasty (RTSA) (OR, 2.47; P < .0001), and postoperative infection (OR, 2.18; P = .007) in addition to higher rates of venous thromboembolism (VTE) (OR, 1.78; P = .031) and emergency department visits (OR, 1.51; P = .002) compared with the control group. Patients who underwent bilateral RCR with a <3-month interval had higher rates of revision surgery (OR, 1.56; P = .003), RTSA (OR, 1.89; P = .002), and lysis of adhesions (OR, 2.31; P < .0001) in addition to increased rates of VTE (OR, 1.92; P = .015) and emergency department visits (OR, 1.62; P < .0001) compared with the control group. There were no differences in any surgical or medical complications when surgeries were staged by ≥3 months compared with controls.

CONCLUSION

Patients with Medicare undergoing single-stage and staged bilateral RCR who had the second repair within 3 months had significantly higher rates of multiple medical and surgical complications compared with patients waiting >2 years between procedures.

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.

Asymptomatic Pulmonary Embolism After Shoulder Arthroscopy: Case Report and Literature Review

BACKGROUND

Pulmonary embolism (PE) is extremely rare after shoulder arthroscopy. However, early identification of the situation deserves attention due to its potential risk of causing death. By now, it is still difficult to detect the PE without symptoms and clear sources during the perioperative period.

CASE PRESENTATION

We report here two cases of asymptomatic PE, both happening within 24 h after shoulder arthroscopy, without any detected deep venous thrombosis of extremities. It is suspected the cases were due to the abnormal decrease in partial pressures of oxygen and arterial oxygen saturation, and were confirmed by computed tomography pulmonary angiography. We also discuss the reason why the patients showed no related symptoms when PE occurred and perform a review of PE following shoulder arthroscopy.

CONCLUSIONS

This report highlights that PE could occur in the early phase after shoulder arthroscopy. An unexplained decrease in partial pressure of oxygen or arterial oxygen saturation should be considered seriously. The symptoms of PE might be masked due to patients' tolerance to hypoxia.

Rate of venous thromboembolism after surgical treatment of proximal humerus fractures

INTRODUCTION

The rate of venous thromboembolism following surgical treatment of proximal humerus fractures is not well established.

METHODS

A retrospective review of all patients undergoing surgical treatment for proximal humerus fractures from September 2011 to May 2017 was performed. Included patients received only mechanoprophylaxis using sequential compression devises. All patients had at least 6 months follow-up. The primary outcome of interest was the rate of postoperative DVT and PE.

RESULTS

131 patients underwent 139 surgeries for proximal humerus fracture. After exclusion criteria were applied, 92 patients who underwent 92 surgeries were included. There were 47 females and 45 males. Five (5.4%) were taking Aspirin 81 mg preoperatively. There were 76 cases of open reduction and internal fixation (ORIF), 8 cases of reverse total shoulder arthroplasty, 4 cases of hemiarthroplasty, 3 cases of closed reduction percutaneous pinning (CRPP), 1 case of open reduction without fixation. 53.3% of patients had one or more risk factors for VTE. There were no cases of fatal PE or DVT. There were two cases of symptomatic PE (2.2%) following one ORIF and one CRPP. There was one additional case of asymptomatic PE found incidentally after ORIF. Overall VTE rate was 3.3%. Fisher's exact test yielded that there was no significant association between the presence of VTE risk factors and prevalence of VTE postoperatively (p = 0.245).

CONCLUSIONS

The incidence of symptomatic VTE after surgery for proximal humerus fractures is low. Chemical VTE prophylaxis in patients after surgical fixation for proximal humerus fractures is not universally indicated. Selective prophylaxis for patients with systemic risk factors may be warranted.

Perioperative Venous Thromboembolism Prophylaxis

Venous thromboembolism (VTE) is a preventable cause of postoperative morbidity and mortality; however, audits suggest that the use of thromboprophylaxis is underused. In this review, we describe our approach to prevention of postoperative VTE and provide guidance on how to formulate an optimal VTE prophylaxis plan. We recommend that all patients undergo thrombosis- and bleeding-risk assessment as part of their preoperative evaluation. The risk of thrombosis can be estimated based on patient- and procedure-specific factors, using validated risk-assessment models such as the Caprini score. There are no validated models to predict perioperative bleeding; however, several risk factors have been proposed. Patients should ambulate early and frequently after surgery. We recommend no additional prophylaxis in patients at very low risk of VTE (Caprini score 0). Patients at low risk of VTE (Caprini 1 to 2) are recommended to receive either mechanical or pharmacological prophylaxis. Patients at moderate (Caprini 3 to 4) to high risk of VTE (Caprini ≥5) are recommended pharmacological prophylaxis either alone or combined with mechanical prophylaxis. Patients at high risk of bleeding should receive mechanical prophylaxis until their risk of bleeding is reduced and pharmacological prophylaxis can be reconsidered. Populations for which the Caprini score has not been validated (such as orthopedic surgery) are recommended prophylaxis based on individual and procedure-specific risk factors. Prophylaxis is typically continued until the patient is ambulatory or until hospital dismissal; however, longer durations can be considered in certain circumstances (high-risk patients undergoing malignant abdominopelvic operations, bariatric operations, and certain orthopedic operations).

Timing and Risk Factors for Venous Thromboembolism After Rotator Cuff Repair in the 30-Day Perioperative Period

PURPOSE

To analyze the American College of Surgeons National Surgical Quality Improvement Program database to evaluate the incidence of deep venous thrombosis and pulmonary embolism in patients undergoing rotator cuff repair surgery. In addition, we aim to identify risk factors associated with the development of thromboembolic events following rotator cuff repair.

METHODS

A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database was performed. Current Procedural Terminology codes were used to identify patients who underwent rotator cuff repair between 2005 and 2017. The presence of deep venous thrombosis or pulmonary embolism during the 30-day perioperative period were the primary outcomes assessed. Logistic regression analysis was performed to identify risk factors for postoperative venous thromboembolic events (VTEs).

RESULTS

In total, 39,825 rotator cuff repairs (RCRs) were performed and 117 (0.3%) VTE events occurred. VTE was identified at a mean of 11.5 ± 7.4 days. A total of 31,615 RCRs were performed arthroscopically. There was no significant difference of VTE between groups comparing arthroscopic RCR VTE 0.3% (94) with open RCR 0.3% (23) (P = .81). RCR in patients with an American Society of Anesthesiologists classification of III or IV was associated with >1.5-fold increase risk of VTE (odds ratio [OR] 1.68, 95% confidence interval [CI] 1.14-2.45). Increased risks of VTE included surgery >80 minutes (OR 2.10, 95% CI 1.42-3.15), performed under general anesthesia (OR 4.38, 95% CI 1.18-36.6), and in the outpatient setting (OR 6.09, 95% CI 1.06-243.7), male sex (OR 1.53, 95% CI 1.01-2.33), bleeding disorders (OR 2.87, 95% CI 1.17-7.05), or dyspnea (OR 1.51, 95% CI 1.02-2.23). The biggest risk for VTE was unplanned reoperation OR 16.6 (95% CI 5.13-53.5).

CONCLUSIONS

Venous thromboembolism is a rare complication following rotator cuff repair 0.3%. Understanding the risk factors: duration of surgery >80 minutes, male sex, body mass index >30 kg/m², ASA III or IV, RCR as an inpatient under general anesthesia, bleeding disorder, or dyspnea may be useful in guiding treatment to prevent VTE. The largest risk for VTE is a patient with unplanned reoperation. RCR surgery performed in an outpatient setting resulted in a significantly lower incidence of VTE.

LEVEL OF EVIDENCE

III Retrospective Comparative Study.

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.

[Thromboembolic prophylaxis in orthopaedics: update on the current S3 guideline, effective 2015]

BACKGROUND

Thromboembolism is one of the most significant complications in many orthopaedic treatments and illnesses. Therefore, prevention is of vital importance.

CURRENT STATUS

The existing S3 guideline, revised in 2015, investigates the various symptoms and treatments in great detail, and thus provides very good recommendations. The difficulties of thrombosis prophylaxis in orthopaedics were ever-present in 2018, which is shown by the large number of publications on the topic. These new findings can be incorporated into further versions of the guideline, thereby adapting them to the current status. Finally, the fact that is especially important for everyday practice should be mentioned, that is, in particular when patients are transferred or discharged, information about the necessary prophylaxis is communicated to the colleagues who will be carrying out further treatment to guarantee uninterrupted prophylaxis.

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.].

Oral Contraceptive Pills Are Not a Risk Factor for Deep Vein Thrombosis or Pulmonary Embolism After Arthroscopic Shoulder Surgery

Background:

Worldwide, more than 100 million women between the ages of 15 and 49 years take oral contraceptive pills (OCPs). OCP use increases the risk of venous thromboembolism (VTE) through its primary drug, ethinylestradiol, which slows liver metabolism, promotes tissue retention, and ultimately favors fibrinolysis inhibition and thrombosis.

Purpose:

To evaluate the effects of OCP use on VTE after arthroscopic shoulder surgery.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A large national payer database (PearlDiver) was queried for patients undergoing arthroscopic shoulder surgery. The incidence of VTE was evaluated in female patients taking OCPs and those not taking OCPs. A matched group was subsequently created to evaluate the incidence of VTE in similar patients with and without OCP use.

Results:

A total of 57,727 patients underwent arthroscopic shoulder surgery from 2007 to 2016, and 26,365 patients (45.7%) were female. At the time of surgery, 924 female patients (3.5%) were taking OCPs. The incidence of vascular thrombosis was 0.57% (n = 328) after arthroscopic shoulder surgery, and there was no significant difference in the rate of vascular thrombosis in male or female patients (0.57% vs 0.57%, respectively; P > .99). The incidence of VTE in female patients taking and not taking OCPs was 0.22% and 0.57%, respectively (P = .2). In a matched-group analysis, no significant difference existed in VTE incidence between patients with versus without OCP use (0.22% vs 0.56%, respectively; P = .2). On multivariate analysis, hypertension (odds ratio [OR], 2.00; P < .001) and obesity (OR, 1.43; P = .002) were risk factors for VTE.

Conclusion:

OCP use at the time of arthroscopic shoulder surgery is not associated with an increased risk of VTE. Obesity and hypertension are associated with a greater risk for thrombolic events, although the risk remains very low. Our findings suggest that patients taking OCPs should be managed according to the surgeon’s standard prophylaxis protocol for arthroscopic shoulder surgery.

Venous Thromboembolism in Upper Extremity Fractures

BACKGROUND

Venous thromboembolism (VTE) has been studied in lower extremity fractures but little is known of its relation with upper extremity (UE) fractures. As an often overlooked but serious complication, VTE may compromise patient outcomes.

METHODS

Using data on inpatients (aged ≥ 18 years) at a level-I trauma center and patients in the National Surgical Quality Improvement Program database who sustained UE fractures (clavicle, humerus, or radius/ulna) and VTE in the same hospitalization between 2007 and 2014, the authors analyzed data on demographic characteristics, fracture type, VTE location (pulmonary embolism, lower extremity, or UE), VTE onset, polytrauma, operative or nonoperative management, comorbidities, and mortality.

RESULTS

Of 1984 inpatients with UE fractures at 1 instution, 9 experienced VTE on admission, and 17 (15 received thromboprophylaxis) experienced VTE during hospitalization, for an overall VTE rate of 1.3%. VTE occurred most often in patients with fractures of the proximal humerus (3.0%) followed by the clavicle (2.0%), midshaft humerus (1.9%), distal radius/ulna (0.95%), and distal humerus/elbow (0.36%) (p = 0.0035). There were no significant trends in the incidence of PE (p = 0.33) over the study period, but there was a sharp rise since 2011. In the national database, 42 of 11570 (0.36%) patients with UE fracture had VTE, with incidence by fracture location ranging from 0.14% (radius/ulna) to 0.98% (proximal humerus) (p = 0.00001). Predictors were chronic steroid use (odds ratio [OR] = 6.22, p = .030), inpatient status (OR = 4.09, p = .002), and totally disabled functional status (OR = 3.31, p = .021).

CONCLUSIONS

VTE incidence was highest following proximal humerus or clavicle fractures and are rarely associated with radius/ulna fractures. There may have been a rise in the incidence of PE since 2007, warranting further investigation.

Thromboembolic risk after lumbar spine surgery: a cohort study on 325 000 French patients

Essentials The risk of venous thromboembolism (VTE) after lumbar spine surgery (LBS) is not precisely known. More than 320 000 patients who underwent LBS in France between 2009 and 2014 were followed-up. The overall risk of VTE after LBS is less than 1% but modulated by patient and procedural factors. Surgical device implantation, anterior approach and complex surgery increase the risk of VTE. SUMMARY: Background Postoperative venous thromboembolism (VTE) is a severe complication, the risk of which after lumbar spine surgery (LBS) is not precisely known. Objective To estimate the incidence of VTE after LBS, and to identify individual and surgical risk factors. Methods All patients aged >18 years who underwent LBS in France between 2009 and 2014 were identified. Among 477 024 patients screened, exclusions concerned recent VTE or surgery, and multiple surgeries during the same hospital stay. Results In 323 737 patients (mean age 52.9 years, 51.4% male), we observed 2911 events (0.91%) after a median time of 12 days (Q1-Q3: 5-72 days). The multivariate adjusted Cox model showed increased risks associated with age (4% per year of age; 95% confidence interval [CI] 3.8-4.3), obesity (hazard ratio [HR] 1.32, 95% CI 1.18-1.46), active cancer (HR 1.65, 95% CI 1.5-1.82), previous thromboembolism (HR 5.41, 95% CI 4.74-6.17), severe paralysis (HR 1.47, 95% CI 1.17-1.84), renal disease (HR 1.28, 95% CI 1.04-1.6), psychiatric disease (HR 1.21, 95% CI 1.1-1.32), use of antidepressants (HR 1.13, 95% CI 1.03-1.24), use of contraceptives (HR 1.56, 95% CI 1.19-2.03), extended surgery for scoliosis (HR 3.61, 95% CI 2.96-4.4), implantation of pedicular screws with a 'dose-effect' association, and an anterior approach (HR 1.97, 95% CI 1.6-2.43) or a combined approach (HR 2.03, 95% CI 1.44-2.84). Conclusions The overall VTE risk after LBS is moderate (< 1%) but is widely modulated by several easily identifiable risk factors. The surgical community should be aware of this heterogeneity, adapt prevention according to patients and to the procedure, and use drug prophylaxis in the event of a high risk being present.

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.

Acute pulmonary embolism after arthroscopic glenoid labral repair and subacromial decompression: case report and review of the literature

This report describes the case of a 29 year-old female with a history of polycystic ovary syndrome (PCOS) and on combined oral contraceptives who presents with an acute, CT confirmed pulmonary embolus of the right lower lobe, one week following arthroscopic labral repair of the right shoulder. This patient's relevant risk factors including obesity, oral contraceptive use, PCOS, and surgical positioning are discussed. Literature surrounding venous thromboembolism (VTE) following shoulder arthroscopy is also reviewed.

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.].

VTE primary prevention, including hospitalised medical and orthopaedic surgical patients

Primary prevention is the key to managing a significant proportion of the burden of venous thromboembolism (VTE), defined as deep venous thrombosis (DVT) or pulmonary embolism (PE). This is because VTE may lead to sudden death or are often misdiagnosed and therefore treatment is not feasible. Primary prevention usually commences in hospital as VTE following hospitalisation adds to the significant disease burden worldwide. Numerous medical, surgical and other risk factors have been recognised and studied as indications for prophylaxis. The risk of VTE continues following admission to hospital with a medical or surgical condition, usually long after discharge and therefore prolonged primary prophylaxis is often recommended. Clinical and observational studies in surgical patients show this risk extends for months and perhaps more than one year, for medical patients the risk extends for at least several weeks. For the specific groups of patients at higher risk of developing VTE primary prevention, either pharmaceutical or mechanical, is recommended. The aim of this review is to describe the population at risk, the main related risk factors and the approach to thromboprophylaxis in different populations.

High altitude is an independent risk factor for venous thromboembolism following arthroscopic rotator cuff repair: a matched case-control study in Medicare patients

BACKGROUND

Although the risk of venous thromboembolism (VTE) following elective shoulder arthroscopy is low, the large volume of procedures performed each year yields a significant annual burden of patients with thromboembolic complications. The purpose of this study was to evaluate the association of high procedural altitude with the incidence of postoperative VTE following arthroscopic rotator cuff repair.

METHODS

A Medicare database was queried for all patients undergoing arthroscopic rotator cuff repair from 2005 to 2012. All patients with procedures performed at an altitude of 4000 feet or higher were grouped into the "high-altitude" study cohort. Patients with procedures performed at an altitude of 100 feet or lower were then matched to patients in the high-altitude cohort on the basis of age, gender, and medical comorbidities. The rate of VTE was then assessed for both the high-altitude and matched low-altitude cohorts within 90 days postoperatively.

RESULTS

The rates of combined VTE (odds ratio [OR], 2.6; P < .0001), pulmonary embolism (OR, 4.3; P < .0001), and lower extremity deep venous thrombosis within 90 days (OR, 2.2; P = .029) were all significantly higher in patients with procedures performed at high altitude compared with matched patients with the same procedures performed at low altitude.

CONCLUSIONS

Procedural altitude >4000 feet is associated with significantly increased rates of postoperative VTE, including deep venous thrombosis and pulmonary embolism, compared with age-, gender-, and comorbidity-matched patients undergoing the same procedures at altitudes <100 feet.

Isolated Pulmonary Embolism following Shoulder Arthroscopy

Pulmonary embolism (PE) following shoulder arthroscopy is a rare complication. We present a unique case report of a 43-year-old right-hand dominant female who developed a PE 41 days postoperatively with no associated upper or lower extremity DVT. The patient had minimal preoperative and intraoperative risk factors. Additionally, she had no thromboembolic symptoms postoperatively until 41 days following surgery when she developed sudden right-hand swelling, labored breathing, and abdominal pain. A stat pulmonary computed tomography (CT) angiogram of the chest revealed an acute PE in the right lower lobe, and subsequent extremity ultrasounds showed no upper or lower extremity deep vein thrombosis. After a thorough review of the literature, we present the first documented isolated PE following shoulder arthroscopy. Although rare, sudden development of an isolated PE is possible, and symptoms such as sudden hand swelling, trouble breathing, and systemic symptoms should be evaluated aggressively with a pulmonary CT angiogram given the fact that an extremity ultrasound may be negative for deep vein thrombosis.

The impact of diabetes on the short- to mid-term outcome of total ankle replacement

We compared the clinical and radiographic results of total ankle replacement (TAR) performed in non-diabetic and diabetic patients. We identified 173 patients who underwent unilateral TAR between 2004 and 2011 with a minimum of two years’ follow-up. There were 88 male (50.9%) and 85 female (49.1%) patients with a mean age of 66 years (sd 7.9, 43 to 84). There were 43 diabetic patients, including 25 with controlled diabetes and 18 with uncontrolled diabetes, and 130 non-diabetic patients. The clinical data which were analysed included the Ankle Osteoarthritis Scale (AOS) and the American Orthopaedic Foot and Ankle Society (AOFAS) scores, as well the incidence of peri-operative complications.

The mean AOS and AOFAS scores were significantly better in the non-diabetic group (p = 0.018 and p = 0.038, respectively). In all, nine TARs (21%) in the diabetic group had clinical failure at a mean follow-up of five years (24 to 109), which was significantly higher than the rate of failure of 15 (11.6%) in the non-diabetic group (p = 0.004). The uncontrolled diabetic subgroup had a significantly poorer outcome than the non-diabetic group (p = 0.02), and a higher rate of delayed wound healing.

The incidence of early-onset osteolysis was higher in the diabetic group than in the non-diabetic group (p = 0.02). These results suggest that diabetes mellitus, especially with poor glycaemic control, negatively affects the short- to mid-term outcome after TAR.

Cite this article: Bone Joint J 2014;96-B:1674–80.

Thromboembolism Following Shoulder Arthroscopy: A Retrospective Review

Background:

Thromboembolism following shoulder arthroscopy is considered an uncommon complication, with fewer than 50 cases reported in the literature. Arthroscopy of the shoulder is one of the most commonly performed orthopaedic procedures, with low associated risks.

Purpose:

To identify potential risk factors for the development of venous thromboembolism (VTE) following shoulder arthroscopy and to determine the overall incidence of this complication.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

A retrospective case-control review was performed of patients who developed symptomatic deep venous thrombosis (DVT) or pulmonary embolism (PE) following shoulder arthroscopy. Multiple surgeons from across North America were queried. For every case of DVT or PE identified, 2 control cases of shoulder arthroscopy were analyzed. The incidence of DVT/PE following shoulder arthroscopy was determined. A univariate analysis and a multivariate logistic regression model were conducted to identify any potential risk factors for the development of VTE following shoulder arthroscopy.

Results:

A total of 17 surgeons participated in this study and had performed a total of 15,033 cases of shoulder arthroscopy from September 2002 through August 2011. Eleven of the 17 participating surgeons had had a patient with a VTE complication during this time frame. The incidence of VTE in the 15,033 cases was 0.15%; 22 patients of the 15,033 patients had a DVT (n = 15) and/or PE (n = 8). Forty-four control cases were also analyzed. Univariate and multivariate analyses were performed. No significant risk factors were identified other than patient positioning. All cases and controls were positioned in the beach-chair position for surgery.

Conclusion:

The results of this study show that although rare, VTE occurs following shoulder arthroscopy at a rate of 0.15%. The variables analyzed in the cases of VTE compared with the control cases did not show any significant risk factors. All cases were positioned in the beach-chair position. Further analysis of future cases is warranted.

Postoperative Morbidity by Procedure and Patient Factors Influencing Major Complications Within 30 Days Following Shoulder Surgery

BACKGROUND

Little data are available to prioritize quality improvement initiatives in shoulder surgery.

PURPOSE

To stratify the risk for 30-day postoperative morbidity in commonly performed surgical procedures about the shoulder completed in a hospital setting and to determine patient factors associated with major complications.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This retrospective study utilized the National Surgical Quality Improvement Program (NSQIP) database from the years 2005 to 2010. Using Current Procedural Terminology codes, the database was queried for shoulder cases that were divided into 7 groups: arthroscopy without repair; arthroscopy with repair; arthroplasty; clavicle/acromioclavicular joint (AC) open reduction and internal fixation (ORIF)/repair; ORIF of proximal humeral fracture; open tendon release/repair; and open shoulder stabilization. The primary end point was any major complication, with secondary end points of incisional infection, return to the operating room, and venothromboembolism (VTE), all within 30 days of surgery.

RESULTS

Overall, 11,086 cases were analyzed. The overall major complication rate was 2.1% (n = 234). Factors associated with major complications on multivariate analysis included: procedure performed (P < .001), emergency case (P < .001), pulmonary comorbidity (P < .001), preoperative blood transfusion (P = .033), transfer from an outside institution (P = .03), American Society of Anesthesiologists (ASA) score (P = .006), wound class (P < .001), dependent functional status (P = .027), and age older than 60 years (P = .01). After risk adjustment, open shoulder stabilization was associated with the greatest risk of major complications relative to arthroscopy without repair (odds ratio [OR], 5.56; P = .001), followed by ORIF of proximal humerus fracture (OR, 4.90; P < .001) and arthroplasty (OR, 4.40; P < .001). These 3 groups generated over 60% of all major complications. Open shoulder stabilization had the highest odds of reoperation (OR, 8.34; P < .001), while ORIF of proximal humerus fracture had the highest risk for VTE (OR, 6.47; P = .001) compared with the reference group of arthroscopy without repair.

CONCLUSION

Multivariable analysis of the NSQIP database suggests that open shoulder stabilization, ORIF for proximal humerus fractures, and shoulder arthroplasty are associated with the highest risk of major complications within 30 days after shoulder surgery in a hospital setting. Age, functional status, ASA score, pulmonary comorbidity, emergency case, preoperative blood transfusion, and transfer from an outside institution are patient variables that significantly influence complication risk.

Perioperative complications after hemiarthroplasty and total shoulder arthroplasty are equivalent

BACKGROUND

Total shoulder arthroplasty (TSA) results in superior clinical outcomes to hemiarthroplasty (HA); however, TSA is a more technical and invasive procedure. This study retrospectively compares perioperative complications after HA and TSA using the National Surgical Quality Improvement Program (NSQIP) database.

METHODS

The NSQIP user file was queried for HA and TSA cases from the years 2005 through 2010. Major complications were defined as life-threatening or debilitating. All complications occurred within 30 days of the initial procedure. We performed multivariate analysis to compare complication rates between the two procedures, controlling for patient comorbidities.

RESULTS

The database returned 1,718 patients (HA in 30.4% [n = 523] and TSA in 69.6% [n = 1,195]). The major complication rates in the HA group (5.2%, n = 29) and TSA group (5.1%, n = 61) were similar (P = .706). Rates of blood transfusions for postoperative bleeding in patients undergoing HA (2.3%, n = 12) and TSA (2.9%, n = 35) were indistinguishable (P = .458). Venous thromboembolism was a rare complication, occurring in 0.4% of patients in each group (2 HA patients and 5 TSA patients, P > .999). On multivariate analysis, the operative procedure was not associated with major complications (P = .349); however, emergency case, pulmonary comorbidity, anemia with a hematocrit level lower than 36%, and wound class of III or IV increased the risk of a major complication (P < .05 for all).

CONCLUSION

Multivariate analysis of patients undergoing TSA or HA in the NSQIP database suggests that patient factors-not the procedure being performed-are significant predictors of major complications. Controlling for patient comorbidities, we found no increased risk of perioperative major complications in patients undergoing TSA compared with HA.

Venous thromboembolism incidence in upper limb orthopedic surgery: do these procedures increase venous thromboembolism risk?

BACKGROUND

In 2005, the House of Commons (HoC) Health Committee stated deaths attributed to preventable, hospital-acquired venous thromboembolism (VTE) numbered upwards of 25,000 per annum. Nationwide prevention of VTE became the topic of a major health campaign. The HoC Health Committee stated there was an unstratified VTE risk of between 45% and 51% associated with orthopedic surgery. VTE research in orthopedic surgery has been concentrated on lower limb procedures. Experience suggests that this kind of relation does not hold true for upper limb orthopedic procedures. This project aimed to estimate the incidence of postoperative VTE in upper limb orthopedic surgery.

METHODS

The incidence of postoperative VTE was assessed in 3357 consecutive upper limb orthopedic operations performed by 4 surgeons in Lancashire Teaching Hospitals National Health Service (NHS) Trust (LTHTR) between July 1, 2009, and July 31, 2012.

RESULTS

Four pulmonary embolisms and 2 deep vein thromboses occurred. Incidence of postoperative VTE was 0.0018%, significantly lower than rates reported in the literature. Five of 6 patients who developed a VTE reported a personal or family history of VTE. Three patients would not have been identified as at risk under the current VTE screening guidelines. Three of these patients received appropriate anticoagulation according to present guidelines, yet VTE events still occurred.

CONCLUSION

These results indicate VTE risk in orthopedic upper limb surgery is much lower than reported in the literature. The necessity for screening for VTE in upper limb surgery is contested. The efficacy of VTE screening and current VTE prophylaxis is discussed, and an alternative and much simplified method of screening is suggested.

Peri-operative complications in pediatric and adolescent shoulder arthroscopy

BACKGROUND

Shoulder arthroscopy is not common in the pediatric and adolescent population, but the frequency may be on the rise. The purpose of the study was to determine the incidence of acute complications of arthroscopic shoulder surgery in children and adolescents.

METHODS

A retrospective, cross-sectional review was performed identifying patients aged 18 years or less who underwent an arthroscopic shoulder procedure from 1997 to 2009 at Institution 1 and 2007 to 2010 at Institution 2. Exclusion criteria included open procedures and missing records. Demographic and surgical data were collected, including intra-operative and post-operative complications during the first 6 months. The complications were divided into minor (no secondary treatment) and major (secondary treatment rendered).

RESULTS

Two hundred children, mean age 15.9 years, met criteria and 73 % were boys. All procedures were performed under general anesthesia, but 51 % included inter-scalene regional anesthesia. There were 16 (8.0 %) total complications recorded. Major complications occurred in five (2.5 %) patients, including two tendinitis/bursitis requiring injections, one broken pain pump catheter requiring an accessory incision to retrieve, one pain control readmission, and one laceration of the cephalic vein requiring ligation. Minor complications occurred in 11 (5.5 %) patients, including allergic reactions, transient dysesthesias, headaches, bronchitis, syncope, transient hypotension, and uvula swelling.

CONCLUSION

Although we found no seriously deleterious outcomes, it is important to recognize that an additional service was rendered for 2.5 % of children undergoing shoulder arthroscopy. The events that did occur may be preventable and this study should serve as a baseline to improve quality and safety of shoulder arthroscopy in the pediatric population.

In-office diagnostic arthroscopy for knee and shoulder intra-articular injuries its potential impact on cost savings in the United States

Background

The purpose of this analysis was to determine whether in office diagnostic needle arthroscopy (Visionscope Imaging System [VSI]) can provide for improved diagnostic assessment and; more cost effective care.

Methods

Data on arthroscopy procedures in the US for deep seated pathology in the knee and shoulder were used (Calendar Year 2012). These procedures represent approximately 25-30% of all arthroscopic procedures performed annually. Sensitivities, specificities, positive predictive, and negative predictive values for MRI analysis of this deep seated pathology from systematic reviews and meta-analyses were used in assessing for false positive and false negative MRI findings. The costs of performing diagnostic and surgical arthroscopy procedures (using 2013 Medicare reimbursement amounts); costs associated with false negative findings; and the costs for treating associated complications arising from diagnostic and therapeutic arthroscopy procedures were then assessed.

Results

In patients presenting with medial meniscal pathology (ICD9CM diagnosis 836.0 over 540,000 procedures in CY 2012); use of the VSI system in place of MRI assessment (standard of care) resulted in a net cost savings to the system of $151 million. In patients presenting with rotator cuff pathology (ICD9CM 840.4 over 165,000 procedures in CY2012); use of VSI in place of MRI similarly saved $59 million. These savings were realized along with more appropriate care as; fewer patients were exposed to higher risk surgical arthroscopic procedures.

Conclusions

The use of an in-office arthroscopy system can: possibly save the US healthcare system money; shorten the diagnostic odyssey for patients; potentially better prepare clinicians for arthroscopic surgery (when needed) and; eliminate unnecessary outpatient arthroscopy procedures, which commonly result in surgical intervention.

Venous thromboembolism after elective shoulder surgery: a prospective cohort study of 175 patients

BACKGROUND

The purpose of this study was to investigate the incidence of venous thromboembolism (VTE) after elective arthroscopic shoulder surgery.

MATERIALS AND METHODS

One hundred seventy-five consecutive patients who underwent arthroscopic shoulder surgery were enrolled (mean age, 61 years). Patients who had VTE preoperatively and underwent trauma surgery or arthroplasty were excluded. All the patients used foot pumps or elastic stockings after surgery for deep venous thrombosis (DVT) prophylaxis. DVT in the 4 limbs was assessed by ultrasound before and after surgery. Pulmonary embolism was diagnosed by computed tomography pulmonary angiography. Risk factors related to DVT were assessed.

RESULTS

The overall incidence of DVT was 10 of 175 patients (5.7%). Most of the DVT cases were detected at 1 to 2 days after surgery. All patients were asymptomatic. There were no patients who had symptomatic pulmonary embolism. However, an asymptomatic pulmonary embolus developed in 1 patient during the 3-month follow-up period. There were no significant differences between the DVT and non-DVT groups regarding the risk factors.

DISCUSSION AND CONCLUSION

Our data have shown that symptomatic VTE is rare after elective arthroscopic shoulder surgery. However, asymptomatic VTE may occur even with DVT preventive measures. Because most of the DVTs were found in the calf veins, we recommend that surgeons pay attention to the possibility of DVT in the lower extremities even after arthroscopic shoulder surgery. The incidence of asymptomatic VTE after elective arthroscopic shoulder surgery was 5.7%. All patients were asymptomatic, and most of the DVTs occurred 1 or 2 days after surgery.

Incidence of symptomatic venous thrombo-embolism following shoulder surgery

PURPOSE

This clinical study was performed to establish the incidence of symptomatic deep vein thrombosis and pulmonary embolism after shoulder surgery as the incidence of venous thrombo-embolism complicating shoulder surgery is poorly described in literature.

METHODS

We reviewed retrospectively clinical records of 920 consecutive patients who had any surgical procedure performed on their shoulder in Glan Clwyd Hospital, North Wales and a further 1,421 consecutive patients who had surgery in Morriston and Singleton Hospitals, South Wales. Patients' records were assessed for any admissions due to proven VTE; we investigated for any radiological results suggestive of venous thrombo-embolism and for deaths in the post-operative period.

RESULTS

We analyzed data of 2,341 patients. There was one fatal PE in this group, whereby the patient died within 48 hours following reverse shoulder replacement, and post mortem revealed massive pulmonary embolism. There were a further three cases of symptomatic, non-fatal PE. There were six cases of symptomatic DVT of lower limb. All these cases were treated successfully with anticoagulation. No upper limb DVT was identified.

CONCLUSION

Recent studies suggest that DVT prevalence following shoulder arthroplasty is as high as 13 %. In our study we examined occurrence of symptomatic VTE only. According to our results the prevalence of symptomatic DVT following shoulder surgery is 0.26 %, symptomatic PE 0.17 % and combined prevalence of VTE is 0.43 %. We would advise careful thought about the risk of thrombosis and use mechanical prophylaxis in shoulder surgery, especially for longer procedures. We would not recommend routine pharmacological prophylaxis unless there are additional risk factors.