Venous Thromboembolism After Total Shoulder Arthroplasty

A Database Study of 31,918 Cases

Dafang Zhang, MD; George S. M. Dyer, MD; Brandon E. Earp, MD

Disclosures

J Am Acad Orthop Surg. 2022;30(19):949-956. 

In This Article

Abstract and Introduction

Abstract

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

Introduction

The utilization of total shoulder arthroplasty (TSA) has dramatically increased in the past three decades.[1,2] It is estimated that more than 800,000 people in the United States have undergone a type of shoulder arthroplasty.[1] The annual incidence of TSA, including both anatomic and reverse TSAs, is approximately 31.8 per 100,000 people.[3] The rise in the utilization of TSA is in part due to the widening indications for reverse TSA, which have expanded beyond rotator cuff arthropathy to include select cases of osteoarthritis, proximal humerus fractures, and irreparable rotator cuff tears. The trend also reflects growing surgeon experience because TSA patients in the past two decades have had on average more medical comorbidities, but fewer short-term complications, shorter surgical times, and shorter hospital lengths of stay.[3,4]

Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), is a rare but serious complication of orthopaedic surgery that may entail hospital admission, anticoagulation therapy, cardiopulmonary morbidity, and even death.[5,6] The incidence of symptomatic VTE after lower extremity orthopaedic surgery has been well described;[7] moreover, the rates of VTE after lower extremity orthopaedic surgery have been shown to decrease from 40% to 60% in an untreated population to approximately 1.8% for DVT and 1% for PE in patients treated with VTE chemoprophylaxis.[7,8] Although established guidelines for the use of chemoprophylaxis after lower extremity arthroplasty are in place, no definitive guidelines exist for shoulder arthroplasty.[5]

The prevalence of VTE after TSA is low, ranging from 0.2% to 16% in the literature, with most publications with larger sample sizes citing a prevalence between 0.24% and 2.6%.[5,6,9] The evidence guiding VTE prophylaxis after TSA is limited, and current Clinical Practice Guidelines recommend mechanical prophylaxis while leaving chemoprophylaxis to surgeon discretion based on each individual patient's risk profile.[10,11] As a result, empiric practice varies widely, and there is a need to effectively identify patients at high risk for VTE to guide chemoprophylaxis.[12–14]

The primary objective of this study was to identify the prevalence and risk factors independently associated with VTE in the 30-day postoperative period in a large number of patients after TSA over a 10-year period. Secondary objectives of this study were to identify the prevalence and risk factors independently associated with PE and DVT in this population. Our null hypothesis was that there are no identifiable factors associated with VTE in the 30-day postoperative period after TSA.

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