Venous thromboembolism after arthroscopic shoulder surgery: a systematic review

Frequent shoulder dysfunction is the third cause of musculoskeletal consultations in primary health care [1]. The majority of shoulder dysfunction is caused by trauma and degenerative diseases such as arthritis, rotator cuff (RC) injuries and shoulder instabilities [2‐5]. For most of those who need surgical therapy, arthroscopic surgery can be a good option since it allows for less trauma to the deltoid, less risk of axillary nerve palsy, less immediate postoperative pain, decreased operation time and better cosmetic results [6, 7]. Besides, recent studies of multi-institutional outcome databases reported low overall rates of complications (1.0–1.6%) and low infection rates after arthroscopic shoulder surgery [8, 9].

With these advantages, the use of the arthroscopic shoulder surgery has expanded greatly [10, 11]. However, despite the application of arthroscopy, venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is still known to be a serious, sometimes even life-threatening, complications following elective upper extremity surgeries [12]. Approximately 20–50% of VTE patients suffered post-thrombotic syndrome, which is detrimental to their quality of life due to chronic hyperpigmentation, edema, pruritus, pain, and ulceration [13].

To reduce and even eliminate the occurrence of VTE, identifying the risk factors is very crucial [14]. Some studies pointed out that comorbidities associated with greater VTE risk include advanced age (≥ 70 years), VTE history, BMI > 40, diabetes mellitus (insulin-dependent and non-insulin-dependent), chronic lung disease and Charlson Comorbidity Index (CCI) ≥ 1 [15‐22]. However, little information regarding the risk factors and implementation of preventive measures for VTE after arthroscopic shoulder surgeries have been reported. Therefore, the decision to provide prophylaxis to this population of patients remains subject to the surgeons’ discretion and personal experience. Following an extensive literature search, this systematic review aims to summarize the incidence, risk factors, diagnosis methods, preventive measures and management of VTE after arthroscopic shoulder surgeries and detect the efficacy of chemoprophylaxis in these cases. The hypothesis was that the risk factors for VTE after arthroscopic shoulder surgeries were similar to those mentioned above and the chemoprophylaxis was unnecessary in these cases.

To our knowledge, systematic reviews focusing on VTE after arthroscopic shoulder surgeries only are rare, and this study has the largest sample size. Dattani et al. conducted a systematic review to assess the risk factors for and incidence of VTE complications following shoulder and elbow surgeries [66]. However, they discussed not only arthroscopic shoulder surgeries but also open surgeries. Greene et al. focused on thromboembolic complications in arthroscopic surgeries, but the knee instead of the shoulder surgeries was their primary focus [67]. Researchers have illustrated that VTE was rare after shoulder surgery, and it is even fewer after arthroscopic shoulder surgeries than after shoulder arthroplasty [12, 68]. According to this systematic review, there is a large amount of variability in the incidence of VTE after arthroscopic shoulder surgeries reported in the literature, which ranged from 0 to 5.71% [24‐41]. The lowest incidence value was shown in a retrospective study, which represented the occurrence of VTE events in anticoagulated patients [33]. The highest incidence value was reported from a prospective cohort study in which 10 asymptomatic VTE events were detected by ultrasound [24]. With 10 large-sample database-dependent studies included, the overall rate of 0.26% is relatively credible [25, 28‐32, 35, 37, 38, 41]. This incidence rate demonstrates that the VTE risk for most patients undergoing arthroscopic shoulder surgeries is low. However, surgeons should still be aware of the serious complications in patients after arthroscopic shoulder surgeries due to its potentially fatal risks.

Multiple risk factors are mentioned in the included studies, and the surgery itself elevates the risk of VTE as well. DVT in upper limbs is in majority (60.5%) in this systematic review, while DVT in lower extremities is more common in all patients [69]. A possible theory is that the surgery position may lead to the twisting and stretching of the veins in upper extremities, but it is lacking for validation.

Searching for the risk factors was one of the main focuses of this systematic review. According to previous studies, the risk factors for VTE include advanced age (> 70 years), obesity (BMI ≥ 30 kg/m²), diabetes mellitus, thrombophilia, history of VTE, prolonged operation time, hormone use and immobilization after surgery [70]. However, very few studies have attempted to detect the risk factors in patients undergoing arthroscopic shoulder surgeries. Due to the lack of prospective studies, relatively low incidence and conflicting conclusions from different studies, it is difficult to clearly identify and define every certain risk factor. There are several assessment tools to evaluate the VTE risk of patients, but there are also a few articles that dispute them [71]. Establishing a suitable risk assessment tool is one of the goals of future research.

For surgeons, it is obvious that most of the risk factors such as age and existing comorbidities are not controllable, making primary prevention interventions difficult to implement. Based on the existing evidence, the most effective way to reduce the damage of VTE to patients is to evaluate the patients’ risk levels in detail and take corresponding preventive measures for high-risk patients. The education of patients is also very important. The patients should give an explanation of the relevant risks so that they will be able to seek immediate medical attention when they have symptoms of VTE.

In doing this systematic review, we did find that VTE prophylaxis was not provided to most patients. The reasons may be the rarity of the conditions and the fear of bleeding complications. When applied, the prophylaxis was mainly mechanical since they represent the reasonable, safe, and cost-effective option for most patients [68]. Rapp et al. [12] recommended that the efficacious and low-risk mechanical preventions should be used in all patients when feasible. Chemoprophylaxis was used in 5 studies and no bleeding complication was reported, so it seems that hemorrhage is not a concern [42, 45, 55, 56, 64]. However, the efficacy of chemical prophylaxis is doubtable based on this systematic review. A retrospective case–control study conducted by Alyea et al. [42] suggested that the addition of aspirin chemoprophylaxis does not provide protective effect of reducing the incidence of VTE. Schick et al. [41] stated that postoperative anticoagulation use did not show significant influence on VTE development following shoulder arthroscopy. Previous studies and the guidelines in America and Europe did not recommend routine use of chemoprophylaxis in patients undergoing arthroscopic shoulder surgeries unless the patients were assessed to be high risk [12, 70, 72, 73]. Based on the above information, the preferred prevention method we recommend is mechanical prophylaxis, which provides the limb with intermittent pressure, and this can be a routine. The specific method can be selected according to the actual situations of the hospitals and the patients. For high-risk patients, we recommend using DOACs for prophylaxis besides the adoption of mechanical methods [73].

Though the therapeutic regimens varied from study to study, most cases used heparinization followed by oral warfarin, which is different from the recommendations given by the guideline of the American Society of Hematology [74]. In the guideline, DOACs instead of vitamin K antagonists (VKAs) are the first choice for patients with DVT or/and PE if there is not a hemodynamic compromise. This inconsistency can be explained by the time gap between the literature we reviewed, which include studies conducted before September, 2021, and the publishment of the guideline published in 2020. A proof is that cases reported by Ji et al. [65] in 2021 were treated with rivaroxaban or rivaroxaban combined with low molecular weight heparin and the outcomes were good. Therefore, we still recommend following the guideline unless it is proved to be incorrect by further research.

There are several limitations of this study. First, the level of evidence is low since most of the included studies are case reports. However, this is inevitable since there is still a lack of original research with higher level of evidence. Therefore, publication bias as well as other bias was unavoidable. Second, the included studies were inevitably heterogeneous. For these reasons, the conclusion of this systematic review needs to be interpreted with caution. Finally, this study included only the research published in English, so some studies may be missed, whereas this disadvantage did not result in significant bias, given that most high-quality literature around the world is published in English.

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.