Symptomatic Venous Thromboembolism after Shoulder Arthroscopy
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1 Symptomatic Venous Thromboembolism after Shoulder Arthroscopy Diane Thi Tran, MD Sports Medicine Fellow, TRIA Orthopaedic Center Jonathan P. Braman, MD Associate Professor, Department of Orthopaedic Surgery, University of Minnesota TRIA Orthopaedic & Sports Medicine Conference: Tackling Football Injuries June 06, 2015
2 Objectives of the presentation 1. State the incidence of venous thromboembolism (VTE) after arthroscopic shoulder surgery. 2. Identify risk factors that may be associated with symptomatic venous thromboembolism after arthroscopic shoulder surgery. No disclosures
3 Objectives of the presentation 1. State the incidence of venous thromboembolism (VTE) after arthroscopic shoulder surgery. 2. Identify risk factors that may be associated with symptomatic venous thromboembolism after arthroscopic shoulder surgery. No disclosures
4 VTE after shoulder arthroscopy Standard guidelines are lacking
5 VTE after shoulder arthroscopy Standard guidelines are lacking 10% of lower extremity DVT Pulmonary embolus
6 VTE after shoulder arthroscopy Standard guidelines are lacking 10% of lower extremity DVT 17-36% of upper extremity DVT Pulmonary embolus
7 VTE after shoulder arthroscopy Standard guidelines are lacking 10% of lower extremity DVT 17-36% of upper extremity DVT Pulmonary embolus Mortality of acute PE 30%
8 VTE after shoulder arthroscopy Standard guidelines are lacking 10% of lower extremity DVT 17-36% of upper extremity DVT Pulmonary embolus Mortality of acute PE treatment 30% 2-8%
9 Incidence of VTE Literature Upper extremity surgery - VTE 0.01% to 13%
10 Incidence of VTE Literature Upper extremity surgery - VTE 0.01% to 13% Shoulder arthroscopy - VTE 0% to 0.65%
11 Incidence of VTE Literature Upper extremity surgery - VTE 0.01% to 13% Shoulder arthroscopy - VTE 0% to 0.65% Shoulder arthroscopy PE 0% to 0.65%
12 Incidence of VTE Literature Upper extremity surgery - VTE 0.01% to 13% TRIA Shoulder arthroscopy - VTE 0% to 0.65%? Shoulder arthroscopy PE 0% to 0.65%? What is the incidence at TRIA Orthopaedic Center?
13 Objective The objective of this study was to determine the incidence of and risk factors for symptomatic VTE following shoulder arthroscopy at TRIA Orthopaedic Center
14 Hypotheses We hypothesize that: 1. The incidence of symptomatic VTE at this institution is much higher than currently reported in the literature. 2. Increased incidence over time is due to increased utilization of diagnostic imaging studies over time because of clinicians heightened indexes of suspicion.
15 Hypotheses We hypothesize that: 1. The incidence of symptomatic VTE at this institution is much higher than currently reported in the literature. 2. Increased incidence over time is due to increased utilization of diagnostic imaging studies over time because of clinicians heightened indexes of suspicion.
16 Methods Retrospective chart review Arthroscopic shoulder surgery at TRIA Orthopaedic Center July 2011 to December 2014
17 Methods Retrospective chart review Arthroscopic shoulder surgery at TRIA Orthopaedic Center July 2011 to December 2014 Imaging Doppler: upper and lower extremity DVT Chest CT PE
18 Methods Retrospective chart review Arthroscopic shoulder surgery at TRIA Orthopaedic Center July 2011 to December 2014 Imaging Doppler: upper and lower extremity DVT Chest CT PE Postoperative time period: 90 days
19 Methods Retrospective chart review Arthroscopic shoulder surgery at TRIA Orthopaedic Center July 2011 to December 2014 Imaging Doppler: upper and lower extremity DVT Chest CT PE Postoperative time period: 90 days Risk factors: patient and surgical VTE factors
20 Number of cases performed
21 Number of cases performed Total number of cases performed = 2408
22 Number of imaging performed within 90 days
23 Number of imaging performed within 90 days Total number of imaging performed within 90 days = 33
24 Number of imaging performed within 90 days 10 CT-A LE UE Total number of imaging performed within 90 days = 33
25 Number of cases with VTE within 90 days Total number of cases with VTE within 90 days = 4 Incidence of VTE within 90 days = 0.17%
26 Number of cases with VTE within 90 days 3 PE LE DVT UE DVT Total number of cases with VTE within 90 days = 4 Incidence of PE within 90 days = 0.17%
27 Patient Demographics, n = 4 Age Average 57.8 years Range Gender 2 females 2 males BMI Average Range Relevant PMHx 1 of 4 (inflammatory condition) Relevant Meds 0% PMHx of VTE 0% FHx of hereditary thrombophilia 0% FHx of VTE 75% Tobacco use 0%
28 Surgical factors Laterality 3 right 1 left Anesthesia 4 regional (+1 general) ASA Average 1.75 Range 1 2 Positioning 3 beach chair 1 lateral with traction Surgical time Average min Range
29 Surgical factors Sling Average 6 weeks Range 4 8 weeks Sedentary postop 3 of 4 Chemoprophylaxis postop 1 of 4 (ASA Plavix)
30 Discussion
31 Incidence of VTE Literature Upper extremity surgery - VTE 0.01% to 13% TRIA Shoulder arthroscopy - VTE 0% to 0.65% 0.17% Shoulder arthroscopy PE 0% to 0.65% 0.17%
32 Number of imaging performed within 90 days 10 CT-A LE UE Total number of imaging performed within 90 days = 33
33 Limitations
34 Limitations Short time span Expand to 5-10 years
35 Limitations Short time span Expand to 5-10 years Outpatient surgery center bias Expand to include other institutions
36 Limitations Short time span Expand to 5-10 years Outpatient surgery center bias Expand to include other institutions Imaging performed elsewhere Expand to include other hospital systems
37 Limitations Short time span Expand to 5-10 years Outpatient surgery center bias Expand to include other institutions Imaging performed elsewhere Expand to include other hospital systems Limited cohort Expand to evaluate all patients
38 Conclusions While VTE after shoulder arthroscopy is unusual, VTE remains an important complication with potentially fatal consequences Further studies are needed for evidence-based prevention of VTE after shoulder arthroscopy
39 Thank you If we knew what it was we were doing, it would not be called research, would it? -- Albert Einstein
40 Year Author Journal Type of study N = Incidence VTE Incidence PE 2007 Brislin Arthroscopy Retrospective cohort % 0.00% 2008 Hoxie IntJShoulderSurg Retrospective cohort 309 N/A 0.65% 2008 Kuremsky % 0.07% 2009 Bongiovanni CORR Case report and retrospective report % 0.00% 2010 Garofalo BMCMskDo Retrospective review % 0.01% 2010 Randelli JSES Survey of surgeons % 0.01% 2011 Jameson JSES English registry % 0.01% 2011 Kuremsky Arthroscopy Retrospective cohort % 0.21% 2011 Ojike ActaOrthopBelg Retrospective review % 0.02% 2013 Dattani BJJ Retrospective review % 0.02% 2014 Hastie JSES Retrospective cohort % 0.21% 2014 Imberti Thrombosis Res Prospective multicenter Italian registry % 0.10% 2014 Takahashi JSES Prospective cohort 175 0% 0%
41 Incidence of VTE Type of surgery VTE PE THA/TKA 10-67% Knee arthroscopy % Upper extremity % % Shoulder arthroplasty % 0.2-3% Shoulder arthroscopy % %
42 Average age
43 Surgical factors Rotator cuff repair 4 Subacromial decompression 4 Biceps tenotomy 2 Arthroscopic biceps tenodesis 1 Open biceps tenodesis 1 Extensive debridement 1 Distal clavicle excision 3 Synovial biopsy 1
44 VTE factors Days after surgery Average 8.5 days Range 2 21 PE 4 LE DVT 2 (contralateral) UE DVT 1 (ipsilateral) Treatment Full-dose anticoagulant 3-6 months Hematology workup 2 Not found to have hereditary thrombophilia
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COPYRIGHT Ó BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED ACEVEDO ET AL. ASURVEY OF EXPERT OPINION REGARDING ROTATOR CUFF REPAIR
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