What is the recommended prophylaxis for Deep Vein Thrombosis (DVT) in patients undergoing shoulder orthopedic surgery?

DVT Prophylaxis Following Shoulder Orthopedic Surgery

For patients undergoing shoulder orthopedic surgery, mechanical prophylaxis with intermittent pneumatic compression devices (IPCD) is recommended as the primary method of DVT prophylaxis, with pharmacological prophylaxis reserved for patients with additional risk factors. 1

Risk Assessment for Shoulder Surgery

The risk of symptomatic venous thromboembolism (VTE) following shoulder surgery is relatively low compared to other orthopedic procedures:

• Symptomatic DVT: 0.26%
• Symptomatic PE: 0.17%
• Combined VTE prevalence: 0.43% 1

This is significantly lower than the 40-60% risk of asymptomatic VTE reported in major orthopedic surgeries without prophylaxis 2.

Prophylaxis Recommendations

First-line Approach

• Mechanical prophylaxis: Intermittent pneumatic compression devices (IPCD) during hospitalization 2, 1
  • Target: 18 hours of daily compliance
  • Portable, battery-powered IPCDs with wear-time recording capability are preferred 2
  • Early mobilization should be encouraged when appropriate

For Patients with Additional Risk Factors

Consider adding pharmacological prophylaxis for patients with:

• Previous VTE history
• Active cancer
• Prolonged immobility
• Advanced age
• Obesity
• Known thrombophilia

Pharmacological Options (when indicated)

In order of preference:

1. Low molecular weight heparin (LMWH) - preferred agent 2
2. Apixaban or dabigatran (Grade 1B) 2
3. Rivaroxaban or adjusted-dose vitamin K antagonists (if options 1-2 unavailable) 2
4. Fondaparinux (if other options contraindicated) 2, 3

Duration of Prophylaxis

• For standard shoulder procedures without additional risk factors:

  • Mechanical prophylaxis during hospitalization
  • Early mobilization

• For patients with additional risk factors receiving pharmacological prophylaxis:

  • Minimum duration: 10-14 days post-surgery 2, 4
  • Extended prophylaxis (up to 35 days) may be considered for very high-risk patients 2

Important Considerations and Pitfalls

• Avoid routine pharmacological prophylaxis for all shoulder surgery patients, as the risk of bleeding may outweigh the benefit in low-risk cases 1

• Risk-benefit assessment is crucial: While the American College of Chest Physicians recommends LMWH as the preferred agent for orthopedic surgery in general, this recommendation must be balanced against the relatively low VTE risk in shoulder surgery specifically 2, 1

• Mechanical prophylaxis compliance is essential - ensure proper application and patient education on the importance of consistent use 2

• Monitor for signs of VTE during follow-up visits, as some events may occur after hospital discharge 5

• Consider individual patient factors that may increase bleeding risk when deciding on pharmacological prophylaxis

Special Situations

• For shoulder arthroplasty (particularly reverse shoulder replacement), which carries a higher VTE risk than arthroscopic procedures, consider more aggressive prophylaxis approaches 1

• For prolonged procedures or complex reconstructions, the threshold for adding pharmacological prophylaxis should be lower 1