Do shoulder surgeries require prophylactic anticoagulation (blood thinning medication)?

From the Guidelines

Prophylactic anticoagulation is generally not required for most shoulder surgeries in patients without risk factors for venous thromboembolism (VTE). The overall risk of VTE in shoulder procedures is relatively low compared to lower extremity surgeries, as noted in the guidelines for orthopedic surgery patients 1. However, certain higher-risk patients may benefit from prophylaxis, including those with a history of previous VTE, known thrombophilia, active cancer, significant immobility, or multiple risk factors.

When anticoagulation is deemed necessary, common regimens include low molecular weight heparin (such as enoxaparin 40mg subcutaneously once daily), aspirin (81-325mg daily), or direct oral anticoagulants (like rivaroxaban 10mg daily) 1. The choice of thromboprophylaxis should be guided by its relative effectiveness, propensity to cause major bleeding, and challenges with logistics and expected compliance, as outlined in the American College of Chest Physicians evidence-based clinical practice guidelines 1.

Some key points to consider in the decision-making process include:

• The risk of VTE in shoulder procedures is relatively low
• Certain patient populations may be at higher risk and benefit from prophylaxis
• The choice of anticoagulant should balance the risk of bleeding complications against the risk of thrombosis
• Prophylaxis typically continues until the patient regains normal mobility, often 2-6 weeks depending on the specific procedure and recovery.

It's also important to consider the recommendations for thromboprophylaxis in various risk groups, as outlined in the guidelines for nonorthopedic surgical patients 1. These guidelines provide a framework for assessing the risk of VTE and major bleeding complications, and selecting the most appropriate prophylactic strategy. The decision to use prophylaxis should be individualized based on the patient's specific risk factors and clinical circumstances.

From the Research

Shoulder Surgeries and Prophylactic Anticoagulation

• The need for prophylactic anticoagulation in shoulder surgeries is a topic of discussion, with various studies providing insights into the risk of venous thromboembolism (VTE) and the effectiveness of different prophylactic measures 2, 3, 4.
• A study published in the Mayo Clinic proceedings in 2020 recommends that patients undergo thrombosis- and bleeding-risk assessment as part of their preoperative evaluation, and that the risk of thrombosis can be estimated based on patient- and procedure-specific factors using validated risk-assessment models such as the Caprini score 2.
• Another study published in Thrombosis research in 2014 found that the incidence of symptomatic VTE after shoulder surgery is low, and that the potential need for thromboprophylaxis should be based on a case-by-case evaluation 3.
• A study published in the Journal of shoulder and elbow surgery in 2015 found that VTE rates after shoulder arthroplasty were generally lower than those after lower extremity arthroplasty, and that the risk of bleeding combined with the lower rates of VTE does not warrant the routine use of anticoagulation 4.
• The use of mechanical prophylaxis combined with aspirin may be sufficient for shoulder arthroplasty patients who are not at increased risk of VTE, while chemoprophylaxis with agents other than aspirin may be warranted in patients with a demonstrated risk of VTE 4.
• A study published in the Journal of shoulder and elbow surgery in 2020 found that therapeutic postoperative anticoagulation is a risk factor for wound complications, infection, and revision after shoulder arthroplasty, highlighting the need for careful consideration of the risks and benefits of anticoagulation in these patients 5.

Risk Factors for VTE

• Patient factors that are associated with an increased risk of VTE include a principal diagnosis of fracture, history of VTE, cardiac arrhythmia, presence of a metastatic tumor, coagulopathy, congestive heart failure, alcohol abuse, and obesity 4.
• Duration of surgery >60 minutes was found to be an independent risk factor for VTE in a study published in Thrombosis research in 2014 3.

Prophylactic Measures

• Mechanical prophylaxis, such as graduated compression stockings, can be effective in preventing VTE, especially when combined with pharmacological prophylaxis 6.
• Pharmacological prophylaxis, such as low molecular weight heparin, can be effective in preventing VTE, but may increase the risk of bleeding complications 6.
• Aspirin may be a suitable alternative to anticoagulation for patients at low risk of VTE, especially when combined with mechanical prophylaxis 4.