Venous thromboembolism following elbow,wrist and hand surgery: a review of the literature and prophylaxis guidelines

Introduction

Venous thromboembolism (VTE), encompassing both deep vein thrombosis (DVT) and pulmonary embolism (PE), is an important cause of both morbidity and mortality following major surgical procedures. The treatment of non-fatal symptomatic VTE and related long-term morbidities is associated with a considerable cost to health services. Most epidemiological and prevention data in orthopaedic surgery have been accumulated from studies of patients undergoing hip and knee arthroplasty. The risk of VTE after lower limb major surgery is considerably higher than elbow, wrist and hand surgery.

Guidelines are generally accepted as a means of ensuring thromboprophylaxis is given to those that may benefit, without incurring disproportionate risk or expense (Warwick et al. 2008). There appears to be very little guidance for hand surgeons. Advice for lower limb surgery could lead to unjustified expense and unnecessary risk of side-effects when translated to the upper limb.

We present a review of the literature quantifying the rate of VTE after elbow, wrist and hand surgery, together with a critique and comparison of thromboprophylaxis guidelines.

Methods

We examined the electronic databases Medline, EMBASE, Cochrane database and CINAHL with no date restriction. We used the following keywords or phrases: deep vein thrombosis; pulmonary embolism; venous thromboembolism; upper limb orthop(a)edic; upper limb plastic; elbow surgery; wrist surgery; hand surgery. The titles and abstracts in English or English translations via the database were downloaded and analysed. All case reports, review articles, outcome studies and trials in relation to VTE following elbow, wrist and hand (elective and trauma) surgery were selected and the full text was examined in further detail. The references cited within the selected articles were examined for any further relevant articles.

The existence of guidelines was derived from the senior author’s work elsewhere in the field of VTE as well as internet search engine results incorporating a variety of regions across the globe. Nine guidelines were reviewed from Europe, North America and Australasia relating to the prevention of VTE. The British Society for Surgery of the Hand (BSSH, 2011); National Institute for Health and Clinical Excellence (NICE, 2010); Scottish Intercollegiate Guidelines Network (SIGN, 2010); International Consensus Statement (ICS) (Nicolaides et al., 2006); American College of Chest Physicians (ACCP) (Falck-Ytter et al., 2012); American Academy of Orthopaedic Surgeons (AAOS, 2011); Institute for Clinical Systems Improvement (ICSI, 2011); National Health and Medical Research Council (NHMRC, 2009); and The Australia and New Zealand Working Party (ANZWP, 2007).

Results

Literature review

We found 737 cited articles within the four databases we searched (Medline 554; EMBASE 145; CINAHL 32; Cochrane 6). We removed duplicates, citations regarding VTE following surgically and conservatively managed shoulder complaints, which is out of the remit for this review, and any other studies that were irrelevant to upper limb surgery. Only four articles were included. In one there were three occurrences of VTE (Duncan et al., 2007), a second highlighted four occurrences (Krenek et al., 2011) and the remaining two identified single occurrences (Basat et al., 2011; Jupiter et al., 2002). The relevant anatomic sites are shown in Table 1.

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Table 1.

Literature search results per region

Anatomical region	Articles	VTE
Elbow	2	7
Forearm	1	1
Wrist	1	1
Hand	0	0
Total	4	9

VTE, venous thromboembolism.

Elbow

In a case series from the Mayo clinic, three PEs (one fatal) occurred after 1076 total elbow arthroplasties equating to an incidence of 0.28% (Duncan et al., 2007). Standard mechanical prophylaxis was used (intermittent calf compression device and graduated compression stockings). One patient who had a PE underwent four-limb ultrasound surveillance, which found no evidence of upper or lower limb DVT. This suggests a pelvic DVT possibly as a consequence of immobility during the procedure.

A more recent outcome study from the University of California, Los Angeles (UCLA) had comparable rates with four PEs (two fatal) after 1625 total elbow arthroplasties (0.25%) (Krenek et al., 2011). No details were given regarding associated upper or lower limb DVT nor information about the methods of thromboprophylaxis that were used.

Forearm, wrist and hand

One non-fatal PE occurred after distal radius fixation following an acute fracture (Jupiter et al., 2002). There is no mention of the site of origin (upper or lower limb DVT), nor details regarding the use of mechanical prophylaxis in the operating room; however there had been abdominal surgery 14 days prior to this procedure. This would have independently increased the susceptibility of VTE.

There has also been one report of a non-fatal PE with an associated asymptomatic upper limb DVT following revision osteosynthesis of the proximal diaphysis of the ulna (Basat et al., 2011). This article included no details of the use of prophylaxis; the procedure took 110 minutes.

There have been no reports of VTE following elective or trauma hand and wrist surgery, nor any report of VTE following upper limb orthopaedic or plastic surgery under local or awake regional anaesthesia. None of the above articles recorded the precise anaesthesia used.

Guidelines

The recommendations from the available guidelines are listed below in order of region and year of publication, and in full as written in the individual guidelines. Table 2 gives a summary of these recommendations.

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Table 2.

Summary of guideline recommendations

Guideline	Recommendation	Caveat
NICE	Do not routinely offer VTE prophylaxis	Consider mechanical and pharmacological methods if at increased risk
SIGN	Nil	Assessment of bleeding and thrombosis risk
BSSH	No risk – no prophylaxis Low/moderate risk – mechanical Higher risk – mechanical and consider pharmacological
ACCP	Nil
AAOS	Nil
ICSI	Nil
ICS	Nil
NHMRC	Nil
ANZWP	Nil	Requirement for prophylaxis dependent on any additional risk factors

NICE, National Institute for Health and Clinical Excellence; VTE, venous thromboembolism; SIGN, Scottish Intercollegiate Guidelines Network; BSSH, British Society for Surgery of the Hand; ACCP, American College of Chest Physicians; AAOS, American Academy of Orthopaedic Surgeons; ICSI, Institute for Clinical Systems Improvement; ICS, International Consensus Statement; NHMRC, National Health and Medical Research Council; ANZWP, The Australia and New Zealand Working Party.

Discussion

The literature suggests that the frequency of VTE following hand, wrist and elbow surgery is extremely low. Only nine cases have been reported; all were PE with no occurrences of upper or lower limb symptomatic DVT as a primary diagnosis. Seven of these nine VTE events were secondary to total elbow arthroplasty (three fatal) having an overall incidence of fatal PE of 0.11% and non-fatal PE of 0.15%. This is lower than the 0.34% and 1.20% frequency seen after hip replacement (Warwick et al., 1995). The Scottish Arthroplasty Project identified a fatal PE rate of 0.22% following 44,785 hip replacements (Howie et al., 2005). As a control group, this same study determined a fatal PE rate of 0.12% at one year after cataract surgery having a comparable rate following total elbow arthroplasty as determined from this review.

Chemical prophylaxis carries the risk of complications. Since the overall rate of complications following total elbow arthroplasty is much higher than other joint replacements, especially wound problems and infection (Kim et al., 2011; Voloshin et al., 2011), this may increase further if chemical thromboprophylaxis were to be used. Only those with a particularly high risk of VTE are likely to benefit from chemical prophylaxis; however the published rate of PE would probably justify routine mechanical prophylaxis for elbow arthroplasty.

The length of immobilization is an independent risk factor for lower limb VTE (Heit et al., 2001). According to the NICE guidelines, a patient is at a potentially increased risk of VTE during upper limb surgery if the total anaesthetic and surgical time is greater than 90 minutes. In this situation it is deemed appropriate to use intra-operative mechanical thromboprophylaxis, ongoing if immobility continues postoperatively. This may be pertinent, for example, in cases of complex elbow trauma or when iliac crest grafting is needed.

The use of regional anaesthesia has been shown to reduce significantly the incidence of DVT following hip fracture surgery (Urwin et al., 2000), but owing to the low incidence of VTE following upper limb surgery it is not possible to extrapolate these data. The articles examined in this review did not specify the method of anaesthesia and therefore the length of intra-operative and/or postoperative immobility may be a more significant risk factor.

The prevalence of asymptomatic DVT and PE following elbow, wrist and hand surgery is unknown because there are no relevant studies with routine screening. The only reasonably comparable information is a screening study following shoulder arthroplasty. Willis et al., (2009) identified a DVT rate of 13% in the postoperative period using routine four-limb Doppler ultrasound surveillance for all patients. Over half of these were in the lower limb. This rate is comparable to hip arthroplasty studies (Liebermann and Geerts, 1994; Sudo et al., 2003). It would suggest that asymptomatic upper and lower limb DVTs occur quite frequently following relatively prolonged shoulder surgery. However, it may be that shoulder surgery increases the risk of VTE owing to manipulation of the axillary–brachial vein during joint dislocation and systemic release of thromboplastins during reaming and implant insertion. If so, rates from shoulder surgery should not be extrapolated to elbow, wrist and hand surgery.

The limitation of this review is that it is not possible to identify accurately the true rate of VTE following elbow, wrist and hand surgery. This would rely on surgeons reporting complications and therefore the literature almost certainly underestimates the true incidence. The study only looked at databases that search for articles written in the English language and not all non-English language articles. It was therefore not possible to identify the true incidence in the worldwide literature.

Upper limb DVT accounts for 0.15% of hospitalized patients (Mustafa et al., 2003) and for 1–4% of the total DVT rate (Sajid et al., 2007). Several studies have analysed the risk factors and different aetiologies of upper limb DVT and orthopaedic or plastic upper limb surgery was not deemed a risk factor (Joffe et al., 2004; Kommareddy et al., 2002; Lee et al., 2012; Martinelli et al., 2004; Mustafa et al., 2003; Sajid et al., 2007). These DVTs generally relate to malignancy, indwelling venous catheter, proximal venous occlusion or thrombophilia. A previous review examining solely upper limb DVT rates following all types of orthopaedic surgery (including spinal surgery) found no occurrences after orthopaedic elbow, wrist and hand surgery (Smith et al., 2011). Our review has found only one case of a confirmed asymptomatic upper limb DVT that was detected following investigation after a PE occurred secondarily to proximal ulna fixation (Basat et al., 2011). No cases of isolated symptomatic upper limb DVT after hand, wrist or elbow surgery have been identified.

Recommendations

Surgeons operating on the elbow, wrist and hand should realize that VTE is rare but is a possibility after major elbow surgery and major forearm reconstruction.

The guidelines written by BSSH are the most comprehensive, but have not been published in the literature. This article aims to present the literature base and rationale on which these guidelines were prepared, since the senior author of this article was engaged by the BSSH to prepare their guidelines. The published guidelines from Europe, North America and Australasia do not include specific stratification for the use of thromboprophylaxis in forearm surgery and indeed most do not even allude to this surgical sub-speciality.

We recommend that risk factors should be sought for those having prolonged elbow and osseous forearm surgery because of the potential for VTE suggested by the literature (Table 3). For the small subgroup deemed to be at risk, prophylaxis is recommended (Table 4). For those patients undergoing short-duration elbow, wrist and hand soft tissue surgery using local or regional anaesthesia, risk assessment is not required given the negligible risk of VTE. Formal exclusion of such cohorts from routine risk assessment would save unnecessary assessment time.

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Table 3.

Risk factors for VTE

Risk factors
• Active cancer or cancer treatment
• Age over 60 years
• Critical care admission
• Dehydration
• Known thrombophilias
• Obesity (body mass index [BMI] over 30 kg/m2)
• One or more significant medical co-morbidities (for example: heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions)
• Personal history or first-degree relative with a history of VTE
• Use of hormone replacement therapy
• Use of oestrogen-containing contraceptive therapy
• Varicose veins with phlebitis

VTE, venous thromboembolism.

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Table 4.

Recommendation for prophylaxis in hand, wrist and elbow orthopaedic surgery

Risk	Example	Recommendation
Low	LA, regional anaesthesia or <90 minutes GA	No prophylaxis
Moderate	>90 minutes GA (including elbow arthroplasty) and/or 1 risk factor	Mechanical prophylaxis until mobile
High	>90 minutes GA and >1 risk factor, prolonged postoperative immobility or tumour surgery	Mechanical prophylaxis and consider pharmacological prophylaxis until mobile

LA, local anaesthesia; GA, general anaesthesia.