Differences in the use of post-operative DVT prophylactic medications in TKA and THA patients vs. shoulder arthroscopy rotator cuff tear repair patients

 Lower extremity joint surgeries, such as a total hip arthroplasty (THA) or total knee arthroplasty (TKA), are considered safe but carry a higher risk than arthroscopic rotator cuff tear repairs. 

One reason THAs and TKAs are riskier than shoulder arthroscopy with rotator cuff tear repairs is the potential for postoperative venous thromboembolism (VTE), such as deep vein thrombosis (DVT) or pulmonary embolism (PE). For this reason, post-operative lower extremity joint replacement protocols are designed to mitigate the risk of these events. This is often mitigated by DVT prophylaxis medication, such as antiplatelet medications like Aspirin or Factor Xa inhibitors like apixaban (Eliquis) or enoxaparin (Lovenox) for 2-4 weeks after surgery. Aspirin acts as an antiplatelet medication by irreversibly inhibiting cyclooxygenase-1, which is upstream of thromboxane A2, a promoter of platelet aggregation. Factor Xa inhibitors act as anticoagulants by directly inhibiting Factor Xa in the common pathway of the coagulation cascade, thereby preventing the downstream formation of clots.

The use of post-operative DVT prophylactic medications in THAs and TKAs is globally accepted. However, the use of DVT prophylactic medications after shoulder arthroscopy with rotator cuff tear repairs is not universally agreed upon by orthopedic surgeons. Some surgeons do, and some surgeons do not. Common discussion of this has centered on conflicting results in the published literature. 

In a systematic review by Li et al., 42 articles were included, and the overall incidence of VTEs after arthroscopic shoulder surgery was 0.26%. They identified that possible risk factors of having a VTE were patients who were older than 70 years of age, obesity (BMI ≥ 30 kg/m2), diabetes mellitus, thrombophilia, history of VTE, prolonged operation time, hormone use, and immobilization after surgery. When the authors examined the efficacy of DVT prophylaxis with medications, none of the studies reported statistically significant results. From this, the authors concluded that there was no evidence that DVT prophylaxis with medications provided any benefits.

Based on this review of a large body of published articles, it’s reasonable not to include anticoagulation

medication as the DVT prophylaxis method in post-operative care for patients undergoing arthroscopic

shoulder surgery. In accordance with the biomedical ethics principle of nonmaleficence, it's important

not to require patients to take a medication that carries risks when it is not beneficial. Furthermore,

many of these medications can be very expensive and require significant out-of-pocket payments even

with insurance coverage.

References: 

Li, T., Li, Y., Zhang, L., Pang, L., Tang, X., & Zhu, J. (2023). Venous thromboembolism after arthroscopic shoulder surgery: A systematic review. Journal of Orthopaedic Surgery and Research, 18, 103. https://doi.org/10.1186/s13018-023-03592-0