J Shoulder Elbow Surg (2015) 24, e141-e143
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CASE REPORTS
Bilateral pulmonary emboli after elective elbow arthroscopy: a case report Michael J. Carroll, MD, FRCSC*, Kevin A. Hildebrand, MD, FRCSC Section of Orthopedic Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada Elbow arthroscopy is an expanding area of upper extremity orthopedic surgery. As the evidence supporting the utility of elbow arthroscopy continues to accumulate, the indications for and complexity of the procedures continue to increase.8,13 Despite this, relatively little has been published on complications related to arthroscopic elbow surgery.5 A recent systematic review of available retrospective case series noted the overall complication rate for arthroscopic procedures involving the elbow to range from 6% to 11%.5 The associated complications include neurovascular injury, compartment syndrome, intra-articular infections, articular cartilage damage, synovial fistula, loss of motion, instrument breakage, and tourniquet-related complications.3,5,8 The work of Dattani et al2 focused on complications of venous thromboembolism (VTE) in shoulder and elbow surgery. They found that 0.25% of elbow arthroplasty is complicated by VTE, but they found no studies reporting on elbow arthroscopy complicated by VTE. A prospective study by Takahashi et al11 found the incidence of clinically asymptomatic deep venous thrombosis (DVT) in patients undergoing shoulder arthroscopy to be 5.7%; no patients in that study were determined to have a symptomatic DVT or pulmonary embolism. In a large retrospective review, the work of Kuremsky and colleagues9 showed the incidence of symptomatic VTE (DVT and pulmonary embolism) after arthroscopic shoulder surgery to be 0.31%. In other areas of orthopedic surgery, particularly hip and knee arthroplasty and lower extremity fracture care, VTE is
*Reprint requests: Michael J. Carroll, MD, FRCSC, Section of Orthopedic Surgery, Department of Surgery, University of Calgary, 3280 Hospital Drive, Calgary, AB T2N 4Z6, Canada. E-mail address: [email protected] (M.J. Carroll).
a well-recognized complication, and evidence-based guidelines are an important element of patient care.6 A symptomatic upper extremity DVT is an uncommon complication; however, it is of significant clinical importance. The diagnosis should raise concern about the risk of progression to pulmonary embolism, mortality, and recurrent thromboembolic events.10 To our knowledge, VTE has not been reported as a complication of arthroscopic elbow surgery. We present a case report of a patient who developed symptomatic bilateral pulmonary emboli after an arthroscopic procedure for elbow osteoarthritis.
Case report A 51-year-old right-hand-dominant man presented to the clinic for evaluation of several years of progressive right elbow discomfort. He complained of pain while carrying groceries as well as when using his arms to rise from a seated position. The patient also noted instances in which the affected elbow would catch or lock and described associated brief spikes in pain intensity. He had a remote history of minor elbow trauma. Past medical history was unremarkable, and he is otherwise healthy. Neither the patient nor his family has a history of venous thromboembolism (VTE). He is a nonsmoker. General physical examination revealed a healthyappearing man with a body mass index of 32. Focused physical examination of the right elbow demonstrated mild tenderness over the olecranon and a decreased arc of motion. He could flex to 100 and exhibited mild discomfort with terminal extension to 30 . Radiographs demonstrated osteophyte formation in the olecranon and coronoid fossae. After unsuccessful nonoperative treatment, the patient
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2015.01.002
e142 consented to arthroscopic debridement and removal of osteophytes. The elbow arthroscopy was performed in the lateral position with the operative arm flexed over a bolster; a tourniquet was placed but not inflated, and standard portals were established. Operative time was 60 minutes, and no intraoperative complications were noted in the operative report. Mechanical or chemical prophylaxis for deep venous thrombosis (DVT) was not used. After the procedure, the patient was brought to the postanesthesia recovery room in stable condition and was discharged home later that day without complication. Seven days postoperatively, the patient developed symptoms of VTE. He was seen in the emergency department of a rural hospital for complaints of shortness of breath and back pain that were exacerbated with deep inspiration. The treating physician ordered computed tomography pulmonary angiography, which identified bilateral pulmonary emboli. An ultrasound examination was not performed to identify the presence and location of the peripheral thrombus. Anticoagulation therapy was initiated and managed by the patient’s family physician. Six months of low-molecular-weight heparin was recommended; further laboratory testing to evaluate for hypercoagulable disorders was not performed. At the last follow-up appointment, the patient had no clinical sequelae of postthrombotic syndrome or radiographic findings indicative of ongoing pulmonary disease. He was satisfied with the result of the arthroscopic procedure and improvement in function of the limb. Elbow range of motion was improved, and he was free of mechanical symptoms.
Discussion Upper extremity venous thrombosis In general, upper extremity DVT may be classified into two types: primary and secondary. Paget-Schroetter syndrome, the primary form, is the less common type. It may occur as a consequence of strenuous activity involving the upper extremity, occur in conjunction with thoracic outlet syndrome, or arise spontaneously in the absence of identifiable risk factors.10 A secondary DVT arises from a known predisposing factor, the more common of which include placement of a central venous catheter, malignant disease, hospitalization, and presence of a hereditary thrombophilic disorder.10
Venous thrombosis in upper extremity surgery The complications associated with shoulder and elbow surgery are well described.2,3,8 However, upper extremity surgery, particularly that about the elbow, is uncommonly complicated by VTE; and in comparison to other
M.J. Carroll, K.A. Hildebrand complications, the incidence is extremely low.2 The true incidence, however, is difficult to define because many of the studies report on heterogeneous populations and are retrospectively designed. A recent prospective study showed the incidence of asymptomatic DVT and pulmonary embolism in 175 patients undergoing shoulder arthroscopy to be 5.7% and 0.57%, respectively.11 The incidence of DVT or pulmonary embolism in arthroscopic elbow surgery has not been quantified in the literature. The senior author (K.A.H.) performs approximately 35 arthroscopic procedures about the elbow per year; this is the first known VTE complication after elbow arthroscopy. A retrospective review of 1076 patients undergoing total elbow arthroplasty reported the prevalence of pulmonary embolus to be 0.25% in the primary and 0.38% in the revision settings.4 However, our literature search did not identify any reports of VTE in association with the (1) treatment of fractures about the elbow or (2) elective arthroscopic elbow surgery.
Risk factors for and etiology of VTE in upper extremity surgery The risk factors for and causes of VTE specific to elective upper extremity surgery have not been clearly identified in the literature. Willis et al12 evaluated 100 patients undergoing shoulder arthroplasty and reported several factors that trended toward significance: increasing age, weight, prolonged operative time, and previous history of VTE. In 2013, a systematic review by Dattani et al2 suggested that diabetes mellitus, rheumatoid arthritis, and ischemic heart disease may also be risk factors for VTE in shoulder surgery. Hoxie et al7 retrospectively reviewed 137 consecutive patients undergoing operative management of proximal humerus fracture and found the incidence of computed tomography-confirmed pulmonary emboli to be approximately 5%. Regarding elbow surgery, we were unable to identify any literature reporting on VTE and elbow fracture care or elbow arthroscopy. On the basis of these studies, our patient with bilateral pulmonary emboli was not at high risk for VTE. The potential risk factors included an elevated body mass index of 32 and an age of 51 years. Whereas these have been cited as potential risk factors for or causes of VTE, we do not know specific body mass index values or ages that stratify increasing risk. There is no literature at present to quantify norms in operative time. In this case report, the patient’s elbow arthroscopy was completed in 60 minutes. It is our opinion that this time frame is within normal limits and should not pose a significant risk. Tourniquet-related soft tissue trauma is a potential concern; however, the patient’s tourniquet was placed but not inflated. A detailed history revealed no previous VTE, hereditary hypercoagulable disorders, or active malignant disease that would also place the patient at increased risk for development of VTE.
Bilateral pulmonary emboli after elbow arthroscopy Kuremsky et al9 reported on 6 patients who developed thromboembolic disease after shoulder arthroscopy. Because all patients diagnosed with VTE underwent arthroscopy in the lateral decubitus position, it was postulated that this may also be a risk factor. In their systematic review of VTE in shoulder arthroscopy, Dattani et al2 also noted a relationship between the lateral decubitus position and likelihood for having the procedure complicated by VTE. The strength of the association between patient positioning and risk of VTE is difficult to determine. Whether surgeons more commonly choose a lateral decubitus over a beach chair position is not accurately known. Takahashi et al11 reported on 175 patients undergoing shoulder arthroscopy in the beach chair position and showed the incidence of DVT and symptomatic pulmonary embolus to be 5.7% and 0.57%, respectively. This highlights the fact that VTE complications are uncommon in the beach chair position but lends little support to the idea that lateral positioning may be implicated. Our patients are routinely placed in the lateral decubitus position with the shoulder abducted and the elbow supported in a flexed position by a bolster. This position may compress the soft tissues immediately proximal to the antecubital fossa and impede venous return. If the thrombus originated in the operative extremity of our patient, this may be a possible explanation. The study by Takahashi et al11 highlights another important point relating to the origin of the thrombus. They reported a differential in location where the incidence of DVT was 0.57% in the upper extremity and 5.1% in the lower extremity. Unfortunately, our patient did not undergo ultrasound examination to identify the precise location of the clot. We do not routinely use intermittent pneumatic compression devices during elective elbow arthroscopy. It is therefore possible that this may also be a contributing factor toward the development of our patient’s VTE. At present, there is no high-level evidence to suggest that upper extremity surgery is an important risk factor in itself for development of VTE. Although the quality of evidence is poor, the literature suggests that the risk is low.1 To our knowledge, at present, there are no evidence-based guidelines for risk stratification or recommendations on prophylaxis against VTE in upper extremity surgery.
Conclusion We present a case report of a patient who developed symptomatic bilateral pulmonary emboli after elective elbow arthroscopy for osteoarthritis. The available literature focuses primarily on shoulder surgery and suggests that VTE is relatively uncommon but an important consideration in these patients. The risk factors for development of VTE in upper extremity surgery have not been clearly identified. At present, there are no previous reports of symptomatic VTE after elbow arthroscopy. The senior author’s practice includes approximately 35
e143 arthroscopic elbow procedures per year; this is the first instance in which a symptomatic DVT or VTE has occurred. This report highlights a rare but potentially serious complication of elbow surgery. It may serve as a reminder to the upper extremity surgeon that VTE is part of the differential diagnosis in the postoperative patient presenting with pleurisy and shortness of breath.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Anakwe RE, Middleton SD, Beresford-Cleary N, McEachan JE, Talwalkar SC. Preventing venous thromboembolism in elective upper limb surgery. J Shoulder Elbow Surg 2013;22:432-8. http://dx.doi.org/ 10.1016/j.jse.2012.10.033 2. Dattani R, Smith CD, Patel VR. The venous thromboembolic complications of shoulder and elbow surgery: a systematic review. Bone Joint J 2013;95-B:70-4. http://dx.doi.org/10.1302/0301-620X.95B1. 29854 3. Dodson CC, Nho SJ, Williams RJ, Altchek DW. Elbow arthroscopy. J Am Acad Orthop Surg 2008;16:574-85. 4. Duncan SFM. Prevalence of pulmonary embolism after total elbow arthroplasty. J Bone Joint Surg Am 2007;89:1452. http://dx.doi.org/10. 2106/JBJS.F.01328 5. El-Gazzar Y, Baker CL, Baker CL. Complications of elbow and wrist arthroscopy. Sports Med Arthrosc 2013;21:80-8. http://dx.doi.org/10. 1097/JSA.0b013e31828b685d 6. Falck-Ytter Y. Prevention of VTE in orthopedic surgery patients. Chest 2012;141(Suppl):e278S. http://dx.doi.org/10.1378/chest.11-2404 7. Hoxie SC, Sperling JW, Cofield RH. Pulmonary embolism after operative treatment of proximal humeral fractures. J Shoulder Elbow Surg 2007;16:782-3. http://dx.doi.org/10.1016/j.jse.2006.12.004 8. Kelly EW, Morrey BF, O’Driscoll SW. Complications of elbow arthroscopy. J Bone Joint Surg Am 2001;83:25-34. 9. Kuremsky MA, Cain EL, Fleischli JE. Thromboembolic phenomena after arthroscopic shoulder surgery. Arthroscopy 2011;27:1614-9. http://dx.doi.org/10.1016/j.arthro.2011.06.026 10. Mai C, Hunt D. Upper-extremity deep venous thrombosis: a review. Am J Med 2011;124:402-7. http://dx.doi.org/10.1016/j.amjmed.2010.11.022 11. Takahashi H, Yamamoto NMP, Nagamoto H, Tanaka M, Itoi E. Venous thromboembolism after elective shoulder surgery: a prospective cohort study of 175 patients. J Shoulder Elbow Surg 2014;23:60512. http://dx.doi.org/10.1016/j.jse.2014.01.054 12. Willis AA, Warren RF, Craig EV, Adler RS, Cordasco FA, Lyman S, et al. Deep vein thrombosis after reconstructive shoulder arthroplasty: a prospective observational study. J Shoulder Elbow Surg 2008:1-7. http://dx.doi.org/10.1016/j.jse.2008.07.011 13. Yeoh KM, King GJW, Faber KJ, Glazebrook MA, Athwal GS. Evidence-based indications for elbow arthroscopy. Arthroscopy 2012;28: 272-82. http://dx.doi.org/10.1016/j.arthro.2011.10.007
www.elsevier.com/locate/ymse
CASE REPORTS
Bilateral pulmonary emboli after elective elbow arthroscopy: a case report Michael J. Carroll, MD, FRCSC*, Kevin A. Hildebrand, MD, FRCSC Section of Orthopedic Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada Elbow arthroscopy is an expanding area of upper extremity orthopedic surgery. As the evidence supporting the utility of elbow arthroscopy continues to accumulate, the indications for and complexity of the procedures continue to increase.8,13 Despite this, relatively little has been published on complications related to arthroscopic elbow surgery.5 A recent systematic review of available retrospective case series noted the overall complication rate for arthroscopic procedures involving the elbow to range from 6% to 11%.5 The associated complications include neurovascular injury, compartment syndrome, intra-articular infections, articular cartilage damage, synovial fistula, loss of motion, instrument breakage, and tourniquet-related complications.3,5,8 The work of Dattani et al2 focused on complications of venous thromboembolism (VTE) in shoulder and elbow surgery. They found that 0.25% of elbow arthroplasty is complicated by VTE, but they found no studies reporting on elbow arthroscopy complicated by VTE. A prospective study by Takahashi et al11 found the incidence of clinically asymptomatic deep venous thrombosis (DVT) in patients undergoing shoulder arthroscopy to be 5.7%; no patients in that study were determined to have a symptomatic DVT or pulmonary embolism. In a large retrospective review, the work of Kuremsky and colleagues9 showed the incidence of symptomatic VTE (DVT and pulmonary embolism) after arthroscopic shoulder surgery to be 0.31%. In other areas of orthopedic surgery, particularly hip and knee arthroplasty and lower extremity fracture care, VTE is
*Reprint requests: Michael J. Carroll, MD, FRCSC, Section of Orthopedic Surgery, Department of Surgery, University of Calgary, 3280 Hospital Drive, Calgary, AB T2N 4Z6, Canada. E-mail address: [email protected] (M.J. Carroll).
a well-recognized complication, and evidence-based guidelines are an important element of patient care.6 A symptomatic upper extremity DVT is an uncommon complication; however, it is of significant clinical importance. The diagnosis should raise concern about the risk of progression to pulmonary embolism, mortality, and recurrent thromboembolic events.10 To our knowledge, VTE has not been reported as a complication of arthroscopic elbow surgery. We present a case report of a patient who developed symptomatic bilateral pulmonary emboli after an arthroscopic procedure for elbow osteoarthritis.
Case report A 51-year-old right-hand-dominant man presented to the clinic for evaluation of several years of progressive right elbow discomfort. He complained of pain while carrying groceries as well as when using his arms to rise from a seated position. The patient also noted instances in which the affected elbow would catch or lock and described associated brief spikes in pain intensity. He had a remote history of minor elbow trauma. Past medical history was unremarkable, and he is otherwise healthy. Neither the patient nor his family has a history of venous thromboembolism (VTE). He is a nonsmoker. General physical examination revealed a healthyappearing man with a body mass index of 32. Focused physical examination of the right elbow demonstrated mild tenderness over the olecranon and a decreased arc of motion. He could flex to 100 and exhibited mild discomfort with terminal extension to 30 . Radiographs demonstrated osteophyte formation in the olecranon and coronoid fossae. After unsuccessful nonoperative treatment, the patient
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2015.01.002
e142 consented to arthroscopic debridement and removal of osteophytes. The elbow arthroscopy was performed in the lateral position with the operative arm flexed over a bolster; a tourniquet was placed but not inflated, and standard portals were established. Operative time was 60 minutes, and no intraoperative complications were noted in the operative report. Mechanical or chemical prophylaxis for deep venous thrombosis (DVT) was not used. After the procedure, the patient was brought to the postanesthesia recovery room in stable condition and was discharged home later that day without complication. Seven days postoperatively, the patient developed symptoms of VTE. He was seen in the emergency department of a rural hospital for complaints of shortness of breath and back pain that were exacerbated with deep inspiration. The treating physician ordered computed tomography pulmonary angiography, which identified bilateral pulmonary emboli. An ultrasound examination was not performed to identify the presence and location of the peripheral thrombus. Anticoagulation therapy was initiated and managed by the patient’s family physician. Six months of low-molecular-weight heparin was recommended; further laboratory testing to evaluate for hypercoagulable disorders was not performed. At the last follow-up appointment, the patient had no clinical sequelae of postthrombotic syndrome or radiographic findings indicative of ongoing pulmonary disease. He was satisfied with the result of the arthroscopic procedure and improvement in function of the limb. Elbow range of motion was improved, and he was free of mechanical symptoms.
Discussion Upper extremity venous thrombosis In general, upper extremity DVT may be classified into two types: primary and secondary. Paget-Schroetter syndrome, the primary form, is the less common type. It may occur as a consequence of strenuous activity involving the upper extremity, occur in conjunction with thoracic outlet syndrome, or arise spontaneously in the absence of identifiable risk factors.10 A secondary DVT arises from a known predisposing factor, the more common of which include placement of a central venous catheter, malignant disease, hospitalization, and presence of a hereditary thrombophilic disorder.10
Venous thrombosis in upper extremity surgery The complications associated with shoulder and elbow surgery are well described.2,3,8 However, upper extremity surgery, particularly that about the elbow, is uncommonly complicated by VTE; and in comparison to other
M.J. Carroll, K.A. Hildebrand complications, the incidence is extremely low.2 The true incidence, however, is difficult to define because many of the studies report on heterogeneous populations and are retrospectively designed. A recent prospective study showed the incidence of asymptomatic DVT and pulmonary embolism in 175 patients undergoing shoulder arthroscopy to be 5.7% and 0.57%, respectively.11 The incidence of DVT or pulmonary embolism in arthroscopic elbow surgery has not been quantified in the literature. The senior author (K.A.H.) performs approximately 35 arthroscopic procedures about the elbow per year; this is the first known VTE complication after elbow arthroscopy. A retrospective review of 1076 patients undergoing total elbow arthroplasty reported the prevalence of pulmonary embolus to be 0.25% in the primary and 0.38% in the revision settings.4 However, our literature search did not identify any reports of VTE in association with the (1) treatment of fractures about the elbow or (2) elective arthroscopic elbow surgery.
Risk factors for and etiology of VTE in upper extremity surgery The risk factors for and causes of VTE specific to elective upper extremity surgery have not been clearly identified in the literature. Willis et al12 evaluated 100 patients undergoing shoulder arthroplasty and reported several factors that trended toward significance: increasing age, weight, prolonged operative time, and previous history of VTE. In 2013, a systematic review by Dattani et al2 suggested that diabetes mellitus, rheumatoid arthritis, and ischemic heart disease may also be risk factors for VTE in shoulder surgery. Hoxie et al7 retrospectively reviewed 137 consecutive patients undergoing operative management of proximal humerus fracture and found the incidence of computed tomography-confirmed pulmonary emboli to be approximately 5%. Regarding elbow surgery, we were unable to identify any literature reporting on VTE and elbow fracture care or elbow arthroscopy. On the basis of these studies, our patient with bilateral pulmonary emboli was not at high risk for VTE. The potential risk factors included an elevated body mass index of 32 and an age of 51 years. Whereas these have been cited as potential risk factors for or causes of VTE, we do not know specific body mass index values or ages that stratify increasing risk. There is no literature at present to quantify norms in operative time. In this case report, the patient’s elbow arthroscopy was completed in 60 minutes. It is our opinion that this time frame is within normal limits and should not pose a significant risk. Tourniquet-related soft tissue trauma is a potential concern; however, the patient’s tourniquet was placed but not inflated. A detailed history revealed no previous VTE, hereditary hypercoagulable disorders, or active malignant disease that would also place the patient at increased risk for development of VTE.
Bilateral pulmonary emboli after elbow arthroscopy Kuremsky et al9 reported on 6 patients who developed thromboembolic disease after shoulder arthroscopy. Because all patients diagnosed with VTE underwent arthroscopy in the lateral decubitus position, it was postulated that this may also be a risk factor. In their systematic review of VTE in shoulder arthroscopy, Dattani et al2 also noted a relationship between the lateral decubitus position and likelihood for having the procedure complicated by VTE. The strength of the association between patient positioning and risk of VTE is difficult to determine. Whether surgeons more commonly choose a lateral decubitus over a beach chair position is not accurately known. Takahashi et al11 reported on 175 patients undergoing shoulder arthroscopy in the beach chair position and showed the incidence of DVT and symptomatic pulmonary embolus to be 5.7% and 0.57%, respectively. This highlights the fact that VTE complications are uncommon in the beach chair position but lends little support to the idea that lateral positioning may be implicated. Our patients are routinely placed in the lateral decubitus position with the shoulder abducted and the elbow supported in a flexed position by a bolster. This position may compress the soft tissues immediately proximal to the antecubital fossa and impede venous return. If the thrombus originated in the operative extremity of our patient, this may be a possible explanation. The study by Takahashi et al11 highlights another important point relating to the origin of the thrombus. They reported a differential in location where the incidence of DVT was 0.57% in the upper extremity and 5.1% in the lower extremity. Unfortunately, our patient did not undergo ultrasound examination to identify the precise location of the clot. We do not routinely use intermittent pneumatic compression devices during elective elbow arthroscopy. It is therefore possible that this may also be a contributing factor toward the development of our patient’s VTE. At present, there is no high-level evidence to suggest that upper extremity surgery is an important risk factor in itself for development of VTE. Although the quality of evidence is poor, the literature suggests that the risk is low.1 To our knowledge, at present, there are no evidence-based guidelines for risk stratification or recommendations on prophylaxis against VTE in upper extremity surgery.
Conclusion We present a case report of a patient who developed symptomatic bilateral pulmonary emboli after elective elbow arthroscopy for osteoarthritis. The available literature focuses primarily on shoulder surgery and suggests that VTE is relatively uncommon but an important consideration in these patients. The risk factors for development of VTE in upper extremity surgery have not been clearly identified. At present, there are no previous reports of symptomatic VTE after elbow arthroscopy. The senior author’s practice includes approximately 35
e143 arthroscopic elbow procedures per year; this is the first instance in which a symptomatic DVT or VTE has occurred. This report highlights a rare but potentially serious complication of elbow surgery. It may serve as a reminder to the upper extremity surgeon that VTE is part of the differential diagnosis in the postoperative patient presenting with pleurisy and shortness of breath.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Anakwe RE, Middleton SD, Beresford-Cleary N, McEachan JE, Talwalkar SC. Preventing venous thromboembolism in elective upper limb surgery. J Shoulder Elbow Surg 2013;22:432-8. http://dx.doi.org/ 10.1016/j.jse.2012.10.033 2. Dattani R, Smith CD, Patel VR. The venous thromboembolic complications of shoulder and elbow surgery: a systematic review. Bone Joint J 2013;95-B:70-4. http://dx.doi.org/10.1302/0301-620X.95B1. 29854 3. Dodson CC, Nho SJ, Williams RJ, Altchek DW. Elbow arthroscopy. J Am Acad Orthop Surg 2008;16:574-85. 4. Duncan SFM. Prevalence of pulmonary embolism after total elbow arthroplasty. J Bone Joint Surg Am 2007;89:1452. http://dx.doi.org/10. 2106/JBJS.F.01328 5. El-Gazzar Y, Baker CL, Baker CL. Complications of elbow and wrist arthroscopy. Sports Med Arthrosc 2013;21:80-8. http://dx.doi.org/10. 1097/JSA.0b013e31828b685d 6. Falck-Ytter Y. Prevention of VTE in orthopedic surgery patients. Chest 2012;141(Suppl):e278S. http://dx.doi.org/10.1378/chest.11-2404 7. Hoxie SC, Sperling JW, Cofield RH. Pulmonary embolism after operative treatment of proximal humeral fractures. J Shoulder Elbow Surg 2007;16:782-3. http://dx.doi.org/10.1016/j.jse.2006.12.004 8. Kelly EW, Morrey BF, O’Driscoll SW. Complications of elbow arthroscopy. J Bone Joint Surg Am 2001;83:25-34. 9. Kuremsky MA, Cain EL, Fleischli JE. Thromboembolic phenomena after arthroscopic shoulder surgery. Arthroscopy 2011;27:1614-9. http://dx.doi.org/10.1016/j.arthro.2011.06.026 10. Mai C, Hunt D. Upper-extremity deep venous thrombosis: a review. Am J Med 2011;124:402-7. http://dx.doi.org/10.1016/j.amjmed.2010.11.022 11. Takahashi H, Yamamoto NMP, Nagamoto H, Tanaka M, Itoi E. Venous thromboembolism after elective shoulder surgery: a prospective cohort study of 175 patients. J Shoulder Elbow Surg 2014;23:60512. http://dx.doi.org/10.1016/j.jse.2014.01.054 12. Willis AA, Warren RF, Craig EV, Adler RS, Cordasco FA, Lyman S, et al. Deep vein thrombosis after reconstructive shoulder arthroplasty: a prospective observational study. J Shoulder Elbow Surg 2008:1-7. http://dx.doi.org/10.1016/j.jse.2008.07.011 13. Yeoh KM, King GJW, Faber KJ, Glazebrook MA, Athwal GS. Evidence-based indications for elbow arthroscopy. Arthroscopy 2012;28: 272-82. http://dx.doi.org/10.1016/j.arthro.2011.10.007
