Anticoagulation After Shoulder Arthroplasty

Standard Prophylaxis Approach

• Mechanical prophylaxis should be used intraoperatively and during the immediate postoperative period for all shoulder arthroplasty patients, as recommended by the American Academy of Orthopaedic Surgeons 1, 2
• The American Academy of Orthopaedic Surgeons consensus recommendation supports routine use of mechanical and/or chemical prophylaxis despite limited evidence, acknowledging that shoulder arthroplasty carries lower VTE risk than lower extremity procedures 1, 2

High-Risk Patient Identification and Management

• Chemical prophylaxis beyond aspirin should be considered for patients with specific high-risk features, including active malignancy or metastatic disease, as stated by the American College of Chest Physicians 3
• Patients with known thrombophilia or hypercoagulable state, including coagulopathy, may require enhanced prophylaxis, according to the American Society of Hematology 4

Special Considerations for Patients with History of Thromboembolic Events

• For patients on chronic warfarin therapy who require shoulder arthroplasty, warfarin should be discontinued 4 days before the procedure, as recommended by the American Association of Neurological Surgeons 5
• Postoperative intravenous heparin should be considered only for patients with recent arterial or venous thromboembolism, continuing until therapeutic anticoagulation is re-established with warfarin, as suggested by the American College of Chest Physicians 5
• The decision to bridge with heparin depends on the timing of the prior thromboembolic event and the patient's ongoing thrombotic risk versus surgical bleeding risk, according to the American College of Chest Physicians 3

Patients with Mechanical Heart Valves or Atrial Fibrillation

• Shoulder arthroplasty is classified as a procedure with low-to-moderate bleeding risk, which influences perioperative anticoagulation management decisions, as stated by the American Society of Hematology 4, 3
• For patients with high thrombotic risk, bridging anticoagulation may be warranted despite the surgical bleeding risk, according to the American College of Chest Physicians 3
• For patients with lower thrombotic risk, temporary interruption of anticoagulation without bridging is generally acceptable, as recommended by the American College of Chest Physicians 3

Critical Pitfalls to Avoid

• Do not assume all patients require the same prophylaxis regimen—the evidence supports risk-stratified approaches rather than universal aggressive anticoagulation, as stated by the American Academy of Orthopaedic Surgeons 1