Commentary & Perspective on
"Pulmonary Embolism Following Shoulder Arthroplasty"
by John W. Sperling, MD, and Robert H. Cofield, MD

Commentary & Perspective:
"Pulmonary Embolism After Shoulder Arthroplasty:
Don't Shrug It Off"
by Samuel Z. Goldhaber, MD*,
Division of Cardiovascular Medicine,
Brigham and Women's Hospital, Boston, MA

Until the article in this month's issue of The Journal, pulmonary embolism after shoulder arthroplasty was on no one's radar screen. To their credit, Sperling and Cofield have explored this potentially important issue. I'm concerned, though, that their take-home message may not be on target, and that the orthopaedic surgical community may simply shrug off the possibility of deep venous thrombosis in the setting of shoulder arthroplasty.

My greatest concern is whether all of the incidents of pulmonary embolism were detected in this impressively large retrospective study. I doubt it. Even under optimal circumstances for its diagnosis, confirming or excluding acute pulmonary embolism is difficult¹. Computed tomography scanning of the chest was not widely utilized as a diagnostic tool for pulmonary embolism² during most of the study period (1981-2001); many pulmonary emboli were probably undiagnosed because the quality of the lung scans was insufficient to allow their detection. It is likely, therefore, that deaths secondary to undetected occult pulmonary embolism did occur among these 2885 patients within thirty days after shoulder arthroplasty. These deaths probably were ascribed to acute myocardial infarction or explained as sudden death due to cardiac arrhythmia.

With respect to upper-extremity venous thrombosis as a possible predictor of pulmonary embolism, the former would be difficult for even a master clinician to detect because of the expected postoperative discomfort and edema in the shoulder area. Radiologists would have an equal degree of difficulty in detecting upper-extremity venous thrombosis because the site of potential blood clotting is obscured when the transducer is placed directly above the clavicle in patients undergoing venous ultrasonography.

My message to orthopaedic surgeons is: Despite this report, don't let down your guard. If you suspect a pulmonary embolism, begin heparin administration and obtain a computed tomography scan of the chest³.

I hope that this article by Sperling and Cofield stimulates further formal study that includes postoperative computed tomography scanning of the chest, so that we can determine, once and for all, whether we should continue to worry about the risk of pulmonary embolism after shoulder arthroplasty or shrug off our concerns about this potentially deadly problem⁴.

*The author did not receive grants or outside funding in support of the research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (Aventis, Pharmacia) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Bounameaux H. Integrated diagnostic approach to venous thromboembolism. In: Goldhaber SZ, Ridker PM, editors. Thrombosis and thromboembolism (Fundamental and clinical cardiology). New York: Marcel Dekker; 2002. p 225-34.
2. Costello P, Gupta KB. Pulmonary embolism: Imaging modalities—V/Q scan, spiral (helical) CT, and MRI. In: Bounameaux H, Goldhaber SZ, editors. Seminars in vascular medicine. New York: Thieme; 2001. p 155-64.
3. Gelfand EV, Piazza G, Goldhaber SZ. Venous thromboembolism guidebook. Critical pathways in cardiology. 2002;1:26-43.
4. Goldhaber SZ. Venous thromboembolism: Clinical impact and multifactorial etiology. In: Goldhaber SZ, Ridker PM, editors. Thrombosis and thromboembolism (Fundamental and clinical cardiology). New York: Marcel Dekker; 2002. p 211-24.