key: cord-1045385-2uqq4kmh
authors: Chauhan, Aakash; Villacis, Diego; Boente, Ryan; Romeo, Anthony A.
title: Venous Thromboembolism after Arthroscopic Rotator Cuff Repair in a Patient with a Negative Pre-Surgical SARS-CoV-2 Test that Developed Symptomatic COVID-19 Three Days after Surgery
date: 2021-02-23
journal: J Shoulder Elbow Surg
DOI: 10.1016/j.jse.2021.02.003
sha: c9c196bfb30bf920d8164f56047707b6882da79f
doc_id: 1045385
cord_uid: 2uqq4kmh

nan

A 42-year-old right-hand dominant woman, with no significant past medical history, 24 suffered a left shoulder injury after a fall eight months prior to presentation. She failed 25 conservative treatment with physical therapy, and magnetic resonance imaging (MRI) was 26 obtained by her primary care physician. She was then sent to orthopedic surgery for evaluation shoulder function, and severity of the rotator cuff tear on MRI. The patients' preoperative 37 reported outcomes were a VAS score of 5, ASES Shoulder Score of 6/30, shoulder score index 38 of 35/100, and simple shoulder test of 2/12. 39

The patient underwent routine arthroscopic management of her shoulder under an 40 interscalene regional block. Given the high grade of the articular side of the tear, the bursal side 41 of the tendon was taken down to complete the tear to perform a full repair. A trans-osseous 42 equivalent, double-row repair with a medial row double pulley was performed as previously 43 described (Figure 2 ). 2 Based on her pre-operative clinical and imaging findings, a subacromial 44 described. 4 The operative time was recorded as 65 minutes for this case. 46

At our institution, a pre-procedure SARS-CoV-2 viral PCR test is administered 48-72 47 hours prior to all elective surgeries. The patient's test was negative three days prior to surgery. 48

However, unknown to the patient, she had a positive exposure with an infected individual he day 49 before her scheduled surgery. She became symptomatic 3 days after surgery with a confirmed 50 positive SARS-CoV-2 test. She was initially treated with home isolation and routine 51 management of her symptoms. After her positive diagnosis, she was instructed by her primary 52 care physician to take Aspirin 325 mg daily for prophylaxis against any potential coagulopathy. 53

On post-operative day 10, the patient called stating she had new and increased pain and swelling 54 of the operative upper arm and forearm. She was immediately sent for an ultrasound that showed 55 a 56 an extensive deep venous thrombosis involving the subclavian, axillary, brachial, mid basilic and 57 mid cephalic veins. Additionally there was superficial thrombus within the left proximal basilic 58 vein to the cephalic vein. She was sent to the emergency room where computed tomography 59 (CT) of the chest with IV contrast was obtained that showed a left lower lobe pulmonary 60 embolus (PE) in the setting of bilateral lobe pneumonia that is also commonly seen in COVID-61 19 patients. (Figure 3 ) She was admitted to the intensive care unit (ICU) for respiratory 62 monitoring and started on a heparin drip to treat her coagulopathy. During her admission, 63 vascular surgery was consulted and recommended a venogram with possible thrombectomy. At 64 the time of the procedure, she was found to have some residual clot in the brachial veins, but overall the course from the subclavian vein distal was widely patent, indicating success with discharged post-admission day four on Eliquis as outpatient treatment for her coagulopathy. 69

The patient was seen during follow-up in clinic shortly after testing negative for active 70 infection and started formal physical therapy with gentle passive range of motion three weeks 71 after surgery due to the delay in care from her illness. A wide range of coagulopathy labs were 72 ordered and have been found to be negative. Her mother did have a previous history of DVT in 73 the past. However, the patient has never had previous venous thromboembolism (VTE) events, 74 even after prior orthopedic surgeries on her hip and knee. The patient continues to have some 75 symptomatic sequelae from COVID-19 but is expected to have a full recovery. 

The emergence of the novel coronavirus, SARS-CoV-2, that causes COVID-19, has 79 placed an unprecedented amount of stress and burden on our healthcare system. Early in 2020, 80 rapid cancellation of inpatient and outpatient elective orthopedic surgery was implemented to 81 preserve resources for hospitals. As we have slowly emerged and tried to return to a new 82 normalcy in day-to-day orthopedic care, the long-lasting effects of the pandemic will continue to 83 be felt. 84

Our case report highlights concerns we have so that we can raise awareness surrounding 85 potential complications related to COVID-19 and elective orthopedic surgeries. Our patient was 86 appropriately screened three days prior to her surgery with a negative SARS-CoV-2 PCR test. 87

The sensitivity and specificity of SARS-CoV-2 PCR Testing has been reported over the last year 88 to be 71-98% and 95%, respectively. 11, 12 Unfortunately for our patient, she had a known positive 89 exposure at work that led to a positive and symptomatic infection three days after surgery. 90

Routine incubation time for symptoms to emerge for COVID-19 has ranged from 2-14 days. 3 We 91 recommend self-isolation prior to surgery for all patients, but in reality, this can be difficult to 92 effectively implement. It's unrealistic to expect that all patients will comply with strict pre-93 operative isolation protocols or be able to mitigate the risk of exposure from other sources, which 94 are simply out of their control. 95

To add more complexity to this case, an otherwise healthy, young patient developed a 96 significant post-operative coagulopathy in the form of a DVT in her operative shoulder and a 97 subsequent pulmonary embolus. This was diagnosed ten days after surgery but was likely 98 developing from the onset of her illness. The rate of DVT and PE in routine elective arthroscopic 99 other significant concern about this case, which is the rapid development of a DVT with an 102 associated PE that could have been life-threatening to this patient. 103 As our healthcare system has learned more about the complications that arise from 104 COVID-19 infections, coagulopathy is being recognized as a common finding in these patients. 105

Large systematic reviews have analyzed the rate of VTE in COVID-19 patients with reported 106 rates ranging from 12-17% for DVT and 8-14% for PE. 3,5,10 Surprisingly, a large majority of 107 PE's were not associated with a DVT and it is thought the rate of undiagnosed clots s even 108 higher than reported. Also, as expected, the rates of DVT and PE are higher in critically ill or 109 ICU patients. 5 Although surgery is always considered a risk factor for DVT or PE, especially in 110 lower extremity procedures, the rates of DVT or PE after arthroscopic shoulder surgery is 111 exceedingly rare. We believe that in this circumstance, the patient experienced the perfect storm 112 of risk factors to lead to this complication. Her undiagnosed COVID-19 infection with recent 113 surgery placed her at increased risk to develop a DVT and subsequent PE. Our concern is that 114 this situation may become more common even in light of negative pre-operative testing. The 115 patient was appropriately started on anti-coagulation after her diagnosis, but whether it was too 116 late at that point is yet to be determined. COVID-19 has been proposed to stimulate a significant 117 inflammatory response along the endothelial lining of venous and arterial blood vessels that 118 starts almost immediately after infection. 7 This unusual, but robust response has been found to 119 result in high VTE rates in severely ill patients. 3, 5 We still have yet to understand the effect on 120 baseline risk for developing a DVT or PE in less severe infections. Certainly, other factors such 121 as immobilization and deconditioning from the illness can additionally predispose patients to complication in a routine, elective, outpatient surgery in an otherwise healthy, young patient. 125

In conclusion, this case report serves to make orthopedic surgeons aware of the possible 126 

The 138 Effectiveness of Aspirin for Venous Thromboembolism Prophylaxis for Patients 139

Undergoing Arthroscopic Rotator Cuff Repair

Hybrid Repair of Large Crescent Rotator Cuff Tears 142

Using a Modified SpeedBridge and Double-Pulley Technique

Clinical Features, and Management Options of COVID

Shock 2020

The Loop 'N' Tack Biceps Tenodesis: An 149

Incidence of VTE and Bleeding Among 152

Hospitalized Patients With Coronavirus Disease 2019: A Systematic Review and Meta-153 analysis

Thromboembolic phenomena after arthroscopic COVID-19 INDUCED DVT/PE AFTER SHOULDER SCOPE

Timing and Risk Factors for Venous Thromboembolism After Rotator Cuff Repair in the 30-Day Perioperative Period

Thromboembolism 163 Following Shoulder Arthroscopy: A Retrospective Review

Pulmonary Embolism and Deep Vein Thrombosis in 166 COVID-19: A Systematic Review and Meta-Analysis

False-positive COVID-19 results: hidden 169 problems and costs

Interpreting a COVID-19 Test Result