Postoperative bleeding complications in total shoulder arthroplasty patients with atrial fibrillation or flutter: a matched cohort analysis

Background Total shoulder arthroplasty (TSA) is becoming an increasingly common procedure done for a variety of indications, including proximal humerus fractures and glenohumeral osteoarthritis. The incidence of atrial fibrillation (AF) in the general population is also increasing, posing the question of anticoagulation use in patients undergoing TSA. This study aims to assess postoperative outcomes in patients with AF or atrial flutter undergoing TSA. Methods The TriNetX database was queried for all patients undergoing TSA who had a concurrent diagnosis of AF or atrial flutter on anticoagulants (rivaroxaban, apixaban, warfarin). Patients were grouped based on their exposure to each medication and were followed for 30 and 90 days postoperatively. Outcomes collected include prosthetic joint infection, wound complications, thrombotic events (deep vein thrombosis and pulmonary embolism), bleeding events (intracranial, respiratory, and gastrointestinal bleeding), ischemic events (myocardial infarction and stroke), and laboratory measures of hemoglobin and hematocrit. Results A total of 3,334 propensity-matched patients were included in the study. At 30 and 90 days, rivaroxaban compared to warfarin was associated with a significantly lower rate of intracranial bleeds ( P < .01) and higher mean hemoglobin ( P < .01) and hematocrit levels ( P < .01). In addition, patients on warfarin had a higher risk of ischemic stroke ( P = .032). Rivaroxaban and apixaban showed similar bleeding, ischemic, and embolic events at 90 days. However, patients on rivaroxaban had a higher rate of death within 30 days when compared to patients on apixaban ( P < .01), but after 90 days, there was no significant difference. At the 30- and 90-day follow-up, apixaban was associated with fewer pulmonary embolisms, deep vein thrombosis ( P < .05), bleeding complications, including intracranial bleed ( P < .05) and gastrointestinal bleed ( P < .01) when compared to warfarin. There was no significant difference found between any group for prosthetic joint infection, wound breakdown, hematoma, respiratory bleed, myocardial infarction, revision, and death. Conclusion Rivaroxaban and apixaban demonstrated fewer postoperative bleeding and embolic events when compared to warfarin. This may indicate their superiority in the treatment of AF and atrial flutter in the perioperative period for patients undergoing shoulder arthroplasty. However, further research is indicated to understand the causes of these differences and whether preoperative anticoagulation medication changes should be considered among patients undergoing shoulder arthroplasty.