Saturday, December 27, 2014

Total shoulder arthroplasty - is the patient healthy enough to undergo it?

What Are Risk Factors for 30-day Morbidity and Transfusion in Total Shoulder Arthroplasty? A Review of 1922 Cases.

In reviewing 1922 cases of total shoulder arthroplasty from the National Surgical Quality Improvement Program database (2006-2011), these authors sought to identify for the first 30 days after surgery (1) the type and incidence of complications; (2) the frequency of and risk factors for both minor and major complications; and (3) the risk factors for bleeding resulting in transfusion.

One out of 12 (155, 8%) of total shoulders had complications:

*bleeding resulting in transfusion (82 patients [4.26%]) 
*urinary tract infections (27 patients [1.40%]), 
*return to the operating room (14 patients [0.73%]), 
*pneumonia (10 patients [0.52%]), 
*peripheral nerve injury (nine patients [0.47%]). 

One out of 50 patients (44, 2%) had a major morbidity: 5 patients (0.26%) died.

They found that steroid use, hematocrit < 38%, American Society of Anesthesiologists (ASA) Class 4, and operating time > 2 hours were independent predictors of complications.

Congestive heart failure was an independent risk factor for major morbidity or mortality. 

Hematocrit < 38%,  resident involvement,  steroid use, and ASA Class 3 versus 1 or 2 were risk factors for bleeding resulting in transfusion.

Comment:  This paper points to some important patient-related risk factors for complications that need to be considered before proceeding with total shoulder arthroplasty. Some of these risk factors (heart failure, pulmonary health, steroid management) may be modified by preoperative medical management. Others (such as hematocrit under 38 and high ASA Class) may prompt exploration of the underlying causes. Patients with the identified risk factors should be informed about their increased risk of complications. 

In considering these results, there is a danger in confusing association with cause: it seems doubtful complications would be reduced by 
* hurrying the surgery to achieve completion in less than two hours 
* excluding residents from the surgical team
* transfusing a patient's hematocrit so that it will be over 38 at the time of surgery
* stopping steroid medication before surgery

It is of interest that, in contest to prior studies, this investigation did not reveal age or diagnosis as risk factors for total shoulder complications.

In conclusion, total shoulder arthroplasty is an elective procedure. As surgeons it is our responsibility to partner with each patient in assessing both their individual risk of complications and potential benefits of the procedure.


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