Each complication is one too many.
Insurance status
A recent article reported that Medicaid status is independently predictive of increased complications, readmission, and mortality following primary total shoulder arthroplasty.
See a detailed assessment of this paper here.
Let's start by putting this assertion to the "sniff test" by considering a hypothetical 63 year old widow living alone with diabetes, osteoporosis and shoulder arthritis.
In the absence of alternatives, her health care is covered by Medicaid. The is scheduled for shoulder arthroplasty in two months. According to the article referenced above, she is at increased risk for complications, readmission, and mortality if she undergoes the arthroplasty. She has fallen in love with and marries a childhood friend and, as a result, now has high quality private insurance. Does this insurance change affect her risk of complications, readmission and mortality?
The article provides some useful comparisons of patients on Medicaid with others: patients on Medicaid were propensity score matched in a 1:1 proportion based on age, sex, and discharge weight.
From the below, we can see that the matching did not include the Cormorbidity Idex (CCI), the patient location, or household income; each of these characteristics could be expected to have an effect on the outcome of shoulder arthroplasty.
Note also that the study fails to control for the rates of preoperative congestive heart failure, chronic lung disease, coagulopathy, anemia, dementia, electrolyte disorder, hypertension, liver disease, lymphoma, myocardial infarction, obesity, paralysis, peptic ulcer, renal failure and substance abuse
There are probably other important differences between the two groups, such as occupation, surgeon experience, social support, nutrition, and nicotine and alcohol habits.
Thus, what we have here is a fundamental attribution error: i.e. attributing the difference between the two groups to Medicaid status instead of to the differences in the two groups' social determinants of health and comorbidities. (In Thinking Fast and Slow, Kahneman addresses how we construct coherent stories and causal narratives, often ignoring situational factors in favor of internal traits —a hallmark of the fundamental attribution error.)
With the realization that the two groups were not matched for key variables, we can understand the likely reasons for the differences in outcome between the two groups.
The statement "Medicaid status was independently predictive of readmission, complications, and mortality within 180 days of primary TSA, as well as other specific medical and surgical complications." focuses attention on insurance status - which in an of itself can't be a risk factor - rather than on the true risk factors which may be managed.
Avoiding Acromioplasty
While some surgeons routinely perform acromioplasty in conjunction with cuff repair, there is only minimal evidence to support a clinically significant benefit in terms of patient reported outcomes:
Acromioplasty combined with arthroscopic rotator cuff repair can reduce the risk of reoperation: a systematic review and meta-analysis. "Combining arthroscopic cuff repair with acromioplasty can reduce the rate of reoperation, especially in patients with type 3 acromion, but it provides no clinically important change in the retear rate and postoperative patient reported outcomes compared with arthroscopic cuff repair without acromioplasty"
Chochrane on rotator cuff repair "Not surprisingly, there were no observed benefits to acromioplasty in terms of pain, function, or health-related quality of life—a finding that has been known for some time and is based on several high-quality randomized controlled trials"
Efficacy of concomitant acromioplasty in the treatment of rotator cuff tears: A systematic review and meta-analysis "our present study demonstrated that acromioplasty treatment is significantly superior to nonacromioplasty in shoulder pain relief at 12 months postoperatively and in ASES score improvement at the final follow-up in conjunction with rotator cuff repair. However, these statistically significant differences were not clinically relevant. Thus, there were no differences in shoulder function or pain scores for patients undergoing rotator cuff repair with and without acromioplasty."
Reverse total shoulder arthroplasty is often performed for patients with failed rotator cuff repair. For example, It is known that acromioplasty can increase the risk of anterior/superior escape after a failed attempt at cuff repair.
One of the most debilitating complications of reverse total shoulder after failed cuff repair is acromial/scapular spine stress fracture.
By definition, acromioplasty thins the acromion, making it more prone to fracture.
In addition, there is evidence that sacrifice of the coracoacromial arch can increase the risk of acromial stress fractures.
The authors of Prior Subacromial Decompression is a Significant Risk Factor for Development of Acromial Stress Fracture After Reverse Total Shoulder Arthroplasty sought to determine if prior acromioplasty increases the risk of these fractures after reverse total shoulder arthroplasty (rTSA). 106,599 patients undergoing primary rTSA were identified. One out of 100 patients sustained an acromial stress fracture. Prior acromioplasty was a significant independent risk factor, conferring a 26% higher risk. Additional independent risk factors for these fractures included increased Charlson Comorbidity Index, history of a rotator cuff tear, osteoporosis and inflammatory arthropathy.
In performing rotator cuff repair, surgeons need to balance the possible advantages of acromioplasty against the increased risk of acromial / spine fractures should subsequent reverse total shoulder arthroplasty become necessary.
Managing Body weight
Obesity and total joint arthroplasty: Does weight loss in the preoperative period improve perioperative outcomes? assessed whether a 10% weight loss prior to TJA had a impact on perioperative and 30-day outcomes in obese patients. The authors found no difference between groups with or without weight loss in terms of operative time, length of stay, discharge destination, or 30-day adverse events, including complications, re-admissions, re-operations, and mortality.
An abrupt weight loss before surgery may create a state of malnutrition, increasing the risk of complications by making the patient catabolic with adverse effects on healing, strength and balance. Medical and social support of the patient and careful monitoring increase the chances of success.
One in five patients having shoulder arthroplasty has diabetes and one in three are obese. Glucagon-like peptide-1 (GLP-1) receptor agonists, are increasingly used for diabetes management and weight loss. The authors of Glucagon-like Peptide-1 Receptor Agonist Use is Associated With Increased Risk of Perioperative Complication and Readmission Following Shoulder Arthroplasty conducted a propensity matched study of 1259 patients taking GLP-1 receptor agonists to 1259 patients not taking the medication with respect to adverse outcomes after anatomic (aTSA) or reverse (rTSA) total shoulder arthroplasty. They found that GLP-1 receptor agonist users experienced significantly higher 90-day rates of medical complications, such as deep vein thrombosis, myocardial infarction, pneumonia, transfusion and readmission. There may also be an increased risk of aspiration, nausea and vomiting because these agents delay gastric emptying. The increase in the rate of surgical revision of the arthroplasties was statistically insignificant.
GLP-1) receptor agonists
At present, guidelines for the perioperative management of patients taking GLP-1 receptor agonists are still being fine tuned. The American Society of Anesthesiologists (ASA) has recommended holding daily GLP-1 RAs (e.g., liraglutide) on the day of surgery and holding weekly GLP-1 RAs (e.g., semaglutide, dulaglutide) at least 1 week prior to surgery. The potential risks of holding GLP-1 RAs before surgery include hyperglycemia, overeating post-op, increased cardiovascular risk and gastrointestinal symptoms. Preoperative consultation with internal medicine and anesthesia is advisable.
Managing Nutrition
Malnourished patients had significantly higher risks of 90-day major complications, including sepsis, myocardial infarction, readmission, pneumonia, renal failure, and blood transfusion. These patients were also at increased risk of periprosthetic infection and surgical revision within 2 years after arthroplasty.
Consultation with an experienced nutritionist and social support are indicated for malnourished patients. The patients need to be advised that the necessary dietary changes can be difficult and may take months or longer to create a meaningful reduction in surgical risk.
Stopping tobacco use
While it is commonly recognized that cigarette smoking increases the risk of surgical complications, patients may wish to continue their use of other forms of tobacco. The authors of Effects of Smokeless Tobacco Use on Primary Total Shoulder Arthroplasty Outcomes compared outcomes between smokeless tobacco users and nontobacco users. They found that patients using smokeless tobacco had higher average Charlson-Deyo Comorbidity Indices and concomitant alcohol use and lower socioeconomic status. Smokeless tobacco users had higher rates of acute respiratory disease syndrome, sepsis, and mortality at 180 days. These adverse outcomes are attributed to the vasoconstriction, impaired tissue oxygenation, and immunosuppression occurring with tobacco use. Tobacco use predicts a more difficult episode of care after anatomic total shoulder arthroplasty pointed out that current tobacco use is associated with increased postoperative pain.
The current thinking is that use of all tobacco products should be discontinued at least three months prior to elective arthroplasty. Active use of tobacco may be associated other risk-taking patterns of behavior, such as alcohol abuse and failure to comply with postoperative restrictions. Impulsivity is associated with behavioral decision-making deficits
As every orthopaedic surgeon knows, osteoporosis predisposes patients to fractures and failure of joint reconstructions. One in four women over the age of 65 has this condition. Because there is a high prevalence of undiagnosed or untreated osteoporosis, surgeons need to screen patients with risk factors for this common condition: female, advanced age, low BMI, malnourishment, inflammatory arthropathy, steroid medication, inactivity, and poor diet. The authors of Anti-osteoporotic treatment reduces risk of revision following total shoulder arthroplasty in patients with osteoporosis investigated whether anti-osteoporotic therapy correlates with improved revision outcomes following total shoulder arthroplasty.
Patients with a preoperative diagnosis of osteoporosis were stratified into 2 groups: (1) patients with osteoporosis who underwent anti-osteoporotic therapy within 6 months prior to surgery (anti-OP cohort) and (2) patients with osteoporosis who never received anti-osteoporotic treatment (no anti-OP cohort).
In total 40,532 osteoporotic patients were included, with 11,577 (28.5%) having undergone anti-osteoporotic treatment.
Patients who did not receive anti-osteoporotic treatment had significantly higher odds of 2-year all-cause revision and mechanical loosening following TSA when compared to those treated for osteoporosis.
Simple steps can reduce the risk of osteoporosis: a diet with substantial protein (e.g. at least 1/2 gram of protein/pound of body weight), fat and calories, Vitamin C and D supplementation, calcium supplementation, and general bone-loading exercise (e.g. walking, rowing machine). Be aware of the "tea and toast" diet and inactivity. Patients at risk should be monitored with DEXA scans. Formal anti-osteoporotic treatment should be administered by a physician knowledgeable about metabolic bone disease.
Managing Osteoporosis
As every orthopaedic surgeon knows, osteoporosis predisposes patients to fractures and failure of joint reconstructions. One in four women over the age of 65 has this condition. Because there is a high prevalence of undiagnosed or untreated osteoporosis, surgeons need to screen patients with risk factors for this common condition: female, advanced age, low BMI, malnourishment, inflammatory arthropathy, steroid medication, inactivity, and poor diet. The authors of Anti-osteoporotic treatment reduces risk of revision following total shoulder arthroplasty in patients with osteoporosis investigated whether anti-osteoporotic therapy correlates with improved revision outcomes following total shoulder arthroplasty.
Patients with a preoperative diagnosis of osteoporosis were stratified into 2 groups: (1) patients with osteoporosis who underwent anti-osteoporotic therapy within 6 months prior to surgery (anti-OP cohort) and (2) patients with osteoporosis who never received anti-osteoporotic treatment (no anti-OP cohort).
In total 40,532 osteoporotic patients were included, with 11,577 (28.5%) having undergone anti-osteoporotic treatment.
Patients who did not receive anti-osteoporotic treatment had significantly higher odds of 2-year all-cause revision and mechanical loosening following TSA when compared to those treated for osteoporosis.
Simple steps can reduce the risk of osteoporosis: a diet with substantial protein (e.g. at least 1/2 gram of protein/pound of body weight), fat and calories, Vitamin C and D supplementation, calcium supplementation, and general bone-loading exercise (e.g. walking, rowing machine). Be aware of the "tea and toast" diet and inactivity. Patients at risk should be monitored with DEXA scans. Formal anti-osteoporotic treatment should be administered by a physician knowledgeable about metabolic bone disease.
For those of us in the Pacific Northwest and other less sunny climates, it is notable that the authors of Vitamin D Deficiency is Associated with Adverse Medical Outcomes Following Total Shoulder Arthroplasty found that Vitamin D deficiency was associated with higher rates of kidney failure (AKF), deep vein thrombosis (DVT), pulmonary embolism, pneumonia, and periprosthetic fractures at 90 days and at one year. Additionally, readmission rates were significantly higher in the vitamin D-deficient cohort at 1 year. At 2 years, AKF, DVT, pneumonia, and readmission continued to be significantly associated with vitamin D deficiency.
Managing steroid use
Approximately one in twenty patients having shoulder arthroplasty are taking chronic steroid medication. Chronic preoperative steroid use and total shoulder arthroplasty: a propensity score matched analysis of early-onset infectious outcomes aimed to evaluate the impact of chronic preoperative steroid use on early-onset postoperative infectious outcomes and readmission within 30 days following TSA compared to patients without chronic steroid use. A total of 3,445 identified cases were included in this analysis after propensity score matching, with 1,157 exhibiting chronic steroid use. The steroid group demonstrated significantly greater rates of readmission; this study did not document the reasons for readmission. In this short term followup study, no significant differences were observed between groups in all other adverse outcomes, including reoperation and infectious outcomes.
Managing Anemia
Anemia (e.g preoperative hemoglobin < 13.5 g/L) is present in up to one of three patients having shoulder arthplasty.
Complications Associated with Preoperative Anemia and Risk Factors for Blood Transfusion after Shoulder Arthroplasty: A Systematic Review found the patients with preoperative anemia (PA) demonstrated a 24.4% complication rate in comparison to 8.8% in those without such a diagnosis. Stratification by PA severity revealed a 34.9% complication rate in patients with moderate to severe PA. In patients with PA, pulmonary complications were the most prevalent followed by thromboembolic, renal, and postoperative transfusion-related complications.
Lower preoperative hemoglobin and revision shoulder arthroplasty were correlated with a higher risk of postoperative transfusion.
Because anemia is associated with chronic illness and malnutrition, it is difficult to know how much of the adverse effect is due to the anemia itself or to the underlying condition that may be contributing to it. Thus the management of PA is complicated.
Erythropoiesis-stimulating agents can increase hemoglobin levels but carry potential risks (e.g., thromboembolic events), particularly in older populations.There is no strong evidence that administration of erythropoietin (EPO) significantly reduces complication rates in anemic patients undergoing shoulder arthroplasty.
There is currently no strong evidence that preoperative blood transfusion lowers complication rates in mild or moderately anemic patients undergoing shoulder arthroplasty. In fact, preoperative transfusion may increase the risk of complications in some cases. Allogeneic blood transfusion, including preoperative transfusion, is associated with increased risk of surgical site infection, increased thromboembolic events and immunomodulatory effects.
In patients with ferritin <30 ng/mL or transferrin saturation <20%, oral or especially intravenous iron may be the most cost effective approach for raising serum hemoglobin before surgery
Notably, tranexamic acid (TXA) is effective in reducing blood loss and transfusion need; this medication is now in common use in patients having shoulder arthroplasty and has been found to have a very low rate of adverse reactions
Inspiring the patient
Finally, as surgeons we have an opportunity to inspire the patient to take responsibility for their own health as detailed here.
Conclusion
In order to do our very best for each of our patients, we need to be on the watch for and to manage the factors that may threaten the outcome of their shoulder arthroplasty.
At a young age, barred owls learn to be watchful for threats
Barred Owl Fledgeling
Washington Park Arboretum
June 5, 2025
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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).
Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/
Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).
