Outpatient shoulder arthroplasty - should there be an age cut-off?

Is outpatient shoulder arthroplasty safe in patients aged >65 years? A comparison of readmissions and complications in inpatient and outpatient settings

This study sought to compare surgical complication rates and 90-day readmission rates between inpatient and outpatient TSA performed in adults aged ≥ 65 years by an individual surgeon.

Patients were preselected for outpatient or inpatient surgery based on lack of significant cardiopulmonary comorbidities (e.g. presence of cardiac stents, congestive heart failure, and severe chronic obstructive pulmonary disease) and patient preference.

Outpatient TSA was defined as those procedures in which patients were discharged home from

the postanesthesia care unit (PACU),

A total of 145 shoulders (138 patients; 95 male, 43 female) were included in the analysis, of which 98 received inpatient TSA and 47 received outpatient TSA. Average age was 75.5 for inpatient TSA and 70.5 for outpatient TSA. 

Patient age, ASA score ≥3, and reverse TSA were significantly positively correlated with receiving inpatient surgery. 

Each 1-year increase in age increased the predicted odds of having a surgical complication by 14%, irrespective of surgical setting. 

In the inpatient group, there were a total of 16 complications (complication rate 16.3%). 4 major surgical complications required reoperation (4.1%): implant instability in 3 cases (all reverse TSA) and 1 patient with anatomic TSA sustained a greater tuberosity fracture after a seizure. 7 minor complications consisted of 1 heterotopic ossification, 2 isolated acromial stress reactions, 1 ruptured distal biceps tendon, and 1 acromial stress reaction with concomitant proximal biceps tendon rupture (long head). The 2 minor medical complications were hyponatremia secondary to acute kidney injury and anemia requiring transfusion. There were 5 intraoperative complications, consisting of 1 instance of skin shearing while positioning the arm and 4 intraoperative fractures.

In the outpatient group there were 9 complications (19.1%).  3 major complications required reoperation within 1 year (6.4%). Two of the 3 major complications were rotator cuff dysfunction after anatomic shoulder arthroplasty. The third major complication was instability after reverse TSA. There were 3 minor complications, all surgical, consisting of 3 acromial stress reactions. There was 1 intraoperative fracture sustained by a patient with osteogenesis imperfecta.

The most common causes of presentation to the ED within 90 days were medical complaints including fall (7), chest pain (2), urinary tract infection (2), syncope (2), bleeding (2), and angioedema (2). 

The causes for readmission included revision surgery (5), cardiovascular workup (3), urinary tract infection (3), acute kidney injury (2), pneumonia (1), extremity edema (1), gastrointestinal workup (1), and fall (1).

Comment: This surgeon offered outpatient arthroplasty to patients without clinically significant cardiovascular or pulmonary conditions and who desired to have outpatient surgery. Patients selected for inpatient surgery were older and had worse ASA scores. 

The incidences of surgical and medical complications are shown below. In spite of their worse ASA scores, the rate of medical complications for inpatients was not substantially different from that for outpatients. The big difference was in the rate of ED visits and readmissions. These differences were not caused by the inpatient/outpatient decision, but rather are a reflection of the greater fragility of those selected for inpatient surgery.

These results suggest that in this surgeon's practice, outpatient surgery is not a major risk factor for medical or surgical complications. Rather patients selected by this surgeon for inpatient surgery are at higher risk for postoperative ED visits and readmission

Each increase in age by 1 year increased the odds of postoperative surgical complications by 14%; this was true for both inpatient and outpatient surgery. This finding does not support the application of an age cut-off but rather using other criteria as discussed in this related post, "Is outpatient arthroplasty a good idea?"

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Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

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The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

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The safety of outpatient shoulder arthroplasty

The Feasibility of Outpatient Shoulder Arthroplasty: Risk Stratification and Predictive Probability Modeling 

These authors sought to identify risk factors for adverse events (AEs) following shoulder arthroplasty and to generate predictive models to improve patient selection using a retrospective review of a single institution shoulder arthroplasty registry as well as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, including subjects undergoing hemiarthroplasty, total shoulder arthroplasty (TSA), and reverse TSA. Predicted probability of suitability for same-day discharge was calculated from multivariable logistic models for different patient subgroups based on age, comorbidities, and Charlson/Deyo Index scores. 

A total of 2314 shoulders (2079 subjects) in the institutional registry met inclusion criteria. 17% had adverse events. The most common were transfusion, bloodloss anemia, hypotension/shock, syncope,  and pulmonary problems

Factors associated with suitability for discharge included younger age, higher body mass index (BMI), male sex, and prior steroid injection.

Factors associated with adverse events included preoperative narcotic use, comorbidities (heart disease and anemia/other blood disease), and Charlson/Deyo Index score of 2.

Compared with TSA, reverse TSA was associated with less suitability for discharge.

15,254 patients were identified from the ACS-NSQIP database. 

Factors associated with unsuitability for discharge were female sex, BMI less than 35 kg/m², American Society of Anesthesiologists class III/IV, preoperative anemia, functional dependence, low preoperative albumin, and hemiarthroplasty.

The lowest risk subgroup included males 55 to 59 years old with no comorbidities nor history of narcotic use. Transfusion was the primary driver of adverse events.

The authors concluded that the majority of patients undergoing shoulder arthroplasty could safely be managed on an outpatient basis. In their institutional database, younger male patients with higher BMI were particularly likely to avoid adverse events, whereas those with certain comorbidities (anemia/blood disorder, heart disease) or history of narcotic use were somewhat more likely to have AEs. The authors found similar results on the national level, with female sex, lower BMI, significant comorbidities, and low preoperative albumin and hematocrit levels being risk factors for AEs. 

Comment: These authors have investigated patient characteristics related to adverse events after shoulder arthroplasty. While this information is helpful, avoiding these risk factors is only one component of the safety of outpatient joint replacement. Some important risk factors not mentioned are (a) history of prior problems with surgery or anesthesia and (b) history of urinary retention.

Other essential elements of successful outpatient arthroplasty include:

(1) Assurance that the patient is emotionally and intellectually "on board" with the plan for same day discharge and their responsibility for self-care and monitoring.

(2) Preoperative identification of family member or close friend who will be with patient during the first 24 hours after surgery and establishment of secure communication pathway between the surgical team and the support person.

(3) Confirmation with anesthesiologist of the plan for outpatient surgery

(4) Scheduling of case for the morning

(5) Preoperative education in wound management, pain management, physical therapy

(6) Call from surgical team to patient the night before and the evening of surgery

(7) Two hour preoperative hydration and calorie boost using clear energy shake

(8) Preoperative analgesic meds (such as Tylenol, Celebrex, Lyrica)

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Shoulder joint replacement arthroplasty - what are the complications?

Outpatient shoulder arthroplasty: outcomes, complications, and readmissions in 2 outpatient settings

These authors reported their experience with outpatient shoulder arthroplasty including 90-day complications and readmissions in 50 consecutive patients (44 anatomic total shoulder arthroplasties, 4 reverse total shoulder arthroplasties, and 2 hemiarthroplasties).  18 had had a total of 28 prior surgeries, including 4 labral repairs, 2 Latarjets, 3 capsular shifts, 4 cuff repairs, 5 debridements, and 9 others.

The average age was 56.9 6.9 years; average body mass index, 29.75 5.9; and average Charleston Comorbidity Index, 1.6 1.2. 

All patients received an interscalene block for regional anesthesia (an indwelling catheter, used at the discretion of the surgeon, remained for 48-72 hours in most cases). All arthroplasties were performed through the deltopectoral interval, with 8 patients undergoing a tenotomy and 42 undergoing a subscapularis peel. Rehabilitation protocols varied based on surgeon and type of arthroplasty. In general, all patients were kept in a sling for 6 weeks, with HA and TSA patients allowed to perform Codman exercises and supervised limited passive range of motion with physical therapy, whereas RTSA patients were limited to Codman and basic home exercises. At 6 weeks, active range of motion was initiated, with strengthening at 12 weeks. RTSA patients received physical therapy at the discretion of the attending surgeon.

The average functional scores and ranges of motion were improved. There were 6 complications (12%) (hematoma, deep venous thrombosis, axillary nerve injury, acute infection, and 2 subscapularis failures). Four of these occurred within the 90-day global period, and only 1 patient required readmission. The subscapularis failures occurred after 3 months postoperatively and required additional surgery (arthroscopic repair and revision to reverse total shoulder arthroplasty). 

Comment: These procedures were performed in the outpatient setting. These experienced surgeons carefully report the complications among 50 carefully selected patients. They observe that the key to safe and successful outpatient shoulder arthroplasty is patient selection, noting that complications, length of stay, and readmission rates increase with age, female sex, steroid use, and comorbidities (especially cardiac disease).

None of their complications appear to be related to the fact that these surgeries were performed in the outpatient setting. 

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Outpatient shoulder arthroplasty - risk factors

Ambulatory Total Shoulder Arthroplasty: A Comprehensive Analysis of Current Trends, Complications, Readmissions, and Costs

These authors queried a national insurance database for patients who underwent anatomic total shoulder arthroplasty between the fourth quarter of 2010 and 2014, comparing 706 patients undergoing ambulatory total shoulder arthroplasty to a matched group of patients undergoing inpatient total shoulder arthroplasty.

They found no statistically different complication rates or rates of readmission between the two groups. The patients undergoing ambulatory total shoulder arthroplasty had significantly lower costs (p <0.0001) at $14,722 compared with the matched controls at $18,336 in numerous itemized cost categories as well as costs related to diagnosis-related groups.

Comments: While this retrospective study of an insurance database demonstrated that ambulatory shoulder arthroplasty can result in cost savings, this study did not clarify the selection criteria for such procedures nor the particular infrastructure elements necessary to support patients having outpatient arthroplasty. The safe conduct of ambulatory shoulder arthroplasty would seem to depend on the 24/7 availability of qualified support for patients in the event of bleeding, unexpected pain, urinary retention and other medical and surgical complications.

Of interest is the factors associated with readmission after either inpatient or ambulatory arthroplasty.
It is clear that patient safety and economics are more dependent on these factors than in which setting the surgery is done.

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Consultation for those who live a distance away from Seattle.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, reverse total shoulder patient information,  CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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