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.
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