90 day reverse total shoulder complications: over 14% in patients without depression and over 45% in patients with depression

Depression is not included in the Charlson Comorbidity Index calculation, yet it may be one of the most important factors in determining surgical outcomes.

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The authors of How Does Depressive Disorder Impact Outcomes in Patients with Glenohumeral Osteoarthritis Undergoing Primary Reverse Shoulder Arthroplasty? sought to compare in-hospital length of stay (LOS); medical complications; emergency department (ED) utilizations; and cost of care for patients with and without depression disorder undergoing primary reverse total shoulder (RSA).

Their retrospective query of a nationwide administrative claims database found 28,410 patients who underwent primary RSA for the treatment of glenohumeral osteoarthritis. Interestingly, of these 14% (4,084) had ICD 9 or ICD 10 codes for depression disorder (DD).

Patients with DD undergoing primary RSA had significantly longer length of stay, higher frequency of complications such as pneumonia, cerebrovascular accidents, myocardial infarctions, and other adverse events. 

Patients with DD also had a 2-3 fold increase in postoperative ED use within 90 days after surgery.

Comment: These data are interesting, both with respect to the rate of 90 day medical complications in patients without a depression diagnosis (15%) and the increased rate of these complications in patients with depression (47%). 

It is important to note that many of the complications of RSA occur well beyond the 90 postoperative period covered in this study. It would be of interest to know how the 2 and 5 year complication rates for DD and non-DD patients compare.

The study did not compare self-assessed comfort and function after RSA for patients without and with a depression diagnosis.

Some questions not answered in this study are:

(1) in a surgeon's arthroplasty practice, what is the most practical method for diagnosing depression?

(2) is depression a modifiable risk factor? (note that patients with diagnosed depressive disorder taking selective serotonin re-uptake inhibitors (SSRIs) and receiving other types of treatments for depression were excluded in this study).

(3) what is the best approach to a patient who has both depression and shoulder arthritis: 

    (a) avoid surgery because of the increased complication rate?

    (b) delay surgery until the depression has been satisfactorily treated?

    (c) proceed with surgery after informing the patient that they are at significantly increased risk for complications (would that make the patient even more depressed)?

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