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

Cancienne, Jourdan M.; Brockmeier, Stephen F.; Gulotta, Lawrence V.; Dines, David M.; Werner, Brian C.

doi:10.2106/jbjs.16.00287

Cited by 124 publications

(145 citation statements)

References 27 publications

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“… 39 Studies that do present risk estimates at 30 and 90 days post-surgery are typically limited by small sample size and again are skewed by the inclusion of trauma and revision procedures. 40 41 42 We did not include additional estimates of symptomatic deep vein thrombosis in our study.…”

Section: Discussionmentioning

confidence: 99%

Serious adverse events and lifetime risk of reoperation after elective shoulder replacement: population based cohort study using hospital episode statistics for England

Craig

Lane

Carr

et al. 2019

BMJ

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ObjectivesTo provide accurate risk estimates of serious adverse events after elective shoulder replacement surgery for arthritis, including age and sex specific estimates of the lifetime risk of revision surgery.DesignPopulation based cohort study.SettingHospital episode statistics for NHS England, including civil registration mortality data.Participants58 054 elective shoulder replacements in 51 895 adults (aged ≥50 years) between April 1998 and April 2017.Main outcome measuresThe lifetime risk of revision surgery, calculated using an actuarial life table approach and the cumulative probability method. Rates of serious adverse events at 30 and 90 days post-surgery: pulmonary embolism, myocardial infarction, lower respiratory tract infection, acute kidney injury, urinary tract infection, cerebrovascular events, and all cause death. Secondary outcome measures were the number of surgeries performed each year and Kaplan-Meier estimates of revision risk at 3, 5, 10, and 15 years.ResultsThe number of shoulder replacements performed each year increased 5.6-fold between 1998 and 2017. Lifetime risks of revision surgery ranged from 1 in 37 (2.7%, 95% confidence interval 2.6% to 2.8%) in women aged 85 years and older to 1 in 4 (23.6%, 23.2% to 24.0%) in men aged 55-59 years. The risks of revision were highest during the first five years after surgery. The risk of any serious adverse event at 30 days post-surgery was 1 in 28 (3.5%, 3.4% to 3.7%), and at 90 days post-surgery was 1 in 22 (4.6%, 4.4% to 4.8%). At 30 days, the relative risk of pulmonary embolism compared with baseline population risk was 61 (95% confidence interval 50 to 73) for women aged 50-64. Serious adverse events were associated with increasing age, comorbidity, and male sex. 1 in 5 (21.2%, 17.9% to 25.1%) men aged 85 years and older experienced at least one serious adverse event within 90 days.ConclusionsYounger patients, particularly men, need to be aware of a higher likelihood of early failure of shoulder replacement and the need for further and more complex revision replacement surgery. All patients should be counselled about the risks of serious adverse events. These risks are higher than previously considered, and for some could outweigh any potential benefits. Our findings caution against unchecked expansion of shoulder replacement surgery in both younger and older patients. The more accurate age and sex specific estimates of risk from this study are long overdue and should improve shared decision making between patients and clinicians.Study registrationClinicalTrials.govNCT03573765.

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Section: Discussionmentioning

confidence: 99%

Serious adverse events and lifetime risk of reoperation after elective shoulder replacement: population based cohort study using hospital episode statistics for England

Craig

Lane

Carr

et al. 2019

BMJ

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“…In particular, policymakers and hospitals are frequently looking at length of stay (LOS) after surgery as an area of focus for improvement, with recent interest in outpatient TSA 21 . According to an insurance-based database, outpatient TSA results in a $3614 cost reduction compared with matched inpatients 7 …”

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confidence: 99%

Safety and patient satisfaction of outpatient shoulder arthroplasty

et al. 2018

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BackgroundThere is increasing interest in outpatient shoulder arthroplasty (SA); however, the clinical evidence behind this practice is sparse. The purpose of this study was to assess the safety of outpatient SA performed in an ambulatory surgery center and to determine patient factors that are associated with increased risk for perioperative complications or dissatisfaction.MethodsPatient demographics and operative variables were collected retrospectively for patients undergoing outpatient SA at 2 ambulatory surgery centers with a minimum follow-up of 90 days. Patients completed a postsurgery questionnaire about their experience, satisfaction, pain control, and health care use.ResultsForty-one anatomic total SAs (n = 32) and reverse SAs (n = 9) with a mean follow-up of 60 weeks (16.4 weeks-3 years) were included. The mean age, body mass index, Charlson Comorbidity Index, and American Society of Anesthesiologists class were 60.6 ± 4.8 years, 31.8 ± 6.6, 2.9 ± 1.9, and 2.3 ± 0.6, respectively. Three (7.3%) minor complications occurred within 90 days of the SA, none before first follow-up. Two patients stayed in the ambulatory surgery center 23-hour observation unit. Thirty-five patients (85.4%) completed the questionnaire, of whom 97.0% (n = 32) were satisfied with the outpatient procedure. Two patients had difficulties with postoperative pain control and were taking chronic narcotic medication before surgery.ConclusionOutpatient SA in an ambulatory surgery center is safe with high patient satisfaction and low rates of perioperative complications. Although larger cohorts are required to adequately determine which patients will be appropriate candidates for an outpatient SA, our findings do suggest that patients with a history of preoperative narcotic use may have difficulties or dissatisfaction with outpatient SA.

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“…Some of these variables include increased body mass index, comorbid cardiac disease, vascular disease, tobacco use, perioperative blood transfusion, and insurance status. 121314151617181920 With increased emphasis by the Centers for Medicare and Medicaid Services on value-based reimbursement programs and an overall surgeon concern for improving patient outcomes, it is essential to appropriately risk stratify patients and medically optimize patients before shoulder arthroplasty. This step is especially important in the elderly patient population because of an increased number and severity of medical comorbidities.…”

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Thirty-day Complications and Readmission Rates in Elderly Patients After Shoulder Arthroplasty

et al. 2018

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Introduction:Shoulder arthroplasty procedures are increasingly being performed in older patients despite an increased perioperative risk. The purpose of this study is to determine the complications and 30-day readmission rates in the elderly population after shoulder arthroplasty and hemiarthroplasty.Methods:Total shoulder arthroplasty, reverse total shoulder arthroplasty, and hemiarthroplasty cases were collected from the National Surgical Quality Improvement Program database from 2006 to 2015. The 30-day complication and readmission rates, surgical time, discharge destination, and total hospital length of stay were calculated, comparing patients by age (elderly: ≥80 years; older: 65 to 79 years; younger: <65 years). Multivariable logistic regression analysis was performed to identify variables associated with any complication within 30 days of surgery.Results:Of 11,450 patients, 1,956 (17.1%) underwent shoulder hemiarthroplasty and 9,494 (82.9%) underwent total shoulder arthroplasty. By age group, 1,708 (14.9%) were ≥80, 6,073 (53.0%) were 65 to 79, and 3,669 (32.0%) were <65. The overall 30-day postoperative complication rate was significantly higher in elderly patients (15.3% versus 8.2% versus 6.8%; P < 0.001), length of stay (2.6 versus 2.1 versus 1.8 days; P < 0.001), and unplanned readmissions (5.5% versus 2.6% versus 2.3%; P < 0.001). The strongest independent variables significantly associated with any complication included revision arthroplasty indication (odds ratio [OR], 4.34; P < 0.001), fracture indication (OR, 4.14; P < 0.001), and history of cardiac disease (OR, 2.33; P < 0.001), followed by elderly age (OR, 2.01; P < 0.001).Conclusions:The 15.3% complication rate (major, 4.8%; minor, 10.7%), 2.6 days of average length of stay, and 5.5% unplanned readmission among elderly patients (>80) are significantly higher than younger patients. Although surgical indications and comorbidities are higher-quality predictors of complications, elderly patients should be appropriately counseled and medically optimized according to the perioperative risk profile before surgery.

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

Abstract: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cited by 124 publications

References 27 publications

Serious adverse events and lifetime risk of reoperation after elective shoulder replacement: population based cohort study using hospital episode statistics for England

Serious adverse events and lifetime risk of reoperation after elective shoulder replacement: population based cohort study using hospital episode statistics for England

Safety and patient satisfaction of outpatient shoulder arthroplasty

Thirty-day Complications and Readmission Rates in Elderly Patients After Shoulder Arthroplasty

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