Is outpatient shoulder arthroplasty safe? A systematic review and meta-analysis

Outpatient versus inpatient total shoulder arthroplasty: A meta-analysis of clinical outcomes and adverse events

BACKGROUND

In recent years, orthopaedic procedures have increasingly shifted from inpatient to outpatient settings. This trend includes total shoulder arthroplasty (TSA), which is being performed more frequently in outpatient facilities and ambulatory surgical centres. The purpose of this study was to compare the clinical outcomes and rates of adverse events between outpatient and inpatient TSA.

METHODS

PubMed, Cochrane, and Google Scholar (pages 1-20) databases were screened for articles comparing outpatient to inpatient TSA through June 2024, using relevant and holistic search terms. Non-comparative articles and those utilizing national databases were excluded from our study. Data on complications, myocardial infarction (MI), thromboembolic events, anaemia/transfusions, infections, readmissions, emergency department (ED) visits, revision surgery, and patient reported outcome measures at one year (Visual Analog Scale [VAS] and American Shoulder and Elbow Surgeons [ASES] score) were extracted.

RESULTS

A total of 14 articles were included in our study, involving 1070 outpatient and 1330 inpatient TSA patients. Patients in the inpatient group were older and had a higher ASA compared to the patients in the outpatient group. The outpatient TSA group was found to have significantly lower rates of overall complications (odds ratio [OR] = 0.59, p = 0.001), medical complications (OR = 0.43, p < 0.001), and readmissions (OR = 0.47, p = 0.008), as well as higher mean ASES scores (81.4 vs. 78.5, p = 0.01) when compared to the inpatient TSA group. There were no significant differences in rates of ED visits (p = 0.27), revisions (p = 0.06), and VAS scores (p = 0.15) between inpatient and outpatient TSA groups.

CONCLUSION

TSAs performed in the outpatient setting had a lower rate of overall adverse events, medical complications, readmissions, and a higher ASES score compared to inpatient TSAs. However, since patients in the inpatient group had higher ASA and were older, our results support the safety of the outpatient TSA based on the current selection criteria.

Racial and ethnic disparities in short-stay primary total shoulder arthroplasty

Background

There is a paucity of literature evaluating the utilization of short-stay total shoulder arthroplasty (TSA) in different racial groups. The purpose of this study is to compare short-stay TSA utilization and postoperative outcomes across racial groups.

Methods

The National Surgical Quality Improvement Program (NSQIP) database was queried from 2010 to 2018 to identify patients who underwent primary short-stay TSA, defined as a length of stay of less than 2 midnights. Annual proportions of short-stay TSA, demographic variables, preoperative comorbidities, and postoperative complications were compared across groups.

Results

All racial groups showed increases in the proportion of short-stay TSA cases over time, but this increase was most evident in Whites. Hispanics had increased rates of pneumonia (0.8% vs. 0.2%; p = 0.002) and transfusion (2.0% vs 1.0%; p = 0.015) compared to Whites, but no other differences in outcomes were observed between groups.

Discussion

Postoperative outcomes were similar across groups despite differing comorbidity profiles, suggesting that short-stay TSA is being implemented appropriately based on perceived preoperative risk. However, differences in utilization across groups suggest that underlying disparities may exist. Given the continued increase in short-stay TSA procedures, opportunities to resolve racial disparities are essential in mitigating the effects of social determinants of health in minority patient groups.

Same-day discharge vs. inpatient total shoulder arthroplasty: an age stratified comparison of postoperative outcomes and hospital charges

BACKGROUND

As the number of total shoulder arthroplasty (TSA) procedures increases, there is a growing interest in improving patient outcomes, limiting costs, and optimizing efficiency. One approach has been to transition these surgeries to an outpatient setting. Therefore, the purpose of this study was to conduct an age-stratified analysis comparing the 90-day postoperative outcomes of primary TSA in the same-day discharge (SDD) and inpatient (IP) settings with a specific focus on the super-elderly.

METHODS

This retrospective study included all patients who underwent primary anatomic or reverse TSA between January 2018 and December 2021 in ambulatory and IP settings. The outcome measures included length of stay (LOS), complications, hospital charges, emergency department (ED utilization), readmissions, and reoperations within 90 days following TSA. Patients with LOS ≤8 hours were considered as SDD, and those with LOS >8 hours were considered as IP. P < .05 was considered statistically significant.

RESULTS

There were 121 and 174 procedures performed in SDD and IP settings, respectively. There were no differences in comorbidity indices between the SDD and IP groups (American Society of Anesthesiologists score P = .12, Elixhauser Comorbidity Index P = .067). The SDD cohort was younger than the IP group (SDD 67.0 years vs. 73.0 IP years, P < .001), and the SDD group higher rate of intraoperative tranexamic acid use (P = .015) and lower estimated blood loss (P = .009). There were no differences in 90-day overall minor (P = .20) and major complications (P = 1.00), ED utilization (P = .63), readmission (P = .25), or reoperation (P = .51) between the SDD and IP groups. When stratified by age, there were no differences in overall major (P = .80) and minor (P = .36) complications among the groups. However, the LOS was directly correlated with increasing age (LOS = 8.4 hours in ≥65 to <75-year cohort vs. LOS = 25.9 hours in ≥80-year cohort; P < .001). There were no differences in hospital charges between SDD and IP primary TSA in all 3 age groups (P = .82).

CONCLUSION

SDD TSA has a shorter LOS without increasing postoperative major and minor complications, ED encounters, readmissions, or reoperations. Older age was not associated with an increase in the complication profile or hospital charges even in the SDD setting, although it was associated with increased LOS in the IP group. These results suggest that TSA can be safely performed expeditiously in an outpatient setting.

Trends in the Adoption of Outpatient Joint Arthroplasties and Patient Risk: A Retrospective Analysis of 2019 to 2021 Medicare Claims Data

INTRODUCTION

Total joint arthroplasties (TJAs) have recently been shifting toward outpatient arthroplasty. This study aims to explore recent trends in outpatient total joint arthroplasty (TJA) procedures and examine whether patients with a higher comorbidity burden are undergoing outpatient arthroplasty.

METHODS

Medicare fee-for-service claims were screened for patients who underwent total hip, knee, or shoulder arthroplasty procedures between January 2019 and December 2022. The procedure was considered to be outpatient if the patient was discharged on the same date of the procedure. The Hierarchical Condition Category Score (HCC) and the Charlson Comorbidity Index (CCI) scores were used to assess patient comorbidity burden. Patient adverse outcomes included all-cause hospital readmission, mortality, and postoperative complications. Logistic regression analyses were used to evaluate if higher HCC/CCI scores were associated with adverse patient outcomes.

RESULTS

A total of 69,520, 116,411, and 41,922 respective total knee, hip, and shoulder arthroplasties were identified, respectively. Despite earlier removal from the inpatient-only list, outpatient knee and hip surgical volume did not markedly increase until the pandemic started. By 2022Q4, 16%, 23%, and 36% of hip, knee, and shoulder arthroplasties were discharged on the same day of surgery, respectively. Both HCC and CCI risk scores in outpatients increased over time ( P < 0.001).

DISCUSSION

TJA procedures are shifting toward outpatient surgery over time, largely driven by the COVID-19 pandemic. TJA outpatients' HCC and CCI risk scores increased over this same period, and additional research to determine the effects of this should be pursued.

LEVEL OF EVIDENCE

Level III, therapeutic retrospective cohort study.

A Systematic Review of Patient Selection Criteria for Outpatient Total Shoulder Arthroplasty

The utilization of total shoulder arthroplasty (TSA) is increasing, driving associated annual health care costs higher. Opting for outpatient over inpatient TSA may provide a solution by reducing costs. However, there is no single set of accepted patient selection criteria for outpatient TSA. Here, the authors identify and systematically review 14 articles to propose evidence-based criteria that merit postoperative admission. Together, the studies suggest that patients with limited ability to abmluate independently or a history of congestive heart failure may benefit from postoperative at least one night of hospital based monitoring and treatment.

Outpatient versus inpatient shoulder arthroplasty outcomes using an updated patient-selection algorithm: minimum 2-year follow-up

BACKGROUND

Previous studies have demonstrated the safety and cost-effectiveness of outpatient total shoulder arthroplasty (TSA), with the majority of studies focusing on 90-day outcomes and complications. Patient selection algorithms have helped appropriately choose patients for an outpatient TSA setting. This study aimed to determine the outcomes of TSA between outpatient and inpatient cohorts with at least a 2-year follow-up.

METHODS

A retrospective review identified patients older than 18 years who underwent a TSA with a minimum of 2-year follow-up in either an inpatient or outpatient setting. Using a previously published outpatient TSA patient-selection algorithm, patients were allocated into three groups: outpatient, inpatient due to insurance requirements, and inpatient due to not meeting algorithm criteria. Outcomes evaluated included visual analog scale pain, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, range of motion (ROM), strength, complications, readmissions, and reoperations. Analysis was performed between the outpatient and inpatient groups to demonstrate the safety and efficacy of outpatient TSA with midterm follow-up.

RESULTS

A total of 779 TSA were included in this study, allocated into the outpatient (N = 108), inpatient due to insurance (N = 349), and inpatient due to algorithm (N = 322). The average age between these groups was significantly different (59.4 ± 7.4, 66.5 ± 7.5, and 72.5 ± 8.7, respectively; P < .0001). All patient groups demonstrated significant improvements in preoperative to final patient-outcomes scores, ROM, and strength. Analysis between cohorts showed similar final follow-up outcome scores, ROM, and strength, with few significant differences that are likely not clinically different, regardless of surgical location, insurance status, or meeting patient-selection algorithm. Complications, reoperations, and readmissions between all three groups were not significantly different.

CONCLUSION

This study reaffirms prior short-term follow-up literature. Transitioning appropriate patients to outpatient TSA results in similar outcomes and complications compared to inpatient cohorts with midterm follow-up.

Outpatient vs. inpatient total shoulder arthroplasty: complication rates, clinical outcomes, and eligibility parameters

Background

Improvements in total shoulder arthroplasty (TSA), fast-track surgery, multimodal anesthesia, and rehabilitation protocols have opened up the possibility of outpatient care that is now routinely practiced at our European institution. The first objective of this study was to define the TSA outpatient population and to verify that outpatient management of TSA does not increase the risk of complications. The second objective was to determine patient eligibility parameters and the third was to compare functional outcomes and identify influencing factors.

Methods

The study included 165 patients who had primary TSA (106 outpatient and 59 inpatient procedures). The operative technique was the same for both groups. Demographics, complications, readmissions, and revisions were collected. American Society of Anesthesiologists, Constant, American Shoulder and Elbow Surgeons, University of California Los Angeles shoulder, and Shoulder Pain and Disability Index scores were obtained preoperatively and at 1.5, 6, and 12 months postoperatively. Satisfaction and visual analog scale pain scores also were documented. Statistical analysis was completed using multivariate linear regression.

Results

Outpatients were significantly younger and had lower American Society of Anesthesiologists scores than inpatients. The rates of complications, readmissions, and reoperations were not significantly different between groups. Outpatient surgery was not an independent risk factor for complications. At 1.5 months, better outcomes were noted in the outpatient group for all scores, and these reached statistical significance. Distance to home, dominant side, operative time, and blood loss were not associated with functional results. Multivariate analysis demonstrated that outpatient care was significantly associated with improved scores at 1.5 months and did not affect functional outcomes at 6 and 12 months.

Conclusion

This study reports the results of routine outpatient TSA within a European healthcare system. TSA performed in an outpatient setting was not an independent risk factor for complications and seemed to be an independent factor in improving early functional results.

Anatomic total shoulder arthroplasty with a nonspherical humeral head and inlay glenoid: 90-day complication profile in the inpatient versus outpatient setting

BACKGROUND

Total shoulder arthroplasty (TSA) with a nonspherical humeral head component and inlay glenoid is a successful bone-preserving treatment for glenohumeral arthritis. This study aimed to describe the 90-day complication profile of TSA with this prosthesis and compare major and minor complication and readmission rates between inpatient- and outpatient-procedure patients.

METHODS

A retrospective review was performed of a consecutive cohort of patients undergoing TSA with a nonspherical humeral head and inlay glenoid in the inpatient and outpatient settings by a single surgeon between 2017 and 2022. Age, sex, body mass index, American Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI), and 90-day complication and readmission rates were compared between inpatient and outpatient groups.

RESULTS

One hundred eighteen TSAs in 111 patients were identified. Mean age was 64.9 years (range, 39-90) and 65% of patients were male. Ninety-four (80%) and 24 (20%) patients underwent outpatient and inpatient procedures, respectively. Four complications (3.4%) were recorded: axillary nerve stretch injury, isolated ipsilateral arm deep venous thrombosis (DVT), ipsilateral arm DVT with pulmonary embolism requiring readmission, and gastrointestinal bleed requiring readmission. There were no reoperations or other complications. Outpatients were younger with lower ASA and CCI scores than inpatients; however, there was no difference in complications (1/24 vs. 3/94, P=1.00) or readmissions (1/24 vs. 1/94, P=0.37) between these two groups.

CONCLUSIONS

TSA with a nonspherical humeral head and inlay glenoid can be performed safely in both inpatient and outpatient settings. Rates of early complications and readmissions were low with no difference according to surgical setting. Level of evidence: IV.

Identifying risk factors for 30-day readmission after outpatient total shoulder arthroplasty to aid in patient selection

Background

A recent meta-analysis comparing inpatient and outpatient total shoulder arthroplasty (TSA) showed no statistically significant differences in complications, readmissions, revisions, and infections. However, there remains no research on the appropriate patient selection for outpatient TSA surgeries. This retrospective review seeks to aid surgeons in refining a safe patient selection algorithm by evaluating risk factors through a large database analysis of TSA surgeries.

Methods

Patients who underwent TSA between 2015 and 2020 were identified in the National Surgical Quality Improvement Program database. Patients with a hospital stay of 0 days were designated as outpatient procedures. Multivariate analyses were used to determine risk factors for 30-day readmission following outpatient TSA and whether risk factors remained significant following overnight hospital stay.

Results

A total of 2431 outpatient TSA patients were identified. The incidence of 30-day readmission was 1.8%. The majority of readmissions were due to pulmonary complications. The clinically significant risk factors for 30-day readmission were chronic steroid use (odds ratio [OR] 3.55, 95% confidence interval [CI] 1.34-9.43; P = .011), chronic obstructive pulmonary disease (COPD) (OR 3.11, 95% CI 1.16-8.34; P = .024), and current smoking status (OR 2.27, 95% CI 1.02-5.03; P = .045). After overnight hospital stay, chronic steroid use and current smoking status were not significant, but COPD remained significant.

Conclusion

Patients with chronic steroid use, COPD, or current smoking status are at increased risk for 30-day readmission. Inpatient hospital stay appears to benefit patients with chronic steroid use and current smoking status. Patients with COPD should be admitted for inpatient stay postoperatively but may still have high 30-day readmission rates following discharge.

Smoking is an independent risk factor for complications in outpatient total shoulder arthroplasty

Background

Smoking is a major public health concern and an important risk factor to consider during preoperative planning. Smoking has previously been reported as the single most important risk factor for developing postoperative complications after elective orthopedic surgery. However, there is limited literature regarding the postoperative complications associated with smoking following outpatient total shoulder arthroplasty (TSA). The purpose of this study was to investigate the association between smoking status and early postoperative complications following outpatient TSA using a large national database.

Methods

We queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients who underwent TSA between 2015 and 2020. Smoking status in National Surgical Quality Improvement Program is defined as any episode of smoking with 12 months prior to surgery. Bivariate logistic regression was used to identify patient demographics, comorbidities, and complications significantly associated with current or recent smoking status in patients who underwent TSA with a length of stay (LOS) of 0. Multivariate logistic regression, adjusted for all significantly associated patient demographics and comorbidities, was used to identify associations between current or recent smokers and 30-day postoperative complications.

Results

22,817 patients were included in the analysis, 2367 (10.4%) were current or recent smokers and 20,450 (89.6%) were nonsmokers. These patients were further stratified based on LOS: 2428 (10.6%) patients had a LOS of 0 days, 15,267 (66.9%) patients had a LOS of 1 day, and 5122 (22.4%) patients had a LOS of 2 days. Within the outpatient cohort (LOS = 0), 202 (8.3%) patients were current or recent smokers and 2226 (91.7%) were nonsmokers. Multivariate logistic regression identified current or recent smoking status to be independently associated with higher rates of myocardial infarction (odds ratio [OR] 9.80, 95% confidence interval [CI] 1.48-64.96; P = .018), deep vein thrombosis (OR 20.05, 95% CI 1.63-247.38; P = .019), and readmission (OR 2.82, 95% CI 1.19-6.67; P = .018) following outpatient TSA. Readmission was most often due to pulmonary complication (n = 10, 22.7%).

Conclusion

Current or recent smoking status is independently associated with higher rates of myocardial infarction, deep vein thrombosis, and readmission following TSA performed in the outpatient setting. Current or recent smokers may benefit from an inpatient setting of minimum 2 nights. As outpatient TSA becomes increasingly popular, refining proper patient selection criteria is imperative to optimizing postoperative outcomes.

Validated Wearable Device Shows Acute Postoperative Changes in Sleep Patterns Consistent With Patient-Reported Outcomes and Progressive Decreases in Device Compliance After Shoulder Surgery

Purpose

To assess the utility of a validated wearable device (VWD) in examining preoperative and postoperative sleep patterns and how these data compare to patient-reported outcomes (PROs) after rotator cuff repair (RCR) or total shoulder arthroplasty (TSA).

Methods

Male and female adult patients undergoing either RCR or TSA were followed up from 34 days preoperatively to 6 weeks postoperatively. Sleep metrics were collected using a VWD in an unsupervised setting. PROs were assessed using the following validated outcome measures: Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function questionnaire; American Shoulder and Elbow Surgeons self-evaluation questionnaire; visual analog scale assessing pain; and Disabilities of the Arm, Shoulder and Hand questionnaire. Data were analyzed preoperatively and at 2-week intervals postoperatively with χ2 analysis to evaluate device compliance. Sleep metrics and PROs were evaluated at each interval relative to preoperative values within each surgery type with an analysis of variance repeated on time point. The relation between sleep metrics and PROs was assessed with correlation analysis.

Results

A total of 57 patients were included, 37 in the RCR group and 20 in the TSA group. The rate of device compliance in the RCR group decreased from 84% at surgery to 46% by 6 weeks postoperatively (P < .001). Similarly, the rate of device compliance in the TSA group decreased from 81% to 52% (P < .001). Deep sleep decreased in RCR patients at 2 to 4 weeks (decrease by 10.99 ± 3.96 minutes, P = .021) and 4 to 6 weeks postoperatively (decrease by 13.37 ± 4.08 minutes, P = .008). TSA patients showed decreased deep sleep at 0 to 2 weeks postoperatively (decrease by 12.91 ± 5.62 minutes, P = .045) and increased rapid eye movement sleep at 2 to 4 weeks postoperatively (increase by 26.91 ± 10.70 minutes, P = .031). Rapid eye movement sleep in the RCR group and total sleep in the TSA group were positively correlated with more favorable PROs (P < .05).

Conclusions

VWDs allow for monitoring components of sleep that offer insight into potential targets for improving postoperative fatigue, pain, and overall recovery after shoulder surgery. However, population demographic factors and ease of device use are barriers to optimized patient compliance during data collection.

Level of Evidence

Level IV, diagnostic case series.

Shoulder Arthroplasty as a Day Case: Is It Better?

Introduction: A retrospective case-controlled study was performed to evaluate the outcomes of shoulder arthroplasty performed as a day case in carefully selected patients, compared to the traditional inpatient approach. Materials and Methods: Patients who had total or hemiarthroplasty of the shoulder performed as a day case or inpatient procedure were recruited. The primary outcome compared rates of uneventful recovery, defined by the absence of complications or readmission to the hospital within six months of surgery, between the inpatient and outpatient groups. Secondary outcomes included examiner-determined functional and patient-determined pain scores at one, six, twelve, and twenty-four weeks post-surgery. A further assessment of patient-determined pain scores was carried out at least two years post-surgery (5.8 ± 3.2). Results: 73 patients (36 inpatients and 37 outpatients) were included in the study. Within this time frame, 25/36 inpatients (69%) had uneventful recoveries compared to 24/37 outpatients (65%) (p = 0.17). Outpatients showed significant improvement over pre-operative baseline levels in more secondary outcomes (strength and passive range-of-motion) by six months post-operation. Outpatients also performed significantly better than inpatients in external rotation (p < 0.05) and internal rotation (p = 0.05) at six weeks post-surgery. Both groups showed significant improvement compared to pre-operative baselines in all patient-determined secondary outcomes except the activity level at work and sports. Inpatients, however, experienced less severe pain at rest at six weeks (p = 0.03), significantly less frequent pain at night (p = 0.03), and extreme pain (p = 0.04) at 24 weeks, and less severe pain at night at 24 weeks (p < 0.01). By a minimum of two years post-operation, inpatients were more comfortable repeating their treatment setting for future arthroplasty (16/18) compared to outpatients (7/22) (p = 0.0002). Conclusions: At a minimum of two years of follow-up, there were no significant differences in rates of complications, hospitalizations, or revision surgeries between patients that underwent shoulder arthroplasty as an inpatient versus an outpatient. Outpatients demonstrated superior functional outcomes but reported more pain at six months post-surgery. Patients in both groups preferred inpatient treatment for any future shoulder arthroplasty. What is Known About This Subject: Shoulder arthroplasty is a complex procedure and has traditionally been performed on an inpatient basis, with patients admitted for six to seven days post-surgery. One of the primary reasons for this is the high level of post-operative pain, usually treated with hospital-based opioid therapy. Two studies demonstrated outpatient TSA to have a similar rate of complications as inpatient TSA; however, these studies only examined patients within a shorter-term 90-day post-operative period and did not evaluate functional outcomes between the two groups or in the longer term. What This Study Adds to Existing Knowledge: This study provides evidence supporting the longer-term results of shoulder arthroplasty done as a day case in carefully selected patients, which are comparable to outcomes in patients that are admitted to the hospital post-surgery.

Outpatient total shoulder arthroplasty in the ambulatory surgery center: a comparison of early complications in patients with and without glenoid bone loss

Background

The purpose of this study is to compare the 90-day complications and readmission rates between patients undergoing total shoulder arthroplasty (TSA) in an ambulatory surgery center (ASC) with glenoid bone loss requiring an augmented glenoid component compared to patients without bone loss.

Methods

This is a retrospective cohort study of patients undergoing outpatient TSA at an ASC (2018-2021). Readmission, direct transfer, and complications were recorded. Major and minor complications were compared. Secondary outcomes included operative time, estimated blood loss, range of motion, and patient-reported outcome measures.

Results

There were 44 patients (45 shoulders) included in the study, 20 with augmented implants for glenoid bone loss and 25 nonaugmented with a concentric glenoid. There were no statistical differences in demographics. Two complications were seen in both the augmented and nonaugmented groups (10% vs. 8%). There were no readmissions or direct transfers. The augmented group had significantly increased preoperative glenoid retroversion (23° vs. 9°, P < .05), posterior humeral head subluxation (78% vs. 61%., P < .05), and longer operative time (124.4 min vs. 112.3 min., P < .05). Patient-specific instrumentation was used in 60% of augmented cases and 29% of nonaugmented cases.

Conclusion

There was no significant difference in complications, direct transfers, or readmissions between patients with and without glenoid bone loss being treated in an outpatient ASC. The augmented group had significantly worse preoperative deformities, longer operative times, and increased utilization of patient-specific instrumentation. Outpatient TSA in the setting of glenoid bone loss requiring augmentation was found to be safe and effective at a stand-alone ASC.

Safety and short-term outcomes of anatomic vs. reverse total shoulder arthroplasty in an ambulatory surgery center

BACKGROUND

A scarcity of literature exists comparing outcomes of outpatient anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA). This study was performed to compare early outcomes between the 2 procedures in a freestanding ambulatory surgery center (ASC) and to determine if the addition of preoperative interscalene nerve block (ISNB) with periarticular liposomal bupivacaine injection (PAI) in the postanesthesia care unit (PACU) would improve outcomes over PAI alone.

METHODS

Medical charts of all patients undergoing outpatient primary aTSA or rTSA at 2 ASCs from 2012 to 2020 were reviewed. A total of 198 patients were ultimately identified (117 aTSA and 81 rTSA) to make up this retrospective cohort study. Patient demographics, PACU outcomes, complications, readmissions, reoperations, calls to the office, and unplanned clinic visit rates were compared between procedures. PACU outcomes were compared between those receiving ISNB with PAI and those receiving PAI alone.

RESULTS

Patients undergoing rTSA were older (61.1 vs. 55.7 years, P < .001) and more likely to have American Society of Anesthesiologists (ASA) class 3 (51.9% vs. 41.0%, P = .050) compared to patients having aTSA. No patient required an overnight stay. Time in the PACU before discharge (89.1 vs. 95.6 minutes, P = .231) and pain scores at discharge (3.0 vs. 3.0, P = .815) were similar for aTSA and rTSA, respectively. One intraoperative complication occurred in the aTSA group (posterior humeral circumflex artery injury) and 1 in the rTSA group (calcar fracture) (P = .793). Ninety-day postoperative total complication (7.7% vs. 7.4%), shoulder-related complication (6.0% vs. 6.2%), medical-related complication (1.7% vs. 1.2%), admission (0.8% vs. 2.5%), reoperation (2.6% vs. 1.2%), and unplanned clinic visit (6.0% vs. 6.1%) rates were similar between aTSA and rTSA, respectively (P ≥ .361 for all comparisons). At 1 year, there were 8 reoperations and 15 complications in the aTSA group compared with 1 reoperation and 8 complications in the rTSA group (P = .091 and P = .818, respectively). Patients who had ISNB spent less time in PACU (75 vs. 97 minutes, P < .001), had less pain at discharge (0.2 vs. 3.9, P < .001), and consumed less oral morphine equivalents in the PACU (1.2 vs. 16.6 mg, P < .001).

CONCLUSION

Early postoperative outcomes and complication rates were similar between the 2 groups, and all patients were successfully discharged home the day of surgery. The addition of preoperative ISNB led to more efficient discharge from the ASC with less pain in the PACU.

A validated preoperative risk prediction tool for extended inpatient length of stay following anatomic or reverse total shoulder arthroplasty

BACKGROUND

Recent work has shown inpatient length of stay (LOS) following shoulder arthroplasty to hold the second strongest association with overall cost (after implant cost itself). In particular, a preoperative understanding for the patients at risk of extended inpatient stays (≥3 days) can allow for counseling, optimization, and anticipating postoperative adverse events.

METHODS

A multicenter retrospective review was performed of 5410 anatomic (52%) and reverse (48%) total shoulder arthroplasties done at 2 large, tertiary referral health systems. The primary outcome was extended inpatient LOS of at least 3 days, and over 40 preoperative sociodemographic and comorbidity factors were tested for their predictive ability in a multivariable logistic regression model based on the patient cohort from institution 1 (derivation, N = 1773). External validation was performed using the patient cohort from institution 2 (validation, N = 3637), including area under the receiver operator characteristic curve (AUC), sensitivity, specificity, and positive and negative predictive values.

RESULTS

A total of 814 patients, including 318 patients (18%) in the derivation cohort and 496 patients (14%) in the validation cohort, experienced an extended inpatient LOS of at least 3 days. Four hundred forty-five (55%) were discharged to a skilled nursing or rehabilitation facility. Following parameter selection, a multivariable logistic regression model based on the derivation cohort (institution 1) demonstrated excellent preliminary accuracy (AUC: 0.826), with minimal decrease in accuracy under external validation when tested against the patients from institution 2 (AUC: 0.816). The predictive model was composed of only preoperative factors, in descending predictive importance as follows: age, marital status, fracture case, ASA (American Society of Anesthesiologists) score, paralysis, electrolyte disorder, body mass index, gender, neurologic disease, coagulation deficiency, diabetes, chronic pulmonary disease, peripheral vascular disease, alcohol dependence, psychoses, smoking status, and revision case.

CONCLUSION

A freely-available, preoperative online clinical decision tool for extended inpatient LOS (≥ 3 days) after shoulder arthroplasty reaches excellent predictive accuracy under external validation. As a result, this tool merits consideration for clinical implementation, as many risk factors are potentially modifiable as part of a preoperative optimization strategy.

Histopathological Examination and Endoscopic Sinusectomy: Is It Possible?

Introduction

Although carcinomatous degeneration is a rare occurrence, some authors support the need for a histopathological examination after pilonidal cyst excision. Today, minimally invasive techniques are widely spread for the treatment of pilonidal sinus disease but opposed to standard procedures, these techniques could not allow to perform a histopathological examination because of the absence of a specimen. The aim of this two-institutions study is to evaluate whether histopathological examination of the pilonidal sinus excision material can be successfully performed after an endoscopic ablation of the cyst.

Materials and Methods

We identified all consecutive patients from January 2021 to September 2021 with diagnosis of pilonidal sinus disease who underwent Video Assisted Ablation of Pilonidal Sinus (VAAPS) followed by histopathological examination.

Results

A total of 45 patients were included in the study. All patients were Caucasians and aged below 50 years. Nine of them underwent surgery due to recurrence of PSD. No evidence of malignancy was detected in the histopathological examination of the pilonidal sinus sampling material.

Discussion

We were able to send pilonidal sinus sampling material for a histopathological examination in all patients who underwent minimally invasive technique for the treatment of pilonidal sinus disease. No evidence of malignancy was found in any of the 45 samples. Our findings prove that minimally invasive ablation of pilonidal sinus does not preclude histopathological examination of the cysts.

Comparison of outpatient vs. inpatient anatomic total shoulder arthroplasty: a propensity score–matched analysis of 20,035 procedures

Background

As the proportion of anatomic total shoulder arthroplasty (aTSA) operations performed at outpatient surgical sites continues to increase, it is important to evaluate the clinical implications of this evolution in care.

Methods

Patients who underwent TSA for glenohumeral osteoarthritis from 2007 to 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Demographic data and 30-day outcomes were collected, and patients were separated into inpatient and outpatient (defined as same day discharge) groups. To control for confounding variables, a propensity score–matching algorithm was utilized. Outcomes included 30-day adverse events, readmission, and operative time.

Results

A total of 20,035 patients who underwent aTSA between 2007 and 2019 were identified: 18,707 inpatient aTSAs and 1328 outpatient aTSAs. On matching, there were no significant differences in patient characteristics between inpatient and outpatient cohorts. Patients who underwent outpatient aTSA were less likely to experience a serious adverse event when compared with their matched inpatient aTSA counterparts (outpatient: 1.1% vs. inpatient: 2.1%, P = .03). Outpatient aTSA was associated with similar rates of all specific individual complications and readmissions (1.5% vs. 1.9%, P = .31).

Conclusion

When compared with a propensity score–matched cohort of inpatient counterparts, the present study found outpatient aTSA was associated with significantly reduced severe adverse events and similar readmission rates. These findings support the growing use of outpatient aTSA in appropriately selected patients.