The transition to outpatient shoulder arthroplasty: a systematic review

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.

Patient-selection algorithm for outpatient shoulder arthroplasty in ambulatory surgery center: a retrospective update

BACKGROUND

Outpatient total shoulder arthroplasty (TSA) presents a safe alternative to inpatient arthroplasty, while helping meet the rapidly rising volume of shoulder arthroplasty needs and minimizing health care costs. Identifying the correct patient for outpatient surgery is critical to maintaining the safety standards with TSA. This study sought to update an ambulatory surgery center (ASC) TSA patient-selection algorithm previously published by our institution.

METHODS

A retrospective chart review of TSAs was performed in an ASC at a single institution to collect patient demographics, perioperative risk factors, and postoperative outcomes with regard to reoperations, hospital admissions, and complications. The existing ASC algorithm for outpatient TSA was altered based on collected perioperative information, review of pertinent literature, and anesthesiology recommendations.

RESULTS

A total of 319 TSAs were performed in an ASC in 298 patients over 7 years. Medically related complications occurred in 3 patients (0.9%) within 90 days of surgery, 2 of whom required hospital admission (0.6%) for acute kidney injury and pulmonary embolus. There were no instances of major cardiac events. Orthopedic-related complications occurred in 11 patients (3.4%), with hematoma development requiring evacuation and instability requiring revision being the most common causes.

CONCLUSIONS

There was a low rate of perioperative complications and hospital admissions, confirming the safety of TSAs in an ASC setting. Based on prior literature and the population included, a pre-existing patient-selection algorithm was updated to better reflect increased comfort, knowledge, and data regarding safe patient selection for TSA in an ASC.

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.

Evolution of Perioperative Pain Management in Shoulder Arthroplasty

Historically, opioids have been used as a primary conservative treatment for pain related to glenohumeral osteoarthritis (GHOA). However, this practice is concerning as it often leads to overuse, which has contributed to the current epidemic of addiction and overdoses in the United States. Studies have shown that preoperative opioid use is associated with higher complication rates and worse outcomes following surgery, particularly for shoulder arthroplasty. To address these concerns, perioperative pain management for shoulder arthroplasty has evolved over the years to the use of multimodal analgesia.

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.

Perioperative risk stratification tools for shoulder arthroplasty: a systematic review

BACKGROUND

Risk stratification tools are being increasingly utilized to guide patient selection for outpatient shoulder arthroplasty. The purpose of this study was to identify the existing calculators used to predict discharge disposition, postoperative complications, hospital readmissions, and patient candidacy for outpatient shoulder arthroplasty and to compare the specific components used to generate their prediction models.

METHODS

This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol. PubMed, Cochrane Library, Scopus, and OVID Medline were searched for studies that developed calculators used to determine patient candidacy for outpatient surgery or predict discharge disposition, the risk of postoperative complications, and hospital readmissions after anatomic or reverse total shoulder arthroplasty (TSA). Reviews, case reports, letters to the editor, and studies including hemiarthroplasty cases were excluded. Data extracted included authors, year of publication, study design, patient population, sample size, input variables, comorbidities, method of validation, and intended purpose. The pros and cons of each calculator as reported by the respective authors were evaluated.

RESULTS

Eleven publications met inclusion criteria. Three tools assessed patient candidacy for outpatient TSA, 3 tools evaluated the risk of 30- or 90-day hospital readmission and postoperative complications, and 5 tools predicted discharge destination. Four calculators validated previously constructed comorbidity indices used as risk predictors after shoulder arthroplasty, including the Charlson Comorbidity Index, Elixhauser Comorbidity Index, modified Frailty Index, and the Outpatient Arthroplasty Risk Assessment, while 7 developed newcalculators. Nine studies utilized multiple logistic regression to develop their calculators, while 1 study developed their algorithm based on previous literature and 1 used univariate analysis. Five tools were built using data from a single institution, 2 using data pooled from 2 institutions, and 4 from large national databases. All studies used preoperative data points in their algorithms with one tool additionally using intraoperative data points. The number of inputs ranged from 5 to 57 items. Four calculators assessed psychological comorbidities, 3 included inputs for substance use, and 1 calculator accounted for race.

CONCLUSION

The variation in perioperative risk calculators after TSA highlights the need for standardization and external validation of the existing tools. As the use of outpatient shoulder arthroplasty increases, these calculators may become outdated or require revision. Incorporation of socioeconomic and psychological measures into these calculators should be investigated.

Ambulatory anesthesia and discharge: an update around guidelines and trends

PURPOSE OF REVIEW

Provide an oversight of recent changes in same-day discharge (SDD) of patient following surgery/anesthesia.

RECENT FINDINGS

Enhanced recovery after surgery pathways in combination with less invasive surgical techniques have dramatically changed perioperative care. Preparing and optimizing patients preoperatively, minimizing surgical trauma, using fast-acting anesthetics as well as multimodal opioid-sparing analgesia regime and liberal prophylaxis against postoperative nausea and vomiting are basic cornerstones. The scope being to maintain physiology and minimize the impact on homeostasis and subsequently hasten and improve recovery.

SUMMARY

The increasing adoption of enhanced protocols, including the entire perioperative care bundle, in combination with increased use of minimally invasive surgical techniques have shortened hospital stay. More intermediate procedures are today transferred to ambulatory pathways; SDD or overnight stay only. The traditional scores for assessing discharge eligibility are however still valid. Stable vital signs, awake and oriented, able to ambulate with acceptable pain, and postoperative nausea and vomiting are always needed. Drinking and voiding must be acknowledged but mandatory. Escort and someone at home the first night following surgery are strongly recommended. Explicit information around postoperative care and how to contact healthcare in case of need, as well as a follow-up call day after surgery, are likewise of importance. Mobile apps and remote monitoring are techniques increasingly used to improve postoperative follow-up.

Clinical care pathways for ambulatory total shoulder arthroplasty

PURPOSE OF REVIEW

Total shoulder arthroplasty (TSA) is growing in popularity and is increasingly done on an ambulatory basis. This review examines recent developments in anesthesia and analgesia for ambulatory shoulder surgery. Pathway components are discussed and a sample pathway is described.

RECENT FINDINGS

Adoption of pathways for shoulder surgery improves patient experience by reducing pain, opioid use, and side effects while improving patient satisfaction. Long-acting nerve blockade using adjuvants like dexamethasone provide long-lasting analgesia without rebound pain. Peripheral nerve blockade provides better analgesia than peri-articular injection of local anesthetic. There are multiple approaches to nerve blockade for shoulder surgery to consider, including interscalene, superior trunk, supraclavicular, and anterior suprascapular nerve blocks. Multimodal analgesia should include acetaminophen and nonsteroidal anti-inflammatory drugs, but routine gabapentinoids should not be used.

SUMMARY

Anesthesiologists should lead the way to create and implement pathways for ambulatory total shoulder arthroplasty, incorporating appropriate patient selection, patient education, long-lasting nerve blockade, and multimodal analgesia.