Relative Complications and Trends of Outpatient Total Shoulder Arthroplasty

Abstract

Outpatient arthroplasty is an appealing option among select patient populations as a mechanism for reducing health care expenditure. The purpose of this study was to determine the nationwide trends and complication profile of outpatient total shoulder arthroplasty (TSA). The authors reviewed a national administrative claims database to identify patients undergoing TSA as outpatients and inpatients from 2007 to 2016. The incidence of perioperative surgical and medical complications was determined by querying for relevant International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes. Multivariate logistic regression adjusted for age, sex, and Charlson Comorbidity Index was used to calculate odds ratios of complications among outpatients relative to inpatients undergoing TSA. The query identified 1555 patients who underwent outpatient TSA and 15,987 patients who underwent inpatient TSA. The median age was in the 70 to 74 years age group in both the outpatient and the inpatient cohorts, and the age distribution was comparable between the 2 cohorts (P=.287). The incidence of both outpatient (P<.001) and inpatient (P<.001) TSA increased during the study period. On adjustment for age, sex, and comorbidities, patients undergoing outpatient TSA had significantly lower rates of stiffness requiring manipulation under anesthesia (outpatient, 1.09%; inpatient, 2.35%; odds ratio, 0.52; 95% confidence interval, 0.38-0.71; P<.001) and higher rates of postoperative surgical site infections requiring reoperation (outpatient, 0.90%; inpatient, 0.65%; odds ratio, 1.65; 95% confidence interval, 1.15-2.35; P<.001) at 1 year. Rates of all other postoperative complications were comparable. Ambulatory TSA is increasing in incidence nationwide and is associated with an overall favorable postoperative complication profile. [Orthopedics. 2018; 41(3):e400-e409.].

Outpatient Shoulder Arthroplasty—A Systematic Review

“…Following full text review, 26 articles were included in the review (Figure 1). Of the included studies, 18 articles discussed complications, readmissions, and safety, [16][17][18][19]21,22,[24][25][26][27][28][29][30][31][32][33]40,41 7 articles discussed patient selection, 21,[27][28][29][30][31]40 6 articles discussed pain management, 20,28,[34][35][36][37] 6 articles discussed the cost implications of outpatient surgery, 15,22,23,30,38,41 2 articles discussed patient satisfaction, 24,32 and 1 article discussed surgeon satisfaction. 15 The level of evidence of the included articles ranges from Level II to Level V.…”

“…16,17,24,32,40 Brolin et al found no statistical difference between inpatient (10%) and outpatient (13%) complication rates when comparing 30 inpatient and outpatient SA performed by a single surgeon, 29 and Arshi et al found higher rates of surgical site infections (SSI) requiring irrigation and debridement at 6 months (OR ¼ 1.49; 95% confidence interval (CI), 1.01-2.19; P ¼ .045) and 1 year (OR ¼ 1.65; 95% CI, 1.15-2.35; P < .001) in an outpatient SA cohort. 26 Medical complications were more common in inpatient cohorts relative to outpatient SA patients, with complications ranging from 0%-17.7% for inpatients and 0%-15.9% for outpatients. 16,18,21,22,24,25,28,30,31 Common complications identified in the inpatient vs outpatient cohorts were blood transfusion (range, 4.48-4.7% vs 0.49-3.5%), urinary tract infection (range 0.9-8.7% vs 0.58-6.8%) and acute kidney injury (range, 0.4-4.3% vs 0-4.5%).…”

“…The 18 studies examining complications and safety of outpatient SA fall into two categories: retrospective cohorts and series from single centers [16][17][18]22,24,28,29,32,33,40 and larger database or registry studies (Table 1). 19,21,[25][26][27]30,31,41 Seven studies found higher complications with inpatient SA, 18,21,27,28,30,31,33 one study found higher complications in outpatient SA, 25 four studies found no differences in complications or readmissions, 19,22,29,41 one study had mixed findings, 26 and five studies did not compare inpatient and outpatient SA. 16,17,24,32,40 Brolin et al found no statistical difference between inpatient (10%) and outpatient (13%) complication rates when comparing 30 inpatient and outpatient SA performed by a single surgeon, 29 and Arshi et al found higher rates of surgical site infections (SSI) requiring irrigation and debridement at 6 months (OR ¼ 1.49; 95% confidence interval (CI), 1.01-2.19; P ¼ .045) and 1 year (OR ¼ 1.65; 95% CI, 1.15-2.35; P < .001) in an outpatient SA cohort.…”

The safety of outpatient total shoulder arthroplasty: a systematic review and meta-analysis

“…The revision rates were reported in three studies, with a revision incidence of 1.9% (N = 50) in the outpatient group and 1.6% (N = 346) in the inpatient group. At 12 month follow-up, Cancienne et al [8] and Arshi et al [29] found no statistically significant difference in TSA revision at 12 months. Similarly, Erickson et al [18] reported no difference in revision between both groups at 24 months.…”

“…Additionally, Cancienne et al [8] found that outpatient TSA had significantly less urinary tract infections (P = 0.003) and less blood transfusions (P = 0.028) [8]. On the other hand, Arshi et al [29] found that outpatient TSA was associated with higher rates of surgical site infections.…”