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

Abstract

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.

Serious postoperative complications and reoperation after carpal tunnel decompression surgery in England: a nationwide cohort analysis

“… 1 , 2 , 28 However, as previous studies comparing surgical practices in England for upper limb conditions have shown a lower intervention rate, we consider this difference to reflect changes in clinical practice in England in comparison to other countries, rather than incomplete data capture. 29 , 30 , 31 Carpal tunnel decompression surgery was more common in women than men, especially among women in the perimenopausal age range. Longitudinal follow-up within this dataset enabled us to calculate overall serious complication rates, which show that carpal tunnel decompression is usually a safe operation.…”

Routine Health Outcome Measurement: Development, Design, and Implementation of the Hand and Wrist Cohort

“…Other commonly used cohorts consist of administrative or claim data on the hospital, regional, or national level. [29][30][31][32] To our knowledge, the present cohort is unique within the field of hand and wrist disorders because it contains a large number of patients with relatively detailed data, covering both outcomes, treatment information, and patient characteristics. A limitation, however, is that this cohort is not representative of all hand and wrist patients in The Netherlands, for example, because complex trauma patients and patients with more severe comorbidities may be treated more often elsewhere.…”

Trends in total shoulder arthroplasty from 2005 to 2018: lower complications rates and shorter lengths of stay despite patients with more comorbidities

“… 16 This trend is not unique to the United States, as England saw an even larger 5.6-fold increase in TSA volume between 1998 and 2017. 14 The use of TSA is expected to continue to rise, driven by an increasing prevalence of shoulder pathology and expanding operative indications in an aging population. 12 …”