Outpatient Shoulder Arthroplasty



Outpatient Shoulder Arthroplasty


Jessica Welter, DO

Thomas (Quin) Throckmorton, MD



INTRODUCTION

The number of shoulder arthroplasties performed each year is increasing at a comparable or even higher rate than that of lower extremity arthroplasty, with more than 150,000 being performed each year. Traditionally, total joint arthroplasty (TJA) has remained an inpatient procedure because of concerns over pain control, blood loss, and potential postoperative complications. However, with a growing awareness of health care costs and an emphasis on savings without sacrificing quality, attention has turned to ambulatory joint replacement.


DRIVING FACTORS

The recent history of total shoulder arthroplasty (TSA) has shown that primary and revision shoulder arthroplasty has increased at annual rates of 6% to 13% from 1993 to 2007.1 During the same time, charges also have increased at annual rates of $900 to $1700. This rising number of arthroplasties combined with the increased cost has the potential to place a financial strain on the health care system.2 At the same time, the mean length of stay (LOS) following TJA is declining.3 In a study of over 2000 patients undergoing TSA from 2005 to 2011, the LOS was 2.2 days.3 In a survey of American Shoulder and Elbow Surgeons members, 69.8% of shoulder surgeons responded that their patients had an average LOS of less than 1.5 days (unpublished data, Brolin 2017). More recently, Brolin et al4 in a comparative outpatient to inpatient study found an average LOS of 1.1 days in their group of 30 hospitalized patients.

With growing awareness of health care expenditures, there has been much emphasis on providing quality care in the most efficient and cost-effective manner possible. The United States has the world’s highest per capita health care cost—about double that of other wealthy nations.5 According to a paper published in 2016, tax-funded health expenditures totaled $1.877 trillion in 2013 and were projected to increase to $3.642 trillion by 2024.5 However, the United States has already exceeded this projection with expenditures of $3.6 trillion in 2018. Furthermore, the National Health Expenditure is now projected to grow 5.5% per year and to reach nearly $6.0 trillion by 2027.6 Public demands for improved cost control of physician services are increasing, while insurance companies seek to measure quality of care metrics. As a result, physicians are now required to provide cost-effective care cost-effective care without compromising quality. One such method of efficiency and cost savings is transitioning traditionally inpatient procedures, such as TJA, to outpatient procedures.


PATIENT SELECTION

Proper medical evaluation preoperatively is imperative to identify factors that place patients at an increased risk of a complication or readmission after shoulder arthroplasty. Anthony and colleagues found increased complications following TSA with chronic steroid use, a preoperative hematocrit of less than 38%, American Society of Anesthesiologists class 4, and an operative time longer than 2 hours.7 Congestive heart failure also was associated with an increased mortality rate. Waterman and colleagues evaluated 30-day morbidity and mortality following elective shoulder arthroplasty and found preexisting cardiac disease to be a significant risk factor.8 Both cardiac disease and increased age were associated with a higher risk of mortality, and both peripheral vascular disease (PVD) and operative time of more than 174 minutes were associated with increased complications. Courtney et al9 found in their national database study that patients who were aged more than 70 years, those with malnutrition, cardiac history, smoking history, or diabetes mellitus are at higher risk for both readmission and complications after total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Using published risk factors and consulting with our ambulatory surgery center (ASC) anesthesiology team, our center proposed an algorithm for selecting outpatient TSA candidates (FIGURE 50.1)10 and then validated it with a cohort of patients. Use of this algorithm produced a low rate of perioperative complications and no hospital admissions. The first two decision points in this algorithm are age and preoperative anemia. Patients older than 70 years are considered contraindicated for an outpatient TSA, and a preoperative hematocrit <30 warrants anemia workup and reevaluation. The second branch of decision-making involves
pulmonary and cardiac conditions. Lastly, a history of thromboembolic disease and the use of anticoagulation are evaluated. In this algorithm, a patient can still be a candidate for outpatient TSA even with a single pulmonary comorbidity and/or stable cardiovascular risk factors. To validate the algorithm, 61 outpatient shoulder arthroplasty patients were identified and followed up for the 90-day episode of care; all complications were noted. The average patient age was 58 years (range 37-69 years); 49 had anatomic TSAs; and 12 had reverse TSAs. All patients were able to be discharged home on the day of surgery. None required 23-hour stays, and no patient was subsequently admitted to the hospital. There were seven complications (11.5%), one requiring reoperation within 90 days (hematoma evacuation). Nonsurgical complications included one patient with postoperative bradycardia that resolved and one patient who became acutely hypotensive with induction of anesthesia. This surgery was then aborted and the patient had successful, uncomplicated shoulder arthroplasty in a hospital environment 1 month later. Four additional complications occurred in the 90-day episode-of-care period: two patients developed arthrofibrosis requiring additional therapy, one patient sustained a fall and traumatic rupture of subscapularis repair but declined further intervention, and one patient had mild anterior subluxation on postoperative radiographs.






Other authors have also published patient selection criteria. Biron et al11 used a machine learning model to successfully predict which patients would be considered “short stay” candidates following TSA, and Meneghin et al12 developed an outpatient arthroplasty risk assessment score that classified patients as a “low-moderate” and “not appropriate” for early discharge. Regardless of the algorithm chosen, a reliable and safe method to determine which patients are eligible for outpatient shoulder arthroplasty and those better suited to the hospital setting is critical for developing an outpatient shoulder program.


PAIN MANAGEMENT PROTOCOL

Significant advances in pain management protocols have facilitated the transition to outpatient TJA. Preoperative analgesia, multimodal pain regimens, nerve blocks, periarticular injections of long-acting local anesthetics, and patient education all help to decrease postoperative pain and subsequently the consumption of opioids.
Minimizing opioid use not only increases patient satisfaction but also decreases opioid-related adverse effects and facilitates rehabilitation. Assessment of patient expectations is vital to preoperative evaluation. Specifically, patients who have a history of anxiety or depression, a history of preoperative opioid use, or multiple medical comorbidities are at increased risk for less effective pain control.13 It is, therefore, important to identify these patients before scheduling surgery and to educate and psychologically prepare them for the planned protocol in order to effectively manage their postoperative pain. Experience and expertise of the anesthesia team can strongly influence the development of pain management protocols.


Multimodal Pain Regimens

Preemptive analgesia has been shown to reduce postoperative pain and opioid consumption postoperatively. This includes acetaminophen, nonsteroidal anti-inflammatory drugs, and gabapentinoid medications given to patients in the immediate perioperative period.13 Ongoing research is directed at optimizing the timing and dosage of these medications.


Periarticular Injections and Nerve Blocks

There is an emerging body of evidence comparing the use of periarticular injections to regional nerve blockade for treatment of postoperative pain following shoulder arthroplasty.14,15,16,17,18,19 While most studies show general equivalence in overall pain metrics, which of these is chosen is likely dependent on a combination of surgeon, institutional, and anesthesia preferences.

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Jun 23, 2022 | Posted by in ORTHOPEDIC | Comments Off on Outpatient Shoulder Arthroplasty
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