Outpatient versus inpatient shoulder arthroplasty outcomes using an updated patient-selection algorithm: minimum two-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 (VAS) pain, American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, range of motion (ROM), strength, complications, re-admissions, and re-operations. 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 < 0.0001). 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 mid-term follow-up.

Patients undergoing reverse total shoulder arthroplasty have less pain and require fewer opioid pain medications compared to anatomic total shoulder arthroplasty in the early postoperative period: a retrospective review.

BACKGROUND: Recovery after anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) has many similarities; however, recently surgeons have suggested patients undergoing rTSA have a less difficult postoperative course with less pain compared with aTSA patients. Given the heightened awareness to postoperative pain control and opioid consumption, as well as the expanding indications for rTSA, we sought to determine the differences in pain and opioid consumption between aTSA and rTSA patients in a 12-week postoperative period. METHODS: A retrospective chart review was performed to identify all patients who underwent a primary aTSA or rTSA from January 2013 to April 2018 at a single institution. Patients with recorded visual analog scale (VAS) and American Shoulder and Elbow Surgeons scores were included for analysis. Revision arthroplasties were excluded. VAS scores were recorded preoperatively and at standard 2-week, 6-week, and 12-week postoperative time points. P values < .05 were considered statistically significant, except where Bonferroni corrections were applied. RESULTS: A total of 690 patients underwent TSA (278 aTSA, 412 rTSA). Preoperatively, aTSA and rTSA patient groups had similar VAS scores (6 vs. 6, P = .38). Postoperatively, the aTSA group had a higher VAS at the 6-week visit, compared with rTSA patients (2.8 vs. 2.2, P = .003). aTSA patients remained on opioids at a higher rate at the 2-week (62.4% vs. 45.6%, P ≤ .001) time period. aTSA patients needed more opioid prescription refills before the 2-week (61.7% vs. 45.5%, P ≤ .001) and 6-week (40.4% vs. 30.7%, P = .01) follow-up visits. CONCLUSIONS: Despite similar preoperative VAS and rates of preoperative opioid use, aTSA patients required more opioid medication refills and remained on opioids for a longer duration in the early postoperative period to achieve similar postoperative pain control as indicated by similar VAS. This study suggests that the recovery from rTSA is less difficult compared with aTSA as indicated by VAS and opioid consumption.

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-Related Risk Factors Predict Outcomes After Arthroscopic Rotator Cuff Repair.

The objective of this study was to determine if preoperative patient characteristics have an effect on pain and function after primary arthroscopic rotator cuff repair. Seventy-five arthroscopic primary rotator cuff repairs with at least 2 years of follow-up were identified. Studied variables were preoperative tobacco, opioid, and alcohol use; obesity; mood disorders; disability claim; and Workers' Compensation status. Outcome measures included visual analog pain scores, American Shoulder and Elbow Surgeons (ASES) scores, Single Assessment Numeric Evaluation (SANE) scores, range of motion, and strength. Preoperative smoking was significantly associated with worse pain (p = 0.009), ASES (p = 0.004), and SANE (p = 0.011) scores. Opioid use showed no statistically significant difference in pain or functional scores. Alcohol use did predict improved ASES scores at long-term follow-up (p = 0.046). The other variables were not associated with inferior outcomes. Smoking and preoperative opioid use represent modifiable risk factors that can be corrected before surgery to optimize outcomes. (Journal of Surgical Orthopaedic Advances 33(1):005-009, 2024).

Artificial intelligence in shoulder and elbow surgery: overview of current and future applications.

Artificial intelligence (AI) is amongst the most rapidly growing technologies in orthopedic surgery. With the exponential growth in healthcare data, computing power, and complex predictive algorithms, this technology is poised to aid providers in data processing and clinical decision support throughout the continuum of orthopedic care. Understanding the utility and limitations of this technology is vital to practicing orthopedic surgeons, as these applications will become more common place in everyday practice. AI has already demonstrated its utility in shoulder and elbow surgery for imaging-based diagnosis, predictive modeling of clinical outcomes, implant identification, and automated image segmentation. The future integration of AI and robotic surgery represents the largest potential application of AI in shoulder and elbow surgery with the potential for significant clinical and financial impact. This editorial's purpose is to summarize common AI terms, provide a framework to understand and interpret AI model results, and discuss current applications and future directions within shoulder and elbow surgery.

Grit Score is Predictive of Increased Risk for Opioid Prescription Refill Following Primary Arthroscopic Rotator Cuff Repair.

The grit score is used to measure passion and perseverance for long-term goals. We hypothesized that higher grit scores would predict improved 90-day outcomes and reduced opioid requirements after primary arthroscopic rotator cuff repair (RCR). Included were 103 patients. The median grit score was 3.9 (2.2-5.0). There was no statistically significant association between grit and morphine milligram equivalents prescribed or patient-reported pain control. Higher grit score was associated with a significant reduction in opioid prescription refill at 6 weeks, though this association was not seen at 2 or 12 weeks. The odds of requiring opioid medication 6 weeks after RCR increased 3.5 times per each 1.0 unit decrease in grit score. Patients with higher levels of grit, especially a score over 4.0, have a less difficult postoperative course after RCR. The grit score may help identify patients who are at increased risk for prolonged opioid use after RCR. (Journal of Surgical Orthopaedic Advances 32(3):177-181, 2023).