Risk factors for and timing of adverse events after total shoulder arthroplasty

Venous thromboembolism prophylaxis in shoulder surgery: a break-even cost-effectiveness study

BACKGROUND

Venous thromboembolism (VTE) is a serious complication following orthopedic shoulder surgery; however, research is limited involving the break-even cost-effectiveness of VTE prophylaxis. The purpose of this study was to determine whether the cost of aspirin and enoxaparin would break even for VTE prevention in patients following shoulder surgery.

METHODS

A drug retail database was used to obtain the lowest price for a course of aspirin (81 mg) and enoxaparin (40 mg) to perform a break-even cost analysis. Our institutional purchasing records were then searched to estimate the cost of treating a symptomatic VTE. The TriNetX national database was queried to establish a rate of VTE after shoulder surgery. A break-even cost analysis was performed by determining the absolute risk reduction (ARR). This value was used to calculate the number of patients who are treated to prevent a single VTE while breaking even on cost. Sensitivity analyses were performed for drugs that did not break even at the database-derived VTE rates.

RESULTS

Full medication courses of aspirin and enoxaparin were found to cost $1.18 and $125.37, respectively. The cost of treating a symptomatic VTE was determined to be $9407.00. Data from the TriNetX database showed rates of symptomatic VTE following shoulder arthroplasty, hemiarthroplasty, and arthroscopic rotator cuff repair of 1.60%, 1.50%, and 0.68%, respectively. Aspirin broke even on cost for all procedures if the initial rate decreased by an ARR of 0.01% (number needed to treat, 7972). Similarly, enoxaparin broke even for shoulder arthroplasty and hemiarthroplasty if the initial rate of VTE decreased by an ARR of 1.33% (number needed to treat, 75). Enoxaparin did not break even at the initial VTE rate for arthroscopic rotator cuff repair; however, sensitivity analysis found enoxaparin would break even if the drug could be obtained at a cost of ≤$60.00. Enoxaparin broke even if the cost of treating a symptomatic VTE was ≥$20,000.00.

CONCLUSIONS

The cost of a 3-week course of twice-daily aspirin or once-daily enoxaparin breaks even for VTE prophylaxis following shoulder arthroplasty and hemiarthroplasty if these drugs reduce the VTE rate by a calculated ARR. Given the lower rate of VTE observed for patients undergoing arthroscopic rotator cuff repair, only the 3-week course of aspirin broke even under these conditions. Once-daily enoxaparin did not break even at current market rate. Further research is needed to help determine optimal VTE prophylaxis after shoulder surgery.

Predicting operative outcomes of total shoulder arthroplasty using the model for end-stage liver disease score

Background

The aim of this study was to assess the efficacy of the Model for End-Stage Liver Disease (MELD) score in predicting postoperative complications following total shoulder arthroplasty (TSA).

Methods

The American College of Surgeons National Surgical Quality Improvement database was queried for all patients who underwent TSA between 2015 and 2019. The study population was subsequently classified into two categories: those with a MELD score ≥ 10 and those with a MELD score < 10. A total of 5265 patients undergoing TSA between 2015 and 2019 were included in this study. Among these, 4690 (89.1%) patients had a MELD score ≥ 10, while 575 (10.9%) patients had a MELD score < 10. Postoperative complications within 30 days of the TSA were collected. Multivariate logistic regression analysis was conducted to explore the correlation between a MELD score ≥ 10 and postoperative complications. The anchor based optimal cutoff was calculated by receiver operating characteristic analysis to determine the MELD score cutoff that most accurately predicts a specific complication. Youden's index (J) determined the optimal cutoff point calculation for the maximum sensitivity and specificity; these were deemed to be "acceptable" if the area under curve (AUC) was greater than 0.7 and "excellent" if greater than 0.8.

Results

Multivariate regression analysis found a MELD score ≥ 10 to be independently associated with higher rates of reoperation (OR, 2.08; P = .013), cardiac complications (OR, 3.37; P = .030), renal complications (OR, 7.72; P = .020), bleeding transfusions (OR, 3.23; P < .001), and nonhome discharge (OR, 1.75; P < .001). The receiver operating characteristic analysis showed that AUC for a MELD score cutoff of 7.61 as a predictor of renal complications was 0.87 (excellent) with sensitivity of 100.0% and specificity of 70.0%. AUC for a MELD score cutoff of 7.76 as a predictor of mortality was 0.76 (acceptable) with sensitivity of 81.8% and specificity of 71.0%.

Conclusion

A MELD score ≥ 10 was correlated with high rates of reoperation, cardiac complications, renal complications, bleeding transfusions, and nonhome discharge following TSA. MELD score cutoffs of 7.61 and 7.76 were effective in predicting renal complications and mortality, respectively.

A comprehensive analysis of age and 30-day complications following total shoulder arthroplasty: nonagenarians, octogenarians, and septuagenarians

Background

Increased age is a well-known risk factor for development of osteoarthritis. Total shoulder arthroplasty (TSA) is a common treatment option for patients with severe glenohumeral osteoarthritis. The purpose of this study was to investigate the association between the septuagenarian, octogenarian, and nonagenarian populations and postoperative outcomes following TSA.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent TSA between 2015 and 2020. Patients were divided into cohorts based on age: sexagenarians (60-69), septuagenarians (70-79), octogenarians (80-89), and nonagenarians (90+). Multivariate logistic regression was used to identify associations between age and postoperative complications.

Results

On bivariate analysis, compared to sexagenarians, septuagenarians were significantly associated with higher rates of myocardial infarction (P = .038), blood transfusion (P < .001), organ/space surgical site infection (P = .048), readmission (P = .005), and nonhome discharge (P < .001. Compared to septuagenarians, octogenarians were significantly associated with higher rates of urinary tract infection (P < .001), blood transfusion (P < .001), readmission (P = .002), non-home discharge (P < .001), and mortality (P = .027). Compared to octogenarians, nonagenarians were significantly associated with higher rates of sepsis (P = .013), pneumonia (P = .003), reintubation (P = .009), myocardial infarction (P < .001), blood transfusion (P < .001), readmission (P = .026), nonhome discharge (P < .001), and mortality (P < .001).

Conclusion

From age 60, each decade of age was identified to be an increasingly significant predictor for blood transfusion, readmission, and nonhome discharge following TSA. From age 70, each decade of age was additionally identified to be an increasingly significant predictor for mortality.

Investigating immediate postoperative medical complication risks relative to in-hospital length of stay after total shoulder arthroplasty

Background

The purpose of this study was to investigate the association between in-hospital length of stay (LOS) and postoperative complication rates within 30 days of total shoulder arthroplasty (TSA).

Methods

All patients who underwent either anatomic or reverse TSA between 2015 and 2019 were queried from the American College of Surgeons National Surgical Quality Improvement database. The study population was stratified into three cohorts as follows: LOS 0 (same-day discharge), LOS 1 (next-day discharge), and LOS 2-3 (LOS of 2-3 days). Patient demographics and comorbidities were compared between cohorts using bivariate analysis. Multivariate logistic regression analysis was conducted to investigate the relationship between LOS and postoperative complications.

Results

In comparison to the LOS 0 day cohort, LOS 2-3 day cohort had a greater likelihood of developing overall complication (OR, 2.598; P < .001), major complication (OR, 1.885; P < .001), minor complication (OR: 3.939; P < .001), respiratory complication (OR: 12.979; P = .011), postoperative anemia requiring transfusion (OR, 23.338; P < .001), non-home discharge (OR, 10.430; P < .001), and hospital readmission (OR, 1.700; P = .012). Similarly, in comparison to the LOS 1 cohort, LOS 2-3 cohort had a greater likelihood of developing overall complication (OR: 2.111; P < .001), major complication (OR, 1.423; P < .001), minor complication (OR, 3.626; P < .001), respiratory complication (OR, 2.057; P < .001), sepsis or septic shock (OR: 2.795; P = .008), urinary tract infection (OR, 1.524; P = .031), postoperative anemia requiring transfusion (OR, 10.792; P < .001), non-home discharge (OR: 10.179; P < .001), hospital readmission (OR, 1.395; P < .001), and return to the operating room (OR. 1.394; P = .014). There was no significant difference in the risk of developing postoperative complications between LOS 0 day and LOS 1 day cohort. On baseline, the LOS 1 and LOS 2-3 day cohort had a higher proportion of patients with the following demographics and comorbidities compared to LOS 0 day cohort: advanced age, higher body mass index, female gender, positive smoking status, insulin-dependent diabetes, noninsulin-dependent diabetes, dyspnea at rest and moderate exertion, partially dependent functional status, an American Society of Anesthesiologists classification of 3 or higher, a history of severe chronic obstructive pulmonary disease, a history of congestive heart failure, the use of hypertension medication, disseminated cancer, wound infection, the use of steroids, and a history of bleeding disorder.

Conclusion

Patients who were discharged on the same and next day following TSA demonstrated a reduced probability of experiencing respiratory complications, infections, postoperative anemia requiring transfusion, non-home discharge, and readmission in comparison to those with a LOS of 2-3 days. There was no difference in postoperative complications between same and nextday discharged patients. Patients who underwent outpatient arthroplasty were healthier at baseline compared to those who underwent inpatient arthroplasty.

Smoking is an independent risk factor for complications in outpatient total shoulder arthroplasty

Background

Smoking is a major public health concern and an important risk factor to consider during preoperative planning. Smoking has previously been reported as the single most important risk factor for developing postoperative complications after elective orthopedic surgery. However, there is limited literature regarding the postoperative complications associated with smoking following outpatient total shoulder arthroplasty (TSA). The purpose of this study was to investigate the association between smoking status and early postoperative complications following outpatient TSA using a large national database.

Methods

We queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients who underwent TSA between 2015 and 2020. Smoking status in National Surgical Quality Improvement Program is defined as any episode of smoking with 12 months prior to surgery. Bivariate logistic regression was used to identify patient demographics, comorbidities, and complications significantly associated with current or recent smoking status in patients who underwent TSA with a length of stay (LOS) of 0. Multivariate logistic regression, adjusted for all significantly associated patient demographics and comorbidities, was used to identify associations between current or recent smokers and 30-day postoperative complications.

Results

22,817 patients were included in the analysis, 2367 (10.4%) were current or recent smokers and 20,450 (89.6%) were nonsmokers. These patients were further stratified based on LOS: 2428 (10.6%) patients had a LOS of 0 days, 15,267 (66.9%) patients had a LOS of 1 day, and 5122 (22.4%) patients had a LOS of 2 days. Within the outpatient cohort (LOS = 0), 202 (8.3%) patients were current or recent smokers and 2226 (91.7%) were nonsmokers. Multivariate logistic regression identified current or recent smoking status to be independently associated with higher rates of myocardial infarction (odds ratio [OR] 9.80, 95% confidence interval [CI] 1.48-64.96; P = .018), deep vein thrombosis (OR 20.05, 95% CI 1.63-247.38; P = .019), and readmission (OR 2.82, 95% CI 1.19-6.67; P = .018) following outpatient TSA. Readmission was most often due to pulmonary complication (n = 10, 22.7%).

Conclusion

Current or recent smoking status is independently associated with higher rates of myocardial infarction, deep vein thrombosis, and readmission following TSA performed in the outpatient setting. Current or recent smokers may benefit from an inpatient setting of minimum 2 nights. As outpatient TSA becomes increasingly popular, refining proper patient selection criteria is imperative to optimizing postoperative outcomes.

Rheumatoid arthritis patients are at increased risk for adverse events following lumbar discectomy

BACKGROUND CONTEXT

Lumbar discectomy is a common procedure for which patients with rheumatoid arthritis (RA) may be considered. RA is an autoinflammatory disease that may predispose patients to postoperative adverse outcomes.

PURPOSE

To assess the relative odds of adverse events after lumbar discectomy for those with versus without RA in a large, national, administrative dataset.

STUDY DESIGN/SETTING

Retrospective cohort study using the 2010 to 2020 MSpine PearlDiver dataset.

PATIENT SAMPLE

After exclusion of patients under 18 years old, those with any trauma, neoplasm, or infection diagnosis within the month before lumbar discectomy, and any patients who had any alternative lumbar spinal surgery performed on the same day as lumbar discectomy, we identified 36,479 lumbar discectomy patients. 2,937 (8.1%) of these patients had a prior diagnosis of RA. After matching 4:1 by patient age, sex, and Elixhauser Comorbidity Index (ECI, a longitudinal measure of patient comorbidity burden generated via ICD-9 and 10 diagnosis codes), 8,485 lumbar discectomy patients without RA and 2,149 with RA were included.

OUTCOME MEASURES

Incidence of severe and minor adverse events in the 90-days following lumbar discectomy, predictive factors for adverse events within 90-days of lumbar discectomy, risk of adverse events within 90-days of lumbar discectomy stratified by patient medication regimen, 5-year survival to reoperation following lumbar discectomy.

METHODS

Patients undergoing lumbar discectomy were identified from the PearlDiver MSpine dataset. The subset of those with versus without RA were identified and matched 1:4 based on patient age, sex, and ECI scores. The incidence of 90-day adverse events in the two groups was determined and compared by univariate and multivariate analyses. Subgroup analysis was performed based on RA medications being taken.

RESULTS

Matched lumbar discectomy patients with RA (n=2,149) and without RA (n=8,485) were identified. Controlling for patient age, sex, and ECI, those with RA were at significantly higher odds of any (odds ratio [OR] 3.30), severe (OR 2.78), and minor (OR 3.30) adverse events (p<.0001 for all). Stratifying by medications being taken (and relative to those without RA), there was increasing odds of all adverse events (AAE) based on potency of medications (no biologic or disease modifying antirheumatic drugs [DMARDs] OR 2.33, DMARDs only OR 3.86, biologic±DMARDs OR 5.69 (p<.0001 for all). Despite this, no statistically significant difference in 5-year survival from subsequent lumbar surgery was found between those with versus without RA (p=.1000).

CONCLUSIONS

Lumbar discectomy patients with RA were found to be at significantly higher risk for 90-day adverse events following lumbar discectomy, and this was incrementally greater for those on increasingly suppressive medications. Lumbar discectomy patients with RA bear specific consideration and perioperative monitoring when considered for lumbar discectomy.

Utilization of comorbidity indices to predict discharge destination and complications following total shoulder arthroplasty

Background

Comorbidity indices can help identify patients at risk for postoperative complications. Purpose of this study was to compare different comorbidity indices to predict discharge destination and complications after shoulder arthroplasty.

Methods

Retrospective review of institutional shoulder arthroplasty database of primary anatomic (TSA) and reverse (RSA) shoulder arthroplasties. Patient demographic information was collected in order to calculate Modified Frailty Index (mFI-5), Charlson Comorbidity Index (CCI), age adjusted CCI (age-CCI), and American Society of Anesthesiologists physical status classification system (ASA). Statistical analysis performed to analyze length of stay (LOS), discharge destination, and 90-day complications.

Results

There were 1365 patients included with 672 TSA and 693 RSA patients. RSA patients were older and had higher CCI, age adjusted CCI, ASA, and mFI-5 (p < 0.001). RSA patients had longer lengths of stay (LOS), more likely to have an adverse discharge (p < 0.001), and higher reoperation rate (p = 0.003). Age-CCI was most predictive of adverse discharge (AUC 0.721, 95% CI 0.704-0.768).

Discussion

Patients undergoing RSA had more medical comorbidities, experienced greater LOS, higher reoperation rate, and were more likely to have an adverse discharge. Age-CCI had the best ability to predict which patients were likely to require higher-level discharge planning.

Impact of cervical spine pathology on outcomes after total shoulder arthroplasty

BACKGROUND

Cervical spine pathology can affect the supporting muscles and function of the shoulder and contribute to shoulder and arm pain and hence may impact postoperative outcomes following shoulder arthroplasty. The purpose of this study was to evaluate the impact of a history of cervical spine arthrodesis and its timing, before or after total shoulder arthroplasty (TSA), on the outcomes of TSA. Our hypothesis is that a history of cervical arthrodesis (CA) will negatively impact patient outcomes after shoulder arthroplasty.

METHODS

A retrospective analysis was performed on a prospectively collected cohort at a single institution. Anatomic (aTSA) and reverse TSA (rTSA) patients with CA were identified and compared to a cohort of patients without CA (NCA) enrolled in an institutional registry from 2011 to 2020. Demographic characteristics, diagnoses, implant type, range of motion, adverse events, and clinical outcome metric scores (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], Constant, Shoulder Function score, patient satisfaction) were recorded. Outcomes between cohorts were analyzed using conventional statistics as well as stratification by minimal clinically important difference and substantial clinical benefit (SCB) thresholds where applicable.

RESULTS

Of the 573 TSAs evaluated, 48 (20a CA-aTSA and 28 CA-rTSA) had a history of CA and 525 (280 NCA-aTSA and 245 NCA-rTSA) had no history of CA. The CA-TSA (aTSA and rTSA) had lower Constant, ASES, and Shoulder Function scores postoperatively as well as less improvement in active external rotation and an overall lower satisfaction rating (P < .05 for all) compared with NCA-TSA. The adverse event rate in the CA-TSA cohort was higher compared with the NCA-TSA cohort (25% vs. 6.5% [rTSA; P = .004] and 24.5% vs. 11% [aTSA; P = .068]). Optimal cutoff analysis showed that a time from CA to TSA of greater than 1.33 years had a sensitivity of 75.0% and specificity of 75.0% in predicting achievement of SCB for ASES score.

CONCLUSION

The current study demonstrates that patients with a history of CA undergoing shoulder arthroplasty results in lower postoperative functional outcomes, lower satisfaction, and higher rates of postoperative adverse events requiring surgical revision when compared to a cohort without a history of CA. Additionally, the current study demonstrates that a time interval of at least 16 months between CA and shoulder arthroplasty optimizes the chances of achieving SCB for ASES score.

Does age at surgery influence short-term outcomes and readmissions following anatomic total shoulder arthroplasty?

Background

Increasing age has been associated with adverse outcomes in various orthopedic procedures including anatomic total shoulder arthroplasty (aTSA). Moreover, both indications and the ages at which the procedure is done has expanded. For these reasons, it is important to characterize the impact age has on complication and readmission rates following shoulder replacement.

Methods

The National Readmissions Database was used to identify patients who underwent aTSA between the years 2016-2018. Patients were stratified into five cohorts based on age at surgery: 18-49, 50-59, 60-69, 70-79, and 80+ years old. We analyzed and compared data related to patient demographics, length of stay, readmission and complication rates, and healthcare charges. A multivariate analysis was used to identify the independent impact of age on complication rates.

Results

42,505 patients were included with 1,541, 6,552, 16,364, 14,694, 3,354, patients in the 18-49, 50-59, 60-69, 70-79, and 80+ years old cohorts respectively. Length of stay had a stepwise increase with age increases (p < 0.001), however total charges were comparable between cohorts (p = 0.40). Older patients were more likely to experience intraoperative complications, pulmonary embolism complications, and postoperative infection, but were less likely to experience hardware, surgical site, and prosthetic joint complications. Older patients had higher rates of readmission. Age was an independent predictor for higher 30-/90-day readmission, postoperative/intraoperative complication, and respiratory complication rates. Increasing age provided a protective measure for prosthetic complications surgical site infection.

Conclusion

This study identified multiple differences in complication rates following aTSA based on age at surgery. Overall, age had varying effects on intraoperative and postoperative complication rates at short-term follow-up. However, increasing age was associated with longer lengths of stay and increased readmission rates. Surgeons should be aware of the identified complications that are most prevalent in each age group and use this information to avoid adverse outcomes following shoulder replacement surgery.

Survivorship analysis of revision reverse total shoulder arthroplasty

BACKGROUND

The expansion of indications for reverse total shoulder arthroplasty (RTSA) has resulted in a rapid increase in the incidence of subsequent revision procedures. The purpose of this study was to identify the incidence and risk factors for re-revision shoulder arthroplasty after first revision RTSA.

METHODS

We retrospectively queried our institutional shoulder arthroplasty database of prospectively collected data from 2003 to 2019. To assess revision implant survival, patients were censored on the date of re-revision surgery or, if the revision arthroplasty was not revised, at the most recent follow-up or their date of death. Patients with a prior infection, concern for infection at the time of revision, antibiotic spacer, or oncologic indication for primary arthroplasty were excluded. A total of 186 revision RTSAs were included, with 32 undergoing re-revision shoulder arthroplasty. The Kaplan-Meier method and bivariate Cox regression were used to assess the relationship of patient and surgical characteristics on implant survivorship. Multivariate Cox regression was performed to identify independent predictors of re-revision.

RESULTS

Re-revision shoulder arthroplasty was most commonly performed for instability (34%), infection (28%), and glenoid loosening (19%). Overall re-revision rates at 6 months (7%), 1 year (9%), and 2 years (13%) were relatively low; however, the rate of re-revision increased at 5 years (35%). Men underwent re-revision more often than women within the first 6 months after revision RTSA (12% vs. 2%; P = .025), but not thereafter. On multivariate analysis, increased estimated blood loss was associated with a greater risk of undergoing re-revision shoulder arthroplasty (hazard ratio: 41.16 [3.34-506.50]; P = .004).

CONCLUSION

The rate of re-revision after revision RTSA is low in the first 2 years postoperatively (13%) but increases to 35% at 5 years. Increased estimated blood loss, which may reflect greater operative complexity, was identified as a risk factor that may confer an increased chance of re-revision after revision RTSA. Knowledge of risk factors for re-revision after revision RTSA can aid surgeons and patients in preoperative counseling.

Few UK vascular centres offer a fully NICE-compliant supervised exercise programme: a national audit

INTRODUCTION

To determine the current (pre-COVID-19) provision of supervised exercise training (SET) for patients with peripheral arterial disease (PAD) in UK Vascular Centres.

METHODS

Hospital Trusts delivering vascular care to patients with PAD were identified from the National Vascular Registry and asked to complete an online questionnaire on their provisions for SET. If a centre offered SET, they were asked questions to determine whether the programme was compliant with NICE guidelines and the difficulties they faced delivering the service. If centres did not offer SET, they were asked what obstacles prevented them implement SET.

RESULTS

Of the 78 UK vascular centres, 59 (76%) responded and were included in the audit. Of these, 27 (46%) were able to offer SET but only 21 (36%) could offer it to all their patients with PAD. Only four (6.8%) offered SET that was fully compliant with current NICE guidelines. Reasons identified included insufficient funding, lack of resource and poor patient compliance.

CONCLUSIONS

The benefits of SET are well established yet the availability of the service in the UK is poor. The reasons for this are readily identified but have not yet been overcome. Research on novel methods of delivering supervised exercise that mitigates existing barriers, such as home exercise with remote monitoring, should be prioritised to facilitate optimal management for our patients with PAD.

Abnormal Preoperative Platelet Count May Predict Postoperative Complications Following Shoulder Arthroplasty

Background

The purpose of this study is to investigate the association between preoperative platelet counts and postoperative complication rates within 30 days of total shoulder arthroplasty (TSA).

Methods

The American College of Surgeons National Surgical Quality Improvement database was queried for all patients who underwent TSA between 2015 and 2019. The study population was then divided into 5 groups based on their preoperative platelet count: <100k (moderate-to-severe thrombocytopenia), 100-150k (mild thrombocytopenia), 150-200k (low-normal preoperative platelet count), 200-450k (normal, reference cohort), and >450k (thrombocytosis). Postoperative complications within 30 days of the TSA were collected. Multivariate logistic regression analysis was conducted to investigate the relationship between preoperative platelet counts and postoperative complications.

Results

A total of 19,721 patients undergoing TSA between 2015 and 2019 were included in this study. One hundred fifty-five patients (0.8%) had moderate-to-severe thrombocytopenia, 982 (5.0%) had mild thrombocytopenia, 3945 (20.0%) had a low-normal preoperative platelet count, 14,386 (72.9%) had a normal preoperative platelet count, and 253 (1.3%) had thrombocytosis. An increasing rate of overall complications was observed as the severity of thrombocytopenia progressed from low-normal (6.4%) to mild thrombocytopenia (10.2%) and to moderate-to-severe thrombocytopenia (18.7%). The overall complication rate of the thrombocytosis cohort was 14.6%. In comparison to normal platelet count, low-normal thrombocytopenia, mild thrombocytopenia, moderate-to-severe thrombocytopenia, and thrombocytosis were identified by multivariate analysis as significant predictors of overall complications (odds ratios [ORs] of 1.12, 2.15, 2.43, 2.71, respectively), postoperative anemia requiring transfusion (ORs of 1.63, 3.45, 5.97, 4.21, respectively), and minor complications (ORs of 1.39, 2.64, 3.40, 3.34, respectively). Minor complications include progressive renal insufficiency, urinary tract infection, transfusions within 72 hours after surgery, pneumonia, and superficial incisional surgical site infection.

Conclusion

Increasing severity of thrombocytopenia correlated with higher overall postoperative complication rates following TSA. Interestingly, patients with thrombocytosis had the highest overall postoperative complication rates among all cohorts included in this study. Platelet counts are often the reflection of other comorbidities and a good indicator of patient's general health status. Long-term optimization of abnormal platelet counts may potentially reduce surgical complications.

Perioperative Clopidogrel (Plavix®) Continuation in Shoulder Arthroplasty: Approach Cautiously

Background

Methods

Results

Conclusion

Outpatient versus inpatient total shoulder arthroplasty: A cost and outcome comparison in a comorbidity matched analysis

Background

Previous studies comparing total and reverse shoulder arthroplasty (TSA/RSA) are subject to surgeon selection bias. This study objective is to compare the outcomes and cost of outpatient TSA/RSA to inpatient TSA/RSA.

Methods

108,889 elective inpatient and outpatient TSA/RSA from Medicare claims data (2016-2018). 90-day readmission and total 90-day costs were compared following propensity score matching.

Results

Younger and healthier patients are receiving outpatient TSA/RSA. Outpatient TSA/RSA was associated with fewer 90-day readmissions (OR 0.48 CI 0.38-0.59, p < 0.001) and lower 90-day costs (-20.1% CI -19.1%; -21.1%, p < 0.001).

Conclusions

Outpatient TSA/RSA surgery offers lower complication rates and total costs.

Level of evidence

III.

Risk factors for complications and revision surgery after anatomic and reverse total shoulder arthroplasty

BACKGROUND

Complications and revisions following anatomic (aTSA) and reverse (rTSA) total shoulder arthroplasty have deleterious effects on patient function and satisfaction. The purpose of this study is to evaluate patient-specific, implant-specific and technique-specific risk factors for intraoperative complications, postoperative complications, and the occurrence of revisions after aTSA and rTSA.

METHODS

A total of 2964 aTSA and 5616 rTSA patients were enrolled in an international database of primary shoulder arthroplasty. Intra- and postoperative complications, as well as revisions, were reported and evaluated. Multivariate analyses were performed to quantify the risk factors associated with complications and revisions.

RESULTS

aTSA patients had a significantly higher complication rate (P = .0026) and a significantly higher revision rate (P < .0001) than rTSA patients, but aTSA patients also had a significantly longer average follow-up (P < .0001) than rTSA patients. No difference (P = .2712) in the intraoperative complication rate was observed between aTSA and rTSA patients. Regarding intraoperative complications, female sex (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.17-3.68) and previous shoulder surgery (OR 2.9, 95% CI 1.73-4.90) were identified as significant risk factors. In regard to postoperative complications, younger age (OR 0.987, 95% CI 0.977-0.996), diagnosis of rheumatoid arthritis (OR 1.76, 95% 1.12-2.65), and previous shoulder surgery (OR 1.42, 95% CI 1.16-1.72) were noted to be risks factors. Finally, in regard to revision surgery, younger age (OR 0.964, 95% CI 0.933-0.998), more glenoid retroversion (OR 1.03, 95% CI 1.001-1.058), larger humeral stem size (OR 1.09, 95% CI 1.01-1.19), larger humeral liner thickness or offset (OR 1.50, 95% CI 1.18-1.96), larger glenosphere diameter (OR 1.16, 95% CI 1.07-1.26), and more intraoperative blood loss (OR 1.002, 95% CI 1.001-1.004) were noted to be risk factors.

CONCLUSIONS

Studying the impact of numerous patient- and implant-specific risk factors and determining their impact on complications and revision shoulder arthroplasty can assist surgeons in counseling patients and guide patient expectations following aTSA or rTSA. Care should be taken in patients with a history of previous shoulder surgery, who are at increased risk of both intra- and postoperative complications.

Short-stem uncemented anatomical shoulder replacement for osteoarthritis in patients older than 70 years: is it appropriate?

Background

Despite a new trend to systematically use reverse shoulder arthroplasty (RSA) in elderly population regardless of the indication, total anatomical shoulder arthroplasty can get good functional results in this population. The purpose of this study was to evaluate clinical and radiological outcomes of uncemented short-stem anatomic total shoulder arthroplasty (TSA) for primary glenohumeral osteoarthritis in patients older than 70 years and to compare these results to a matched population with an uncemented short-stem RSA.

Methods

In this retrospective monocentric study, clinical outcomes were based on constant score (Cst), subjective shoulder value (SSV) score, and range of motion. The aim of radiographic analysis was to identify glenoid component loosening and humeral bone remodeling around the uncemented short stem.

Results

At an average follow-up of 44 ± 12.5 months, 32 uncemented short-stem TSA in 31 patients with a minimum of 2 years of follow-up were included and were compared to 32 uncemented RSA. Fifty three percent of the patients had “a forgotten prosthesis”. ROM was significantly improved in all cases. Cst reached 73 ± 9 pts and SSV 90 ± 10.8% (P < .001). In 8 patients with repairable supraspinatus tendon tears, clinical outcomes were not statistically different from patients with an intact rotator cuff: Cst (77 ± 6.2 points vs 72 ± 9.6 points, P = .3) and SSV (88 ± 11.5% vs. 91 ± 10.5%; P = .59). The type of glenoid wear (A vs B) did not influence the constant score: 73 ± 9 points versus 74 ± 11 points respectively; P = .81. Despite a complication rate of 6% (n = 2), no prosthesis revision was performed. At last follow-up, range of motion was better in the TSA group compared to the RSA group for internal (7.8 ± 1.3 vs 6.25 ± 2; P = .001) and external (47 ± 14 vs 24 ± 21; P < .001) rotations. The postoperative SSV score was also better in the TSA group (91.3 ± 10% vs 82.2 ± 13%; P = .002).

Conclusions

At medium-term, uncemented short-stem anatomic TSA in patients older than 70 years provided satisfactory clinical results. Patients have forgotten their prosthesis in over 50% of cases. This prosthetic design is still indicated in this patient population in case of primary osteoarthritis with a functional rotator cuff with an almost normal rotator cuff muscle trophicity.

Is venous thromboembolism prophylaxis beneficial in upper limb major joint replacement surgery? A systematic review

BACKGROUND

Upper limb arthroplasty is an increasingly used treatment modality for end-stage joint disease of the shoulder, elbow and wrist. Whilst complications have been reported, the risk of venous thromboembolism has received less attention when compared to the lower limb. Guidance to aid clinical decision-making remains limited. This review aims to ascertain whether venous thromboembolism prophylaxis is beneficial after upper limb major joint replacement surgery.

METHODS

A systematic review was performed in April 2019, utilising EMBASE, MEDLINE, Cochrane and Google Scholar. All clinical studies reporting venous thromboembolism incidence and risk reduction (after prophylaxis) in upper limb joint replacement were included.

RESULTS

Twenty-four observational studies were identified. The reported incidence of venous thromboembolism ranged from 0.2% to 16% (weighted mean 0.68%) and 0.2% to 0.8% (weighted mean 0.49%) in shoulder and elbow arthroplasty, respectively. No records for wrist arthroplasty were found. In the literature, baseline venous thromboembolism risk of patients without an operation is reported as 0.5%.

DISCUSSION

There is a lack of good quality evidence regarding the risks and benefits of venous thromboembolism prophylaxis in upper limb major joint replacement surgery. We recommend further research, ideally formal randomised controlled trials to guide recommendations. Although venous thromboembolism is rare in upper limb surgery, surgeons should remain vigilant to this possibility.

Comparison of machine learning techniques to predict unplanned readmission following total shoulder arthroplasty

BACKGROUND

Machine learning (ML) techniques have been shown to successfully predict postoperative complications for high-volume orthopedic procedures such as hip and knee arthroplasty and to stratify patients for risk-adjusted bundled payments. The latter has not been done for more heterogeneous, lower-volume procedures such as total shoulder arthroplasty (TSA) with equally limited discussion around strategies to optimize the predictive ability of ML algorithms. The purpose of this study was to (1) assess which of 5 ML algorithms best predicts 30-day readmission, (2) test select ML strategies to optimize the algorithms, and (3) report on which patient variables contribute most to risk prediction in TSA across algorithms.

METHODS

We identified 9043 patients in the American College of Surgeons National Surgical Quality Improvement Database who underwent primary TSA between 2011 and 2015. Predictors included demographics, comorbidities, laboratory data, and intraoperative variables. The outcome of interest was 30-day unplanned readmission. Five ML algorithms-support-vector machine (SVM), logistic regression, random forest (RF), an adaptive boosting algorithm, and neural network-were trained on the derivation cohort (2011-2014 TSA patients) to predict 30-day unplanned readmission rates. After training, weights for each respective model were fixed and the classifiers were evaluated on the 2015 TSA cohort to simulate a prospective evaluation. C-statistic and f1 scores were used to assess the performance of each classifier. After evaluation, features were removed independently to assess which features most affected classifier performance.

RESULTS

The derivation and validation cohorts comprised 5857 and 3186 primary TSA patients, respectively, with similar demographics, comorbidities, and 30-day unplanned readmission rates (2.9% vs. 2.7%). Of the ML algorithms, SVM performed the worst with a c-statistic of 0.54 and an f1-score of 0.07, whereas the random-forest classifier performed the best with the highest c-statistic of 0.74 and an f1-score of 0.18. In addition, SVM was most sensitive to loss of single features, whereas the performance of RF did not dramatically decrease after loss of single features. Within the trained RF classifier, 5 variables achieved weights >0.5 in descending order: high bilirubin (>1.9 mg/dL), age >65, race, chronic obstructive pulmonary disease, and American Society of Anesthesiologists' scores ≥3. In our validation cohort, we observed a 2.7% readmission rate. From this cohort, using the RF classifier we were then able to identify 436 high-risk patients with a predicted risk score >0.6, of whom 36 were readmitted (readmission rate of 8.2%).

CONCLUSION

Predictive analytics algorithms can achieve acceptable prediction of unplanned readmission for TSA with the RF classifier outperforming other common algorithms.

The Impact of Preoperative Anemia on Complications After Total Shoulder Arthroplasty

This study investigated the relationship between varying levels of preoperative anemia and postoperative complications within 30 days of total shoulder arthroplasty (TSA).

The impact of fellowship type on trends and complications following total shoulder arthroplasty for osteoarthrosis by recently trained board-eligible orthopedic surgeons

BACKGROUND

Total shoulder arthroplasty (TSA) with an anatomic or reverse prosthesis is a commonly used and successful treatment option for many degenerative shoulder conditions. There is an increasing trend toward fellowship training and subspecialization in newly trained orthopedic surgeons. The literature also suggests that subspecialization and high volume are associated with better clinical outcomes. The purpose of this study was to evaluate the effects of fellowship training on the trends and outcomes of TSA in board-eligible orthopedic surgeons.

METHODS

The American Board of Orthopaedic Surgery database was used to identify primary TSA cases performed for osteoarthrosis submitted by American Board of Orthopaedic Surgery Part II Board Certification candidates. Candidates were grouped based on fellowship training and subspecialty examination being taken. Groups were analyzed with analysis of variance and Bonferroni post hoc analysis to evaluate significant differences between groups for a number of candidates, cases per candidate, and patient age/sex. Differences in complications, reoperations, and readmissions were statistically evaluated with χ² tests and multivariate logistic regression analysis.

RESULTS

From 2010 to 2017, 854 candidates performed at least 1 primary TSA (anatomic or reverse) after a diagnosis of osteoarthritis and 2720 submitted cases met inclusion criteria. Candidates completing a Shoulder fellowship performed significantly more TSAs per candidate compared with all other groups (Shoulder = 8.0 ± 6.2, Sports Medicine = 2.4 ± 2.1, Hand and Upper Extremity = 2.9 ± 2.9, General Orthopedics = 2.4 ± 2.3, P < .001). The Shoulder fellowship group had significantly lower complication rates (17.9%) as compared with the Sports Medicine fellowship (23.7%, P = .008) and Hand and Upper Extremity fellowship (25.0%, P = .008) groups.

CONCLUSIONS

Shoulder fellowship-trained surgeons performed significantly more TSAs per year than other groups, with a lower complication rate when compared with other fellowship-trained candidates. Fellowship type had no effect on reoperation or readmission rates.

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

Background

Total shoulder arthroplasty (TSA) is an increasingly common procedure. This study looked at trends in TSA using a nationwide registry, with a focus on patient demographics, comorbidities, and complications.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent TSA from 2005 to 2018. Cohorts were created based on year of surgery: 2005-2010 (N = 1116), 2011-2014 (N = 5920), and 2015-2018 (N = 16,717). Patient demographics, comorbidities, operative time, hospital length of stay, discharge location, and complications within 30 days of surgery were compared between cohorts using bivariate and multivariate analysis.

Results

Bivariate analysis revealed significantly more comorbidities among patients in the 2015-2018 cohort compared with the 2005-2010 cohort, specifically American Society of Anesthesiologist class III or IV (57.0% vs. 44.3%, P < .001), morbid obesity (10.8% vs. 7.8%, P < .001), diabetes (17.8% vs. 12.1%, P < .001), and chronic obstructive pulmonary disease (6.7% vs. 4.1%, P = .003). The use of regional anesthesia has decreased (5.6% in 2005-2010 vs. 2.8% in 2015-2018, P < .001), as has operative time (▵: −16 minutes, P < .001) and length of stay (▵: −0.6 days, P < .001). There were also significant decreased rates of perioperative blood transfusion (OR [odds ratio], 0.46), non-home discharge (OR, 0.79), urinary tract infection (OR, 0.47), and sepsis (OR, 0.17), (P < .001 for all comparisons) between the 2005-2010 and 2015-2018 cohorts.

Conclusions

Between 2005 and 2018, patients undergoing TSA had increasingly more comorbidities but experienced lower rates of short-term complications, in the context of shorter hospitalizations and more frequent discharge to home.

Shoulder Arthroplasty for a Fracture Is Not the Same as Shoulder Arthroplasty for Osteoarthritis: Implications for a Bundled Payment Model

INTRODUCTION

The Center for Medicare Services currently bundles all shoulder arthroplasties, total shoulder arthroplasty and reverse total shoulder arthroplasty, into one Diagnosis-Related Group on which bundled reimbursements are then further characterized. An arthroplasty performed for traumatic indications, such as fractures, may have a different postoperative course of care compared with the one being done for degenerative arthritis/osteoarthritis (OA), despite having the same Current Procedural Terminology (CPT) and Diagnosis-related Group code.

METHODS

The 2012 to 2016 American College of Surgeons-National Surgical Quality Improvement Program databases were queried using CPT-23472 to retrieve records of patients undergoing total shoulder arthroplasty/reverse total shoulder arthroplasty for degenerative arthritis/OA or proximal humerus fracture.

RESULTS

A total of 8,283 (92.5%) and 667 (7.5%) patients underwent a shoulder arthroplasty for OA and proximal humeral fracture, respectively. After adjustment, the fracture group was associated with a higher risk for a longer length of stay of >2 days (P < 0.001), 30-day surgical complications (P = 0.005), revision surgeries within 30 days (P = 0.008), 30-day medical complications (P < 0.001), pulmonary embolism (P = 0.013), postoperative transfusions (P < 0.001), non-home discharge (P < 0.001), and 30-day readmissions (P < 0.001).

DISCUSSION

Shoulder arthroplasty is associated with higher resource utilization when this procedure is performed for a fracture. As we move toward the era of bundled payment models, an appropriate risk adjustment based on the indication of surgery should be promoted to maintain the quality of care for all patients.

Analysis of 90-Day Readmissions After Total Shoulder Arthroplasty

Background

The number of total shoulder arthroplasty (TSA) procedures performed annually is increasing as a result of an aging population and an increased access to subspecialty-trained upper extremity arthroplasty surgeons. An up-to-date analysis of the incidence of, risk factors for, and reasons for 90-day readmissions in primary anatomic TSA has yet to be performed.

Purpose

To characterize 90-day readmissions on a national level. An understanding of these data will help to predict resource utilization and expenses in shoulder arthroplasty.

Study Design

Case-control study; Level of evidence, 3.

Methods

All adult patients undergoing elective primary TSA in 2014 who were included in the National Readmission Database were included in the analysis. Two cohorts were created according to 90-day readmission status. Multivariable analysis was then performed to determine predictors of 90-day readmissions. Reasons for 30-, 60-, and 90-day readmissions were identified, and total hospital resource utilization was calculated.

Results

An estimated 26,023 patients were identified. The 30-, 60-, and 90-day rates of readmissions were 0.6%, 1.2%, and 1.7%, respectively. There was no difference in comorbidity burden between the cohorts. Medicare payer status (odds ratio [OR], 1.63; 95% CI, 1.00-2.65; P = .05), transfer to a skilled nurse facility (OR, 1.50; 95% CI, 1.05-2.14; P = .02), and chronic obstructive pulmonary disease (OR, 1.32; 95% CI, 1.04-1.66; P = .02) were identified as predictors of 90-day readmission. Female sex decreased odds of 90-day readmission (OR, 0.72; 95% CI, 0.59-0.87; P = .001). Ninety-day readmissions were associated with significant cost increases (P < .001). The most common identifiable reason for related readmissions was a hardware-related complication at all time points.

Conclusion

While uncommon, 90-day readmissions after primary TSA are associated with significant patient morbidity and ultimately substantial hospital costs. Truncating readmission analysis at a 30-day period will miss most arthroplasty-related hospital readmissions.

Modified frailty index predicts medical complications, length of stay, readmission, and mortality following total shoulder arthroplasty

HYPOTHESIS

The purpose of this study was to evaluate the 5-factor modified frailty index (mFI-5) as a predictor of postoperative complications in patients undergoing total shoulder arthroplasty (TSA).

METHODS

We conducted a retrospective analysis of the National Surgical Quality Improvement Program database for patients undergoing TSA between the years 2005 and 2017. The mFI-5 score, which includes the presence of comorbid diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functional status, was calculated for each patient. Multivariate logistic regression models were used to assess the relationship between the mFI-5 and postoperative complications.

RESULTS

A total of 18,957 patients undergoing TSA were identified. The mFI-5 was a strong predictor of serious medical complications (cardiac arrest, myocardial infarction, septic shock, pulmonary embolism, postoperative dialysis, reintubation, and prolonged ventilator requirement), discharge to a facility, and readmission (odds ratio ≥ 1.309, P ≤ .001). Length of stay also increased as the mFI-5 score increased (P < .001). However, among all the measured complications, the mFI-5 was the strongest predictor of mortality, with the risk more than doubling for each point increase in the mFI-5 score (odds ratio, 2.113; 95% confidence interval, 1.447-3.086; P < .001).

CONCLUSION

The mFI-5 predicts serious medical complications, increased length of stay, discharge to a facility, hospital readmission, and mortality in patients undergoing TSA. All of the variables within the mFI-5 are easily obtained through the patient history, allowing for a practical clinical tool that hospitals and surgeons can use to identify high-risk surgical candidates, inform preoperative counseling, and guide perioperative care to optimize patient outcomes.

Risk factors for and timing of adverse events after revision total shoulder arthroplasty

BACKGROUND

Despite increasing rates of revision total shoulder arthroplasty (RTSA), there is a paucity of literature on optimizing perioperative outcomes. The purposes of this study were to identify risk factors for unplanned readmission and perioperative complications following RTSA, risk-stratify patients based on these risk factors, and assess timing of complications.

METHODS

Bivariate and multivariate analyses of risk factors were assessed on RTSA patients from the ACS-NSQIP database from 2011 to 2015. Patients were risk-stratified and timing of severe adverse events and cause of readmission were evaluated.

RESULTS

Of 809 RTSA patients, 61 suffered a perioperative complication or readmission within 30 days of discharge. Multivariate analysis identified operative time, BMI > 40, infection etiology, high white blood cell count, and low hematocrit as significant independent risk factors for 30-day complications or readmission after RTSA (p ≤ 0.05). Having at least one significant risk factor was associated with 2.71 times risk of complication or readmission within 15 days compared to having no risk factors (p < 0.001). The majority of unplanned readmission, return to the operating room, open/deep wound infection, and sepsis/septic shock occurred within two weeks of RTSA.

DISCUSSION

Patients at high risk of complications and readmission after RTSA should be identified and optimized preoperatively to improve outcomes and lower costs.

Delayed hospital discharge after total shoulder arthroplasty: why, and who is at risk?

Background

There is growing policy interest in reducing the length of stay (LOS) after discretionary orthopedic surgery but few data to guide improvement efforts. We characterized the primary reasons and predisposing factors associated with extended LOS after elective total shoulder arthroplasty.

Methods

We retrospectively identified 415 patients undergoing elective primary total shoulder arthroplasty between 2016 and 2017. Extended LOS was defined as a stay greater than the 75th percentile. Medical records were manually reviewed to ascertain the primary reason for extended LOS. Multivariable logistic regression modeling was used to determine preoperative characteristics associated with prolonged hospitalization.

Results

The most common reason for extended LOS was pain (41%), followed by medical problems (39%), limited social support (18%), and blood transfusions (2%). Only 41% of patients with delayed discharges had documented adverse events (any medical or surgical problem), all of which were minor. The top 4 medical issues were transient hypoxemia (42%), nausea and/or vomiting (13%), electrolyte abnormalities (12%), and altered mental status (10%). In decreasing order of magnitude, the predictors of prolonged LOS were greater number of self-reported allergies, female sex, unmarried patient, diabetes, lower American Shoulder and Elbow Surgeons score, depression, reverse shoulder arthroplasty, and American Society of Anesthesiologists score of 3 or greater. Operative time did not correlate with LOS.

Conclusions

Prolonged hospitalizations after shoulder arthroplasty are commonly related to pain and limited social support. Sociodemographic and psychological factors seem to have more influence than patient infirmity and technical issues. These findings support a comprehensive approach to care with attention to the physical, mental, and social determinants of health.

Risk factors for venous thromboembolism in total shoulder arthroplasty

Background

Although venous thromboembolism (VTE) has been studied in lower-extremity arthroplasty, there are few guidelines regarding established risk factors for VTE in total shoulder arthroplasty (TSA). With literature suggesting the VTE rate may be as high as 13%, VTE prevention and risk factors should be considered in preoperative planning.

Methods

All TSAs from 2011 through 2016 were queried from the National Surgical Quality Improvement Program database. Age, sex, body mass index, American Society of Anesthesiologists class, ethnicity, functional status, comorbidities, discharge destination, surgical indication, length of stay, and operative time were compared between patients with and without 30-day postoperative VTE. Pearson χ² and t tests were used to assess baseline categorical and continuous variables, respectively. Multivariate logistic regression analysis was conducted to determine associated independent risk factors for VTE.

Results

The analysis included 13,299 patients; VTE developed in 83 patients (0.62%). Patients with VTE were older (72 years vs. 69 years) and had a longer hospital stay (3.5 days vs. 1.9 days). Compared with patients with no VTE, patients with VTE were more likely to undergo TSA for proximal humeral fractures, to be discharged to a rehabilitative center, to have a preoperative albumin level lower than 3.5 g/dL, to undergo non-elective surgery, to have an American Society of Anesthesiologists class of 3 or greater, to have a surgical-site infection develop, and ultimately to need a shoulder reoperation (all P < .05). Multivariate logistic regression analysis revealed that hypoalbuminemia (albumin level < 3.5 g/dL), an increased length of stay, and African American ethnicity were independent risk factors for VTE development.

Conclusion

Patients with hypoalbuminemia, an increased length of stay, and African American ethnicity are at an increased risk of VTE after shoulder arthroplasty. A high index of suspicion is warranted for elderly patients with fractures who may need preoperative medical optimization.

Predictors of Length of Stay and Discharge Disposition After Shoulder Arthroplasty: A Systematic Review

INTRODUCTION

Identifying patient factors that affect length of stay (LOS) and discharge disposition after shoulder arthroplasty is key in managing patient expectations. In this systematic review, we identify patient-specific covariates that correlate with increased LOS and need for discharge to a facility.

METHODS

We searched biomedical databases to identify associations between patient-specific factors and LOS and discharge disposition after shoulder arthroplasty. We included all studies involving hemiarthroplasty, anatomic shoulder arthroplasty, and reverse shoulder arthroplasty. Reported patient and provider factors were evaluated for their association with increased LOS and discharge to a facility.

RESULTS

Twenty-two studies were identified. Age >65 years, female sex, obesity, and reverse shoulder arthroplasty were associated with extended LOS and correlated with discharge to a facility. Greater hospital and surgeon volume were associated with decreased LOS and decreased risk of discharge to a facility. Local injection of liposomal bupivacaine combined with intravenous dexamethasone was associated with reduced LOS.

DISCUSSION

Patient factors affecting LOS and likelihood of discharge to a facility include age >65 years, female sex, diabetes, obesity, and reverse shoulder arthroplasty. These factors can be used to develop studies to preoperatively predict outcomes after shoulder arthroplasty and to help identify patients who may be at risk of prolonged postoperative admission.

LEVEL OF EVIDENCE

Prognostic level IV.

Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: evaluation of periprosthetic shoulder infection

The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. More than 800 experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology were assembled to form the International Consensus Group. The shoulder workgroup reached consensus on 27 questions related to culture techniques, inflammatory markers, and diagnostic criteria used to evaluate patients for periprosthetic shoulder infection. This document contains the group's recommendations and rationale for each question related to evaluating periprosthetic shoulder infection.

Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: management of periprosthetic shoulder infection

The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. A multidisciplinary team of international experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology was assembled to form the International Consensus Group. The following consensus proceedings from the International Consensus Meeting involve 30 questions pertaining to the management of periprosthetic shoulder infection.

Shoulder surgery in beach chair position causing perioperative stroke: Four cases and a review of the literature

Perioperative stroke is a rare, but serious complication in shoulder-arthroscopy or arthroplasty. Recent literature suggests the beach chair position, widely used during shoulder surgery, might induce severe perioperative hypotension, and with this cerebral desaturation and ultimately perioperative stroke. In this article we report four cases of perioperative stroke in shoulder surgery. In all cases, patients underwent brief periods of hypotension, which might have caused perioperative stroke. Based on an analysis in our hospital, we think the prevalence of perioperative stroke during shoulder surgery is higher than reported. Surgeons should be aware of this risk when using the beach chair position.

Venous Thromboembolism After Shoulder Arthoplasty and Arthroscopy

Venous thromboembolism (VTE) in the orthopaedic literature largely focuses on lower extremity trauma and arthroplasty, with relatively few investigations of VTE after shoulder surgery. Because the rate of shoulder surgery, especially arthroplasty, continues to expand, it is important for practicing surgeons to understand the magnitude of risk, potential consequences, and prevention methods with regard to VTE. VTE after shoulder surgery has been a topic of increasing interest over the past decade, and the purpose of this review is to examine the recent literature on pathophysiology, risk factors, incidence, diagnosis, sequelae, prevention, treatment, and current recommendations regarding VTE after shoulder surgery.

Elective Total Shoulder Arthroplasty in Octogenarians: A Safe Procedure

INTRODUCTION

There has been a lack of studies investigating the perioperative course of total shoulder arthroplasty (TSA) performed in the increasingly octogenarian (≥80 years old) population in a large sample size. The purpose of this study was to compare perioperative complications between primary TSA performed in octogenarians and that performed in younger populations (<70 and 70 to 79 years old) from the National Surgical Quality Improvement Program database.

METHODS

Patients who underwent primary TSA between January 2005 and December 2015 were identified from the National Surgical Quality Improvement Program database and stratified into three age groups: <70, 70 to 79, and ≥80 years old. Patient characteristics and comorbidities were compared between the three groups. Propensity score-matched comparisons were then performed for length of hospital stay, 30-day perioperative complications, and readmissions. Risk factors and reasons for readmission in the octogenarians were characterized.

RESULTS

This study included 3,007 patients who were <70 years old, 2,155 patients who were 70 to 79 years old, and 900 octogenarian patients. Statistical analysis was carried out after matching for propensity score. While no significant differences in perioperative complications were observed between the octogenarians and 70- to 79-year-olds, significantly higher rates of readmission (4.2% versus 1.7%; P = 0.002), pneumonia (1.1% versus 0.0%; P = 0.002), and urinary tract infection (1.8% versus 0.2%; P = 0.001) were found in the octogenarians compared with <70-year-olds. In addition, the octogenarians also had a slightly longer length of hospital stay compared with the younger populations (0.6 days longer than <70-year-olds and 0.4 days longer than 70- to 79-year-olds; both P < 0.001).

CONCLUSION

These data suggest that primary TSA can safely be considered for octogenarians with only mildly increased morbidities. However, greater preoperative optimization or post-discharge care for octogenarians may be warranted to reduce the rates of readmission.

Time-Driven Activity-Based Costing to Identify Patients Incurring High Inpatient Cost for Total Shoulder Arthroplasty

BACKGROUND

As payment models shift toward a focus on value, an accurate understanding of surgical costs and preoperative correlates of high-cost patients is important for effective implementation of cost-saving strategies. This study used time-driven activity-based costing (TDABC) to explore inpatient cost of total shoulder arthroplasty (TSA) and to identify preoperative characteristics of high-cost patients.

METHODS

Using TDABC, we calculated the cost of inpatient care for 415 patients undergoing elective primary TSA between 2016 and 2017. Patients in the top decile of cost were defined as high-cost patients. Multivariable logistic regression modeling was employed to determine preoperative characteristics (e.g., demographics, comorbidities, American Society of Anesthesiologists [ASA] score, and American Shoulder and Elbow Surgeons [ASES] score) associated with high-cost patients.

RESULTS

Implant purchase price was the main driver (57%) of total inpatient costs, followed by personnel cost from patient check-in through the time in the operating room (20%). There was a 1.3-fold variation in total cost between patients in the 90th percentile for cost and those in the 10th percentile; the widest cost variation was in personnel cost from the post-anesthesia care unit through discharge (2.5-fold) and in medication cost (2.4-fold). High-cost patients were more likely to be women and chronic opioid users and to have diabetes, depression, an ASA score of ≥3, a higher body mass index (BMI), and a lower preoperative ASES score than non-high-cost patients. After multivariable adjustment, the 3 predictors of high-cost patients were female sex, an ASA score of ≥3, and a lower ASES score. Total inpatient cost correlated strongly with the length of the hospital stay but did not correlate with operative time.

CONCLUSIONS

Our study provides actionable data to contain costs in the perioperative TSA setting. From the hospital's perspective, efforts to reduce implant purchase prices may translate into rapid substantial cost savings. At the patient level, multidisciplinary initiatives aimed at reducing length of stay and controlling medication expenses for patients at risk for high cost (e.g., infirm women with poor preoperative shoulder function) may prove effective in narrowing the existing patient-to-patient variation in costs.

LEVEL OF EVIDENCE

Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

Thromboembolic risk after lumbar spine surgery: a cohort study on 325 000 French patients

Essentials The risk of venous thromboembolism (VTE) after lumbar spine surgery (LBS) is not precisely known. More than 320 000 patients who underwent LBS in France between 2009 and 2014 were followed-up. The overall risk of VTE after LBS is less than 1% but modulated by patient and procedural factors. Surgical device implantation, anterior approach and complex surgery increase the risk of VTE. SUMMARY: Background Postoperative venous thromboembolism (VTE) is a severe complication, the risk of which after lumbar spine surgery (LBS) is not precisely known. Objective To estimate the incidence of VTE after LBS, and to identify individual and surgical risk factors. Methods All patients aged >18 years who underwent LBS in France between 2009 and 2014 were identified. Among 477 024 patients screened, exclusions concerned recent VTE or surgery, and multiple surgeries during the same hospital stay. Results In 323 737 patients (mean age 52.9 years, 51.4% male), we observed 2911 events (0.91%) after a median time of 12 days (Q1-Q3: 5-72 days). The multivariate adjusted Cox model showed increased risks associated with age (4% per year of age; 95% confidence interval [CI] 3.8-4.3), obesity (hazard ratio [HR] 1.32, 95% CI 1.18-1.46), active cancer (HR 1.65, 95% CI 1.5-1.82), previous thromboembolism (HR 5.41, 95% CI 4.74-6.17), severe paralysis (HR 1.47, 95% CI 1.17-1.84), renal disease (HR 1.28, 95% CI 1.04-1.6), psychiatric disease (HR 1.21, 95% CI 1.1-1.32), use of antidepressants (HR 1.13, 95% CI 1.03-1.24), use of contraceptives (HR 1.56, 95% CI 1.19-2.03), extended surgery for scoliosis (HR 3.61, 95% CI 2.96-4.4), implantation of pedicular screws with a 'dose-effect' association, and an anterior approach (HR 1.97, 95% CI 1.6-2.43) or a combined approach (HR 2.03, 95% CI 1.44-2.84). Conclusions The overall VTE risk after LBS is moderate (< 1%) but is widely modulated by several easily identifiable risk factors. The surgical community should be aware of this heterogeneity, adapt prevention according to patients and to the procedure, and use drug prophylaxis in the event of a high risk being present.

Revision Total Shoulder Arthroplasty is Associated with Increased Thirty-Day Postoperative Complications and Wound Infections Relative to Primary Total Shoulder Arthroplasty

BACKGROUND

With an increasing volume of primary total shoulder arthroplasties (TSA), the number of revision TSA cases is expected to increase as well. However, the postoperative medical morbidity of revision TSA has not been clearly described.

QUESTIONS/PURPOSES

The purpose of this study was to determine the rate of postoperative complications following revision TSA, relative to primary TSA. In addition, we sought to identify independent predictors of complications, as well as to compare operative time and postoperative length of stay between primary and revision TSA.

METHODS

Patients who underwent primary/revision TSA between 2005 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program. Differences in complications, readmission rates, operative time, length of stay, and predictors of complications were evaluated using bivariate and multivariate analyses.

RESULTS

A total of 10,371 primary TSA (95.4%) and 496 revision TSA cases (4.6%) were identified. The overall complication rate was 6.5% in primary and 10.7% in revision TSA patients (p < 0.001). Multivariate analysis identified an increased risk of any complication (odds ratio 1.73, p < 0.001), major complication (2.08, p = 0.001), and wound infection (3.45, p = 0.001) in revision TSA patients, relative to primary cases. Operative time was increased in revision cases (mean ± standard deviation, 125 ± 62.5), relative to primary (115 ± 47.7, p < 0.001). Age > 75, female sex, history of diabetes or chronic obstructive pulmonary disease, and American Society of Anesthesiologists classification ≥ 3 were associated with increased risk of any complication. Smoking history was the only significant predictor of wound infection.

CONCLUSION

Revision TSA, in comparison to primary, poses an increased risk of postoperative complications, particularly wound infections. A history of smoking was an independent predictor of wound infections.