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Root KT, Hones KM, Hao KA, Brolin TJ, Wright JO, King JJ, Wright TW, Schoch BS. A Systematic Review of Patient Selection Criteria for Outpatient Total Shoulder Arthroplasty. Orthop Clin North Am 2024; 55:363-381. [PMID: 38782508 DOI: 10.1016/j.ocl.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
The utilization of total shoulder arthroplasty (TSA) is increasing, driving associated annual health care costs higher. Opting for outpatient over inpatient TSA may provide a solution by reducing costs. However, there is no single set of accepted patient selection criteria for outpatient TSA. Here, the authors identify and systematically review 14 articles to propose evidence-based criteria that merit postoperative admission. Together, the studies suggest that patients with limited ability to abmluate independently or a history of congestive heart failure may benefit from postoperative at least one night of hospital based monitoring and treatment.
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Affiliation(s)
- Kevin T Root
- College of Medicine, University of Florida, 1600 SW Archer Road, Gainesville, FL 32610, USA
| | - Keegan M Hones
- Department of Orthopaedics and Sports Medicine, University of Florida, 3450 Hull Road # 3341, Gainesville, FL 32607, USA
| | - Kevin A Hao
- College of Medicine, University of Florida, 1600 SW Archer Road, Gainesville, FL 32610, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, 1211 Union Avenue # 500, Memphis, TN 38104, USA
| | - Jonathan O Wright
- Department of Orthopaedics and Sports Medicine, University of Florida, 3450 Hull Road # 3341, Gainesville, FL 32607, USA
| | - Joseph J King
- Department of Orthopaedics and Sports Medicine, University of Florida, 3450 Hull Road # 3341, Gainesville, FL 32607, USA
| | - Thomas W Wright
- Department of Orthopaedics and Sports Medicine, University of Florida, 3450 Hull Road # 3341, Gainesville, FL 32607, USA
| | - Bradley S Schoch
- Department of Orthopedic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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Roca Ruiz LJ, Ruiz Ibán MÁ, Díaz Heredia J, López-Millán JM. Consensus on the preoperative management of patients with chronic moderate to severe shoulder pain to improve postoperative outcomes: Delphi results. J Shoulder Elbow Surg 2024; 33:e364-e376. [PMID: 38182020 DOI: 10.1016/j.jse.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 11/08/2023] [Accepted: 11/14/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Appropriate preoperative management of patients with chronic moderate to severe shoulder pain who are candidates for surgery owing to rotator cuff disease or glenohumeral osteoarthritis may improve surgery and patient outcomes, but published evidence in this regard is scarce. Therefore, the availability of recommendations on preoperative interventions based on expert consensus may serve as guidance. METHODS A Delphi study was conducted to develop a preoperative management algorithm based on a national expert consensus. A Delphi questionnaire was developed by a scientific committee following a systematic review of the relevant literature published during the past 10 years using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) criteria. It consisted of 48 statements divided into 5 blocks (block I, assessment and diagnosis of preoperative pain; block II, preoperative function and psychosocial aspects; block III, therapeutic objectives; block IV, treatment; and block V, follow-up and referral), and 28 experienced shoulder surgeons from across the country were invited to answer. RESULTS All participants responded to the Delphi questionnaire in the first round, and 25 responded in the second round (89.3% of those invited). Overall, 46 of 49 final statements reached a consensus, on the basis of which a final preoperative management algorithm was defined by the scientific committee. First, surgeons should assess shoulder pain intensity and characteristics, shoulder functionality, and psychosocial aspects using specific validated questionnaires. Preoperative therapeutic objectives should include shoulder pain control, depression and/or nocturnal sleep improvement, opioid consumption adjustment, and substance abuse cessation. Postoperative objectives regarding the degree of shoulder pain reduction or improvement in functionality and/or quality of life should be established in agreement with the patient. Treatment of preoperative chronic moderate to severe shoulder pain should comprise nonpharmacologic as well as pharmacologic interventions. Follow-up of the shoulder pain levels, treatment adherence, and mental health status of these patients may be carried out by the surgical team (surgeon and anesthesiologist) together with the primary care team. Patients with very intense shoulder pain levels may be referred to a pain unit following specific protocols. CONCLUSION A preoperative management algorithm for patients with chronic moderate to severe shoulder pain who are candidates for surgery owing to rotator cuff disease or glenohumeral osteoarthritis was defined based on a national expert consensus. Main points include comprehensive patient management starting with an objective assessment of shoulder pain and function, as well as quality of life; establishment of preoperative and postoperative therapeutic targets; prescription of individualized therapeutic interventions; and multidisciplinary patient follow-up. Implementation of these recommendations into clinical practice may result in better preoperative shoulder pain management and more successful surgical outcomes and patient satisfaction.
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Affiliation(s)
- Luis Javier Roca Ruiz
- Orthopedic Surgery and Traumatology Service, Virgen Macarena University Hospital, Seville, Spain; Department of Surgery, University of Seville, Spain
| | - Miguel Ángel Ruiz Ibán
- Department of Surgery, Health and Medical Sciences, University of Alcaláde Henares, Alcalá de Henares, Madrid, Spain; Area of Traumatology and Orthopedics, CEU San Pablo University, Madrid, Spain; Shoulder and Elbow Unit, Ramón y Cajal University Hospital, Madrid, Spain.
| | - Jorge Díaz Heredia
- Department of Surgery, Health and Medical Sciences, University of Alcaláde Henares, Alcalá de Henares, Madrid, Spain; Area of Traumatology and Orthopedics, CEU San Pablo University, Madrid, Spain
| | - José Manuel López-Millán
- Department of Surgery, University of Seville, Spain; Pain Unit, Anesthesiology and Reanimation Service, Virgen Macarena University Hospital, Seville, Spain
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Kishan A, Pearson ZC, Li SS, Pressman Z, Ahiarakwe U, Pathiravasan CH, Srikumaran U. How low can we go? A randomized controlled trial of low-quantity initial opioid prescriptions for shoulder surgery. J Shoulder Elbow Surg 2024; 33:1211-1218. [PMID: 38461934 DOI: 10.1016/j.jse.2024.01.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Orthopedic surgeons are the third most frequent prescribers of opioid medications. Given the current opioid addiction crisis, it is critical to limit opioid prescriptions to the lowest effective dose. In this study, we investigated how the initial opioid prescription after shoulder surgery affects maximum possible opioid consumption. We hypothesized that fewer pills in the initial opioid prescription would lead to less opioid consumption, a lower refill request rate, and fewer post-surgery office contacts for pain. METHODS In this single-center, prospective, randomized controlled clinical trial, 74 adults who underwent shoulder arthroplasty, rotator cuff repair, or other arthroscopic shoulder procedures were enrolled from December 2020 to July 2022. Follow-up was completed by February 2023. Participants were randomly assigned to receive postoperative prescriptions of seven 5-mg oxycodone pills (n = 20), 15 pills (n = 29), or 23 pills (n = 25). The primary outcome was maximum possible opioid consumption within 2 weeks after surgery, calculated by assuming consumption of all pills in the initial prescription, as well as any refills. Secondary outcomes were the opioid prescription refill request rates, post-surgery pain-related telephone calls or messages to the provider's office ("office contacts") within 2 weeks after surgery, and American Shoulder and Elbow Surgeons pain scores 2 weeks after surgery. Baseline characteristics did not differ among groups except for mean age, which was younger in the 7-pill group (P = .047). RESULTS Maximum possible opioid consumption increased with the number of pills initially prescribed, with means of 78 morphine milligram equivalents (MME) for the 7-pill group, 118 MME for the 15-pill group, and 199 MME for the 23-pill group (P < .001). None of the secondary outcome measures differed among groups. Refill request rates were 20% for the 7-pill group, 3.4% for the 15-pill group, and 12% for the 23-pill group (P = .20). The proportions of patients with at least 1 office contact were 35% in the 7-pill group, 45% in the 15-pill group, and 28% in the 23-pill group (P = .43). Mean American Shoulder and Elbow Surgeons pain scores were 49 in the 7-pill group, 44 in the 15-pill group, and 40 in the 23-pill group (P = .20). CONCLUSION After shoulder surgery, an initial prescription of fewer opioid pills was associated with less maximum possible opioid consumption without an increase in the percentage of patients requesting opioid refills or contacting the provider's office for pain-related concerns. An initial postoperative prescription of fewer 5-mg oxycodone pills may be equally or more effective compared with larger quantities for most patients.
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Affiliation(s)
- Arman Kishan
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Zachary C Pearson
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Steve S Li
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Zachary Pressman
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Uzoma Ahiarakwe
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Chathurangi H Pathiravasan
- Department of Biostatistics, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD, USA
| | - Uma Srikumaran
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA.
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Vijittrakarnrung C, Freshman R, Anigwe C, Lansdown DA, Feeley BT, Ma CB. Periarticular injection in addition to interscalene nerve block can decrease opioid consumption and pain following total shoulder arthroplasty: a comparison cohort study. J Shoulder Elbow Surg 2023; 32:e597-e607. [PMID: 37311486 DOI: 10.1016/j.jse.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 04/25/2023] [Accepted: 05/06/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Interscalene nerve block (INB) is an effective technique to provide postoperative analgesia for total shoulder arthroplasty (TSA). However, the analgesic effects of the block typically resolve between 8 and 24 hours postadministration, which results in rebound pain and subsequent increased opioid use. The objective of this study was to address this issue by determining how adding an intraoperative periarticular injection (PAI) in combination with INB affects acute postoperative opioid consumption and pain scores in patients undergoing TSA. We hypothesized that compared with INB alone, INB + PAI will significantly reduce opioid consumption and pain scores for the first 24 hours postsurgery. METHODS We reviewed 130 consecutive patients who underwent elective primary TSA at a single tertiary institution. The first 65 patients were treated with INB alone, followed by 65 patients treated with INB + PAI. The INB used was 15-20 mL of 0.5% ropivacaine. The PAI used was 50 mL of a combination of ropivacaine (123 mg), epinephrine (0.25 mg), clonidine (40 μg), and ketorolac (15 mg). The PAI was injected using a standardized protocol: 10 mL into the subcutaneous tissues prior to incision, 15 mL into the supraspinatus fossa, 15 mL at the base of the coracoid process, and 10 mL into the deltoid and pectoralis muscles-a protocol analogous with a previously described technique. For all patients, a standardized postoperative oral pain medication protocol was used. The primary outcome was acute postoperative opioid consumption represented by morphine equivalent units (MEUs), whereas the secondary outcome was visual analog scale (VAS) pain scores over the first 24 hours postsurgery, operative time, length of stay, and acute perioperative complications. RESULTS No significant differences in demographics existed between patients who received INB alone vs. INB + PAI. Patients who received INB + PAI had a significantly lower 24-hour postoperative opioid consumption compared to the INB alone group (38.6 ± 30.5 MEU vs. 60.5 ± 37.3 MEU, P < .001). Additionally, VAS pain scores for the first 24 hours postsurgery in the INB + PAI group were significantly lower compared to those for the INB alone group (2.9 ± 1.5 vs. 4.3 ± 1.6, P ≤ .001). No differences existed between groups regarding operative time, length of inpatient stay, and acute perioperative complications. CONCLUSION Patients undergoing TSA with INB + PAI demonstrated significantly decreased 24-hour postoperative total opioid consumption and 24-hour postoperative pain scores compared to the group treated with INB alone. No increase in acute perioperative complications related to PAI was observed. Thus, compared to an INB, the addition of an intraoperative periarticular cocktail injection appears to be a safe and effective method to reduce acute postoperative pain following TSA.
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Affiliation(s)
- Chaiyanun Vijittrakarnrung
- Department of Orthopedic Surgery, Sports Medicine & Shoulder Surgery, University of California, San Francisco, San Francisco, CA, USA; Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Ryan Freshman
- Department of Orthopedic Surgery, Sports Medicine & Shoulder Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Christopher Anigwe
- Department of Orthopedic Surgery, Sports Medicine & Shoulder Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Drew A Lansdown
- Department of Orthopedic Surgery, Sports Medicine & Shoulder Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Brian T Feeley
- Department of Orthopedic Surgery, Sports Medicine & Shoulder Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - C Benjamin Ma
- Department of Orthopedic Surgery, Sports Medicine & Shoulder Surgery, University of California, San Francisco, San Francisco, CA, USA
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Farronato DM, Pezzulo JD, Rondon AJ, Sherman MB, Davis DE. Distressed communities demonstrate increased readmission and health care utilization following shoulder arthroplasty. J Shoulder Elbow Surg 2023; 32:2035-2042. [PMID: 37178966 DOI: 10.1016/j.jse.2023.03.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 03/22/2023] [Accepted: 03/30/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Socioeconomic status (SES) has been shown to affect outcomes following total shoulder arthroplasty (TSA), but little is known regarding how SES and the communities in which patients reside can affect postoperative health care utilization. With the growing use of bundled payment models, understanding what factors put patients at risk for readmission and the ways in which patients utilize the health care system postoperatively is crucial for preventing excess costs for providers. This study helps surgeons predict which patients are high-risk and may require additional surveillance following shoulder arthroplasty. METHODS A retrospective review of 6170 patients undergoing primary shoulder arthroplasty (anatomic and reverse; Current Procedural Terminology code 23472) from 2014-2020 at a single academic institution was performed. Exclusion criteria included arthroplasty for fracture, active malignancy, and revision arthroplasty. Demographics, patient zip code, and Charlson Comorbidity Index were attained. Patients were classified according to the Distressed Communities Index (DCI) score of their zip code. The DCI combines several metrics of socioeconomic well-being to generate a single score. Zip codes are then classified by scores into 5 categories based on national quintiles. The primary outcome of interest was 90-day readmissions. Secondary outcomes included number of postoperative medication prescriptions, patient telephone calls to the office, and follow-up office visits. RESULTS Among all patients undergoing total shoulder arthroplasty, individuals from distressed communities were more likely than their prosperous counterparts to experience an unplanned readmission (odds ratio = 1.77, P = .045). Patients from comfortable (relative risk [RR] = 1.12, P < .001), midtier (RR = 1.13, P < .001), at-risk (RR = 1.20, P < .001), and distressed (RR = 1.17, P < .001) communities were all more likely to use more medications compared to those from prosperous communities. Likewise, those from comfortable (RR = 0.92, P < .001), midtier (RR = 0.88, P < .001), at-risk (RR = 0.93, P = .008), and distressed (RR = 0.93, P = .033) communities, respectively, were at a lower risk of making calls compared to prosperous communities. CONCLUSIONS Following primary total shoulder arthroplasty, patients who reside in distressed communities are at significantly increased risk of experiencing an unplanned readmission and increased health care utilization postoperatively. This study revealed that patient socioeconomic distress is more associated with readmission than race following TSA. Increased awareness and employing strategies to maintain and ultimately improve communication with patients offers a potential solution to reduce excessive health care utilization, benefiting both patients and providers alike.
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Affiliation(s)
- Dominic M Farronato
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Joshua D Pezzulo
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander J Rondon
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Matthew B Sherman
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Daniel E Davis
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA.
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Sabesan V, Lapica H, Fernandez C, Fomunung C. Evolution of Perioperative Pain Management in Shoulder Arthroplasty. Orthop Clin North Am 2023; 54:435-451. [PMID: 37718083 DOI: 10.1016/j.ocl.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Historically, opioids have been used as a primary conservative treatment for pain related to glenohumeral osteoarthritis (GHOA). However, this practice is concerning as it often leads to overuse, which has contributed to the current epidemic of addiction and overdoses in the United States. Studies have shown that preoperative opioid use is associated with higher complication rates and worse outcomes following surgery, particularly for shoulder arthroplasty. To address these concerns, perioperative pain management for shoulder arthroplasty has evolved over the years to the use of multimodal analgesia.
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Affiliation(s)
- Vani Sabesan
- Department of Orthopedics, JFK/University of Miami, Palm Beach, FL, USA.
| | - Hans Lapica
- Department of Orthopedics, JFK/University of Miami, Palm Beach, FL, USA
| | - Carlos Fernandez
- Department of Orthopedics, JFK/University of Miami, Palm Beach, FL, USA
| | - Clyde Fomunung
- Department of Orthopedics, JFK/University of Miami, Palm Beach, FL, USA
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Kamma SA, Pathapati RK, Somerson JS. Smoking cessation prior to total shoulder arthroplasty: A systematic review of outcomes and complications. Shoulder Elbow 2023; 15:484-496. [PMID: 37811391 PMCID: PMC10557933 DOI: 10.1177/17585732221131916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 07/18/2022] [Accepted: 09/13/2022] [Indexed: 10/10/2023]
Abstract
Background We conducted a review of current literature to examine the effects of smoking and smoking cessation on shoulder arthroplasty surgery. Methods A literature search was performed using the search terms "shoulder arthroplasty AND [smoke OR smoking OR tobacco OR nicotine]." Studies included English-language clinical outcomes studies on anatomic total shoulder arthroplasty (TSA), reverse TSA, and partial shoulder arthroplasty with evidence levels 1 through 4. Descriptive statistics calculated in the included studies were used during the analysis. Categorical variables were reported as proportions, while continuous variables were reported as means with minimum to maximum absolute ranges. Results Twenty-four studies were included and analyzed. Following TSA, patients who quit smoking at least 1 month preoperatively had improved outcomes compared to current smokers. Current smokers had statistically significant higher pain scores or opioid use. Five studies found increased rates of revision surgery in smokers. Smokers were significantly (p < 0.05) more likely to have increased rates of surgical, wound, superficial, and deep surgical site complications. Discussion Former smokers had lower complication rates and visual analog scale scores when compared to current users. A period of four weeks or more of preoperative smoking cessation is recommended. Level of Evidence Level III, Systematic Review.
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Affiliation(s)
- Sai A Kamma
- John Sealy School of Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - Rajeev K Pathapati
- School of Medicine, The University of Texas Health Science Center – San Antonio, San Antonio, TX, USA
| | - Jeremy S Somerson
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, TX, USA
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Kelly PJ, Twomey-Kozak JN, Goltz DE, Wickman JR, Levin JM, Hinton Z, Lassiter TE, Klifto CS, Anakwenze OA. Perioperative pain control represents the primary concern for patients considering outpatient shoulder arthroplasty: a survey-based study. J Shoulder Elbow Surg 2022; 31:e628-e633. [PMID: 35998781 DOI: 10.1016/j.jse.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/27/2022] [Accepted: 07/07/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Outpatient (OP) total shoulder arthroplasty (TSA) with same-day discharge can now be performed safely in appropriately selected patients. Patient knowledge and perspectives regarding OP TSA are yet unknown and such information may inform surgeon decision-making and provide a framework for addressing patient concerns. The goal of this study was to understand and quantify patient knowledge of and concerns for OP TSA, with a working hypothesis that majority of patients are unaware of OP TSA as a realistic option and that their primary concern would be postoperative pain control. METHODS This was a retrospective cohort study at a tertiary care academic medical center including patients who underwent anatomic or reverse shoulder arthroplasty and completed an OP TSA expectations questionnaire/survey. This survey was provided preoperatively and included demographic factors, self-rated health evaluation, and perioperative expectations. Surveys evaluated whether patients undergoing TSA had any prior awareness of OP TSA and evaluated their primary concern with same-day discharge. Secondary questions included an assessment of patient expectations of outcomes of outpatient vs. inpatient surgery as well as their expected length of inpatient stay. RESULTS A total of 122 patients who underwent anatomic and reverse shoulder arthroplasty completed the questionnaire and comprised the study cohort. Fifty-two (42.6%) of the patients were unaware that OP TSA was an option, and 26 (50%) of these were comfortable with the idea of OP TSA. Comfort with OP TSA was significantly associated with higher subjective patient-reported health status. Fifty-eight patients (47.5%) expected that following TSA they would require <24 hours of in-hospital postoperative care. The primary concern for patients considering OP TSA was postoperative pain control, endorsed by 44.3% of patients, compared with 13.1% of patients stating this would be their primary concern if admitted as an inpatient postoperatively. Pain control being a primary concern was significantly different between those considering outpatient vs. inpatient TSA. Most patients anticipated that OP shoulder arthroplasty would lead to a better (36%) or comparable (53%) outcome, whereas only 11% had concerns that it would lead to a worse outcome. CONCLUSION Expanding OP TSA crucially depends on awareness and education. Perceived ability to control pain is an important concern. Patients may benefit from preoperative counseling, including emphasizing a comprehensive postoperative pain management strategy.
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Affiliation(s)
- Patrick J Kelly
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA.
| | | | - Daniel E Goltz
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - John R Wickman
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Jay M Levin
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Zoe Hinton
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Tally E Lassiter
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | | | - Oke A Anakwenze
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
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Khoury LH, Stephens J, Brown S, Chatha K, Girshfeld S, Lozano Leon JM, Lavin A, Sabesan VJ. Application of risk assessment tools to predict opioid usage after shoulder surgery. JSES Int 2022; 6:833-842. [PMID: 36081685 PMCID: PMC9446226 DOI: 10.1016/j.jseint.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Currently 128 people die daily from opioid-related overdoses in the United States. This burden has instigated a search for viable means to guide postoperative prescription decision-making. The Opioid Risk Tool (ORT) and the Screener and Opioid Assessment for Patient with Pain (SOAPP) are validated risk assessment tools to predict opioid usage in high-risk populations. The purpose of this study was to evaluate the accuracy of these opioid risk assessments and pain intensity scores, including the Patient-Reported Outcomes Measurement Information System (PROMIS), to predict postoperative opioid use and dependence in shoulder surgery. Methods A retrospective review of 81 patients who underwent shoulder surgery and completed 3 preoperative risk and pain assessments within a single hospital system from 2018 to 2020 was performed. Demographic variables and ORT-O, SOAPP-R (the revised version of the SOAPP assessment), and PROMIS 3a scores were recorded from preoperative assessments. Opioid prescriptions were recorded from Electronic-Florida Online Reporting of Controlled Substances Evaluation. Dependence was defined as opioid prescriptions at or greater than 3 months after surgery. Risk assessment scores were compared and tested against postoperative opioid prescriptions using statistical analyses and logistic regression modeling. Results In the cohort, there were 36 female and 45 male patients with an average age of 64.5 years and body mass index of 28.0. Preoperatively, the average pain score was 6.2, and 7.8% of patients reported prolonged preoperative narcotics use. The average ORT-O score was 3.0, with 35.8% of patients defined as either medium or high risk, and the average PROMIS pain intensity preoperatively was 10.8. Neither the ORT-O nor the PROMIS pain score were good predictors of postoperative opioid dependence (area under curve = 0.39 and 0.43, respectively). The SOAPP-R performed slightly better (area under curve = 0.70) and was the only assessment with significantly different mean scores between patients with postoperative opioid dependence and those without (33.4 and 24.5, respectively, P = .049) and a moderate correlation to postoperative total morphine equivalents (R = 0.46, P = .007). Conclusion With recent focus on preoperative risk assessments to predict postoperative opioid use and dependence, it is important to understand how well these tools work when applied to orthopedic patients. While the ORT may be helpful in other fields, it does not seem to be a strong predictor of postoperative opioid use or dependence in patients undergoing various types of shoulder surgery. Future studies are needed to explore the utility of the SOAPP-R in a larger sample and identify tools applicable to the orthopedic population to assist surgeons in screening at-risk patients.
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Affiliation(s)
- Laila H. Khoury
- Charles E. Schmidt School of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Josh Stephens
- NOVA Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, FL, USA
| | - Shimron Brown
- Charles E. Schmidt School of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Kiran Chatha
- Levitetz Department of Orthopedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Sarah Girshfeld
- Charles E. Schmidt School of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | | | - Alessia Lavin
- Palm Beach Shoulder Service – HCA Florida Atlantis Orthopedics, Palm Beach FL, USA
| | - Vani J. Sabesan
- Levitetz Department of Orthopedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
- Palm Beach Shoulder Service – HCA Florida Atlantis Orthopedics, Palm Beach FL, USA
- Corresponding author: Vani J. Sabesan, MD, Atlantis Orthopedics, 4560 Lantana Rd Suite 100, Lake Worth, FL 33463, USA.
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10
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Sandler AB, Scanaliato JP, Narimissaei D, McDaniel LE, Dunn JC, Parnes N. The transition to outpatient shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg 2022; 31:e315-e331. [PMID: 35278682 DOI: 10.1016/j.jse.2022.01.154] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/24/2022] [Accepted: 01/29/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND HYPOTHESIS Transitioning shoulder arthroplasty (SA) from an inpatient to outpatient procedure is associated with increased patient satisfaction and potentially decreased costs; however, concerns exist about complications following same-day discharge. We hypothesized that outpatient SA would be associated with low rates of failed discharges, readmissions, and complications, rendering it a safe and effective option for SA. METHODS A systematic review of the outpatient SA literature identified 16 of 447 studies with level III and IV evidence that met the inclusion criteria with at least 90 days of follow-up. Data on patient demographic characteristics, preoperative and postoperative protocols, surgery characteristics, failed discharges, complications, and readmissions were collected and pooled for analysis. RESULTS A total of 990 patients were included in our analysis. Many studies identified specific institutional protocols for determining eligibility for outpatient SA, including preoperative clearance from an anesthesiologist; identification of a perioperative caretaker; and exclusion of patients based on cardiac, pulmonary, or hematologic risk factors. Failed same-day discharge occurred in only 0.9% of patients (7 of 788), and 2.1% of patients (9 of 418) and 0.79% of patients (2 of 252) presented to an emergency department or urgent care facility for a perioperative concern. The readmission rate for periprosthetic fracture, arthrofibrosis, infection, subscapularis rupture, and anterior subluxation was 1.3% (7 of 529 patients). Complications occurred in 7.0% of patients (70 of 990), with 5.4% of patients (53 of 990) experiencing a surgical complication and 1.7% (17 of 990) having a medical complication. There were 28 total reoperations (2.9%, 28 of 955 patients). DISCUSSION AND CONCLUSION Outpatient SA is associated with low rates of failed discharges, readmissions, and complications. Additionally, the medical and surgical complications that occur after outpatient SA are unlikely to be prevented by the short inpatient stay characteristic of traditional SA. With careful screening measures to identify appropriate candidates for same-day discharge, outpatient SA represents a safe approach to prevent unnecessary hospitalizations and to decrease costs associated with SA.
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Affiliation(s)
- Alexis B Sandler
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA; Department of Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, TX, USA.
| | - John P Scanaliato
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Danielle Narimissaei
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Lea E McDaniel
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - John C Dunn
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Nata Parnes
- Department of Orthopaedic Surgery, Carthage Area Hospital, Carthage, NY, USA; Department of Orthopaedic Surgery, Claxton-Hepburn Medical Center, Ogdensburg, NY, USA
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Rojas Lievano J, Rotman D, Shields MN, Morrey ME, Sanchez-Sotelo J, Shukla DR, Olson TS, Vaichinger AM, Fitzsimmons JS, O’Driscoll SW. Patients Use Fewer Opioids Than Prescribed After Arthroscopic Release of Elbow Contracture: An Evidence-Based Opioid Prescribing Guideline to Reduce Excess. Arthrosc Sports Med Rehabil 2021; 3:e1873-e1882. [PMID: 34977643 PMCID: PMC8689263 DOI: 10.1016/j.asmr.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 09/02/2021] [Indexed: 11/24/2022] Open
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Kaiser TJ, Shanley E, Denninger TR, Reuschel B, Kissenberth MJ, Tolan SJ, Thigpen CA, Pill SG. Preoperative screening in patients having elective shoulder surgery reveals a high rate of fall risk. J Shoulder Elbow Surg 2021; 30:S84-S88. [PMID: 33895300 DOI: 10.1016/j.jse.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Fall risk is an acknowledged but relatively understudied concern for older patients undergoing shoulder surgery. The cause is multifactorial, and it includes advanced age, impaired upper extremity function, use of shoulder abduction braces, and postoperative use of opioid medications. No previous study has examined preoperative fall risk in patients undergoing elective shoulder surgery. Previous literature looking at fall risk in elective orthopedic procedures has predominantly focused on falls occurring in the hospital setting, although falls have also been shown to occur in the outpatient setting. Gait speed and Timed Up and Go (TUG) are well-researched functional measures in the aging population with established cutoff scores indicating increased fall risk. The purpose of this study was to quantify gait speed and TUG scores in a series of patients who were scheduled to undergo either rotator cuff repair (RCR) or total shoulder arthroplasty (TSA) in order to assess overall risk of fall in these populations. METHODS A total of 198 patients scheduled for TSA or RCR surgery were evaluated preoperatively from multiple outpatient physical therapy clinics within Greenville, South Carolina. The TUG score (>14 seconds considered high fall risk) and 10 Meter Walk test (<0.7 m/s considered high risk for falls) were recorded for each patient. Patient-reported outcomes were also collected, including Veteran's Rand 12 Physical Component and Mental Component Scores, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, and the Single Assessment Numeric Evaluation. RESULTS Patients undergoing TSA (n = 80; 65.4 ± 11.4 years) were older than those undergoing RCR (n = 118; 59.0 ± 14.2 years). Fifty-nine percent of all patients were classified as being a high risk for falls based on gait speed <0.7 m/s. Patients in the TSA group were more likely to display preoperative fall risk compared to patients in the RCR group (62% vs. 38%; χ2 = 8.9, P = .03). There were no significant differences in ambulatory status, Veteran's Rand 12 Physical Component and Mental Component Scores, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, or Single Assessment Numeric Evaluation scores between groups (P = .11). DISCUSSION Both patient groups demonstrated a high rate of fall risk in preoperative evaluation. Patients undergoing TSA more often displayed fall risk compared with patients undergoing RCR. Although patients in the TSA group were older, there was no association between age or ambulatory status and fall risk. CONCLUSION Our results suggest that fall risk screening may be important for patients undergoing TSA and RCR surgeries. The higher fall risk in the TSA group may be an important consideration as this procedure shifts toward outpatient status.
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Affiliation(s)
- Thomas J Kaiser
- Steadman Hawkins Clinic of the Carolinas, Greenville, SC, USA
| | - Ellen Shanley
- Steadman Hawkins Clinic of the Carolinas, Greenville, SC, USA
| | | | - Beth Reuschel
- Steadman Hawkins Clinic of the Carolinas, Greenville, SC, USA
| | | | - Stefan J Tolan
- Steadman Hawkins Clinic of the Carolinas, Greenville, SC, USA
| | | | - Stephan G Pill
- Steadman Hawkins Clinic of the Carolinas, Greenville, SC, USA.
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13
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Sethi PM, Mandava NK, Liddy N, Denard PJ, Haidamous G, Reimers CD. Narcotic requirements after shoulder arthroplasty are low using a multimodal approach to pain. JSES Int 2021; 5:722-728. [PMID: 34223421 PMCID: PMC8245905 DOI: 10.1016/j.jseint.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Background Recent "multimodal" approaches to pain, although understudied, have shown promise in reducing reliance on narcotics in shoulder arthroplasty (SA). Many surgeons report being unsure of how many narcotic pills to prescribe after the surgery. As result, patients are prescribed upwards of 60 oxycodone 5-mg pills for a 6-to-12-week treatment period despite studies showing postoperative pain can be managed without any medication at all. Purpose The purpose of this multicenter study was to prospectively determine the number of opiate pills required after SA to develop generalizable, evidence-based prescription guidelines for surgeons. We hypothesized that opioid prescription would be low using a multimodal approach to pain management. Methods The study enrolled 63 patients undergoing SA. Subjects received either an interscalene nerve block with liposomal bupivacaine, standard bupivacaine, or a local infiltration standard bupivacaine field block based on preference. All subjects were provided with postoperative "Pain Journals" to document their daily pain on a Numerical Rating Scale and daily opioid consumption during the 14-day postoperative period. Results Overall, patients consumed an average of 8.6 oxycodone 5-mg pills (64.5 morphine milligram equivalents) after SA. Seventy-nine percent of patients required 15 or fewer oxycodone 5-mg pills, and 27% successfully managed their postoperative pain with zero opioids. Average pain remained low for patients in all groups. Conclusion With a multimodal approach, most patients undergoing SA can manage postoperative pain with 15 or fewer oxycodone 5-mg tablets, or 112.5 morphine milligram equivalents. The addition of a liposomal bupivacaine interscalene nerve block may further reduce the consumption of postoperative narcotics compared with a standard interscalene nerve block. This study provides evidence that may be used for surgeon guidelines in the effort to reduce opioid prescriptions after SA.
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Affiliation(s)
- Paul M Sethi
- Orthopedic and Neurosurgery Specilaists Foundation, Greenwich, CT, USA
| | - Nikhil K Mandava
- Orthopedic and Neurosurgery Specilaists Foundation, Greenwich, CT, USA
| | - Nicole Liddy
- Orthopedic and Neurosurgery Specilaists Foundation, Greenwich, CT, USA
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Abstract
Introduction Pain control following a total shoulder arthroplasty (TSA) is multifactorial. The current standard of care includes the utilization of a multimodal analgesic approach including breakthrough prescription opioid medication in an effort to provide postoperative analgesia. While this original opioid prescription is sufficient for the majority of patients, some go on to require prolonged opioid use. Our study investigated patient risk factors associated with opioid refill postsurgery. Methods The Truven Marketscan® database was queried for all patients who underwent either a primary anatomic TSA or primary reverse TSA from 2010 to 2017. Opioid data were collected using National Drug Codes (NDC) from outpatient pharmacy claims. Only opioid-naïve patients were included. Patients were then grouped into 1 of 3 cohorts based on postoperative opioid use: 1) Patients with no additional refills, 2) patients with a minimum of one additional refill up through 6 months postoperatively, and 3) patients with additional refills and continued opioid use past 6 months. Results Of the total of 17,706 opioid-naïve patients that underwent a TSA, 10,882 (61.5%) did not have any additional refills, 4473 (25.3%) required an additional prescription within 6 months after surgery, and 2351 (13.3%) had prolonged opioid use beyond 6 months postoperatively. A dose-dependent relationship was identified between initial opioid prescription quantity and risk for refill and prolonged use. The prolonged use group was prescribed an equivalent of 20.0 more 5 mg oxycodone pills than the no refill group and 12.7 more than the refill group (P < .001). On multivariate analysis, younger age, female gender, and tobacco use, along with the comorbidities of coronary artery disease, clinical depression, diabetes, and rheumatic disease were all found to be predictive factors of prolonged opioid use. Discussion The dose-dependent relationship observed between original opioid prescription data and number of additional refills needed, suggests that initially overprescribing opioids may lead to prolonged dependency. This study also identified several independent risk factors for prolonged opioid use, including younger age, depression, and tobacco use. This study will hopefully help recognize high-risk patient populations and serve as the foundation for future studies into opioid prescription standardization and preoperative opioid education.
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Editorial Commentary: Opioids After Orthopaedic Surgery: Who Needs 'Em? Arthroscopy 2020; 36:2258-2259. [PMID: 32747066 DOI: 10.1016/j.arthro.2020.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 02/02/2023]
Abstract
Multimodal analgesia protocols have been developed to reduce the number of opioids prescribed after orthopaedic surgery, although no previous studies have examined the effectiveness of a nonopioid multimodal analgesia protocol following common sports medicine procedures. Clinicians should feel assured that this type of strategy can be effective at reducing pain and the number of opioids needed for breakthrough pain with minimal side effects and without compromising patient satisfaction. The use of rescue opioids is associated with pain level, procedure type, and psychiatric illness.
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