Impact of the COVID-19 pandemic on shoulder arthroplasty: surgical trends and postoperative care pathway analysis

The Relationship Between Preoperative International Normalized Ratio and Postoperative Major Bleeding in Total Shoulder Arthroplasty

INTRODUCTION

This study aimed to assess the relationship between preoperative international normalized ratio (INR) levels and major postoperative bleeding events after total shoulder arthroplasty (TSA).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried for TSA from 2011 to 2020. A final cohort of 2405 patients with INR within 2 days of surgery were included. Patients were stratified into four groups: INR ≤ 1.0, 1.0 < INR ≤ 1.25, 1.25< INR ≤ 1.5, and INR > 1.5. The primary outcome was bleeding requiring transfusion within 72 hours, and secondary outcome variables included complication, revision surgery, readmission, and hospital stay duration. Multivariable logistic and linear regression analyses adjusted for relevant comorbidities were done.

RESULTS

Of the 2,405 patients, 48% had INR ≤ 1.0, 44% had INR > 1.0 to 1.25, 7% had INR > 1.25 to 1.5, and 1% had INR > 1.5. In the adjusted model, 1.0 < INR ≤ 1.25 (OR 1.7, 95% CI 1.176 to 2.459), 1.25 < INR ≤ 1.5 (OR 2.508, 95% CI 1.454 to 4.325), and INR > 1.5 (OR 3.200, 95% CI 1.233 to 8.302) were associated with higher risks of bleeding compared with INR ≤ 1.0.

DISCUSSION

The risks of thromboembolism and bleeding lie along a continuum, with higher preoperative INR levels conferring higher postoperative bleeding risks after TSA. Clinicians should use a patient-centered, multidisciplinary approach to balance competing risks.

Trends in the Adoption of Outpatient Joint Arthroplasties and Patient Risk: A Retrospective Analysis of 2019 to 2021 Medicare Claims Data

INTRODUCTION

Total joint arthroplasties (TJAs) have recently been shifting toward outpatient arthroplasty. This study aims to explore recent trends in outpatient total joint arthroplasty (TJA) procedures and examine whether patients with a higher comorbidity burden are undergoing outpatient arthroplasty.

METHODS

Medicare fee-for-service claims were screened for patients who underwent total hip, knee, or shoulder arthroplasty procedures between January 2019 and December 2022. The procedure was considered to be outpatient if the patient was discharged on the same date of the procedure. The Hierarchical Condition Category Score (HCC) and the Charlson Comorbidity Index (CCI) scores were used to assess patient comorbidity burden. Patient adverse outcomes included all-cause hospital readmission, mortality, and postoperative complications. Logistic regression analyses were used to evaluate if higher HCC/CCI scores were associated with adverse patient outcomes.

RESULTS

A total of 69,520, 116,411, and 41,922 respective total knee, hip, and shoulder arthroplasties were identified, respectively. Despite earlier removal from the inpatient-only list, outpatient knee and hip surgical volume did not markedly increase until the pandemic started. By 2022Q4, 16%, 23%, and 36% of hip, knee, and shoulder arthroplasties were discharged on the same day of surgery, respectively. Both HCC and CCI risk scores in outpatients increased over time (P < 0.001).

DISCUSSION

TJA procedures are shifting toward outpatient surgery over time, largely driven by the COVID-19 pandemic. TJA outpatients' HCC and CCI risk scores increased over this same period, and additional research to determine the effects of this should be pursued.

LEVEL OF EVIDENCE

Level III, therapeutic retrospective cohort study.

Optimizing Surgical Care Amidst COVID-19: A Scoping Review of Practices and Policies

BACKGROUND

The coronavirus disease (COVID-19) pandemic significantly disrupted surgical care worldwide, affecting different specialties in various ways. Lockdowns, surges in COVID-19 cases, and changes in hospital policies notably impacted patient attendance, management practices, and access to surgical services. This scoping review examines the adverse impacts of the COVID-19 pandemic on surgical services and the policies adopted to address these care barriers.

METHODS

We conducted a comprehensive literature review using the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) guidelines. Our search, spanning 31 December 2019, to 29 January 2023, focused on understanding the multifaceted impacts of COVID-19 on surgical services, particularly across different specialties.

RESULTS

An analysis of 75 articles indicated that the pandemic challenged surgeons worldwide to maintain a balance between delivering emergency and elective surgical care, and implementing safety measures against viral transmission. There was a marked decline in the surgical volume, leading to extended waitlists and decreased operating theater usage. Strategies such as prioritizing medically necessary and time-sensitive surgeries and integrating telemedicine have emerged as pivotal for ensuring the continuity of urgent care. Despite the reduced rates, essential surgeries such as appendectomies and cancer-related operations continued, yet faced hurdles, including reduced staffing, limited operating theater capacity, and complications in patient transfers.

CONCLUSIONS

This review emphasizes the steep reduction in surgical service utilization at the beginning of the pandemic and emergence of new compounded barriers. Policies that designated surgeries as essential, and focused on equitable and timely access, were effective. Incorporating these findings into post-pandemic assessments and future planning is crucial to sustain adequate surgical care during similar health emergencies.

Trends in Orthopedic Management of Distal Radius Fractures Among Medicare Beneficiaries From 2019 to 2020: A Claims Analysis

Purpose

Radius and ulna fractures are among the most common fractures. These fractures are managed through operative or nonsurgical treatment, with varying implications in terms of cost and functional outcome. There are few studies that robustly characterize the management of distal radius fractures (DRFs) in the United States during the COVID-19 pandemic. Furthermore, this has not been studied among the Medicare patient population, who are particularly vulnerable to fragility fractures and COVID-19. The purpose of this study is to analyze the services provided to Medicare beneficiaries both before and during the COVID-19 pandemic to determine how procedure volume was affected in this patient population.

Methods

We retrospectively analyzed services using the physician or supplier procedure summary data from the Centers for Medicare and Medicaid Services. All services provided by physicians between January 1, 2019, and December 31, 2020, were included. The data were stratified by US census region using insurance carrier number and pricing locality codes. We also compared data between states that maintained governors affiliated with the Democratic or Republican parties for the duration of the study.

Results

There was an overall decrease in claims regarding DRFs management from 2019 to 2020. There was a dramatic decline in procedure volume (-6.3% vs -12.9%). Of all distal radius related claims there was a relative increase in the proportion of operatively managed DRFs in 2020, from 50.2% to 52.0%. The Midwest saw the greatest decline in operatively managed DRFs, whereas the West experienced the smallest per-capita decline across all procedures. After separating the data by party affiliation, it was also found that operative and nonsurgical procedure volumes fell more sharply in states with Democratic governors.

Conclusions

This study shows a decrease in DRF procedural volume among Medicare beneficiaries. This data suggests that the operative and nonsurgical management of DRFs may have been affected by pandemic factors such as quarantine guidelines and supply chain or resource limitations. This may assist surgeons and health care systems in predicting how similar crises may affect operative volume.

Type of study/level of evidence

Therapeutic IV.

Outcomes of Reverse Total Shoulder Arthroplasty Were Not Adversely Affected by the COVID-19 Pandemic

Introduction

The objective was to investigate outcomes in reverse total shoulder arthroplasty (RTSA) in patients affected by the COVID-19 pandemic shutdown. We hypothesized that patients undergoing RTSA in early 2020 would have decreased access to physical therapy (PT) and worse postoperative outcomes compared to historical controls.

Materials and Methods

Patients who received primary RTSA between 1/1/2020 to 3/17/2020 were included and patients who received primary RTSA between 1/1/2019 to 3/17/2019 were used as a control group. Retrospective chart review was performed, and patient reported outcomes were recorded at an average of 2.69 ± 0.06 years and a minimum of 1 year postoperatively. Patient data were collected and statistically analyzed using the 2-sample t-test and Chi-square test. The Mann Whitney U test and Fisher's Exact test were used when appropriate.

Results

38 patients in 2020 were included in this study and compared to 31 patients in 2019. RTSA performed in 2019 had improvements in forward elevation (FE) (95.7º ± 47.2º to 144.7º ± 17.2º, p<0.001), but not in external rotation (ER) (32.5º ± 20.3º to 41.0º ± 13.3º, p=0.15), or internal rotation (IR) (S1 to L5, p=0.76). RTSA 2020 cases had improvements in FE (111.5º ± 40.3 to 132.8º ± 30.6, p=0.016), but not ER (31.9º ± 18.2 to 35.7º ± 15.9, p=0.36) or IR (S1 to L5, p=0.13). Patients in 2019 (FE: 4 to 5-, p<0.001; ER: 4+ to 5-, p=0.003; IR: 5- to 5, p<0.001) and 2020 (FE: 4 to 5-, p<0.001; ER: 4+ to 5, p<0.001; IR: 5- to 5, p=0.02) both experienced improvements in strength. Patients in 2020 initiated PT later (2019: 39.3 ± 27.3 days, 2020: 57.1 ± 35.5 days, p=0.028) and completed less PT sessions (2019: 20.7 ± 11.1, 2020: 12.9 ± 6.6, p<0.001) than patients in 2019. In the 2020 cohort, 10.5% (4/38) did not complete any PT, 34.2% (13/38) reported a delay in initiating PT, and 47.4% (18/38) reported that their recovery was negatively affected by the COVID-19 pandemic. At final follow-up, patients in 2020 reported a mean SANE score of 73.6 ± 17.5 on their affected shoulder and a mean VAS score of 1.68 ± 1.23.

Discussion

Despite a delay in initiating PT and completing less PT overall, patients who received RTSA in 2020 experienced significant improvements in ROM and strength at final follow-up and were comparable to the 2019 patients.