Published online Apr 18, 2020. doi: 10.5312/wjo.v11.i4.213
Peer-review started: November 11, 2019
First decision: December 5, 2019
Revised: February 24, 2020
Accepted: March 12, 2020
Article in press: March 12, 2020
Published online: April 18, 2020
Processing time: 154 Days and 10.2 Hours
Total shoulder arthroplasty is typically performed as an inpatient procedure with an overnight stay for adequate analgesia and observation. Advances in regional anaesthesia have enabled this major operation to be conducted as an outpatient procedure. The safety, efficacy and cost-effectiveness of the outpatient procedure are well established in the United States, but evidence and experience in the techniques are lacking elsewhere.
Worldwide, there is significant scarcity in healthcare resources in terms of funding and bed capacity. These pressures are particularly serious in publicly funded health systems, such as that in the United Kingdom’s National Health Service, where we report our experience. Performing procedures such as total shoulder arthroplasty as outpatient procedures may reduce bed occupancy while obtaining significant cost benefits. The study was registered with our local clinical governance department as a service evaluation, no explicit patient consent was required for this study of anonymised retrospective data.
We aimed to compare standard inpatient total shoulder arthroplasty with outpatient total shoulder arthroplasty. The primary outcomes were change in flexion and extension at 3 mo postoperatively in each group. Adverse events, re-admission rates and cost analyses were also obtained.
We conducted a retrospective cohort study of all patients who underwent total shoulder arthroplasty at North Middlesex University Hospital, London, United Kingdom between January 2017 and July 2018. Both inpatient and outpatient surgical groups underwent general anaesthesia and the same operative procedures. The outpatient group had continuous intrascalene analgesic infusion catheters which were retained postoperatively and they were discharged on the day of surgery. These patients were followed up by telephone by specialist community pain nurses for 3 d postoperatively and the catheter removed by the patient in their home on day 3. Costs were calculated with median length of stay and admission costs in the inpatient group and catheter, infusion and community nursing costs in the outpatient group. Between group differences were assessed using Student’s t-test or χ2 tests as appropriate. Multivariate linear and logistic regression was conducted to adjust for confounding variables.
Fifty nine patients were included, 18 d cases and 41 inpatients. There were no adverse events or re-admissions at 30 d postoperatively in either group. There were no significant differences in adjusted flexion (mean difference: 16.4, 95%CI: 17.6-50.5, P = 0.337) or abduction (mean difference: 13.2, 95%CI: 18.4-44.9, P = 0.405) postoperatively between groups. Median savings with outpatient arthroplasty were £529 (interquartile range: 247.33-789, P < 0.0001).
This study shows that outpatient total shoulder arthroplasty is a safe procedure with similar efficacy to traditional inpatient arthroplasty. We demonstrate significant cost savings with the outpatient procedure in our publicly funded, United Kingdom setting. These findings suggest that outpatient total shoulder arthroplasty should replace traditional inpatient arthroplasty in suitable patients, in the United Kingdom and beyond, to save costs and relieve capacity.
Ideally an appropriately powered, randomised control trial comparing outpatient and inpatient procedures is required to evaluate the technique. Formal functional assessment with tools such as the Oxford shoulder score is also needed to accurately assess efficacy. New methods of anaesthesia such as total regional anaesthesia with brachial plexus blockade need further study and may obviate the need for general anaesthesia and extend availability of surgery to those unfit for general anaesthesia. Novel minimally invasive surgical techniques such as arthroscopic and robotic shoulder arthroplasty may also reduce pain and the need for inpatient admission.