Safety and Cost Effectiveness of Outpatient Total Shoulder Arthroplasty

A Systematic Review

Tyler E. Calkins, MD; Zachary A. Mosher, MD; Thomas W. Throckmorton, MD; Tyler J. Brolin, MD


J Am Acad Orthop Surg. 2022;30(2):e233-e241. 

In This Article


This systematic review was conducted according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses statement. This study did not require institutional review board approval.

Search Strategy and Study Selection

The Embase, Medline, and CENTRAL (Cochrane Central Register of Controlled Trials) databases were queried April 30, 2020. The search strategy included the following keywords: (["shoulder replacement" OR "shoulder arthroplasty"] AND ["outpatient" OR "same-day" OR "same day" OR "ambulatory"]). Study inclusion criteria were (1) studies reporting complications, clinical outcomes, costs, patient satisfaction, or risk factors in outpatient TSA patients; (2) studies reported in English or were translated to English; and (3) full-text articles. Studies were excluded if they were (1) review articles, (2) nonsurgical, or (3) did not include outpatients. Two independent reviewers screened all titles and abstracts for the above criteria and subsequently screened full-text articles for the final inclusion. References of the articles that underwent full-text review were reviewed for any studies not found in the initial database per the Preferred Reporting Items of Systematic Reviews and Meta-Analyses guidelines.

Quality Assessment

An assessment of study quality was performed using the Methodological Index for Non-Randomized Studies, which uses a separate grading scale for cohort comparison (max = 24) and noncomparison (max = 16) study designs.[37] Two independent reviewers used the scoring system, and the scores were averaged.

Data Collection and Statistics

Data collection was performed by two reviewers and included the following when available: study characteristics (year of publication, nation, journal, study design, and level of evidence), patient characteristics (age, sex, and body mass index [BMI]), surgical technique (approach, type of surgeries included, and anesthesia technique), complications (surgical complications, medical complications, revision surgeries, emergency department [ED] visits, readmissions, and mortality), patient outcomes (patient-reported outcome measures, range of motion [ROM], and patient satisfaction), and risk factors analysis for complications and readmissions. Frequencies of readmission, revision surgery, and complications among outpatient TSA were aggregated when raw numbers were available. For simplicity, TSA is used as a broad term within this review, which may encompass anatomic TSA, reverse TSA, and even shoulder hemiarthroplasty. No meta-analyses were performed because of the lack of prospective, high-quality comparative studies in the literature. Statistical significance for comparisons between outpatient and inpatient TSA within individual studies was set at an alpha of 0.05. Data were collected in Microsoft Excel for Mac version 16.36.