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


The shift to outpatient and SDD total joint arthroplasty is increasing in appropriately selected patients. Most studies (20 of 21 studies) in this systematic review demonstrated that outpatient TSA is safe, cost-effective, and provides high patient satisfaction. This study found successful planned SDD after outpatient TSA in more than 98% of patients. This compares with the recent reviews by Hoffmann et al[5] (TKA, THA, and partial knee arthroplasty) and Jaibaji et al[12] (THA) that found a 94.7% and 93.4% successful SDD rate, respectively. Although all are acceptable rates, these results expand on the fact that the perioperative complications associated with TSA may be less than with THA or TKA.[3]

Patient selection is key in successful SDD after outpatient TSA while minimizing complications, readmissions, and ED utilizations. Although individual studies had some minor differences in selection criteria, the overall consensus was that a team-based approach using surgeon evaluation and preoperative visits with anesthesiologists or medical specialists are paramount in a successful selection process.[8,9,24–26,28–31,33] In addition to a thorough assessment of medical comorbidities (cardiopulmonary, hepatic, renal, coagulopathy, anemia, endocrine, psychiatric conditions, etc), social support,[8,24,25,30,33] the proximity of residence to the place of surgery,[8,24] and preoperative narcotic dependence[9,24,25] are important factors for consideration. When triaged appropriately, many studies report a 100% success rate, with no need for overnight stay after TSA.[8,9,24–26,29,31] Certain patient factors, including increasing age, hypertension, chronic lung disease, diabetes, bleeding disorder, CHF, dialysis, cancer, poor functional status, ASA class 3 or 4, peripheral vascular disease, depression, and chronic anemia, have been associated with the risk of requiring longer stays and readmissions after outpatient TSA.[22,23,34–36] The senior authors of this systematic review use the algorithm that has been described and validated by Fournier et al[26] for indicating patients for outpatient TSA. These include age younger than 70 years old, preoperative hematocrit greater than 30%, no pulmonary comorbidity risk factors (eg, COPD, obstructive sleep apnea, BMI > 35), stable cardiac comorbidity (meaning less than or equal to two cardiac stents or less and not on anticoagulation), and no history of deep vein thrombosis or pulmonary embolism that requires anticoagulation. Relative contraindications for outpatient TSA include patients with more than two cardiac stents or the need for anticoagulation because of cardiac disease or history of deep vein thrombosis/pulmonary embolism (these patients do not receive TXA) and one pulmonary risk factor as described above (these patients do not receive interscalene nerve blocks). Absolute contraindications include two or more pulmonary risk factors, cardiac intervention within 6 months of surgery, and history of pacemaker or implantable cardiodefibrillator device.

Outpatient surgery is a broad term, which can mean surgeries performed with less than 24-hour stay at the hospital, SDD from a hospital surgery department, or those performed at freestanding ASCs. Outpatient surgery performed within a hospital has the safety net of intensive care units and other emergency consultants if complications are to arise perioperatively. It is important for surgeons and others involved in formulating outpatient selection criteria to take into account the added risk when performing TSA at freestanding ASCs without the additional resources that a hospital provides. Many studies within this review involved TSA at ASCs;[9,20,24–26,28,29,31] however, some involved those performed at hospital outpatient surgery centers,[8,20,25,30,38] and many did not specify the location.[21–23,27,32–35]

Perioperative outcomes compared among outpatient and inpatient cohorts often are similar but often favor the outpatient groups. A comparison of the rate of readmissions between outpatient and inpatient TSA was largely similar, with only one study identifying higher inpatient readmissions (2.9% versus 2%).[23] Complications (medical- and surgical-related) were more prevalent (P < 0.05) in inpatients than outpatients in five of 11 studies.[10,22,23,32,33] Only one study identified a higher rate of complications (manipulation under anesthesia [MUA]) in outpatients than inpatients.[32] The total episode of care charges and reimbursements were markedly lower in outpatient than inpatient TSA,[20–22] with additional cost savings identified in ASCs.[20] In certain healthcare systems, bundled payment plans may provide additional cost savings in SDD TSA.[31] Patient satisfaction is becoming an increasingly important variable in evaluating healthcare delivery and often is tied to reimbursement. Patient satisfaction after outpatient TSA was found to be good to excellent in more than 95% of patients,[7,8,28] with patients preferring the outpatient setting.[29]

Initial attempts at outpatient TSA were made using peripheral nerve blocks, including indwelling continuous interscalene catheters, and had very successful results.[7,8,38] Later studies continued with the use of peripheral nerve blocks, including interscalene, supraclavicular, and brachial plexus;[25,28,30,33] however, many had successful results with only general anesthesia and long-acting local anesthetic injections at the end of the procedure.[9,24,26,29,31] If resources allow, many centers may consider performing peripheral nerve block procedures; however, studies have shown that long-acting local anesthetic injections may provide similar pain relief with much less cost and complications in TSA.[39] The senior authors of this study currently use interscalene nerve blocks preoperatively in addition to liposomal bupivacaine in the periarticular tissues and musculature. Further preoperative and postoperative multimodal pain regimens are used including celecoxib, gabapentin, and short-acting oxycodone. Blood management consists of the use of TXA intravenously. Single doses of preoperative antibiotics are used including vancomycin and cefazolin. Patient positioning is done with the patient in a beach-chair position. Sling immobilization is used while the patients is in the operating room. Discharge criteria to be met include pain score of 4 of 10 or less, ability to tolerate fluids by mouth without nausea, and stable vital signs without tachycardia, hypoxia, or hypotension during ambulation.

Despite the advances and successes in outpatient TSA, a 2018 survey of the American Shoulder and Elbow Surgeons found that only 21% of respondents perform outpatient TSA.[40] The most commonly perceived barriers were patient age, comorbidities, social support, concern for medical complication, and readmission risk. Those who had performed outpatient TSA still reported concern with these barriers but were also largely concerned with insurance contract issues. Most these concerns can be mitigated through the patient-selection process, and the use of an interdisciplinary approach with surgeons, anesthesiologists, and medical specialists is paramount.

Limitations of this study include that no meta-analysis was performed because of a lack of studies with level I or II evidence. Instead, this review aimed to provide a synopsis of the literature for surgeons who perform outpatient TSA and for those who might be interested in beginning outpatient TSA. Furthermore, given the relatively new nature of outpatient TSA, many studies were performed using large national databases and the data are subject to coding error and limit our ability to do a detailed analysis of reasons for complications and readmissions. In addition, these studies did not specify whether the surgeries were performed at a hospital or ASC. Nonetheless, these studies assist in making comparisons between outpatient and inpatient cohorts. In addition, no studies made comparisons between the different types of TSA, including anatomic, reverse, or hemiarthroplasty, and therefore, conclusions cannot be drawn between the different procedures. Finally, an inherent difference exists in the baseline medical well-being of patients who are eligible for outpatient surgery compared with those eligible for inpatient surgery and may skew the differences in complication and readmission rates via selection bias. One might feel that outpatient TSA should have lower complication rates because of relatively younger and healthier patient cohorts who are selected for this pathway, but this was found in only five comparative studies in this review.[10,22,23,32,33] Among the two matched cohort studies in this review, one showed no differences in complications,[9] whereas the other found lower rates of medical complications in the outpatient cohort.[22] Regardless, the goal of this systematic review was to show noninferiority about safety of outpatient surgery when compared with inpatient pathways. Future work should be directed at comparing more similar patient cohorts in prospective or randomized study designs.