Shoulder Arthroplasty as a Day Case: Is It Better?

Introduction: A retrospective case-controlled study was performed to evaluate the outcomes of shoulder arthroplasty performed as a day case in carefully selected patients, compared to the traditional inpatient approach. Materials and Methods: Patients who had total or hemiarthroplasty of the shoulder performed as a day case or inpatient procedure were recruited. The primary outcome compared rates of uneventful recovery, defined by the absence of complications or readmission to the hospital within six months of surgery, between the inpatient and outpatient groups. Secondary outcomes included examiner-determined functional and patient-determined pain scores at one, six, twelve, and twenty-four weeks post-surgery. A further assessment of patient-determined pain scores was carried out at least two years post-surgery (5.8 ± 3.2). Results: 73 patients (36 inpatients and 37 outpatients) were included in the study. Within this time frame, 25/36 inpatients (69%) had uneventful recoveries compared to 24/37 outpatients (65%) (p = 0.17). Outpatients showed significant improvement over pre-operative baseline levels in more secondary outcomes (strength and passive range-of-motion) by six months post-operation. Outpatients also performed significantly better than inpatients in external rotation (p < 0.05) and internal rotation (p = 0.05) at six weeks post-surgery. Both groups showed significant improvement compared to pre-operative baselines in all patient-determined secondary outcomes except the activity level at work and sports. Inpatients, however, experienced less severe pain at rest at six weeks (p = 0.03), significantly less frequent pain at night (p = 0.03), and extreme pain (p = 0.04) at 24 weeks, and less severe pain at night at 24 weeks (p < 0.01). By a minimum of two years post-operation, inpatients were more comfortable repeating their treatment setting for future arthroplasty (16/18) compared to outpatients (7/22) (p = 0.0002). Conclusions: At a minimum of two years of follow-up, there were no significant differences in rates of complications, hospitalizations, or revision surgeries between patients that underwent shoulder arthroplasty as an inpatient versus an outpatient. Outpatients demonstrated superior functional outcomes but reported more pain at six months post-surgery. Patients in both groups preferred inpatient treatment for any future shoulder arthroplasty. What is Known About This Subject: Shoulder arthroplasty is a complex procedure and has traditionally been performed on an inpatient basis, with patients admitted for six to seven days post-surgery. One of the primary reasons for this is the high level of post-operative pain, usually treated with hospital-based opioid therapy. Two studies demonstrated outpatient TSA to have a similar rate of complications as inpatient TSA; however, these studies only examined patients within a shorter-term 90-day post-operative period and did not evaluate functional outcomes between the two groups or in the longer term. What This Study Adds to Existing Knowledge: This study provides evidence supporting the longer-term results of shoulder arthroplasty done as a day case in carefully selected patients, which are comparable to outcomes in patients that are admitted to the hospital post-surgery.

Ultrasound Guided Arthroscopic Removal of Calcific Tendonitis: A Minimum of 2-Year Followup.

Background: We have developed a novel technique for managing rotator cuff calcific tendonitis, involving arthroscopic debridement of calcific tendonitis with localization assistance from a breast biopsy needle under ultrasound guidance. While we have demonstrated encouraging results at six-month follow-up, the medium-term outcomes and the long-term outcomes of this technique at 2 years or beyond are unknown. The aim of this paper was to determine if this technique was successful in resolving symptoms after two years and beyond. Study Design: Retrospective Cohort Study. Methods: Patients who underwent arthroscopic debridement of calcific tendonitis with localization assistance from a breast biopsy needle under ultrasound guidance by a senior surgeon were evaluated using patient-rated pain scores and functional status with the use of the Likert scales and via examiner-rated shoulder range-of-motion and strength at the pre-operative visit, at 1, 6, 12, and 24 weeks post-operatively, and long-term at a mean of 249 weeks after surgery. Results: At a mean follow-up period of 4.8 years (range, 2-10 years), 31 patients (33 shoulders) experienced significant improvement in the severity of pain at rest, with overhead activities, and during sleep compared to their pre-operative presentation (p < 0.001). The patient experienced less frequent pain during activities and sleep, and a decreased frequency of extreme pain (p < 0.001). Passive range of abduction (p = 0.003), forward flexion (p < 0.001), and supraspinatus strength (p = 0.018) improved compared to the presurgical presentation. Out of 27 patients, 24 patients (89%) had complete resolution of calcific tendonitis, and 26 patients (96%) had an intact rotator cuff. Conclusion: Arthroscopic debridement of calcific tendonitis with localization assistance from a breast biopsy needle under ultrasound guidance was very effective. Patients had significant pain relief, improved range of motion, and a reduction in stiffness at a mean post-operative period of 4.8 years. Patients had a significant reduction in residual calcification, and rotator cuff integrity was largely preserved by long-term follow-up. What is known about this subject: Calcific tendonitis of the rotator cuff is one of the most painful and debilitating disorders of the shoulder. This condition is characterized by the deposition of calcium-phosphate crystals within the rotator cuff tendons. Arthroscopic debridement and excision of rotator cuff calcifications have proven to be efficacious treatments with regards to clinical and functional outcomes in the short and medium term. Identifying the calcific lesion intra-operatively, however, can prove to be challenging. Furthermore, inadequate excision of the calcific deposit has been shown to have poorer clinical outcomes. We designed a technique that utilizes the assistance of ultrasound to guide a localization-biopsy wire to the calcific lesion. This technique aids in precisely identifying the location of the lesion intra-operatively to optimize accuracy in removing the maximum amount of calcific deposit possible. A short-term follow-up study by us has demonstrated successful outcomes with regards to the return of function and relief of pain. However, there have been no studies evaluating the effectiveness of this particular technique beyond six months. What this study adds to current knowledge: At a mean of 4.8 years, arthroscopic debridement of calcific tendonitis, using our technique, was successful in relieving the severity and frequency of pain with overhead activities, pain at rest, and pain during sleep, as well as improving range of motion.

Factors Predicting Frequency and Severity of Postoperative Pain After Arthroscopic Rotator Cuff Repair Surgery.

BACKGROUND: Postoperative pain after arthroscopic rotator cuff repair (RCR) is difficult to predict and manage. The experience of pain is thought to be influenced by a range of different factors. Determining which patient factors contribute to the pain may help us to better understand and manage it. PURPOSE: To evaluate the preoperative patient characteristics that may be predictive of, and correlated with, postoperative pain after arthroscopic RCR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The study evaluated 2172 patients who underwent an arthroscopic RCR between February 2004 and December 2015. Pain frequency and severity were measured preoperatively and at 6 weeks after surgery using a modified L'Insalata questionnaire with Likert scales. This 6-week time point was chosen as previous studies have shown patients rank this time point as high in terms of pain after RCR. Logistic regression analysis was conducted to examine the relationship between postoperative pain scores and preoperative pain scores, age, sex, tear size, strength, level of sporting and work activity, and work-related injury status. RESULTS: The severity of preoperative pain at night (r = 0.33; P < .001), preoperative pain at rest (r = 0.32; P < .001), and frequency of extreme pain (r = 0.31; P < .001) were the strongest independent associations with the frequency of pain at 6 weeks postoperatively. Other associations with postoperative pain frequency included reduced liftoff strength (r = -0.21; P < .001), work-related injury status (P < .001), younger age (P = .001), and female sex (P = .04). Tear size was inversely related with pain severity (R2 = 0.85). The severity of preoperative pain had the strongest independent association with the severity of postoperative pain at 6 weeks after surgery (r = 0.35; P < .001). Other associations with postoperative pain severity included increased patient-ranked preoperative stiffness (P < .001), a poorer impression of one's shoulder (P < .001), reduced level of sporting activity (P < .001), and work-related injury status (P < .001). CONCLUSION: Multiple risk factors have been identified for postoperative pain after RCR, the strongest of which is preoperative pain. However, of note, the magnitude of the correlations between preoperative severity and frequency of pain and postoperative severity and frequency of pain were found to be weak to moderate (r = 0.30-0.35). This suggests that while preoperative pain and its severity are associated with postoperative pain, other factors are likely involved in predicting pain. Smaller tear size, younger age, female sex, and work-related injuries were also associated with postoperative pain at 6 weeks after surgery.

Repair Integrity in Patients Returning for an Unscheduled Visit After Arthroscopic Rotator Cuff Repair: Retorn or Not?

BACKGROUND: After rotator cuff repair, some patients have ongoing problems significant enough to warrant presentation to a clinic for reassessment. PURPOSE/HYPOTHESIS: The purpose of this study was to determine whether this cohort of patients was more likely to have a healed rotator cuff. We hypothesized that patients who had an unscheduled postoperative visit were more likely to have a healed rotator cuff than those who did not have an unscheduled postoperative visit. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 321 consecutive patients who underwent arthroscopic rotator cuff repair were evaluated; of these, 50 patients had an unscheduled return to clinic that included an ultrasound assessment of the cuff repair within 4 months postoperatively. Repair integrity was evaluated in all patients at 6 months postoperatively via ultrasonography. RESULTS: The failure-to-heal rate was greater in patients who had an unscheduled assessment (8/50; 16%) than in those who did not (14/275; 5%) (P = .01). The patients most likely to have a repair failure were those who were assessed before 2 weeks and after 12 weeks (7/18; 39%) compared with those who were assessed between 3 and 12 weeks (1/32; 3%) (P = .001). The failure-to-heal rate was very low in patients who had an unscheduled assessment with a tear size smaller than 4 cm2 (0/34; 0%) compared with those with tear sizes greater than 4 cm2 (8/16; 50%) (P < .0001, Fisher exact text). CONCLUSION: Patients who had an unscheduled clinic visit after rotator cuff repair had a 16% chance of a failed healing response, whereas those who did not have an unscheduled visit had a 5% rate of failed healing. The risk of a failed healing response was greater if the tear was larger than 4 cm2, if patients presented within 2 weeks following surgery, or if they presented after 12 weeks postsurgery.