The transition to outpatient shoulder arthroplasty: a systematic review

Background and hypothesis: Transitioning shoulder arthroplasty (SA) from an inpatient to outpatient procedure is associated with increased patient satisfaction and potentially decreased costs; however, concerns exist about complications following same-day discharge. We hypothesized that outpatient SA would be associated with low rates of failed discharges, readmissions, and complications, rendering it a safe and effective option for SA. Methods: A systematic review of the outpatient SA literature identified 16 of 447 studies with level III and IV evidence that met the inclusion criteria with at least 90 days of follow-up. Data on patient demographic characteristics, preoperative and postoperative protocols, surgery characteristics, failed discharges, complications, and readmissions were collected and pooled for analysis. Results: A total of 990 patients were included in our analysis. Many studies identified specific institutional protocols for determining eligibility for outpatient SA, including preoperative clearance from an anesthesiologist; identification of a perioperative caretaker; and exclusion of patients based on cardiac, pulmonary, or hematologic risk factors. Failed same-day discharge occurred in only 0.9% of patients (7 of 788), and 2.1% of patients (9 of 418) and 0.79% of patients (2 of 252) presented to an emergency department or urgent care facility for a perioperative concern. The readmission rate for periprosthetic fracture, arthrofibrosis, infection, subscapularis rupture, and anterior subluxation was 1.3% (7 of 529 patients). Complications occurred in 7.0% of patients (70 of 990), with 5.4% of patients (53 of 990) experiencing a surgical complication and 1.7% (17 of 990) having a medical complication. There were 28 total reoperations (2.9%, 28 of 955 patients). Discussion and conclusion: Outpatient SA is associated with low rates of failed discharges, readmissions, and complications. Additionally, the medical and surgical complications that occur after outpatient SA are unlikely to be prevented by the short inpatient stay characteristic of traditional SA. With careful screening measures to identify appropriate candidates for same-day discharge, outpatient SA represents a safe approach to prevent unnecessary hospitalizations and to decrease costs associated with SA.