Rotator Cuff Arthropathy

### **Chapter 4**

## Subacromial InSpace Balloon Interposition for Massive Irreparable Rotator Cuff Tears

*Vladimir Senekovic*

#### **Abstract**

Massive rotator cuff tears are a challenging problem for treatment. The best results we can still achieve with reconstruction. For treatment of massive rotator cuff tears when reconstruction is not possible, a new method has been developed recently: the implantation of the biodegradable balloon spacer/InSpace™ balloon/filled with the saline in the subacromial space. The main characteristic of this method is that to allow gliding of the humeral head against acromion without friction and to depress the humeral head for 2–3 mm. This depression is just enough that the humerus is in a better center of rotation that allows the deltoid muscle more strength—better vector forces for the deltoid muscle. This function of the balloon permits better deltoid activation and compensation through the arc of motion. Results of our first study and results of others show clinical safety and efficacy of the insertion of the InSpace™ balloon in a group of patients with massive irreparable rotator cuff tears. The insertion of this device shows significantly better early improvement, significant improvement in subjective pain scores, and a decrease in reported night pain. The measurement of the Total Constant score showed statistically significant improvement after insertion of the InSpace™ balloon at 5 years of follow-up**.** Generally, all studies show 75–80% of good results.

**Keywords:** massive rotator cuff tear, subacromial balloon spacer

#### **1. Introduction**


### **2. Preoperative assessment**

#### **2.1 Clinical assessment**


*Subacromial InSpace Balloon Interposition for Massive Irreparable Rotator Cuff Tears DOI: http://dx.doi.org/10.5772/intechopen.102558*


#### **2.2 Imaging assessment**

#### *2.2.1 Radiographs*

	- US is useful for detecting the tear and size of the tear.
	- We can see calcium depots and muscle atrophy [23].
	- MRI arthrography is nearly 100° accurate to show RC tear and size of the tear.
	- We can determine tendon retraction.
	- We can determine atrophy of the muscle and degree of fatty degeneration.
	- We can detect osteoarthritic changes in the joint [4, 23].

#### **3. Timing for surgery**


#### **4. Surgical preparation**

#### **4.1 Surgical equipment**


**Figure 2.** *InSpaceTM resorbable balloon—The ballon has been inflated already.*


#### **4.2 Equipment positioning**

• The arthroscopic monitor faces the surgeon on the opposite side of the table at the level of the patient's shoulder [2, 7].

#### **4.3 Patient positioning**

• We have to put the patient in the beach chair position or in lateral decubitus position with the arm in a special holder like at all other shoulder arthroscopic procedures. For the lateral decubitus position, we need a special holding device for the body of the patient [2, 7].

#### **4.4 Further preparation**

• Implantation of the material justify antibiotic prophylaxis [2, 7].

### **5. Surgical technique**


*Subacromial InSpace Balloon Interposition for Massive Irreparable Rotator Cuff Tears DOI: http://dx.doi.org/10.5772/intechopen.102558*


**Figure 3.** *Debridement of the subacromial space.*

#### **Figure 4.** *Grasping the edges of the tendons with an arthroscopic clamp in an attempt to draw it to the footprint region.*

**Figure 5.**

*Measurement of the distance between the lateral border of the acromion and the superior rim of the glenoid.*

#### **Figure 6.** *Insertion of the proper balloon (cylindrical shape, insertion tube is removed from the joint).*


*Subacromial InSpace Balloon Interposition for Massive Irreparable Rotator Cuff Tears DOI: http://dx.doi.org/10.5772/intechopen.102558*

**Figure 7.** *Inflation of the balloon in the subacromial space.*

**Figure 8.** *Balloon is inflated in the subacromial space, we can see that humeral head is pushed down.*


#### **6. Postoperative course**

#### **6.1 Postoperative regime**

• Medications: pain killer, nonsteroidal anti-inflammatory drugs (NSAI).


#### **6.2 Early phase postoperative complications**


#### **Figure 9.**

*(a) graphical presentation of constant variables following biodegradable spacer insertion. TCS—total constant score, pain score, ADL—Activity of daily living, ROM—Range of motion, power. Figure presents change in score from baseline to 5 years following insertion. Values are presented as means ±SD. (b)-graphical presentation of range of motion scores variables during 5 years follow-up. Active, pain-free range of elevation: 2 points per 30°; 0 = worst, 10 = best; position of hand:0 = worst, 10 = best. Values are presented as means.*

*Subacromial InSpace Balloon Interposition for Massive Irreparable Rotator Cuff Tears DOI: http://dx.doi.org/10.5772/intechopen.102558*

#### **7. Conclusion**


#### **Author details**

Vladimir Senekovic Arbormea Medical, Ljubljana, Slovenia

\*Address all correspondence to: vladimir.senekovic@arbormea.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Green A. Chronic massive rotator cuff tears: evaluation and management. The Journal of the American Academy of Orthopaedic Surgeons. 2003;**11**(5):321-331

[2] Gerber C, Wirth SH, Farshad M. Treatment options for massive rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2011;**20**(2 Suppl):S20-S29

[3] Anley CM, Chan SK, Snow M. Arthroscopic treatment options for irreparable rotator cuff tears of the shoulder. World Journal of Orthopedics. 2014;**5**(5):557-565

[4] Burkhart SS, JRH B, Richards DP, Zlatkin MB, Larsen M. Arthroscopic repair of massive rotator cuff tears with stage 3 and 4 fatty degeneration. Arthroscopy: Journal of Arthroscopic Related Surgery. 2007;**23**(4):347-354

[5] Berth A, Neumann W, Awiszus F, Pap G. Massive rotator cuff tears: functional outcome after debridement or arthroscopic partial repair. Journal of Orthopaedics and Traumatology. 2010;**11**(1):13-20

[6] Senekovic V, Poberaj B, Kovacic L, Mikek M, Adar E, Dekel A. Prospective clinical study of a novel biodegradable sub-acromial spacer in treatment of massive irreparable rotator cuff tears. European Journal of Orthopaedic Surgery and Traumatology. 2013;**23**(3):311-316

[7] Savarese E, Romeo R. New solution for massive, irreparable rotator cuff tears: the subacromial "biodegradable spacer." Arthroscopy Techniques. 2012;**1**(1):e69-e74

[8] Kilinc AS, Ebrahimzadeh MH, Lafosse L. Subacromial internal spacer for rotator cuff tendon repair: "the balloon technique." Arthroscopy Journal of Arthroscopic Related Surgery. 2009;**25**(8):921-924

[9] Sartoretti C, Sartoretti-Schefer S, Duff C, Buchmann P. Angioplasty balloon catheters used for distraction of the ankle joint. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 1996;**12**(1):82-86

[10] Chaudhury S, Holland C, Thompson MS, Vollrath F, Carr AJ. Tensile and shear mechanical properties of rotator cuff repair patches. Journal of Shoulder and Elbow Surgery. 2012;**21**(9):1168-1176

[11] Kukkonen J, Kauko T, Vahlberg T, Joukainen A, Aärimaa V. Investigating minimal clinically important difference for Constant score in patients undergoing rotator cuff surgery. Journal of Shoulder and Elbow Surgery. 2013;**22**(12):1650-1655

[12] Conboy VB, Morris RW, Kiss J, Carr AJ. An evaluation of the Constant-Murley shoulder assessment. Journal of Bone and Joint Surgery. British Volume (London). 1996;**78**(2):229-232

[13] Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clinical Orthopaedics. 1987;**214**:160-164

[14] Katolik LI, Romeo AA, Cole BJ, Verma NN, Hayden JK, Bach BR. Normalization of the Constant score. Journal of Shoulder and Elbow Surgery. 2005;**14**(3):279-285

[15] Gustavson K, von Soest T, Karevold E, Røysamb E. Attrition and generalizability in longitudinal studies: *Subacromial InSpace Balloon Interposition for Massive Irreparable Rotator Cuff Tears DOI: http://dx.doi.org/10.5772/intechopen.102558*

findings from a 15-year population-based study and a Monte Carlo simulation study. BMC Public Health. 2012;**12**:918

[16] Omid R, Lee B. Tendon transfers for irreparable rotator cuff tears. The Journal of the American Academy of Orthopaedic Surgeons. 2013;**21**(8):492-501

[17] Warner JJ. Management of massive irreparable rotator cuff tears: the role of tendon transfer. Instructional Course Lectures. 2001;**50**:63-71

[18] Hirooka A, Yoneda M, Wakaitani S, Isaka Y, Hayashida K, Fukushima S, et al. Augmentation with a Gore-Tex patch for repair of large rotator cuff tears that cannot be sutured. Journal of Orthopaedic Science. 2002;**7**(4):451-456

[19] Moore DR, Cain EL, Schwartz ML, Clancy WG. Allograft reconstruction for massive, irreparable rotator cuff tears. The American Journal of Sports Medicine. 2006;**34**(3):392-396

[20] Ozaki J, Fujimoto S, Masuhara K, Tamai S, Yoshimoto S. Reconstruction of chronic massive rotator cuff tears with synthetic materials. Clinical Orthopaedics. 1986;**202**:173-183

[21] Hawkins RJ, Misamore GW, Hobeika PE. Surgery for full-thickness rotator-cuff tears. The Journal of Bone and Joint Surgery. American Volume. 1985;**67**(9):1349-1355

[22] Rockwood CA, Williams GR, Burkhead WZ. Débridement of degenerative, irreparable lesions of the rotator cuff. The Journal of Bone and Joint Surgery. American Volume. 1995;**77**(6):857-866

[23] Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures.

Pre- and postoperative evaluation by CT scan. Clinical Orthopaedics. 1994;**304**:78-83

[24] Gerber C. Latissimus dorsi transfer for the treatment of irreparable tears of the rotator cuff. Clinical Orthopaedics. 1992;**275**:152-160

[25] Scheibel M, Lichtenberg S, Habermeyer P. Reversed arthroscopic subacromial decompression for massive rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2004;**13**(3):272-278

[26] Nové-Josserand L, Costa P, Liotard J-P, Safar J-F, Walch G, Zilber S. Results of latissimus dorsi tendon transfer for irreparable cuff tears. Orthopaedics & Traumatology: Surgery & Research. 2009;**95**(2):108-113

[27] Lee BG, Cho NS, Rhee YG. Results of arthroscopic decompression and tuberoplasty for irreparable massive rotator cuff tears. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2011;**27**(10):1341-1350

[28] Walch G, Edwards TB, Boulahia A, Nové-Josserand L, Neyton L, Szabo I. Arthroscopic tenotomy of the long head of the biceps in the treatment of rotator cuff tears: clinical and radiographic results of 307 cases. Journal of Shoulder and Elbow Surgery. 2005;**14**(3):238-246

[29] Wong I, Burns J, Snyder S. Arthroscopic GraftJacket repair of rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2010;**19**(2 Suppl):104-109

[30] Gartsman GM. Arthroscopic acromioplasty for lesions of the rotator cuff. The Journal of Bone and Joint Surgery. American Volume. 1990;**72**(2):169-180

[31] Szabó I, Boileau P, Walch G. The proximal biceps as a pain generator and results of tenotomy. Sports Medicine and Arthroscopy Review. 2008;**16**(3):180-186

#### **Chapter 5**

## Outpatient Total Shoulder Replacement Procedures

*Brandon J. Erickson, Yousef Shishani and Reuben Gobezie*

#### **Abstract**

The number of total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA) procedures performed each year has continued to rise. While these procedures were historically done in the inpatient setting, many surgeons have migrated to performing TSA and RTSA in the outpatient setting. This can either involve sending patients home the same day from the hospital or performing these in an outpatient center. Specific protocols should be followed in regard to patient selection to minimize the risk of complications and readmission. Similarly, a team approach between the anesthesiologist and the surgeon is critical to ensure adequate pain control. Use of tranexamic acid (TXA), a preoperative nerve block as well as specific combinations of preoperative and postoperative medications are helpful in creating an optimal environment in which to perform the shoulder arthroplasty for the patient. When done well, TSA and RTSA can successfully be performed as an outpatient with a very high success rate and a low risk of complications.

**Keywords:** total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RTSA), outpatient, hospital, surgical center, shoulder, arthroplasty, ambulatory, complication, readmission, outcome

#### **1. Introduction**

The number of total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA) procedures performed each year has continued to rise, and will continue to rise as the population ages and lives longer (**Figure 1**) [1–3]. While shoulder arthroplasty has historically been performed in the inpatient setting, over the several years, many surgeons have moved to performing TSA/RTSA in the outpatient setting. Performing shoulder arthroplasty in the outpatient setting decreases cost to the healthcare system as well as provides an excellent patient experience. Recent studies have shown excellent results with few complications in patients who have undergone outpatient TSA/RTSA [4–7]. However, not every patient is a candidate for an outpatient shoulder arthroplasty.

**Figure 1.** *Examples of advanced arthritis (Coronal X-ray and axial CT scan).*

#### **2. What patients are eligible for outpatient shoulder arthroplasty?**

While a great many patients are candidates for TSA and RTSA, not every patient is a candidate for a shoulder arthroplasty in an outpatient setting. First, some patients may not be comfortable having surgery in an outpatient center and some insurance companies may not be accepted by the outpatient center. In these cases the surgery should be done in the hospital setting. It also helps if patients have a good home support system to help them with activities of daily living following surgery. While they will be able to do many things on their own, there will be some things that they will likely need help with. There are many services an outpatient center does not have that a hospital has, so patients at increased risk for complications, bleeding, breathing issues, etc. should not have their shoulder arthroplasty done in an outpatient center. The authors have developed criteria to determine whether patients are good candidates for shoulder arthroplasty in the outpatient setting.

From a medical perspective, patients who are American Society of Anesthesiology (ASA) 1 and 2 are often eligible. Occasionally patients who are ASA 3 are eligible, but this should be a case-by-case decision. Patients under 65 years of age are often better suited for an outpatient arthroplasty, although older, high functioning patients can be good candidates as well. Patients should be off chronic narcotics before having an outpatient shoulder arthroplasty and must be willing to participate in a multimodal pain management program. Furthermore, the patient should be a good candidate for a regional block for pain control. The following is a list of relative contraindications to patients having their TSA/RTSA in an outpatient setting. Any patients who have conditions on this list may require a proper medical/cardiology and anesthesia evaluation preoperatively.

	- Significant heart disease
	- Poor LVEF (<50%)

*Outpatient Total Shoulder Replacement Procedures DOI: http://dx.doi.org/10.5772/intechopen.101974*

	- CVA or significant neurologic illness
	- History of frequent falls
	- History of cognitive dysfunction (dementia, Parkinson's)

#### **3. How to successfully perform an outpatient shoulder arthroplasty**

#### **3.1 Before surgery**

There are several keys to a successful outpatient shoulder arthroplasty. Two of the most important issues surrounding outpatient shoulder arthroplasty are pain control and infection prevention. There are several pieces to pain control including preoperative, intraoperative and postoperative pain management. First, patients undergoing outpatient shoulder arthroplasty are premedicated in the preoperative area prior to surgery. Typically, the authors use 1000 mg of Acetaminophen, 300 mg of Neurontin, and 200 mg of Celecoxib all given orally. The patients are also given regional anesthesia, typically a supraclavicular or interscalene block. The medication used by the anesthesiologist for the block should include a long-acting local anesthetic such as Bupivacaine. Some facilities have moved to using an even longer acting anesthetic such as Bupivacaine liposome injectable suspension (trade name: Exparel), although this can sometimes be cost prohibitive. From an infection prevention

perspective, patients are asked to wipe the operative site twice daily with benzoyl peroxide beginning 2 to 3 days prior to surgery and continuing this up until surgery. This helps decrease the C. Acnes load on the skin. Finally, from a timing perspective, it is important to schedule these patients early in the day so they have adequate time to recover before going home. Performing an outpatient arthroplasty later in the day can be tricky and runs the risk that the patient may need to stay overnight.

#### **3.2 Intraoperative**

Once the patient has received their block and preoperative medications they are brought back to the operating room where they are given general anesthesia (**Figure 2**). A general anesthetic allows for muscle relaxation which facilitates exposure during a shoulder arthroplasty. To minimize the amount of time the patient is under anesthesia and to mitigate infection risk, it is important to perform the TSA/RTSA efficiently.

*Outpatient Total Shoulder Replacement Procedures DOI: http://dx.doi.org/10.5772/intechopen.101974*

**Figure 3.** *Instrument and back table organization help expedite the performance of outpatient procedures.*

As such, it is important for the surgeon to be comfortable with TSA and RTSA procedures before attempting these in the outpatient setting (**Figure 3**). Having major delays during the procedure keeps the patient under anesthesia for a longer time and may increase the likelihood that they will not go home after surgery. Furthermore, revision TSA/RTSA are not typically performed in the outpatient setting as these patients often have more pain, lose more blood, and have longer operative times than primary cases (**Figure 4**). As surgeons get comfortable with sending patients home the same day following TSA/RTSA, we recommend surgeons perform these cases in an inpatient setting to begin with and send the patients home the same day. Once they have successfully sent these patients home the same day they can progress to performing these cases in the outpatient setting.

Prior to incision the patient should be given 1 g of IV Tranexamic acid (TXA). This acts as a clot stabilizing agent (it is not prothrombotic) and will help minimize blood loss during the procedure. Cvetanovich et al. performed a prospective, double-blind,

#### **Figure 4.**

*Revision surgery is usually more complex and demanding. This can require an osteotomy of the humerus that can then be secured with metal or FiberTape cerclages.*

placebo-controlled, randomized clinical trial where patients undergoing primary TSA and RTSA were randomized to either receiving 1 g of IV TXA or a placebo to determine if TXA reduced blood loss [8]. The authors included 108 patients (52 for TXA, 56 for placebo) who had no significant differences in preoperative characteristics. They found that the TXA group had significantly lower postoperative blood loss compared with the placebo group. They also found that TXA had lower weight of hemoglobin loss compared with placebo. Similar results were seen in the total knee and total hip arthroplasty literature [9–12]. Similarly, Gillespie et al. randomized 111 patients who underwent shoulder arthroplasty to receive topical saline or topical saline mixed with 2 g of TXA into the wound at the conclusion of the case and measured postoperative drain output (patients at the time of this study all received a drain. This is not done anymore) [13]. The authors found significantly less blood loss in the TXA group compared to the placebo group (108 mL vs. 170 mL) as well as a greater drop in hemoglobin level in the placebo group compared to the TXA group (2.6 g/dL vs. 1.7 g/dL). As such, we routinely use TXA in all of our outpatient shoulder arthroplasty procedures.

Once the preoperative antibiotics (2 g Cefazolin) and Tranexamic acid have been administered, the TSA/RTSA is performed in the standard fashion. The patient is prepped with a hydrogen peroxide wash to decrease the load of C. Acnes on the skin prior to their chlorhexidine prep [14]. The authors use a deltopectoral approach (**Figure 5**). As previously mentioned, exposure is key in TSA and RTSA, so it is important to ensure each layer of dissection is complete to avoid shrinking the operative field. The authors perform a subscapularis peel on all TSA and RTSA (**Figure 6**). Adequate releases on both the humeral and glenoid side will help facilitate glenoid exposure so this is imperative to avoid issues with glenoid pin placement. Once the humeral head cut is made and the glenoid is adequately exposed, the authors use a patient specific guide to place the glenoid pin. A preoperative CT scan is obtained on all patients prior to TSA and RTSA and is unloaded into a preoperative planning software (Virtual Implant Positioning (VIP) Arthrex, Naples FL USA) (**Figure 7**). The ideal glenoid position can then be planned out, and a reusable guide is used to

**Figure 5.** *An example of a deltopectoral incision used in outpatient procedures.*

**Figure 6.**

*As part of the optimal visualization, the subscapularis is identified and released from the humerus via a peel technique.*

#### **Figure 7.**

*Preoperative 3D modeling and visualization help execute the surgical plan. This can help minimize the number of trays that need to be available during the procedure.*

place the pin in the preoperatively planned position. Once the glenoid component is secured the final humeral implant is placed. The subscapularis is either repaired using a suture anchor repair technique in TSA (SpeedScap, Arthrex, Naples FL, USA) or in transosseous manner with high tensile sutures in RTSA. Based on evidence from the total knee and total hip arthroplasty literature, once the subscapularis has been repaired, it is important to allow the shoulder to soak in dilute betadine for 5 minutes to help decrease the risk of infection [15, 16]. Some surgeons do not allow betadine into operative field as they believe betadine can "burn" tissues. In the author's opinion, this has not been an issue and the addition of betadine has helped mitigate infection risk. Once the dilute betadine has had time to sit it is irrigated out. Next, 1 g of Vancomycin powder is placed in the incision, part just over the subscapularis

and part over the deltopectoral closure [17–21]. A running absorbable stitch is used to close the skin along with skin glue. A waterproof silver impregnated dressing is utilized to decrease infection risk [22]. During the case the anesthesia team should ensure adequate patient hydration to avoid postoperative dehydration.

#### **3.3 Postoperative**

Following surgery patients are given a set or oral medication including 1000 mg of Acetaminophen, 300 mg of Neurontin, and 200 mg of Celecoxib. If patients are experiencing pain, medications including ketorolac, oxycodone, or tramadol can be utilized on an as needed basis. Ondansetron should be used to control postoperative nausea. A second dose of IV TXA can be given in the recovery room before discharge. A second dose of antibiotics (2 g Cefazolin) is not routinely used unless it has been more than 8 hours since the preoperative dose and the patient has not gone home. Patients are not sent home with any antibiotics. Patients are sent home with a multimodal pain regimen. Further work is needed to determine the ideal combination of medications, but some of the options to include are: Acetaminophen, Tramadol, Oxycodone, Gabapentin, Celecoxib, Aspirin and Pantoprazole.

#### **3.4 Physical therapy**

The demand for shoulder arthroplasty is projected to exceed that of hip/knee arthroplasty [23]. For instance, it has been reported that a total of 39,072 patients were admitted for total shoulder arthroplasty in 2010, 5 times the number of patients in 1998 [24]. This increase is proportionally associated with the need for effective and feasible physical therapy, which is critical in the recovery pathway following shoulder replacements [25]. Traditionally, physical therapy following shoulder surgery has occurred via in-office supervised visits [26]. Home-based physical therapy reduces costs and decreases the need for travel [27]. Home-based therapy has been shown to be as effective as in-office therapy after total knee arthroplasty and has been utilized for rehabilitation after proximal humerus fracture [28–30]. It has also been reported to be a safe and effective alternative in the early phase following rotator cuff repair [31]. However, home-based therapy lacks the ability to monitor patient performance, compliance, and progress. Digital health has been incorporated in various medical fields over the past few decades. This process has accelerated since the COVID-19 pandemic which has brought to the forefront of medicine the need to deliver care and rehabilitation remotely. Remote patient monitoring has emerged as a concept in which patient physiologic parameters are measured and remotely delivered to a care team. Within our practice, remote patient monitoring is implemented via a secure cloud-based provider rehabilitation platform that communicates with a patient application powered by marker-less artificial intelligence (AI) technology with a dedicated built-in telemedicine capability (PT Genie; Orlando, FL) (**Figure 8**).

At the initial visit patients are instructed on how to use the platform and are provided a QR code to scan and download the app onto their device (Android/iOS). PT Genie has instructions on the home-based exercise protocol, demonstrates the exercises to be performed and keeps track of progress including pain score, completed repetitions and number of sessions all via the AI driven sensor less motion tracking using the front facing camera of a cellphone or a tablet. Monitoring is performed on *Outpatient Total Shoulder Replacement Procedures DOI: http://dx.doi.org/10.5772/intechopen.101974*

#### **Figure 8.**

*The patient-facing application (PT Genie) which tacks ROM using AI marker less technology.*

the web-based clinical dashboard by a dedicated care team, who also monitor the daily progress and communicate with the patients via in-app messages, telemedicine calls, and emails (**Figure 9**). PT Genie allows the provider to fully customize and control the rehabilitation protocol by adding or modifying exercises to go along with the patient's pace of recovery, the addition of bands and calculation of force on certain exercises, and the ability to set up a pre habilitation phase, if needed prior to surgery.

#### **Figure 9.**

*A secure telemedicine platform (PT Genie) enables the provider and the patient to communicate and interact remotely.*

#### **4. Results of outpatient shoulder arthroplasty**

Several studies have shown the efficacy of outpatient TSA and RTSA compared to inpatient shoulder arthroplasty. Cimino et al. performed a systematic review of 12 studies (194,513 patients, of whom 7162 were outpatients) to evaluate the outcomes following outpatient TSA and RTSA [32]. The average age of the outpatients was 66.6 years while the average age of the inpatients was 70.1 years. The authors found the odds ratio for complications was significantly lower in outpatients than in inpatients. Furthermore, there was no significant difference in rates of 90-day readmission, revision, and infection rate between outpatients with inpatients. Similarly, Fournier et al. reported the results of 61 patients who underwent outpatient TSA and RTSA [6]. There were no cardiopulmonary events that required intervention or hospital admission. These studies evaluated both TSA and RTSA together. This happens commonly because the CPT code for TSA and RTSA is the same (23472). Below are examples of studies that separated outcome based on TSA and RTSA.

#### i. TSA

Erickson et al. reported the results of 94 patients (average age 60.4, 67.0% male) who underwent TSA 2015–2017 by the senior author. The authors matched this group of patients to a group of 77 patients who underwent TSA as an inpatient. Patients who underwent outpatient TSA saw significant improvement in all clinical outcome scores at both 1 and 2 year postoperatively (**Figure 10**). There were baseline differences between groups such that patients who underwent inpatient TSA were more likely to be diabetic than those who underwent outpatient TSA. The authors found no significant differences in improvements in clinical outcome scores between inpatients vs. outpatient groups. They noted that complications were more frequent in patients who underwent inpatient TSA (11.4% vs. 2.1%), although this did difference did not reach statistical significance (p = 0.080). Brolin et al. evaluated 30 patients who underwent outpatient TSA at a freestanding ambulatory surgery center and compared *Outpatient Total Shoulder Replacement Procedures DOI: http://dx.doi.org/10.5772/intechopen.101974*

**Figure 10.** *A 2-years follow-up X-ray for an outpatient total shoulder arthroplasty (TSA).*

**Figure 11.** *A 2-years follow-up X-ray for an outpatient reverse total shoulder arthroplasty (RTSA).*

them with an age- and comorbidities-matched cohort of 30 patients who underwent inpatient TSA [5]. The authors evaluated 90-day complications, hospital admissions/ readmissions and reoperations. There were significant differences between outpatient and inpatient cohorts regarding preoperative demographics. The authors reported no

hospital admissions from the outpatient cohort and no readmissions from the inpatient cohort. There was no difference in the complication rates between outpatient (13%) and inpatient (10%) shoulder arthroplasty.

#### ii.RTSA.

Erickson et al. reported the results on 241 patients (average age 68.9, 52.3% female) who underwent outpatient RTSA between 2015 and 2017 by the senior author (**Figure 11**). The authors matched this group of patients to a group of 373 patients who underwent RTSA as an inpatient. There were baseline differences between the two groups such that significantly more inpatient RTSA had diabetes (p = 0.007) and had a significantly higher body mass index (p = 0.022). The authors found that patients who underwent outpatient RTSA had significant improvement in all clinical outcome scores at both 1 and 2 year postoperatively (all p < 0.0001). There were no significant differences in improvements in clinical outcome scores between inpatient vs. outpatient RTSA groups. Most importantly, complication rates were significantly lower for patients who underwent RSTA as an outpatient compared to those who underwent RTSA as an inpatient (7.0% vs. 12.7% p = 0.023).

#### **5. Conclusion**

Many patients are candidates for outpatient TSA and RTSA. Some patients may be better suited to have their surgery performed in the hospital setting while other are excellent candidates for an outpatient surgical center. A thorough preoperative evaluation is critical for proper patient selection and a set protocol is necessary for the day of surgery to ensure proper pain control and to minimize risk of complications and readmissions. When performed properly, patients should expect the same outcomes as those who undergo TSA and RTSA in the inpatient setting with potentially lower complication rates.

#### **Author details**

Brandon J. Erickson1 \*, Yousef Shishani<sup>2</sup> and Reuben Gobezie2

1 Rothman Orthopaedic Institute, New York, USA

2 Cleveland Shoulder Institute, Beachwood, OH, USA

\*Address all correspondence to: brandon.erickson@rothmanortho.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Outpatient Total Shoulder Replacement Procedures DOI: http://dx.doi.org/10.5772/intechopen.101974*

#### **References**

[1] Erickson BJ, Bohl DD, Cole BJ, et al. Reverse total shoulder arthroplasty: Indications and techniques across the world. American Journal of Orthopedics (Belle Mead, N.J.). 2018;**47**(9). DOI: 10.12788/ajo.2018.0079

[2] Gupta AK, Harris JD, Erickson BJ, et al. Surgical management of complex proximal humerus fractures -A systematic review of 92 studies including 4,500 patients. Journal of Orthopaedic Trauma. 2015;**29**(1):54-59

[3] Hadley CSN, Anis H, Ricchetti E, Mont MA, Erickson BJ, Romeo AA. Nationwide trends of surgical site infections rates after primary shoulder arthroplasty. Seminars in Arthroplasty: JSES. 2021;**31**(2):191-196

[4] Basques BA, Erickson BJ, Leroux T, et al. Comparative outcomes of outpatient and inpatient total shoulder arthroplasty: An analysis of the Medicare dataset. The Bone & Joint Journal. 2017;**99-B**(7):934-938

[5] Brolin TJ, Mulligan RP, Azar FM, Throckmorton TW. Neer Award 2016: Outpatient total shoulder arthroplasty in an ambulatory surgery center is a safe alternative to inpatient total shoulder arthroplasty in a hospital: A matched cohort study. Journal of Shoulder and Elbow Surgery. 2017;**26**(2):204-208

[6] Fournier MN, Brolin TJ, Azar FM, Stephens R, Throckmorton TW. Identifying appropriate candidates for ambulatory outpatient shoulder arthroplasty: Validation of a patient selection algorithm. Journal of Shoulder and Elbow Surgery. 2019;**28**(1):65-70

[7] Leroux TS, Basques BA, Frank RM, et al. Outpatient total shoulder

arthroplasty: A population-based study comparing adverse event and readmission rates to inpatient total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2016;**25**(11):1780-1786

[8] Cvetanovich GL, Fillingham YA, O'Brien M, et al. Tranexamic acid reduces blood loss after primary shoulder arthroplasty: A double-blind, placebocontrolled, prospective, randomized controlled trial. JSES Open Access. 2018;**2**(1):23-27

[9] Fillingham YA, Darrith B, Calkins TE, et al. Mark Coventry Award: A multicentre randomized clinical trial of tranexamic acid in revision total knee arthroplasty: Does the dosing regimen matter? The Bone & Joint Journal. 2019;**101-B**(7\_Supple\_C):10-16

[10] Fillingham YA, Ramkumar DB, Jevsevar DS, et al. Tranexamic acid in total joint arthroplasty: The endorsed clinical practice guides of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. Regional Anesthesia and Pain Medicine. 2019;**44**(1):7-11

[11] Fillingham YA, Ramkumar DB, Jevsevar DS, et al. The efficacy of tranexamic acid in total knee arthroplasty: A network metaanalysis. The Journal of Arthroplasty. 2018;**33**(10):3090-3098 e3091

[12] Kayupov E, Fillingham YA, Okroj K, et al. Oral and intravenous tranexamic acid are equivalent at reducing blood loss following total hip arthroplasty: A randomized controlled trial. The Journal of Bone and Joint Surgery. American Volume. 2017;**99**(5):373-378

[13] Gillespie R, Shishani Y, Joseph S, Streit JJ, Gobezie R. Neer Award 2015: A randomized, prospective evaluation on the effectiveness of tranexamic acid in reducing blood loss after total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2015;**24**(11):1679-1684

[14] Chalmers PN, Beck L, Stertz I, Tashjian RZ. Hydrogen peroxide skin preparation reduces Cutibacterium acnes in shoulder arthroplasty: A prospective, blinded, controlled trial. Journal of Shoulder and Elbow Surgery. 2019;**28**(8):1554-1561

[15] Brown NM, Cipriano CA, Moric M, Sporer SM, Della Valle CJ. Dilute betadine lavage before closure for the prevention of acute postoperative deep periprosthetic joint infection. The Journal of Arthroplasty. 2012;**27**(1):27-30

[16] Calkins TE, Culvern C, Nam D, et al. Dilute betadine lavage reduces the risk of acute postoperative periprosthetic joint infection in aseptic revision total knee and hip arthroplasty: A randomized controlled trial. The Journal of Arthroplasty. 2020;**35**(2):538-543 e531

[17] Buchalter DB, Kirby DJ, Teo GM, Iorio R, Aggarwal VK, Long WJ. Topical vancomycin powder and dilute povidone-iodine lavage reduce the rate of early periprosthetic joint infection after primary total knee arthroplasty. The Journal of Arthroplasty. 2021;**36**(1): 286-290 e281

[18] Hatch MD, Daniels SD, Glerum KM, Higgins LD. The cost effectiveness of vancomycin for preventing infections after shoulder arthroplasty: A break-even analysis. Journal of Shoulder and Elbow Surgery. 2017;**26**(3):472-477

[19] Hosack LW, Overstreet DJ, Lederman ES. In vitro susceptibility of *Propionibacterium acnes* to simulated

intrawound vancomycin concentrations. JSES Open Access. 2017;**1**(3):125-128

[20] Iorio R, Yu S, Anoushiravani AA, et al. Vancomycin powder and dilute povidone-iodine lavage for infection prophylaxis in high-risk total joint arthroplasty. The Journal of Arthroplasty. 2020;**35**(7):1933-1936

[21] Miquel J, Huang TB, Athwal GS, Faber KJ, O'Gorman DB. Vancomycin is effective in preventing *Cutibacterium acnes* growth in a mimetic shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2021;**31**(1):159-164

[22] Grosso MJ, Berg A, LaRussa S, Murtaugh T, Trofa DP, Geller JA. Silverimpregnated occlusive dressing reduces rates of acute periprosthetic joint infection after total joint arthroplasty. The Journal of Arthroplasty. 2017;**32**(3): 929-932

[23] Day JS, Lau E, Ong KL, Williams GR, Ramsey ML, Kurtz SM. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. Journal of Shoulder and Elbow Surgery. 2010;**19**(8):1115-1120

[24] Issa K, Pierce CM, Pierce TP, et al. Total shoulder arthroplasty demographics, incidence, and complications-A nationwide inpatient sample database study. Surgical Technology International. 2016;**29**:240-246

[25] Christiansen DH, Frost P, Falla D, et al. Effectiveness of standardized physical therapy exercises for patients with difficulty returning to usual activities after decompression surgery for subacromial impingement syndrome: Randomized controlled trial. Physical Therapy. 2016;**96**(6):787-796

[26] Arshi A, Kabir N, Cohen JR, et al. Utilization and costs of postoperative

*Outpatient Total Shoulder Replacement Procedures DOI: http://dx.doi.org/10.5772/intechopen.101974*

physical therapy after rotator cuff repair: A comparison of privately insured and medicare patients. Arthroscopy. 2015;**31**(12):2392-2399 e2391

[27] Pastora-Bernal JM, Martin-Valero R, Baron-Lopez FJ, Estebanez-Perez MJ. Evidence of benefit of telerehabitation after orthopedic surgery: A systematic review. Journal of Medical Internet Research. 2017;**19**(4):e142

[28] Moffet H, Tousignant M, Nadeau S, et al. In-home telerehabilitation compared with face-to-face rehabilitation after total knee arthroplasty: A noninferiority randomized controlled trial. The Journal of Bone and Joint Surgery. American Volume. 2015;**97**(14):1129-1141

[29] Piqueras M, Marco E, Coll M, et al. Effectiveness of an interactive virtual telerehabilitation system in patients after total knee arthoplasty: A randomized controlled trial. Journal of Rehabilitation Medicine. 2013;**45**(4):392-396

[30] Tousignant M, Giguere AM, Morin M, Pelletier J, Sheehy A, Cabana F. In-home telerehabilitation for proximal humerus fractures: A pilot study. International Journal of Telerehabilitation. 2014;**6**(2):31-37

[31] Buvik A, Bergmo TS, Bugge E, Smaabrekke A, Wilsgaard T, Olsen JA. Cost-effectiveness of telemedicine in remote orthopedic consultations: Randomized controlled trial. Journal of Medical Internet Research. 2019;**21**(2): e11330

[32] Cimino AM, Hawkins JK, McGwin G, Brabston EW, Ponce BA, Momaya AM. Is outpatient shoulder arthroplasty safe? A systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2021;**30**(8):1968-1976

Section 3
