Abstract
Purpose
Outpatient orthopedic surgery is becoming more common as a method of providing safe and cost-effective medical care. The purpose of this study was to compare outcomes between adult patients undergoing outpatient versus inpatient brachial plexus surgery.
Methods
A single institution database was queried for patients with brachial plexus injuries undergoing brachial plexus exploration with or without concomitant reconstructive procedures from 2010 to 2022. Outcome measures included 90-day major and minor complications, as well as longer term pain scores and reoperation rates. Multivariate analysis was performed to compare outcomes between the cohorts.
Results
In a group of 51 adult patients, 36 (70.6 %) were admitted for at least one night following surgery and 15 (29.4 %) underwent outpatient surgery. The cohorts were similar with respect to demographics. When compared to brachial plexus procedures performed between 2010 and 2016, those performed between 2017 and 2022 were 67 % more likely to be outpatient (OR 0.33; p = 0.11). The overall major complication rate during the 90-day episode of care was 11.8 % (n = 6), all of which occurred in the inpatient cohort. There was no significant difference in minor complication rate. 90-day reoperation rate due to complications was 2.8 % in the inpatient cohort and 0.0 % in the outpatient cohort.
Conclusion
No prior study has assessed the safety of brachial plexus exploration and reconstruction in an outpatient setting. This study demonstrates that outpatient brachial plexus surgery is a safe option for properly selected patients. Procedures were more often performed outpatient in recent years, reflecting a continuing evolution of our practice.
Keywords: Brachial plexus, Outpatient, Safety, Complications, Reoperation
1. Introduction
Interest in outpatient orthopaedic surgery has grown in response to increasing emphasis on the efficient delivery of safe, high quality, value-based medical care. To date, significant emphasis has been placed on outpatient arthroplasty to minimize hospital length of stay and associated complications, as well as cost. A number of studies have documented equivalent outcomes, complications and readmission rates in outpatient total shoulder arthroplasty and total elbow arthroplasty.1,2 Same-day discharge after total hip arthroplasty has shown improved patient satisfaction with no increase in complications.3 Studies on spinal surgery – including anterior cervical decompressions and fusions and anterior lumbar fusions, among others – have shown similar outcomes compared with inpatient procedures, and the frequency of these procedures on an outpatient basis is increasing.4, 5, 6, 7 Given the prior positive results following outpatient surgery in multiple orthopaedic subspecialities, we sought to evaluate the safety of same-day discharge following brachial plexus exploration and reconstruction.
Adult brachial plexus injuries are increasing in number.8, 9, 10, 11 Treatment of these frequently life-altering injuries with surgery is intended to restore function and protective sensation, ideally improving a patient's quality of life.8,12 Patients have historically been admitted to the hospital following this procedure in order to monitor for complications and ensure pain control prior to discharge. Establishing the safety and efficacy of outpatient brachial plexus surgery may provide benefits in terms of cost, patient satisfaction, and avoidance of inpatient-stay related complications. The present study aims to compare the complication rates, reoperation rates, and clinical outcomes of patients undergoing inpatient versus outpatient brachial plexus exploration and associated procedures.
2. Materials and methods
This study is an institutional review board-approved, single-center, retrospective study evaluating 90-day outcomes as well as two-year follow up of patients following outpatient versus inpatient brachial plexus surgery between 2010 and 2022. Study data were collected and managed using Research Electronic Data Capture (REDCap) tools.13 REDCap is a secure, web-based software platform designed to support data capture for research studies, providing an interface for validated data capture, audit trails for tracking data manipulation, automated export procedures, and procedures for data integration and interoperability with external sources.
Patients were included if they were greater than 18 years of age at the time of primary brachial plexus surgical exploration and associated reconstruction. Patients were considered to have had inpatient surgery if they stayed overnight following operative intervention. Less than 24 h hospital stays that still included an overnight stay were considered inpatient for the purposes of this study. Surgeon discretion as well as patient preference determined whether a patient was admitted or discharged on the same day of surgery, though over the last decade outpatient surgery has become increasingly common in our practice. All patients undergoing tendon or peripheral nerve transfers without a brachial plexus exploration were excluded. Those with an active or pre-existing infection were also excluded.
Records were reviewed for patient demographics. This included age, gender, body mass index (BMI), American Society of Anesthesiologists class (ASA) classification, and medical comorbidities. Age was defined as the age at the time of the index operation. Sex was defined on the basis of patients' self-reported gender. BMI was defined in the standard fashion (kg/m2) using patients’ height and weight recorded on the day of surgery or as close to the index operation as possible. The American Society of Anesthesiologists (ASA) score was determined by reviewing records from the anesthesiology department, and patients were categorized using the standard I-IV scale. Additionally, specific data points related to the injury were reviewed: hand dominance, date of injury, side of injury, length of time from injury to surgery, other associated injuries, and other associated surgeries. Surgical details were collected including year of surgery, estimated blood loss, procedure length, concomitant procedures, and hospital length of stay (LOS).
Outcome measures included operative time, estimated blood loss, emergency department (ED) visits and hospital readmission within 90-days of the index procedure. Unplanned office visits alone did not count toward readmission or ED visitation. Minor complications were defined as wound drainage, delayed wound healing, hematoma, and superficial wound infection resolving with oral antibiotics. Major complications included presentation to the ED related to postoperative course, hospital readmission, reoperation within 90 days, and severe infection requiring admission, IV antibiotics, or surgery. Beyond 90 days, we reviewed the electronic medical records to collect information on any other reoperation for all patients. We collected final clinic follow up visit date as well as last available Visual Analog Scale (VAS) Pain score. This study was designed and reported in accordance with the STROBE (Strengthening and Reporting of Observational Studies in Epidemiology) statement.
Descriptive statistics including measures of central tendency, variability, frequencies, and proportions were calculated. The differences in means and subsequent t-tests were used to analyze and make group comparisons for continuous measures. For key variables of interest, odds ratios, confidence intervals and p-values were used to quantify their associations with hospital admission. Chi-square and fisher's test were used to test for independence between other variables and hospital admission. The threshold for significance was set with an alpha level of at p = 0.05.
3. Results
53 patients were identified who met inclusion criteria and underwent brachial plexus exploration and reconstruction between 2010 and 2022. Two patients were excluded as no follow up data was available. Demographic and injury mechanism data for the 51 patients included in our analysis is presented in Table 1. Of the 51 patients, 42 were male (82.4 %) and 9 were female (17.6 %). Mean age at the time of surgery was 35.8 ± 13.2 years. 34 self-identified as white race (66.7 %) and 41 identified as not Hispanic or Latino in ethnicity (80.4 %). The majority of patients (52.9 %) were categorized as ASA II, with mild systemic disease. Average BMI was 29.5 ± 5.5. Data regarding smoking status was available for 40 patients; of these 40 patients, 12 people reported current tobacco use (30 % from those with available data, 23.5 % of total cohort). The most common injury mechanism was motorcycle collision (45.1 %), followed by motor vehicle accident (15.7 %) and all-terrain vehicle accident (7.8 %). While all patients underwent brachial plexus exploration, 68.6 % underwent concomitant nerve transfers and 29.4 % underwent nerve reconstruction.
Table 1.
Preoperative patient and injury characteristics of the total cohort, outpatient, and inpatient brachial plexus surgery cohorts.
| Patient and Injury Characteristics | Overall (n = 51) | Outpatient surgery (n = 15) | Inpatient surgery (n = 36) | Statistical Analysis |
|---|---|---|---|---|
| Demographics | ||||
| Age at Surgery In Years (Mean ± SD) | 35.8 ± 13.2 | 36.7 ± 14.1 | 35.5 ± 12.9 | p > 0.5 |
| Body Mass Index (Mean ± SD) | 29.5 ± 5.5 | 29.4 ± 5.3 | 29.5 ± 5.7 | p > 0.5 |
| Charlson Comorbidity Index (Mean ± SD) | 0.6 ± 1.1 | 0.6 ± 1.4 | 0.6 ± 1.0 | p = 0.28 |
| Patient Sex: Male |
82.4 % (n = 42) |
73.3 % (n = 11) |
86.1 % (n = 31) |
p > 0.5 |
| ASA Classification | ||||
| Normal healthy patient (ASA I) | 11.8 % (n = 6) | 20.0 % (n = 3) | 8.3 % (n = 3) | Referent |
| Mild systemic disease (ASA II) | 52.9 % (n = 27) | 40.0 % (n = 6) | 58.3 % (n = 21) | p = 0.18 |
| Severe systemic disease (ASA III) | 23.5 % (n = 12) | 33.3 % (n = 5) | 19.4 % (n = 7) | p > 0.5 |
| Severe systemic disease that is a constant threat to life (ASA IV) | 3.9 % (n = 2) | – | 5.6 % (n = 2) | p > 0.5 |
| Not Reported/Data Unknown |
7.8 % (n = 4) |
6.7 % (n = 1) |
8.3 % (n = 3) |
– |
| Initial Injury Mechanism | ||||
| Motor cycle collision | 45.1 % (n = 23) | 40.0 % (n = 6) | 47.2 % (n = 17) | Referent |
| Motor vehicle collision | 15.7 % (n = 8) | 33.3 % (n = 5) | 8.3 % (n = 3) | p = 0.10 |
| All-terrain vehicle crash | 7.8 % (n = 4) | 6.7 % (n = 1) | 8.3 % (n = 3) | p > 0.5 |
| Other (ex: gun shot, fall, sports injury) | 31.4 % (n = 16) | 20.0 % (n = 3) | 36.1 % (n = 13) | p = 0.33 |
Postoperatively, 36 patients (70.6 %) were admitted for at least one night following surgery and 15 patients (29.4 %) were discharged on the day of surgery. There was no statistically significant difference in baseline demographics between the two cohorts including age, ethnicity, BMI, Charlson Comorbidity Index, or ASA classification. However, compared to patients with ASA I classification, ASA II demonstrated a trend towards admission as 3.5 times more likely (p value = 0.18). Only two of the 51 patients were deemed ASA IV, and both of these patients were admitted postoperatively. Mean surgical time was 316.3 ± 130.2 min. Patients who were admitted postoperatively tended to have longer procedures, with average length of procedure 50 min longer than those performed on an outpatient basis (p = 0.22) (Table 2). Mean estimated blood loss (EBL) was 69.9 ± 121.0 mL across all cases. EBL was not significantly different between groups, with EBL of 77.9 mL versus 66.5 mL for the outpatient and inpatient cohorts, respectively (p = 0.77). When compared to procedures performed between 2010 and 2016, there was a trend that those performed between 2017 and 2022 were 67 % more likely to be outpatient (Odds Radio (OR): 0.33; p = 0.11). Five out of 26 patients (19.2 %) underwent outpatient surgery from 2010 to 2016, whereas 10 out of 25 patients (40.0 %) underwent outpatient surgery from 2017 to 2022. This demonstrates a trend toward selecting patients for outpatient surgery in more recent years (p = 0.09).
Table 2.
Operative characteristics of the total cohort, outpatient, and inpatient brachial plexus surgery cohorts.
| Operative Characteristics | Overall (n = 51) | Outpatient surgery (n = 15) | Inpatient surgery (n = 36) | Statistical Analysis |
|---|---|---|---|---|
| Year of surgery | Bivariate Odds Radio (95 % CI) = 0.33 (0.09, 1.28); p = 0.11 |
|||
| 2010–2016 | 51.0 % (n = 26) | 33.3 % (n = 5) | 58.3 % (n = 21) | |
| 2017–2022 |
49.0 % (n = 25) |
66.7 % (n = 10) |
41.7 % (n = 15) |
|
| Brachial Plexus Procedure (In Addition to Brachial Plexus Exploration) | ||||
| Muscle/Tendon transfer | 2.0 % (n = 1) | – | 2.8 % (n = 1) | p > 0.5 |
| Nerve Reconstruction | 29.4 % (n = 15) | 13.3 % (n = 2) | 36.1 % (n = 13) | p = 0.11 |
| Nerve transfer |
68.6 % (n = 35) |
66.7 % (n = 10) |
69.4 % (n = 25) |
p > 0.5 |
| Procedure Length in Minutes (Mean±SD) | 316.3 ± 130.2 | 282.1 ± 100.5 | 332.3 ± 140.7 | p = 0.22 |
| Estimated Blood Loss in mL (Mean±SD) | 69.9 ± 121.0 | 77.9 ± 160.0 | 66.5 ± 103.0 | p > 0.5 |
There was no significant difference in major or minor complication rates when comparing inpatient and outpatient cohorts (Table 3). Nine (17.6 %) total patients experienced either a major or minor complication. One of these patients experienced both a major and a minor complication, presenting to the ED for surgical site pain and also developing a superficial wound infection requiring oral antibiotics. The overall major complication rate during the 90-day episode of care was 11.8 % (n = 6). All six (100 %) of these complications occurred in the inpatient cohort. Four patients presented to the ED within 90 days: three for operative site pain and one for shortness of breath with an unremarkable workup. One patient had a congested free functional gracilis flap that required an unplanned admission and reoperation for irrigation and debridement. The final patient presented to the ED for shortness of breath and was admitted for pneumonia eventually requiring intubation; this patient's course was also complicated by acute renal failure. This patient had undergone brachial plexus exploration, neurolysis, and nerve grafting; she did not have an intercostal nerve transfer or other reason to believe the pulmonary symptoms were directly related to surgery.
Table 3.
Minor and major complications for the total cohort, outpatient, and inpatient brachial plexus surgery cohorts.
| Overall (n = 51) | Outpatient surgery (n = 15) | Inpatient surgery (n = 36) | P-value | |
|---|---|---|---|---|
| Experienced a Minor Complication | >0.5 |
|||
| Superficial surgical site infection requiring oral antibiotics |
7.8 % (n = 4) |
13.3 % (n = 2) |
5.6 % (n = 2) |
|
| Experienced a Major Complication | >0.5 | |||
| Overall | 11.8 % (n = 6) | – | 16.7 % (n = 6) | |
| Presentation to emergency room within 90 days of index surgery, discharged home | 7.8 % (n = 4) | – | 11.1 % (n = 4) | |
| Unplanned readmission to hospital within 90 days of index surgery, complicated by pneumonia and acute renal failure | 2.0 % (n = 1) | – | 2.8 % (n = 1) | |
| Congestion at skin paddle site from free functional gracilis flap, requiring return to OR | 2.0 % (n = 1) | – | 2.8 % (n = 1) | |
The overall minor complication rate across both cohorts was 7.8 % (n = 4). In the outpatient cohort, 2 patients (13.3 %) had superficial surgical site infections requiring oral antibiotics. In the inpatient cohort, 2 patients (5.6 %) had superficial surgical site infections requiring only oral antibiotics. This difference was not significantly different (p = 0.60). As mentioned, one of these patients with a superficial surgical site infection also returned to the ED for operative site pain, placing them in both major and minor complication categories.
90-day reoperation rates were low, with the aforementioned patient with a congested flap being the only individual undergoing reoperation from the inpatient cohort, amounting to a 90-day reoperation rate of 2.0 % across both cohorts and 2.8 % in the inpatient cohort. Reoperation in the 90-day time frame was 0.0 % in the outpatient cohort. Beyond the 90-day period, at an average follow up of 30.8 months, 14 patients (27.5 %) across both cohorts underwent reoperation for issues unrelated to infection or wound complications (Table 4). Reoperation rates in the inpatient versus outpatient cohorts were 30.6 % (11/36 patients) and 20.0 % (3/15 patients), respectively (p = 0.32). Procedures performed at time of reoperation included tendon transfers, Steindler flexorplasty, glenohumeral arthrodesis, neurolysis with additional nerve transfers, and two amputations. At an average of 26 month follow up, VAS pain score was 4.1 ± 3.1 across both cohorts. In the outpatient cohort, average VAS score was 3.3 ± 3.4. In the inpatient cohort, average score was 4.5 ± 2.9 (p = 0.21).
Table 4.
Reoperation rates for surgery performed more than 90 days after index surgery and Visual Analog (VAS) Pain scores for the total cohort, outpatient, and inpatient brachial plexus surgery cohorts.
| Overall (n = 51) | Outpatient surgery (n = 15) | Inpatient surgery (n = 36) | P-value | |
|---|---|---|---|---|
| Underwent Reoperation After 90 Days (Average Follow Up Clinic Visit: 30.8 months) | 27.5 % (n = 14) | 20.0 % (n = 3) | 30.6 % (n = 11) | 0.32 |
| Visual Analog Scale Score (Mean ± SD) (Average Follow Up at VAS Collection: 26.0 months) | 4.1 ± 3.1 | 3.3 ± 3.4 | 4.5 ± 2.9 | 0.21 |
4. Discussion
This study sought to evaluate the safety and efficacy of outpatient brachial plexus surgery in a group of 51 adult patients, 70.6 % of whom were admitted for at least one night following surgery and 29.4 % who underwent outpatient surgery. The overall major complication rate during the 90-day episode of care was 11.8 % (n = 6), all of which occurred in the inpatient cohort. There was no significant difference in minor complication rate. 90-day reoperation rate due to complications was 2.8 % in the inpatient cohort and 0.0 % in the outpatient cohort. Beyond the 90 day period, at an average follow up of 30.8 months, 14 patients (27.5 %) across both cohorts underwent reoperation with no difference in reoperation rate between inpatient and outpatient cohorts. At an average follow up of 26 months, there was no statistically significant difference in VAS pain scores between cohorts.
As medical costs in the United States continue to rise, policy makers continue to emphasize efficient delivery of medical care, including the transition of previously performed inpatient procedures to the outpatient setting when appropriate.14 There is currently an abundance of literature demonstrating the safety of outpatient shoulder, hip, and knee arthroplasty as well as spine procedures, resulting in a trend toward increasing outpatient surgery utilization.15, 16, 17 While the majority of upper extremity procedures are regularly performed on an outpatient basis, the safety of brachial plexus exploration and reconstruction in the outpatient setting has not been established in the literature. Patients undergoing this procedure have historically been admitted to the hospital following intervention at our institution and at many others. In our study, brachial plexus procedures performed between 2017 and 2022 were 67 % more likely to be outpatient when compared to those performed between 2010 and 2016 (OR: 0.33; p = 0.11). While we did not identify any patient-specific factor that led to a statistically significant increase in likelihood of admission, we did identify a trend that compared to patients with ASA I classification, ASA II patients were 3.5 times more likely to be admitted. Despite the overall increase in performing outpatient brachial plexus surgery, proper patient selection is critical, and we do not advocate all patients be managed in an outpatient manner, but rather suggest that in properly selected patients outpatient brachial plexus surgery appears safe.
With no significant difference in 90-day complication rates in our series, outpatient brachial plexus surgery appears to offer comparable rates of postoperative complications. Relevant potential short-term complications for any patient undergoing brachial plexus exploration include wound problems, infection, and persistent or worsened pain.18,19 Post-operative seroma, hematoma or lymphocele can occur and negatively impact healing, although we did not have any case of this in either inpatient or outpatient cohorts.20, 21, 22 Patients in our study underwent a variety of concomitant procedures, including nerve transfers, muscle transfers, and nerve reconstruction, introducing their own set of possible complications within the 90-day period. Site-specific complications during nerve transfer – for example, pleural effusion following intercostal nerve transfer – can occur and be identified post-operatively.23 Patients undergoing free functioning muscle transfer can experience flap failure due to vascular problems or donor site issues.24,25 While one patient in our cohort developed a congested free functional gracilis flap that required reoperation, this patient had been admitted postoperatively, discharged the following day, and presented to clinic with this finding five days after surgery. While it is important to understand the array of post-operative complications that can occur, this highlights that many of these complications may not be clinically detectable until after discharge, regardless of whether patients are admitted overnight or discharged from same-day surgery.
Beyond limitations of this study inherent to its retrospective nature, determination of inpatient versus outpatient management was frequently based on surgeon discretion and patient preference, introducing potential selection bias. At times, non-medical factors such as travel distance or overnight care provider at home can influence the decision. Further, brachial plexus exploration cases with more complex concomitant procedures – such as intercostal nerve transfers or free functioning tissue flaps – may require increased monitoring and not be amenable to outpatient surgery. We again emphasize that our results and experiences do not advocate for outpatient surgery for all brachial plexus cases, but rather that this study provides proof-of-concept that brachial plexus exploration with certain concomittant procedures can be safely performed on an outpatient basis in appropriately selected patients. Additionally, a cost analysis would allow us to comment more definitively on differences between outpatient and inpatient procedures and hospital stays. Unfortunately, we were not able to access cost data from the institution where surgery and admission occurred. Although a cost comparison analysis could not be performed in our cohort, many prior studies have demonstrated that outpatient orthopedic procedures incur lower costs than inpatient procedures.14 Finally, a larger sample size would allow us to better elucidate any patient-specific or injury-related factors that are predictive of success or failure with outpatient management.
5. Conclusions
While patients undergoing brachial plexus exploration and reconstruction have historically been admitted postoperatively for observation, the safety of this procedure in an outpatient setting has not been previously vetted. When comparing 36 patients in an inpatient cohort to 15 in an outpatient cohort, there were no significant differences in 90-day major complication rate, minor complication rate, or reoperation rate. No major complications occurred in the outpatient cohort. Longer term reoperation rates and pain scores also demonstrate comparable results. On properly selected patients, outpatient brachial plexus surgery appears to be equally safe compared to inpatient surgery. Procedures were more often performed outpatient in recent years, reflecting a continuing evolution of our practice.
Statement of informed consent
This study is an institutional review board (IRB) approved observational retrospective study. Therefore, all patient information has been protected according to IRB standards. Given the retrospective and observational nature of the study without any intervention, no informed consent process was deemed necessary for this study.
Statement of human and animal rights
Not applicable - This study is an institutional review board (IRB) approved observational retrospective study without any intervention.
Statement of funding
No funding was received for this study.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements of Grant Support
None.
References
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