Outpatient Reverse Total Shoulder Arthroplasty

Abstract

Purpose of Review

This review aims to evaluate the current landscape of outpatient reverse total shoulder arthroplasty, as well as summarize protocols to facilitate safe and effective patient selection and implementation. It also aims to demystify cost and reimbursement concerns surrounding this topic.

Recent Findings

Formal risk stratification, structured perioperative pathways, and proactive follow-up can make outpatient RTSA safe and highly effective. Medical comorbidity profile, age, social factors as well as non-medical barriers can all assist with decision making. Additionally, there are considerable cost savings that do not compromise outcomes or safety, which will drive more patients to receive outpatient RTSA. Caution should be exercised if considering RTSA for fracture as well as in a revision setting given the case unpredictability, anticipated blood loss and the possible need for a higher level of care. Further work is needed to standardize nomenclature in reporting care settings around outpatient RTSA.

Summary

Outpatient RTSA can be safe and effective with careful patient selection.

Introduction

The incidence of reverse total shoulder arthroplasty (RTSA) has been increasing in recent decades due to expanding indications, an aging population and increasing surgeon familiarity. Due to an increased emphasis on cost-effective health care delivery in the United States, there has been a growth of outpatient orthopaedic surgery, including ambulatory surgery centers [1]. This has coincided with significant advances in surgical techniques, implants, and perioperative pain management. This has resulted in reduced hospital length of stay [2], making outpatient RTSA feasible. Some concerns remain about the safety of same-day discharge and the associated complication and hospital readmission rates. This review aims to explore these and summarize protocols to enhance safety. It also touches on economic implications and challenges, as well as how revision RTSA may safely be performed as an outpatient in select patients.

How is Outpatient defined?

The definition of outpatient RTSA is heterogeneously reported in the literature, making comparisons challenging. Most shoulder arthroplasty studies performed in the United States define outpatient as discharge on the day of surgery, however, this is sometimes without explicit mention of observation status [3–9]. Indeed, some ambulatory surgery center (ASC) and hospital series report outpatient arthroplasty that involves 23-hour observation, blurring strict same-day versus overnight definitions [10]. Studies using large US databases generally classify outpatient by length of stay (LOS) (0 or 1), or by claims disposition rather than distinguishing between care settings [4, 5, 8, 9]. Given its importance in risk profiling and safety, a universally agreed-on definition of outpatient surgery should be established and future studies should conform to help advance the field.

Outpatient RTSA can be performed at Hospital Outpatient Departments (HOPDs) or Ambulatory Surgery Centers (ASCs). HOPDs are located within or adjacent to hospitals, commonly with rapid access to imaging, blood products, and inpatient conversion. Indeed, many large database analyses consist of hospital-based outpatient care where high-risk patients can still be discharged the same day with acceptable safety [4, 8, 9, 11]. On the other hand, ASCs are freestanding or satellite facilities that are limited to low to moderate acuity patients, and have no on-site inpatient bed capacity. It has been well reported that ASCs show high same-day discharge (SDD) success, low complications, and large cost savings in RTSA, however they typically apply stricter medical and social exclusion criteria than HOPDs [2, 12–14]. ASC charges and reimbursement are substantially lower than HOPD and inpatient surgery, with similar 90-day readmissions and ED visit rates [15]. However, compared to inpatient RTSA, there are lower costs and readmissions for all outpatient RTSA [5].

Patient Selection

Patient selection is paramount of ensuring patient safety in outpatient RTSA. Multiple selection algorithms have been proposed and studied to identify appropriate candidates.

Medical Comorbidity Profile

A history of congestive heart failure (CHF) and significant coronary artery disease are the most consistent reasons to avoid same-day discharge or ASC care [2, 9, 13, 14]. Similarly, COPD and poorly controlled obstructive sleep apnea increase the risk of unplanned admission and readmission. COPD, in particular, is associated with a higher 30-day readmission and may warrant at least overnight monitoring [16, 17]. ASA Class of I-II and occasional well-compensated ASA III has been used for selection for ASCs [2, 10, 18], but some recent registry data showed safe same day discharge even for ASA ≥ 3 with careful selection and hospital-based infrastructure [19]. Insulin-dependent diabetes, chronic steroid use, active smoking, and bleeding disorders are associated with higher readmission and complication risk and may benefit from inpatient observation [16, 17].

Social Factors

Good candidates for outpatient RTSA include those with: independent ambulation, cognitive integrity, a reliable overnight caregiver, an appropriate social support network, and the ability to access emergency care rapidly in the case of an emergency [2, 12, 14].

Age

While chronological age alone is not a strict contraindication, older age (> 70 years) increases risk of failed same-day discharge but not necessarily of major complications when medically optimized [19]. Indeed, several outpatient RTSA series have included patients up to 85 years old with ASA I – mild III [3, 6, 20].

Procedure Indications

While the indications for RTSA continue to expand, elective indications such as cuff tear arthropathy and osteoarthritis appear to be the most amenable to an outpatient setting, given the ability to plan and optimize patients preoperatively. RTSA for fracture, bone loss, tumor and revision have generally been excluded from outpatient series, and should be performed with caution in an outpatient setting [2, 6, 8, 21].

Revision RTSA

Revision RTSA has been performed safely in an outpatient setting [7, 22], but carries additional risks, including prolonged operative time, the need for intraoperative decision making, need for intraoperative imaging, and the higher risk of neurovascular injury which may require occasional urgent access to vascular/thoracic surgery. As such, patient selection for outpatient surgery must be based on procedure specifics and complexity of revision. Suitable “lower complexity” revisions, with lower expected blood loss may include: modular component/polyethylene exchange, conversion of hemiarthroplasty/anatomic TSA to RTSA and second stage revision (removal of antibiotic spacer to RTSA). On the other hand, cases including possible infection, humerus/glenoid bony explanations, massive bone loss and custom implants would likely be better reserved for inpatient settings. Khan et al. found outpatient revision RTSA to be safe and effective with complication and reoperation rates comparable to inpatient procedures [23]. They also recommended avoiding stem extractions and cases when intraoperative specimen processing was needed, such as to diagnose infection, due to logistical challenges [23]. Methods to improve safety further may include: pre-operative CT planning, blood management (transexamic acid, readiness for transfusion), and rigorous post-discharge monitoring.

Non-medical Barriers

Practically, insurance requirements, institutional policies, operative room capacity, and surgeon preference may be important drivers even for patients who would otherwise meet ASC criteria. Indeed, some ASCs limit participation to commercially insured patients because private health plans generally provide higher facility reimbursement than Medicare or other government payers, which help offset the substantial fixed costs and overhead. Institutional protocols may additionally impose restrictions based on factors such as age, medical comorbidity, BMI, availability of postoperative support, or the need for medical or anaesthesia clearance. Operating room availability, staffing, block-time allocation, and the predictability of case duration may also influence whether a patient is scheduled in an ASC versus a hospital. Finally, surgeon-specific factors may be taken into account —including experience with outpatient RTSA, comfort with same-day discharge pathways, and preference for access to hospital-based resources.

Algorithms and Risk Tools

Several groups have developed patient selection algorithms and tools to reduce risk (Table 1). At the Campbell Clinic, age and cardiopulmonary based stratification was used to select for ASCs and this produced no cardiopulmonary events or hospital admissions in their initial series [2]. This was subsequently updated over 7 years, with less than 1% major medical complications [13]. Adapted from the hip and knee literature, Levy and colleagues found the Outpatient Arthroplasty Risk Assessment (OARA) Tool to be useful for predicting same-day discharge suitability but not for ASC-specific logistics, complications, or coding [24]. The Duke-Rush Shoulder Consortium developed a short-stay prediction model (postoperative day 0–1 discharge) in > 5400 TSA/RTSA patients, and could predict discharge by postoperative day 1 with very good accuracy using only 13 variables [25]. Other models have used demographics, co-morbidity indices, and intraoperative factors to estimate same-day discharge probability [26, 27].

Table 1.

Summary of important algorithms and tools used to assist decision making surrounding outpatient reverse shoulder arthroplasty

Study/Tool	Context & procedures	Selection strategy	Key inclusion/exclusion features	Outpatient RTSA implications
Fournier 2019 algorithm [2]	ASC TSA + RTSA (61 pts)	Algorithm driven selection based on age & cardiopulmonary comorbidities	Stratification by age, history of CAD, CHF, COPD, OSA, pulmonary hypertension; exclusion of high risk (essentially ASA IV/unstable).	Produced 0 cardiopulmonary events or admissions in ASC cohort; widely adopted/cited as template.
Jennewine 2023 (algorithm update) [13]	319 TSAs (ASC) using updated algorithm	Iterative revision of Fournier’s selection criteria	Incorporates ASA class, OSA, BMI, anticoagulation, distance from facility; tuned using 7 year complication data (0.9% major medical events).	Tailors ASC eligibility; widely adopted for modern ASC RTSA selection.
Goltz 2021 risk prediction tool [25]	5,410 shoulder arthroplasties (2,605 reverses)	Multivariable model predicting short stay (POD 0–1)	Uses Elixhauser comorbidities, demographics, intraop parameters; yields probability of short LOS.	Proxy for outpatient candidacy for TSA and RTSA combined; provides quantitative risk score.
Steinhaus 2020 feasibility model [27]	Institutional registry + NSQIP, including RTSA	Predictive modelling of suitability for same day discharge (SDD)	Younger age, higher BMI, male sex SDD probability; heart disease, anemia, narcotic use risk of adverse events.	Supports focusing on cardiac and anemia optimization before outpatient RTSA.
OARA score (Polisetty 2020) [24]	Single surgeon; 422 then 734 TSA/RTSA	Applies Outpatient Arthroplasty Risk Assessment (OARA) to shoulder	Demonstrated that higher OARA thresholds are safe for SDD in shoulder arthroplasty; threshold higher than for hip/knee.	Provides a numeric medical risk cutoff to guide SDD across anatomic and reverse cases.

Author Recommendations

In the authors’ practice, we currently implement a multidimensional preoperative assessment and shared decision-making process incorporating medical, functional, cognitive, and social factors rather than relying on a single age or comorbidity threshold. Surgical complexity, anesthesia risk, functional independence, cognitive status, postoperative support, and institutional criteria should be considered collectively, with hospital-based observation favored when concerns remain (Fig. 1).

Fig. 1.

The authors’ current framework for preoperative selection and site-of-care decision-making for outpatient reverse total shoulder arthroplasty (RTSA)

Operations and Logistics

Many components are required to be coordinated to establish a successful outpatient RTSA program, from the pre-operative workup to perioperative safety protocols, discharge criteria and post-operative care.

Pre-operative Workup

• Standardized medical clearance processes with explicit go/no-go criteria; for example stable vital signs, recent cardiac events, untreated pulmonary conditions, non-optimized anemia [2, 13, 14].

• Use of risk scores (ASA, OARA, Charleston/Elixhauser, specific cardiopulmonary flags) to route patients to ASC vs. HOPD vs. inpatient [24–27].

• Optimization of anemia, diabetes, and cardiopulmonary status is particularly important for ASCs where transfusion or complex resuscitation is limited [2, 13, 14].

Patient Education and Logistics

Clear communication preoperatively can substantially avoid confusion and complications. This includes detailed pre-operative counselling on the expected pain course, block resolution, sling usage, home preparation, activity restrictions, warning signs (hematoma, common dyspnea, common neurological deficits), and escalation pathways in the event of a problem [2, 10, 12, 14, 28]. From a logistical point of view, confirmation of transportation and an overnight caregiver, as well as a pre-scheduled phone call on post-operative day 0 and/or day 1, are consistently associated with low failed discharge and low emergency department visit rates [10, 12, 28].

Anesthesia and Analgesia

Regional anesthesia with use of an interscalene nerve block, either single shot or catheter-based, is considered standard of care [2, 3, 6, 12]. Periarticular injection with liposomal bupivacaine alone without interscalene nerve block has also been found to be effective in the ASC setting [12]. In terms of general anesthesia, low-opioid balanced or total intravenous anesthesia techniques emphasizing early emergence, low post-operative nausea and vomiting, and hemodynamic stability are very effective for outpatient care. Multimodal post-operative pain protocols including acetaminophen, NSAIDs or COX-2 inhibitors, and limited opioids are standard and crucial for managing rebound pain after block resolution [2, 3, 12, 14]. Dexamethasone intraoperatively combined with a methylprednisolone tapering dose pack, has also been shown to be effective in a randomized control trial [29].

Infection and VTE Prophylaxis

A single pre-operative IV dose without 24-hour post-operative antibiotics is standard in outpatient settings [30]. For moderate-risk patients, mechanical VTE prophylaxis and aspirin-based chemoprophylaxis are standard, and in higher-risk patients, such as those with prior VTE and hypercoagulable states, are often routed to inpatient or HOPD care. There is a low rate of VTE in outpatient cohorts [8, 14].

Discharge Criteria

Standard discharge criteria include stable vitals, adequate pain control with oral medications, ability to void, intact neurovascular exam, caregiver present, and a clear understanding of instructions [2, 6, 12, 28]. Some European programs use a formal scoring systems e.g. PADSS > 9/10, combined with pain thresholds [18].

Clinical Outcomes and Complications

Across multiple studies, there is no significant difference between the clinical outcomes after outpatient RTSA compared to inpatient RTSA at 1–2 years [3, 6]. Indeed patient satisfaction appears to be no less after outpatient shoulder arthroplasty [13, 21, 31, 32]. There also appears to be no increase in total or surgical complications, and in some cases lower medical complication rates for outpatient cases even after risk adjustment [33]. Additionally, 90-day complication rates typically are very low, with readmissions around 0–3.7%, which is comparable to inpatient rates [34]. United Kingdom National Joint Registry data also indicates similar revision rates for day cases versus non-day cases in RTSA, at 7 year follow-up [35].

Collectively, outpatient-specific concerns are manageable with structured education, phone triage, and clear escalation plans and do not seem to translate into increased serious adverse events when selection is appropriate. Specifically, pain and rebound pain after interscalene block resolution, appears to be the major driver of unplanned calls and ED/urgent care visits. Patient counselling, pre-emptive oral analgesia prior to this and 24-hour phone support are helpful strategies [3, 12, 34]. Additionally swelling, bruising, and hematoma/seroma frequently cause patient concern but can be managed well with early phone contact, clinical follow-up and reassurance.

Economic Implications

Cost

Performing RTSA in ASCs or HOPDs generates substantially lower costs compared to inpatient care. In a multi-state database study, charges for combined outpatient shoulder arthroplasty were 40% lower than inpatient, and when stratified, charges were $63,000 for inpatient, $56,000 for HOPD, and $32,000 for ASC cases [15]. Similarly, in a managed care setting, outpatient shoulder arthroplasty substantially reduced procedure expenses by 20–30%, with implants comprising up to 63% of the outpatient RTSA cost [36]. As such, with appropriate patient selection and a perioperative infrastructure, performing RTSA in ASCs or HOPDs would potentially generate large cost savings, reserving hospital-based outpatient or inpatient settings for higher-risk RTSA candidates more appropriate to this site of service.

Reimbursement

In January 2021, CMS removed shoulder arthroplasty from the inpatient-only list and allowed payment under the hospital outpatient prospective payment system for RTSA [4]. Sharp increases in outpatient volumes for Medicare fee-for-service were subsequently noted; 90-day complications, common readmissions, or mortality were similar in those undergoing outpatient RTSA [4]. The inclusion of shoulder arthroplasty on the ASC Covered Procedures List permits Medicare reimbursement for RTSA performed in ASCs. Of note, surgeon professional fees are generally not different between sites, while facility fees typically differ substantially between HOPD and ASCs [37].

Future Work and Challenges

Despite major leaps in delivering outpatient RTSA in the last decade, some challenges remain. When reporting data in outpatient RTSA, there needs to be standardized nomenclature in documenting the resources available at each individual care setting and outcomes need to be stratified by ASC vs. HOPD. Additionally, outpatient revision RTSA is fraught with challenges, and more evidence is needed to identify specific procedural steps, as well as patient factors that are high risk that should be avoided in the outpatient setting.

Conclusion

Outpatient RTSA can be safe and effective with careful patient selection. Systems to help facilitate this include: using a formal algorithm or risk score, implementing structured preoperative and perioperative pathways with patient education, regional anesthesia, multimodal pain management, clear discharge criteria, and proactive early follow-up. High-risk or borderline candidates can often undergo RTSA with same-day discharge in hospital outpatient settings but with immediate access to inpatient care as necessary. There are considerable cost savings for outpatient RTSA that do not compromise outcomes or safety. Policy-wide changes will continue to accelerate migration of suitable RTSA cases to outpatient settings.

Key References

• Jennewine BR, Throckmorton TW, Pierce AS, Miller AH, 2nd, Azar AT, Sharp CD, et al. Patient-selection algorithm for outpatient shoulder arthroplasty in ambulatory surgery center: a retrospective update. Journal of shoulder and elbow surgery/American Shoulder and Elbow Surgeons [et al]. 2024;33(4):900-7. doi: https://doi.org/10.1016/j.jse.2023.07.018.

  • ○ An updated algorithm including 319 total shoulder arthroplasties that has been widely adopted for modern ASC RTSA patient selection.
• Goltz DE, Burnett RA, Levin JM, Wickman JR, Belay ES, Howell CB, et al. Appropriate patient selection for outpatient shoulder arthroplasty: a risk prediction tool. Journal of shoulder and elbow surgery/American Shoulder and Elbow Surgeons [et al]. 2022;31(2):235 − 44. doi: https://doi.org/10.1016/j.jse.2021.08.023.

  • ○ Provides a quantitative risk score for outpatient candidacy for TSA and RTSA using a cohort of 5,410 arthroplasties.
• Khan AA, Hussain ZB, Lew RM, Shen AC, Kurowicki J, Forsythe B, et al. Outpatient revision shoulder arthroplasty can Be safe and effective: a matched analysis. J Shoulder Elb Arthroplast. 2026;10(3):100,037. doi: https://doi.org/10.1016/j.jsea.2026.100037.

  • ○ A recent article reporting that outpatient revision RTSA can be safe and effective with complication and reoperation rates comparable to inpatient procedures, and recommended avoiding stem extractions and cases when intraoperative specimen processing was needed.

Author Contributions

Z.B.H., T.W.T and G.E.G wrote the main manuscript text and prepared tables. All authors reviewed the manuscript.

Funding

No funding was disclosed by the authors.

Data Availability

No datasets were generated or analysed during the current study.

Declarations

Thomas W. Throckmorton has received royalties from Exactech, Inc., Saunders/Mosby-Elsevier, Responsive Arthroscopy and Zimmer; stock or stock options from Exactech, Inc., Gilead, Responsive Arthroscopy, and Shoulder JAM; consulting fees from Osteocentrics, Pacira and Zimmer Biomet; and financial or material support from Saunders/Mosby-Elsevier.

Grant E. Garrigues reports the following disclosures: Academic Orthopaedic Consortium: Board or committee member; Aevumed: Stock or stock options; American Shoulder and Elbow Surgeons: Board or committee member; Arthroscopy Association of North America: Board or committee member; CultivateMD: Stock or stock options; DJ Orthopaedics: IP royalties; other financial or material support; paid consultant; paid presenter or speaker; Elsevier: Publishing royalties, financial or material support; Genesys: Stock or stock options; Journal of Shoulder and Elbow Surgery: Editorial or governing board; Mitek: paid consultant; Patient IQ: Stock or stock options; Restor3d: Paid consultant; stock or stock options; ROM 3: Stock or stock options; Sparta Biopharma: Stock or stock options; Tornier: IP royalties; paid consultant.

Competing interests

The authors declare no competing interests.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.