Although the overall rate of anesthetic complications was low (1.0%), 61.6% of the total anesthetic complications were attributed to nerve block-related issues (Figure 4). There were no differences in the rate of anesthetic complications by patient sex (P = 0.14).
The main findings of this analysis are that the rate of surgical, medical, and anesthetic complications are 7.9%, 2.2%, and 1.0%, respectively. Although arthroscopic surgeries are minimally invasive and most cases are performed in the outpatient setting, the overall rate of complications is not insignificant. The rate of surgical complications is also higher than that reported in the literature.6,7 Patients at increased risk of complications after shoulder arthroscopy should be identified preoperatively to improve outcomes and reduce costs.5 Moreover, patients should be appropriately counseled regarding the risk of complications.
Using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database for the years 2005 to 2011, Shields et al7 reported a 1% complication rate after shoulder arthroscopy. The authors reported return to operating room and superficial surgical site infection were the most common major and minor complications, respectively.7 In another study of over 7,000 patients, using the NSQIP database, Rubenstein et al6 similarly reported an overall adverse event rate of 1.6%. However, the NSQIP database is a voluntary program in which participating hospitals collect and submit limited data (20% of cases in high-volume participating centers). Moreover, whereas Shields et al7 and Rubenstein et al6 reported complications that occurred within 30 days after surgery, the ABOS database contains information from every case performed during the entire collection period. Whereas stiffness/arthrofibrosis was the most common surgical complication identified in the current study, Shields et al7 noted that stiffness is a clinical outcome that cannot be assessed using a database which keeps track of early complications. Thus, it is difficult to make a direct comparison as the ABOS data represent a more complete and longitudinal database.
Another important consideration regarding the higher complication rates is that ABOS applicants are generally less experienced surgeons than their board-certified counterparts. This database represents information gathered from surgeons who are early in their independent careers and should not be seen as generalizable to all surgeons. The “learning curve” concept in orthopaedic surgery and more specifically in arthroscopic procedures has been well documented.9,13,14 Improved clinical and radiographic outcomes, decreased operative time, and lower complication rates have been associated with higher surgeon experience.9,15 A surgeon who is in the early phase of practice is unlikely to have the same clinical acumen, indication for surgery, or task efficiency in the operating room. Patient outcomes may reflect clinical skills of the surgeon, which is developed through practice, experience, knowledge, and continuous critical analysis acquired in-training as well as through independent practice.16 Therefore, although the complications rates in this database may be higher than what is quoted in the literature, it is possible that the results of these surgeons may normalize with experience and increased proficiency.
There was a significant variation in the surgical complication rate among different arthroscopic shoulder procedures, ranging from 5.4% for labral repair to 10.3% for rotator cuff repair and biceps tenodesis. Erickson et al17 reported significantly higher revision surgery rates at 6 months and 1 year in patients who underwent rotator cuff repair and concomitant biceps tenodesis, compared with rotator cuff repair alone. Concomitant rotator cuff repair and labral surgery had higher complications than either of the procedures had in isolation. Predictably, increasing complexity and added steps in cases resulted in higher complication rates.
Similarly to a previous study analyzing the ABOS database and rates of complication,12 the present study also noted significantly higher complication rates among surgeons with fellowship training compared with those without (8.8% versus 7.4%, respectively). This disparity may be explained by the potential differences in the complexity of cases (ie, revision case, massive rotator cuff tear, instability with more bone loss). However, like in the previous study, without patient-specific data for the 27,072 procedures, a multivariate analysis to determine whether case complexity played a factor in observed differences between fellowship-trained and untrained physicians cannot be determined. It may also represent differences in threshold for identifying and reporting surgical complications.
In a review of 9,410 cases also obtained through the NSQIP database, Martin et al18 reported no difference in complications between men or women after shoulder arthroscopy. On the contrary, Shields et al19 reported significantly higher complications in women after shoulder surgery. Whereas two previous studies combined and reported on all types of complications, the results from the current ABOS database, looking specifically at surgical complications, indicate that women had a higher rate than men. The findings are not unexpected as stiffness and persistent pain were the most common surgical complications in this study. The results of this study confirms previous observations that reported a higher rate of stiffness and pain in women after surgery.20-22 Women tend to report more stiffness as women tend to have a high level of difficulty in lifestyle domains such as styling hair and dressing or undressing. Moreover, Razmjou et al21 reported that emotionally, female patients have more difficulty than men. Others have attributed these differences to overall difference in symptom perception between genders.23
The overall reported rate of medical complications after surgery was 2.2%. Complications ranged from 0.3% for venothromboembolism (pulmonary embolism and deep vein thrombosis) to 0.04% for cerebrovascular accidents. The ABOS database may represent an underestimate of the true medical complication rate because of the self-reporting process by orthopaedic surgeons rather than medical physicians. Nevertheless, a low rate of medical complications suggest that surgeons appropriately indicated patients who could withstand an arthroscopic procedure, for elective, quality-of-life-improving surgery.
Despite an overall anesthetic complication rate of 1.0%, nerve block-related issues made up a significant proportion of the complication (61.6%). Interscalene brachial plexus blocks are an effective anesthetic and analgesic method after arthroscopic shoulder surgery. Its use in outpatient surgery has resulted in earlier discharge, reduced narcotic usage, and increased patient satisfaction.24-26 Although complications after brachial plexus blocks are rare, devastating complications have been reported such as hemodynamic instability, respiratory depression, cardiac arrest, pneumothorax, and permanent nerve injury.25 Whereas ultrasound-guided injections are becoming standard of care and can minimize inaccurate injections, the less experienced anesthesiologists and community hospitals have been associated with increased complications.2,27 In contrast, in a review of over 15,000 cases of shoulder arthroscopy, performed in the beach chair position with an interscalene nerve block, over an 11-year period at a high-volume university setting ambulatory surgical center, the total rate of adverse events was 0.37%.28 Among this group of experienced anesthesiologists, only five nerve-related injuries were reported.
This study has limitations that are inherent to studies analyzing registries and databases. The data used in this study are self-reported by the ABOS applicants. Unlike figures such as revision surgery and readmission, which are absolute, candidate surgeons may have differing definitions or thresholds to classify varying degrees of stiffness as a complication. The same is also true for patient-reported outcomes such as persistent pain. No validated functional outcome measures or orthopaedic-specific parameters such as range of motion or pain scale are available in this database. Owing to a lack of strict, uniform definitions and criteria, candidates may have under- or overreported their complications. Additionally, specific details about the procedures and on why patients were readmitted or underwent revision surgery were unavailable. Another weakness of this study is that we did not analyze specific factors that increased the risk of complication for each category of shoulder procedure—as it was not the aim of this study. Additionally, type of anesthesia, surgical positioning, and anesthesiologist training or experience were not recorded; therefore, these factors were not investigated as potential predictors of outcome. Lastly, the length of time during which complications were reported is variable. For example, if a case was performed at the beginning of the collection period, the complication collection time would be 7 months compared with a case performed at the end of the period where collection time would be 30 days. As a result, in this database, complications that may have occurred outside the collection period would not have been accounted. Results of this study should be interpreted and used with caution. This study reports on outcomes of relatively novice surgeons. With increasing emphasis on bundled cost of care and hospitals facing responsibility for related costs, treatment of high-risk patients could be rationed by providers.5 Despite limitations of registries, such databases with high compliance and large numbers can provide comprehensive data on orthopaedic procedures and their outcomes, which may improve patient expectations and surgical practice.
The overall self-reported surgical complication rate for arthroscopic shoulder procedures was 7.9%, which is higher than the rates reported in the literature. The most common complications are stiffness and residual pain. Although the rate of anesthetic complications is low (1.0%), adverse events related to nerve blocks made up most of the overall anesthetic-related complications.
The authors would like to thank American Board of Orthopaedic Surgery for providing the data. The authors acknowledge John Harrast, PhD, and Clair Smith, MS, for their assistance with data analysis.
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Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons
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