Predictors of Return to Emergency Department and Readmission Following Primary Elective Total Shoulder Arthroplasty

Document Type : RESEARCH PAPER


1 Albert Einstein College of Medicine, Bronx, New York, United States

2 Albert Einstein College of Medicine - Department of Epidemiology & Population Health, Bronx, New York, United States

3 Montefiore Medical Center - Department of Orthopaedic Surgery, Bronx, New York, United States



Objectives: Returns to the Emergency Department (ED) and unplanned readmissions within 90 days of 
shoulder arthroplasty represent a significant financial burden to healthcare systems. Identifying the 
reasons and risk factors could potentially reduce their prevalence. 
Methods: A retrospective review of primary anatomic (aTSA) and reverse shoulder arthroplasty (rTSA) cases from 
January 2016 through August 2023 was performed. Demographic patient and surgical data, including age, diagnosis 
of anxiety or depression, body mass index (BMI), smoking status, age-adjusted Charlson Comorbidity Index (ACCI), 
modified 5-item fragility index (mFI-5), and hospital length of stay (LOS) was collected. Patient visits to the ED within 
12 months prior to surgery were recorded. Predictors for return to the ED within 90 days postoperatively and any 
readmissions were determined. 
Results: There were 338 cases (167 aTSA and 171 rTSA), of which 225 (67%) were women. Patients with anxiety 
(OR=2.44, 95% CI 1.11–5.33; P=0.026), surgical postoperative complications (OR=3.22, 95% CI 1.36–7.58; 
P=0.008), ED visit within 3 months prior to surgery (OR=3.80, 95% CI 1.71–8.45; P=0.001), ED visit 3 to 6 months 
prior to surgery (OR=2.60, 95% CI 1.12–6.05; P=0.027), and ED visit 6 to 12 months prior to surgery (OR=2.12, 
95% CI 1.02–4.41; P=0.045) were more likely to have ED visit within 90 days postoperatively. Patients with prior 
ipsilateral shoulder surgery (OR=3.32, 95% CI 1.21–9.09; P=0.02), surgical postoperative complications (OR=13.92, 
95% CI 5.04–38.42; P<0.001), an ED visit within 3 to 6 months preoperatively (OR=8.47, 95% CI 2.84–25.27; 
P<0.001), and an mFI-5 ≥2 (OR=3.66, 95% CI 1.35–9.91; P=0.011) were more likely to be readmitted within 90 
Conclusion: Patients who present to the ED within 12 months prior to shoulder arthroplasty, those with anxiety, 
those with surgical complications and those with higher fragility should be monitored closely during the early 
postoperative period to minimize returns to the ED and/or unplanned readmissions. 
 Level of evidence: III


Main Subjects

1. Wagner ER, Farley KX, Higgins I, Wilson JM, Daly CA, 
Gottschalk MB. The incidence of shoulder arthroplasty: rise 
and future projections compared with hip and knee 
arthroplasty. J Shoulder Elbow Surg. 2020; 29(12):2601-
2609. doi: 10.1016/j.jse.2020.03.049.
2. Dillon MT, Chan PH, Inacio MCS, Singh A, Yian EH, Navarro RA. 
Yearly trends in elective shoulder arthroplasty, 2005-2013. 
Arthritis Care Res (Hoboken). 2017; 69(10):1574-1581. doi: 
3. Best MJ, Aziz KT, Wilckens JH, McFarland EG, Srikumaran U. 
Increasing incidence of primary reverse and anatomic total 
shoulder arthroplasty in the United States. J Shoulder Elbow 
Surg. 2021; 30(5):1159-1166. doi: 10.1016/j.jse.2020.08.010.
4. Gowd AK, Agarwalla A, Beck EC, Rosas S, Waterman BR, Romeo 
AA, Liu JN. Prediction of total healthcare cost following total 
shoulder arthroplasty utilizing machine learning. J Shoulder 
Elbow Surg. 2022; 31(12):2449-2456. doi: 
5. Werner BC, Bustos FP, Gean RP, Deasey MJ. Emergency 
department visits in the year prior to total shoulder 
arthroplasty as a risk factor for postoperative emergency 
department visits. HSS J. 2021; 17(2):200-206. doi: 
6. Walters JD, Walsh RN, Smith RA, Brolin TJ, Azar FM, 
Throckmorton TW. Bundled payment plans are associated 
with notable cost savings for ambulatory outpatient total shoulder arthroplasty. J Am Acad Orthop Surg. 2020; 
28(19):795-801. doi: 10.5435/JAAOS-D-19-00441.
7. Pezzulo JD, Farronato DM, Rondon AJ, Sherman MB, Getz CL, 
Davis DE. Predicting hospital readmissions after total 
shoulder arthroplasty within a bundled payment cohort. J Am 
Acad Orthop Surg. 2023; 31(4):199-204. doi: 10.5435/JAAOSD-22-00449.
8. Bosco JA, Harty JH, Iorio R. Bundled Payment Arrangements: 
Keys to Success. J Am Acad Orthop Surg. 2018; 26(23):817-822. 
doi: 10.5435/JAAOS-D-17-00022.
9. Cvetanovich GL, Bohl DD, Frank RM, Verma NN, Cole BJ, 
Nicholson GP, Romeo AA. Reasons for readmission following 
primary total shoulder arthroplasty. Am J Orthop (Belle Mead 
NJ). 2018; 47(7). doi: 10.12788/ajo.2018.0053.
10. Chung AS, Makovicka JL, Hydrick T, Scott KL, Arvind V, 
Hattrup SJ. Analysis of 90-day readmissions after total 
shoulder arthroplasty. Orthop J Sports Med. 2019; 
7(9):2325967119868964. doi: 
11. Scott KL, Chung AS, Makovicka JL, Pena AJ, Arvind V, Hattrup 
SJ. Ninety-day readmissions following reverse total shoulder 
arthroplasty. JSES Open Access. 2019; 3(1):54-58. doi: 
12. Holzgrefe RE, Wilson JM, Staley CA, Anderson TL, Wagner ER, 
Gottschalk MB. Modified frailty index is an effective riskstratification tool for patients undergoing total shoulder 
arthroplasty. J Shoulder Elbow Surg. 2019; 28(7):1232-1240. 
doi: 10.1016/j.jse.2018.12.004.
13. Traven SA, McGurk KM, Reeves RA, Walton ZJ, Woolf SK, Slone 
HS. Modified frailty index predicts medical complications, 
length of stay, readmission, and mortality following total 
shoulder arthroplasty. J Shoulder Elbow Surg. 2019; 
28(10):1854-1860. doi: 10.1016/j.jse.2019.03.009. 
14. Xu S, Baker DK, Woods JC, Brabston EW 3rd, Ponce BA. Risk 
factors for early readmission after anatomical or reverse total 
shoulder arthroplasty. Am J Orthop (Belle Mead NJ). 2016; 
45(6):E386-E392. PMID: 27737300.
15. Kind AJH, Buckingham W. Making neighborhood 
disadvantage metrics accessible: the neighborhood atlas. N 
Engl J Med. 2018:378:2456-2458. doi: 
16. About the Neighborhood Atlas®.University of Wisconsin 
School of Medicine Public Health. Area Deprivation Index 
Datasets. Available at: 
Accessed December 15, 2023.
17. Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a 
combined comorbidity index. J Clin Epidemiol .1994; 
18. Chowdhury MZI, Turin TC. Variable selection strategies and 
its importance in clinical prediction modelling. FAM Med 
Community Health. 2020; 8(1):e000262. doi: 10.1136/fmch2019-000262. 
19. Young GP, Wagner MB, Kellermann AL, Ellis J, Bouley D. 
Ambulatory visits to hospital emergency departments. 
Patterns and reasons for use. 24 Hours in the ED Study 
Group. JAMA. 1996; 276(6):460-465. doi: 
20. Vinton DT, Capp R, Rooks SP, Abbott JT, Ginde AA. Frequent 
users of US emergency departments: characteristics and 
opportunities for intervention. Emerg Med J. 2014; 
31(7):526-532. doi: 10.1136/emermed-2013-202407.
21. Kuhlmann NA, Franovic S, Burdick GB, et al. Shoulder 
arthroplasty outcomes in patients with major depressive 
disorder or generalized anxiety disorder. Seminars in 
Arthroplasty: JSES. 2023; 33(4):722-726. doi: 
22. Lu Y, Oeding JF, Parkes C, Patel H, Berlinberg E, Forsythe B, 
Camp CL, Sanchez-Sotelo J. Incidence and 30- and 90-day 
readmission rates after primary shoulder arthroplasty in the 
United States: an analysis using the National Readmissions 
Database. J Shoulder Elbow Surg. 2023; 32(6):1174-1184. 
doi: 10.1016/j.jse.2022.12.003. 
23. Malik AT, Morris J, Bishop JY, Neviaser AS, Khan SN, 
Cvetanovich GL. Undergoing an arthroscopic procedure prior 
to shoulder arthroplasty is associated with greater risk of 
prosthetic joint infection. Arthroscopy. 2021; 37(6):1748-
1754.e1. doi: 10.1016/j.arthro.2021.01.013.