Commentary

Wilson and co-authors have shown that operative time is an important factor in determining early postoperative complications following total shoulder arthroplasty. However, their analysis provides an enhanced understanding of the factors that are responsible for this observation. The large database of over 10,000 patients enhances the validity of the conclusions. They emphasize that operative time “represents a surgeon-specific potentially modifiable risk factor,” while other risk factors associated with increased complications after TSA-like ASA classification, increasing body mass index, preoperative anemia, steroid use and others – are not modifiable. I would take some exception to this statement. What can be modified with respect to some of these factors is the surgeon’s decision whether to offer total shoulder arthroplasty as a treatment option. Asking patients to decrease their body mass index, correcting preoperative anemia, correcting hypoalbuminemia, discontinuing smoking or other comorbidities like hemoglobin A1C level are indeed modifiable if the surgeon tries to effect the change before proceeding with surgery. This is an important point to be emphasized since, as surgeons, we ultimately determine the indications for surgery. Patient selection has been shown over and over again to be an important factor in determining postoperative complications and outcomes.

This study defines the specific factors that result in increased rates of postoperative complications, including anemia requiring transfusions, peripheral nerve injury and urinary tract infection. The authors clearly documented what experienced arthroplasty surgeons already knew: that young patients, muscular males and those with elevated BMI, require longer operative time. It was interesting to note that the operative time for patients with a BMI above 35 and/or above 40 were essentially the same. The documentation of complications was limited to the first 30 days postoperatively. As a result, the issue of infection and its relation to prolonged operative time could not be fully evaluated. This is certainly an association that has been documented in other settings.

Although operative time may be “modifiable,” the ease with which it is modified is an entirely different matter. The authors make important suggestions as to how this can be addressed by increasing OR efficiency and having experienced teams. Of course, the issue of surgeon experience is also an important consideration. One factor that was not evaluated by the authors is whether the type of anesthesia was associated with different rates of complications. The use of general anesthesia vs. regional anesthesia may have an impact on postoperative complications or, at the very least, is a variable that could be controlled for in the analysis. The ultimate question to answer is “Is there an operative time range within which complications can be minimized?” Although this paper does not specifically answer that question, it does provide information to lead us in the right direction.