Pay Attention to Trends
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By: J. Gabriel Horneff III
Published: 12/6/2022
Same-day shoulder replacements are very much in their infancy, but the migration from inpatient hospitals to ambulatory ORs is moving fast. In fact, the rate at which shoulder replacements are increasing is higher than total knees and hips. This industry-wide relocation will only speed up — CMS is whittling its inpatient-only list and shoulder arthroplasty is on tap for removal. At Penn Medicine, where I practice, about 300 to 400 total shoulders are performed each year. Many are still done inpatient, but it's only a matter of time before these procedures make the move to outpatient facilities. Focusing on these essential elements of shoulder replacement success will position your facility to capture case volumes that are certain to increase in the coming years.
Patients should be reclined at approximately 45 degrees to offload pressure on the sciatic nerve and specialized attachments are needed to stabilize the head, including a foam mask that supports the patient during the entirely of the procedure. Attachment are also available that allow surgeons to position the arm in a way that provides optimal access to the surgical site.
The 6cm to 8cm incision is made with dissection through the deltopectoral total interval, down to the fascia and under the conjoint tendon. The subscapularis muscle is approached and removed from the humerus with either a peel or osteotomy. The shoulder is then dislocated, and the replacement performed. Implants are typically placed based on pre-op planning and surgeon experience. Cases range from one to two-and-a-half hours, depending on the patient and the severity of their arthritis.
Shoulder replacement patients should be sent home with a clear understanding of physical therapy requirements and post-op care instructions. Educational videos are helpful, as is a post-operative assessment by an occupational or physical therapist. Additionally, take-home materials should include detailed information that address the following issues:
I use an open shoulder tray (instrumentation is dependent on the specific implant used), an oscillating saw and a drill. Patients receive pre- and post-operative doses of tranexamic acid, which minimizes the amount of blood loss. Patients who shouldn't receive it include those with stroke histories or a clotting disease. The incision is closed with absorbable sutures that are attached with a clear dermal glue dressing, which patients never have to clean or change. The less responsibility you give them after surgery, the better off they are.
The biggest issue shoulder patients experience after surgery is finding a comfortable position in which to sleep. During the initial days of recovery, they should try to sleep in a recliner or propped up in bed with pillows, rather than lying flat or on their side. Instruct patients to use ice at 20-minute intervals to control pain and swelling for the first two to three days post-op. I tell patients that a frozen bag of vegetables is a nice, light option to drape over their shoulder. Include a medication chart — a list of prescribed medications and when they should be taken — for patients to refer to if they're given a five-day course of opioids for breakthrough pain. Patients should be encouraged to wait until evenings to take opioids in order to maximize their analgesic benefits for sleeping. After the five-day opioid prescription, non-narcotic medications are usually effective in managing post-op pain.
More patients are inquiring about having their procedures done in outpatient facilities because of fears of contracting COVID-19, but these surgeries were heading out of main hospital ORs before the pandemic hit. Patients who had a shoulder replacement done 10 or more years ago could be in the hospital for three days. Post-op stays were eventually reduced to one night. Now we realize patients are at less of a risk for blood clots, infection and other complications if they're able to recover at home. Knee and hip replacements led the charge into the outpatient arena, but shoulders are following suit and gaining momentum. Follow these steps and you can make them the fastest growing component of your orthopedic service line. OSM
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