Tapping Into the Potential of Total Joints

St. Cloud (Minn.) Surgery Center underwent a recent renovation to accommodate a steady increase in demand for outpatient arthroplasties. The center expanded its sterile processing department by 8,000 square feet and built two 650-square-foot operating rooms. Last year, its surgeons completed close to 1,000 hip and knee replacements. Orthopedic surgeon Joseph Nessler, MD — who performs about eight hip or knee replacements on a typical day, plus several complex arthroscopies — says the facility is seeing a 15% to 20% growth in case volumes and predicts the number of joint replacements will blow past last year’s figure. It’s clear that business is booming in outpatient total joints, and facilities like St. Cloud that want to add the procedures or expand their current caseload should plan on increasing the size of their ORs as well as their storage and instrument reprocessing capacities, according to Dr. Nessler.

Larger ORs give the surgical team more room to move and decrease the density of people around the sterile field, factors Dr. Nessler thinks are important to improve case efficiencies and reduce infection risks.

“The whole design perspective has changed,” he says. “Many older ASCs have smaller ORs that can’t handle technology-intensive procedures. Rooms in new ortho facilities are being built bigger to accommodate complex cases such as total joints.”

Dr. Nessler says high-volume orthopedic facilities must have the ability to reprocess instrument trays in a timely fashion several times throughout a day. He also points to the importance of building enough PACU bays to accommodate the extended recoveries of total joint patients before they’re ready to be discharged.

“It’s clear joint replacements can be performed in ASCs, but facilities have to plan for being able to perform more than a handful of cases per day as demand continues to increase,” says Dr. Nessler.

Forward-thinking surgery centers are adding robotics to help surgeons perform joint replacements with improved accuracy and repeatability. The latest platforms don’t take up as much floor space and reduce the number of instrument trays needed to perform the procedures, according to Jess H. Lonner, MD, a joint replacement specialist at Rothman Orthopaedic Institute and a professor of orthopedic surgery at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.

Facilities have to plan for being able to perform more than a handful of cases per day as demand continues to increase.
— Joseph Nessler, MD

Dr. Lonner has been using robotic assistance to perform knee and hip replacements since 2008, making him one of the earliest adopters of the technology and a continued supporter of using it to perform more precise procedures that can lead to improved outcomes. “The robots made a decade ago were very expensive, making them cost prohibitive for surgery centers,” says Dr. Lonner. “Today’s versions don’t require the same level of capital investment, which is increasing their market penetration and making them more accessible to ASCs.”

Joint replacement surgeons are at increased risk of suffering significant musculoskeletal injuries, according to Dr. Lonner. At the very least, he says, the physical nature of replacing joints causes chronic aches and pains that can warrant the use of opioids and even shorten careers. Robotic assistance improves surgeon ergonomics, no small factor as case volumes continue to climb.

Does the technology have the potential to extend the careers of joint replacement specialists? “That’s the hope,” says Dr. Lonner. “Some robots can reduce the stress and strain of surgery, improve the ergonomics of the back, shoulders and neck, and therefore reduce the risks of musculoskeletal pain and serious injury.”

He also believes robotic assistance enhances the outcomes of total and partial knee replacements, although he concedes the technology isn’t necessarily helping to move more cases to the outpatient setting — effective pain control methods, enhanced recovery protocols and setting patient expectations are more significant factors for the continuing shift of cases.

Dr. Lonner points out that not all patients are suitable candidates to have their joints replaced in surgery centers — those with significant comorbidities should still undergo the procedures in a hospital setting — but the same protocols that prepare patients for discharge after an overnight stay can work in the same-day setting. He also says the pandemic has been a major catalyst for a more rapid expansion of performing joint replacements in ASCs. Even surgeons who had been hesitant to move their cases to outpatient ORs have been forced to do so during the pandemic — and in some cases saw for the first time not only that their patients did exceedingly well and the protocols worked, but that they preferred operating in the specialized setting.

“Most surgeons over the past three years have transitioned from keeping joint replacement patients hospitalized for conventional three-day postoperative stays to admitting patients overnight for observation,” says Dr. Lonner. “The exact same protocols translate really well to surgery centers. The only thing that changes is the messaging to patients — they need to be prepared and buy into going home after their procedures. There will be an increase in case volumes as more surgeons are exposed to the possibility of performing total joint replacements in surgery centers and see that patients can be safely discharged on the day of surgery.” OSM

Note: This three-part article series is supported by Stryker.