Keys to Success in Shoulder Replacements

The origin story of total shoulders moving to outpatient ORs begins with sports medicine surgeons, who performed complex rotator-cuff repairs in the same-day setting. The procedures took between one to two hours, and patients recovered for at least two hours before discharge. “It’s a high-resource and demanding procedure,” says Anthony Romeo, MD, a shoulder and elbow specialist who practices in Chicago. “Surgeons at my practice realized it would take about the same time — or maybe even less — to perform a shoulder replacement, and the recovery time for patients would be similar.”

In the U.S., close to 800,000 total knee replacements and about 600,000 total hips are performed each year. Dr. Romeo says surgeons perform close to 200,000 shoulder replacements annually. “It’s a smaller volume, but case numbers have increased significantly over the past 10 to 15 years because of innovative technology and new techniques that are making the procedures more effective,” he adds.

The data and literature suggest the number of primary shoulder arthroplasties is increasing exponentially due to the aging population and the growing number of fellowship-trained shoulder reconstruction specialists who are entering the field, according to Michael Khazzam, MD, an associate professor of orthopedic surgery at UT Southwestern Medical Center in Dallas. Even though Dr. Khazzam performs shoulder replacements in the hospital setting, 95% of his patients are discharged the day of surgery. “The majority of my cases are outpatient, and that’s a trend across the nation,” he says. “The pendulum has shifted significantly in that direction.” Capitalizing on that trend and setting your facility up for success in shoulder replacement surgery demands focusing on these key elements: 

• Patient selection. The first and perhaps most important step is developing a standardized approach to identifying appropriate candidates for surgery. Dr. Romeo suggests prioritizing patients who have a BMI under 40 and are without uncontrolled comorbidities, particularly diabetes with an AIC of greater than 8 and underlying cardiac issues. Advanced age isn’t typically a limiting factor, according to Dr. Romeo. “The age cutoff was reevaluated during the pandemic,” says Dr. Romeo. “When cases were moved out of hospitals to outpatient facilities, surgeons realized patients in their 70s were healthy enough to tolerate the procedure and did quite well.”

Dr. Romeo says demand for the procedure among younger patients has increased in recent years — he performs most shoulder replacements on patients in their mid-60s — thanks to newer implants and evolving surgical techniques that are extending the expected lifespan of the hardware past 10 years, which creates opportunity to immediately improve a patient’s quality of life without needing to redo the procedure several times as they age.

• Evolving techniques. Most current implants are placed with a press-fit technique and without the use of cement. The latest implants are also designed to match the natural function of the joint, which helps patients move their shoulder sooner and more effectively after surgery. “Closely matching the implant to the patient’s natural anatomy improves the joint’s stability and significantly increases the longevity of the implant,” says Dr. Romeo.

During anatomical replacements, surgeons attempt to place the implant’s humeral head in the same center of rotation of the patient’s natural shoulder. “The glenoid has a six times increased chance of survival over 10 years when the humeral head is properly sized and positioned,” says Dr. Romeo. “Being more anatomic and more aligned with the structures in and around the shoulder has led to much greater longevity of the implants.”

The reverse shoulder replacement is emerging as a viable surgical option in outpatient shoulders, according to Dr. Romeo. “Surgeons who perform reverse replacements on a routine basis can complete them in about an hour,” says Dr. Romeo. “Impressively, long-term outcomes studies show 80% or more of the implants are functioning 20 years after they’re placed. Implant longevity has been a focus of hip- and knee-replacement specialists for years. Now we’re seeing it become more of an emphasis in shoulders, which is fantastic.”

• Pre-op planning. Dr. Romeo, as one of the leaders of his practice, evaluates prospective surgeons to determine if they’re suitable candidates to perform shoulder replacements in outpatient ORs. He suggests assessing a surgeon’s last five replacements performed in the hospital setting. Surgeons who take longer than two hours to complete the procedures aren’t ready to bring their cases to an ASC, according to Dr. Romeo.

“Taking more than two hours to complete procedures could be representative of their surgical skill, but it’s often an indication of peripheral factors,” says Dr. Romeo. “They’re not conducting appropriate preoperative planning or they haven’t worked with the surgical team to confirm that the necessary equipment and supplies are on hand, and that every member knows and understands their role during the case. That seems like common sense, right? But it’s remarkable how many surgeons simply show up in the OR only when it’s time to operate.”

Dr. Romeo says the surgeons who first performed osteosynthesis were famous for saying, Surgery is the time to do, not the time to think. “The idea is that preoperative planning is essential to surgical success,” he explains.

Computer navigation is an extremely useful tool for helping surgeons prepare for procedures, notes Dr. Romeo. He says the technology allows surgeons to map out bone cuts and select the size of the implant based on the patient’s pre-op CT scans and specific joint anatomy. In the OR, the navigation platform guides surgeons to place the implant in an alignment that matches the pre-op plan.

Planning and intraoperative guides help surgeons place the glenoid component of implants on the scapula with more accuracy. Placing the humeral component — knowing where to make the proper cuts to perform an anatomic reconstruction — is more challenging. Dr. Romeo believes robotic assistance will help with this portion of the procedure when the technology, which is already being used more frequently during hip and knee replacements, is applied more regularly to shoulder procedures.

• Advanced anesthesia care. Surgical technology is not what’s driving the increase in outpatient shoulder replacements, says Dr. Khazzam. “Anesthesia techniques play a more vital role in allowing patients to go home on the day of surgery,” he explains. The perioperative management of pain has improved dramatically, according to Dr. Romeo. “Anesthesia providers are the key members of the surgical team,” he says. “They need to partner with surgeons to enhance the care of these patients.” Dr. Romeo recommends investing in the tools and equipment anesthesia providers need to place regional blocks under ultrasound guidance. The interscalene blocks used for shoulder replacements should be placed outside of the OR in a procedure room to help maintain surgical efficiencies.

“The OR should be used to operate,” says Dr. Romeo. “If you’re performing non-surgical tasks when the patient is there, you’re wasting valuable and expensive time.” Patients who are blocked in a procedure area enter the OR with the surgical site completely numb and require only low-flow general anesthesia, according to Dr. Romeo, who says this leads to them emerging faster and recovering sooner. His patients do not receive opioids in recovery, but are given a two-day opioid script at discharge to manage breakthrough pain and a prescription for a less potent narcotic for five to seven days post-op. Most patients use the medications only at night to help them rest and many patients return most of the pills at the one-week follow-up appointment.

It’s crucial to sit down with all stakeholders who will take care of patients and explain the importance of the shoulder replacement program and their role in its success, says Dr. Romeo. “Let everyone work at the highest level of their license,” he adds. “It’s amazing what can be accomplished when a hardworking and dedicated team works in concert to improve patient care.”

When surgeons approach cases with a plan and a talented, committed team of providers, shoulder replacements can be performed efficiently, effectively and safely. “I tell my patients that we’ll get them into and out of the OR before their physiology is challenged,” says Dr. Romeo. “They’ll be recovering in the comfort of their home before their body knows they’ve had surgery.” OSM