Gaining Ground

The impressive growth of shoulder replacements has total hips and knees looking in the rearview.

Even though outpatient shoulder replacements were approved years after the Centers for Medicare & Medicaid Services (CMS) gave total knees and hips the nod, it’s still a wonder that more of these cases weren’t performed at ambulatory surgery centers. The reason shoulders are still coming in third is no more complex than understanding the reality that people can get on with their lives with a bum shoulder more easily than with a bum leg.

“There’s always been a higher demand for hips and knees,” says Kory B. Reed, MD, from Excelsior Orthopaedics in Buffalo, N.Y. “A lot is based on the simple fact that people aren’t walking on their hands. You can get around on a bad shoulder, so it’s not as urgent to people in terms of functionality.”

Inside the numbers

Outpatient total shoulders are gaining ground, however. More total shoulder arthroplasties (TSAs) are being performed overall and even more patients are being discharged home from inpatient cases on a same-day basis. The 2019 American Academy of Orthopaedic Surgeons Shoulder & Elbow Registry (AAOS SER) shows that 71.3% of patients were discharged to their homes from 2015 to 2020, while the 2024 AAOS SER puts the number at 79.1% from 2015 to 2023.

That growth has continued after CMS placed TSA on its ASC-approved list in 2024. (CPT codes for total ankle replacement were added in 2024 too, so the outpatient future for those procedures is also bright.) The shoulder boom should continue, according to two shoulder specialists we spoke with, especially because TSAs are in many ways easier outpatient surgeries than more common shoulder procedures, something many physicians aren’t aware of.

Perfectly suited for outpatient settings

Surprisingly, shoulder arthroscopy is less painful for most patients than other shoulder surgeries such as rotator cuff repairs, says David M. Dare, MD, a surgeon with Raleigh (N.C.) Orthopaedic. “Combine that with the nerve block we use, and our patients will take no pain medication, or very little, afterward,” he says. “They are surprised by the delta between their pre-op and post-op pain levels.”

The 2024 CMS approval cleared much of what once was the biggest obstacle to more outpatient TSAs: payor reluctance. While patients with bad knees or hips are less likely to delay needed surgeries than those with bad shoulders, upper extremity procedures are actually easier for patients and their surgeons than lower extremity surgeries.

“Hip and knee surgeons have the distinct disadvantage of having their patients walk on their joint replacements immediately after surgery, so it takes a very special and virile patient to be able to go home after a total hip or a total knee, whereas for a total shoulder you put patients in a sling and they have no pain,” explains Dr. Dare. “Almost anyone can go home like that.”

Physicians who perform other shoulder procedures at ASCs shouldn’t be uncomfortable about the prospect of outpatient TSA, which Dr. Reed has been doing since 2014.

“There’s always been a little bit of reluctance by a lot of surgeons to jump into the total shoulder realm,” he says. “But if you are at an outpatient facility and are accustomed to doing rotator cuff repairs, you’re already performing surgeries that are significantly more painful for patients in the immediate postoperative period. Many of my total shoulder patients, on the other hand, have no pain postoperatively.”

Dr. Reed’s total shoulder patients don’t need to stay at the overnight recovery suite that his physicians’ group sometimes offers their knee and hip patients. “Again, that illustrates that shoulder patients leave with the legs they came in with,” he says. “Upper extremity patients are ambulatory, so they’re very conducive to the surgery center experience.”

Culture shift underway

LIFE’S A BEACH Shoulder patients in the beach chair position give surgeons 360-degree access.

Some patients are shocked at first about the concept of receiving a new shoulder and going home the same day, says Dr. Dare. That’s why patient education is a key component of a successful shoulder program.

“It’s helpful to take the time necessary to explain the process to patients. I tell them it’s completely safe and that they’ll have very little, if any, pain after surgery,” he says. “Then I explain that it’s safer for them to be in an outpatient setting than an inpatient setting because of the lower risk of infection and other reasons.”

Patients simply do better at home, says Dr. Dare. They sleep well at night because they’re where they are most comfortable and aren’t bothered by sick patients or awakened by nurses through the night.

Dr. Reed stresses the importance of being transparent with patients. “Part of the education is explaining that there’s nothing to be anxious about getting a total shoulder done at an outpatient facility. There’s not a lot of blood loss during the procedure and very little difficulty controlling postoperative pain,” he says. “This helps them get comfortable with the idea that they don’t need a hospital setting.

“We also are transparent about how this drives business in our direction, which is a win for us as well. We explain, yes, it’s good for business, but it also drives consistency in your care. We work with the same people every day, all of whom drive the process changes needed for you to have an excellent outcome, so we want you to come here. And — we’re going to save you money.”

Technique, anesthesia and aftercare

Drs. Reed and Dare perform more reverse total shoulders than anatomic TSAs. Reverse TSAs, FDA approved in 2004 and currently more common than anatomics, are performed on patients with a torn rotator cuff. It’s a condition Dr. Reed says is more prevalent in older patients. Reverse procedures can also be performed for patients with thin rotator cuffs that doctors fear could soon suffer a tear. The technique allows doctors to be more aggressive about releasing tissue to reduce patients’ shoulder stiffness.

“My patients resting at home two hours after I make the incision is a complete paradigm shift.”
—David M. Dare, MD

Outpatient anatomic procedures are more appropriate for younger and healthier patients. More of them could be performed at ASCs if more workers’ compensation carriers didn’t require that their clients get their surgeries in hospitals, notes Dr. Reed.

Neither doctor intubates their patients. Dr. Dare uses an interscalene nerve block with liposomal bupivacaine with all TSA patients, which provides up to 72 hours of pain relief. He also uses light sedation to avoid general anesthesia and the intubation and extended recovery times it causes. Patients sit in a modified beach chair position, usually with an arm holder attached to the table. “It’s not overly complex equipment-wise,” says Dr. Reed. “You don’t need a robot or a specially designed orthopedic table that other types of surgery require.”

Excelsior’s patients receive tutorials before and immediately after their surgeries about how to use a sling and an ice machine. They also talk to durable medical equipment personnel or physical therapists about how to perform daily living tasks in the immediate aftermath of their procedures, and receive a detailed booklet with photos that explains which exercise to do before they go to a physical therapist a week or so later.

Consistency and efficiency

The top reason for Excelsior’s success with its total shoulder program is that it’s protocol-driven and consistent. The alignment of protocols for the cases of all surgeons allows for at least six total joint replacements of all kinds per day at its facility.

“We have consistent treatment protocols across the board, with only slight fluctuations surgeon to surgeon. Every surgeon wants what they want, but we’ve become very consistent in the implants that we use, not all the same company, but we trimmed it down to companies that are best suited cost-wise, tray-wise and equipment-wise, so we’ve been able to reduce costs,” says Dr. Reed. “We’ve also been able to streamline the processing of equipment to ensure sterility and ensure accessibility of trays in the smaller-than-a-hospital surgery center environment.

“We’ve all made little compromises even for postoperative physical therapy, follow-ups and discharge instructions. By putting our heads together, we maintain remarkable consistency. Staff and patients know what to expect. This reduces variability and increases the likelihood that we’ll execute a joint procedure without problems.”

Dr. Dare pared down his tray to only what he needs for TSAs and uses the same retractors and other tools for every case. It makes things easier for him, the scrub tech and the sterile processing staff.

“All the instruments fit on one mayo stand next to me, so there’s no going back and forth between the back table,” he says. “That makes the cases very predictable and reproducible.”

The doctors see a future for ASC surgical schedules where TSAs will be as common as rotator cuff repairs. “The procedure takes an hour. Patients are in the recovery room for 30 to 45 minutes and if they live close to the center, they’re soon in the comfort of their recliner or bed watching TV,” says Dr. Dare. “My patients resting at home two hours after I make the incision is a complete paradigm shift. I have 85-year-old patients who get reversal replacement, and they leave the surgery center lucid and feeling great and have no problems at home.” OSM