Inside Successful Total Shoulder Programs

Experts share five keys to optimize your service line.

Hip and knee replacements have long dominated the same-day total joints market, but outpatient total shoulder replacements were gaining traction even before CMS approved them for ambulatory surgery centers (ASCs) this year. With that approval, experts believe that outpatient total shoulders will continue to grow at a pace higher than hips and knees.

Converging factors

“The demand for outpatient shoulder replacement surgery is definitely increasing,” says Grant E. Garrigues, MD, a surgeon at Midwest Orthopaedics at RUSH in Chicago. “There are a few reasons for this, including the change in Medicare’s regulations, the COVID pandemic and having more surgeons become more comfortable with performing joint replacements in an outpatient setting.”

We spoke with experts in the field to gather insights into the techniques, tools and strategies that make their ambulatory shoulder replacements successful. If you’re considering adding outpatient total shoulders to your caseload, here are five keys to success.

1. Patient selection

Experts emphasize the importance of following stringent qualification criteria, taking into account patient conditions such as cardiopulmonary conditions, blood clotting history, body mass index, age and other comorbidities.

Dr. Garrigues says it often comes down to a favorable combination of patient, procedural and surgeon factors to determine the suitability of outpatient surgery. “Patient factors like elevated BMI, pacemakers and cardiopulmonary issues guide our selection process,” he says. “If it’s something that’s going to put the patient at a higher risk, it’s a no-brainer that the case should be done in an inpatient setting.

“There are other factors to consider too, such as complexity, operative time and the surgeon’s experience with performing these types of cases,” he continues. “Social structure is also vital because patients need a supportive environment post-surgery.”

Gregory N. Lervick, MD, an orthopedic surgeon at Twin Cities Orthopedics in Minneapolis who looks closely at these factors, also sticks to a specific age requirement. His patients must be under 75 years of age to receive outpatient total shoulder surgery. However, he notes that this is something he and his Twin Cities colleagues continue to review.

“Age is an important cutoff that probably needs to be studied more as the population ages,” says Dr. Lervick. “How important is chronological age versus social support, general health, patient education and using the surgeon’s and anesthesiologist’s judgment? That’s something we’re trying to collect more data on to better understand.”

A thorough workup of a patient’s health prior to the procedure is especially crucial because sometimes patients themselves may forget or not be aware of an existing condition, adds J. Gabriel Horneff III, MD, FAAOS, associate professor of orthopedic surgery and director of the Shoulder and Elbow Fellowship at the University of Pennsylvania in Philadelphia.

“I am very strict about getting clearances and pre-op workups,” he says. “It is amazing how many times I have helped diagnose other issues in patients who had no idea they had things like diabetes, hypertension and other conditions.”

2. Patient and staff education

Dr. Lervick notes that preparation begins with instructing the patient about what to expect on the day of surgery and the ensuing weeks and months.

“Patient education starts in the surgeon’s office and extends through our EXCEL Orthopedic Surgery and Recovery Program, where nurses and care coordinators ensure patients understand the process and are well prepared,” he says. “The program offers total joint classes — both in-person and virtual — that cover everything from home preparation, assistive devices and post-surgery care, providing patients with comprehensive guidance well before their procedure.”

It’s especially important to go over what patients should expect postoperatively, says Dr. Horneff, since typically the amount of pain is a top concern. He uses handouts to provide patients tips on sling wearing, how to sleep and more. Other surgeons offer patients a short video to summarize what to expect postoperatively.

“This is probably the most paramount aspect in patients having a successful outcome,” says Dr. Horneff. “It is all about setting expectations and letting them know what common post-op symptoms will be, that surgery is trauma in a controlled setting, and that pain is part of the deal.”

Dr. Garrigues says educating your staff is equally important. “If a patient comes in, and the front desk sees they’re getting a shoulder replacement and says something like, ‘Oh wow, we don’t do a lot of those here,’ an already nervous patient is going to feel even more anxious,” he says. “You want every single person in your center to communicate the message that this is safe, effective and the patient is in good hands.”

3. Tools, technologies and equipment

BLOCK IT OUT Regional nerve blocks administered before surgery provide comprehensive pain relief for approximately 24 to 36 hours, covering the most painful phase of the patient’s recovery.  |  OSM file photo

Improved implants, robotics, augmented reality and more are powering the increasing migration of total shoulder replacements to outpatient settings.

Dr. Garrigues notes that many implant systems manufacturers are adjusting their offerings to the outpatient world. For example, implants continue to get less invasive, providing shorter and stemless offerings with fewer steps. These newer implants potentially could result in less blood loss and shorter operative times. The latest offerings also aim to limit the number of trays involved, given that outpatient environments often require economical options with smaller footprints.

New technologies including augmented reality are also contributing to the outpatient migration. Dr. Garrigues notes that some new technologies allow the surgeon to wear glasses that allow surgeons to visualize landmarks while performing the procedure. This technology enables the surgical facility to reap the benefits of surgical navigation and robotics, but with lower budgetary costs and minimal storage requirements.

“Instead of having to use huge monitors, you can wear glasses that will give you an overlay of what you’re looking at and the metrics you want to see,” says Dr. Garrigues. “The hardware is less expensive, and the software can be updated much more quickly. I think augmented reality technology will really take off in the coming years.”

“The focus is on performing the operation safely, effectively and efficiently,” says Dr. Lervick. “Future research will likely explore the impact of navigation and technology on outcomes, considering the rising demand for shoulder replacements.”

4. Pain management

The surgeons tout the benefits of a multimodal pain management approach for total shoulder patients that includes preemptive analgesia, regional anesthesia and reduced opioid use.

Dr. Horneff emphasizes the importance of regional nerve blocks in this regard. Single-shot blocks administered before surgery provide comprehensive pain relief for approximately 24 to 36 hours, addressing the most painful phase of recovery. By numbing the operative arm, these blocks also enable the use of general anesthesia with reduced medication, ensuring the patient remains comfortable throughout the procedure.

Following the block, Dr. Horneff employs a regimen that typically includes acetaminophen and ketorolac for ongoing pain control, supplemented by a small number of low-dose oxycodone tablets for breakthrough pain. “Some earlier studies had shown that NSAIDs could affect tendon healing, but I think more surgeons are comfortable with perioperative use of them as they are very effective,” he says.

Dr. Garrigues’ multimodal approach includes a long-acting regional anesthetic. He notes it not only keeps patients comfortable for a longer amount of time compared to other methods, but it also wears off a bit more gradually. “Liposomal bupivacaine, used for interscalene blocks, has been a game changer in the outpatient setting,” he notes. “It can numb the shoulder for a long amount of time, but there’s also a slower offset, so it’s not a sudden dropoff of pain relief.”

Dr. Lervick underscores the value of evolving anesthesia techniques, especially as the use of narcotics for pain relief continues to trend lower. “Ten years ago, the use of opioids was more prevalent and common. With the opioid epidemic, patients’ mindsets have shifted. They are more educated, and the demand has gone down,” he says. “It’s not necessarily opioid-free across the board, but if patients are motivated to not use them as much, and are supported with a multimodal regimen, they generally don’t want to rely on them.”

5. Post-op care

Successful outpatient programs take a hands-on approach to ensure patients recover well at home. “Our program includes thorough follow-ups, with my team seeing patients 10 days after surgery and additional check-ins at six and 12 weeks,” says Dr. Lervick. “The EXCEL program offers follow-up calls at 48 hours, one or two weeks and 30 to 60 days post-surgery. Patients love the follow-up, and providers appreciate the safety net it provides.”

Dr. Horneff calls the family after surgery to provide an update on how the case went. Patients are also called two days post-op and have visits two and six weeks after the procedures. “I find that the patients often forget any conversations in the PACU due to the effects of anesthesia,” he says.

Exciting evolution

With the right approach, outpatient settings can be safe, effective and patient-friendly settings for shoulder replacements.

“When you do a hip or knee replacement, you have to ensure the patient can go home safely and is not at risk of falling. Since patients don’t walk on their hands, shoulder replacements are a natural evolution in outpatient procedures,” says Dr. Garrigues. “The data conclusively shows that outpatient total shoulder arthroplasty is safer, has a lower complication rate and is more cost-effective. This evolution benefits both patients and the healthcare system.” OSM