Are You Ready for the Shoulder Replacement Boom?

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Outpatient procedures are a growing service line that can be performed safely on select patients.


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.

  • Pre-op assessments. You need a competent clinical team that confers with surgeons and anesthesia providers to identify appropriate candidates for outpatient shoulder replacements. The best candidates for outpatient shoulders have healthy BMIs and no comorbidities such as congestive heart failure, COPD, immunodeficiencies or severe shoulder deformities. I've operated on patients in their teens and some in their nineties, but the majority of patients are arthritis sufferers in their sixties, seventies and eighties. As a new endeavor, you should err on the side of caution until your program is up and running and your team gains experience in performing the procedures and managing patient care.
  • Anesthesia pros. Having a good anesthesia team that is skilled at administering regional blocks and willing to communicate with patients about what to expect before and after blocks are placed is paramount. Nerve block recipients will experience numbness in their arm, and perhaps even lack the ability to use their arm for a day or so after their surgery. This could cause undo anxiety if they're not told to expect the lack of sensation in advance, as they'll think it's abnormal and a potentially serious complication. You need an anesthesia group that not only answers calls from concerned patients, but that checks in on the patients proactively after procedures to assess their condition and answer questions they have.
  • In the OR. Surgical tables should recline so the patient can be placed in the beach chair position, which is the only option for shoulder replacement surgery because it allows surgeons to see all areas of the joint in an anatomically correct way.

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.

POST-OP CARE
Provide Patients With Detailed Discharge Instructions

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:

  • Sling instructions. Instruct patients how to put a sling on and take it off, how to hold their arm while showering without it, how to get dressed and undressed while wearing it, and any restrictions they're under while having it on, such as driving.
  • Wound care. Patients need to know how to shower with the wound dressing on, making sure they don't submerge it in water, and how to dry it if it gets wet.
  • Blood clot prevention. Even though shoulder replacement patients are less likely to develop DVT than hip and knee patients, they should still take an 81mg aspirin daily for four weeks post-surgery. They should also ambulate as much as possible and perform ankle pumps by moving their feet up and down to contract calf muscles.
  • Physical therapy. Shoulder patients have an advantage over hip and knee patients because they move around after surgery. They can't, however, perform aggressive strengthening exercises right away —surgeons must take down and repair a portion of the rotator cuff to perform a shoulder arthroplasty, and that alone takes weeks to heal. We therefore recommend a series of passive range-of-motion exercises for the shoulder area, as well as active-motion exercises for the elbow, forearm, wrist and hand.

— J. Gabriel Horneff III, MD, FAAOS

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.

  • Pain control. This is the biggest barrier to performing shoulder arthroplasties on an outpatient basis. In general, shoulder replacements are more painful than hip procedures. Nerve blocks have revolutionized how we can control pain over the past decade. Patients who underwent total shoulder surgeries in hospitals used to be given hydromorphone. Now we can use non-narcotic pain regimens using multiple modes of relief, which is obviously preferrable in light of the opioid addiction crisis. My patients are given IV acetaminophen preoperatively and a single-shot interscalene nerve block with long- acting liposomal bupivacaine during surgery.
MOTION TABLE\D
MOTION TABLED Several positioning aids are needed to stabilize and protect patients placed in the beach chair position.  |  Penn Medicine

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.

Demand is increasing

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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