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November 2, 2022
Publish Date: November 1, 2022   |  Tags:   Orthopedics

THIS WEEK'S ARTICLES

Secrets to Same-Day Shoulder Success

Five Keys to Starting an Outpatient Spine Program

Riverfront Surgery Center Opens Its Doors to Serve a Community's Orthopedic Needs - Sponsored Content

New Shoulder Replacement Technique Salvages More Patient Bone

Essentia Health Opens New High-Tech Surgery Center

 

Secrets to Same-Day Shoulder Success

Here's what it takes to perform shoulder replacements consistently and safely at outpatient facilities.

Shoulder J. Gabriel Horneff III
BOLD SHOULDER Numerous advances are contributing to the steady movement of total shoulder procedures to outpatient facilities.

Shoulder replacements, which once required hospital stays as a matter of course, have been consistently shifting to same-day outpatient settings. As a result, more patients have access to these surgeries. Anthony Romeo, MD, a Chicago-based shoulder and elbow specialist, estimates that surgeons now perform close to 200,000 shoulder replacements annually, many of the same-day variety due to advances in surgical technique and anesthesia care.

Driven by an aging population combined with a growing number of fellowship-trained shoulder reconstruction specialists entering the field, total shoulders present a tantalizing opportunity for ASCs. Dr. Romeo suggests that interested facilities focus on four key considerations before taking the plunge.

Patient selection. Develop a standardized approach to identifying appropriate candidates for shoulder replacement 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. Age isn't typically a limiting factor, however.

"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," says Dr. Romeo, who performs most of his shoulder replacements on patients in their mid-60s, bolstered by evolving surgical techniques that are extending the expected lifespan of implants beyond 10 years.

New techniques. Implants are increasingly placed with a cementless press-fit technique, and they are designed to better match the joint's natural function. As a result, patients can 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 its longevity," says Dr. Romeo.

More surgeons also now attempt to place the implant's humeral head in the same center of rotation as 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.

Additionally, reverse shoulder replacements, which rely on the deltoid muscle rather than the rotator cuff to power and position the arm, are emerging as a viable surgical option in outpatient shoulders. "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."

Pre-op planning. Computer navigation 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, says Dr. Romeo. In the OR, the navigation platform guides surgeons to place the implant in an alignment that matches the pre-op plan, particularly in terms of placing the glenoid component of the implant on the scapula with more accuracy. Placement of the humeral component remains more challenging, however, but Dr. Romeo believes robotic assistance can help with this portion of the procedure.

Advanced anesthesia care. Perioperative pain management has improved dramatically in shoulder replacements. Dr. Romeo recommends investing in the tools and equipment anesthesia providers need to place regional blocks under ultrasound guidance in pre-op to help maintain surgical efficiencies. Patients thus enter the OR with the surgical site completely numb and require only low-flow general anesthesia, leading to them emerging more quickly and recovering sooner. Dr. Romeo's patients do not receive opioids in recovery, although they are provided 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. Many of Dr. Romeo's patients return most of the pills at their one-week follow-up appointment.

Dr. Romeo believes that when surgeons approach shoulder replacements with an informed plan and a talented, committed team of providers, the procedures can be performed efficiently, effectively and safely at outpatient facilities.

Five Keys to Starting an Outpatient Spine Program

A focused, careful and targeted approach should be in place before you activate a spine service line.

Spine Elisa Maines Photography
SMOOTHER RECOVERIES Dr. Sielatycki says improved pain control methods are part of the reason he can safely perform same-day spinal fusions and disc replacements.

Thanks to advances in minimally invasive techniques, cost reductions and the reality that it's what patients and commercial insurance companies want, spine procedures are migrating to outpatient settings. Here are five suggestions on how to successfully start an outpatient spine line from those who've done it.

Get expert advice. Before the leadership at Steamboat Orthopaedic and Spine Institute opened Steamboat Surgery Center in Steamboat Springs, Colo., in 2019, they considered new construction, but after consulting with an architect opted to retrofit an existing building instead. The consultant also facilitated a compromise among surgeon-owners to build two larger operating rooms instead of three smaller ones, a decision that co-founders Andreas Sauerbrey, MD, says helped with patient flow and in turn became a crucial element of the facility's daily success.

Negotiate with payers. As more data and positive outcomes roll in from ASCs and HOPDs, insurance companies increasingly prefer that many spine procedures be performed on a same-day basis. "The fee structures associated with outpatient spine surgery are often much lower, so payers have an interest because it saves them a lot of money," says Steamboat orthopedic surgeon J. Alex Sielatycki, MD. Dr. Sauerbrey suggests getting payer contracts in place in advance, and advises that leaders understand before launching a spine line how long it will take to secure reimbursements.

Work with the best. The surgeons you recruit should be experienced in achieving good results with same-day spine, and should be comfortable or open to using a variety of surgical techniques and implants.

Perform non-instrumented cases. At the surgery center, Dr. Sielatycki performs many less-invasive procedures that relieve pressure caused by one or more compressed nerve roots on the spinal column, and which don't require implants. "If a patient has a one- or two-level nerve root irritation, I can make a small incision and take the pressure off those nerves," he says.

Spend money to make money. Complex fusion means buying expensive technology and equipment, including fluoroscopy, navigational systems, robotics platforms and surgical microscopes. However, the investment allows the center's surgeons to perform more involved surgeries. "With some of the newer techniques, particularly pain control methods, I can safely perform spinal fusions and disc replacements in an outpatient setting for more patients," says Dr. Sielatycki.

Keeping these factors in mind will enable a center to safely and profitably perform spinal procedures at facilities that patients and payers prefer over hospitals.

Riverfront Surgery Center Opens Its Doors to Serve a Community's Orthopedic Needs
Sponsored Content

The journey to developing and opening this new ASC took many decisions, customized options and collaborative teamwork with an experienced solutions provider like Stryker to become a reality.

Greeson Kathleen Greeson (KG Photography)

The "one-size-does-not-fit-all" theory is certainly true in the ambulatory surgery world. Each facility has its own personality and footprint in its community. In a physician-owned facility, the stakes are high to ensure a successful launch and ongoing operations. That's why ASC owners and administrators look to others for advice and seek partnerships, from companies like Stryker, that are tailored to their specific needs.

A great example of a successful partnership is Riverfront Surgery Center in Chattanooga, Tenn. Their journey can shed some light into the process and challenges of opening a new ambulatory center and the future planning critical to its success. In January 2022, Riverfront Surgery Center opened its doors and began surgeries.

With a focus primarily on spine, total joints, sports medicine, pain management, podiatry and orthopedic procedures, this physician-owned facility delivers options to its community for customized patient care. Dawn McElhone, RN, administrator, who was involved in the planning and construction process of the ASC, currently oversees daily operations and completed every step required to get to grand opening. Outpatient Surgery Magazine spoke with Dawn about the path to opening the ASC and Riverfront's partnership with Stryker.

Q: First of all, congratulations on opening up a new ambulatory center in Chattanooga. What impact will your new facility have on your local community?

Thank you! Riverfront Surgery Center will provide, not only for our local, but for neighboring communities, an alternate choice for their surgical needs. ASCs have been shown to provide more cost-effective and personalized care to their patients with lower risk of infection.

Q: What and who drove the decision to build this new ambulatory center?

Some of the physician owners discussed how Chattanooga had very few surgery centers compared to other major cities in Tennessee. Those physicians approached other independent physicians about joining an ASC and received a positive response. Most of these doctors had never worked at a surgery center before, and they liked the idea of investing in a patient-centered approach to surgery that would benefit the community. Today, we have 17 physicians on medical staff at Riverfront Surgery Center.

Q: How important was it to choose Stryker as your partner? What did you learn in the process?

It was the service that sold me on Stryker. Stryker did not try to sell us on products we did not need. They were very receptive to my questions and concerns and were very transparent. Partnering with Stryker allowed us to obtain the majority of our capital with low-cost, high-quality equipment.

Through this process I have learned so much it is difficult to express. I knew very little of what the process of opening a surgery center would entail. In working with Stryker, I was able to find guidance, teamwork and support.

Q: What types of surgery did your center decide to focus on initially and why?

Riverfront Surgery Center offers a variety of orthopaedic, spine and pain management procedures. This includes podiatry, hand surgery, sports medicine, total joint replacements, minimally invasive back and neck surgery, spinal fusions, total disc replacement, steroid injections, spinal cord stimulators, along with other interventional pain management options.

Q: What three tips would you give anyone contemplated a project of this size?

  1. Perform due diligence, read the fine print and question everything.
  2. Don't be afraid to ask for help. Find people who have been in your situation and learn from their experiences
  3. Build a strong team from the inside! I have been blessed with the best staff Chattanooga has to offer. They have worked harder than ever before with getting Riverfront's doors opened and passing our inspections and surveys and doing so with a genuine smile on their faces and joy in their hearts. They are just as dedicated to Riverfront as I and the physicians are.

Note: Whether you're building a new ASC or adding a spine sub-specialty to your ASC, Stryker's ASC business can help you build and grow strategically. By giving you access to our world-class portfolio of wall-to-wall capital, head-to-toe implants, and ASC specialists who understand your unique challenges and ongoing support, we deliver everything your ASC needs to win today – and tomorrow. To learn more about Stryker's ASC business, visit https://www.stryker.com/us/en/care-settings/asc.html

New Shoulder Replacement Technique Salvages More Patient Bone

A live surgery showing the procedure in action was streamed at a recent conference.

At The 2022 Orthopaedic Summit in Boston in September, a groundbreaking total shoulder arthroplasty procedure pioneered by Anthony Miniaci, MD, deputy chief medical executive with Baptist Health Orthopedic Care, was livestreamed. The 40-minute surgery was performed by John Zvijac, MD, at Baptist Health's Surgery Center in Coral Gables, Fla., while Dr. Miniaci moderated the case from Boston.

Described as "total shoulder arthroplasty with a nonspherical humeral head implant with an inlay glenoid," the two-part technique is designed to more accurately mimic the anatomy of a patient's shoulder while employing a minimally-invasive inlay technology on the glenoid that salvages more of the patient's bone than traditional techniques do.

Dr. Miniaci first proposed the technique after observing unmet needs in his patients, predominantly athletes. A specialist in sports medicine and shoulder and knee surgery, he joined Baptist Health in August after two decades with Cleveland Clinic Foundation's Center for Sports Health in Cleveland and Sports Medicine Clinic in Toronto, where he treated numerous Olympic, MLB, NFL and NHL athletes and served as the head team physician for the Cleveland Browns.

Several Baptist Health surgeons now perform a high volume of procedures using Dr. Miniaci's method. "This technique gives our doctors the ability to preserve as much of the bone as possible and to replicate a patient's own anatomy," said Dr. Zvijac.

"It's rewarding to know this concept we formulated nearly 30 years ago is now being used as a standard approach and shifting the way in how we perform this type of shoulder surgery," says Dr. Miniaci.

Essentia Health Opens New High-Tech Surgery Center

Four zero-footprint, digitally connected, 600-square-foot ORs fit into a long-term goal of performing joint replacements at the facility.

Some facilities are built to provide total joints surgeries on day one. In the case of facilities like Essentia Health's recently opened Miller Hill Surgery Center in Duluth, Minn., they're built to accommodate them in the future.

Currently the new multispecialty center is equipped to perform orthopedic, ophthalmic, ENT, urologic, gynecologic and pediatric surgeries, with a stated long-term goal of adding joint replacements. The groundwork for a smooth launch of a total joints line, however, has been well-laid for whenever that time comes.

The center's four 600-square-foot ORs are equipped with state-of-the-art technology, including an integration system that is easily accessible via touch panel controls. The 55-inch monitors in the ORs display crystal-clear images and x-rays of the patient for the entire surgical team to view. Those images can be easily uploaded into the electronic health record, which providers can access during future consults with the patient and their family.

A surgeon's preference card can also be pulled into the integration platform and displayed on the monitors, ensuring surgical techs know exactly how the room should be set up and how back table instruments should be laid out for a particular case.

The ORs' zero-footprint design means that all surgical equipment used is located outside the actual room. This provides a safer, cooler, more sterile operative environment, according to Jefferson Davis, DO, an orthopedic surgeon at Essentia Health. "The integration clears up a lot of the cords and monitors and everything else that tends to clutter up the OR, making it much easier to navigate around without worrying about slips and trips and bumping into things that aren't sterile," he says.

Stacy Lund, operations director for acute surgery, says the ultimate purpose off all the technology is to maintain patient safety. "This is an ambulatory surgery center that is not connected to our main campus, so one of the things we really wanted to be able to provide for our physicians and patients in this space is the ability to contact others if needed," she says. "It was really important for us to have the ability to do that immediately during a procedure, so the technology and the integration platform allows us to video conference and engage in peer-to-peer consults in real time."

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