Total Shoulders Advance at ASCs

Learn what a successful outpatient shoulder replacement looks like from the first freestanding ASC certified for shoulder replacements by The Joint Commission.

Outpatient total shoulder arthroplasties (TSAs), popularly known as shoulder replacements, were already gaining ground before CMS approved them for ASCs in 2024. Now the sky is the limit for volume growth, provided your center has the right providers and protocols in place to operate safely, efficiently and profitably.

Case study in efficiency

Summit Orthopedics, which runs five ASCs in Minnesota, was recognized this year by The Joint Commission (TJC) as Disease Specific Certified in Arthroplasty (Shoulder Joint Replacement), the first freestanding ASC in the U.S. to achieve the designation. Such honors are nothing new for Summit, which Chief Operating Officer Beckie Hines notes became Minnesota’s first Joint Commission-accredited ASC in 2007.

Michael Freehill, MD, and Peter Parten, MD, are Summit’s TSA experts. “A number of our partners do shoulder surgery, but we are the only two fellowship-trained shoulder specialists in the group,” says Dr. Freehill, a shoulder specialist for 25 years who joined Summit in 2022. He estimates TSAs now account for more than half of his surgeries.

Dr. Freehill says Summit saw an opportunity to become a center of excellence for TSAs based on its existing foundation and protocols for knees, hips and spine. The program’s pillars center around the development of pre-op and post-op rehab programs and evidence-based standards of practice in the performance and management of TSAs that address pain management and mitigation of preventable errors and complications, advanced practice provider (APP) “navigators” who ensure the patient is safe for surgery, pre-op patient optimization and intraoperative consistency for anesthesia. The idea, he says, was to make Summit’s TSA service line “consistent, reliable and reproducible.”

Reimbursement. Summit has performed TSAs with reimbursement through commercial payors at its ASC since 2014. Ms. Hines says last year’s CMS approval led the group to further refine and standardize its TSA practices. “CMS patients are usually more elderly patients, so you want to really make sure you have a very optimized process,” she says.

“We bundle our complex total joints with our commercial payors. You can’t bundle with Medicare,” says Ms. Hines. “But when you do volume and have an efficient, standardized process, and your surgeon is able to stay in your doors rather than driving to the hospital and back, even though you make less on Medicare, it’s still worth it. Always evaluate your costs and negotiate with your vendors and payors to make sure you’re never getting in the red.”

Reasons for TSA surgery. Arthritis is the primary driver for TSA, but Dr. Freehill says TSAs can also address avascular necrosis from a medical condition or old injury that reduces blood supply to the shoulder, or fractures for which patients aren’t a candidate for traditional fixes with plates and screws. “In some patients, a joint replacement is the most predictable way to treat a fracture,” he says.

Drs. Freehill and Parten don’t immediately opt for TSA. They first try to manage symptoms with nonsurgical interventions such as injection therapies under ultrasound guidance, gentle physical therapy and pain-reducing medical therapies. Do these just delay the inevitable? “The analogy I use for my patients is that arthritis is the human body’s version of rust and corrosion,” says Dr. Freehill. “We can do things to maybe slow it down or not feel as bad but eventually, depending on the part that’s ‘rusting’ and ‘corroding,’ you need to replace the shoulder.”

Navigators. Ms. Hines says Summit’s key to achieving its Joint Commission Disease Specific Certifications is its APP navigators, four nurse practitioners who preoperatively guide and optimize every patient to prepare for every total joint procedure.

Summit’s providers create the best practices for TSAs, and the navigators operate within that framework. “Once the patient and surgeon share in the decision that it’s time for surgery, an order goes in for the navigator,” says Ms. Hines. “Within 24 hours, the navigator calls the patient to get to know not only their health history, but also their social environment. What care support will they have for their aftercare? What are their living conditions? Are there steps? Do they have dogs? That way we can make sure they’re able to go home and can set them up with assistive devices they would need, even make sure meals are brought in by family members beforehand to improve their care and their outcome. After that phone call, those healthy enough without a lot of comorbidities are done in the ASC.” After surgery, the navigator or someone they oversee follows up with the patient with seven-day and 30-day phone calls and works to resolve any issues.

Summit’s navigators work with its contracted anesthesiologists and family practice physicians to seek input about patients’ medical conditions and histories when needed. “They’re navigating it, but there’s also follow-through all the way through the patient’s entire episode of care,” says Ms. Hines, adding that the surgeon is always kept in the loop.

Episode of care

Preoperatively. A CAT scan or MRI of the shoulder is performed for preoperative planning. “Once we have that plan, we pick the timing and they enter the surgical arm of the pathway,” says Dr. Parten.

With the navigator’s help, a pre-op optimization plan is created, which can involve optimized nutrition, weight loss or other methods to improve the patient’s healing potential. “Most people are okay and don’t need major modifications,” says Dr. Parten. Upon arrival at the ASC, the patient checks in and meets with the anesthesiologist and nurses. They receive an IV for hydration and what Dr. Parten calls a “presurgical cocktail” that mixes anti-inflammatory and anti-nausea meds, antibiotics, acetaminophen and an agent that decreases bleeding risk.

Intraoperatively. In the OR, the patient is met by the surgeon and their physician assistant, an anesthesiologist and certified registered nurse anesthetist — both are present at the beginning and end of the procedure, with one present for the duration — a scrubbed-in surgical tech and a circulating nurse.

The patient receives a regional interscalene block in pre-op and then general anesthesia in the OR. “The general anesthesia keeps them relaxed, asleep and safe for the procedure, while the nerve block helps in two ways,” says Dr. Parten. “It works during the procedure so they’re not having any sensation in the arm, but it also lasts anywhere from 48 to 72 hours after the surgery.” The block, if well-functioning, minimizes and even eliminates the need to administer intraoperative opioids. “That’s really helpful for making patients wake up quickly, feel good and be able to mobilize so they can sit up, stand up and start moving right after the procedure,” says Dr. Parten.

The surgeon uses saws to remove the arthritis, drills to insert the implant and hammers to secure it into place, along with vendor-proprietary implant-specific tools. Dr. Freehill says patient-specific instrumentation and even patient-customized implants are becoming more popular. “Software programs allow us to use a patient’s CT scan to determine the severity of their arthritis and, if there’s enough deformity of the joint, sometimes we order a specific guide designed for that patient to help us put the implant in the right position,” he says. “On rare occasions, we might do a customized implant to help it fit properly within the patient.” The surgery itself usually takes around 60 to 75 minutes, but total OR time can stretch from 90 to 120 minutes when accounting for anesthesia administration and emergence, patient positioning and wound closure.

Dr. Freehill says patients appreciate Summit’s wound care protocol. “We usually do a subcuticular closure, so typically there aren’t stitches that need to come out,” he says. “It leaves a nice scar in most cases once it’s healed. We use a waterproof dressing so the patient can shower soon after surgery. It typically stays on until their postoperative visit, when we remove it. At that point, the wounds are usually healing pretty well.”

Recovery area. The patient quickly emerges from general anesthesia, and soon can sit up and have something to eat and drink. “Once they’re more awake, they stand up and take a little stroll,” says Dr. Parten. “With the block working, we don’t need to give them additional narcotics that may make them slower and lethargic. A lot of times, 15 minutes after surgery, they’re sitting there eating crackers, having some apple juice and asking when they can go home. Sometimes I leave the recovery room to talk to the family, come back and the patient is wide awake. It’s amazing.”

At home. The block provides pain relief for the crucial first couple of days after surgery. “We typically give them some form of narcotic medication, but frankly most of our patients are taking Tylenol or ibuprofen,” says Dr. Freehill. “The multimodal approach to pain management — preoperative, intraoperative and postoperative — has allowed the ambulatory capability for shoulder arthroplasty to really expand. It’s been key for us to have that extended pain relief with the block. They really do not have substantial postoperative pain in the great majority of cases.” Adds Dr. Parten, “I’d say at least 50% of patients say they’ve not taken any of their narcotics, only Tylenol and ice, and are doing fine.”

Home exercises begin in the first week or two after surgery. “Fairly early on we get them on a gentle program — pendulum exercises, elbow, wrist and hand exercises — that they are instructed on how to perform before discharge,” says Dr. Freehill. “They’re learning how to don and doff their sling and get their activities of daily living manageable again in terms of showering and hygiene. Typically, once they start their home exercise program, we ease them into their standard therapy program. We’ve developed standardized rehab protocols that allow for fairly predictable and reliable approaches. They get started on that program and it guides them through the first three to four months of their rehabilitation and recovery process.”

Most patients regain full use and strength of the shoulder three to four months postoperatively, but some jump the gun. “They’re not normal yet, but they’re feeling normal and sometimes try to do more than they should,” says Dr. Parten. “Often, by a month or six weeks, they’re out and about, driving themselves around, taking care of things, sometimes doing more than we like them to be doing.”

It’s important, then, to monitor patients postoperatively and inform them about do’s and don’ts to prevent negative outcomes. “The thing we are most aggravated by are falls in the early postoperative timeframe,” says Dr. Freehill. “Wearing a sling can make some patients a little unbalanced, so traumatic falls that cause a fracture or a dislocation of the implant have been one of the bigger nemeses in the early postoperative timeframe. We’re pretty good at communicating the do’s and don’ts, and hopefully they follow the roadmap like they’re supposed to.”

Care suites. Summit offers outpatient TSA patients discharged from the ASC access to no-cost post-op stays in care suites located in the same building as the ASC, operated through a separate home healthcare license. A nurse and an aide are onsite overnight in case of emergencies. Because TSA patients can ambulate after recovery, most of Summit’s TSA patients don’t utilize the suites as much as hip and knee patients. Dr. Parten estimates 90% of his TSA patients go home after recovery. “On occasion, they will stay and enjoy the care suite because it’s comfortable,” he says. The suites are handy for patients who drove two or three hours to get to the ASC. “Some elect just to stay overnight if it’s a later surgical time,” says Dr. Freehill.

Reprocessing. Ms. Hines says the standardization guided by Drs. Freehill and Parten of TSA supplies such as implants, dressings and surgical packs helps maintain and enhance the line’s profitability, especially for Medicare-funded TSAs. Ms. Hines notes, however, that there are still 10-plus trays of instruments to deal with before and after every TSA case. “Evaluate your sterile processing department,” she says. “If you don’t have the size or the capacity, figure that out. You need bigger autoclaves to be able to sterilize everything and have it ready.”

Improvements. Dr. Freehill says the biggest innovations in TSA lately have been in the materials used for implants. Shoulder implants are the first major joint to use pyrocarbon, a bone-friendly material designed for younger patients who desire very active lifestyles.

“Total shoulders often come with restrictions because we need to protect the joint,” says Dr. Freehill. “It’s a metal-plastic interface and relationship. Pyrocarbon, however, might help patients do higher-energy activities without worrying about damaging the implant or the joint.”

Dr. Freehill is also intrigued by plastic implants that are infused with vitamin E. “Multiple studies have shown that vitamin E-infused implants have much less wear over time than traditional polyethylene, so they hopefully will allow the plastic components to last longer,” he says. OSM