STRONG BASE Ankle replacements rival the positive outcomes achieved in total hip and knee surgery.

It's hard not to take notice when the renowned Andrews Institute Ambulatory Surgery Center in Gulf Breeze, Fla., decides to capitalize on one of surgery's hottest trends by adding total ankles, shoulders and knees to its case mix. The Andrews ASC team realizes what you should, if you haven't already: Excellent clinical outcomes, incredible growth potential and promise of significant profits are turning the continued migration of joint replacement patients to outpatient settings into a stampede, albeit a limping one.

Ankles arrive
Surgeon Erik Nilssen, MD, an ankle specialist at Andrews ASC, says patients and payers are becoming more interested in outpatient ankle replacement. "Implant companies have been focusing on total knees and total hips, because that's where the patient demand has been," he says. "But instrumentation and implants included in total ankle systems have improved dramatically in recent years. The quality and longevity of the repairs are evolving to match the positive outcomes achieved in hip and knee replacements."

Because Medicare doesn't yet reimburse surgery centers for total joint cases, Dr. Nilssen has no choice but to perform total ankle procedures at the hospital across the street from the Andrews ASC. Most of his ankle patients have had traumatic injuries or suffer from genetic osteoarthritis. The typical patient is older, with long-standing degenerative ankle arthritis, but Dr. Nilssen is seeing more younger patients seeking the surgery. He recently operated on a woman in her late 30s. The 33 joints in her foot were pristine, but the ankle joint was shot. Ankle fusion has long been the gold standard for treating her condition, but replacing the diseased portions of the joint instead of fusing the ankle preserves the range of motion in both the ankle and foot. That's especially important in young, active patients, says Dr. Nilssen.

"The incisions are smaller and it's a smaller joint to manage, but in many ways the procedure resembles total knee surgery," says Dr. Nilssen. He employs an anterior approach by making a lateral incision down the middle of the ankle, much like he would during a fusion procedure. Once the ankle joint is exposed, he uses alignment and cutting guides to determine how much bone to resect on the distal tibia and the proximal talus before making the cuts. The implants are placed and fixated by bone ingrowth. The ankle is splinted after surgery and patients must avoid putting weight on the joint for 4 to 6 weeks.

Dr. Nilssen's staff calls private insurers before cases to get authorization for the procedures. The center works out the co-pays and confirms payment amounts for the needed implants, which typically cost between $10,000 and $12,000 — that's much more expensive than the hardware used in total knees and total hips.

With the profit potential and patients benefiting from longer-lasting implants that preserve the range of motion in the ankle and reduce wear and tear on the joints in the foot, Dr. Nilssen believes efforts to move total ankles to the outpatient setting will resemble the evolution that has taken place with hip and knee replacements.

ANESTHESIA ASSIST
Regional Anesthesia Key to Total Joint Success

LEAD BLOCK Anesthesiologist Gregory Hickman, MD, uses ultrasound to pinpoint the precise placement of a regional block.

Anesthesiologists are essential to the success of the joint replacement procedures performed at Andrews Institute Ambulatory Surgery Center in Gulf Breeze, Fla. "Their abilities to provide consistent regional blocks let me do what I do," says Chris O'Grady, MD, a shoulder specialist at Andrews ASC. Anesthesiologist Greg Hickman, MD, the center's medical director, breaks down the techniques his team employs to ensure patients are ready for same-day discharge.

• Shoulders. Interscalene blocks numb the anterior approach to the joint preferred by Andrews ASC's surgeons and pain pumps infuse 4 cc of pain medication an hour.
• Ankles. Sciatic and saphenous catheters, which attach to a single pain pump with dual tubing, "cover the area so well, that's typically all we have to do," says Dr. Hickman

All shoulder and ankle patients are prescribed Vicodin (hydrocodone) and Demerol (meperidine) to control breakthrough pain and Phenergan (promethazine) to control post-op nausea. The center's anesthesiologists call patients the day after surgery to assess their pain levels and often find they don't need pain pumps beyond 4 days post-op.

• Knees. Keeping patients comfortable following knee replacement surgery requires a multimodal approach: a general anesthetic, a single-shot femoral block and an adductor canal catheter to spare the quadriceps muscles. Patients typically regain quad function on post-op day 1 when the femoral block wears off.

Dr. Hickman also uses a single-shot selective tibial block for posterior analgesia in the knee to control pain during the first post-op night. He'll prescribe a 3- to 4-day supply of Robaxin (methocarbamol) to help control muscle spasms in the posterior knee. To help manage breakthrough pain, patients are sent home with scheduled gabapentin and NSAIDs while oral opioids are used as needed.

One of the center's anesthesiologists stays in touch with patients. "If there are any issues, we'll have them back in before the surgeon even knows there's a problem," says Dr. Hickman. Blocks aren't 100% successful, even for the team of anesthesiologists at Andrews ASC, who place close to 3,000 a year. "It's critically important to manage blocks when there's an issue," adds Dr. Hickman. "That's where a lot of providers fall short."

— Daniel Cook

Shouldering the load
Chris O'Grady, MD, a shoulder specialist at Andrews ASC, says the typical patient suffers from end-stage glenohumeral osteoarthritis, although his patients span the spectrum of older individuals with worn-out shoulder joints to young, active adults with degenerative joints caused by previous injury.

Like Dr. Nilssen, his ability to bring more patients to the surgery center is limited only by Medicare. He points out that performing shoulder replacements in the outpatient setting is inherently less problematic than managing the logistics of ambulation and fall risks for total hip and knee patients. "My patients walk out of the hospital on post-op day 1 with a smile on their face," he explains. "They might as well walk out of the ASC on the day of surgery with the same smiles."

READY TO GO Chris O'Grady, MD, a shoulder specialist at Andrews, says his patients walk out of the hospital on post-op day 1 with a smile on their face.

Dr. O'Grady uses a delta pectoral technique, which is an intramuscular approach that generally limits post-op pain. The procedure involves shaving a few millimeters off the top of the glenoid, a flat oval piece of bone that's part of the shoulder blade. Dr. O'Grady resurfaces the glenoid by reaming it flat and cementing a plastic implant component into the bone. A total shoulder involves replacing both sides of the shoulder joint, while hemiarthroplasty involves addressing either the glenoid or humeral side.

"I perform the same procedure in the ASC as I do across the street at the hospital," he says. "It's an identical procedure. I tell my Medicare patients that I'm required to hold them hostage overnight because Medicare tells me I have to."

The shoulder implant cost is also identical — $7,500 to $8,000. However, the average case payment ensures plenty of margin for the center to profit.

"Procedure volume will absolutely increase," says Dr. O'Grady. "Pain and recovery is getting easier for surgeons and patients to manage, primarily because patients are ambulatory immediately after surgery."

Knees, of course
Demand for total knee procedures is skyrocketing across the country and serves as the foundation of any outpatient joint program. At Andrews ASC, orthopedic surgeon Charlie Roth, MD, replaces the knees of patients with BMIs between 35 and 40 who are free of comorbidities. The total knee system he uses features computerized alignment, thanks to MRI-based cutting blocks, which Dr. Roth says limit blood loss by eliminating the need to drill into the intra-medullary canal on the tibia or the femur. Computerized alignment of the limb also lets Dr. Roth predict the actual size of the implant before implanting it.

Dr. Roth approaches the joint through an anterior longitudinal incision. He laterally resects the patella and extensor mechanism in the knee before cutting blocks are placed on the tibia and femur to shape the ends of both bones. He removes the ACL and possibly the PCL and all meniscus remnants, makes the cuts needed to match the femur and tibia implant components and places trial spacers between the components on the femur and tibia. Once the spacers are placed, he tests the joint's range of motion and makes sure it's stable. He removes the trial spacers and cements in the implant components. Importantly, Dr. Roth performs the procedure without use of a tourniquet, which lets him control bleeding at the time of surgery and reduces risks of post-op clotting and tourniquet-related injury.

Dr. Roth adds that bleeding at the joint is reduced by administering the clotting agent tranexamic and employing bipolar radiofrequency probes that coagulate capillaries within the joint that are invisible to the naked eye. He's done with the typical case in less than 2 hours and says the cases reimburse enough to provide the center with substantial profits. OSM