Orthopedics: More Joint Reconstruction Moving to Outpatient Setting

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Hand and Upper Limb Orthopedic Surgeon Dr. Alejandro Badia Offers Tips on New Techniques, Implants Driving Trend.

The latest evidence indicates that total reconstruction or replacement of the shoulder joint, much like knees and other joints, can be performed effectively in an outpatient setting, with outcomes often superior to those of joint replacements done when patients are in the hospital,

June 2020 – The latest evidence indicates that total reconstruction or replacement of the shoulder joint, much like knees and other joints, can be performed effectively in an outpatient setting, with outcomes often superior to those of joint replacements done when patients are in the hospital, says noted hand and upper limb orthopedic surgeon Alejandro Badia, MD. This avoids many hospital related issues, whether exposure to Covid19, or long standing hospital acquired infections such as MRSA.

Dr. Badia was referencing the latest study, published in the first-quarter 2020 issue of Ambulatory Surgery, indicating that total shoulder arthroplasty -- joint reconstruction – can be conducted safely in the outpatient setting with what scientists call “a low complication rate and a high degree of patient satisfaction.” Any prosthetic joint replacement of the upper limb, such as thumb, wrist, elbow and of course, shoulder, is best suited for outpatient setting simply because the patient does not need to walk on the new joint. Going back to the comfort, and infection free environment, of home in a sling is preferable for many reasons.

The retrospective research, which reviewed the two-year outcomes of participating shoulder-joint patients, corroborates the results of earlier reports, including one that appeared in 2017 in the Journal of Shoulder and Elbow Surgery showing “no significant differences in the 30-day adverse event and readmission rates between outpatient and [hospital] inpatient total shoulder arthroplasty.”

And, it is not just shoulder patients benefitting from the outpatient trend. As early as 2006, scientists writing in the journal, Anesthesia & Pain Medicine, concluded that, with the appropriate post-operative analgesic regimen, a “subset of patients” could undergo total elbow arthroplasty as an ambulatory procedure.

“These studies are among a growing mound of evidence supporting the anecdotal experience of orthopedic surgeons who have reported performing total or partial joint arthroplasty on an outpatient basis safely and at much less cost to the patient AND overall healthcare system,” says Dr. Badia, author of the recently published book Healthcare in the Trenches. Dr. Badia is a specialist in treating joint disorders of the upper limb and is founder of the Florida-based Badia Hand to Shoulder Center and OrthoNOW®, a network of immediate care orthopedic clinics, where he is also Chief Medical Officer.

Despite the benefits of outpatient joint replacement, including lower infection risk and better recovery at home, Dr. Badia agrees with researchers that an effective outpatient orthopedic surgical program is not automatic. “It requires experienced orthopedic surgeons knowledgeable in the latest minimally-invasive approaches to joint replacement; specialized anesthesia protocols including regional block anesthesia, highly trained nurses and other dedicated clinical support staff; aggressive protocols for managing post-operative pain; careful, at-home patient monitoring; and selection and education of the ‘right patients’ for outpatient surgery.”

Dr. Badia says the “right patients” include those who are somewhat younger (under age 70), have a normal or only moderately elevated body mass index and are without any cardiopulmonary disorders or other major ailments. “Good candidates for outpatient joint replacement also need to have a positive mindset and be motivated participants in their recovery and typically have a good support system at home,” he says.

Noted for his application of innovative business principles and technology to enhance patient access to health services, Dr. Badia has been an early physician leader in moving joint replacement surgery to the outpatient setting and sees the trend as only accelerating in the future. A major obstacle continues to be the lack of CMS (Medicare) support for these procedures in stand-alone ASCs (ambulatory surgery centers) although that may change since, ironically, total knee replacements are now reimbursable in this environment, paving the way for other less challenging outpatient joint protocols.

According to a June 1, 2020 Orthopedic Joint Replacement Market Research Report, “the increasing prevalence of bone disease among the geriatric populations” globally will continue pushing demand for partial and total joint replacements. Even now, joint arthroplasties are among the most common surgical procedures in the United States, with more than a million performed annually.

Report authors cite continued development of new surgical techniques, including robotic surgery, and “patient-specific 3-D printed [joint] implants” as helping spur the market for partial and total joint replacements. Dr. Badia says such advancements will only enhance orthopedic surgeons’ capabilities in the future for performing outpatient joint replacements with effective long-term outcomes.

Meanwhile, he offers these tips to patients who have been told they require joint reconstruction and are considering outpatient surgery as an option:

  • Select a surgeon who is experienced in performing successful outpatient joint replacements. For example, results of a 2018 online survey of active members of the American Shoulder and Elbow Surgeons indicated that only about 21 percent of 179 respondents were performing total shoulder arthroplasties. Many times the surgeons are hospital affiliated and simply don’t have good access to this option.
  • Consider a facility where the surgeon is supported by a team trained specifically in joint replacement procedures and where patient education is emphasized.
  • Ask questions, especially concerning postoperative monitoring and pain management.
  • Have the proper mindset; determine to be a positive participant in the recovery process.
  • In a 2015 paper, the Foundation for Government Accountability (FGA) reported that “ambulatory surgical centers and recovery care centers have proven to be lower-cost, high quality care [facilities],” saving patients and employers as much as 60 percent in health care expenses, Dr. Badia says.

“My advice to patients – in the words made famous by Indiana Jones – ‘Choose wisely.’”

Alejandro Badia, MD, FACS, internationally renowned hand and upper-limb surgeon and founder of Badia Hand to Shoulder Center and OrthoNOW®, a walk-in orthopedic care clinic. He is a member of the American Society for Surgery of the Hand, American Association for Hand Surgery and the American Academy of Orthopedic Surgeons and an honorary member of many international professional hand societies. Dr. Badia specializes in treating all problems related to the hand and upper extremities, including trauma, sports injury, joint reconstruction, nerve injuries and arthroscopic surgeries. http://www.drbadia.com http://www.OrthoNOWcare.com

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