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ORTHOPEDIC SECTION
Outpatient Rotator Cuff Repairs Increase 272% in
a Decade — 5 Facts on Orthopedics in ASCs
By Jessica Kim Cohen
A
recent article in Journal of the Ameri-
can Academy of Orthopaedic Sur-
geons provided an overview of com-
plications and adverse events associated with
outpatient orthopedic surgery performed in
an ambulatory surgery center.
Here's what you need to know:
1. In the decade between 1996 and 2006,
there was a 272 percent population-adjusted
increase in outpatient rotator cuff repairs.
2. The rate of complications and adverse
events following orthopedic surgery per-
formed at an ASC ranges from 0.05 per-
cent to 20 percent.
3. When considering both surgical and pa-
tient risk factors, the most common compli-
cations following orthopedic surgery at an
ASC are pain, nausea, infection, impaired
healing and bleeding.
4. The most important surgeon-controlled
factors related to complications are surgical
time, type of anesthesia and site of surgery.
5. The most important patient risk factors
related to complications are older age, fe-
male sex, diabetes mellitus, smoking status
and high body mass index.
The article concludes, "As the use of ASCs
continues to rise, an understanding of risk
factors and outcomes becomes increas-
ingly important to guide indications for
and management of orthopedic surgery in
the outpatient setting."
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NYT: Surgeons Divided on Outpatient Total Knees
for Medicare Patients, but Support to CMS Grows
By Laura Dyrda
T
he New York Times ran an article de-
bating whether Medicare should allow
beneficiaries to undergo total knee
replacement in outpatient centers with sur-
geons representing both sides of the issue.
At the center of the story, Ira Kirschenbaum,
MD, chairman of orthopedics at Bronx-
Lebanon Hospital Center in New York and
co-founder of SwiftPath, a technology de-
signed to support outpatient joint replace-
ment centers, describes his satisfaction
with the outpatient knee replacement he
underwent. At 59 years old, he isn't eligible
for Medicare, but he mused that the once
"crazy" idea of sending patients home after
total knee replacements is now a common
consideration in his surgical practice.
Surgeons and healthcare professionals are
divided about whether outpatient total knee
replacement surgery is safe for Medicare ben-
eficiaries; some surgeons have had success
with outpatient procedures while others worry
the widespread implementation could lead to
complications and patient safety issues.
Both sides concede that not every patient —
particularly in the Medicare population — is
a good candidate for the outpatient setting.
In general, outpatient surgery centers serve
otherwise-healthy patients undergoing
elective procedures. Advancement in surgi-
cal technique and pain management part-
nered with a better understanding of post-
surgical rehabilitation and patient education
have made outpatient knee replacement
possible for a certain subset of patients.
Earlier this year, Medicare floated the idea
of removing total knee replacements from
the inpatient only list; the agency did so
once before in 2012 but abandoned its
efforts after receiving negative feedback,
according to the report. However, there
is more support for outpatient total knee
replacements today, according to recent
CMS comments. MedPAC recommend-
ed CMS remove the procedure from the
inpatient-only list in August.
Typically, the physician and patient make
the decision together about the appropri-
ate site of service for surgery, but Medicare
currently does not reimburse for total joint
replacements in ASCs. CMS will likely decide
whether to remove total joint replacements
from the inpatient only list in 2017. The Times
article notes this decision could be reflective
of a "changing of the guard" on Capitol Hill,
as President Donald Trump takes office with
a philosophy to limit government controls.
n
present this information during contract
negotiations as supporting evidence for
a fair and comprehensive contract."
13. Device companies are increasingly
developing strategies around value-
based care and outpatient orthopedic
procedures. Smith & Nephew's Syncera,
DePuy Synthes Advantage, Zimmer
Biomet's Signature Solutions and Flow-
erOrthopedics' FlowerAdvantage are a
few examples. ese programs aim to
help lower the cost of care while main-
taining or improving quality.
14. Research on same-day total joint
replacement patients found compa-
rable outcomes to inpatient orthopedic
surgeries. e research, presented at
the American Academy of Orthopae-
dic Surgeons annual meeting in 2014,
examined 243 patients who either un-
derwent inpatient or outpatient total
knee or hip replacement surgery. e
researchers found:
• 10.2 percent of the patients who
underwent outpatient procedures
were readmitted within 30 days of
surgery, compared to 6.6 percent
of the inpatient procedure group.
• e hospital length of stay didn't
have an impact on patient satis-
faction measurements.
• Outcomes were comparable be-
tween the two groups.
15. Pain management and anesthesia
advancement has played a big role in
transitioning total joints to the outpa-
tient setting. According to an article by
Jack M. Bert, MD, of Minnesota Bone &
Joint Specialists, adductor canal blocks
are the anesthesia procedure of choice
for total knee arthroplasty. Short act-
ing spinal blocks allow for rapid reha-
bilitation and a decreased risk of post-
operative nausea and vomiting. e
anesthesia techniques can help patients
ambulate sooner aer surgery and re-
turn home the same day. e patient's
postoperative recovery can include oral
hyrdrocodone and intravenous fentanyl
"for breakthrough discomfort."
16. Patient selection is critical, as not all
patients are good candidates for outpa-
tient total joint replacement. Dr. Bert
recommends patients be ASA class 1 to
3 and have a BMI of 35 or less, although
he acknowledged that some surgeons
will take patients with a BMI up to 40 if
the patient is otherwise healthy. Some
surgeons also require patients to be 70
years old or younger.
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