The Evolution of Outpatient Joint Surgery (March 18, 2021)




ASCA Chief Executive Officer Bill Prentice talks about the evolution of outpatient joint surgery with Dr. Anthony Romeo, a leading orthopedic surgeon who specializes in outpatient shoulder and elbow procedures. Today, thanks to advances in anesthesia, arthroscopic surgical techniques and postoperative pain management, joint surgery is more commonly performed on an outpatient basis, allowing patients to recover more quickly and more comfortably in their own homes. During this discussion, Bill Prentice invites Dr. Romeo to draw on his knowledge and experience of caring for thousands of patients to answer some of the most common questions about outpatient joint surgery.

Narrator: 0:06
Welcome to the Advancing Surgical Care Podcast brought to you by ASCA, the Ambulatory Surgery Center Association. ASCA represents the interests of outpatient surgery centers of every specialty and provides advocacy and resources to assist them in delivering safe, high-quality, cost-effective patient care. As with all of ASCA’s communications, please check to make sure you are listening to or viewing our most up-to-date podcasts and announcements.

Bill Prentice: 0:37
Hi, I'm Bill Prentice, and I'm ASCA’s CEO and host of this episode. On this ASC podcast, I'm pleased to welcome Dr. Anthony Romeo, a leading orthopedic surgeon who specializes in outpatient shoulder and elbow procedures. I've invited Dr. Romeo onto the podcast today to talk about the evolution of outpatient joint surgery. Not long ago, surgery to repair or replace a damaged or diseased joint typically required very invasive surgical techniques, several days of convalescence in a hospital bed and a long and painful recovery for the patient. Today, thanks to advances in anesthesia, arthroscopic surgical techniques and postoperative pain management, joint surgery is more commonly performed every day on an outpatient basis, allowing patients to recover more quickly and more comfortably in their own homes. For the millions of Americans who have firsthand experience with modern outpatient joint surgery, either because they had a surgery themselves or because they helped care for a loved one who did, we have data that tells us they were extremely satisfied with their treatment and their recovery. But we also know millions more have questions about outpatient surgical procedures, and that because we are living longer and living more active lives, the number of Americans who will eventually need joint surgery in the future will only continue to grow. So to help address some of the more common questions about outpatient joint surgery, I've asked Dr. Romeo to share his knowledge and experience with having cared for thousands of patients in the outpatient setting. Dr. Romeo is a graduate of Notre Dame University and the St. Louis University School of Medicine. He completed his residency in orthopedic surgery in the Cleveland Clinic Foundation and a fellowship in shoulder and elbow surgery at the University of Washington Medical Center in Seattle. Dr. Romeo is a member of many professional societies, including ASCA, and is a regular contributor to several medical journals. With that introduction, let me welcome our guest, Dr. Anthony Romeo.

Anthony Romeo: 2:33
Bill, thank you for the opportunity to be with you today.

Bill Prentice: 2:36
So happy you're going to be here with us, Tony, and spend a little time with us. So in my opening remarks, I very briefly summarized how advances in anesthesia, surgical technique and pain management have enabled surgeons like yourself to operate on more patients in the outpatient setting. I'm eager to discuss each of these topics with you but before we talk about how joint surgery has evolved, it might be helpful to our listeners to first talk about which patients are the best candidates for outpatient joint surgery, and those that may still require an inpatient setting. Can you share your perspective and criteria for recommending which patients belong outpatient and which should be seen inpatient?

Anthony Romeo: 3:12
When I'm evaluating a patient in the office and I recognize that they have the appropriate indication for joint replacement, the next thought for me is, where's the appropriate site to perform that procedure? And so I want to make sure that I understand how their overall health is, I want to particularly know about any issues related to heart disease or any issues related to pulmonary disease because they do undergo anesthesia. I also want to know about conditions such as if there's a bleeding disorder that might be a concern, or if there's problems with their diabetes, or problems with their kidneys or liver—so a general health status is very important to understand that they would be capable of being able to have the surgery and go home on the same day. In that same light, I also want to ask them a little bit about their socioeconomic environment. They need to have somebody at home with them to support them, especially for the first few days, and that's very important to do that. They should be motivated to have this procedure and be able to go home, so at times we almost act as a coach to encourage them to say this is going to be a great experience for you and you're going to be home, you're going to sleep in your own bed, you're going to be able to eat your meals in your own kitchen, and that's going to be a much better experience for you. We also look at sort of general overall social determinants of health and see if we need to intervene there. And the key ones are nutrition—sometimes it's remarkable people don't really eat very well and some of our preoperative labs will show that their protein levels are quite low and we know this is a risk factor for complications. We also are very, very strict about the rules with regards to smoking and we would like our patients to be off of smoking for at least a minimum of four weeks so that they don't have a problem with their lungs in any way whatsoever. And we do sort of a general cognitive function test, especially on our older patients. We want to make sure that when they go home, they're going to have the mental capacity to be able to provide their own personal care and work with the people that will be at home with them. So those are the key issues that we'll assess immediately, once we decide this looks like the right kind of patient we want to do in the surgery center.

Bill Prentice: 5:28
That's very interesting and that seems really comprehensive. Before we get on to more questions, we're going to take a very short break to hear a few words from our podcast sponsor. Stand by, and we'll be back shortly.

Narrator: 5:40
This episode of the Advancing Surgical Care Podcast is brought to you by in2itive Business Solutions, a revenue cycle management company who has served the ASC community for over 10 years. in2itive Business Solutions works with existing billing systems to streamline your processes and maximize your centers reimbursements. Visit in2itive today at

Bill Prentice: 6:08
So Tony, let's presume you've determined that I'm a good candidate for outpatient joint surgery. What can you tell me about the anesthesia I'll be given and how sedation has evolved over time, not only in terms of the use of regional anesthetics versus general applications, but also how the medications themselves have evolved and what it will mean for my recovery.

Anthony Romeo: 6:27
This is actually a critical issue with our joint replacement program in the ambulatory surgery center, and what I encourage surgeons to do is to develop essentially a partnership in care of the patient with their anesthesiologist. It really has to be in sync the entire process. We start initially with what we call a thought towards enhanced recovery after surgery protocols that have been developed in inpatient care, and recognized as another way to help the experience in the outpatient environment work very well. And so, again, going back a little bit with regards to their overall status, particularly for hips and knees, they may require a physical therapy evaluation to make sure that you use crutches or canes because they're going to be ambulating with those and they need to pass that test to be able to leave the surgery center. For shoulders, we don't have the same requirement so it's not as much of an issue. We want to make sure that they understand that they're going to have to clean the area of the surgical site. Usually, we recommend two to three days in a row before the surgery so that the patients need to participate in that process. And we let them know that there's going to be some medications that they're going to take to prevent the potential risk for blood clots—typically, low dose aspirin works very, very well for all types of joint replacement surgery to reduce that risk—as well as we're going to be giving them some antibiotics when they come in and just before they leave to try to prevent any risk of infection. With regards to the actual medications, the anesthesiologists have done such a fantastic job in putting together the concept of a multimodal approach to the management of pain, and it actually begins prior to the patient's experiencing any pain, which is a very critical concept for them to understand, too. So we begin typically with acetaminophen, or Tylenol, before the procedure. We give them an anti-inflammatory medication, often a medication known as Celebrex is used and frequently we use Lyrica. Lyrica is a little bit more controversial; this is a medication which is known as pregabalin. It does help to reduce the potential for neurologic symptoms after surgery, but some patients can be very sensitive, so we're careful about that. But that starts even before we do anything for the patient. Then we discuss with them regional anesthesia. This has been such a fantastic advancement in the management of our patients and there's two things that happen. We used to do regional anesthesia or give the patient a block so we would numb up the area where we were doing surgery. With the advent of the use of ultrasound to put the medicine very close but not actually have to disturb or potentially injure the nerves around that area, it's made this part of the procedure much better. They're much more accurate at getting the medicine in the right place and so the blocks have a very, very high success rate, better than 95 percent in most centers. And that allows us to put the medication in the place that's going to give them anywhere from 12 even up to 24 hours of pain relief with some of the medications they add in with the local anesthetic to make that work even better. And that's very important because they go into the procedure without pain, they wake up after the procedure without pain, and then there's a gradual onset of the discomfort, which we then supplement with the oral medications that are typically used in the hospital anyways. And those medications after surgery are going to include our narcotic medication, of course that's going to be important. We continue with an anti-inflammatory medication. We continue with Tylenol as needed, and make sure that that's balanced well so they don't take too much of that medication. And then we do a couple of other things. We make sure that their gastrointestinal system is working well, so we give them a stool softener to make sure that that's working okay. And during the surgical procedure or just before, we use a medication called tranexamic acid. It's a generic medication that really wasn't used on a routine basis, but it's a fantastic medication at reducing blood loss during surgery and appears to be extremely safe. And by doing this, we showed in one of our studies a reduction of up to 100 cc of less blood during the procedure like a shoulder replacement. So you go from about 200 to 250, which is about what you would donate at the Red Cross, down to about 100 to 150. The reduced blood loss causes less swelling, less pain, more comfort. When you put that whole program together, it's amazing the experience the patients have. And for those patients who have had joint replacement surgery in the hospital, and it was sort of the general approach that didn't have this kind of preemptive multimodal process, they will tell you more than 95 percent of the time, there's no way I would have this again in the hospital if I could have this in the ambulatory surgery center. What they're really saying is that whatever you did from the anesthesia point of view and the surgical point of view, that's the way I want to have that done again. And because we push this so strong in the ambulatory surgery center, in fact, the same protocols are now being brought back into the hospital because patient experiences become a much higher priority throughout the entire healthcare system. So I give a lot of credit to our anesthesiology specialists in helping us make this happen.

Bill Prentice: 11:47
Well, I'll tell you for this hypothetical surgery of mine embedded in my question, I feel a lot better about not being concerned about postoperative pain. Well, let's talk about the actual surgery now. You specialize in surgeries to correct and repair damaged and diseased shoulder and elbow joints. I have a three-part question for you. First, tell us about the surgical techniques you use to repair or replace a shoulder joint. Second, please tell us how shoulder surgery has evolved over your career in terms of the invasiveness of procedures. And finally, tell us how these changes have made it possible to do more of these surgeries on an outpatient basis.

Anthony Romeo: 12:23
I'm going to start out with the most common surgical repair that's done in the shoulder, and that's a repair of a rotator cuff tendon. The typical age of the patient is somewhere in their 50s to 60s and the surgical procedure when I started my practice many years ago was an open incision, we took down the deltoid, the larger muscle on the outside, we smoothed off the bone above the rotator cuff and then we took sutures through the tendon and passed them through the bone, and then we sewed everything back up again. And I can tell you when those patients came back at seven to 10 days for the postoperative visit, I knew when I was walking into the room I was going to see somebody that was going to be miserable. No matter what we did in terms of the medication, it was a very, very painful operation, even taking a deep breath was hard for them. And by the time they came in, you could almost sense fatigue of dealing with the level of pain that they were experiencing. When we transitioned to doing this procedure arthroscopically where we did not have to make an incision on the skin other than about a half an inch in size just to be able to put our arthroscope through the deltoid into the shoulder, it changed everything. The patients were so much more comfortable at seven to 10 days after surgery. It was very clear from the procedures being done in the hospital at that time that they could easily have gone home the same day and it rapidly moved into the outpatient environment. We were able to be more specific with our care, we were able to cause less damage to the normal tissues and we were able to be more precise with the actual repair techniques that we used. So, it dramatically changed over the last 20 or 30 years and this is definitely a very, very common procedure done in an ambulatory surgery center that's well accepted by all aspects of the healthcare system—the patient, the anesthesiologist and the surgeon—and it's because of the advancements that we talked about. Now shoulder replacement surgery or joint replacement surgery has been a little bit more difficult because we still have to cut bone to put in a joint replacement. So there is some significant discomfort that would occur from these types of procedures. So it took a little while longer to understand how to adjust our anesthesia, but now that we have this multimodal approach, it's quite remarkable how well patients do. I'm always amazed at someone who has severe arthritis that's lived with it for a number of years and we do a shoulder replacement or knees and hips, and they tell us within one to two days that arthritis pain was gone and only feel it where the incision is. I can handle that, that's easy. That pain from that arthritis and being able to finally get some sleep at night, literally within a few days, most patients will be so gratified that that experience is gone. So, for shoulder replacements, what's happened? Well, actually not a whole lot. In hips and knees, their approaches have been less damaging to the normal tissues—they've kind of gone around the tendons. We don't really have that ability yet in the shoulder. So we still have to take down part of the rotator cuff, but that is essentially a rotator cuff repair. When we remove the arthritic bone and we put in a new arthritic ball and socket, it's remarkable how quickly the arthritis pain goes away. So essentially, the pain that they experienced is the equivalent of a rotator cuff repair, so now we're back on that protocol. So it's been really a wonderful experience for us, and we are now able to do more than 50 percent of our shoulder replacements in the outpatient environment. And the reasons we can't do more is typically related to the patient's medical issues, or things that we talked about earlier, not because of what's actually going on in the shoulder.

Bill Prentice: 16:07
That's fascinating. And of course, from our perspective from ASCA trying to work with the Medicare program, we still need to obviously get total shoulder approved on the ASC-payable list so you could be doing those on Medicare beneficiaries as well. And we're working on that.

Anthony Romeo: 16:24
I greatly appreciate that. As president of the American Shoulder and Elbow Surgeons, we did lobby CMS specifically as you can imagine, self-serving interests of course, but we wanted to get shoulders up there. And they basically said, well, you know, hips and knees are a lot more, let's get those taken care of. And I said to them, shoulders would be so much easier, they should have been first because there would have been no issues with that. But it didn't go over well.

Bill Prentice: 16:49
Yeah, and that's something we're working on. And I would say it's not self-serving, it's obviously to the benefit of the Medicare program because it'll save them tons of money by being able to do these in the ASC setting rather than the hospital outpatient department or inpatient hospital, as well as saving the Medicare beneficiary a lot of money as well, and actually allowing them to get care in a better environment. Let me get on to my last question, which is probably one you get the most often when patients are considering outpatient surgery for something like a total shoulder, the postoperative discomfort and pain that they will have and how they're going to manage dealing with it while they're recovering at home on their own.

Anthony Romeo: 17:28
Part of our assessment of the patient preoperatively that I didn't mention before is their current need for taking narcotic medication. So that's a very important assessment. We need to ask them, are you taking any type of opioid or narcotic medication before surgery, because that's going to affect our ability to manage their pain after surgery. For those patients that are what we call opioid naïve, they really are not taking those medications, we have a pretty strong protocol that works effectively in the vast majority of patients. And what we tell them is that when you're in the recovery room, you will not feel anything in your arm and you'll be comfortable. When you go home, you'll be very comfortable and we want you to kind of make arrangements in your house—that any last-minute arrangements that you didn't do before: make sure your bed is comfortable on the side you're going to sleep and food. And then when you start to feel a little pressure in your arm, take your first dose of your strong pain medication at that time. And the reason why is because usually within 30 to 60 minutes of that sense of pressure is when the actual pain experience will occur. And for the next six to 12 hours, there is a significant sense of discomfort that patients struggle with if they sort of get this attitude that, well, you know what, I'm just gonna see if I can handle this. We try very hard to tell them nobody handles this the first one to two days, take your medication, get through the first 24 hours, get into your daytime of the next day, and then you can start to taper off during the day. But for the next few nights, you're going to need some of the pain medication that would be entirely normal. I do occasionally, rarely, get these individuals who've literally come back and hand me their entire bottle of pills saying, “Doc, I don't know what you did but I didn't need any of these. I just took the Tylenol and I was fine.” And that's a fantastic experience, but we try to prepare them for the fact there is going to be this transition when the block wears off, get ahead of it, stay ahead of it for at least 24 hours, then you can start to manage it.

Bill Prentice: 19:38
That's great. And clearly, I think patients listening to this podcast are going to have a much better sense of relief knowing that they can get care in an ASC or outpatient for one of these procedures and have it done very safely and at a lower cost for themselves and their families. So I very much appreciate the information you've provided to us today. I'm hoping that you'll come with me to Baltimore back when things open up, and we can go lobby together to try and make sure that we get total shoulders and the other joint procedures that are still not payable on the Medicare list.

Anthony Romeo: 20:14
I'd be very happy to do that. I actually started a political advocacy committee in the American Shoulder and Elbow Surgeons, and this was one of the main issues why I initiated that three years ago, and it's kind of taken off. So, we would definitely want to be able to help out and participate to inform CMS what a fantastic experience this is for the patients and we're actually improving the care and giving the patients a better experience, really addressing the triple aim of healthcare very effectively with performing these procedures in an outpatient environment.

Bill Prentice: 20:46
Great. Well, again, thank you very much for being on the podcast. Well, that's all the time we have for today. I hope our discussion has been helpful and informative for prospective patients seeking care, as well as for policymakers who are looking for a better understanding of the evolution of joint surgery. Before we close, I'd also like to thank the sponsor of our Advancing Surgical Care Podcast, in2itive Business Solutions, a revenue cycle management company that has served the ASC community for more than 10 years. So, until next time, please wear a mask and please make sure you get vaccinated as soon as you are eligible so we can all stay healthy and safe.