Is Outpatient Surgery a Viable Option for Shoulder Arthroplasty?
Dr. Quin Throckmorton answers questions from ICJR on the future of shoulder replacement as an outpatient procedure.
ICJR: Outpatient surgery is a hot topic in hip and knee replacement. Do you think shoulder specialists are ready to perform shoulder arthroplasty on an outpatient basis?
Thomas (Quin) Throckmorton, MD: Outpatient shoulder arthroplasty has been shown to be a safe alternative to surgery in the hospital setting in appropriately selected patients; in fact, patient selection has been found to be absolutely paramount for safe outpatient procedures. 
In general, good candidates for outpatient shoulder arthroplasty:
- Are less than 70 years old
- Have a BMI less than 35
- Have minimal cardiopulmonary risk factors, such as chronic obstructive pulmonary disease, sleep apnea, coronary artery disease, hypertension, congestive heart failure
Similar to our hip and knee colleagues, shoulder specialists need to develop pathways for blood management and pain management prior to initiating an outpatient shoulder arthroplasty program, as well as commit to being available for questions after the patient leaves the facility.
An issue unique to shoulder surgeons is the complication rate for indwelling interscalene catheters: The associated pulmonary risks are a concern with patients undergoing outpatient shoulder arthroplasty. 
However, a combination of careful patient selection and the development of appropriate perioperative pathways make outpatient shoulder arthroplasty a viable option for shoulder specialists.
ICJR: Do you think outpatient shoulder arthroplasty will become as widespread as outpatient hip and knee replacement in the next 5 years?
Dr. Throckmorton: The current data and level of interest suggest that demand for outpatient joint replacement procedures in general is going to rise. It is certainly an attractive option for healthy and active patients who prefer to avoid the hospital environment.
Much will depend on the decisions of government payers (Medicare and Medicaid) regarding approval for outpatient joint replacements. CMS is currently considering whether to allow outpatient hip and knee arthroplasty, but there has yet to be a similar movement for shoulder arthroplasty.
Our experience at the Campbell Clinic indicates that roughly 40% of all patients (and up to 75% of commercially insured patients) are candidates for outpatient lower extremity arthroplasty. In contrast, only 15% to 20% of our shoulder arthroplasty candidates are appropriate for an outpatient procedure. Remember, too, that shoulder arthroplasty is performed much less commonly overall than hip or knee arthroplasty
Therefore, although the number of outpatient shoulder arthroplasty will likely rise in the future, it is difficult to predict that it will equal or surpass outpatient hip or knee arthroplasty.
ICJR: Which protocols and processes would need to be in place for surgeons to feel they could safely perform outpatient total shoulder arthroplasty?
Dr. Throckmorton: The most important process for any outpatient joint replacement program is buy-in from all stakeholders. This includes group and facility administration, nursing staff, OR staff, anesthesia providers, and partners. We found that multiple meetings among stakeholders were necessary to generate consensus on patient selection and the appropriate pathways.
The relevant pathways include the following:
- Prehabilitation, which prepares the patient for surgery and helps to set appropriate expectations
- Patient selection, which requires close collaboration with anesthesia providers and perioperative nursing staff to ensure the right patients undergo outpatient procedures
- Blood product triggers, which includes an agreement with a hospital for transferring patients from the ambulatory surgery center to the hospital should they require admission
- PACU staff education, which reinforces the unique discharge criteria for joint replacement patients
- Pain control, which focuses on a multimodal pain management regimen 
- Post-discharge availability, which requires surgeons and their staff to be available for phone calls and questions after the patient leaves the facility
- Outcomes tracking, which allows the facility to provide data to payers on outcomes associated with the outpatient program (including complications or perioperative events). Tracking the data is crucial for negotiation of insurance contracts for outpatient arthroplasty.
- Brolin TJ, Mulligan RP, Azar FM, Throckmorton TW. Neer Award 2016: Outpatient total shoulder arthroplasty in an ambulatory surgery center is a safe alternative to inpatient total shoulder arthroplasty in a hospital: a matched cohort study. J Shoulder Elbow Surg. 2017 Feb;26(2):204-208. doi: 10.1016/j.jse.2016.07.011. Epub 2016 Aug 31.
- Weller WJ, Azzam MG, Smith RA, Azar FM, Throckmorton TW. Liposomal bupivacaine mixture has similar pain relief and significantly fewer complications at less cost compared to indwelling interscalene catheter in total shoulder arthroplasty. J Arthroplasty. 2017 Mar 16. pii: S0883-5403(17)30219-X. doi: 10.1016/j.arth.2017.03.017. [Epub ahead of print]
About the Expert
Thomas (Quin) Throckmorton, MD, is Professor of Shoulder and Elbow Surgery and Residency Program Director in the Department of Orthopaedic Surgery at the University of Tennessee-Campbell Clinic in Memphis.
Dr. Throckmorton has disclosed that he is a consultant for Zimmer Biomet for shoulder arthroplasty. In addition, his practice group owns 2 ambulatory surgery centers that house their outpatient joint replacement program.