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Issue: December 2020
Source: Amin N, et al. Arthroscopy. 2019;doi:10.1016/j.arthro.2018.09.030.
Disclosures: Amin reports he is a consultant and is on the surgeon board for Trice Medical. Bailie reports he is chief medical officer at Integrated Endoscopy. Culp reports he has a consulting agreement with Arthrex and has royalty agreements with Arthrosurface and Zimmer Biomet. Dines reports he is a consultant for Arthrex and a former consultant for Trice Medical. McMillan reports he is a paid consultant for Trice Medical and Arthrex. Tokish reports he is a consultant for and receives royalties from Arthrex; is on the scientific advisory board for DePuy Mitek; is associate editor of the Journal of Shoulder and Elbow Surgery; and the Mayo Clinic Arizona Orthopedic Sports Medicine Fellowship receives support from Arthrex, Johnson & Johnson and Smith & Nephew.
December 16, 2020
10 min read
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Advancements pave the way for office-based surgery

Office-based surgery may present challenges to orthopedic surgeons

Issue: December 2020
Source: Amin N, et al. Arthroscopy. 2019;doi:10.1016/j.arthro.2018.09.030.
Disclosures: Amin reports he is a consultant and is on the surgeon board for Trice Medical. Bailie reports he is chief medical officer at Integrated Endoscopy. Culp reports he has a consulting agreement with Arthrex and has royalty agreements with Arthrosurface and Zimmer Biomet. Dines reports he is a consultant for Arthrex and a former consultant for Trice Medical. McMillan reports he is a paid consultant for Trice Medical and Arthrex. Tokish reports he is a consultant for and receives royalties from Arthrex; is on the scientific advisory board for DePuy Mitek; is associate editor of the Journal of Shoulder and Elbow Surgery; and the Mayo Clinic Arizona Orthopedic Sports Medicine Fellowship receives support from Arthrex, Johnson & Johnson and Smith & Nephew.
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In the 1990s, with advancements in technology and greater patient demand, physicians began to shift from performing surgical procedures in a hospital or ASC to an office-based setting.

Randall W. Culp

“[Office-based surgery] began probably 20 or 25 years ago when physicians were seeing diminishing health care reimbursements and, at the same time, there was growing consumer demand for surgical procedures,” Randall W. Culp, MD, FACS, of the Philadelphia Hand and Shoulder Center and professor at Thomas Jefferson University Hospital, told Orthopedics Today. “In addition, there was growing concern about the cost of health care, in general. So, physicians began to shift initially from hospital based to surgery center based and then after that, they shifted to in-office procedures.”

Nirav H. Amin

However, sources who spoke with Orthopedics Today noted the adoption of office-based therapeutic procedures is relatively uncommon among orthopedic surgeons as it is still in its infancy. Prior to the adoption of any new technology, Nirav H. Amin, MD, associate professor at VA Loma Linda and Restore Orthopedics in Orange, California, noted there is a timeframe for showing the safety and efficacy, as well as clinical effects and relevance, of the procedure platform. He believes the foundational steps of safety have been validated and now the clinical utility and benefits are growing in an expedited manner.

“Clearly, we have seen a shift from the hospital to the ASC setting and I think over time, in the next decade or so, we may see some of the procedures that are historically done in an ASC shift into the office-space model,” Amin said. “Additionally, needle arthroscopy has the ability to improve visualization in current surgical procedures, such as massive rotator cuff repairs, PCL reconstructions and other complex arthroscopic procedures.”

Office-based diagnosis

Among procedures currently performed in the office, arthroscopy has become a diagnostic solution for patients who either cannot undergo MRI or choose not to wait for an MRI while providing the visualization of standard arthroscopy, according to Sean McMillan, DO, chief of orthopedics at Virtua Willingboro in Burlington, New Jersey.

Sean McMillan, DO, said in-office arthroscopy is a diagnostic solution that provides the visualization of standard arthroscopy and may be preferable to use over MRI in many instances.

Source: Sean McMillan, DO

“The idea of being able to insert a tiny camera in [the joint] made sense because ... arthroscopy is still considered a gold standard for intra-articular pathology and [in-office arthroscopy] is similar to doing a scope in the operating room,” McMillan told Orthopedics Today.

John M. Tokish

John M. Tokish, MD, professor and consultant of orthopedic surgery and fellowship director of orthopedic sports medicine at Mayo Clinic Arizona, said in-office second-look arthroscopy can be advantageous in the evaluation of meniscal repair, integrity of cartilage and stability of an osteochondritis dissecans lesion.

“If one wants to evaluate early a rotator cuff reconstruction, a lot of time we do that with ultrasound, but if one wants to truly get inside the joint and look more carefully, you can probably do that now,” Tokish, an Orthopedics Today Editorial Board Member, said.

With the availability of technology that allows surgeons to see within the joint, he said the next step is to identify additional uses. With the proper technology, Tokish said surgeons may be able to perform a lateral epicondylitis release, ankle arthroscopy, debridement of plica tears in the ankle and biceps tenotomy in an office-based setting.

“[Surgeons] may be able to do some meniscal pathology in the knee. [When patients] have a meniscal tear or a flap, they might be able to remove that from the area,” Tokish said. “Depending on how we can do with pain control, one wonders if it is possible to potentially do things like cartilage procedures in the elbow or in the small joints in that regard.”

The adoption of wide-awake local anesthesia no-tourniquet (WALANT) has facilitated performing office-based procedures for hand and wrist pathology, such as trigger finger release, percutaneous Dupuytren’s release, fracture reductions and pin removal, carpal tunnel release and tendon repairs, according to Culp. The use of epinephrine during WALANT reduces bleeding and allows hand and wrist procedures to be performed without a tourniquet, paving the way for more procedures to be performed in the office, he said.

“Even flexor tendon repairs, which would almost be taboo to do in the office and are almost always taken to the hospital for the operating room or a surgery center, now can be done safely in the office with wide-awake anesthesia,” said Culp, who is an Orthopedics Today Editorial Board Member.

Pain control challenges

The amount of anesthesia to use and methods to control pain are two challenges related to in-office orthopedic procedures, according to Tokish, who told Orthopedics Today, “We want to make it as pain- free as possible.”

Tokish said one challenge is determining which procedures will be reimbursed by insurance companies.

For office-based hand and wrist procedures that are reimbursed, Culp has found the amount of reimbursement is the same or more than for hospital-based procedures.

“As long as [the procedure is] safe, [insurance companies] are happy that surgeons are doing them in the office as opposed to a hospital or surgery center,” he said.

Visualization and quality of imaging during office-based diagnostic arthroscopy is a concern, according to Amin.

However, McMillan noted the quality of in-office imaging has improved over time with the equipment he uses.

“The quality of the images for the various systems that are out there right now have gotten better in the last 5 years and tremendously better in the last 10 years,” McMillan said. “They are still a bit behind what we see in the operating room, but they are more than adequate and sufficient, meaning I do not worry about missing pathology based on the quality of the image.”

Office integration

As office-based procedures are still on the early side of adoption, Amin noted surgeons may experience challenges integrating these into the office workflow.

Tokish said it is currently more efficient for surgeons to perform these surgeries in a hospital OR where the instruments and patient are already prepped.

“In the in-office setting, anesthesia, position, sterile fields, prepping, draping all become the surgeon’s responsibility, so then, at some point, ... [surgeons realize] this is taking up more time in the office than it would be in the OR,” Tokish said.

When implementing office-based arthroscopic procedures, Culp said it is important to have a dedicated room in the office with a good light source, a small surgical table with a minimal number of instruments, spare drapes and a tourniquet to use for non-WALANT procedures.

“We happen to have a mini C-arm in our area which is helpful for fractures, for simple pinnings, and we also have an ultrasound,” he said. “When you are doing arthroscopy of the wrist or fingers, you want to be careful about where you put your anesthesia ... Ultrasound can help with that if you are lucky enough to have one.”

Reduced complication rates

Advantages associated with office-based diagnostic arthroscopy performed percutaneously include quicker, less painful recovery, according to McMillan.

A study by McMillan and colleagues showed office-based intra-articular knee and shoulder arthroscopy had low complication rates.

“We found the complication rate from doing in-office needle arthroscopy in regard to major and minor complications, with major being infections or breaking of instruments and minor being vasovagal or soreness that requires medications postoperatively, was the same as that of regular in-office injections,” McMillan said.

A patient who is awake poses an advantage to physicians with regard to surgical outcomes as this allows the patient to actively participate in the repair, according to Culp. During a typical flexor tendon repair, the repair may become held up on pulley systems in the finger, leading to its rupture or poor range of motion. However, an awake patient “can show you exactly whether there is any problem with the repair and the pulleys in the finger and, with some judicial use of venting of those pulleys, you can prove to yourself and the patient that there is no impingement of the repair on any of the pulleys,” Culp said.

Ideal candidates

Complications may be reduced by performing a patient safety profile prior to deciding whether to perform an office- or hospital-based procedure, according to Amin. As local anesthetic is used in lieu of regional anesthetic, surgeons should avoid performing office-based procedures on patients with chronic pain syndrome or fibromyalgia, he said.

“Someone who has potential for not being a good candidate for tolerating a surgical procedure in the office is someone who probably has chronic opioid use or opioid tolerance,” Amin told Orthopedics Today. “Those patients probably need to be shifted to a safer and more controlled environment.”

Joshua S. Dines

Cases that present a possible bleeding problem or require added sterility should not be performed in the office, Culp said.

“For example, a total elbow or total wrist replacement may best be done in [a hospital] because you can give IV antibiotics,” Culp said.

Patients with multiple medical comorbidities should not undergo office-based procedures where an anesthesiologist is unavailable, according to Joshua S. Dines, MD, orthopedic surgeon at Hospital for Special Surgery.

Other patient factors to consider when it comes to office-based procedures include patient age and anxiety levels, Culp noted.

“I do not think kids {[younger than] than 6 [years of age] or so are going to be able to do well and maybe even some older children would probably not be best served by doing [their surgery] in-office,” Culp said. “If there is an anxiety problem with the patient, I do not think this is a good idea.”

However, anxiety is not solely a factor that should be considered for patients, he said.

“I also think you should not be an anxious physician,” Culp said. “[For] some physicians, [office-based procedures are] not a good idea. This is not the way they like to run things.”

‘Not a cure all’

Dines noted that office-based diagnosis and procedures are not a cure all and do not offer all the benefits of the OR.

“You have to have a good discussion with the patient beforehand and have a firm idea of what you are going to try to accomplish from a procedural standpoint to make sure that it can be done safely in the office,” Dines said.

David S. Bailie

David S. Bailie, MD, FAAOS, president of Arizona Institute for Sports Knees and Shoulders LLC and chief medical officer of Integrated Endoscopy, told Orthopedics Today arthroscopic procedures should be performed in a surgical facility, despite the cost-effectiveness and safety of current office-based technologies, such as the NanoScope (Arthrex) and Mi-Eye 2 (Trice Medical).

“[In-office arthroscopes] may be useful for a small, select group of diagnoses, but unless you have a sterile environment and a safe environment to do invasive procedures in the office, which many places do not, ... you run the risk of infection and [complications],” he said.

Also, office-based needle arthroscopy used to be less expensive than MRI, but that is no longer the case, Bailie said.

“Now that MRIs are only a couple hundred bucks ... and they are covered by insurance, it is not worth doing an invasive procedure for diagnostic purposes when that ability to see everything is limited with arthroscopy vs. an MRI where you can see the areas in the joint, as well as the areas around the joint,” Bailie said.

He explained that patients are mostly unaware of office-based diagnostic arthroscopy and many would become frustrated at the prospect of undergoing a minimally invasive procedure now and possibly scheduling another procedure at a later date.

There may be cases in which the surgeon determines from an MRI that a simple procedure can be done with in-office arthroscopy to address the pathology, Bailie said.

“That may be something that comes to fruition, but I am not familiar with anybody who is doing that at any significant level unless they have some financial interest in doing it,” he said.

Removed touch points

Despite overall challenges and hesitation associated with office-based surgery, Culp saw an increase in office-based procedures at his institution when hospitals and ASCs were required to pause elective surgeries in the spring to conserve personal protective equipment due to the COVID-19 pandemic.

McMillan said he found his patients were “a bit leery” of coming into the office to then have to go to another facility to undergo diagnostic testing.

“Depending on where you live, a lot of times these MRI machines are actually in hospitals, which patients are trying to stay away from because of the fear of COVID and, more importantly, they are now going to see and interact with another group of individuals, technicians, whomever it might be, to get the MRI done,” McMillan said.

In the post-COVID era, the ability to eliminate multiple touch points during care of a patient with office-based surgery may be invaluable, according to Amin.

“People are going to have to change the shift of dialogue as we move forward, especially for patients in this post-COVID era” in response to the rise and decrease in COVID-19 cases in some geographic areas in the United States, Amin said.

Culp said office-based procedures will be done more often in the future, not only due to COVID-19, but to reduce health care costs, as well. However, how the future of office-based procedures unfolds will have a lot to do with continued surgical and technological improvements, according to Dines.

“We are just in the infancy of this diagnostic arthroscopy and in-office arthroscopy. As we get better at it, as the instruments improve, we will probably do more, but now most people would err on the side of being more conservative and err on the side of caution and do less in the office,” he said.