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Abstract

Total joint replacement (TJR) surgery in the ambulatory surgery centers (ASCs) has grown significantly over the past several years, along with the ability to improve the value of care. Standardization of high-quality, perioperative care is pivotal to the success of a TJR ASC program. As surgeons are experiencing increasing overhead with decreasing reimbursement, technology integration can provide major advantages. In this article, we will therefore highlight several examples of technologies that are changing the field and improving care in the preoperative, intraoperative, and postoperative settings.

Keywords

outpatient total joint replacement ambulatory surgery center enabling technology

Introduction

Total joint replacement (TJR) surgery in ambulatory surgery centers (ASCs) has grown significantly over the past several years, along with the ability to improve the value of care [7]. Standardization of high-quality, perioperative care is pivotal to a program’s success and is often achieved with the implementation of advanced technologies. Advanced technology in the hospital setting often refers to intraoperative technology such as navigation and robotic platforms. Success in ASCs, however, requires a comprehensive, holistic approach to patient care and implementation of technology throughout the entire episode of care. In this article, we highlight several examples of technologies that are changing the field and standardizing care in the preoperative, intraoperative, and postoperative settings.

Preoperative Applications

For TJR in the ASC, appropriate patient selection, education, informed decision-making, and patient optimization are critical to successful outcomes. Yet traditional, in-person methods are resource-intensive and difficult to achieve in high-volume settings. For many clinicians, appropriate patient selection is one of the main barriers for transition to the ASC, as it requires confidence in the program as well as agreement among team members including anesthesiology, nursing, and physical therapy. Therefore, appropriate patient selection varies widely among settings. Some technologies attempt to standardize the selection processes based on clinical evidence. For example, the Outpatient Arthroplasty Risk Assessment (OARA) score is a clinically proven learning algorithm that evaluates patient comorbidities to determine level of risk associated with rapid discharge and likelihood of successful outpatient TJR outcomes [18]. Researchers compared the OARA to the American Society of Anesthesiologists Physical Status Classification System and Charlson Comorbidity Index for patients undergoing TJR by a single surgeon; they reported higher positive predictive value for same- or next-day discharge using the OARA [18]. While the utility of such a tool depends heavily on the processes and functioning of an ambulatory surgery program, clinicians can use this or other tools to more confidently select patients who otherwise may have been hesitant about proceeding with TJR in an ASC. Alternatively, these tools may prevent a clinician from performing an ASC TJR on an inappropriate candidate. Regardless, appropriate patient selection remains one of the most crucial aspects of a successful TJR ASC program.

In addition to screening tools, several virtual care management platforms are designed to provide educational resources and care in the preoperative setting: mymobility (Zimmer), RecoveryCOACH (Stryker), Velys Patient Path (DePuy), ARIA (Smith & Nephew). These platforms offer a virtual environment to prepare patients for TJR while attempting to offload staff requirements for information sharing, phone calls, messages, and joint classes. Each platform differs with respect to specific function, user interface (ie, web-based, smart phone application), and compatibility with patient wearables. For example, the mymobility platform provides patients with virtual therapy exercises and educational material for their upcoming surgery, collects survey and outcome reports, and allows for telecommunication and messaging. Overall, the platform increases team member efficiency by assisting in time-consuming preoperative tasks. It has the added benefit of following the patient through the entire episode of care and collecting basic objective, functional, patient data that can be used by clinicians to provide individual insights and customize care. Crawford et al [5] compared this platform to conventional physical therapy after partial and total knee arthroplasty and found significant reduction in utilization of 1 or more formal in-person physiotherapy sessions postoperatively as determined by surgeon discretion with no difference in 90-day range of motion or need for manipulation; furthermore, patients were overall more satisfied with the virtual platform experience.

Intraoperative Applications

Perhaps the most widely promoted applications in TJR that have demonstrated adaptability for the ASC are intraoperative technologies. Their main benefit is reproducible execution of intraoperative steps in precise implant positioning and evaluation of soft-tissue tension, ultimately ensuring a high-quality arthroplasty. These technologies include robotic and navigation-assisted platforms that can be placed in a spectrum of offerings from low profile, handheld navigation devices to large, external console, and robotic-assisted platforms. Identification of an ideal platform depends upon many factors unique to an individual ASC, such as operating room size, sterilization requirements, contract and vendor arrangements, surgeon technique, and product familiarity.

Both OrthAlign and Intellijoint offer platforms that are suitable to an ASC with small operating rooms, low-volume technology users, or those with surgeons who prefer different vendors. For total hip arthroplasty (THA), a single-surgeon study of the HipAlign system (OrthAlign) with anterior THA demonstrated a mean accuracy of 3.2° and 1.8° for version and inclination, respectively, when comparing intraoperative measurements to postoperative measurements [13]. The navigation cohort also demonstrated lower fluoroscopic radiation dose and time compared to conventional techniques. Similarly, an evaluation of the Intellijoint HIP system in direct anterior THA reported a mean difference between the intraoperative device and radiographic measurements was 3.4° (standard deviation [SD]: 4.1° for anteversion and 4.0° for inclination) [2]. For TKA, KneeAlign (OrthAlign) is a low profile, handheld navigation system that uses accelerometers and gyroscopes in a small sterile screen to navigate steps in the procedure according to the surgeon’s preference. This product does not rely on an external console, requires no upfront investment, and allows use with multiple implant systems, potentially making it ideal for the ASC setting.

A large, external console, robotic-assisted platform (eg, ROSA, Mako, VELYS, CORI) may be the ideal choice for ASCs with larger size capabilities and vendor alignment between surgeons. Such platforms offer the benefit of preoperative planning that can assist in implant inventory management, in addition to the highest level of navigated execution [10,12,19]. In addition, the same platform can be used for multiple procedures such as total knee, total hip, partial knee, total shoulder, and revision applications; this multiuse capacity increases the value of the individual robot. A novel, smaller robotic system that can be used with multiple implant companies (Think Surgical) is a new alternative surgical robotic system that has just received US Food and Drug Administration (FDA) clearance and may be an ideal robotic system for use in the ASC [17,23]. Robotic-assisted joint replacement has been shown to improve accuracy and precision compared to conventional methods. While reproducibility and efficiency are important to successful outpatient TJR, the specific technology depends on many individual ASC factors [8,21].

There has been rapid innovation in intraoperative technologies. For example, the emergence of mixed and virtual reality platforms represents a relatively new category that varies widely from simple heads-up display to full augmented reality capabilities. Complete virtual reality platforms, such as Osso VR, have changed the way students and trainees are educated but also provide the ability to plan for surgical cases and interaction with anatomy [1,3]. However, when it comes to intraoperative utilization, we are just now seeing applications of the mixed reality experience being used to improve the execution of TJR. HipInsight is the first FDA-cleared mixed-reality navigation application for THA running on the Zimmer OptiVu headset which leverages the Microsoft HoloLens 2 capabilities [16,22]. This application has the ability to navigate component placement in real time without breaking line of sight or the need of a robot or external console. The advantage of this in the ASC remains to be seen. This technology, however, has potential to improve value with potential cost savings from resource management and potential shorter surgery time from operational efficiency.

Regardless of the tool used, significant advantages can be gained from the adoption of intraoperative technologies; this occurs by improving implant, sterilization, and tray management, improving time efficiency, and enabling surgical consistency.

Postoperative Applications

Postoperative technologies can assist with patient monitoring to ensure good outcomes through proactive management of potential complications and assessment of activity or therapy gains [4,14,24]. This is an evolving area, one that may improve care delivery. Given the nature of same-day discharge from the ASC, remote monitoring products are increasingly relied upon to provide access for patients to the clinical team to avoid emergency room visits, misinformation, and poorer outcomes. Currently, patients can be monitored via various wearable devices, virtual care platforms, telehealth platforms, and recently through implants [6]. While many younger patients report being comfortable with wearable technology [9,15], compliance remains a concern. This concern is addressed by the Persona IQ (Zimmer), a smart total knee implant that removes compliance from the equation when it comes to patient monitoring. The implant allows for real-time data acquisition and provides kinematic data that can offer insights to the clinician and allow proactive intervention to prevent poor outcomes. The ZB Edge (Zimmer) connects of all these technologies in the episode of care, with the ultimate goal of improving patient outcomes in a cost and time-efficient manner. Each piece of technology collects data at various stages of the episode of care and stores data red on the patient’s virtual care platform, which is used to educate the patient, provide insights to the clinician for proactive care delivery, and monitor patients passively through an artificial intelligence (AI) model. This allows the patient access to information and the clinical team to provide improved remote care capabilities from the surgeons’ ASC.

The next step to improve time efficiency and outcomes is the incorporation of AI into the postoperative setting, although AI applications throughout the entire episode of care are inevitable [20]. The promise of this technology—to account for hundreds of individual variables from an ever-growing data set—will allow clinicians to customize care to individual patients. This may mean improvements to preoperative risk stratification, intraoperative decision-making, or postoperative recommendations and preventative treatments [11]. We will discover more creative uses as AI becomes ubiquitous in health care.

Conclusions

Adoption of perioperative technology is crucial to success in an era of increasing overhead and decreasing reimbursements. The specific technology should be tailored to the ASC’s resources, physical capacity, and surgeon preferences. A needs evaluation is recommended to determine the most suitable technologies to integrate, but many options are available, as the industry evolves to incorporate AI, improved user experiences, and smart decision-making capabilities.

Supplemental Material

sj-docx-1-hss-10.1177_15563316231209500 – Supplemental material for Joint Replacement Technology in the Ambulatory Surgery Center: Current and Future Applications

Supplemental material, sj-docx-1-hss-10.1177_15563316231209500 for Joint Replacement Technology in the Ambulatory Surgery Center: Current and Future Applications by James B. Chen, Tracy M. Borsinger, Brian P. Chalmers and Eytan M. Debbi in HSS Journal®

Supplemental Material

sj-docx-2-hss-10.1177_15563316231209500 – Supplemental material for Joint Replacement Technology in the Ambulatory Surgery Center: Current and Future Applications

Supplemental material, sj-docx-2-hss-10.1177_15563316231209500 for Joint Replacement Technology in the Ambulatory Surgery Center: Current and Future Applications by James B. Chen, Tracy M. Borsinger, Brian P. Chalmers and Eytan M. Debbi in HSS Journal®

Supplemental Material

sj-docx-3-hss-10.1177_15563316231209500 – Supplemental material for Joint Replacement Technology in the Ambulatory Surgery Center: Current and Future Applications

Supplemental material, sj-docx-3-hss-10.1177_15563316231209500 for Joint Replacement Technology in the Ambulatory Surgery Center: Current and Future Applications by James B. Chen, Tracy M. Borsinger, Brian P. Chalmers and Eytan M. Debbi in HSS Journal®

Supplemental Material

sj-docx-4-hss-10.1177_15563316231209500 – Supplemental material for Joint Replacement Technology in the Ambulatory Surgery Center: Current and Future Applications

Supplemental material, sj-docx-4-hss-10.1177_15563316231209500 for Joint Replacement Technology in the Ambulatory Surgery Center: Current and Future Applications by James B. Chen, Tracy M. Borsinger, Brian P. Chalmers and Eytan M. Debbi in HSS Journal®

Footnotes

Declaration of Conflicting Interest

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Tracy M. Borsinger, MD, declares no potential conflicts of interest. James B Chen, MD, reports relationships with Canary Medical, OrthAlign, and Zimmer Biomet. Brian P. Chalmers, MD, reports relationships with Ortho Development, and Smith & Nephew. Eytan M. Debbi, MD, PhD, reports relationships with DePuy, Ortho Development, and Think Surgical.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Human/Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.

Informed Consent

Informed consent was not required for this review article.

Required Author Forms

Disclosure forms provided by the authors are available with the online version of this article as supplemental material.

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