What Are The Biggest Opportunities for Orthopedics in ASCs? 3 Orthopedic Surgeons Weigh In

Here are three orthopedic surgeons discussing the biggest opportunities for orthopedics in ASCs in the coming years. Kevin Stone, MD (The Stone Clinic, San Francisco): One of the biggest opportunities in ASCs over the next few years will be the enormous growth of the biologic knee replacement. There are multiple forces driving this growth — an aging population, dissatisfaction with artificial joint replacement and the rapidly advancing science of stem cells, articular cartilage regeneration and meniscus transplantation.

A biologic knee replacement involves multiple procedures combined into one surgery. The goal of a biologic knee replacement is to preserve the biology of the knee, restore a biomechanically favorable environment and provide a buffer to prevent bone-on-bone contact and pain. We see a time in the near future where surgeons will be doing more of this type of biologic replacement than artificial knee replacements.

The last few years have seen improvements in cartilage repair and regeneration procedures, with excellent results reported from articular cartilage paste grafting, a procedure using a paste of a patient's stem cells and bone marrow and cartilage from their intercondylar notch to regrow articular cartilage. This ability to treat damaged cartilage will lead to the widespread adoption of a new preemptive approach to arthritis, where damaged joints are repaired soon after injury to prevent arthritis from forming.

Loss of the meniscus cartilage, the shock absorber in the knee joint, leads to increased forces across the knee, and because impact is concentrated in a smaller area, causes traumatic arthritis. These events are preventable by early replacement of the missing meniscus with a cadaveric meniscus transplant. Once arthritis is established then the articular cartilage must be repaired and the meniscus replaced.

The ligaments of the knee guide the motion of the joint and provide stability. The arthritic knee benefits from stabilization when the cartilage surfaces are also repaired and replaced. New ligament techniques and the use of bone patellar tendon bone allografts permits reconstruction with significantly less damage to the knee than in the past.

This combination of articular cartilage repair, meniscus replacement and ligament reconstruction defines the total biologic replacement program we have created at The Stone Clinic and in the San Francisco Surgery Center. We expect these procedures to expand rapidly to centers worldwide and capture a significant portion of the population who would rather remain biologic rather than become bionic.

Casey Taber, MD (The San Antonio Orthopaedic Group): I think one area that surgical centers can potentially have a big opportunity in the field of hip arthroscopy. Hip arthroscopy is a procedure that typically takes anywhere between 1.5 to three hours to perform. We typically perform labral repairs and bony decompression. Other procedures include trochanteric bursectomy, flexor tendon releases, loose body removal and synovectomy.

Based on the patient's personality and the procedure necessary to perform, many patients that fall under this category can be done as a same-day surgery. I typically treat them with general anesthesia and combined local injection with Naropin, Duramorph and Toradol. Other anesthetic options include a spinal or lumbar plexus block. There are some people that require 23 hour observation on patients who have a labral repair and big bony resection.

The only special equipment necessary that most surgical centers do not have is a fracture table or a distraction table. Financially, it is much cheaper to buy the distraction table, which is made by Smith & Nephew or Arthrex. Both work excellent and actually are probably easier to use than a true fracture table. You will also require a C-arm. I think this is a great opportunity to take advantage of a new procedure. It is easier on the patients and easier on the physicians.

Joshua Siegel, MD (Northeast Surgical Care, Newington, N.H.): There are several factors that will provide great opportunities for orthopedics in ASCs in the coming years. They include changing patient demographics, the evolution of healthcare models, technology advances in surgery and anesthesia and biologics replacing traditionally larger procedures.

There are increasing numbers of aging Baby Boomers who have high expectations of remaining physically active throughout their later years. This has forced many of us to change the way that we deliver healthcare. As orthopedic surgeons, we continue to pursue more technologically advanced surgical procedures, offer new and innovative injections or other minimally invasive treatments and work with medical device companies to develop better equipment to improve efficiency and outcomes. All of which fit well into the ASC model.

Healthcare models are evolving to encourage the use of ASCs and outpatient facilities for procedures. The major healthcare providers understand the potential cost savings of directing an outpatient knee or shoulder procedure to an ASC and they are passing along these savings through site-of-service plans and other benefit programs.

As arthroscopic techniques advance, we are seeing more instances where diseases or conditions are caught in an earlier stage and treatment is aimed at slowing or even curing the disease before it creates irreversible damage. The ASC model of outpatient, highly skilled staffing with state-of-the-art equipment allows for the delivery of these procedures in a very cost effective manner.

Another example is the advancement of joint instrumentation which allows us to biologically resurface chondral injuries in knees and shoulders. Also, the advancement of digital imaging provides us with more accurate pictures of pathology allowing us to diagnose and treat many conditions that previously would have not been possible. 

New technologies have brought the whole world of biologic treatments which are ideally done in an ambulatory setting. In fact, these new types of procedures offer many advantages to ASCs where traditionally we have done our most advanced arthroscopic work. The hospital settings have been much slower to allow for the procurement of the new equipment and to approve these advanced procedures. Because ASCs tend to be more progressive and innovative, new biologic advancements will continue to improve efficiency and bring more cases.

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