LOUISVILLE The days of lengthy hospital stays for surgical procedures are long gone. Much of this is fueled by payers, but it’s also supported by a “healing is best at home” philosophy. Beyond being a pithy phrase, there is data to support that patients heal faster at home and that the risk of infection drops significantly once patients leave the hospital.
With advances in technology, many surgical procedures are trending from inpatient to outpatient, including select orthopedic surgeries. Kevin Harreld, MD, orthopedic surgeon at KentuckyOne Health Orthopedic Associates in Louisville, sees “a trend towards upper extremity surgery as outpatient or a 23-hour hospital stay.” Harreld now performs most of his rotator cuff repairs at Jewish Hospital East and Sts. Mary & Elizabeth Hospital, both part of KentuckyOne Health, as outpatient procedures and sees other upper extremity procedures such as shoulder joint replacement trending in that direction.
“Rotator cuff repairs used to be done through a larger open incision, commonly with an overnight stay,” Harreld says. “Now that would be very uncommon. The majority of orthopedic surgeons now do these arthroscopically, so there are smaller incisions and an outpatient basis for most types of surgeries. Even joint replacement surgeries now are moving towards a 23-hour stay or a same-day outpatient joint replacement. A lot of that is made possible by advances in anesthesia in terms of the regional nerve blocks we can give people to keep them comfortable overnight. They have to have a little less anesthetic, so we’re more comfortable discharging them home.”
In addition to the advances in anesthesia, upper extremity procedures lend themselves to the outpatient setting because, unlike hips and knees, patients do not need physical therapy to be ambulatory immediately. In fact, Harreld says therapy for upper extremities can be delayed up to six weeks out.
Harreld, who went to the University of Louisville School of Medicine, specializes in shoulder and elbow procedures. He completed his orthopedic surgical residency at Wake Forest University in North Carolina and completed his elbow and shoulder fellowship at the Florida Orthopedic Institute. He has been at KentuckyOne Health since 2011. Harreld was interested in orthopedics when he began medical school, he says, because of the opportunity to work with athletes of all ages and to see the immediate benefits his work has on patients.
Harreld most commonly sees rotator cuff tears, closely followed by shoulder replacement, both reverse total shoulder and standard anatomic shoulder procedures, and then shoulder instability such as labral repairs.
However, Harreld cautions that there is a common misconception that every trip to the orthopedic surgeon will result in an operation. “We don’t operate on every rotator cuff; every patient with arthritis doesn’t need a replacement,” Harreld says. “Probably at least 80 percent of the patients I see with shoulder problems get better with injections, physical therapy, medication management, or combination thereof. The majority of people with shoulder pain do not need an operation.”
Many of the patients that Harreld sees are young athletes suffering shoulder and elbow injuries. Swimming, volleyball, tennis, baseball, football, wrestling, gymnastics, and cheerleading all require significant upper body movement. Repeated motion, strain, and fatigue can result in injury. Although the majority of Harreld’s sports medicine patients are male, the number of female athletes with upper extremity injury is growing.
“Shoulder injuries are increasing to a certain extent because kids are more sports-specific now,” Harreld says. “They will play baseball year-round or soccer year-round. They don’t get a rest for their shoulder the way they would if they transitioned from baseball to soccer. It’s well-documented that the incidence of elbow injuries continues to increase in baseball players despite attempts at education, pitch counts, and avoiding throwing curve balls.”
While those sports injuries bring in young patients, many of Harreld’s patients come from the opposite end of the spectrum. Older patients will present with conditions such as arthritis, rotator cuff tears, or fractures.
In addition to arthroscopic rotator cuff repairs, shoulder replacements, arthroscopic bankart repairs, and arthroscopic biceps tenodesis, Harreld also performs elbow procedures including surgeries on fractures, arthritis, and ligament reconstruction such as the well-known Tommy John surgery.
Stemless Shoulder Replacement Advances Treatment
While Harreld performs anatomic total shoulder and reverse total shoulder replacement, the relatively new stemless total shoulder replacement is becoming a preferred method of treatment.
“The stemless design has several advantages,” Harreld says. “Patients seem to have a little less pain post-operatively because we don’t violate the humeral canal. It allows us to put the implant right where we want it, whereas with the stem design the position is somewhat dictated by the stem. This allows us to more perfectly match the patient’s anatomy. It is more bone preserving, so it certainly facilitates any future revision surgeries.”
Harreld says that revision surgeries are becoming more common as patients are outliving their implants. A total shoulder replacement can fail after 10–20 years because either the rotator cuff tears or the plastic socket comes loose. He tries to give patients appropriate expectations that their function should be near normal and they should expect pain relief. “But we aren’t able to put anything back as good as what they were born with,” he says.
While some patients might expect too much from their implant, Harreld says others might not expect enough. “Some people are almost afraid to use the implant after the surgery,” he says. “The reason we do this is so patients can go back to doing activities they enjoy. We wouldn’t do it if we didn’t want people to get back to some level of activity. Finding that balance of expectations is when people are really satisfied.”
For his part, Harreld finds satisfaction in being able to help people and have an immediate, positive impact for the patients. “Orthopedics is a very gratifying field,” he says. “We can make a visible, immediate difference for somebody.”
With 23-hour hospital stays, non-surgical options, and optimal surgical techniques, immediate relief is within reach for patients and their providers.