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Shafic Sraj, M.D., began performing awake orthopedic procedures with patients under local anesthesia out of need. His small community practice had limited access to an anesthesiologist. A specialist in hand, upper extremity and sports medicine, he soon became confident that he could operate on patients while they were awake in a dedicated clinic room. The results — better patient outcomes, quicker room turnovers, fewer resources and less waste — led Dr. Sraj to shift his views on orthopedic surgery.
That was more than a decade ago. Dr. Sraj is now an Associate Professor and Director of System Integration in the Department of Orthopaedics at West Virginia University. Patients seek him out to forgo a trip to the hospital for a variety of procedures: carpal tunnel and trigger finger releases; tendon repairs, reconstructions and transfers; arthritis surgery; and fracture repairs. Further, Dr. Sraj has taught generations of residents how to perform procedures with the wide-awake local anesthesia no tourniquet (WALANT) approach in the office setting.
“This is definitely a growing field. Surgeons are posting their experiences on social platforms and teaching these techniques to younger generations, which is going to have an exponential effect on growth moving forward,” Dr. Sraj said. “I believe hand surgeons have been the leaders, but we’re seeing interest in sports medicine and foot and ankle. Even spine surgeons have started performing awake surgery.”
The movement of joint replacement, trauma and spine procedures to ASCs has gained significant traction in recent years and is expected to experience double-digit growth for the foreseeable future. Orthopedic surgeons and companies focused on sports medicine and trauma applications seek to move low-risk procedures out of operating rooms and into offices. They liken it to a dental visit, where the patient walks in, has the procedure and walks out.
This exciting shift in orthopedics will require advancing technology and training surgeons in minimally invasive techniques to achieve success.
Technology Advancements
Size matters for office procedures. Visual equipment needs to be small to fit the space. Instruments and implants need to allow for minimally invasive techniques to aid in faster procedures and quicker recoveries.
Arthrex developed Nano or needle arthroscopy instruments that provide an even less disruptive approach than standard instruments for arthroscopy procedures. Nano arthroscopy uses a 1.9mm, high-quality camera at the tip of a wirelike device, along with other arthroscopic instruments, to diagnose and treat various injuries and conditions within joint spaces. The approach is being used for chronic shoulder issues, carpal tunnel syndrome, meniscal injuries and ankle instability.
Surgeons can perform these procedures in an office-based setting under local anesthesia due to its less invasive nature, said Eric Butler, Senior Director of Product Management, Imaging and Integration at Arthrex. Patients favor this environment, he added. One study reported that 87% of patients prefer a procedure room with local anesthesia instead of an operating room with general anesthesia.1
Nano arthroscopy is linked to less nerve damage, high patient satisfaction rates and faster recovery, according to Mr. Butler. Studies have shown that at two weeks post-op, patients who underwent Nano arthroscopy reported a higher quality of life than those who underwent traditional arthroscopy.2 Another study reported that 96% of patients returned to activity within four weeks of an ankle procedure.1 Because Nano arthroscopy employs a poke-hole or tiny incision, it results in reduced fluid distension, minimal tissue disruption and a small scar.
“While Nano arthroscopy allows for a faster recovery, it also promotes a fast pathway to treatment, as other ways to see and diagnose injuries, such as MRI, may not be necessary,” Mr. Butler said. “Nano can often be used to diagnose and treat many injuries in the same visit.”
Sonex Health seeks to transform the treatment of carpal tunnel and trigger finger release with ultrasound-guided procedures. While sports medicine surgeons are familiar with ultrasound, its use for procedures is new to many hand surgeons. Ultrasound-guided wrist and finger procedures allow for a minimally invasive approach performed under local anesthesia, after which patients can return to work within days instead of months or weeks.
“These procedures are well known, but they require dissecting down and retracting tissue. It’s not the cutting of the TCL to relieve the compressing that’s the biggest challenge for carpal tunnel patients; it’s the wound healing and recovery time afterward,” said Bob Paulson, CEO of Sonex Health. “If you’re going to perform these less invasively in the office, you need improved imaging technology. For the first time, ultrasound allows surgeons to visualize and distinguish the critical anatomy in the hand — the bone, tendon and ligaments — and operate on them in a less invasive manner.”
Mr. Paulson noted that advancements in imaging and processing power in the past decade have significantly improved the quality and footprint of ultrasound technology. What used to be a $200,000 machine that sat on a cart in the radiology department is now a $20,000 piece of equipment the size of a laptop that can move to any room, he added.
Sonex Health’s UltraGuideCTR and UltraGuideTFR are single-use instruments. The technologies’ ease of use also allows surgeons to diagnose and treat a patient on the same day in some instances. Mr. Paulson shared the story of a determined rancher who drove hours to be diagnosed, chose to have the procedure done and then dug postholes for a new fence the next day.
The company’s minimally invasive approach requires a pressure bandage instead of stitches, allowing patients to return to activity once their wound heals. Sonex Health, which recently launched a registry, has collected data on 1,000 patients and 1,300 hands that demonstrate consistent outcomes of two to three days return to activities and three to five days return to work.
Dr. Sraj said the introduction of ultrasound guidance, wireless scopes and smaller high-resolution visualization screens will help push procedures out of the operating room. “I don’t have room for old-fashioned arthroscopy towers in my office surgical suites,” he said. “I want wireless equipment that connects to a tablet that is put on a table.”
He also noted that during office surgeries, he uses sterile O.R. drapes, instruments, sutures and devices that are “lean and green,” which take up a smaller environmental footprint and create less waste. Dr. Sraj has an autoclave in his office, but he still relies on his local hospital. The move toward sterile packaged, single-use instruments and implants will boost the number of procedures that can be done in an office, he added. The flexibility of the office setting allows him to diagnose a patient at 9 a.m. and treat them at 10 a.m. if his schedule and inventory permits and prior authorization doesn’t cause a delay.
For Dr. Sraj, the biggest advantage gained from performing office surgery using WALANT is the ability to tell the patient what he’s doing step by step.
“I’m able to educate them and give them a much better understanding of what’s happening and what I’m trying to achieve, especially during surgery that requires active testing,” he said. “If I’m repairing or transferring a tendon while the patient is awake, the patient can test the tendon and give me immediate feedback. They also become part of the team and appreciate their role in achieving sought-after success. Also, anecdotally, these patients experience less pain following surgery because they are awake and alert during the procedure.”
Surgeon Buy-in and Training
The two barriers to the growth of office-based surgery are surgeons’ willingness to advance their surgical techniques and adjust their practices to accommodate these orthopedic approaches.
“Surgeons are a limiting factor,” Dr. Sraj said. “I know surgeons who are not comfortable performing surgeries that take more than five minutes in an office. My limit is 45 minutes to an hour. To put it into perspective though, surgeries that take me that long in the office take twice as long in the operating room due to the more complex environment.”
Another limiting factor is reimbursement, Dr. Sraj said. He knows highly experienced surgeons who do not offer office surgery because low reimbursement prevents their practice from providing optimal care. Reimbursement advocacy is a priority for surgeons and companies seeking to move procedures to the office.
Mr. Butler said the most common challenge that Arthrex hears from surgeons is habit. Surgeons become comfortable performing the techniques they know in an environment that’s familiar to them. Awake office procedures require learning new technology and often involve talking through the process in real time with patients.
“We have made it a top priority to provide high-quality educational opportunities for surgeons, staff and facilities,” Mr. Butler said. “We offer a number of instructional courses, case presentations and hands-on experiences to ensure that training and education remain of the utmost importance.”
Surgeons are often concerned about how to find time to complete training while running a busy clinic, Mr. Paulson said. Sonex Health continues to adapt its training programs to meet the needs of surgeons and their staff. They hold cadaveric labs, take cadaveric specimens to surgeons’ offices and use robust virtual training tools.
Sonex Health is also using data to get surgeons to buy into adopting their technology. More than 13 million Americans have been diagnosed with carpal tunnel, 2.7 million of which have been clinically indicated for surgery, according to Mr. Paulson. However, only 400,000 procedures are performed every year. That means 80% of patients are sitting on the sidelines, many of whom do not want to undergo the traditional surgical approaches. Ultrasound guidance could transform those numbers.
Surgeons who adopt Sonex Health’s technology often hold ultrasound scanning clinics to confirm diagnosis with a new minimally invasive approach. Mr. Paulson said surgeons who facilitate such clinics have signed up 50% to 85% of their patients for surgery the day of the clinic due to the less invasive nature of the procedure.
Sonex has also found that 80% of the surgeons they train in their technology continue to perform the procedure. “That’s double what I’ve seen in other businesses that have moved a surgical procedure to an office-based setting,” Mr. Paulson said. “Carpal tunnel and trigger finger release are perfect for less invasive treatment.”
Identifying the proper procedures to move to an office-based setting is imperative. A successful shift benefits patients and surgeons, as well as facilities and payors. It frees up an operating room for more lucrative elective surgeries and reduces resources and costs for procedures that are moved to an office.
Dr. Sraj said that performing surgery at his office is a better use of his time overall. It allows him to see more patients, requires less staff and demands turnover of an exam room instead of a full surgical suite. Overall, it leads to better patient experience and higher quality care. Still, getting buy-in from quality control and leadership at his academic institution was an obstacle at first.
“Hand surgery is very low risk for infection no matter where you do it, but quality control people cannot tell the difference,” he said. “They treat a five-minute trigger finger the same way they would a total joint or spine case. It’s the nature of the hospital and their one-size-fits-all policies.”
Dr. Sraj educated administrators on the procedures and created new processes for staffing, room setup and inventory management. “From a practical point of view, you need to ensure patient safety. Do you have proper circulation in the room? How will you process instruments safely before cases? What staff do you need?”
Ultimately, Dr. Sraj has grown his clinical practice and the type of surgeries he performs in the office because he and his patients don’t want to deal with the “hassle factor” of the hospital. He plans to move more of his sports medicine procedures to his office.
Future Growth
Office-based procedures remain in an infancy stage today but face significant growth potential as more surgeries move to outpatient settings. Experts in the space believe that safety and efficiency concerns have been met, but patient tolerance can be a challenge as surgeons seek to perform longer, more complicated procedures.
Further, patient selection and marketing will receive significant consideration. In January, Arthrex launched the Nano Experience, a website that educates patients on the benefits and uses of Nano arthroscopy and helps them locate surgeons who perform the procedure. Mr. Paulson also noted that direct-to-consumer marketing will play a pivotal role in driving the adoption of office procedures.
Dr. Sraj used to screen patients for anxiety, depression, PTSD and language barriers before performing surgery in the office. He conducted a study on how patients’ level of worry before the procedure materialized immediately after the surgery. Patients with the greatest amount of anxiety and fear had the highest satisfaction after the procedure. Patient selection will continue to evolve, he said, but he’s found the most significant factor for success is ensuring that the patient is comfortable.
“Office-based surgery is the future for many straightforward and select demanding procedures,” Dr. Sraj predicted. “The operating room will be used for implant-heavy surgeries that require large surgical teams and bigger technology. Office-based surgery will continue to evolve, especially as technology advances and we build experience with more involved procedures that may require implants, like anchors, plates and screws.”
1. Stornebrink T, Altink JN, Appelt D, Wijdicks CA, Stufkens SAS, Kerkhoffs GMMJ. Two-millimetre diameter operative arthroscopy of the ankle is safe and effective. Knee Surg Sports Traumatol Arthrosc. 2020;28(10):3080-3086. doi:10.1007/s00167-020-05889-7
2. Colasanti CA, Mercer NP, Garcia JV, Kerkhoffs GMMJ, Kennedy JG. In-office needle arthroscopy for the treatment of anterior ankle impingement yields high patient satisfaction with high rates of return to work and sport. Arthroscopy. 2022;38(4):1302-1311. doi:10.1016/j.arthro.2021.09.016
Shafic Sraj, M.D., began performing awake orthopedic procedures with patients under local anesthesia out of need. His small community practice had limited access to an anesthesiologist. A specialist in hand, upper extremity and sports medicine, he soon became confident that he could operate on patients while they were awake in a dedicated clinic...
Shafic Sraj, M.D., began performing awake orthopedic procedures with patients under local anesthesia out of need. His small community practice had limited access to an anesthesiologist. A specialist in hand, upper extremity and sports medicine, he soon became confident that he could operate on patients while they were awake in a dedicated clinic room. The results — better patient outcomes, quicker room turnovers, fewer resources and less waste — led Dr. Sraj to shift his views on orthopedic surgery.
That was more than a decade ago. Dr. Sraj is now an Associate Professor and Director of System Integration in the Department of Orthopaedics at West Virginia University. Patients seek him out to forgo a trip to the hospital for a variety of procedures: carpal tunnel and trigger finger releases; tendon repairs, reconstructions and transfers; arthritis surgery; and fracture repairs. Further, Dr. Sraj has taught generations of residents how to perform procedures with the wide-awake local anesthesia no tourniquet (WALANT) approach in the office setting.
“This is definitely a growing field. Surgeons are posting their experiences on social platforms and teaching these techniques to younger generations, which is going to have an exponential effect on growth moving forward,” Dr. Sraj said. “I believe hand surgeons have been the leaders, but we’re seeing interest in sports medicine and foot and ankle. Even spine surgeons have started performing awake surgery.”
The movement of joint replacement, trauma and spine procedures to ASCs has gained significant traction in recent years and is expected to experience double-digit growth for the foreseeable future. Orthopedic surgeons and companies focused on sports medicine and trauma applications seek to move low-risk procedures out of operating rooms and into offices. They liken it to a dental visit, where the patient walks in, has the procedure and walks out.
This exciting shift in orthopedics will require advancing technology and training surgeons in minimally invasive techniques to achieve success.
Technology Advancements
Size matters for office procedures. Visual equipment needs to be small to fit the space. Instruments and implants need to allow for minimally invasive techniques to aid in faster procedures and quicker recoveries.
Arthrex developed Nano or needle arthroscopy instruments that provide an even less disruptive approach than standard instruments for arthroscopy procedures. Nano arthroscopy uses a 1.9mm, high-quality camera at the tip of a wirelike device, along with other arthroscopic instruments, to diagnose and treat various injuries and conditions within joint spaces. The approach is being used for chronic shoulder issues, carpal tunnel syndrome, meniscal injuries and ankle instability.
Surgeons can perform these procedures in an office-based setting under local anesthesia due to its less invasive nature, said Eric Butler, Senior Director of Product Management, Imaging and Integration at Arthrex. Patients favor this environment, he added. One study reported that 87% of patients prefer a procedure room with local anesthesia instead of an operating room with general anesthesia.1
Nano arthroscopy is linked to less nerve damage, high patient satisfaction rates and faster recovery, according to Mr. Butler. Studies have shown that at two weeks post-op, patients who underwent Nano arthroscopy reported a higher quality of life than those who underwent traditional arthroscopy.2 Another study reported that 96% of patients returned to activity within four weeks of an ankle procedure.1 Because Nano arthroscopy employs a poke-hole or tiny incision, it results in reduced fluid distension, minimal tissue disruption and a small scar.
“While Nano arthroscopy allows for a faster recovery, it also promotes a fast pathway to treatment, as other ways to see and diagnose injuries, such as MRI, may not be necessary,” Mr. Butler said. “Nano can often be used to diagnose and treat many injuries in the same visit.”
Sonex Health seeks to transform the treatment of carpal tunnel and trigger finger release with ultrasound-guided procedures. While sports medicine surgeons are familiar with ultrasound, its use for procedures is new to many hand surgeons. Ultrasound-guided wrist and finger procedures allow for a minimally invasive approach performed under local anesthesia, after which patients can return to work within days instead of months or weeks.
“These procedures are well known, but they require dissecting down and retracting tissue. It’s not the cutting of the TCL to relieve the compressing that’s the biggest challenge for carpal tunnel patients; it’s the wound healing and recovery time afterward,” said Bob Paulson, CEO of Sonex Health. “If you’re going to perform these less invasively in the office, you need improved imaging technology. For the first time, ultrasound allows surgeons to visualize and distinguish the critical anatomy in the hand — the bone, tendon and ligaments — and operate on them in a less invasive manner.”
Mr. Paulson noted that advancements in imaging and processing power in the past decade have significantly improved the quality and footprint of ultrasound technology. What used to be a $200,000 machine that sat on a cart in the radiology department is now a $20,000 piece of equipment the size of a laptop that can move to any room, he added.
Sonex Health’s UltraGuideCTR and UltraGuideTFR are single-use instruments. The technologies’ ease of use also allows surgeons to diagnose and treat a patient on the same day in some instances. Mr. Paulson shared the story of a determined rancher who drove hours to be diagnosed, chose to have the procedure done and then dug postholes for a new fence the next day.
The company’s minimally invasive approach requires a pressure bandage instead of stitches, allowing patients to return to activity once their wound heals. Sonex Health, which recently launched a registry, has collected data on 1,000 patients and 1,300 hands that demonstrate consistent outcomes of two to three days return to activities and three to five days return to work.
Dr. Sraj said the introduction of ultrasound guidance, wireless scopes and smaller high-resolution visualization screens will help push procedures out of the operating room. “I don’t have room for old-fashioned arthroscopy towers in my office surgical suites,” he said. “I want wireless equipment that connects to a tablet that is put on a table.”
He also noted that during office surgeries, he uses sterile O.R. drapes, instruments, sutures and devices that are “lean and green,” which take up a smaller environmental footprint and create less waste. Dr. Sraj has an autoclave in his office, but he still relies on his local hospital. The move toward sterile packaged, single-use instruments and implants will boost the number of procedures that can be done in an office, he added. The flexibility of the office setting allows him to diagnose a patient at 9 a.m. and treat them at 10 a.m. if his schedule and inventory permits and prior authorization doesn’t cause a delay.
For Dr. Sraj, the biggest advantage gained from performing office surgery using WALANT is the ability to tell the patient what he’s doing step by step.
“I’m able to educate them and give them a much better understanding of what’s happening and what I’m trying to achieve, especially during surgery that requires active testing,” he said. “If I’m repairing or transferring a tendon while the patient is awake, the patient can test the tendon and give me immediate feedback. They also become part of the team and appreciate their role in achieving sought-after success. Also, anecdotally, these patients experience less pain following surgery because they are awake and alert during the procedure.”
Surgeon Buy-in and Training
The two barriers to the growth of office-based surgery are surgeons’ willingness to advance their surgical techniques and adjust their practices to accommodate these orthopedic approaches.
“Surgeons are a limiting factor,” Dr. Sraj said. “I know surgeons who are not comfortable performing surgeries that take more than five minutes in an office. My limit is 45 minutes to an hour. To put it into perspective though, surgeries that take me that long in the office take twice as long in the operating room due to the more complex environment.”
Another limiting factor is reimbursement, Dr. Sraj said. He knows highly experienced surgeons who do not offer office surgery because low reimbursement prevents their practice from providing optimal care. Reimbursement advocacy is a priority for surgeons and companies seeking to move procedures to the office.
Mr. Butler said the most common challenge that Arthrex hears from surgeons is habit. Surgeons become comfortable performing the techniques they know in an environment that’s familiar to them. Awake office procedures require learning new technology and often involve talking through the process in real time with patients.
“We have made it a top priority to provide high-quality educational opportunities for surgeons, staff and facilities,” Mr. Butler said. “We offer a number of instructional courses, case presentations and hands-on experiences to ensure that training and education remain of the utmost importance.”
Surgeons are often concerned about how to find time to complete training while running a busy clinic, Mr. Paulson said. Sonex Health continues to adapt its training programs to meet the needs of surgeons and their staff. They hold cadaveric labs, take cadaveric specimens to surgeons’ offices and use robust virtual training tools.
Sonex Health is also using data to get surgeons to buy into adopting their technology. More than 13 million Americans have been diagnosed with carpal tunnel, 2.7 million of which have been clinically indicated for surgery, according to Mr. Paulson. However, only 400,000 procedures are performed every year. That means 80% of patients are sitting on the sidelines, many of whom do not want to undergo the traditional surgical approaches. Ultrasound guidance could transform those numbers.
Surgeons who adopt Sonex Health’s technology often hold ultrasound scanning clinics to confirm diagnosis with a new minimally invasive approach. Mr. Paulson said surgeons who facilitate such clinics have signed up 50% to 85% of their patients for surgery the day of the clinic due to the less invasive nature of the procedure.
Sonex has also found that 80% of the surgeons they train in their technology continue to perform the procedure. “That’s double what I’ve seen in other businesses that have moved a surgical procedure to an office-based setting,” Mr. Paulson said. “Carpal tunnel and trigger finger release are perfect for less invasive treatment.”
Identifying the proper procedures to move to an office-based setting is imperative. A successful shift benefits patients and surgeons, as well as facilities and payors. It frees up an operating room for more lucrative elective surgeries and reduces resources and costs for procedures that are moved to an office.
Dr. Sraj said that performing surgery at his office is a better use of his time overall. It allows him to see more patients, requires less staff and demands turnover of an exam room instead of a full surgical suite. Overall, it leads to better patient experience and higher quality care. Still, getting buy-in from quality control and leadership at his academic institution was an obstacle at first.
“Hand surgery is very low risk for infection no matter where you do it, but quality control people cannot tell the difference,” he said. “They treat a five-minute trigger finger the same way they would a total joint or spine case. It’s the nature of the hospital and their one-size-fits-all policies.”
Dr. Sraj educated administrators on the procedures and created new processes for staffing, room setup and inventory management. “From a practical point of view, you need to ensure patient safety. Do you have proper circulation in the room? How will you process instruments safely before cases? What staff do you need?”
Ultimately, Dr. Sraj has grown his clinical practice and the type of surgeries he performs in the office because he and his patients don’t want to deal with the “hassle factor” of the hospital. He plans to move more of his sports medicine procedures to his office.
Future Growth
Office-based procedures remain in an infancy stage today but face significant growth potential as more surgeries move to outpatient settings. Experts in the space believe that safety and efficiency concerns have been met, but patient tolerance can be a challenge as surgeons seek to perform longer, more complicated procedures.
Further, patient selection and marketing will receive significant consideration. In January, Arthrex launched the Nano Experience, a website that educates patients on the benefits and uses of Nano arthroscopy and helps them locate surgeons who perform the procedure. Mr. Paulson also noted that direct-to-consumer marketing will play a pivotal role in driving the adoption of office procedures.
Dr. Sraj used to screen patients for anxiety, depression, PTSD and language barriers before performing surgery in the office. He conducted a study on how patients’ level of worry before the procedure materialized immediately after the surgery. Patients with the greatest amount of anxiety and fear had the highest satisfaction after the procedure. Patient selection will continue to evolve, he said, but he’s found the most significant factor for success is ensuring that the patient is comfortable.
“Office-based surgery is the future for many straightforward and select demanding procedures,” Dr. Sraj predicted. “The operating room will be used for implant-heavy surgeries that require large surgical teams and bigger technology. Office-based surgery will continue to evolve, especially as technology advances and we build experience with more involved procedures that may require implants, like anchors, plates and screws.”
1. Stornebrink T, Altink JN, Appelt D, Wijdicks CA, Stufkens SAS, Kerkhoffs GMMJ. Two-millimetre diameter operative arthroscopy of the ankle is safe and effective. Knee Surg Sports Traumatol Arthrosc. 2020;28(10):3080-3086. doi:10.1007/s00167-020-05889-7
2. Colasanti CA, Mercer NP, Garcia JV, Kerkhoffs GMMJ, Kennedy JG. In-office needle arthroscopy for the treatment of anterior ankle impingement yields high patient satisfaction with high rates of return to work and sport. Arthroscopy. 2022;38(4):1302-1311. doi:10.1016/j.arthro.2021.09.016
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Carolyn LaWell is ORTHOWORLD's Chief Content Officer. She joined ORTHOWORLD in 2012 to oversee its editorial and industry education. She previously served in editor roles at B2B magazines and newspapers.
