How outpatient total joint replacement surgery is possible
Knee replacement.
Think about that for a second. When I perform a knee replacement surgery, I remove someone’s knee and put in an artificial one. Medical science has come a long way, and at times, I think we take for granted what we’re able to do now.
It’s exciting to see medicine advance. Early in my career, patients used to stay in the hospital for 3-4 days after a knee replacement procedure. The last few years, the stay has decreased a bit, and some centers around the country are doing outpatient hip and knee replacements.
Multi Modal Pain Management
The change that made outpatient joint replacement a more viable option is multi modal pain management, in which we administer anti-inflammatories, a central nervous system medication, and a pure narcotic shortly before surgery.
Then–and this is new and quite exciting just this past year–we also inject a local, long-lasting anesthetic (Exparel®) into the knee joint toward the end of surgery to numb the knee.
10-15 years ago, I never would have imagined this would be possible.
Pre-op pain management keeps patients ahead of the pain rather than playing catch up after surgery. It’s much easier to prevent pain than to overcome it after the fact.
Patients who had knees replaced last year and then did the other knee this year are saying how dramatically different their experiences were. They barely took any pain medication for the second one.
Some people now go home after two days or stay one night in the hospital and then leave in the morning. If you can go home the next morning, you can probably go home the same evening.
Recently, I performed a knee replacement on a patient who went home six hours after his knee replacement, and this is due, for the most part, to multi modal pain management.
Going home the same day is not right for everyone.
You have to be the right candidate.
- A healthy patient – I keep a list of medical conditions that exclude people from being a same-day candidate. It’s vitally important that when a patient leaves, they will not have any complications at home due to a pre-existing medical condition. That’s why I have the checklist–to protect patients.
- Very motivated patient – Patients who want to leave the same day are often enthusiastic and ready to get out of the hospital. They want to get home where it’s comfortable. Sometimes, a patient fears the potential pain of knee replacement, which can affect their readiness to leave the hospital. It’s like a self-fulfilling prophecy. If a patient is afraid of the pain, they will often feel the pain more acutely, which means they will not be ready to go home as quickly.
- Have a coach – The literature uses the term “coach,” but really he/she is a person who can:
- Attend your pre-op visits
- Knows about your medications
- Come to your surgery
- Stays with you after surgery to provide care at home
Coaches can be friends, spouses, children…anybody can fulfill the role as long as they have the time and are committed to being there for the patient to:
- Take them home.
- Stay with the patient for the first few days to nurse them.
- Have a checklist of items.
- Make sure things around the house are safe and prepared.
- Move loose carpets.
- Make all areas of the house more accessible.
Same day patients see physical therapists before they have surgery so that they know what to do when they get home from surgery.
Have all medicine set up in the office and at home before the day of surgery.
When I started practicing medicine, I would have said, “no way.”
10-15 years ago, I never would have imagined this would be possible.
The thing is, we never truly know what medical advances will allow doctors to do next. I read a study recently where surgeons were having patients drink Gatorade before a procedure. Somehow, the carb load, sugar, or something else helps patients after surgery to recover quicker and get back on their feet. Now, the doctors who did the original study are putting one together that specifically focuses on the affect on orthopedic procedures.
The landscape is always changing, and we’re constantly looking for ways to improve patients’ outcomes and recovery time.
When I started practicing, a lot of procedures that are taken for granted (ACL repair, rotator cuff repair, shoulder arthroscopy) were just moving into the outpatient sphere. A vast majority of those patients did go home the same day, but the pain management took awhile to get facile.
Those procedures are “routine” now. Maybe in 15-20 years, joint replacement will be a routine thing.
Do you find that people are motivated to get home sooner, or are people motivated by the idea of a joint replacement being cheaper if they can go home?
Most people don’t want to be in a hospital. Who can blame them? They’re surrounded by people who are sick, or in the case of orthopedics, not sick, but in need of medical care.
I don’t think the financial side plays into the decision to get out of the hospital. It’s about recovering in your own home, in familiar surroundings.
Some patients are not motivated to go home. I had a relative who spent three days in the hospital and then a few weeks in rehabilitation facility.
I would much rather my patients recover at home because the risk of infection is lower. A rehab facility can be like a kindergarten classroom. When a cold goes around, everyone seems to get it. Your house is not a kindergarten classroom, so you are protected from picking up sickness from other people.
It often comes down to how healthy the patient is when considering outpatient surgery. A healthy elderly individual is a better candidate than a fifty year old patient who is not healthy.
I should mention that there is not necessarily a clinical benefit or disadvantage to outpatient joint replacement, other than potentially avoiding contact with disease.
The true benefit of outpatient joint replacement is really the multi modal pain medication. Managing pain means people can get up sooner, which means we decrease the chance of infection and blood clots, among other things.
Physicians want their patients to move quicker, to get up sooner because doing that protects the patient.
To learn more about Dr. Chmell or Total Knee Replacement, visit rockfordortho.com.
