Outpatient TJR rests on these 2 pillars — Sheridan's Dr. Cameron Howard weighs in

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Orthopedic procedures, particularly total knee and hip replacement surgeries, are among the most popular surgical services at ambulatory surgery centers.  

Orthopedic procedures, particularly total knee and hip replacement surgeries, are among the most popular surgical services at ambulatory surgery centers. But ASCs have two key considerations when performing these procedures on an outpatient basis.   

"From a societal standpoint, it's much more cost-effective to do these procedures as outpatient surgeries," says Cameron Howard, MD, an anesthesiologist with Sheridan Healthcare, an AmSurg division.

However, patient selection for these types of procedures is key. For example, outpatient joint replacements are desirable for a middle aged, non-obese patient with no significant medical problems , says Dr. Howard. Typically these patients can go home on the same day as they surgery, and this leads to greater patient satisfaction and lower costs. However, it is essential patients who are sent home fully understand the surgery and rehab process.

"They also need to have a support system in place with family or friends to help them with ambulating, transferring and transporting them to outpatient rehab," he says.

But for other patients, including those who are morbidly obese, brittle diabetics, patients with cognitive decline or those with no support system at home, an inpatient setting may be the better option.

The importance of patient education
Successfully performing total joint surgeries in an ambulatory setting requires a comprehensive program that includes extensive preoperative education, says Dr. Howard. Set expectations for patients so they know they will have some pain.

"It used to be that our primary goal was zero pain, but that led to patients lying in bed, immobile for long periods of time, which is costly and causes complications," he says. "Now, our primary goal is functional recovery. We will manage pain and provide comfort, but our utmost priority is ambulation and return to normal quality of life."

Also, educate patients about the complication risks related to joint replacements. While the complication risks for inpatient and outpatient joint replacements are the same, with same day surgery you are sending the patient home, says Dr. Howard. An ASC's staff will need to teach patients to recognize the signs of wound infection or blood clots in their legs. They will also need to understand the importance of taking the right dose of their medications for the right amount of time.  

The role anesthesia plays
"Regional anesthesia is a prime reason that outpatient knee replacement is possible," says Dr. Howard.

New, more sensory specific nerve blocks allow for earlier ambulation, which makes same day surgery possible. Most facilities that perform total joint procedures have transitioned from the proximal femoral block to the adductor canal block, which provides the same sensory anesthesia to the anterior knee. However, it leaves the motor function from the quadriceps intact, says Dr. Howard.

"It's far superior to the femoral block in terms of early ambulation and it decreases the chance of falls from quadriceps weakness," he adds.

However, regional anesthesia is only one aspect of outpatient joint replacement puzzle. Providers should use regional anesthesia in conjunction with a multimodal pain management strategy. Patients should receive acetaminophen, non-steroidals and gabapentinoids pre- and postoperatively on a schedule, says Dr. Howard. Additionally, regional and multimodal pain management strategies have significantly decreased the use of narcotics, which also has a positive societal impact.

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