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7 Points on Unicompartmental Knee Arthroplasty in the Surgery Center Setting

Unicompartmental knee replacements are moving with increasing speed into the outpatient setting, despite the hesitancy on the part of some orthopedic surgeons to accept the procedure as a legitimate alternative to total knee replacements. John A. Repicci, MD, an orthopedic surgeon who has performed partial knees in the outpatient setting for about 10 years, outlines seven points about performing the surgery in an ASC setting.

1. Insurance companies are pushing partial knee replacements into the outpatient setting. Dr. Repicci says insurance companies are increasingly pushing physicians to take partial knee replacement surgeries to outpatient settings to decrease the cost to the payor. "The standard in our community is outpatient for partial knee," he says. "I've been doing partial knee arthroplasties in the outpatient setting for over 10 years, and recently I'm finding that insurance companies don't want to pay for in-hospital admission."

According to Dr. Repicci, between 2007 and 2011, 2,237 unicompartmental knee implants were inserted in an outpatient setting. Of these procedures, 92.1 percent returned home the same day, with the remainder returning home the following morning. Surgery centers can cite this information, as well as the cost savings to payors, when negotiating contracts with insurance companies.

2. Cost of parts affects profitability most significantly. When performing a partial knee replacement by mini-invasive technique, Dr. Repicci says the biggest cost is the parts required for the replacement. He says the parts, including the prosthesis, can vary from $1,500-$4,000 depending on the vendor and contract. As with most ASC equipment, the key to saving money on parts is to either convince physicians to use a less expensive brand or to negotiate a vendor contract that gives the surgery center some cost savings. Dr. Repicci says this is a more significant issue for Medicare patients, since Medicare reimburses at a lower rate than private payors.

3. Partial knee replacements can save money for surgery centers over total knee replacements. Dr. Repicci says surgery centers can save a significant amount of money in the long-term by performing partial knee replacements rather than total knee replacements on appropriate patients. He says a surgery center can save close to $10,000 by performing a partial knee replacement rather than a total knee replacement.

If you have an expert in total knee replacements, you may have a 2-5 percent revision rate after 10 years, but redoing a total knee replacement can cost up to $50,000 because it's not an easy procedure. On the other hand, partial knee replacements may have a 5-10 percent revision rate after 10 years, but it's much easier to convert a partial to a total knee than to redo a total.

4. Partial knees are performed on a majority of Medicare-age patients. Dr. Repicci says the majority of his patients are Medicare age — but a lot of them have private policies, meaning he doesn't have to depend on Medicare reimbursement. Most partial knee candidates will be over 65, meaning that surgery centers with a high population of Medicare beneficiaries in the area may suffer from lower reimbursement when performing partial knees. The procedure is more profitable for surgery centers with a high reliance on commercial payors, Dr. Repicci says.

5. Anesthesia must be controlled well to send patients home the same day. To perform partial knee replacements in the outpatient setting, Dr. Repicci says you need significant control of patient anesthesia. If the anesthesiologists at your center are used to giving a heavy dose of narcotics, the patient will not be able to go home in a timely fashion. Anesthesia must use short-acting anesthetics because the surgeon should be able to perform the procedure in less than an hour without significant blood loss.

The anesthesiologist should also manage pain post-operatively so the patient can sit there talking to the physician "as if he had a dental appointment, not a major operation," Dr. Repicci says. He says partial knee replacement patients should be able to go home on the day of surgery if the anesthesiologists are able to adjust the type and dose of anesthesia based on the individual patient.  

For these procedures, Dr. Repicci says all surgically incised areas should be infiltrated with Marcaine and epinephrine. "Pre-emptive pain management is essential, [as is] avoiding drugs with a significant cerebral impact," Dr. Repicci says. "Torodol is useful pre- and post-op at adjusted dosage for age." He says Motrin 400 mg and hydrocodone 500 mg are given every four hours for three days as a pre-emptive pain control program, follwed after day three as a PRN dosage.

6. Patient advocates are necessary to increase patient comfort and safety.
Like controlling anesthesia to decrease patient pain, Dr. Repicci says assigning a patient advocate to follow up with the patient is essential when performing partial knee replacements in an outpatient setting. He says physicians will commonly be performing surgery on older patients with other health problems and sometimes a weaker support system than a 25-year-old.

"I have a patient advocate in direct contact with these patients," he says. "They can call her 24 hours a day and ask any questions." He says the patient advocate also follows up with patients after surgery to assess their recovery at home and recommend steps to prevent infection or decrease pain.

7. Outpatient partial knees necessitate a strong relationship with a local hospital.
Dr. Repicci's outpatient center is attached to a hospital, so he can operate on more complex, difficult patients without having to worry about what will happen if a complication arises. He recommends that surgery centers build a relationship with the local hospital to make sure the admission process is easy if a patient needs to be transferred.

He says surgery centers without this connection to a hospital may want to consider focusing on younger patients for unicompartmental knee arthroplasty. "It's not that you can't do the surgery on older patients, but you have to do some sort of management and follow-up," he says.

Related Articles on Surgery Center Specialties:
5 Tips for Building a Strong Surgery Center
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Demystifying Meaningful Use for Anesthesiologists

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