However, many challenges still remain to a full transition of hip and knee surgeries to ASCs.
Here seven orthopedic surgeons discuss the advancements in hip and knee outpatient surgeries that have made these procedures safer and produced better outcomes, as well as the challenges they still face in the ASC operating room.
Question: What are the greatest advancements that have been made to allow for effective hip and knee surgeries in ASCs?
Darwin Chen, MD, Orthopedic Surgeon and Assistant Professor of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York City: There are three main advancements that have allowed some hip and knee replacements to become ambulatory surgery procedures. First, minimally invasive techniques can result in less tissue damage when performed appropriately. Second, multimodal analgesia tackles pain control on many different fronts as opposed to only using traditional narcotics. Third, streamlined nursing and physical therapy rapid rehabilitation protocols allow for early mobilization and safe early discharge.
Gloria Beim, MD, Founder of Alpine Orthopaedics & Sports Medicine, Gunnison, Colo.: Some of the advancements that led to [the ability to perform orthopedic surgery in ASCs] are simply the surgical techniques themselves. Most of the surgeries that I perform in an elective outpatient setting are arthroscopic. This is where you place a fiber optic camera through one tiny incision and perform most of the surgery through another tiny incision. This minimally invasive technique leads to less swelling and pain thus allowing the patient to go home the same day and start PT right away.
More recently, some ASCs are set up to perform total hip and total knee replacement surgeries by utilizing minimally invasive techniques and providing 23 hour overnight observation services with a full time nurse. One advance in the hip replacements is the utilization of an anterior approach to the hip rather than posterior. This is less invasive and enables the patient to have a much shorter stay.
Richard Buch, MD, Orthopedic Surgeon, Dallas Limb Restoration Center: The improvement with instruments, components and pre- and postoperative pain control have led to ability to do procedures faster with smaller incisions. However, this only works on healthy younger patients who are not badly overweight and are relative healthy. If patients are obese, have heart problems, kidney problems, diabetes or over a certain age, many times they can not do surgery that allows them to go home the same day or the day after surgery. But many patients have benefited from these newer procedures now done at ASCs.
But the single most important advancement in replacement and total joint surgery is not the improvement in prosthesis but how we handle pain after surgery. Major advancements in how pain occurs and how to control it in early post operative have lead to shorter hospital stays and quicker recovery.
Gary Brazina, MD, Orthopedic Surgeon, DISC Sports & Spine Center, Marina Del Rey, Calif.: We are now able to routinely perform outpatient unicompartmental knee replacements on a regular basis when the center has the ability to have the patient for a 23-hour hold.
Jeffrey Colbert, MD, Orthopedic Surgeon, DISC Sports & Spine Center, Marina Del Rey, Calif.: The greatest advancement in knee surgery is the ability to perform partial knee replacements on an outpatient basis or else an overnight stay. Another great advancement, in addition to the instrumentation and the technique, is the ability to manage pain post-operatively with nerve blocks. The other major advancement with hip surgery is arthroscopic hip surgery, which can be done effectively in an ASC.
Steven Barnett, MD, orthopedic surgeon, Hoag Orthopedic Institute and Orthopaedic Specialties Institute, Orange County, Calif.: With advances in technology as well as financial pressures to reduce costs in the medical arena, greater attention is being given to performing elective total joint replacement surgery in an outpatient surgical setting. These days it is not uncommon for elective hip and knee patients to be discharged to home within 23 hours of their joint replacement procedure.
Advances in surgical techniques have allowed surgeons to perform hip and knee replacement procedures in a less invasive fashion which impacts the patient's immediate postoperative recovery. This allows for early mobilization and a more rapid discharge from the hospital. For example, it is now commonplace for hip replacement patients to ambulate 500 to 1000 feet with minimal assistance two to three hours after the surgical procedure.
Q: How do you manage pain in these patients so they can return home safely the same day?
Joseph Guettler, MD, orthopedic surgeon and sports medicine specialist, Unasource Surgery Center, Troy, Mich.: One of the greatest advancements in terms of effective knee surgeries has been to manage this pain with regional anesthesia.
Until recently, post-surgical pain was primarily treated with narcotics, which may cause undesirable side effects including post-operative nausea and vomiting, sedation and pose the risk of dependence and addiction. To help reduce the side effects of narcotics, my anesthesiologists regularly use a non-narcotic option, such as nerve blocks, to help control post-operative pain.
I have them perform femoral nerve blocks for surgeries like ACL reconstructions and adductor nerve blocks for routine knee arthroscopies. These blocks definitely help assist patients with their pain management, and I have witnessed firsthand the benefits of nerve blocks utilizing regional anesthesia, specifically with the ON-Q Pain Relief System. My patients experience fewer narcotic-related side effects and a faster early recovery when compared to narcotics alone. I truly believe — as I tell my patients — that these nerve blocks have revolutionized early post-operative pain control.
Dr. Barnett: These rapid progressions through the therapy process in the hospital are also the result of modifications in pain management utilizing multi-modal protocols in the peri-operative period which allows surgeons to rely less on intravenous narcotics. The combination of spinal and regional anesthesia, oral analgesics, and local infiltration of anesthetic "cocktails" in the surrounding tissue at surgery has drastically improved the patient's pain control over the last several years. It is no longer necessary for patients to convalesce in bed for one to two days after elective joint replacement surgery. Instead, these patients are mobilized rapidly and have expedited recoveries with much less pain.
Q: What challenges still remain to performing these procedures in outpatient settings?
Dr. Chen: Not all patients are appropriate candidates for ambulatory joint replacement surgery. These patients should be carefully selected. In addition, ambulatory surgery requires institutional support and infrastructure, which is not always available.
Dr. Beim: For some ASCs, admitting patients overnight is not an option and therefore the hospital setting is necessary. However, with the advancements of the surgical and anesthetic techniques, more and more surgeries are being carried out in the ASC setting.
As Orthopaedic surgical techniques continue to advance offering more minimally invasive solutions, more surgeries will be done in the ambulatory setting. Patients and their families prefer it and there are many advantages over the hospital setting.
Dr. Guettler: The greatest challenge in performing peripheral nerve blocks is not the actual procedure, but the lack of familiarity amongst most patients and many clinicians. Unfortunately, patients aren't as aware as they should be regarding the options that are available to them when it comes to post-operative pain control.
Surgeons and anesthesiologists alike need to remain current and in the loop when it comes to the most advanced pain control options so that they can offer their patients the best options for post-operative pain control – including regional anesthesia.
Dr. Brazina: While we've definitely come a long way in establishing the ability to perform such surgeries in an outpatient setting, having a coordinated post operative program is essential. Regarding hip arthroscopy procedures, we can certainly use better instrumentation and routines. This is especially important with use of traction and image intensifiers. Specialized instrumentation is expensive and reimbursement for newer procedures is difficult.
Dr. Barnett: In the future it is likely that we will see more and more elective joint replacement surgeries performed in the outpatient setting which will definitely decrease the cost associated with these procedures. As surgeons, however, we are first and foremost concerned with patient safety and nothing can be undertaken from a surgical standpoint without taking this in to consideration first. Although total joint replacement surgery is highly successful, there is also the potential for complications related to the surgery. Algorithms and protocols need to be well established for dealing with the rare complication that will be seen in the outpatient setting before this becomes common.
Q: In your experience, how can performing these procedures in the ASC benefit patients?
Dr. Beim: Patients are often intimidated and more scared in the hospital setting as compared to an ambulatory setting. In general, infection risks are lower in most ASCs as they generally do elective cases rather than infections and all comers which a hospital must do.
Years ago, an ACL reconstructive surgery in the knee could take several hours in the OR and the patient may be hospitalized for several days. Physical therapy would be delayed for six weeks, if done at all, and most patients did not return to their pre-injury level of activities. Today, the ACL reconstruction takes about an hour, the patient goes home often an hour later, and therapy is instituted the following day. Most patients getting this surgery can return to their pre-injury level of activities and that includes elite and professional athletes.
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