Overnight Stay After Total Knee Replacement- Are you a candidate?
by Michael Gillman MD
Restore Orthopedics and Spine Center
Efficiency and cost-effective care are imperative as we move forward in practicing medicine. This is particularly true in total knee replacement surgery. A study by the American Academy of Orthopaedic Surgeons estimates a 673% growth rate for patients having knee replacement from 2006-20261. With limited resources, it is important to all stakeholders- patients, physicians, hospitals and insurers to maximize the use of our health care dollars whenever possible.
Current techniques allow for a majority of motivated healthy knee replacement patients to go home after an overnight stay in the hospital or ambulatory surgery center.
Preoperative patient education in the office focuses on rapid recovery. An educated and informed patient is very important in the process. Patients are prepared to have the procedure, and in the mindset from the outset that they will likely go home quickly. Mobilizing family and/or friends to assist in the first few days proactively helps patients to transition home early after surgery.
Newer surgical techniques allow for custom made surgical cutting blocks to be made based upon a preoperative MRI or CT scan. When these are used, they allow for more precision, fewer surgical steps and a less invasive procedure, which likely reduces postoperative pain and may improve implant longevity.
We have gotten better at limiting blood loss from joint replacement surgery. Spinal anesthesia helps and about 90% of patients currently receive it at Mission Hospital. Tranexemic acid is used pre, intra and postoperatively minimizing blood loss. This likely reduces swelling and pain and has greatly reduced the need for blood transfusion postoperatively. Moreover, recent studies have shown a higher risk of infection with blood transfusion2. Fluid resuscitation is recommended as an alternative to transfusion whenever possible. Most recent rates of transfusion are only 6% for all joint replacements at Mission Hospital. This is greatly reduced from just a few years ago.
Multimodal postoperative pain management has become the standard in knee replacement. I have incorporated as a routine in my practice femoral nerve blockade, a newer technique of regional anesthesia. This reduces postoperative pain dramatically and expedites a patient’s participation with physical therapy3,4. In fact, most patients are able to work with a physical therapist the day of surgery because they have less pain and no longer need the amount of narcotic medication required previously.
There is a trend away from discharging patients to skilled nursing care, as home health nursing and home physical therapy are sufficient for the vast majority of patients. Patients are closely followed at home in the first few days after surgery.
A comprehensive approach allows patients to go home as soon as feasible after total knee replacement. Patient satisfaction scores reflect the positives of a fast-track program.
- Journal of Bone and Joint Surgery Am 2007 Apr;89(4);780-5
- Clin Orthop Relat Res 2008;466:1710-5
- Clin Orthop Relat Res 2009;467(9):2379-2402
- 4 Anesthesiology 2010 Nov;113(5):1144-62
ABOUT DR. GILLMAN
Dr. Gillman is an orthopedic surgeon and 3rd generation physician. He received B.S. with honors and M.S. degrees from Stanford University and his Medical Degree with AOA honors from Case Western Reserve University. He completed residency at Tufts University affiliated hospitals, fellowship at Baylor College of Medicine and received a Health Care Executive degree from UC Irvine. He has practiced in Orange Countyt since 1999. He is an early adopter of ambulatory knee replacement teaching other surgeons in the technique. In addition, he has developed a method for patient-specific hip replacement with issued patents and testing validated by academic orthopedic surgeons in the U.S. and London. In his free time he enjoys recreational sports, spending time with his wife Rebecca and three sons. He currently serves on the Board of Tarbut V’Torah Community.
If you would like to find out more about 23 hr stay Total Knee Replacement please call for an appointment with Dr. Gillman at 714.598.1745