By Michael J. Gillman, M.D., M.S., M.B.A.
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 2006-2026. 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. Even more important, from a patient’s perspective, being able to recover at home rather then in the hospital is preferable. At home patients are generally more comfortable, they are able to sleep and are not being kept awake by the typically noisy equipment and never-ending hospital teams coming into their room. Getting out of the hospital quickly also means getting away from the infections and potential risk of acquiring them in any hospital facility.
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. 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 during knee replacement without the need for a general anesthesia. 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 greatly reduced from just a few years ago.
Multimodal postoperative pain management has become the standard in knee replacement. One of these modalities, femoral nerve blockade is a newer technique of regional anesthesia. This reduces postoperative pain dramatically and expedites a patient’s progression with physical therapy3. 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
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 County 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 Total Hip Replacement surgery please call for an appointment with Dr. Gillman at 714.598.1745