Same-day Total Joints Set to Surge

"When surgeons first start performing outpatient total joints, they should select healthier, more active patients and focus on perfecting their surgical techniques and overall program," says Dr. Shah. "As their skills improve and the facility's clinical pathways become more refined, the percentages of patients who are ready for same-day discharge will grow."

• Skilled surgeons. If patient selection is the top consideration in the success of outpatient total joints, surgeon skill is a close second. Dr. Shah says surgeons need to understand and commit to an approach that prepares patients for same-day discharge. They need to implement blood-conserving techniques and operate efficiently to shorten the amount of time patients are anesthetized.

Surgeons must also use instrumentation designed to minimize muscle and tissue damage in the joint. "I use low-profile instruments and avoid pulling on or tearing muscle," says Dr. Shah, "I also focus on limiting how much tissue I grasp or pinch."

Dr. Haas has developed a surgical technique that involves operating through small incisions and eliminates the need to cut the quadriceps tendon, factors that limit post-op pain and help to prepare patients for same-day discharge. He also points to the tremendous strides orthopedic device manufacturers have made in the design and availability of numerous implants that are better anatomical fits for a variety of patients. Anatomically correct femoral and tibial components improve the post-op alignment of the knee, distribute load-bearing forces more evenly and share the stress and pressure placed on the joint with the patient's natural ligaments and tendons. These factors maximize joint mobility and function after surgery.

Running an efficient and successful outpatient total joints program requires building a group of hard-working professionals who work toward a common goal and are driven to achieve excellent outcomes, according to Dr. Shah.

Members of the nursing staff must understand the importance of direct and detailed communication with patients, and sterile processing professionals must oversee the management, sterilization and storage of large and complex instrument sets. Clinical leaders need to make sure patients move along the clinical pathway efficiently and safely. Facility administrators must manage staffing levels, coordinate the actions of the entire team and ensure they have the resources to do their jobs effectively.

Dr. Haas points out that anesthesia providers should be adept at placing regional blocks to help manage post-op pain. "We use an adductor canal block for the front of the knee, an IPACK block for the back of the joint and an additional periarticular injection to numb the entire area," says Dr. Haas. His patients also receive a spinal or epidural anesthetic.

• In-house rehab. The quality of care that patients receive in the weeks and months after surgery and the amount of work they put into their rehab regimens are essential to ensuring they achieve the outcomes they expect. Interestingly, this is another area in which the coronavirus is likely to play a role moving forward as limiting in-person care becomes more of a focus for providers and patients alike.

Digital platforms now allow patients to follow prescribed physical therapy programs at their convenience and from the comfort of their homes. The platforms guide patients through personalized exercise routines, record the results of rehab sessions and send them to providers, who monitor the progress of patients and schedule virtual meetings to discuss the next steps of their recovery.

HSS launched a telehealth physical therapy program before the pandemic hit and used it for select patients. The facility has since expanded its use due to COVID-19. Patients go home, get online and work with a physical therapist remotely. HSS plans to expand the remote rehab program over the coming year and study its impact on post-op results.