Boomers Trigger Hip Surgery Boom

There are three main approaches surgeons can take when replacing hips: posterior, direct lateral and direct anterior. During a posterior hip replacement, the surgeon makes the incision at the back of the hip, close to the buttocks. The incision is placed so the abductor muscles — the major walking muscles — are not cut. The direct lateral approach involves splitting the gluteus medius and, often, vastus lateralis muscles. The direct anterior approach has become more popular over the last decade thanks to better implants, improved instrumentation and specialized surgical tables. It’s a minimally invasive technique involving a small incision near the front of the hip to allow for removal of damaged bone and cartilage, and placement of the implant, without damaging surrounding muscle and tendons.

All three approaches are effective and safe as long as the surgeon has experience performing them. I’ve been utilizing the direct anterior approach for about 12 years, and it’s my preferred method. It has a low dislocation rate and patients recover quickly. The technique does not require the cutting of muscle and therefore the amount of pain patients experience following surgery is quite low. 
I’m also able to use X-rays to modify the procedure and adjust implants intraoperatively in real-time in ways that I believe will improve outcomes. For instance, I place trial pieces in the joint and take an X-ray to determine if I need to make adjustments during surgery, such as using a bigger prosthesis, before placing the implant. During the direct anterior approach, the patient is supine, which makes intraoperative imaging easier to accomplish. Placing patients prone or on their side for posterior or lateral approaches makes it harder to get reproducible images.

Surgeons who operate using the direct lateral or the posterior approach can use standard operating tables. The direct anterior approach can also be performed on a standard OR table, but I use a specialty table specifically designed for this approach. Specialty tables aren’t cheap, but if your volume is high enough, they certainly pay for themselves. The table I use allows the patient’s leg to be placed in almost any position, which helps me gain access to the joint, no matter the size or shape of the patient.

The majority of joint replacement patients aren’t ill — they simply have a bad hip, knee or shoulder — and surgeons wouldn’t operate on them unless they were reasonably healthy. Outpatient hip replacement patients are motivated to go home after surgery because they want to recover in comfortable surroundings. They’ll eat better food at home, and rest easier than they would in a hospital, where they’re often poked and prodded throughout their stay. I know this on a personal level. I recently had cancer surgery, and the staff at the hospital woke me up every two hours to check on me. Their attentive care was appreciated, but I didn’t get much sleep.

Some of my hip replacement patients are ready to go home the day of surgery, often within hours of their procedures. We spend time in the weeks leading up to the surgeries making sure they have proper support systems in place and help from friends or family, as well as a comfortable home set-up, to ensure they’re able to recover safely. They also rarely undergo inpatient rehab after having their hips replaced because rates of infections and hospital readmissions are higher in these facilities. Plus, patients often don’t require that level of post-op care and prefer to recover at home.

It’s important that patients get up and walk as much as possible during their initial recovery — that simple practice works wonders during their rehab. Total knee patients require a significant amount of post-op physical therapy, whereas hip replacement patients do well simply by ambulating to increase their mobility and reduce the risk of blood clots. Patients should have realistic expectations on what to expect during their recoveries, but they also need to do the necessary work to make sure they have a successful outcome.

If a patient has good results, they'll tell their friends and family about the experience they had.

Some of my patients spend the first night after surgery in one of our care suites, which are connected to the surgery center. Having this post-op care option available is a safe alternative for patients who aren’t ready for same-day discharge. A nurse is assigned to care for every two patients, who are monitored overnight and visited by a physical therapist. Patients spend the night in a large, comfortable room and can even order food for delivery.

Outpatient hip replacement has been shown to have a high level of patient satisfaction, and the biggest marketing tool that can help grow your program is often the patients themselves. If a patient has good results, they’ll tell their friends and family about the experience they had.

Total hip replacements can be performed quickly in an ambulatory setting — it takes me around 45 minutes to complete a procedure, which is fast — and they cost significantly less than they do in inpatient facilities. With a highly motivated generation of boomers settling into their golden years, a major opportunity is waiting for outpatient centers that can handle the growing demand for hip replacements coming their way. OSM