Real-Life Lessons in Total Joint Replacements

Patient Experience Pain Management Orthopedics

By: Kendal (Gapinski) Kloiber | Contributing Editor

Published: 1/5/2022

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Henry Ford Health System is providing same-day care in a convenient and effective way for patients.


Virginia Alan knew she needed a total hip replacement before traveling to Paris with her husband to celebrate their wedding anniversary. She also assumed the procedure would require a hospitalization. “I didn’t want to spend the night in the hospital,” she says. “I wanted to eat my own food, sleep in my own bed and be on my own schedule rather than deal with the hospital’s routine.” 

Ms. Alan spoke with one of her husband’s colleagues who underwent a same-day knee replacement at Henry Ford Health System in Detroit and considered the possibility. “It seemed risky to have major surgery done on an outpatient basis, but she had nothing but positive things to say about the experience and had no problem recovering at home,” says Ms. Alan. “And knowing that a visiting nurse would check on me after discharge was reassuring.” 

A consultation with orthopedic surgeon Michael A. Charters, MD, soon followed and Ms. Alan booked her procedure in April 2021. She recovered in the comfort of her home and deems the procedure a life-changing success. “Before surgery, I couldn’t walk up the stairs or around the block,” she says. “Even carrying a bag of groceries in from the car was painful.”

Her experience is becoming commonplace among a growing number of patients whose care is helping to drive increased demand for same-day joint replacements that shows no sign of slowing down.

Forced by circumstances

A couple years ago, about 10% of patients who had their joints replaced at Henry Ford went home the day of surgery. After Medicare removed knee and hip replacements from the inpatient-only list, the health system began to consider shifting more total joint cases to one of its ASCs that had been retrofitted to handle the procedures. Then the pandemic hit. 

“We were shut down for three months and it became clear that patients didn’t want to spend time in the hospital for elective surgeries,” says Robb M. Weir, MD, an orthopedic surgeon at Henry Ford who oversees the joint replacement program. “There wasn’t room in our hospital for them to stay, and that became an opportunity to push the procedures to the outpatient setting. We came up with a plan to streamline the workflow and patient flow, and when elective surgeries resumed, we went for it.” 

Plenty of patients were interested in having their joints replaced before COVID-19, but couldn’t find a convenient time to get it done. “When the nation shut down during the pandemic, they realized it was an opportunity to stay home and recover,” says Dr. Charters. “That led to a boom in same-day joint replacements.”

As part of the plan to grow its program to meet the increased demand, Henry Ford’s leadership had to ensure there was enough space in the health system’s outpatient ORs for the additional equipment and trays of instrumentation needed to perform the procedures. They also needed to add post-op rooms where patients could recover for four to five hours after surgery. Even something as seemingly small as the size of a sink made a big difference when it came to creating the perfect space for same-day joints. 

“We had a great plan and program for converting one of our ASCs to handle the procedures, and then realized that we didn’t have a sink in its sterile processing department that was big enough to clean the instruments,” says Dr. Weir. “That delayed the launch of the program by three months.”   

Their hard work and planning eventually paid off. Today, 70% of the health system’s joint replacement patients are discharged to home on the day of surgery.

Resetting expectations

CLEAR COMMUNICATION Dr. Charters informs patients about the entire perioperative process and sets the tone for same-day discharges early on in their care.  |  Henry Ford Health

Henry Ford’s total joints program was started by surgeons who performed procedures on the healthiest and most active patients, says Dr. Charters. Once the program began to grow, it became important to convince both patients and the entire care team that same-day joints were feasible and safe. “The established culture was that patients need to recover in the hospital,” says Dr. Weir. “Most patients expect that, so they were hesitant when we began suggesting to send them home hours after their procedures ended.”

Over time, though, that expectation began to change. “Maybe it’s the impact of the pandemic or us doing a better job of getting the word out, but a lot more patients are asking if they can go home the day of surgery,” says Dr. Weir. 

Positive outcomes also helped sell the idea to staff members, and it didn’t take long for the entire care team to buy into the program. “When we first started performing the procedures outpatient, some staff members needed some convincing to get on board,” says Dr. Charters. “But after a few months, same-day discharge became a natural expectation because they saw that the patients were doing really well.” 

"A lot more patients are asking if they can go home the day of surgery."
— Robb M. Weir, MD

A collaborative environment has been key to the program’s progression. “The most important element of success is a unified team of providers,” says Dr. Weir. “Everyone who interacts with patients — front desk workers, nurses, anesthesia providers, surgeons — has to be on the same page and believe in the same message: If procedures are safe, we’ll support the program and feel good about sending patients home on the day of surgery.”

That message is sensed by patients, notes Ms. Alan. “The main thing that stood out to me is that I felt like I was getting personal care from Dr. Charters and his team,” she says. “They kept me informed throughout the entire process, and I was extremely impressed by how well they worked together. I was involved in my care from the start and felt like I was part of the team.”

Challenging the status quo

EUROPEAN VACATION Virginia Alan and her husband made it to Paris to celebrate their wedding anniversary after her successful hip replacement surgery.   |  Virginia Alan

The success of Henry Ford’s outpatient joint replacement program is built on a strong patient selection process. Dr. Charters makes sure patients are medically appropriate for same-day discharge and have no significant comorbidities or major heart or lung problems. He also considers if they’ll be physically able to function independently following surgery, perhaps with the help of a cane or walker, and have a strong support system in place. 

“Joint replacement is an elective surgery, so patients having caregivers at home to help out during their recoveries is very important,” says Dr. Charters. “Patients who don’t have a friend, family member, neighbor or someone who can assist them during the first few days post-op shouldn’t be discharged on the day of surgery.” 

He identifies pain management as another key component of successful total joints programs. At Henry Ford, this includes getting patients up and moving soon after surgery, a factor that correlates to less post-op discomfort, and optimizing the use of a multimodal pain management protocol. 

“Most patients receive a short-acting spinal anesthetic that wears off quickly with minimal side effects,” says Dr. Charters. “This helps to reduce the grogginess and nausea that patients can experience after receiving general anesthesia — factors that can impede their ability to ambulate.”

To help control pain in total knee patients, surgeons inject a local anesthetic around the joint during surgery and anesthesiologists place nerve catheters attached to pain pumps, which provide relief for three to five days post-op. 

Additionally, patients follow an analgesic plan that uses a combination of medications, physical therapy and other techniques to prevent pain, with opioids available as a last resort. “My patients recover at home with Tylenol, anti-inflammatories, ice and a nerve catheter,” says Dr. Charters. “I tell them that they should take opioids only as a rescue medication to manage breakthrough pain when those treatments don’t work.”

Ms. Alan says the program’s pain management plan was very effective and adds that she was never in a lot of discomfort after her procedure.

Educating patients on what to expect before and after surgery is another key aspect of successfully performing total joints in outpatient facilities. Ms. Alan received a comprehensive booklet that outlined everything she needed to know about her pre-, intra- and post-op care. If she had a question about any aspect of it, answers were always a phone call away. “The team of providers were readily available, and that took away a lot of my anxiety about the entire process,” says Ms. Alan. 

Improved clinical approaches and engaging patients to become active participants in their own care are contributing to the steady growth of outpatient total joints. “Patients ask me all the time about the technology that’s making the movement possible,” says Dr. Charters. “The implants are the same and most of the instrumentation is the same. Over time we’ve made the procedure less invasive, but I think the two biggest factors are getting patients moving soon after surgery and the effectiveness of multimodal pain management protocols.”

When Dr. Charters was in residency in 2009, joint replacement patients would lie in a hospital bed overnight before their first physical therapy session. “Now, patients are in our care for eight hours from start to finish,” he says. “They’re beginning physical therapy within a few hours of surgery and heading home soon after.”

As for Ms. Alan, her new hip continues to feel great and she made it to Paris with her husband. “I’m back to being the active person I once was,” she says. “I’m still amazed by the results of the surgery and how quickly I recovered.” OSM

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