THIS WEEK'S ARTICLES
Reducing Outpatient Joint Readmissions - Sponsored Content
High-Tech Help for Joint Replacements
Robotic assistance, navigation systems and smart implants are giving surgeons a chance to look at the bigger picture for their patients.
Robotic-assisted joint replacement surgery continues to gain momentum, even though there isn’t much data that shows the technology leads to better joint function.
Orthopedic surgeon David J. Mayman, MD, a joint replacement specialist at the Hospital for Special Surgery in New York City, is a believer in the technology. He says computerized navigation and robotics result in more precise and accurate bone cuts and implant placement than what’s possible with traditional mechanical guides.
Dr. Mayman says the user-friendliness of the latest robotic platforms is helping surgeons achieve high-quality outcomes, unlike earlier generations that were also more expensive, consumed more space and required more time to set up.
Robotic navigation systems work off CT scans of the patient’s joint, providing surgeons with a 3D reconstruction of the unique anatomy. Surgeons then can plot out procedures virtually, including where and how they’ll place implants.
The navigation system then guides surgeons as they make cuts and place implants to ensure they remain in the targeted zone determined by the navigation technology. “Working with a tool that provides reproduceable accuracy allows surgeons to be more precise in their pre-op planning,” says Dr. Mayman. “They’re able to spend more time analyzing ligament alignment and soft tissue balancing in the knee and determining how the anatomy of the pelvis and spine will impact hip replacements.”
He says working with robotics enables surgeons to think about surgeries from a wider perspective. “Instead of focusing on the individual tasks of the case, they’re thinking about why they’re performing them and how they fit into the overall scheme,” says Dr. Mayman. They can also consider making minor modifications in real time, which could lead to better outcomes, he adds.
Robotic assistance also provides surgeons with more confidence in performing technically challenging partial knee replacements, notes Dr. Mayman. “Robotics makes partial knee replacements a more precise and reproduceable procedure,” he says.
As the number of robot-enabled joint replacement procedures increases, Dr. Mayman anticipates significant advances in what the technology enables surgeons to do over the next five years. He believes the tech will also provide a deeper dive into outcomes. “Surgeons will capture data from a very precise tool and see how minor modifications made to surgical techniques impact how well patients do,” he says. “That large feedback loop will eventually help surgeons determine how to best treat individual patients.”
Additionally, the emergence of implants embedded with smart sensors located in the small stem of the tibial component could capture kinematic data — joint range of motion, step count, stride length, distance traveled, average walking speed — and send it to a cloud-based dashboard that surgeons can access to monitor the post-op function of the patient’s knee and track the progress of their rehab and recovery.
“The data is currently very limited, but the capability of the technology is immense,” says Dr. Mayman. “In the future, will smart implants detect early infections or wear and tear and loosening of implants? It’s a brand-new application that carries a lot of potential, so we’ll have to see where it goes.”
Prepping for the Outpatient Shoulder Replacement Boom
The requirements for this surgery differ in several ways when compared to total hips and knees.
Hip and knee arthroplasties continue to drive demand for outpatient total joint procedures, but the volume of same-day shoulder replacements is increasing at a higher rate. The trend is expected to continue, says J. Gabriel Horneff III, MD, FAAOS, an assistant professor of clinical orthopedic surgery in the shoulder and elbow division at University of Pennsylvania in Philadelphia. About 350 total shoulders are performed each year at Penn Medicine, where Dr. Horneff practices. While most of those cases are still inpatient, more are being performed in the ambulatory setting.
Dr. Horneff says these are the essential elements of performing outpatient total shoulders:
Patient selection. The best candidates have healthy BMIs and no comorbidities such as congestive heart failure, COPD, immunodeficiencies or severe shoulder deformities. Because most candidates are at least 60 years old, a cautious approach should be the order of the day when starting this service line at an ambulatory surgery center.
A top-notch anesthesia team. Providers should be skilled at administering regional blocks and able to communicate with patients about what to expect before and after they are placed. Most patients will experience arm numbness and perhaps even be unable to use their arm for a day or so after surgery.
“It could cause undue anxiety if they're not told to expect the lack of sensation in advance, as they'll think it's abnormal and a potentially serious complication,” says Dr. Horneff. “You need an anesthesia group that not only answers calls from concerned patients, but checks in on patients proactively after procedures to assess their condition and answer their questions.”
OR equipment. Surgical tables must recline the patient into the beach chair position at approximately 45 degrees to offload pressure on the sciatic nerve. Specialized attachments are required to stabilize the head, including a foam mask that supports the patient throughout the procedure. Other attachments can enable surgeons to position arms for improved access to the surgical site. An open shoulder tray, oscillating saw and drill are used to perform the procedure.
Pain control. Nerve blocks and non-narcotic multimodal pain regimens make outpatient total shoulders possible. “My patients are given IV acetaminophen preoperatively and a single-shot interscalene nerve block with long-acting liposomal bupivacaine during surgery,” says Dr. Horneff.
Post-op instructions. Patients should be sent home with detailed instructions about how to wear their slings, care for their wound and prevent blood clots with aspirin and movement, along with information about their physical therapy options. Educational videos and a postoperative assessment by an occupational or physical therapist are also helpful.
“These steps can help physicians perform total shoulders safely on select patients and make the procedure the fastest-growing component of a practice’s orthopedics service line,” says Dr. Horneff.
Reducing Outpatient Joint Readmissions
How to optimize your outpatient joint program by preventing, diagnosing and treating key causes of readmission.
More than one million Americans receive a knee or hip replacement every year. Unfortunately, the rate of readmission 30 days after those procedures is an alarming 4.2%.1
The good news is, by knowing the top causes of readmission after large joint procedures and how best to prevent them, healthcare providers can ensure that patients recover fully and without complications — delivering the best care possible and improving their quality of life.
Additionally, there are several well-understood modifiable risk factors which, if carefully considered and addressed during the patient selection process, can have a significant impact on quality, safety, and outcomes.
This article examines three major causes of readmission following joint procedures and outlines several modifiable risk factors to consider when developing patient selection criteria. At the end you will find links to citations and a comprehensive set of resources including products, information and solutions to help optimize your outpatient joint program.
Causes of Readmission
Seven causes of readmission following a joint procedure include: surgical site infections (SSIs), deep vein thrombosis (DVT), pneumonia, urinary tract infections, pain, patient fall and sepsis. (Go here for an assessment of all seven causes.)
As one of the most common indications for revisions in total joint arthroplasty procedures, SSIs occur in one to two percent of patients, and will cost the healthcare sector more than $1.6 billion by 2030.1 Staphylococcus aureus, or MRSA, is the leading cause of SSIs. Research suggests the risk of SSIs increases up to nine percent due to nasal colonization of MRSA, and that 30% of patients are nasally colonized when they reach the operating room.1 Here is more information on how to prevent, diagnose and treat MRSA nasal colonization and other causes of SSIs.
A DVT is a blood clot that forms most commonly in the deep veins of the lower leg. Decreased activity following a joint replacement surgery can slow the flow of blood thereby increasing the risk of clot formation. Other risks include inherited conditions, certain medications, vein disease, obesity, smoking, age, or serious illness. Knee and hip replacement patients are at highest risk for developing a DVT two to 10 days after surgery and remain at risk for approximately three months.
Clot prevention includes a combination of approaches, including anticoagulants, exercise and physical therapy, compression stockings applied before surgery, and the application of a pneumatic/sequential compression device. Read more about preventing, diagnosing and treating DVTs here.
Pneumonia is a serious complication that occurs in one in 300 patients following a total joint procedure and can increase the risk of sepsis.1 A study by the American College of Surgeons National Surgical Quality Improvement Program found that four in five patients who develop pneumonia are subsequently readmitted, and one in 25 die.1 Risk factors include chronic obstructive pulmonary disease, diabetes mellitus, lower body mass index, hypertension, smoking and general anesthesia. Post-anesthesia prevention measures include early ambulation, at-home use of incentive spirometer every two hours for two weeks post operation, and, of course, proper infection prevention measures.
Modifiable Risk Factors
Proper patient selection is critical to improving outcomes in an outpatient program. Several modifiable risk factors contribute to poor clinical outcomes following a total joint replacement. Key patient selection considerations include well-known clinical factors such as obesity, smoking, diabetes, and venous thromboembolic disease; however, care should also be taken to ensure patient living conditions are suitable to recovery, and that the patient’s friends and family members are committed to helping with patient recovery.1 In fact, preoperative education and post-operative support can help reduce readmission rates by almost two percent.1
Note: Visit the McKesson orthopedics website to learn more about these risk factors, their associated complications and how to minimize them.
1. Go to https://mms.mckesson.com/resources/reducing-readmissions/joint-replacement-readmissions-resource-guide for a full list of citations.
The Building Blocks of Outpatient Total Joints
Lay a foundation for success by optimizing patient selection and pain management practices.
Yale Medicine in New Haven, Conn., is at the forefront of the continuing evolution of total joint surgery. The health system’s providers have spent years developing a standardized care pathway that optimizes the outcomes of patients who feel well enough to head home soon after having their knees and hips replaced. “We’ve shown through data and published research that our protocols are best practice,” says Lee Rubin, MD, a hip and knee surgeon at Yale Medicine and an associate professor at Yale School of Medicine.
The first and most important step for surgical success, according to Dr. Rubin, is to identify patients who are appropriate candidates for undergoing the complex procedures in the outpatient setting. “They need to be motivated and enthusiastic about the prosect of being discharged on the day of surgery and have a strong support system in place at home,” he says.
Yale’s team of providers developed a standardized Ortho Risk Score, which is based on a patient’s health history and comorbidities. Patients with a score of five or below are greenlit to have their surgeries performed as outpatient procedures, but Yale’s anesthesia providers and orthopedic surgeons review each patient before giving final approval.
Jinlei Li, MD, PhD, Yale Medicine anesthesiologist and an associate professor at Yale School of Medicine, has been instrumental in making sure patients are comfortable enough to head home hours after their procedures. She spent years researching the latest developments in regional anesthesia before coming up with the innovative idea to add steroids to the anesthetics used in continuous nerve blocks and administer mixtures of short-acting dexamethasone and long-acting methylprednisolone around the surgical site to extend the analgesic effects of the blocks.
It was a masterstroke that leaves joint replacement patients feeling incredibly well after surgery — almost too well, in fact. Many patients are reminded to ask for assistance before getting out of bed in the PACU. “They feel so comfortable that they forget they just had major surgery,” says Dr. Li. “We don’t want them to fall.”
Yale’s providers continue to research ways to optimize the care pathway for patients undergoing hip and knee replacements. “Having standardized evidence-based protocols in place means we can roll it out to new facilities, which allows more patients across the health system to benefit from the care we provide,” says Dr. Rubin. “We’re going to bring these best practices to their communities.”
Giving a Hand to Wide-Awake Surgery
Increasing numbers of patients are undergoing hand procedures without sedation.
Wide-awake hand surgeries are growing in practice, fueled by two major innovations: the use of epinephrine as a local anesthetic and an embrace of the concept of tumescent anesthesia.
Epinephrine, a vasoconstrictor that limits bleeding at the surgical site, eliminates the need for a tourniquet to keep the operative field clear of blood, says Donald H. Lalonde, MD, FRCSC, a professor in the division of plastic surgery at Dalhousie University in Nova Scotia, Canada. As such, patients no longer require sedation to tolerate the tourniquet.
Tumescent anesthesia involves injecting large volumes of low-dose epinephrine into subcutaneous fat to numb a large area of skin. Administering 7 mg/kg of lidocaine with epinephrine is exceedingly safe and does not require vital signs monitoring, says Dr. Lalonde. The local anesthetic is injected under the skin at least 2 cm around where instruments and hardware will be inserted.
“I wasn’t fully aware of the power of communicating with patients during surgery,” says Dr. Lalonde. “I’m able to talk to them about their expected recovery and responsibilities for taking ownership in their post-op care plan. The practice has decreased my rate of complications.”
Steven Yang, MD, a clinical associate professor in the department of orthopedic surgery who’s been instrumental in bringing wide-awake hand surgery to NYU Langone Health in New York City, says patients don’t undergo extensive pre-op testing, don’t need to fast preoperatively, don’t suffer PONV and receive no medications before or during surgery, meaning they can leave almost immediately after the procedure is finished. About 80% of Dr. Yang’s patients opt for wide-awake surgery when it’s offered.
Dr. Yang restricts application of the wide-awake technique to small, quickly performed procedures such as carpal tunnel releases, trigger finger releases and ganglion cyst excisions, although it has also been employed for larger, more complex surgeries such as fixes of distal radius and elbow fractures and nerve repairs. “We’re slowly pushing the limit of what’s possible and what patients can tolerate,” he says.
Dr. Yang provides an example of the effectiveness of wide-awake surgery. Patients with a trigger finger develop thicker flexor tendons, which normally glide through a series of pulley-like structures to control bending of the finger, but can get stuck on them, which leads to a painful, potentially debilitating condition. The corrective surgery involves releasing or cutting one of the pulleys at the base of the finger, allowing the tendon to move freely.
Unfortunately, anatomic variability in the pulleys could require surgeons to dissect more of a pulley or create a release farther along the length of the tendon. “When patients are awake during surgery, surgeons can ask them to move their finger through a full range of motion to confirm the pulley has been fully released before the surgery is concluded,” says Dr. Yang. “That’s a major advantage of wide-awake surgery.”
One issue surrounding the technique is how surgeons who are accustomed to operating on anesthetized patients feel about it. Speaking to awake patients and explaining each step of the procedure as it happens can be unnerving for some. “Even the nicest and most congenial surgeons are not used to social interactions during surgery,” says Dr. Yang. “They view the OR as a quiet place where they can focus solely on performing the operation.”
Proponents of wide-awake hand surgery, however, believe that operating on alert patients can prove beneficial, particularly in terms of getting them more actively involved in their own care and more invested in the outcomes of their surgeries.