When I began performing minimally invasive total hip arthroplasty at Rush-Presbyterian-St. Luke's Medical Center four years ago, I learned very quickly that patients recovered much more rapidly than they did after conventional open hip-replacement surgery.
Our procedure, in which the hip removal and replacement are done through two 1.5-inch to 2-inch incisions and in which no muscles and tendons are cut, has been accompanied by an accelerated rehabilitation protocol, which begins physical and occupational therapy within hours of surgery.
In each of the last 200 cases I've done, the patient has been able to go home on the day of surgery. The last patient who stayed overnight after this minimally invasive process was in December 2002. On average, my patients have discontinued the use of crutches and narcotic pain medications in six days and returned to work in eight days (see "Study: Aggressive Rehab and Minimally Invasive Technique Key to Outpatient Hip Replacement.")
We've also come to realize, though, that many people find it hard to accept total hip arthroplasty as an outpatient procedure. Some skeptics say it can't be done or that it shouldn't be done. We've shown that it can be done - safely - and that patients benefit from the accelerated recovery. Here are some considerations that you'll face in building a minimally invasive total hip replacement program.
Same parts, new path
The surgical setup and requirements for the procedure are very similar to those of a traditional hip replacement. The components that you use - conventional cementless total-hip prostheses - are the same traditional implants that we've been using for years, and that you have on your shelves.
The surgery itself is different, however. The minimally invasive procedure isn't just a little different from the conventional open approach; it's a lot different and technically more demanding. Your surgeons and OR staff must be trained to do this new procedure. In general, the training is more advanced than just watching a video or visiting someone who does the procedure. The American Academy of Orthopedic Surgeons (AAOS) runs courses on the subject, but AAOS has been slow to develop a comprehensive training program for new procedures.
The ones who've actually been offering the best training on these new procedures have been the companies that make and sell the implants. They're a good source of information for surgeons and facilities that want to get involved. Zimmer, the Warsaw, Ind.-based implant and instrument manufacturer, has a specialized training center that teaches the procedure in a cadaver course for surgeons and staff.
Surgeons or staff who are unsure of the procedure's feasibility and simply want to see what's possible can visit surgeons like myself to observe what we're doing. I have somebody watching me do outpatient hip surgery almost every day.
In addition to the training, the procedure will require some outlays for modified instruments with which to perform the minimally invasive procedure - in particular, specially designed retractors, reamers and inserters that allow easy insertion and better visualization. I have a self-designed set of curved instruments outfitted with fiber optic lights that enable better visualization of the hip than with traditional instruments. Zimmer, for one, provides the tools you'll need for this procedure in a three-tray set.
Rethinking the process
To accept total hip arthroplasty as an outpatient procedure, nurses, support staff and members inside and outside of the OR must undergo a substantial learning curve.
Our patients are going to require all the same things that they've always required. Instead of receiving them over four days to five days, though, they're going to get them in a few post-operative hours.
Study: Aggressive Rehab and Minimally Invasive Technique Key to Outpatient Hip Replacement
An aggressive rehabilitation program and a minimally invasive surgical technique are the keys to letting hip replacement surgery patients recover rapidly enough to qualify for same-day discharge, a study of 100 patients suggests.
Richard A. Berger, MD, outlines the process of outpatient hip replacement and recovery in "Rapid Rehabilitation and Recovery with Minimally Invasive Total Hip Arthroplasty," a study published in the December issue of Clinical Orthopaedics and Related Research.
For the study, Dr. Berger observed 100 patients who underwent the procedure between December 2001 and May 2003.
Each patient began physical therapy within six hours of surgery. Once patients were able to get in and out of bed and chairs, walk 100 feet and climb stairs, they were discharged from the hospital and encouraged to participate in daily activities as soon as possible.
Ninety-seven of the patients were discharged on the day of surgery. The other three, who suffered post-operative nausea and hypotension, were discharged the following day.
Dr. Berger calculated that the mean time his patients took to discontinue the use of crutches and pain medication was six days; to return to work, eight days; to walk without any assistive devices, nine days; to walk a half-mile, 16 days. No readmissions or complications were reported.
"We think that the combination of this rapid rehabilitation program and the minimally invasive surgical technique are important to this rapid recovery process," writes Dr. Berger in the study. "Immediate weightbearing as tolerated facilitated rapid rehabilitation (and) the minimal soft tissue trauma has caused patients less pain and a quicker return to function."
- David Bernard
Our discharge planner, for instance, contacts our patients even before surgery, as there's no time to make the arrangements on the day of surgery.
Our scheduling hasn't been a problem as long as we get surgery done by noon or 12:30 p.m. I've managed to complete the surgery in an average of one hour and forty minutes, and patients who are part of the rapid recovery protocol are the first or second surgeries of the day. They have to be. Our physical and occupational therapists - who initiate therapy before the patients are discharged - finish their days by late afternoon, so patients done after noon couldn't complete the process on the same day.
One of the keys to the rapid recovery process is using less anesthesia. What we've been doing for the past 30 years or so is giving the patient a large dose of general anesthesia. When you're doing minimally invasive surgery, you don't need to medicate the patient quite as much. It's not as extensive a procedure, and they're not having as much pain, so you can use less anesthesia. In fact, giving them all that medication will make them dizzy for hours and hours, and will slow recovery. And I've found that my patients actually feel very good after minimally invasive surgery with this new anesthesia technique.
Changing the surgical environment is probably the hardest thing to do. There's no magic to it; you just have to convince the staff it's best for the patient and for the facility.
What of reimbursement?
The only insurmountable obstacle to minimally invasive, outpatient hip replacement at an ambulatory surgery center is reimbursement. There's no ASC list code for total hip arthroplasty and no insurance company will pay for it to be done at an outpatient facility.
There's no reason we couldn't do this procedure at our surgicenter tomorrow except for the reimbursement issue. It's a Catch-22. Most surgeons who want to do this procedure are stuck doing it in a hospital environment. They want to do it in their own facilities, but lack of reimbursement won't allow it. Hospitals may be slow to back the outpatient aspect of the minimally invasive procedure - even when this is cost-effective for the hospital as well as the patient and the insurer.
These rules won't change until a lot more people in a lot more places are doing this surgery as an outpatient procedure. In our hospital, we're doing it on a daily basis, we're doing it safely and we're doing it with great outcomes.