THE NEW NORMAL Surgeons are realizing outpatient total knee will soon be commonplace.

PRIME POSITION Table attachments help place the knee at the proper flexion.

Plenty of planning
Over the last 3 years, we've done more than 800 outpatient total joints, 65% of which were total knee arthroplasties. We reviewed the first 140 cases, and presented the findings at the American Academy of Orthopaedic Surgeons 2 years ago. Our readmission and complication rates were in line with patients who stayed 3 or 4 days in the hospital. In fact, the outpatients fared a little better.

Before that proven success, I met with the hospital's administration and our clinical leaders — representatives from anesthesia, the OR, physical therapy, occupational therapy and nursing — several times to ensure it was feasible and safe to perform total joints on an outpatient basis. When everyone was on board, we set up a standardized protocol that includes identifying candidates for the procedure.

Not everyone meets the criteria for outpatient joint replacement, and clearing someone for surgery is based on individual pre-op assessments. We base the decision on patients' current health, ASA scores, other comorbidities and home environments.

Age is not a limiting factor, but health certainly is. Candidates must be relatively healthy with no serious comorbidities such as active cardiac and pulmonary issues. As a rule, patients who are extremely obese or on sleep apnea machines aren't suitable candidates for same-day discharge. But most patients without active medical problems have the opportunity to go home if they prefer.

Anesthesia definitely needs to work closely with surgeons who want to perform outpatient knee replacements, and needs to use a light touch so patients are able to ambulate soon after reaching the recovery unit.

I do all of my cases with short-acting spinal anesthesia. My initial attempts involved spinals that didn't wear off for 4 to 5 hours after surgery, meaning patients were having difficulty completing the physical and occupational therapies needed to meet same-day discharge criteria.

Now, providers administer a small volume of a low-dose anesthetic so the block wears off in a couple hours. Patients are able to walk 50 to 100 feet soon after surgery, a necessary step before discharge.

Ambulating as soon as possible after surgery is also the best way to prevent DVT, perhaps the most dangerous and common post-op complication of joint replacement procedures.

Sequential compression devices are excellent for preventing DVT in hospitalized patients, but if patients are up and moving, as mine are, the devices are largely unnecessary. In the past, patients would be discharged with orders to take the anticoagulant warfarin for a month, but recent changes to Surgical Care Improvement Project guidelines permit the prescribing of aspirin, a much safer and equally effective preventative therapy (see "Aspirin OK for DVT Prevention" below).

The protocol we use to control post-op pain is fairly intense in order to get patients up and moving in recovery. Patients receive localized injections at the incision site at the time of surgery, and take-home pain pumps are attached to continuous catheters to infuse local anesthesia for 5 days post-op.

We schedule total knees as the initial cases of the morning. The healthy patients who are candidates for same-day discharge are first — the surgical day starts around 6:15 a.m. — so they're ready for discharge in the late afternoon. We allow plenty of time to ensure vital signs are stable, required physical therapy is completed and patients are complication-free.

GUIDELINE REVIEW
Aspirin OK for DVT Prevention

TAKE TWO Aspirin is one of the recommended prophylactics for venous thromboembolism.

Updated guidelines issued by the Surgical Care Improvement Project at the start of this year added aspirin to the list of acceptable prophylactic agents for preventing venous thromboembolism. The addition solved long-standing confusion and controversy over conflicting recommendations from the American Academy of Orthopaedic Surgeons and American College of Chest Physicians, which did not back the use of aspirin in these patients.

Here are the SCIP recommendations for patients undergoing elective total hip or knee replacement:

• low-molecular-weight heparin
• factor Xa inhibitor
• oral factor Xa inhibitor
• vitamin K antagonist (warfarin)
• intermittent pneumatic compression devices (IPCD)
• venous foot pump (VFP)
• low-dose unfractionated heparin (LDUH)
• aspirin

Surgeons choosing to use aspirin and mechanical compression as prophylactic therapies must note doing so in patients' charts so concerns about post-op bleeding are clearly documented, according to Jay R. Lieberman, MD, AAOS's representative to SCIP.

— Daniel Cook

Quad-sparing cuts
When reviewing patients who have undergone total knee replacements, I've found that the implant doesn't make the procedure. Instead, small instrumentation that lets surgeons make smaller approaches that do less damage to surrounding muscle is more of a factor in the procedure's ultimate success.

KNEE DEEP Causing minimal damage and properly placing implant components are keys to success.

I operate through small incisions, but the size of the incision is not as important as the operative technique. I've tried several approaches to the knee, but have found the quad-sparing approach to be the most effective for accessing the joint with minimal dissection before placing implants.

After making a medial parapatellar incision, I move the patella laterally to access the joint and prepare the femur for the insertion of the femoral component and the tibia for its tibial component. When closing, I simply approximate the medial parapatellar incision; there's no muscle cutting or muscle releasing — the muscle's been split in line with its fibers.

Patients see the skin, but they don't see what goes on underneath. With newer techniques, we're able to move more quickly and cause less pain. Not long after surgery, patients are able to perform straight-leg raises, bend their knees up to 90 degrees and take the first steps toward home.

Outpatient total knee doesn't require a special surgical table. We use a well-designed attachment that holds the knee in a bent position and locks in place, so an assistant doesn't have to hold the knee in a proper position for the entire procedure. This attachment involves placing the patient's foot in a boot connected to the positioning device, which we can ratchet up and down when various flexion angles are needed.

BELOW THE SURFACE The size of the incision isn't as important as the operative techniques used under it.

Back for more
My practice hopes to build surgery centers in the coming years, where we'll achieve successful outcomes at a fraction of the cost, which many of my high-volume peers are already doing across the country.

The clear cost savings of performing these procedures outpatient is one of the biggest benefits, especially from the perspective of insurance carriers, who understand sending patients home the day of surgery is far less expensive than hospitalizing them for 3 or 4 days.

Overall healthcare savings is one of the reasons I started doing outpatient total knees, but an equal driver was patient satisfaction. Why stay in the hospital overnight if you can safely be at home with your family and loved ones?

Most patients like to be aggressive in their recoveries. My patients often return for their follow-up exams requesting surgery on their opposite knee. Many patients contact our office requesting information about same-day total joint replacement.

They're relieved to know it's an option. This is a big change from not too long ago, when total joint outpatient replacement was not possible. What was unheard of just 5 years ago is quickly becoming the norm for the healthy and active patient.