POPULAR AND PRACTICAL It's estimated that nearly 70% of orthopedic surgeons use the posterior approach to expose the hip joint for easy, safe and quick access to the joint.

We've performed 90 joint replacements since we launched our same-day total joint program at our ambulatory surgical center 2 years ago. Guess which group of patients has fared the best: knees, hips, shoulders or ankles? Our total hip arthroplasty patients, and it's not even close. Given hip replacement's reputation as a bloody procedure with a grueling recovery, we were surprised, too. But from surgical outcomes and discharge times to patient satisfaction scores and pain scores, the 30 hip cases we've done thus far have gone exceptionally well. The numbers speak for themselves.

• Discharge. On average, our same-day total hip patients leave here about 3 hours after their surgeries (sometimes in a hospital a patient doesn't even get to his room 3 hours after surgery).
• Pain. The average pain score on post-operative day zero is 1.3. Pain scores on days 1 and 2 are between 3 and 4 — and that's their pain scores after physical therapy, not their pain scores at rest.
• Satisfaction. By replacing diseased hip joints with artificial joints, we are truly changing our patients' quality of life — relieving their pain, increasing their motion and helping them get back to enjoying many normal, everyday activities. This reminds us of the post-op patient who rather than use his walker to take his first steps with his new hip actually lifted the walker and began to walk away with it. We gently reminded him that the walker's wheels would help him get around. "No thanks," he told us. "I don't need any help."
• Complications. We haven't seen more than 100cc of blood loss. We've had zero readmissions and revisions, and zero falls.

Outpatient total hips?
At first we were skeptical about the concept of hip replacement without a hospital stay. Discharging a patient in 3 hours who just underwent a bloody and painful surgery that usually requires 2, 3 or more days in a hospital is pretty ambitious. But the same-day joint replacement program here at Advanced Center for Surgery, one of the first of its kind on the East Coast, has exceeded our expectations and garnered national attention. We've found our success by focusing on the fundamentals: patient selection, tailored regional anesthesia, a posterior approach to surgery, physical therapy and home nursing care.

With total hip arthroplasty, we have an outstanding surgical procedure associated with a high degree of clinical success and patient satisfaction. This is achieved with a relatively low rate of complication. Of course, the quality of the clinical outcome is affected by our careful patient selection and preparation, the technical job we do at the time of surgery and our ability to restore the biomechanical function of the hip.

If you stop and think about it for a minute, it makes sense that hips are easier to replace than knees. For one, there aren't any nerves to anesthetize in hip replacement. And unlike knees, there's not a lot of muscle- and bone-cutting in hip replacement. Finally, compared to knees, there's more room for swelling in the hip joint, so it's not as painful post-operatively.

IMAGES OF SURGERY
A Step-by-Step Look at Hip Replacement

Doing total joints same-day offers excellent outcomes, outstanding patient satisfaction and significantly lower healthcare costs. Here's what a total hip arthroplasty performed last month at Advanced Center for Surgery in Altoona, Pa., looks like through the lens of photographer John A. Scarfone of Starfleet Productions. The procedure took about 40 minutes. The patient was discharged in about 3 hours.

REGIONAL BLOCK A CRNA delivers a spinal anesthetic.	PREP WORK The surgical site is prepped, marked and draped.
OUT WITH THE OLD Surgeon Chris McClellan, DO, uses a drill to remove the old socket.
IN WITH THE NEW Readying the new implant.
JOINT ARTHROPLASTY Getting the socket in the right position is key to well-fixed, well-positioned implants, says Dr. McClellan.

INSERTING THE IMPLANT Dr. McClellan says his implants give outstanding range of motion. Despite using a posterior approach, he doesn't need an abductor pillow.

No cookbook answers
So, what's our secret recipe? We've been inundated with phone calls and e-mails from surgical facilities across the country that want us to help them launch same-day joint programs. Before you reach out to us, here's our pat reply: There are no cookbook answers. We can't give you a recipe to follow. It's not that simple.

Ours is a highly detailed program with many variables, one that we're working to license and trademark so that other surgical facilities can follow our protocols and study our new lesson in orthopedics. A massive amount of patient education and caregiver coordination is required. For example, we customize the anesthetic for each patient. We also arrange for a physical therapist to be waiting curbside at our patients' homes to greet them by name, help them navigate stairs and get comfortably settled. A homecare nurse visits to manage their pain, adjust the pain pump and check the incision site.

The surgery itself is only one part of the program, but the surgeon's skill and technique are absolutely essential elements in preventing motor weakness and allowing a same-day discharge. Yes, implant material and design are critical to achieve good surgical results, but there is no substitute for good surgical technique. Our same-day hips take between 40 and 60 minutes. The 2 trademarks in all of our same-day joint procedures are smaller incisions and muscle-sparing surgical technique.

As with most hip replacements in this country, we use the posterior approach to expose the hip joint. In the posterior approach, the surgeon accesses the hip joint through an incision close to the buttocks. The approach goes behind the abductors so it doesn't disrupt the major walking muscles. Not only does the posterior approach allow excellent visualization of the femoral shaft, but it also prevents the loss of abductor power in the immediate post-operative period and lets patients get up and move as soon as possible — like our friend who picked up his walker and carried it around.

Special 2-Day Total Joint Replacement Workshop at ORX

Christopher S. McClellan, DO

Interested in adding total hip and knee procedures to your ORs? Register now for the Same-Day Total Joint Workshop offered as a special pre-conference session at this year's OR Excellence (orexcellence.com) at the New Orleans Marriott. Hosted by the authors of this article, orthopedic surgeon Christopher McClellan, DO, and Dave Berkheimer, BSN, CRNA, the hands-on total joint workshop will run from 1 p.m. to 5:15 p.m. on Tuesday, Oct. 14, and from 7:30 a.m. to 11:30 a.m. on Wednesday, Oct. 15.

Dave Berkheimer, BSN, CRNA

You'll hear firsthand how Dr. McClellan and Mr. Berkheimer launched a total joint replacement program — knees, hips, shoulders and ankles — at their Altoona, Pa., ambulatory surgical center. Seating for the 8-hour workshop is limited to the first 50 attendees. Cost is $239 per person.

— Dan O'Connor

Minimally invasive anesthesia
Without regional anesthesia techniques, there's no way you could perform outpatient joint replacement surgery. Because we avoid general anesthesia and IV narcotics during the procedure, patients leave us awake and alert. As noted, we take a highly individualized approach to anesthesia for patients undergoing total hip replacement. All patients come to our facility for a personal pre-operative evaluation 7 to 10 days before their procedures for a full workup. On the day of surgery, our hip patients receive a major conduction block as part of our multimodal, non-narcotic anesthesia.

They leave the center with blocks that last up to 24 hours — the ultrasound guided nerve blocks, strategically placed, let patients go home pain-free but alert and able to move — and an elastomeric pain pump that will continuously administer anesthetic through the femoral catheter for another 48 hours. We prefer ropivacaine because of its cardiotoxicity profile. Patients also maintain an intravenous line, so visiting nurses can administer antibiotics or other drugs at the patient's home, if needed.

Patient selection is really where the success of our same-day program stops and starts. We follow strict guidelines when selecting joint replacement patients. They must be highly motivated, relatively healthy (1 or 2 comorbidities), ASA 1 or 2, and between the ages of 40 and 65.

When performed in our surgical center, hip replacement costs about one-fourth of what it would in a hospital: a $15,000 bundled payment at our ASC, compared to $60,000 at a hospital. As you might expect, insurers have enthusiastically backed our joint replacement program. They see the great results and the incredible savings. They see us changing the face of health care. What's not to like?