Tackling Total Joints

• Identifying suitable candidates. Many of my patients are overweight, smoke or have other health concerns that need to be addressed before they’re green-lighted for surgery. I’m a big believer in having an independent third-party evaluator review a patient’s entire health history to make sure they can be safely cared for in the outpatient setting. My patients are seen by an internal medicine physician who evaluates their blood pressure and level of diabetic control and determines if they have underlying lung disease, gastrointestinal problems, urinary issues or sleep apnea.

If everything checks out, they can have their procedure done in our surgery center. For some borderline patients, we could delay the decision until they undergo further testing or address the health concerns that are giving us pause. However, patients with significant pulmonary disease who might need ventilator support for a few hours after surgery and those with longstanding kidney disease shouldn’t have their joints replaced in the outpatient setting.

I don’t have automatic cutoffs for patient selection based on BMI. Heavier patients still must pass pre-op screenings for health markers to be cleared for surgery, of course, but eliminating BMI concerns from the screening process will expand your patient pool and increase your caseload. Seeing the results of a successful surgery performed on patients whom other surgeons rejected out of hand because of their weight is also tremendously gratifying.

Discussing weight with heavier patients can be delicate, but emphasize that total joint operations are a two-way street. I tell my patients I’m performing the surgery and they’re going to have to recover from it. Their weight is modifiable, and they’re told that failing to lower their BMI puts them at increased risk for delayed wound healing and post-op infection and could shorten the life of their implant.

You can’t tell patients exactly how much weight to lose, as that can depend on their age, activity level and other factors. Instead, talk to them about taking their overall health seriously and how to take proactive steps to improve it. Our practice has contracted with an online program that assigns willing patients a health coach. They weigh themselves and meet with their coach virtually from their home twice a week to discuss how to improve their diet and exercise. This platform has encouraged and motivated many of our patients to live healthier lives.

Patients who smoke are at increased risk of delayed wound healing and post-op infection. Additionally, nicotine hinders optimal bone healing. Strongly encourage patients to stop smoking for at least a few weeks before their surgeries and explain that doing so could make a meaningful difference in their outcomes. And one never knows: If they quit for a short time, perhaps they’ll be motivated to kick the habit for good.

• Wait time between surgeries. My patients are told they can have their second knee replaced six weeks after the first one, even though there is some research that suggests 12 weeks should pass between the procedures. Our practice settled on the six-week minimum by considering the results of published physiological studies, but also looked at the results of cases performed in our surgery center since 2013. We stratified the patients by how much time had passed between their first and second knee replacements: less than six weeks, at six weeks and beyond six weeks. The analysis showed no appreciable difference in outcomes, so we continue to advise that six weeks is appropriate. That said, we occasionally decrease the interval to four weeks for some patients, including schoolteachers who want to get both knees done during their summer break, younger healthy patients or individuals with an urgent need to return to gainful employment.

• Addressing staph bacteria. Volumes of research shows a high percentage of joint replacement patients are carriers of methicillin-sensitive staphylococcus aureus (MSSA) or methicillin-resistant staphylococcus aureus (MRSA) and that risks of surgical site infection decline significantly if all patients are screened and carriers are treated with mupirocin nasal ointment. We employ a hybrid approach, which involves screening high-risk patients — those on renal dialysis, residents of nursing homes, healthcare workers and individuals with indwelling catheters. We also screen patients who have had a staph infection in the past or who report having had an infection of mysterious origin.

Our pre-op regimen for patients who test positive for MSSA or MRSA consists of treatments with mupirocin nasal ointment and showering with chlorhexidine gluconate (CHG) antiseptic skin cleaner for five days leading up to their procedures. On the day of surgery, pre-op staff wipe every patient’s surgical site with CHG. We’ve looked into swabbing patients’ nares with povidone-iodine, which is very effective at eradicating MSSA and MRSA colonization, and will consider adding the swabs to our pre-op care routine if competition among manufacturers brings the price down a little bit.

• Rehabilitation options. How and where patients receive physical therapy (PT) after surgery is a highly debated topic. Home-care PT is the least desirable option, in my opinion. Physical therapists visit patients at their houses, which likely lack adequate workout equipment, yet charge the same amount as if the patients went to a fully equipped PT facility.

Total joint operations are a two-way street. I tell my patients I’m performing the surgery and they’re going to have to recover from it.
— Dr. Adolph Lombardi, Jr.

I prefer that my patients attend traditional PT sessions. The experience is better and getting to and from the facility is valuable therapy itself. Patients are forced to move and ambulate simply by getting dressed, getting in and out of their car and walking into the facility. This level of basic activity can help speed their recovery.

If fears of COVID-19 make patients resistant to scheduling traditional PT sessions or having a therapist visit their home, apps provide virtual rehab sessions that patients can view on their phone or computer. Still, I advise patients to go to PT sessions at a facility whenever possible if they want to get better, faster.

• DVT prevention. Our approach is for patients to use compression socks that squeeze the blood from their calf and take two 81mg baby aspirin daily. This might be insufficient for morbidly obese patients or individuals with a history of DVT. These higher- risk patients are prescribed an oral blood thinner for 14 days after surgery. Sometimes we’ll give them a half-dose for the first three days to reduce the risk of a surgical wound bleed. The profile of an outpatient surgical patient inherently reduces the risk of DVT, however, as they’re often healthy enough to ambulate soon after surgery and continue moving after they’ve been discharged.

• Pain control. Ten years ago, we wrongly considered pain to be the fifth vital sign and pushed for patients to have zero discomfort after surgery, which was unrealistic. We prescribed patients high doses of painkillers and didn’t hesitate to fill their requests for more. Now we do everything possible to use multimodal pain regimens in an effort to keep narcotic use to a minimum. We educate patients to explain that they will experience post-op pain, which will be treated with ice, acetaminophen and an anti-inflammatory. If narcotics are needed as a last-ditch effort to control pain, we explain the dosing will be right-sized for severe, moderate and mild pain. 

Whether you’re taking steps to launch a total joints program or enhancing your existing one, establishing standardized protocols and following best practices to create a clear-cut care plan will position your facility for continued success when all but the most complex joint replacement revisions are done in the outpatient arena. OSM