As the population over age 65 has risen, so has the demand for total knee replacement.
Nearly 5 million Americans have undergone this procedure to regain knee function, overcome disability and stop arthritis pain — and that number is only going to increase. Knee replacements are expected to rise 673 percent in the next 20 years, according to the American Academy of Orthopaedic Surgeons.
While the surgery has changed dramatically over the last 30 years, recent advances have allowed the surgeons at Tidewater Orthopaedics to take the surgery to a new level of safety and convenience. They offer total knee replacement on an outpatient basis at the CarePlex Orthopaedic Ambulatory Surgery Center (COASC), located at Sentara CarePlex Hospital in Hampton, Va. The COASC, which allows patients to walk and even go home on the same day of surgery, is the only dedicated orthopedic facility on the Peninsula.
The “Well-Patient” Concept and Dedicated Orthopedic Teams
At Tidewater Orthopaedics, physicians and staff members follow a healthy patient model for hip and knee replacement. This model assumes that since these are elective surgeries, patients are generally healthy and should be treated that way. This approach to care has helped lead to many of the changes that allow for outpatient procedures.
“It’s important to recognize and continuously point out that patients are here for a bad joint,” says Dr. Michael Higgins, one of Tidewater Ortho’s orthopedic surgeons. “We don’t need to pretend they are sick. We don’t need to keep them in the hospital.”
Tidewater Ortho has dedicated surgical teams, staff and patient-care areas within Sentara CarePlex. These teams developed outpatient surgery protocols together, ensuring each member of the team is working toward the same goal of getting the patient home to rest and recover.
“The right surgical team increases operating room efficiency, decreases surgery time and decreases the length of stay,” says Dr. Colin Kingston, a knee and sports medicine specialist at Tidewater Ortho. “Patients have fewer complications and lower re-admission rates.”
A New Approach to Anesthesia
New anesthesia techniques are reducing complications and length of stay. In the past, managing pain after a knee replacement involved more narcotics and drugs that may have slowed recovery.
“Anesthesia would often include an indwelling epidural catheter which would be left in place for the first two days after surgery,” says Kingston. “This would result in excellent pain relief, but the patient would be bedridden as their legs would be numb.”
To help patients go home the same day, anesthesiologists use multiple pain management techniques that don’t interfere with walking. Patients receive a local nerve block around the knee before surgery even starts. They receive both narcotic and non-narcotic medicines.
“The most important technique is the block the surgeon does at the end of the surgery that numbs all the local tissues around the knee,” Higgins explains. “That seems to have a significant effect on relieving pain. Patients wake up with less pain compared to the past, and the pain is more controlled using less narcotic drugs.”
Reducing blood loss in the knee can help reduce pain and speed recovery. Up to 30 percent of patients had to have blood transfusions in the past, which could increase the risk of infections. Surgeons used to use tourniquets to try to reduce blood loss, but tourniquets could actually contribute to post-surgical pain and serious complications like deep-vein thrombosis.
A new IV medication — tranexamic acid (TXA) — helps prevent blood loss in the knee without tourniquets. Now few patients need transfusions. They experience less pain related to blood loss and don’t need drains in their knee to remove excess fluid. All of these changes help patients get on their feet faster and participate in physical therapy just a few hours after surgery.
New and constantly improving technology has resulted in huge strides in positive patient outcomes. Computer navigation technology maps out a patient’s knee and, using specialized cameras, tracks it as the knee moves. Instead of eyeballing cuts the old-fashioned way, orthopedic surgeons can now make accurate cuts in the bone every time, removing only the cartilage and bone necessary for pain relief.
“Computer navigation allows me to size the knee virtually on a computer and plan my surgery before I make any cuts to bone or cartilage,” Higgins says. “Because it follows the leg in real time through space, it allows me to verify that I am carrying my plan out in terms of any cartilage being removed or straightening or realigning the leg.”
Kingston says navigation has improved efficiency in the operating room:
“Technology has saved time in the OR and eliminated the need to recut the bone,” he says. “Recent studies have shown this has improved the alignment of total knee replacement better than the traditional cutting methods. Thanks to technology and other advances, a surgery that once took 2-2 ½ hours can now be completed in less than an hour.”
Patients at Tidewater Ortho may also receive custom-made knees. Using a CT scan taken before surgery, a company called Conformis can 3-D print a knee implant and the tools needed to put it into place specifically for that patient. The accurate fit can speed recovery and reduce pain.
“The entire bone surface that has been cut is capped or covered,” says Dr. Loel Payne, a Tidewater Ortho surgeon who specializes in the knees and shoulders, “so it tends to bleed a little less and it tends to help a little with pain.”
Not every patient, however, may benefit from a custom knee replacement.
“About 90 percent of people are good candidates,” Payne says, “but we wouldn’t use the custom knees in somebody who has a lot of deformity in the knee.”
Early Patient Education
Another key component of achieving outpatient knee surgeries is ensuring patients fully understand their surgery and recovery before the surgery takes place.
“We conduct knee replacement classes over the phone, making it easier for patients to attend the classes,” says Brandon Thompson, a nurse and the COASC’s administrator. “We can answer patient questions and explain to them how to prepare their house for surgery, what medications they should get refills for and all those key things that people just don’t think about before surgery.”
These early classes can help ease patient anxiety about going home so quickly after surgery and get patients motivated to have the best recovery possible.
The Benefits and Limitations of Outpatient Knee Replacement
“Going home the same day can decrease the chance for infection,” says Thompson. “Patients also rest better because they aren’t woken up by hospital noises or checks.”
While Tidewater Ortho’s surgeons have been able to perform dozens of outpatient knee replacements, not all patients can — or should — go home the same day as surgery.
“Patients who may have certain medical co-morbidities need to stay in the hospital at least 24 hours,” Higgins says. “Patients who are less mobile or more debilitated to begin with may need to stay in the hospital for additional physical therapy. Fortunately, a large percentage of total knee replacement patients are good candidates for outpatient surgery.”
As insurance coverage of outpatient knee replacement grows and surgical techniques continue to improve, physicians at Tidewater Ortho are confident that more and more patients will qualify for and see the benefits of outpatient knee replacement.