ADVANCES IN JOINT REPLACEMENT AND REHABILITATION IMPLICATIONS

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1 ADVANCES IN JOINT REPLACEMENT AND REHABILITATION IMPLICATIONS VALENTIN ANTOCI JR. MD PHD Hip and Knee Surgeon Assistant Professor of Orthopedic Surgery Alpert Medical School with Brown University University Orthopedics, Providence, RI (401) 684-HIP1

2 ADVANCES IN JOINT REPLACEMENT AND REHABILITATION IMPLICATIONS Dr. Antoci is Fellowship Trained Orthopedic Surgeon in Arthroplasty, a graduate of the Harvard Combined Orthopedic Surgery Program, and the Arthroplasty Fellowship at the Massachusetts General Hospital. He is currently part of the faculty at the Alpert School of Medicine with Brown University and an orthopedic surgeon with University Orthopedics DISCLOSURES I have no financial disclosures pertinent to this presentation.

3 ADVANCES IN JOINT REPLACEMENT DO YOU KNOW ANYBODY WHO HAD A JOINT REPLACEMENT?

4 Total joint replacement is one of the most commonly performed and successful operations in orthopaedics as defined by clinical outcomes and implant survivorship* *

5 Total joint replacement (TJR) is one of the most cost-effective procedures in all of medicine

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7 Early Hip Arthritis Surgery in the 1800s In 1821, Anthony White of the Westminster Hospital in London, performed the first anthroplasty, where an arthritic or joint surface is replaced. The procedure helped with pain and mobility, but failed with stability.

8 Early Hip Arthritis Surgery in the 1800s In 1891, Professor Themistocles Glück led the way in his development of a hip implant fixation. He produced an ivory ball and socket joint that he fixed to bone with nickel plated screws. He also used a mixture of plaster of Paris, and powdered pumice with resin for fixation.

9 Early Hip Arthritis Surgery in the 1900s In 1925, a surgeon in Boston, Massachusetts, Smith-Petersen, M.D., molded a piece of glass into the shape of a hollow hemisphere which could fit over the ball of the hip joint and provide a new smooth surface for movement. While proving biocompatibility, the glass could not withstand the stress of walking and quickly failed. That was subsequently changed to vitalium

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11 In 1958, John Charnley from England introduced the idea of replacing the eroded arthritic socket with a Teflon component. When this failed he used a polyethylene polymer to construct the socket.

12 During the late 1960's, a Canadian orthopedist, Frank Gunston, from Sir John Charnley's Hip Center, developed a metal-on-plastic knee replacement to be secured to the bone with cement. This was really the first metal and plastic knee and the first with cement fixation. In 1972, John Insall, M.D., designed what has become the prototype for current total knee replacements.

13 ARE WE THAT MUCH BETTER? Charnley Modern Tapered Stem

14 SO, HOW LONG WILL MY HIP LAST?

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27 U.S. TJR Payer Mix 60% 50% Proportion of Patients 40% 30% 20% 10% 0% Medicare HMO PPO Indemnity Medicaid % Total Discharges Source: AHRQ, HCUPnet, 2002 Nationwide Inpatient Sample, site accessed on July 26, Total Hip Replacement is sum of ICD9-CM Procedure Codes and Total Hip Replacement, Revise Hip Replacement. NIS data is collected for calendar years (January December). Routine discharge is discharge to home only. Discharge to another institution includes discharge to SNF and IRF.

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29 WHY SO MANY KNEES...?

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34 BUT DOCTOR, WHY CAN T YOU FIX MY KNEE?

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37 WHICH ONE IS THE OBESE CURVE?...

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39 I NEED MY KNEE FIXED TO LOOSE WEIGHT

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42 OBESITY ALMOST DOUBLES LENGTH OF HOSPITAL STAY

43 YET SAME DAY SURGERY IS THE FUTURE

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46 The Ambulatory Surgery Center Association says close to 40 centers around the country are performing outpatient joint replacements Moving these procedures to outpatient settings poses a major threat to hospital finances, since total joint replacements are one of the largest and most profitable service lines at many hospitals.

47 YOUNGER PATIENT POPULATIONS BETTER EDUCATION AND INFORMATION BETTER UNDERSTANDING OF PATIENT FACTORS IMPROVED PAIN CONTROL REGIMENS FASTER AND MORE EFFICIENT SURGERY MINIMALLY INVASIVE APPROACHES

48 HOW BIG SHOULD A HIP INCISION BE?

49 HOW BIG SHOULD A HIP INCISION BE?

50 HOW BIG SHOULD A HIP INCISION BE?

51 MINIMALLY INVASIVE APPROACHES

52 MINIMALLY INVASIVE APPROACHES Domb et al J.Arthropl

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55 Parvizi et al examined the timing of fatal and high-morbidity outcomes after TJA and reported a 6% incidence (104/1636 cases) of major life-threatening complications in the hospital setting. They had 1 inpatient death, and found that 90% of their major complications occurred within 4 days of the index arthroplasty. Parvizi et al said that if these complications had occurred outside the hospital setting, they would have led to the death of 20 to 25 patients in their cohort.

56 TJA patients seem to have higher patient satisfaction and functional outcomes after same-day discharge. Berger found that out of 150 same-day total hip arthroplasties performed, 144 patients were highly satisfied with their experience and would choose the same pathway again. Only 6 patients believed they might have benefited from a night in the hospital due to issues related to nausea and pain. The theoretical risk of higher readmission rates after outpatient TJA has been refuted by several authors in their short-term analyses of same-day discharge patients. The major issues that arise after same-day discharge are not related to major medical or surgical complications requiring readmission, such as pulmonary emboli, problems related to anticoagulation, or infections. Uncontrolled postoperative nausea, orthostasis, and pain control are the most common reasons for delayed discharge from the fasttrack pathway and for emergency department visits in the first few weeks after same-day TJA surgery.

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58 RAPID REHABILITATION PROTOCOLS Short-acting perioperative analgesia, including short-acting epidural and spinal anesthetics Physical therapy is initiated 3-5 hours after surgery. Patients must demonstrate the ability to independently move from a supine to a standing position and return from a standing position to a supine position. After these initial criteria are met, patients must then be able to ambulate at least 100 feet and ascend and descend a full flight of stairs. Plan for postoperative therapy and monitoring of any early complications

59 IS IT FEASIBLE? I THINK SO

60 (401) 684-HIP1