Objectives GRAND TOTAL OF 4! SAME DAY SURGERY TJA NICHOLAS SOTEREANOS MD DISCLOSURES - ZIMMER CONSULTANT 04/12/2016 REMEMBER PATIENTS NEED PROVIDERS

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1 SAME DAY SURGERY TJA NICHOLAS SOTEREANOS MD DISCLOSURES - ZIMMER CONSULTANT EXEC. VICE CHAIRMAN ORTHOPAEDICS ALLEGHENY GENERAL HOSPITAL Objectives DISJOINTED RAMBLINGS OF AN OLD MAD MAN INTERSPERSED WITH WHAT I VE BEEN DOING GRAND TOTAL OF 4! OVER THE LAST TWO YEARS OUT PATIENT THA S MY FIRST OUT PATIENT TOTAL KNEES CASE AFTER CASE AFTER CASE AFTER CASE REMEMBER PATIENTS NEED PROVIDERS Lancet Oct 27;370(9597): The operation of the century: total hip replacement. Learmonth ID1, Young C, Rorabeck C. Author information 1

2 PERSPECTIVE Google Out Patient TJA 340,000 hits 2

3 PERSPECTIVE LITERATURE REVIEW Academy of Orthopaedic Surgeons (AAOS), sameday total joint replacement (TJR) patient outcomes were comparable to those of patients admitted to the hospital" Vegari AAOS 2014 SAME DAY THA DORR ARTH PATIENTS LESS THAN 65 ASA SCORE LESS THAN OR EQUAL TO 1 69 ENROLLED CONTINUOUS EPIDURAL 53 WENT HOME 3

4 SAME DAY THA DORR ARTH NO RE-ADMISSIONS NO COMPLICATIONS 403 DIRECT ANTERIOR APPROACHES 101 PATIENTS AGES YR MEAN 61 YR DC D TO HOME ASA SCORES LESS THAN = 2 BMI AVG MALES 47 FEMALES MEAN F/U 1.2 YEARS PREOP PROTOCOL IN HOUSE ( DEDICATED INTERNIST) PRE-OP EVALUATION DIGITIZED XRAYS AND TEMPLATING MRSA AND MSSE SCREENING HIBOCLENS SHOWERS X 5 FLOWMAX 10MG QDAY X5DAYS -MALES WITH BPH PRE OP ORIENTATION CLASS ENSURE BID X 2 WEEKS 4

5 INTRA OP PROTOCOL IV VANCOMYCIN AND ANCEF WT ADJUSTED DOSING NO FOLEY CATHETERS SECOND DOSE IV VANCO 8 HRS LATER DECADRON 10MG IV AT START OF CASE TXA 1 GRAM IV AT START OF CLOSURE Dexamethasone DECADRON A recent prospective randomized controlled trial evaluated the effect of dexamethasone inclusion in a perioperative multimodal drug regimen: Backes JR et al. Dexamethasone reduces length of hospitalization and improves postoperative pain and nausea after total joint arthroplasty: a prospective, randomized controlled trial. J Arthroplasty. 2013;28: INTRA OP PROTOCOL INTRA OPERATIVE FLURO AVG 53 SEC INTRA OPERATIVE AQUAMANTOS TXA AT START OF CLOSURE.5% MARCAINE WITH EPI 1CC/KG UP TO 80 CC (400MG) 30 MG DURAMORPH 5

6 Radiographic Assessment 6

7 45 +/- 7 deg CLOCKWISE ROTATION 52 +/- 7 DEG COUNTER CLOCKWISE ROTATION 40 +/- 7 DEG 7

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11 45 +/- 7 DEG PELVIS ROTATED TOWARDS CEILING 62 +/- 7 deg 11

12 72 +/- 7 deg PELVIS ROTATED MORE TOWARDS CEILING 80+/- 7 deg THE SAME CUP MEASURED ON DIFFERENT XRAY ORIENTATIONS /- 7 DEG 30 +/- 7 deg 50 DEG! 12

13 Psi of force at Tip is 20x less Than hitting the Broach handle with A mallet NO INTA OP FXS NO PERFORATIONS NO REVISIONS FOR STEM LOOSENING NO SURGEON RTC TEARS OR TSA 13

14 INTRA OP PROTOCAL CLOSURE CLOSURE QUILL AND DERMABOND NO DRAIN SILVER IMPREGNATED DRESSING 14

15 POST OP PROTOCOLS WT BEARING AS TOLERATED NO PRECAUTIONS NO VOID STRAIT CATH X 2 THEN INSERT FOLEY TO PT W/I 3 HOURS MUST AMBULATE 40 FT WITH WALKER OR CRUTCHES UP/DOWN STAIRS SECOND DOSE VANCO 3 PM POSTOP PROTOCOLS AFTER CLEARED BY PT AND SECOND DOSE OF VANCO DVT PROPHYLAXIS INDOCIN AND ASA DC TO HOME HOME VNA AND HOME PT NEXT DAY 15

16 COMPLICATIONS THAT DID NOT GO HOME LOS AVG 1.2 DAYS 3 DISLOCATIONS - ALL ANTERIOR - no reops 5 PERIPROSTHETIC FX S - 3 TRAUMATIC - 2 ATRAUMATIC 2 SUPERFICIAL SEROMAS 1 DEEP INFECTION - REOP ID POLY EXCHANGE 2 FEMORAL NERVE NEUROPRAXIAS 1 CASE SEVERE H.O. ( PAT HX MULTIPLE PE S) 3.63 % INCIDENCE OF MAJOR COMPLICATIONS COMPLICATIONS 77 yo f fell on black ice 5 wks po 16

17 COMPLICATIONS 101 DC D TO HOME ONE SUPERFICIAL INFECTION REQUIRED I&D ONE DEEP INFECTION REQUIRED I&D THEN 2 STAGE REVISION NO DISLOCATIONS - NO PERI PROS -FX S 1.98 % RATE OF MAJOR COMP The Journal of Arthroplasty Vol. 22 No Iliopsoas Tendonitis A Complication After Total Hip Arthroplasty Orth), Simon Richards, FRCS (Tr & Orth), Andrew D. Skyrme, FRCS (Tr & Orth), William ACHILLES HEAL OF 403 DA HIPS 5 % OF CASES 8 PATIENTS CT GUIDED STEROID INJECTIONS 1 CONSIDERATION FOR TENDON RELEASE OLD GUY NEEDS HELP HERE OUT PATIENT TKA 19 YEARS IN PRACTICE 3700 TKA S 4 DC D TO HOME ALL IN

18 OUT PATIENT TKA USING LESSONS FROM OUT PATIENT THA APPROACH UNCHANGED NO TOURNIQUET DIFFERENT INTRA OP INJECTION TECHNIQUE 1 CC.5 % MARCAINE WITH EPI / KG UP TO 80CC MAXIMUM DOSE OF 400MG ADDUCTOR CANAL BLOCK Adductor Canal Anatomy From apex of femoral triangle to Adductor hiatus Bordered by: Vastus medialis (laterally) Adductor longus/magnus (posteriorly) Sartorius (anteriorly) Contents: Saphenous nerve Femoral artery & Vein Lymphatic vessels Adductor Canal Block Anesthesiology 2014;120: At 6 8 hrs post-anesthesia Adductor canal block vs. Femoral nerve block exhibited: Relative sparing of quadriceps strength Equivalent analgesia and reduction of opioid intake 18

19 Adductor Canal Block Technique Adductor Canal Block Intra-op Placement Adductor Canal Block STARTED 8/ CC 0F.1 % MARCAINE ( 500 MG) 5CC BOLUS Q hour CATHETER REMAINS IN DWELLING X 4 DAYS NO LITERATURE ON 4 DAYS! 207 PATIENTS DC D TO HOME WITH CONT ADDUCTOR CANAL BLOCK 19

20 THE ONLY DETRIMENT TO ADDUCTOR CANAL KS WAS THAT I USE TO CONSTANTLY OPINE WITH HE PATIENT DID NOT COME HERE FOR ANESTHE I CAN NO LONGER SAY THAT LOS FOR DRG 470 AVG.72 DAYS 20

21 CONCLUSIONS SAME DAY ARTHROPLASTY IS HAPPENING NOW CAN BE DONE SAFELY PATIENT SATISFACTION HIGH SURGEON SATISFACTION IS HIGH BUNDLED PAYMENTS CONTROLLED BY SURGEON NOT ALL PATIENTS ARE NOT ASA <2 THANK YOU 1793 ARTHROPLASTIES 1510 MLT TYPE IMPLANTS - 2 INTRA OPERATIVE FRACTURES - 4 PERIPROSTECTIC FXS - 2 ONLAY CORTICAL STRUTS FOR THIGH PAIN -2 MODULAR NECK FXS 283 FITMORE STEMS - 2 POST OPERATIVE FXS THRU DA APPROACH - 25 PATIENTS DISCHARGED - SAME DAY SURGERY NO STEMS REVISED FOR LOOSENING 21

22 Prepare for Femoral Preparation THIS IS THE HARD PART! Release gross traction - off for the rest of the case! Internally rotate and insert the femoral lift hook Externally rotate to degrees FEMUR FEMUR 22

23 FEMUR FEMUR FEMUR 23

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25 74 YO F GOT UP FROM CHAIR 10 DAYS PO 25

26 COMPLICATIONS 77 yo f fell on black ice 5 wks po 26