Advances in Joint Replacement Seth Greenky, MD Chairman, Musculoskeletal Services, St. Joseph s Hospital Partner, Syracuse Orthopedic Specialists Associate Clinical Professor, Upstate Medical Center CoMedical Director, Operation Walk Syracuse March 2, 2018
Preoperative: Hardstops None Surgery Exclusion/Hardstop List (surgery not to proceed without review by Joint Council) BMI<19 BMI >40 Hgb A-1 C >8.0 Day of Surgery Glucose >170 Hgb <12 No intra-articular injections of any medication for 3 months prior to surgery Cardiology Consult for any pt > 75 or if has seen cardiologist in 5 years prior to surgery Smoking: Must stop for minimum of 14 days TSH (draw at time of Hgb A-1C) Albumen <3.5 gm/dl (draw at time of Hgb A-1C)
Preoperative: Physical Therapy None Prehab Conditioning & Education
Preoperative: Patient Education Minimal Mandatory Joint Classes Written patient guides Coaches
Preoperative: Care Coordination Patient led Nurse Navigators Patient Engagement Tools
Preoperative: Patient Resources Few to None SOS Patient Ambassador Program
Preoperative: Informed Consent/Shared Decision Making Physician Led Shared Decision Making
Preoperative: Preadmission Testing H&P H&P Robust Preop Clearance & Optimization Process Anemia Management/Iron Infusion Nutritional Counseling MRSA Screening
Hospitalization: Day of Surgery Intake & Prep General Admission day of surgery or night before surgery Dedicated Ortho Rapid Admit Nurses
Hospitalization: Anesthesia Primarily General Anesthesia administered in the OR Epidural anesthesia Short Acting Spinal Anesthesia Regional Blocks (adductor canal, femoral) Dedicated ortho anesthesia teams Dedicated Preinduction Area for Spinals & Blocks
Hospitalization: Intraoperative Generalized OR Team Single OR Room Skin Closure with Staples/Bulky Dressing Urinary Catheter is standard of care Orthopedic Specialty Teams Flip Rooms Skin closure alternatives such as Dermabond Prineo Aquacel Dressings Controlled hypotension Tranexamic Acid Aquamantys
Hospitalization: Intraoperative Hip Approaches: Hip Approaches: Posterolateral Anterolateral Direct Anterior Direct Superior Posterolateral Anterolateral
Hip Approaches Posterolateral Lateral Direct Anterior Direct Superior
Hospitalization: Intraoperative Technology None Robotics Navigation PSI Patient Specific Instrumentation
Surgical Site Infection Prevention Minimal In-Room Traffic Ultraviolet Lights Surgical Hoods MRSA Screening and Decolonization Antibiotic Dosing, Timing, and Selection Medicated Irrigations Perioperative Normothermia Strict Perioperative Glucose Control Anemia Management Surgical Hand Asepsis and Skin Prep Advances Procedural Hardstops Patient Education
Hospitalization: Intraoperative Unicompartmental Arthritis Unicompartmental Arthritis: Treatment: Total Knee Replacement Treatment: Unicompartmental or Partial Knee Replacement
Hospitalization: Intraoperative Implants Materials and Fixation Cemented prostheses Porous coated Polyethylene Early ceramic technology Metal on Metal metallosis Perfection of alloys Advancement in porous ingrowth Pressfit knees Cross-linked polyethylene Vitamin E Polyethylene Advanced ceramic technology Manufacturing advancements 3-D Printing
Pain Management Demerol/Vistaril On Call to OR No Intraoperative Intervention Preoperative Pain Cocktail Preoperative medications to be administered just prior to transport to Operating Room: Acetaminophen 975mg PO Neurontin 600 mg PO Decadron 8 mg IVP, *hold if patient is a Diabetic or if stress dose steroids are ordered* Zofran 4 mg IVP IR Oxycodone 10 mg PO if less than 70 years old - OR- IR Oxycodone 5 mg PO if 70 years old or older- Hold if patient took opioid today prior to admission Reglan 10mg IVP Other: Intraoperative Injection: Morphine, Toradol, Bupivacaine Postoperatively: Pain Buster PO Narcotics Epidural Morphine PCA Ice Bags Preoperative Regional Blocks: Adductor canal and femoral Postoperatively: Minimal Opioids Toradol, Tramadol, and Tylenol Automated Icing Units
Hospitalization: Postoperative Care Foley Catheter VTE Prophylaxis: Coumadin No catheter and bladder scan VTE Prophylaxis: ASA 81 mg QD **risk stratification**
Hospitalization: Postoperative Mobility Stand at bedside on day of surgery Strict Hip Precautions OOB & ambulate day of surgery 90% stair savvy Minimal Hip Precautions approach sensitive DA/Lateral (Harding)/Direct Superior Approach: no hip precautions Posterior lateral: avoid flexion combined with internal rotation x3 weeks
Physical Therapy/Activity Responsibility of the Physical Therapist Total Knee Replacement: Inpatient and Homecare and/or Rehab Responsibility of the Patient Total Knee Replacement: Goal is OP PT Only Total Hip Replacement: Inpatient and Homecare and/or Rehab Return to work no sooner than 3 months Total Hip Replacement: Two Schools of Thought: Plan A initiate PT at 10-14 days postop Plan B possibly not necessary but if needed, begin at 10-12 weeks Return to work at 3-5 weeks for hips and 6-10 weeks for knees
Discharge Disposition Short Term Rehab: 80% Short Term Rehab: <30% Homecare Service: 100% Homecare Services: 30% Home with OP PT Only: 40%
Outcomes Correlate with Volume
Questions?