Orthopedic surgeons who specialize in hand surgery or sports medicine have worked in Ambulatory Surgery Centers (ASC) for a long time.
So why are joint surgeons just now getting into the ASC arena? Some have hesitated since patients tend to be older and have more complex conditions. However, leading orthopedic surgeons and anesthesiologists are now demonstrating that joint replacement procedures can be performed in the ASC setting.
At Becker's 17th Annual Future of Spine + The Spine, Orthopedic and Pain Management-Driven ASC Conference in Chicago in June 2019, Johnson & Johnson Medical Devices hosted a workshop with Charles DeCook, MD and Mark Hamilton, MD, of Arthritis and Total Joint Specialists, an arm of Atlanta-based Northside health system. They discussed how innovation and preparation are the keys to successful total joint outcomes in the ASC.
The ASC model is based on patient preparation
The traditional hospital model is composed of a short period of preoperative preparation, followed by surgery and then a long postoperative recovery. In the ASC, this model simply doesn't work. Advanced preparation and education enable patients to go home on the same day as their procedure.
Checklists are essential. Both patients and caregivers must be mentally prepared for the procedure and the recovery. "Gone are the days when you signed a patient up for surgery and operated the next day. Patients and caregivers have a lot of unknowns that must be addressed. If they have questions after the surgery, it's too late," Dr. DeCook explained. In 2018, 98 percent of Arthritis and Total Joint Specialists' patients went home the same day as their surgery.
Innovative technology is revolutionizing total joint procedures
The KINCISE™ Surgical Automated System is designed to replace the handheld mallet. This automated impactor helps surgeons deliver constant, stable energy to automate bone preparation, implant assembly and positioning, which in turn may lead to more consistent clinical outcomes. This product also may reduce surgeon fatigue compared to traditional mallets, since it is trigger operated.
With anterior hip procedures, surgeons often use fluoroscopy. JointPoint™ is used intraoperatively and helps to reduce surgical time. It automatically templates cases and provides predictive "what if" data which may save time and effort for physicians.
New approaches to anesthesia reduce patient pain and reduce opioid use
Multimodal analgesia protocols are a huge paradigm shift that can reduce and even eliminate the need for narcotics for total joint patients. Drugs used in multimodal analgesia protocols can include Acetaminophen, Gabapentin or Pregabalin, Ketoralac, Dexamethasone and Ketamine, among others. What is important is to truly optimize these medications.
Opioid-free anesthetics are an alternate approach for several reasons. Addiction is a problem. At Arthritis and Total Joint Specialists, 98% of patients are discharged the same day, 90% require no narcotics prior to discharge and one third take no narcotics for the first week post-op. According to Dr. Hamilton, "Narcotics…we can do better. The frontier is an opiate-free era."
Motor sparing blocks are another anesthesia-related innovation that have revolutionized outpatient total joint procedures. These suppress pain, while allowing patients to move their legs and walk. Dr. Hamilton uses surgeon placed PAI as well as anesthesia placed adductor canal and iPACK blocks for all knee joint replacements. After a successful trial, Dr. Hamilton now uses liposomal bupivacaine for the ACB and iPACK blocks for knee revisions, with most patients having long-lasting and excellent pain relief. Dr. Hamilton anticipates making liposomal bupivacaine part of his standard protocol for primary knee replacements as well.
Conclusion
Innovation is the key to enabling total joint surgeries in the ASC. Fortunately, ASCs are the excellent environment for innovation, thanks to their motivated staff, limited bureaucracy and potentially lower infection rates.
Arthritis and Total Joint Specialists illustrates this well. In 2016, the ASC's CMS data for joints showed that it had the lowest length of stay and the third lowest readmission rate in the country, as well as the highest volume in Georgia. Dr. DeCook commented, "We are making the leap over the gap with innovation. We're going to get to the early majority with total joints in the ASC."