Download Frequently Asked Questions Minimally Invasive Joint Replacement

Although it is most closely associated with a military battle, the term is used by analogy
in fields such as business, politics, law, literature, and sports to describe any similar
struggle which is ruinous for the victor.
The phrase is named after King Pyrrhus of Epirus, whose army suffered irreplaceable
casualties in defeating the Romans at Heraclea in 280 BC and Asculum in 279 BC during
the Pyrrhic War. After the latter battle, Plutarch relates in a report by Dionysius:
A Pyrrhic Victory
Minimally invasive total hip replacement
One of the most significant advancements in total hip replacement is the recognition that
the procedure can be done with less invasive techniques which allow the patient to
recover faster. This has even progressed to the point that some patients are able to have
their surgery accomplished as an outpatient procedure. The patients’ recovery is so much
different than previously performed operations, that nurses have labeled these patients
“turbo hips”.
New implants have been designed to reproduce the normal motion and function of the
replaced joint. These new designs incorporate new materials (metals, plastics, and
ceramics) and new biologically active coatings for the implants. These materials include
highly crosslinked polyethylene for the hip and knee. This new plastic has been
approved by the F.D.A. for regular use in the United States. Laboratory tests have shown
implants made of this material to last two or three times as long as previous types.
The less invasive approach can be combined with the new implant designs. Surgeons can
insert the prosthesis using minimally invasive techniques resulting in less trauma to the
patient and the tissues surrounding the hip or knee. This decrease in magnitude of soft
tissue trauma has a number of benefits for the patient. First and most obvious, the scar is
significantly smaller. This has more than a cosmetic value as there is less to heal and
thus the second major advantage is faster recovery from surgery of “smaller” magnitude.
This has been recognized for years with arthroscopic surgery of the knee and even
laproscopic gall bladder removal, appendectomy, hernia repair and even some more
extensive tumor operations that are done partially or completely with the laproscope.
When hip or knee replacement surgery is accomplished with smaller incisions, the
patients will require fewer blood transfusions, will have shorter hospital stays and will
return to work or recreation sooner. Patients report that a joint replaced with these new
techniques is significantly less painful than with the previous, more generous, surgical
exposures. Minimally invasive hip replacement can be performed either through two
incisions each 1½ to 2 inches long or one 3 to 3½ inch incision.
We try to use this limited exposure on all patients, regardless of how long their hospital
stay is intended to be. But it must be remembered that the first priority in performing the
operation is to be able to see all that is necessary. Thus there are still situations that
occasionally arise which require a larger, more extensive exposure.
OUTPATIENT TOTAL HIP REPLACEMENT
The natural extension of minimally
invasive surgery is to do the operation on
patients as outpatients. In this situation,
the patient receives appropriate
education before surgery and then comes
to the hospital the morning of surgery.
After the operation, the patient is able to
leave the hospital on crutches and be
driven home to recover. The most
current anesthetic techniques are used
and appropriate medications given to
minimize any risk of nausea and
decrease pain.
This 50 year old woman had her hip
replaced eight hours ago and is leaving
her hospital room to go home. She is
able to walk independently with crutches
and is taking only oral medication for her
pain.
NEWS RELEASES
To watch recent news coverage of outpatient
total hip replacement click here.
To watch recent news coverage of
outpatient total hip replacement click
here.
New developments in technology and techniques have given rise to minimally invasive
hip replacement surgery. This type of procedure requires smaller incisions, and recovery
time is shorter than with traditional hip replacement. Candidates for this surgery are
usually 50 years or younger, of normal body weight based on body mass index and
healthier than candidates for traditional surgery.
Dr. Bertin has been doing this for patients who meet the following criteria:
1.
The patient is in a stable medical condition.
a.
Minor medical conditions should be well controlled: hypertension,
asthma, thyroid conditions, stomach or gastrointestinal problems.
b. Contraindications include: diabetes, altered mental function
(dementia, Parkinson’s disease), unstable cardiac status, renal failure,
sleep apnea, and significant prostate obstruction interfering with
adequate urination.
c.
2.
Age itself is not very important as long as other considerations are
fulfilled.
The patient is willing to attend physical therapy before coming to the
hospital. The patient must learn the use of crutches and the appropriate
dislocation precautions before surgery.
3.
There is an appropriate caregiver to help take care of the patient at home
for the first few days after surgery. This is the same as for any outpatient
surgical procedure.
4.
The patient desires to have the operation as an outpatient. Obviously this
would not be imposed on anyone.
SURGICAL VIDEO
To watch a total hip replacement performed using a single 7 cm incision click here
Example of minimally invasive hip compared to a “standard” operation of
one year ago:
This patient is a 54-year-old female with
severe arthritis of her right hip. She has had
treatment with arthritis medication that is no
longer providing any significant relief and
she wants to have her hip replaced. The xray shows the cartilage complete worn out
and bone rubbing on bone.
The surgical incision is marked over the
hip. A solid line marks where the incision
will be made and the dotted line illustrates
where a traditional incision would otherwise
have been created. The solid line measures
under 3 inches.
The exposure showing the acetabular
prosthesis in place illustrates that very
adequate visualization is achieved. The
white plastic liner is seen inside the titanium
shell.
This photograph shows how the previous
surgical exposure contrasts to the miniincision. The incision is much longer and
significantly more soft tissue disruption
occurs.
The three inch incision is closed with
sutures that dissolve and is covered with
steri-strips (tape to protect the incision).
The final dressing is in place and the patient
is ready to go back to her room and begin
walking and prepare to go home.
This is the x-ray of the patient’s hip after
the surgery is complete.
SUMMARY OF NEW MINIMALLY INVASIVE HIP REPLACEMENT
Mini Incision Surgical Approach
 The goals of the “Mini Incision” are:
 Minimize blood loss
 Shorten the patient’s hospital stay
 Decrease the pain involved in rehabilitation
 Lower the overall time to return to normal activities of life
 Allow the patient to realize the potential cosmetic benefits of a shorter incision
 New instruments and surgical techniques allow us to minimize the disruption of the
tissues around the hip joint. This can make a big difference in how the patient feels
following surgery.
 Procedure is performed through an opening of 3 to 3½ inches versus up to nine
inches for a conventional procedure.
 Prosthetic implants used are existing, proven designs; only the instruments used and
the surgical incision have been modified to enable the minimally invasive technique.
Outpatient Total Hip Replacement
 Coordinated program emphasizing preoperative education and physical therapy to
prepare the patient for a short hospital stay (8-12 hours) and a rapid recovery.
 Utilization of the most up to date anesthetic and pharmacologic techniques to
minimize any problems associated with surgery and thereby allows the patient to
recover with minimal pain, nausea, or other problem.
 The operation is performed using the “Mini Incision” to accomplish above goals.
 The patient returns home the day of surgery where they are most comfortable and
familiar.
To view video footage of a hip replacement procedure click here. Video requires
QuickTime, if you do not already have QuickTime and do not have a broadband
connection, downloading the 5 megabyte QuickTime player may require a lot of time.
Minimally Invasive Knee Replacement
Total knee replacement can also be performed with much smaller incisions than
previously. Some patients are candidates for what is truly a minimally invasive knee
replacement. This is a unicompartmental knee replacement, which can be used on about
10% of patients who have degenerative arthritis in only part of their knee. All of the
ligaments are preserved with this technique (anterior cruciate, posterior cruciate, medial
collateral and lateral collateral). The knee replaced with a “uni” rehabilitates faster and
seems to function much more like a normal knee than a traditional total knee
replacement.
Example of a minimally invasive unicompartmental knee replacement:
The patient is a 63-year-old male who had
the cartilage removed from his knee
twenty-four years ago after an injury
playing tennis. The x-ray before surgery
shows one side of the knee worn out with
bone rubbing on bone.
The knee is draped and prepared for
surgery. The three inch incision is marked
on the front of the knee.
View during surgery with the new
unicompartmental prosthesis in place
before the skin is closed.
X-ray after surgery showing the new “uni”
knee in place.
Minimally invasive total knee replacement
As the techniques for total knee replacement have improved, surgeons have worked to
develop methods that would allow the operation to be accurately performed and at the
same time cause as little surgical trauma as possible. The goal in this effort is to facilitate
the most rapid recovery possible while doing an operation that we know provides
excellent long term results. This less invasive approach carries with it the associated
benefits of less post operative pain, less blood loss and a smaller incision in addition to
the faster rehabilitation. We anticipate that patients will reach their optimal result much
faster with this less invasive operation. This surgical video is edited to be a five minute
summary of a minimally invasive total knee replacement done through a four inch
incision.
Click here
for video if you have high speed access, here
dial-up.
if you are using
*******************************
He went home in 2 days time after surgery.
This is how his x-ray looked.
He currently has a good range of movements and is undergoing further rehabilitation.
The cost of the implant is around 1,00,000 i.e. expensive. The common complications are
infection, nerve palsies and loosening. Mr. XYZ had no early complications and will
keep following up to detect late complications.
http://www.myrapidrecovery.com/faq.cfm
When can I have sexual intercourse?
The time to resume sexual intercourse should be discussed with your orthopedic surgeon.
Frequently Asked Questions
Minimally Invasive Joint Replacement
What is arthritis?
The bones in your joints are covered by a layer of cartilage. Cartilage is a tough,
lubricating tissue that provides smooth, pain-free motion to your joints. Arthritis causes
the cartilage to wear away, eventually resulting in painful bone-on-bone contact.
Why does my knee or hip hurt?
As the layer of cartilage wears away, bone begins to rub against bone, which causes the
discomfort and stiffness commonly associated with arthritis.
What is Rapid Recovery minimally invasive knee or hip replacement?
Minimally invasive knee replacement is really a cartilage replacement with an artificial
surface. The knee itself is not replaced, only the damaged tissue on the ends of the bones.
The replacement implants include a metal alloy on the end of the thighbone and
polyethylene (plastic) on the shinbone and kneecap. The implants create a new smoothly
functioning joint designed to prevent painful bone-on-bone contact.
Rapid Recovery minimally invasive knee replacement utilizes Microplasty®
Instrumentation and is performed through a smaller incision, up to half the length of a
typical knee replacement incision. Surgeons can perform surgery through such a short
incision because they use instruments specifically designed to move around soft tissue.
It is important to remember that surgeons still use implants that they feel will best treat
your specific condition.
Minimally invasive hip replacement removes the arthritic ball of the upper thighbone as
well as the damaged cartilage from the hip socket. The ball is replaced with a metal ball
that is solidly fixed inside the femur. The socket is replaced with a plastic, ceramic or
metal liner that is usually fixed inside a metal shell. The implants create a new smoothly
functioning joint designed to prevent painful bone-on-bone contact.
Rapid Recovery minimally invasive hip replacement utilizes Microplasty®
Instrumentation and is performed through an approximately two to four inch incision,
sometimes half to one-third the length of a typical hip replacement incision. Surgeons can
perform surgery through such a short incision because they use instruments specifically
designed for minimally invasive hip replacement.
What is the Biomet® Rapid Recovery Program?
The Biomet® Rapid Recovery Program is an evolutionary concept in joint replacement
involving improved technology and techniques. The program encompasses
comprehensive patient education, nutrition, physical conditioning and rehabilitation
methods to facilitate a rapid recovery.
How long does the typical knee or hip implant last?
All implants have a limited life expectancy depending on an individual’s age, weight,
activity level and medical condition(s). A joint implant’s longevity will vary in every
patient. It is important to remember that an implant is a medical device subject to wear.
While it is important to follow all of your surgeon’s recommendations after surgery, there
is no guarantee that your particular implant will last for any specific length of time.
Why do implants fail?
The most common reason for failure in knee and hip replacements is loosening of the
implant from the bone or wearing of the plastic liner. Old components can usually be
replaced with new ones.
What are the results of minimally invasive knee or hip replacements?
Results will vary depending on the quality of the surrounding tissue, the severity of the
arthritis at the time of surgery, the patient’s activity level and the patient’s adherence to
the doctor’s orders.
What are the possible complications or risks of minimally invasive joint
replacement surgery?
While uncommon, complications can occur during and after surgery. Some complications
include, but are not limited to, infection, blood clots, implant breakage, misalignment and
premature wear, any of which may necessitate implant replacement surgery. While these
devices are generally successful in attaining reduced pain and restored function, they
cannot be expected to withstand the activity levels and loads of normal healthy bone and
joint tissue.
Although implant surgery is extremely successful in most cases, some patients still
experience pain and stiffness. No implant will last forever and factors such as the
patient’s post-surgical activities and weight can affect longevity. Be sure to discuss these
and other risks with your surgeon.
When should I have joint replacement surgery?
Your doctor will decide if you are a candidate for the Biomet® Rapid Recovery Program.
Their decision will be based on your history, exam and X-rays. Your doctor will ask you
to decide if your discomfort, stiffness and disability justify undergoing surgery. Most
doctors recommend waiting to have surgery if conservative, non-operative methods can
adequately control your discomfort.
Is age a consideration for joint replacement?
Age is usually not a problem if you are in reasonably good health and have the desire to
continue living a productive, active life. You may ask to see your personal physician for
an opinion about your general health and readiness for surgery. An advantage of the
Biomet® Rapid Recovery Program is the potential to return patients to their daily lives
and activities at a faster rate than traditional joint replacement surgery.
Should I exercise before this surgery?
Yes, an integral part of the Biomet® Rapid Recovery Program is a comprehensive
preoperative exercise program. Your surgeon will prescribe the exercises that will benefit
you the most.
Will I need blood?
You may need blood after surgery. You can donate your own blood, use the blood bank,
or have your relatives donate blood for you. Read “Decide Whether to Donate Blood”
found in the appendix of the GuideBook.
How do I donate my own blood?
Your surgeon’s office will work out the details of your blood donation.
Will I need walking support?
Yes, minimally invasive joint replacement patients may need either a walker, cane or
crutches to facilitate a rapid recovery. Your surgeon can help you make the arrangements
for necessary equipment.
Where will I go after discharge from the hospital?
Most patients are able to go directly home after discharge. Some patients may transfer to
a sub-acute facility and stay there between three to seven days. Your surgeon will help
you decide where to go after you are discharged from the hospital and can make the
appropriate arrangements. Either way, you will continue to receive physical therapy.
Will I need any special equipment?
Most patients do not require any special equipment. However, your occupational
therapist may recommend specific tools to assist you in activities of daily living.
Will I need help at home after surgery?
Yes for the first several days, or weeks, depending on your progress, you will need
someone to assist you with meal preparation, cleaning, etc. If you go directly home from
the hospital your surgeon may order a home healthcare nurse to come to your house until
the sutures are removed (approximately two weeks). Family members or friends need to
be available to help if possible.
Will I need physical therapy when I go home?
A home physical therapist may provide initial physical therapy in your home. You may
then go to an outpatient facility two to three times a week to assist in your rehabilitation.
The length of time required for this type of therapy varies with each patient. If you live
alone, you may stay at a sub-acute facility following your hospital stay or you may go
directly home. A home healthcare nurse and a home physical therapist may assist you at
home.
How often will I need to be seen by my doctor following minimally invasive joint
replacement?
Your first postoperative office visit will occur two to three weeks after discharge. You
will then be seen for further follow-up as required by your orthopedic surgeon. After the
first year, you will need to see your orthopedic surgeon for a check-up every one to two
years.
How long until I can drive and get back to normal?
The ability to drive depends on whether the surgery was performed on your right or left
leg and the type of car you have. If you had surgery on your left leg and you have an
automatic transmission, you could be driving as early as two weeks. If you had surgery
on your right leg, your driving may be restricted for as long as four to six weeks. Getting
“back to normal” will depend somewhat on your commitment and individual
circumstance. Consult with your surgeon or therapist for advice on your level of activity.
When will I be able to return to work?
Most people take at least one month off from work. Patients with more sedentary jobs
may be able to return to work sooner. The timing of your return to work depends
considerably upon your commitment to recovery.
When can I have sexual intercourse?
The time to resume sexual intercourse should be discussed with your orthopedic surgeon.
Will I have any restrictions following this surgery?
Yes, you will be restricted from performing high-impact activities such as running,
singles tennis and basketball. You will also be restricted from performing contact sports
and downhill skiing. Hip patients will additionally be restricted from crossing their legs
or bending their hips more than 90º for at least three months after surgery.
What physical and recreational activities may I participate in after my recovery?
Most patients are encouraged to participate in low-impact activities such as dancing,
golfing, hiking, swimming, doubles tennis and gardening as your surgeon allows. Ask
your physician about other acceptable activities.
Will I notice anything different about my knee or hip?
Yes, you may have some numbness on the outside of the scar. The area around the scar
may feel warm. Refer to the GuideBook for hips or knees for more information on
recognizing a blood clot. In knee patients, kneeling may be uncomfortable for a year or
more. You may also notice some clicking when you move your hip or knee as a result of
the artificial surfaces coming together.
http://www.medscape.com/viewarticle/471809
Two-Incision Hip Replacement Safe on an Outpatient Basis
Alicia Ault
March 15, 2004 (San Francisco) — Total hip replacement surgery can be done safely and
consistently with two 1.5-inch incisions, and most patients can go home the same day,
said a Chicago-area orthopaedic surgeon here at the 71st annual meeting of the American
Academy of Orthopaedic Surgeons.
Richard A. Berger, MD, from Rush–Presbyterian–St. Luke's Medical Center in Chicago,
Illinois, presented two papers on 250 patients who had received total hip replacements
through his two-incision method since 2002. Of those, 100 have gone home the same day
of surgery — that is, every patient who has had the procedure since early 2003, Dr.
Berger told attendees.
In the first paper, he reported on the first 30 patients (18 men and 12 women) who
received the two-incision technique. The first incision is for acetabular preparation and
component placement, and the second, in the inner thigh, is for femoral preparation and
component placement. Fluoroscopy is used to guide placement.
With an average follow-up of 25 months, there was only one complication, a patient who
had a proximal femur fracture while being prepared. Dr. Berger said that 91% of the
femoral stems were in neutral alignment and that the abduction angle for acetabular
components averaged 45 degrees, making it comparable to conventional hip replacement.
Patients stayed in the hospital about three to four days, but they recuperated more
quickly, with an average time on crutches of five days; on a cane, the average time was
eight days.
Encouraged by these results, Dr. Berger decided to push for a shorter hospital stay and
faster rehabilitation. He received permission from his institutional review board to
conduct a prospective study of outpatient hip replacement with his two-incision
technique. Patients with a body mass index higher than 35 kg/m 2 or with three or more
significant comorbidities were excluded, as were those who had had myocardial
infarction or pulmonary embolism within a year of the procedure.
A total of 309 patients met the criteria, and 100 consecutive patients (74 men and 26
women) received the procedure. This was about 21% of Dr. Berger's total patient load
during that period.
Patients were seen by a physical therapist and discharge planner before surgery to ensure
they knew they were going home the same day of the procedure and to receive
postoperative instructions. All but four were given regional anesthesia to minimize
postsurgical nausea. Mean operating time was 101 minutes.
Patients received physical therapy five to six hours after surgery and had to
independently get out of bed, stand up from a chair, walk 100 feet, and climb up and
down stairs before discharge. They were sent home with oral pain medications, usually
oxycodone, said Dr. Berger.
Overall, 92 patients were discharged the same day, and the rest were sent home the
following day. Three of the overnight patients could not tolerate the physical therapy
after the procedure, two wanted to stay, and another's spouse wanted the patient to stay.
There have been no readmissions, reoperations, or complications in these outpatients, Dr.
Berger said.
In a press briefing earlier in the week, Dr. Berger said that only about 5% of hip
replacements in the U.S. are being done less invasively, and he knows of no other
surgeon doing it as a same-day procedure. But he predicted that within five years, all hip
replacements would be done less invasively, largely because patients would demand it,
after seeing the shorter rehabilitation and more appealing scar. He said his patients
typically only need five or six physical therapy sessions compared with three months for
conventional surgery.
David S. Hungerford, MD, from the orthopaedics department at Johns Hopkins
University in Baltimore, Maryland, said in the same briefing thatthere are no rigorous
data showing that less invasive surgery is any better than procedures using a slightly
longer incision. "For this to be widespread, you have to convince skeptics like me," he
said, adding that he was concerned that patient demand was being driven by device
manufacturers' "hype."
Thomas P. Sculco, MD, surgeon-in-chief at the Hospital for Special Surgery in New
York City, cautioned that smaller incision hip replacement — especially on an outpatient
basis — required experience and carefully selected patients. In an interview with
Medscape, he noted that Dr. Berger's patients were young (average age, 55 years) and
that they appeared to be healthier than the average hip replacement patient.
Dr. Sculco said he uses a less invasive technique on most patients, except those who are
overweight, but says for outpatient operations, he'd only select young, highly motivated
patients. He noted that Dr. Berger is being selective by offering outpatient surgery to only
about a third of his patients.
Dr. Berger, however, claimed in his presentation, "Right now, I could do it on 90% of the
patients who walk through the door."
The small-incision technique is meant to preserve muscle and tendon by avoiding large
cuts; but there is some concern that surgeons might actually be crushing muscles and
nerves by trying to move instruments in small areas, said Dr. Sculco and others.
AAOS 71st Annual Meeting: Papers No. 207 and 210. Presented March 12, 2004.
Reviewed by Gary D. Vogin, MD
Alicia Ault is a freelance writer for Medscape.
: Nurs Clin North Am. 1997 Jun;32(2):377-86.Links
Ambulatory surgery. An evolution.
DeFazio-Quinn DM.
Elliot 1-Day Surgery Center, Manchester, New Hampshire, USA.
Technological advances have allowed the number of outpatient surgical
procedures performed each year to increase steadily. Pressure from patients,
physicians, and third-party payers has led to an increase in the number of
freestanding Ambulatory Surgery Centers (ASCs). By virtue of their structure,
freestanding ASCs have been able to provide services at a lower cost than their
hospital counterparts. Rapid changes in the health care environment are forcing
health care facilities to adopt cost-cutting measures in an attempt to compete in
the marketplace.
PMID: 9115483 [PubMed - indexed for MEDLINE]
Related articles

Ambulatory surgery centers: harbinger of managed care shift.
J Healthc Resour Manag. 1996 Apr; 14(3):9-14.
[J Healthc Resour Manag. 1996]

Freestanding ambulatory surgery: cost-containment winner?
Healthc Financ Manage. 1993 Jul; 47(7):26-30, 32.
[Healthc Financ Manage. 1993]

ReviewInterventional techniques in ambulatory surgical centers: a look at
the new payment system.
Pain Physician. 2007 Sep; 10(5):627-50.
[Pain Physician. 2007]

ReviewEndoscopic ambulatory surgery centers: demise, survive, or
thrive?
J Clin Gastroenterol. 1999 Oct; 29(3):253-6.
[J Clin Gastroenterol. 1999]

[Ambulatory surgery in Germany between demand and competition]
Chirurg. 1995 May; 66(5):463-9.
[Chirurg. 1995]

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AAMS | Disclaimer
Parent Section: A History of Day Surgery in Australia
Dr Lindsay Roberts, FRCS FRACS. Chairman, Australian Day
Surgery Council, 1990 – 2000
A History of Day Surgery in Australia
Dr Lindsay Roberts, FRCS FRACS
Chairman, Australian Day Surgery Council, 1990 – 2000
President Elect, International Association For Ambulatory Surgery
1999
Sydney, New South Wales
Australia
The Australian Day Surgery Committee commenced as a working
party to prepare the first guidelines on day surgery in 1981. As
day surgery expanded, slowly at first, the activities of the working
party increased and in 1988 its name was changed to the National
Day Surgery Committee. There has been more rapid expansion of
day surgery over the past 10 years, and in 1996 it became the
Australian Day Surgery Council, which currently has
representatives from 23 health care organisations.
Day surgery is carried out in both free standing and hospital based
centres. By the end of 1999 there were 190 free standing day
surgery centres in Australia, most of them multidisciplinary with a
small but increasing number of unidisciplinary centres. These
centres have been of the 'same day type' however Council has
supported the introduction of extended (overnight) recovery units
in day surgery centres – “23 hour day surgery” – and Medi-motel
convalescent units. It is predicted that within five years
approximately 75% of operations / procedures will be carried out
as day surgery.
Current Papers
Day Surgery Centres In Australia Planning And Design
A successful day (ambulatory) surgery centre/unit must
have two fundamental criteria. It must provide operative
services of high standards of quality and safety. It must be
both patient and cost efficient such that it is financially
sustainable. ... Day surgery can be provided in freestanding
centres or in units within hospitals - there is no preferred
model. Freestanding centres are the most patient and cost
efficient, and the true costs of providing day surgery
services can be collated from data provided by these
centres. (March 2005)
Model Day Surgery complex with Extended Recovery and
Medi-Motel
The detailed model plan of a day surgery/procedure centre,
which includes extended (overnight) recovery and a MediMotel, is illustrated. It also includes other important design
features such as a community nurses centre and a pre-
operative assessment clinic. Details of the model are
discussed (Australian Surgeon Volume 23, No. 1 Summer
2000)
An alternative to Acute Bed Hospitals Based on the Day
Surgery Principle
The greatest challenge to the health care system in
Australia, and other countries, is the escalating cost of
technological advances, diagnostic and therapeutic,
together with the costs of acute-bed hospital
accommodation. It is obvious that only the largest
hospitals can afford to provide all the complex expensive
diagnostic technology, yet it is essential that it should be
available to all levels of the Australian community. This
can only be achieved by providing these services in the
community (outside the hospital system) with private
funding. The large hospitals, generally of teaching hospital
status, can offer these services, but only to a very small
proportion of the population (Australian Surgeon Volume
23, No. 1 Summer 1999)
Recent Advances in Day Surgery
Many intermediate and some more major operations are
suitable for day surgery but are still being treated for two
or more days in acute bed hospitals, both public and
private. ... Over the past 21 months, the Australian Day
Surgery Council has considered a number of fundamental
day surgery principles which will have a significant
influence on the further expansion of Day Surgery in
Australia (Australian Surgeon Winter 1998)
Day Surgery The Past
The initiative of the medical profession to formalise the
establishment and development of high quality day surgery
facilities was expressed in a paper entitled "Introduction
and Establishment of Day Only Facilities and Services",
and adopted at a meeting of the New South Wales
Committee of the Australian Association of Surgeons on
16 June 1980. (Australian Surgeon Winter 1997)
Day Surgery The Future
Day surgery services are provided in hospital based units,
private and public, as well as in free-standing centres.
Some hospitals have constructed separate free functioning
day surgery units, however in many hospitals this ideal
situation does not exist and day surgery patients are mixed
with overnight stay patients. The cost advantage of day
surgery is best achieved in free-standing centres or totally
free-functioning units within acute bed hospitals.
(Australian Surgeon Winter 1997)
National Day Surgery Committee Same Day Surgery
The National Day Surgery Committee was formalised in
1985 to address standards for Day Surgery Facilities. In
1988 its scope was extended to advise on measures that
would encourage the success of quality day surgery. The
preparation of this paper is a continuation of this role to
demonstrate the possible savings which may be achieved
by a determined strategy to encourage a change in
designated procedures from Overnight to Day Only
surgery (Australian Surgeon December 1995)
Paper pushes for Quality in Facilities - International
Association for Ambulatory Surgery
The Chairman of the National Day Surgery Committee, Mr
Lindsay Roberts, presented a speech at a national
conference on health care delivery organised by I.I.R.
Conferences in September, last. The speech was entitled
"Day Surgery - The Past, Present and Future", and the
following is an edited version of the address (Australian
Surgeon December 1994)
High Standards Essential - Clinical Indicators
The following paper was prepared for publication in
'Ambulatory Surgery', which is the recently established
international journal on ambulatory surgery, and includes
Comment on suitable Clinical Indicators identified by the
National Day Surgery Committee. Several other Clinical
Indicators which were considered unsuitable have also
been mentioned. The subject of quality assurance is under
consideration by the International Committee as one of the
major topics for the first International Congress on
Ambulatory Surgery, to be held in Brussels March, 1995
(Australian Surgeon April 1994)
Every Effort Should be made to Ensure Specialty Groups
Utilise Day Surgery to their Maximum Potential
The construction and licensing of day surgery centres is a
State responsibility and each State prepares its own
mechanism for this purpose. Where a licence has been
granted to a day surgery centre there is a simple process of
registration with the Federal Government for the payment
of day surgery facility insurance rebates. A separate body,
the Australian Council on Health Care Standards is the
accreditation organisation for the maintenance of standards
(Australian Surgeon August 1993)
Incentives for the Expansion of Day Surgery
"Incentives for the Expansion of Day Surgery" has been
prepared by the National Day Surgery Committee as a
stimulus for the expansion of day surgery in Australia. It
will be widely distributed to the medical profession,
organisations involved in the delivery of health care,
Government and other interested parties. (Australian
Surgeon June 1992)
Busy Schedule for National Group
A meeting of the Expanded Day Surgery Committee ... met
on June 2 this year to conduct an interim examination and
assessment of overnight certification and banding of Day
Surgery Procedures which took effect from December last
year. (Australian Surgeon August 1990)
Decade of Hard Work Rewarded.
The Australian Association of Surgeons has taken a
Pioneering role in Developing High Day Surgery
Standards. A review of the years 1980 to 1990. (Australian
Surgeon August 1990)
Day Surgery Progress Stalls Last 12 Months.
A decision by Medicare to subdise disadvantged patients
for Day Surgery services would provide added support for
the development of these efficient, cost effective facilities
and at the same time help reduce the Federal Governments
Health Care Expenditure. (Australian Surgeon October
1988)
Day Surgery an Update




American Day Surgery System Outlined
Assurance of Quality a Major Concern in Day Surgery
New Regulations for Day Rates
(Australian Surgeon October 1988)
Guidelines for Day Surgery Facilities
The Guidelines have been drawn up by Mr Lindsay
Roberts following in-depth study of the development of
Day Surgery facilities in Australia and the USA.
(Australian Surgeon August 1987)
Health Insurance Rebates For Day Surgery
There are many advantages of day surgery, not only to
patients and the medical profession, but also to nurses,
health insurance funds and Government. It is the cost
effectiveness of day surgery which should appeal to
Government and the health insurance industry, and this
cost effectiveness is illustrated by comparative costs of
patients treated in day surgery facilities compared to the
same patients treated in overnight bed hospitals.
(Australian Surgeon August 1987)
Day Surgery Facility - Professional Standards Advisory
Committee - Chairman's Report 1986
The most important Activity of the committee to date has
been the preparation of standards for day surgery facility
accreditation culminating in the publication of a "Manual
for the Accreditiation of Day Surgery Facilities"
(Australian Surgeon February 1987).
Day Surgery
It is estimated that over 40% of all operations in the USA
are now carried out in Day Surgery Facilities and with the
ever increasing costs of overnight hospital beds, day
surgery is expected to expand even further. In Australia
there are only a handful of free standing day surgery
facilities but it is anticipated that their numbers will rapidly
increase. (Australian Surgeon July 1986)
Origins of Day Surgery
Extract from a media release in Adelaide by Mr. DG
Macleish, President Royal Australian College of Surgeons,
May 1986.
Day Surgery Plan Gains Wide Acceptance
The Final Report on Day Surgery has now been presented
to the Federal and State Health Ministers who have
accepted the recommendations of the report in principle.
Related Links
International Association for Ambulatory Surgery
AAMS | Disclaimer
Parent Section: A History of Day Surgery in Australia
Dr Lindsay Roberts, FRCS FRACS. Chairman, Australian Day
Surgery Council, 1990 – 2000
Day Surgery Article
Publication 3b (Australian Surgeon Winter 1997 vol 21 no 2 pp
Status
37-39)
Review
Status
SR
Copyright
Copyright of this article is vested in the author.
Permissions for reprints or republications must be
obtained in writing from the copyright holder. This
article has been republished here with permission
from the copyright holder. (Scanned from The
Australian Surgeon. If there is any discrepancy
between this scanned reproduction and the original
the original takes precedence.)
Day Surgery - The Future
Lindsay Roberts, FRCS FRACS
Chairman, Australian Day Surgery Council, 1990 – 2000
President Elect, International Association For Ambulatory Surgery
1999
The concept of day surgery as a high quality, safe procedural
service is now well established in Australia and there has been
rapid expansion in the past five years. Day surgery services are
provided in hospital based units, private and public, as well as in
free-standing centres. Some hospitals have constructed separate
free functioning day surgery units. However in many hospitals this
ideal situation does not exist and day surgery patients are mixed
with overnight stay patients. The cost advantage of day surgery is
best achieved in free-standing centres or totally free-functioning
units within acute bed hospitals.
The number of free-standing day surgery/procedure centres has
almost doubled since 1993. As indicated in Table 1, there were 83
free-standing day surgery/procedure centres registered with the
Commonwealth Government in January 1993 and this increased to
139 by January 1996. The greatest number of these centres are of
multidisciplinary type, but there has been a notable increase in the
number of day eye surgery centres.
In Australia at the present time approximately 40% of operations
are carried out as . day surgery, although it is generally accepted
that 60 % , and possibly more, of surgical operations can be
treated this way.
In 1992, the Australian Day Surgery Council identified 18
commonly performed operations which, at that time, were mostly
carried out as overnight(s) stay surgery in acute bed hospitals.
There has been an increase in the proportion of day surgery for
these procedures from 1993 to 1996, as indicted in Table 2 (this
data applies to private insured patients and was provided by
Medibank Private). Nevertheless, the levels of day surgery for
some of these procedures is unacceptably low.
It is frequently stated by surgeons that many patients having
intermediate type operations have not sufficiently recovered or are
not comfortable enough to be discharged on the same day as the
operation. These patients require an extended period of recovery
involving overnight stay e.g., many laproscopic abdominal
operations, anorectal operations, cataract/lens replacement
operations and tonsils.
The Australian Day Surgery Council, at a meeting on 12 October
1996, unanimously supported the concept of extended recovery
for day surgery and this will include overnight stay. Very
importantly, it will be necessary to provide specifically
constructed/modified recovery units for such patients and these
can be attached to freestanding centres or hospital based units.
These extended recovery units would be of "hotel type" and not
the typical highly sophisticated and serviced acute hospital bed
accommodation.
In view of this important decision, Council considered it was
essential to define all facets of day surgery, and at a subsequent
meeting on 28 February 1997, the following definitions applying
to day surgery were identified.




Office or Outpatient Surgery/Procedure An
operation/procedure carried out in a medical practitioner's
office or outpatient department, other than a service
normally included in an attendance (consultation), which
does not require treatment or observation in a day
surgery/procedure centre (facility) or unit, or as a hospital
patient.
Day Surgery / Procedure An operation / procedure,
excluding an office or outpatient operation / procedure,
where the patient would normally be discharged on the
same day.
Day Surgery / Procedure Patient A patient having an
operation/procedure excluding an office or outpatient
operation / procedure who is admitted and discharged on
the same day.
Day Surgery Centre (Facility) A registered centre
(facility) designed for the optimum management of a day
surgery/procedure patient.




Day Surgery / Procedure Extended Recovery Patient A
patient treated in a registered day surgery/procedure centre
(facility) or unit, free-standing or hospital based, who
requires extended recovery including overnight stay,
before discharge.
Extended Day Surgery / Procedure Recovery Centre/
Unit Purpose constructed / modified patient
accommodation, freestanding or within a registered day
surgery centre (facility) or hospital, specifically designed
for the extended recovery of day surgery/procedure
patients, and registered with Commonwealth/ State
Governments for this purpose.
Limited Care Accommodation Hotel / hostel
accommodation for day surgery / procedure patients where
professional health care is available on a call basis.
Hotel / Hostel Accommodation Accommodation for day
surgery/ procedure patients without professional health
care, when required for domestic, social or travel reasons.
(Registered 1 - Registered with Commonwealth / State
Governments.)
OFFICE-BASED PROCEDURES
A number of minor operations/ procedures carried out under local
anaesthetic, minor oral sedation or without anaesthetic, are
suitable to be carried out as office-based procedures.
Until the present time, there has been a major disincentive for
medical practitioners to carry out office-based surgery as there is
no health insurance facility rebate for these procedures with the
costs of providing this service carried by either the patient or the
medical practitioner. The recent more acute awareness of antiinfection standards necessitating the use of autoclaves, together
with the steady increase in overall costs, has increased this
disincentive.
Legislation in the Australian Capital Territory (The Skin
Penetration Procedures Act 1994) came into force in mid 1995.
This Act provides for minimal anti-infection standards and applies
to any procedure or operation where the skin is penetrated. In
summary, under the Act it will be compulsory to have a certificate
of accreditation where these office-based procedures / operations
are carried out, and the Act applies to medical practitioners
(general and specialist), dentists and other practitioners, such as
acupuncturists and tattooists.
It is understood that other States are considering the introduction
of legislation and accreditation processes for office-based surgery
similar to that which has been introduced into the ACT. As a
result of these influences, it is now imperative that an office-based
facility rebate be introduced into the Medicare Schedule of
Rebates. It would be inappropriate for such a rebate to be paid by
private health insurance funds, as they now only cover about one
third of the population. Furthermore, private health insurance
funds may only pay facility rebates for services provided at
hospitals or registered freestanding day surgery centres.
EXTENDED RECOVERY UNITS FOR DAY SURGERY
Many patients having intermediate type operations are not being
treated in day surgery at the present time because they are
considered to be insufficiently recovered to be discharged on the
day of operation. Some elderly patients, with inadequate social
back-up, may also be unsuitable for discharge on the day of
surgery. Such patients require an extended period of recovery and
this would involve overnight stay.
The standard recovery rooms of operating complexes, be they
freestanding centres or hospital-based day surgery units, do not
provide accommodation for an extended period of recovery.
Specifically designed and constructed / modified extended
recovery units with hotel type facilities are required for these
patients. At existing free-standing day surgery centres these would
mostly be additions to the existing structures as most centres do
not have enough space to construct them within the centre. New
freestanding centres could design and construct the extended
recovery unit as an integral part of the day surgery centre. It would
be much easier in hospitals to relocate and modify existing
sections of the hospital as day surgery recovery units.
It is emphasised that these extended recovery units should be of
hotel type and do not require the sophisticated and expensive acute
hospital wards / rooms, with inbuilt resuscitation and related
equipment. The capital and running costs of these units would
therefore be considerably less than acute bed hospital
accommodation.
Patients in these units would be supervised by appropriately
trained nurses.
A further option is the development of unsupervised hotel/hostel
accommodation for day surgery/procedure patients, with or
without on call professional health care.
In respect of these day surgery options, the paramount principle is
reiterated, that the choice of procedure and the operation venue
must remain the responsibility of the surgeon and/or anaesthetist.
EDUCATION
There has been very little formal education of medical
practitioners up to the present time on the subject of day surgery,
neither undergraduate nor postgraduate, and this needs to be
addressed. Specific anaesthetic and surgical techniques are
necessary if patients are to make a rapid recovery from operations
so that they are fit for discharge either on the same day, or the
following day for extended recovery patients.
It is suggested that a segment on day surgery practice be
introduced into the final year undergraduate medical course. Freestanding day surgery centres, with their high daily number of
patients, have a wealth of clinical material which, at the present
time, is not utilised in either undergraduate or postgraduate
teaching. Secondment of undergraduate medical students and
resident medical officers in their early postgraduate years to
selected day surgery centres deserves serious consideration.
The inclusion of day surgery in postgraduate specialist courses for
surgeons and anaesthetists should also be considered.
On the basis of the above comments, the following
recommendations are made:



The introduction of a Medicare facility rebate for officebased operations/procedures.
Commonwealth and State Government support for the
development of extended recovery day surgery units.
The inclusion of day surgery in undergraduate and
postgraduate medical education.
Introduction of the above mentioned recommendations would
provide a major stimulus for the expansion of day surgery to
achieve its potential of 60%, if not more, of all surgical
operations/procedures, and eliminate the serious disincentive that
currently exists for office-based operations/procedures.
Acknowledgement
The author gratefully acknowledges the Commonwealth
Department of Health and Community Services and Medibank
Private for providing the data in Tables 1 and 2.
TABLE 1
Freestanding Day Procedures Centres in Australia
Population 18 million
Jan 93
Jan 96
Day Surgery Centres
36
67
Endoscopy Centres
23
29
Day Plastic Surgery
10
7
Day Eye Surgery
3
18
Day ENT Surgery
-
1
Day Medical Cnetres
11
17
In Vitro Fertilisation
2
3
Oncology
1
1
Cardiac Clinic
1
1
Sleep Disorders
1
2
Sports Medicine
1
1
Rehabilitation
1
-
Dental
-
1
Medical / Diagnostic
4
8
83
139
Total
TABLE 2
Selected Procedures for Transfer to Day Surgery
Description
Breast Excision of cyst or fibroadenoma
Jan 93 % Jan 96 %
Day Only Day Only
37.2
66.3
ot other local lesion
Breast Excision of cyst or fibroadenoma
ot other local lesion where frozen
section is performed
38.6
68.4
Femoral or inguinal hernia or infantile
hydrocoele repair of ...
13.2
13
Umbilical epigastric or linea alba hernia
repair - < 10 years of age
44.9
86.9
Puilonidal sinus or cyst or sacral sinus
of cyst excision - < 10 years of age
10.7
11.5
Varicose veins, multiple ligation ... one
leg
30.7
30.8
5.6
10.9
47.2
83.8
29
38.5
Cytoscopy with ureteric catherisation,
unilateral or bilateral
38.2
69.3
Cytoscopy with biopsy of bladder ...
44.6
77.5
Hysteroscopy with dilation of cervix
under GA
48.9
91
Hysteroscopy with endometrial biopsy
or suction currettage or both
61.4
91.1
Hysteroscopy with uterine adhesiolysis
or polypectomy or tubal catheterisation
or R/OIUD ...
66.3
88.9
Lens extraction and artificial insertion
30.5
50
Squint operation for one or both eyes
involving one or two muscles
37.8
68.3
Lop ear, bat ear or similiar deformity
correction of
27.3
40.8
Varicose veins, high ligation and
complete stripping ... one leg
Cytoscopy with urethroscopy ... not
associtaed with any other urologoical
procedure
Cytoscopy with ureteric dilation,
insertion of ureteric stent, biopsy
Cost of Doing
Orthopedic Surgery
Written by Susan Kizirian, RN, MBA
Wednesday, 20 August 2008 17:00
With the advent of the updated CMS 2008 fee schedule, orthopedic surgery now becomes
an even more viable option for the ASC. 183 Orthopedic CPTs were added to the list,
including a uni-compartment knee replacement (CPT 27446). In addition, ASCs can now
realize up to a 92 percent increase in reimbursement from Medicare on average for all
orthopedic procedures.
Commercial payors will be taking into consideration the positive reimbursement changes
that CMS has made for orthopedics as they recalibrate their reimbursement schedules for
ASCs. Going forward — as we negotiate future contracts — we need to educate payors
and have in place the best strategy to obtain good reimbursement for our orthopedic
cases.
That being said, when looking at the orthopedic service at your ASC or if thinking of
adding an orthopedic service, what are the prime financial considerations that need to be
addressed?
Certainly space, equipment and instrumentation are critical. Certain subspecialties in
orthopedics require more equipment, instrumentation and trays than others, such as spine,
shoulders and ACL repair.
Space: An assessment of your current work area for decontamination and central sterile
processing and storage area is important for instrumentation, equipment and supplies that
you will require. You may need a C-arm and will need ORs (especially pertinent for older
facilities) that can accommodate a C-arm. If you intend to perform joint replacement
procedures, the trays required are numerous and older ORs may be too cramped to
accommodate.
Equipment/instrumentation: Not counting the items you need to purchase to perform
orthopedic cases, you will find that a 20 x 20 chamber pre-vacuum autoclave is necessary
to process the larger instruments. Usually a washer-disinfector is recommended due to
the amount of instrumentation needed for efficient decontamination and cleaning. Also,
many are organizations using the Neptune waste system, which requires a docking
station.
Video towers can be specialty-specific and you may require a separate tower or,
hopefully, can convert a current tower/camera system from another specialty for use in
orthopedics. Camera inventory and processing can be an issue and you will need to assess
your case mix to determine the number of items necessary to maintain efficient OR
turnover. Many organizations use a liquid sterilization processing method or a gas
sterilization method for cameras.
Let's look at financial considerations as far as the anticipated cost of performing
orthopedic surgery and how to go about estimating costs:
Total cost of a case — how to estimate or calculate
Overhead per case
1. Take each potential case from patient in room to patient out of room and estimate OR
time in minutes.
2. Multiply that estimated time by $18 to $24, depending upon your ASC's costs.
3. This will give you an average overhead (all expenses except for disposable medical
supplies and implants that are costed on the surgeon's preference card).
4. $18/OR minute is an overhead cost goal to measure against.
5. To obtain your facility's overhead cost per OR minute, take your total OR minutes in a
calendar month and divide into your monthly expenses minus medical supplies and
implants on your profit and loss statement (cash basis). That will give you your
OR/minute cost.
6. If this is less than $18/minute, you're doing great.
7. If it is more, you need to look at costs that go into your overhead and try to reduce
them.
One final benchmark for the overhead category — which is the largest overhead cost —
is payroll and benefits. If you are primarily performing orthopedic cases, the range of
payroll and benefits per case is $280 to $400. Orthopedics is more labor-intensive if you
are performing a mix of the subspecialties. If you are performing just hand or just knee
arthroscopy cases, you will find your total employee costs at the lower end of the range.
If going fullblown across all sub-specialties, including spine, you will be at the high end
of the total employee cost range. Labor is also marketplace-dependent and changes
annually.
Disposable medical supplies and implants, prosthetics and tissues
1. This is the cost that you calculate from your surgeon's preference card. This can be as
simple as OR costs or as full-blown as every disposable medical supply, including
pharmaceuticals, used for the patient from pre-op, to anesthesia, to OR, to PACU.
2. You decide how detailed you wish to be. Just remember that the more-detailed the
preference card, the more labor dollars you will spend to obtain the information and to
keep it accurate.
3. Be sure you need that level of detail before you implement the process by asking
yourself how this data improves your bottom line.
4. Implants, prosthetics and tissues: Make sure to also track this on your preference card.
5. The benchmark to measure against for disposable medical supplies and implants,
prosthetics and tissues is an average of $265 to $360 per case with a typical mix of
orthopedic cases. If you perform a lot of shoulder, foot and ankle, pinning and plating,
ACL and joint replacement procedures, then your costs will be much higher.
Ms. Kizirian ( [email protected] ) is COO of Ambulatory Surgical Centers of
America.
96% Percent Of Minimally Invasive Knee
Replacement Patients Leave Same Day,
No Complication
Main Category: Bones / Orthopaedics
Article Date: 20 Dec 2005 - 0:00 PDT
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Find other articles on: "outpatient knee replacement"
Orthopedic surgeons at Rush University Medical Center found that 96 percent of patients
who had minimally invasive total knee replacement surgery were able to go home the
same day, without complications-many walking out unassisted or with a cane. These
results were published in the October issue of the Journal of Arthroplasty.
Lead author surgeon Richard A. Berger says it's not just the surgeon's skills and
techniques that help patients avoid a hospital stay.
"It's a comprehensive management pathway helps the patient avoid an overnight stay. It's
optimal sequencing and timing of interventions by the nursing, physical therapy,
anesthesia surgical team; it's a team approach of equally weighted preoperative,
intraoperative, and postoperative care."
Patients meet with the physical therapist and nurse prior to surgery. "The nurse time is
invaluable to patient before going into surgery," says Berger. "They attend a class led by
with a nurse where potential surgical complications and postoperative care are discussed.
Patients spend an hour learning about the surgery, asking questions about pain, recovery
and surgery. We reassure patients that their pain will be controlled, that they will be
carefully monitored for the occurrence of complications or delayed recovery due to early
discharge, and explain how will be able to move around independently after surgery.
After class with the nurse, patients have a physical therapy session for instruction in gait
training with crutches and a cane. An internist also evaluates patients as part of our
hospital's policy. Lastly, the hospital discharge planner calls the patient at home before
surgery to make sure all someone can take him or her home after surgery."
The 50 study patients (20 female, 30 males) had surgery between August 2003 and
August 2004. The average age was 68 years old, average weight of 203 lbs. with a body
mass index of 29.2. Forty-eight of the patients had osteoarthritis. Each patient was the
first surgical case of the day.
Berger, who pioneered and perfected minimally invasive outpatient surgery, explains his
technique for total knee arthroscopy (TKA) does not cut the quadriceps muscle and
quadriceps tendon.
"The only incision is from the joint line to the superior pole of the patella. The quadriceps
tendon is not cut or split. The knee is not dislocated; instead, in situ cuts are made. The
patient is out of surgery in less than two hours."
After surgery, patients see an occupational and physical therapist. To be released, patients
must be able to independently get in and out of bed, rise from a chair, walk 100 feet, and
walk up and down a full flight of stairs. Patients are then asked if they feel comfortable
and would like to go home and are released with pain medication.
Patients receive home physical therapy until they can drive; then, outpatient physical
therapy is started. Patients were evaluated clinically and radiographically in the office at
one week, two weeks, six weeks, and three months.
Berger says this study demonstrates that, in these selected patients, "outpatient TKA was
safe with no short-term readmission or complications related to early discharge. New
clinical pathways, including improvements in anesthetic techniques, postoperative pain
management, and rehabilitation protocols, will make performing outpatient TKA a
realistic goal. This comprehensive pathway may make it possible for this minimally
invasive knee surgery to be done as an outpatient in specialized surgicenters in the
future."
Mary Ann Schultz
[email protected]
Rush University Medical Center
http://www.rush.edu
1: Clin Orthop Relat Res. 2009 Jun;467(6):1443-9. Epub 2009 Feb
24.
Links
The feasibility and perioperative complications of
outpatient knee arthroplasty.
Berger RA, Kusuma SK, Sanders SA, Thill ES, Sporer SM.
Department of Orthopaedic Surgery, Rush Medical College, Rush-PresbyterianSt. Luke's Medical Center, 1725 West Harrison Street, Suite 1063, Chicago, IL
60612, USA. [email protected]
The duration of hospitalization and subsequent length of recovery after elective
knee arthroplasty have decreased. We hypothesized same-day discharge following
either a unicompartmental (UKA) or total knee arthroplasty (TKA) in an
unselected group of patients would not result in a higher perioperative
complication rate than standard-length hospitalization when following a
comprehensive perioperative clinical pathway, including preoperative teaching,
regional anesthesia, preemptive oral analgesia, preemptive antiemetics, and a
rapid rehabilitation protocol. We prospectively followed 111 of all 121 patients
who had primary knee arthroplasty completed by noon and who agreed to be
followed prospectively; 25 had UKA and 86 TKA. Of the 111 patients, 104 (94%,
24 with UKA and 80 with TKA) met discharge criteria and were discharged
directly to home the day of surgery. Nausea requiring additional treatment before
discharge was the most common reason for a delay in discharge. There were four
(3.6%) readmissions (all with TKA) and one emergency room visit without
readmission (in a patient with a TKA) within the first week after surgery, while
there were four subsequent readmissions (3.6%) and one additional emergency
room visit without readmission within three months of surgery, all among patients
undergoing TKA. There were no deaths, cardiac events, or pulmonary
complications during this study. Outpatient knee arthroplasty surgery is feasible
in a large percentage of patients yet early readmissions may be decreased with a
prolonged hospitalization. Level of Evidence: Level IV, therapeutic study. See
Guidelines for Authors for a complete description of levels of evidence.
PMID: 19238499 [PubMed - indexed for MEDLINE]
1: Clin Orthop Relat Res. 2009 Jun;467(6):1424-30. Epub 2009 Feb 28.
Links
Newer anesthesia and rehabilitation protocols
enable outpatient hip replacement in selected
patients.
Berger RA, Sanders SA, Thill ES, Sporer SM, Della Valle C.
Department of Orthopaedic Surgery, Rush Medical College, Rush-PresbyterianSt. Luke's Medical Center, 1725 West Harrison Street, Suite 1063, Chicago, IL
60612, USA. [email protected]
Advancements in the surgical approach, anesthetic technique, and the initiation of
rapid rehabilitation protocols have decreased the duration of hospitalization and
subsequent length of recovery following elective total hip arthroplasty. We
assessed the feasibility and safety of outpatient total hip arthroplasty in 150
consecutive patients. A comprehensive perioperative anesthesia and rehabilitation
protocol including preoperative teaching, regional anesthesia, and preemptive oral
analgesia and antiemetic therapy was implemented around a minimally invasive
surgical technique. A rapid rehabilitation pathway was started immediately after
surgery and patients had the option of being discharged to home the day of
surgery if standard discharge criteria were met. All 150 patients were discharged
to home the day of surgery, at which time 131 patients were able to walk without
assistive devices. Thirty-eight patients required some additional intervention
outside the pathway to resolve nausea, hypotension, or sedation prior to discharge.
There were no readmissions for pain, nausea, or hypotension yet there was one
readmission for fracture and nine emergency room evaluations in the three month
perioperative period. This anesthetic and rehabilitation protocol allowed
outpatient total hip arthroplasty to be routinely performed in these consecutive
patients undergoing primary total hip arthroplasty. With current reimbursement
approaches the modest savings to the hospital in length of stay may be
outweighed by the additional costs of personnel, thereby making this outpatient
system more expensive to implement. Level of Evidence: Level IV, therapeutic
study. See the Guidelines for Authors for a complete description of levels of
evidence.
PMID: 19252961 [PubMed - indexed for MEDLINE]
1: J Arthroplasty. 2005 Oct;20(7 Suppl 3):33-8.
Links
Outpatient total knee arthroplasty with a
minimally invasive technique.
Berger RA, Sanders S, Gerlinger T, Della Valle C, Jacobs JJ, Rosenberg AG.
Department of Orthopaedic Surgery, Rush Medical College, Rush-Presbyterian-St
Luke's Medical Center, Chicago, Illinois 60612, USA.
Fifty consecutive patients were enrolled in this prospective study. This was 37%
of the 135 patients undergoing primary total knee arthroplasty (TKA) by one
surgeon. The average patient age was 68 years (50-79 years). A comprehensive
perioperative management pathway was developed and was implemented, which
combined regional anesthesia with a minimally invasive, TKA technique in which
the only incision in the capsule and extensor mechanism is a capsular incision
from the joint line to the superior pole of the patella. Postoperatively, patients
received oral analgesia. After specific discharge criteria were met, 48 patients
(96%) chose to go home the day of surgery. No intraoperative complications
occurred. There were 3 readmissions, none related to early discharge:
gastrointestinal bleed at 8 days, superficial irrigation and debridement at 21 days,
and a closed manipulation at 9 weeks. This study demonstrates that, in these
selected patients, outpatient TKA was safe with no short-term readmission or
complications related to early discharge. This comprehensive pathway may make
it possible for this minimally invasive TKA to be done as an outpatient in
specialized surgicenters in the f
1: Am J Orthop. 2006 Jul;35(7 Suppl):4-6.Links
Preoperative planning and perioperative
management for minimally invasive total knee
arthroplasty.
Scuderi GR.
Insall Scott Kelly Institute, New York, NY, USA.
The introduction of minimally invasive surgery (MIS) has led to new clinical
pathways for total knee arthroplasty (TKA). MIS TKA outcomes are affected by
multiple factors--the surgery itself; preoperative planning and medical
management; preoperative patient education; preemptive perioperative and
postoperative analgesia; mode of anesthesia; optimal rehabilitation; and
enlightened home care and social services-and therefore an integrated team
approach to patient and surgery is required.
1: J Bone Joint Surg Am. 2008 May;90(5):1000-6.
Links
Slower recovery after two-incision than miniposterior-incision total hip arthroplasty. A
randomized clinical trial.
Pagnano MW, Trousdale RT, Meneghini RM, Hanssen AD.
Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W.,
Rochester, MN 55905, USA.
BACKGROUND: It has been claimed that the two-incision total hip arthroplasty
technique provides quicker recovery than other methods do. To date, however,
there have been no studies that have directly compared the two-incision technique
with another method in similar groups of patients managed with the same
advanced anesthetic and rehabilitation protocol. We posed the hypothesis that
patients managed with two-incision total hip arthroplasty would recover faster
than those managed with mini-posterior-incision total hip arthroplasty and
designed a randomized controlled trial specifically (1) to determine if patients
recovered faster after two-incision total hip arthroplasty than after mini-posteriorincision total hip arthroplasty as measured on the basis of the attainment of
functional milestones that reflect activities of daily living, (2) to determine if the
general health outcome after two-incision total hip arthroplasty was better than
that after mini-posterior-incision total hip arthroplasty as measured with Short
Form-12 (SF-12) scores, and (3) to evaluate the surgical complexity of the two
procedures on the basis of the operative time and the prevalence of early
complications. METHODS: Between November 2004 and January 2006, seventytwo patients undergoing total hip arthroplasty were randomized to two treatment
groups: one group was managed with the two-incision technique, and the other
group was managed with the mini-posterior-incision technique. The two-incision
group comprised thirty-six patients (twenty men and sixteen women) with a mean
age of sixty-seven years and mean body mass index of 28.7. The mini-posteriorincision group comprised thirty-six patients (twenty men and sixteen women)
with a mean age of sixty-six years and a mean body mass index of 30.2. All
patients received the same design of uncemented acetabular and femoral
components and were managed with the same comprehensive perioperative pain
management and rapid rehabilitation protocol. Operative times and complications
were recorded. At two months and one year, all patients were assessed with
regard to functional outcome and general health outcome. RESULTS: The
patients in the two-incision group recovered more slowly than did those in the
mini-posterior-incision group as measured on the basis of the mean time to
discontinue a walker or crutches, to discontinue all walking aids, and to return to
normal daily activities. The clinical outcome as measured on the basis of the SF12 scores was similar at both two months and one year postoperatively. The twoincision total hip arthroplasty was a more complex surgical procedure, with a
mean operative time that was twenty-four minutes longer; however, the rate of
complications (2.8%; one of thirty-six) was the same in the two groups.
CONCLUSIONS: Our hypothesis that the two-incision technique for total hip
arthroplasty would substantially improve the short-term recovery after total hip
arthroplasty compared with the mini-posterior incision technique was not proved;
instead, the patients managed with the mini-posterior-incision technique had the
quicker recovery.
1: Instr Course Lect. 2008;57:215-22.Links
Minimally invasive total hip arthroplasty: an
overview of the results.
Duwelius PJ, Dorr LD.
St. Vincent Hospital and Medical Center, Orthopaedic and Fracture Clinic,
Portland, Oregon, USA.
Small-incision total hip arthroplasty (THA) has been shown to be safe and
effective in achieving early postoperative improvements in pain and function. The
comparative published reports of the two-incision, anterior, and mini-posterior
techniques have defined indications for small-incision THAs. The mini-posterior
approach appears to be better than the traditional posterior approach for THA in
terms of early patient function and acceptance. There may be little difference
among the mini-incision techniques when preoperative patient education and
postoperative rehabilitation are equivalent. Correct component positioning has
been consistently achieved with small-incision procedures, and short-term results
are the same as those of traditional THA. The mini-posterior approach also has
been shown to have psychological advantages because it allows patients to be
more confident about their outcomes. New anesthesia and pain management
techniques have also improved early functional results. With time and technical
advances such as computer navigation, the use of minimally invasive THA will
become more prevalent.
1: Clin Orthop Relat Res. 2006 Dec;453:156-9.
Links
Patients preferred a mini-posterior THA to a
contralateral two-incision THA.
Pagnano MW, Trousdale RT, Meneghini RM, Hanssen AD.
Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
[email protected]
The two-incision total hip arthroplasty (THA) technique has been touted as
offering substantially faster recovery than other methods of THA, but direct
comparison studies in similar groups of patients have not been done. We sought to
determine if there was a difference in the early functional outcome after a twoincision THA compared to a mini-posterior THA as measured by the time to
reach defined milestones of daily activity. We also evaluated which procedure the
patients preferred. Twenty-six patients underwent staged bilateral total hip
arthroplasties with a two-incision minimally invasive THA on one hip and a miniposterior THA on the contralateral hip. The same comprehensive anesthesia and
rapid rehabilitation protocol was used after each operation. Patients were
reviewed retrospectively a minimum of 6 months after the second total hip
arthroplasty. There were no differences in the time to discontinue ambulatory
aids, return to driving, climb stairs, return to work, or walk 1/2 mile. Sixteen of 26
patients preferred the mini-posterior total hip arthroplasty and two patients had no
preference. The added surgical technical difficulty of the two-incision minimally
invasive total hip arthroplasty was not rewarded with an earlier return to
functional activities and more patients preferred their mini-posterior total hip
arthroplasty.
1: J Bone Joint Surg Am. 2007 Jun;89(6):1153-60.
Links
Early pain relief and function after posterior
minimally invasive and conventional total hip
arthroplasty. A prospective, randomized, blinded
study.
Dorr LD, Maheshwari AV, Long WT, Wan Z, Sirianni LE.
The Arthritis Institute, 501 East Hardy Street, 3rd Floor, Inglewood, CA 90301,
USA. [email protected]
BACKGROUND: Few prospective randomized studies have demonstrated
benefits of minimally invasive total hip arthroplasty when compared with
conventional total hip arthroplasty. We hypothesized that patients treated with a
posterior mini-incision would have better results than those treated with a
posterior long incision with regard to the achievement of established goals for
pain relief and functional recovery permitting hospital discharge by the second
postoperative day. METHODS: Sixty of 231 eligible patients were randomized
(with thirty in each group) to have a total hip arthroplasty performed through
either a posterior mini-incision (10 +/- 2 cm) or a traditional long incision (20 +/2 cm). After completion of the total hip arthroplasty, the mini-incision group
underwent extension of the skin incision to 20 cm. Patients were evaluated on the
basis of self-determined pain scores, requirements for pain medicine, need for
assistive gait devices, and time until discharge. Gait analysis provided objective
functional assessment. RESULTS: The average hospital stay was 63.2 +/- 13.3
hours in the mini-incision group and 73.6 +/- 23.5 hours in the long-incision
group (p = 0.04). More patients with a mini-incision were discharged by the
second postoperative day (p = 0.003) and more were using just a single assistive
device at the time of discharge (p = 0.005). As scored on a verbal analog scale of
0 to 10 points, patients with a mini-incision had less pain on each postoperative
day and the pain score remained significantly lower at the time of discharge
(mean, 2.2 +/- 1.0 points compared with 3.1 +/- 0.9 points in the long-incision
group; p = 0.002). After hospital discharge, there were no clinical differences in
pain or function between the two groups of patients. CONCLUSIONS: Compared
with conventional total hip arthroplasty performed through a posterior incision,
posterior minimally invasive total hip arthroplasty resulted in better early pain
control, earlier discharge to home, and less use of assistive devices. Subsequent
evaluations at six weeks and three months showed equivalency between the
clinical results in the two groups. LEVEL OF EVIDENCE: Therapeutic Level I.
Table 1
The rating scale as published in 1949 (translated by Dr. David Biau)
Score Pain
Mobility
Ability to walk
0
Pain is intense and
permanent
Ankylosis in abnormal
position
1
Pain is severe, disturbing
sleep
Ankylosis in normal
position or in a very
Only with crutches
slight abnormal position
2
Pain is severe when
walking, prevents any
activity
Flexion < 40° (abduction
= 0°) or very light joint Only with two canes
deformity.
3
Pain is severe but may be
tolerated with limited
activity
4
Pain only after walking
Flexion > 60°–80° (can
and disappearing with rest tie shoelaces)
5
Very little pain and
intermittent, does not
preclude normal activity
Flexion < 40°–60°
Flexion > 80°–90°.
Limited abduction (>
25°)
Impossible
Limited with one cane (less
than one hour). Very
difficult without a cane
Prolonged with one cane;
limited without a cane
(limp)
Without a cane but slight
limp
Normal. Flexion > 90°.
Normal
Abduction > 25°
Reprinted with permission and ©Elsevier Masson Editeur from Merle d’Aubigné R,
Cauchoix J, Ramadier JV. Evaluation chiffrée de la function de la hanche. Application à
l’étude des resultants des operations mobilisatrices de la hanche. Rev Chir Orthop
Reparatrice Appar Mot. 1949;35:5–12.
6
No pain at all
Table 3
The rating scale as published in 1970 (and 1990) (translated by Dr. David Biau)
Mobility
Ability to
Score Pain
No joint
walk
Joint deformity in
contracture
Abduction;
Flexion;
Mobility in
adduction;
external
flexion
internal
rotation
rotation
0
Pain is intense and
permanent
1
immediately
2
Before 10
minutes
3
4
Appearing
during
walking
after:
10 to 20
minutes*
30 minutes
to 1 hour
Impossible
Only with
crutches
Only with two
canes
< 30°
50° 30°
Deduct 1 Deduct 2
point
points
Limited with
one cane (less
than one
hour). Very
difficult
without a cane
Prolonged
with one cane;
limited
without a cane
(limp)
70° 50°
none
none
Without a cane
but slight limp
6
No pain at all
≥ 90°
none
*In the text one can read from 10 to 30 minutes.
** In the text one can read from 70° to 90°.
none
Normal
5
Rare and mild
80° 70°**
1: J Arthroplasty. 2005 Oct;20(7 Suppl 3):33-8.
Links
Outpatient total knee arthroplasty with a
minimally invasive technique.
Berger RA, Sanders S, Gerlinger T, Della Valle C, Jacobs JJ, Rosenberg AG.
Department of Orthopaedic Surgery, Rush Medical College, Rush-Presbyterian-St
Luke's Medical Center, Chicago, Illinois 60612, USA.
Fifty consecutive patients were enrolled in this prospective study. This was 37%
of the 135 patients undergoing primary total knee arthroplasty (TKA) by one
surgeon. The average patient age was 68 years (50-79 years). A comprehensive
perioperative management pathway was developed and was implemented, which
combined regional anesthesia with a minimally invasive, TKA technique in which
the only incision in the capsule and extensor mechanism is a capsular incision
from the joint line to the superior pole of the patella. Postoperatively, patients
received oral analgesia. After specific discharge criteria were met, 48 patients
(96%) chose to go home the day of surgery. No intraoperative complications
occurred. There were 3 readmissions, none related to early discharge:
gastrointestinal bleed at 8 days, superficial irrigation and debridement at 21 days,
and a closed manipulation at 9 weeks. This study demonstrates that, in these
selected patients, outpatient TKA was safe with no short-term readmission or
complications related to early discharge. This comprehensive pathway may make
it possible for this minimally invasive TKA to be done as an outpatient in
specialized surgicenters in the future.
1: Chin Med J (Engl). 2008 Aug 5;121(15):1353-7.
Links
Comparative study on early period of recovery
between minimally invasive surgery total knee
arthroplasty and minimally invasive surgeryquadriceps sparing total knee arthroplasty in
Chinese patients.
Yu JK, Yu CL, Ao YF, Gong X, Wang YJ, Wang S, Xing X, Chen LX, Ju
XD.
Institute of Sports Medicine of Peking University Third Hospital, Beijing, China.
[email protected]
BACKGROUND: Different kinds of minimally invasive surgery (MIS)
procedures have now been used in total knee arthroplasty (TKA). Compared with
traditional TKA procedure with a long skin incision, clinical studies showed MIS
procedures had some advantages. Quadriceps sparing (QS) procedures are the
most minimally invasive MIS procedure until now. This study was aimed to find
the insertion types for Chinese patients' vastus medialis and if the QS procedure
had some advantages in patients' early recovery. METHODS: Between February
2006 and May 2007, 120 consecutive patients underwent unilateral primary TKA
under general anesthesia, among whom 14 patients were lost to follow-up, the
remaining 106 cases were enrolled in this study. Among the 106 cases there were
85 right knees, 21 left knees (15 men and 91 women, with a mean age of 65.1+/-
7.4 years); osteoarthritis in 97 patients (91.5%) and rheumatoid arthritis in 9
patients (8.5%). MIS TKA was performed in 49 cases (MIS TKA group), while
MIS-QS TKA in 57 cases (MIS-QS TKA group). During the operation, the type I,
II and III insertions of the vastus medialis for all patients were recorded. Each
knee was rated post-operatively according to the Hospital of Special Surgery
(HSS) scoring system. Clinical follow-up was undertaken at 1 week, 2, 6, 12 and
24 weeks. Operating time and complications were recorded. RESULTS: There
was no statistically significant difference between the two groups for gender
distribution, age, left or right knee incidence, pre-operative diagnosis, incidence
of varus or valgus deformity. Of the 106 cases there was 1 (0.9%) case with a type
I insertion of the vastus medialis, 4 (3.8%) cases with type II insertions, 101
(95.3%) cases with type III insertions. The HSS scoring was significantly
different between the MIS-QS TKA group and MIS TKA group within the first
two weeks post operation. From 2 weeks later to 24 weeks, no significant
difference was found. The average operating time was (53.3+/-12.4) minutes in
the MIS TKA group and (64.1+/-15.1) minutes in the MIS-QS TKA group
(P<0.001). In the MIS-QS TKA group, 1 patient had delayed healing of the partial
skin incision (1.8%). No other complications were found in either group.
CONCLUSIONS: Although most of the Chinese patients had type III insertions
of the vastus medialis, the MIS-QS TKA procedure showed less injury to the
quadriceps than the standard MIS TKA and this could contribute to the earlier
recovery of the patients. But a shorter skin incision and more tension on the skin
may also lead to more skin complications.