Symposium Explores Outpatient TJA, Spine Procedures

By: Jennie McKee

Experts emphasize using a comprehensive approach to achieve positive outcomes

“When I started talking about doing outpatient total joint arthroplasty (TJA) 15 years ago, everyone looked at me like I was crazy,” said Richard Berger, MD. Since then, Dr. Berger has performed thousands of successful outpatient primary hip and knee arthroplasty procedures. In his view, surgery is only one part of the equation for achieving good patient outcomes with outpatient TJA. To achieve rapid rehabilitation, he said, a synergistic approach must be employed that combines various elements, including patient education, minimally invasive surgery, effective pain management, and rehabilitation. 

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Richard Berger, MD, discusses outpatient total joint arthroplasty during a symposium held Tuesday.

During a symposium moderated by Adolph V. Lombardi, Jr, MD, FACS, and held at the AAOS Annual Meeting on Tuesday, Dr. Berger and other experts focused on strategies for performing outpatient surgeries safely and effectively, with the goal of maximizing patient satisfaction and reducing healthcare costs.

Outpatient TJA protocol
According to Dr. Berger, his institution’s protocol for outpatient TJA begins with preoperative patient education that addresses surgery, recovery, and discharge. Patients’ postoperative care and services are also addressed, as are special needs and concerns. Prior to surgery, patients are evaluated by an internist and checked for contraindications to same-day discharge.

Prior to surgery, with some exceptions, patients receive a COX-2 inhibitor, pregabalin, preoperative opioids, and a scopolamine patch. During surgery, an epidural anesthetic is used, while sedation and other agents are minimized.

“Because we use minimal anesthesia, the patients are moving a little bit,” explained Dr. Berger. “It’s a little harder to do the surgery, but it’s better for the patient.”

In the recovery room, patients may receive other medications, depending on their age and previous opioid use.

“We give patients an anti-inflammatory medication and pregabalin for a couple weeks,” said Dr. Berger. “Some patients get up and walk right away with little assistance, but we give them a cane to take home if they want one.”

Surgery is followed by 3 to 4 weeks of outpatient therapy.

Anesthetic techniques, controlling pain
According to Craig J. Della Valle, MD, goals related to anesthesia in an outpatient setting include optimizing pain control while minimizing side effects such as nausea and lower extremity weakness, with a focus on rapid mobilization and early, safe discharge.

“Adductor canal blocks are really helpful in obtaining better pain scores and less lower extremity weakness to facilitate discharge,” he noted.

“In addition,” said Dr. Della Valle, “pericapsular injections have been shown to be helpful in several randomized trials.”

Like Dr. Della Valle, Michael J. Morris, MD, emphasized the importance of preemptive and multimodal anesthesia, which he noted “provides a synergistic benefit for our patients while minimizing undesired side effects.”

Dr. Morris cited a randomized, controlled study of 64 total knee arthroplasty (TKA) patients divided into two groups: one that received a periarticular injection with ropivacaine, ketorolac, epimorphine, and epinephrine, and a control group that received no injection at all, with patient-controlled analgesia standardized for both cohorts.

“The periarticular injection group had significantly less pain at 6 hours, 12 hours, and 24 hours, had less opioid consumption, and were more highly satisfied,” said Dr. Morris.

In another study—a double-blind, randomized controlled trial of 80 primary TKA patients—researchers studied the effects of periarticular injections with the aforementioned types of medications versus normal saline and found less opioid consumption and pain, and higher patient satisfaction in the periarticular injection group.

Blood management
Blood management is another important consideration for outpatient procedures, noted William G. Hamilton, MD.

“For outpatient TJA, you really need to eliminate or radically reduce your transfusion rate, not just for patient safety, but for shortening the length of stay,” he said. Noting that there is no access to blood products at many surgery centers, Dr. Hamilton asserted that, prior to performing TJA in a surgery center, an orthopaedic surgeon’s transfusion rate should be well below 5 percent.

“Preoperatively, it is important to check the patient’s hemoglobin level,” he said. “We know that one of the most important predictors of postoperative transfusions is the preoperative hemoglobin level. All patients get an iron supplement, because my goal is to have the hemoglobin as high as possible in these patients.”

For patients with lower hemoglobin levels, Dr. Hamilton considers postponing surgery or moving them to the main hospital where a blood transfusion would be possible. In addition, he evaluates for risk factors that have been shown to increase blood loss, such as advanced age and multiple comorbidities. He warned that some patients—such as very thin, female patients—do not have the same blood volume as others, which can make them more prone to requiring a transfusion.

“Tranexamic acid is no longer a new issue; I think we’re all using it,” said Dr. Hamilton. “It can be given intravenously using a weight-based protocol, or a standardized dose can be given to all patients.”

Dr. Hamilton acknowledged that there has been some concern that using tranexamic acid could increase the risk of venous thromboembolism (VTE). He cited one study involving more than 13,000 patients who underwent elective total hip arthroplasty (THA) and TKA. At 30-day follow-up, noted Dr. Hamilton, the researchers found no increased risk of VTE or death.

Another large study of TJA patients found no difference in symptomatic VTE in patients who received tranexamic acid compared to those who did not.

In summary, he said, if preoperative, intraoperative, and postoperative techniques for reducing blood loss are followed, “transfusion rates can be reduced to a negligible number.”

Outpatient lumbar fusion
Daniel S. Husted, MD,
discussed performing lumbar fusion at an ambulatory surgery center, noting that patient selection is an important factor, as is using appropriate surgical equipment with which the surgeon is familiar.

Outpatient procedures such as lumbar fusion offer many benefits, he explained, noting reduced costs and increased patient satisfaction. Most importantly, however, Dr. Husted asserted that such procedures can be done safely.

“Infections have been studied and have been found to be less prevalent in the ambulatory surgery setting,” he noted.

He acknowledged that some orthopaedists may be uncomfortable moving to the outpatient setting for some procedures, but moving outside one’s comfort zone is “how we move forward.”

His advice for those who want to transition to using outpatient surgery centers for certain procedures is to select patients and procedures carefully.

“I would start practicing sending patients home from the hospital so that you can establish your own techniques and postoperative care,” he advised.

Also, he added, “make sure you have a home health agency that understands your protocols.”                 

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