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In select patients, minimally invasive hip replacement in the ambulatory setting can allow for a smaller incision, less pain, and faster recovery.

AAOS Now

Published 8/1/2010
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Maureen Leahy

The 23-hour total joint

Performing total hips in an ambulatory surgery center

What if you could offer joint replacement patients surgery that gets them walking within hours instead of days and doesn’t require costly overnight stays in a hospital? Advances in surgical technique, implant technology, and improved anesthesia and pain protocols are enabling some surgeons to perform reconstructive surgeries in ambulatory surgery centers (ASCs). For patients who meet the selection criteria, it’s an option that allows them to recover at home and resume their normal activities faster.

According to James T. Caillouette, MD, joint replacement success in the ambulatory setting relies on careful patient selection, surgical expertise and technique, and judicious pain management.

Patient selection
Demand for adult reconstructive procedures is growing, even as the number of adult reconstruction surgeons is declining. Thus, efficiency in performing these procedures has become increasingly important, said Dr. Caillouette. He stressed, however, that patient safety is still the surgeon’s highest priority, especially in the ambulatory setting. Incidences of life-threatening complications—pulmonary embolism, myocardial infarction, arrhythmia, and bowel obstruction—occur with the highest frequency within the first 72 hours after joint reconstruction surgery. As a result, patient selection is critical.

Medicare does not pay for joint replacements when performed in an ASC, so most patients are younger than age 65. Dr. Caillouette’s indications for an ideal ASC joint replacement patient include good overall health, an anesthesia classification of ASA I or II, a body mass index of less than 30, and the willingness and ability to return home to a reliable support system after a 23-hour stay.

Once selected, patients and their caregivers receive an information booklet and attend a class that further explains what to expect before, during, and after surgery. Dr. Caillouette’s team also performs a very thorough preoperative medical assessment on the patient, teaches relaxation and visualization techniques, discusses pre- and postoperative dietary restrictions, and offers practical tips. Postoperative home health nursing and therapy visits are also arranged prior to the surgery.

Pain protocol, surgical technique
Patients are given a loading dose (400 mg) of a Cox-2 inhibitor (celecoxib) 48 and 24 hours prior to surgery. They are also instructed to stop taking aspirin and other blood-thinning medications that could result in increased bleeding, including clopidogrel, warfarin, and all supplements including fish oil 7 days before surgery. Warfarin is restarted the night of surgery; patients resume the other medications when they return home. Intraoperatively, the patient receives a spinal anesthetic as well as a single dose of methadone. To reduce postoperative nausea and vomiting, antinausea medications are administered intravenously in addition to use of a scopolamine patch and a single dose of dexamethasone.

Dr. Caillouette uses a minimally invasive procedure for hip replacement known as a muscle-sparing approach. In addition to a smaller incision, the technique results in less soft-tissue trauma and faster patient ambulation.

“If you respect the patient’s biology and try to avoid any sort of damage, you can really limit the amount of the inflammatory effect immediately after surgery, which allows you to get the patient up and moving,” he explained.

Dr. Caillouette emphasized that the surgery is performed exactly the same in the ASC as it is in the hospital. Before surgery, the surgeon signs the surgical site. “We have the same equipment available, we wear space suits, we’re in a high-flow operating room, we use a C-Arm. I check implant positioning during and after the procedure, and we are prepared for complications if they occur,” he said.

Stressing the importance of an experienced surgical team, he recommends sending ASC scrub techs and a circulating nurse to the main hospital for several weeks to train on similar cases before performing these procedures in the ASC’s operating room.

Rapid recovery
Following surgery, patients are moved to an overnight room where they receive one-on-one nursing care. Recovery room nurses can be used, but Dr. Caillouette prefers the added experience of intensive care nurses who may be better equipped to handle any complications that might occur.

Patients receive 1,000 mg of acetaminophen every 6 hours and are treated with instant release oxycodone for breakthrough pain. “We try to avoid any intravenous narcotics after surgery, and that has worked out well,” he said.

Patients receive the same prophylactic care as if they were in the hospital—incentive spirometry, sequential compression devices, and deep vein thrombosis prophylaxis. Their vital signs (respiration, pulse oximetry, electrocardiogram) are monitored through a system that is centrally located at the nursing desk, which allows the patients to rest comfortably with fewer interruptions.

When the anesthesia wears off, the patient is encouraged to sit up, dangle the legs, and eat a light, high fiber diet. About 5 hours after surgery, the patient begins to ambulate with the help of a walker. Prior to discharge by the surgeon at 23 hours post-op, patients must be able to get into and out of bed on their own and climb stairs.

Dr. Caillouette and his team have performed nearly 100 total hip arthroplasties in the ASC, and patient feedback has been very positive. “The patients really love it—they love not being hospitalized and they get back to their lives quickly,” he said. “The key is being selective; the right patient is healthy and highly motivated.”

Dr. Caillouette shared his experiences with “Modern Total Hip Replacement in an Ambulatory Surgery Center” during the 8th Annual Orthopedic, Spine and Pain Management-Driven ASC Conference in Chicago.

Disclosure information: Dr. Caillouette—DePuy Orthopaedics.

Maureen Leahy is assistant managing editor for AAOS Now. She can be reached at leahy@aaos.org