Lessons learned during 35 years of arthroplasty surgery

Throughout our medical careers, each of us learns lessons about patient care and adopts techniques that are routinely used during patient encounters. The following techniques have been helpful to me, and I hope they will be useful to others as well.

Deciding to proceed
Because hip or knee replacement surgery is almost always elective, many patients agonize over whether and when to proceed—even if radiographs show severe arthritis in the joint. I reassure these patients by telling them that I take care of them, not their X-ray. There is no urgency for them to proceed.

Patients should not be scheduled for surgery if they are ambivalent. If they say that they are almost ready, I suggest scheduling 6 months to 12 months in the future. This gives them the opportunity to proceed or not, depending on how the pain and disability evolve. They should pick a time of year for the surgery that works well with their schedules and does not conflict with any important family events such as weddings, vacations, graduations, or births of grandchildren.

One at a time or both at once
When a patient has bilateral knee arthritis, some surgeons will never consider doing simultaneous bilateral replacement. Surgeons who perform bilateral arthroplasties must decide which patients are appropriate candidates, assuming the patient is medically fit for bilateral surgery. Often, a patient who has bilateral knee arthritis will have one knee that is much worse than the other, so unilateral surgery would be appropriate.

When the discrepancy between the two knees is not so great, I have found that the following question defines the appropriate candidate for bilateral surgery:

“Pretend that your worse knee is actually normal. Would you still be here today considering a knee replacement for this less symptomatic side?”

If the answer is “yes,” then bilateral arthroplasties are appropriate. If the answer is “no,” replacing the more symptomatic side will likely improve the patient’s pain and functional level to a point where replacement on the less symptomatic side can be delayed.

The power of the phone
Elective hip and knee replacement surgery is often scheduled months in advance. The surgeon’s last personal contact with the patient prior to the surgery may have occurred in the remote past. All recent communication comes from prescreening personnel, hospital admission officers, and computer-generated phone calls.

Patients are naturally anxious about their surgeries and wonder where they are on the surgeon’s “radar.” Will the surgeon remember their drug allergy, their prior incision, or other unique factors about them? Will the surgeon be rested and focused?

For more than 30 years, I have religiously called each patient the evening before surgery. At the end of each week, my secretary gives me the next week’s surgical schedule, each patient’s latest relevant office note, component sizes if simultaneous bilateral surgery is planned, and home and cell phone numbers.

I call to say that I am thinking of them and want to be sure that they are all set. I ask if they have any questions since we last spoke. I remind them to take their anticoagulant (warfarin) and confirm their time of arrival at the hospital. This reassures them that I am thinking of them, and it reassures me that they will take their anticoagulant and will arrive on schedule.

After surgery, telephone calls are also helpful. If I am unable to make hospital rounds on any given morning, I phone my patients in their hospital rooms. This individual connection is often more appreciated than a personal visit! If I must leave town before a patient is discharged, I call daily and inquire about his or her progress. This is very reassuring to patients (especially those struggling with recovery) and assures them that I care.

Web-based wound management
Several years ago, one of my patients left the hospital for an extended care facility 30 miles away while I was still concerned about her wound. A day later, the facility called me. The caretakers were recommending that the patient return to the hospital for evaluation and treatment.

I asked if someone could photograph and e-mail me a picture of the wound. I found that I could manage this particular problem with daily surveillance and wound care recommendations quite easily and with confidence. It saved thousands of dollars of hospital and transportation costs.

I continue to use Internet surveillance, particularly with the knee wound that was fine at the 4-week postoperative check-up, but became worrisome to the patient, visiting nurse, physical therapist, or family member a few weeks later. The e-mailed photo inevitably shows a “spitting” subcuticular resorbable suture, and everyone is reassured that local wound care is all that is necessary.

Dealing with complications
Complications are inevitable. Rather than obsess about them or, even worse, avoid the patient, I keep these patients prominently on my “radar screen.” I see or call them frequently while they are hospitalized. I call them at home after discharge to see how they are. This way, I hope they realize I truly care about them and am sorry for what happened.

The value of analogies
I frequently use analogies to help explain medical issues, such as in the following cases:

If I think that a patient is an ideal candidate for a unicompartmental knee replacement, but the patient is leery, I ask, “If you were at the dentist having a diseased tooth pulled from one side of your mouth, would you want the dentist to remove a normal tooth from the other side merely because your mouth was already open?”

If a patient with severe osteoarthritis asks about autologous chondrocyte implantation (ACI), I use the analogy of a street with a pothole. “ACI fills the pothole,” I say. “Unfortunately, your whole street needs repaving!”

When soothing anxious, questioning, Internet-savvy patients, I ask whether they talk to the airline pilot about air speed, altitude, and flight plan while they are on a commercial flight. I remind them that I am the pilot and they are the passengers. They must have enough confidence in me to sit down, fasten their seatbelts, and let me take them safely through the surgery.

When discussing the possibility of a future revision surgery, I inform patients that a joint replacement is not like a car battery with a finite lifespan. Today, patients have a greater than 90 percent chance that the replacement joint will last for 10 years and a greater than 80 percent chance that it will last for more than 20 years. For hip and knee arthroplasties, the revision rate is a consistent 1 percent per year for these 20 years.

FAQ brochure
Patients consistently ask the same questions preoperatively and postoperatively. I collected the most frequently asked questions (FAQs) in a brochure for patients. I ask them to read it before the surgery and refer to it as questions arise. It includes both normal symptoms and things like fever, wound drainage, and persistent ankle swelling that require an immediate call to the office.

Two issues still prompt calls unless I mention them at the final hospital visit. The first is a reminder that the operated knee may feel warmer than the other knee for several months. The second is that they will discover a numb area of skin just lateral to the incision because a small skin nerve must always be cut to perform the procedure.

Finally, at the 4-week postoperative visit, I remind patients that full recovery takes at least 3 months and they are only a third of the way there. I also tell them that some patients need as much as 6 months to 12 months to achieve their “final result.”

Richard D. Scott, MD, is professor of orthopaedic surgery at Harvard Medical School and senior attending surgeon at Brigham and Women’s and New England Baptist Hospitals in Boston. He can be reached at rscott@partners.org

Disclosure information: Dr. Scott—DePuy, a Johnson & Johnson Company; Conformis.