With direct-to-consumer marketing now mainstream in the orthopedic industry and with information ubiquitously available on the internet, scores of companies are always purporting to deliver a superior product or experience that can lead to improved patient outcomes. The majority of these claims are not backed by non-biased peer-reviewed scientific research are simply claims made by experts who may have an equity stake in the product and thus a conflict of interest to promote its alleged merits.
In truth, many of the advancements in joint replacement that have had the largest impact on outcomes are not directly product related but process related.
Blood Management: not long ago the transfusion rate after hip or knee replacement was as high as 30-40% and patients would routinely have to pre donate 1-2 units of blood before surgery. The use of tranexamic acid (TXA) then became mainstream in joint replacement roughly 6 years. This is a medication that can be given just before skin incision and just prior to closure that significantly reduces surgical bleeding. With the use of this medication, predonation is no longer indicated and the transfusion rate has dropped from 40% to less than 2%. Because transfusions lead to longer hospital stays, immune reactions, higher risk of infection and delayed rehabilitation, the use of TXA has significantly improved our ability to recover patients faster but also transition cases to same day discharge because there is no concern for excessive blood loss.
Pain Management: Patients used to have to stay in the hospital because of pain. Intravenous narcotics were necessary to control postoperative pain and these would cause side effects like nausea, sedation and constipation. Over the years numerous advances in pain management have revolutionized the recovery from joint replacement allowing patients much faster recovery through accelerated rehabilitation protocols. These advancements include regional nerve blocks, local anesthetic mixtures injected around the surgical field during surgery and multimodal medication strategies. The latter involves the use of combinations of medications that act synergistically to control pain while limiting that amount of narcotics patients need to achieve a manageable level of comfort. This allows opioid sparing surgery.
Surgical Stress Response Management: surgery induces physiologic stress on the body and this stress calls on multiple organ systems during the immediate perioperative period. Research into how best to limit the negative impacts of this stress response has led to enhanced surgical recovery protocols that allow faster recovery of overall function and fewer complications associated with other medical problems that can impact recovery from surgery. Such advancements include prophylaxis against nausea and vomiting, better preoperative hydration, preoperative carbohydrate loading, use of intravenous steroids immediately prior to surgery and avoidance of high doses of narcotics.
Patient education and preparation: perhaps one of the most impactful changes in the perioperative management of joint replacement is better patient education and optimization prior to surgery. Having a clear understanding of exactly what to expect and how to best manage the recovery from surgery is empowering to patients and can lead to a much better positive mental outlook. In addition, optimization of risk factors prior to surgery can reduce surgical complications. Starting this process in the weeks prior to surgery can majorly improve a patient’s ingoing status for surgery and thereby improve the recovery process.
Transition to Outpatient Joint Replacement: all of the above improvements have allowed the transition to same-day joint replacement where patients can leave the facility just hours after surgery and recovery in the comfort of their own home. This allows many of these cases to be performed in ambulatory surgery centers which avoids the expense of the hospitals. Abundant research has proven that outpatient joint replacement is safe and leads to high levels of patient satisfaction. There is even data demonstrating lower infection rates and reduced rates of hospital readmission when joint replacement is performed in an outpatient surgery center.
Our AVATAR program uses a comprehensive approach to perioperative care taking full advantage of each of these advancements. This leads to less pain, faster recovery and better outcomes. We have more experience in outpatient joint replacement than any other practice in the region. This experience makes a difference in terms of the patient experience and outcome.