Drive-through joint-replacement surgery may be coming soon

[Guest guest]

Rheumawire

Mar 16, 2004

" Drive-through " joint-replacement surgery may be coming soon

San Francisco, CA - Outpatient minimally invasive total hip and knee

replacement may be the wave of the future, says Dr A Berger

(Rush Medical Center, Chicago, IL) at the 71st annual meeting of the

American Academy of Orthopaedic Surgeons.

But that's not to say that all orthopedic surgeons are in favor of this

new " drive-through " approach.

" Outpatient joint replacement is here, it can be done, and hopefully it

will continue to be done safely by more surgeons across the country, "

says Berger, who pioneered this approach.

Berger makes 2 1- to 1.5-inch incisions when performing total

hip-replacement (THR) surgery [1]. The first incision is a small cut

over the femoral neck, where he pushes muscles and tendons aside. The

second counterincision is a little smaller and goes down the femoral

canal. He uses fluoroscopy for vision, so " we are quite accurate. " One

incision is for cup preparation and placement, the other is for stem

preparation and placement, he explains, likening the procedure to

" building a ship in a bottle. "

The minimally invasive surgery (MIS) 2-incision approach is done without

cutting muscle or tendon, which is why it can be done on an outpatient

basis, he says, " Most remarkable is how quickly patients recover without

[the surgeon] cutting the muscle or tendon. "

To be discharged the same day of the procedure, patients must exhibit

stable vital signs, get in and out of a bed and a chair independently,

walk 100 feet, ascend and descend a full flight of stairs, tolerate a

regular diet, and achieve adequate pain control from oral analgesics.

Since January 2003, Berger has performed this procedure on 100 patients

and every one has gone home the same day. There have been no

readmissions, no reoperations, and no dislocations, he says.

" We can do the same thing with the knee, " he says. Berger has now done

23 knee replacements, where all the patients went home the same day.

However, other orthopedic surgeons are uneasy about such quick dismissal

of patients after surgery. Dr P Sculco (Hospital for Special

Surgery New York, NY) has some doubts about outpatient joint-replacement

surgery.

" There is some risk in it, " he tells rheumawire. " I would like to keep

them overnight and if they are dizzy, I will keep them for a second

day, " he says. " A young patient who is very fit could be kept overnight

and then go home the next day. "

However, " you can't take 80-year-olds with no backup and send them home

the same day, but it may have application to a small population, " he

says in an interview.

Sculco performs MIS-THR sightly differently from Berger. He uses

conventional surgery and shrinks the incision down. " My observation is

that these patients recover more quickly and lose their limp and need

for a cane more quickly than with the standard approach, " he says.

" There have been no increases with this approach in terms of wound

problems, dislocation of the implant, or inferior results when evaluated

by x-ray, " he says.

Dr Hungerford (s Hopkins University School of Medicine,

Baltimore, MD) has concerns about both MIS joint arthroplasty as well as

performing these surgeries on an outpatient basis.

He says that there is no convincing evidence that the patient will

benefit from MIS knee replacement. He recently reviewed 275 standard

revision total-knee replacements and found that 75% had technical

failures. " If a surgeon with full exposure cannot reproducibly and

reliably align the bone, what will the outcome be with limited

exposure? " he says.

That said, for MIS, " the evidence is more compelling for the hip than it

is for the knee, " he adds.

There are even more inherent dangers in doing these on an outpatient

basis, he says. " I think for the average patient, you run the risk of

having easily treated, early recognizable complications and, because the

patient is not there, they are not recognized and can have catastrophic

results, including arrhythmia, bleeding, urinary retention, and

medication complications, " he tells rheumawire. He notes that Berger's

patients tend to be younger than the average joint-replacement surgical

candidate.

" I would have to be convinced with data that after you followed 100 to

200 hips in a 24-hour hospitalization setting that nothing occurred in

the overnight period that was important to know about, " he says.

Another problem is that some patients live 300 miles away. " Are you

going to put someone on a plane and send them back to Florida? I don't

think so, " he says.

Mann

Source

1. Berger RA. Presentation: Minimally invasive total hip arthroplasty

using a two-incision technique. San Francisco, CA: American Academy of

Orthopaedic Surgeons: 2004 meeting; March 10-14, 2004:Paper no 207.

I'll tell you where to go!

Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org