New Data on 3-Hour Outpatient Partial Knee Replacement // More Pain for Younger Hip Replacement Patients // and More!

Outpatient Uni Knee Arthroplasty…Home in 3 Hours!

Don’t fear the outpatient experience, says the largest study ever on outpatient partial knee replacement. Robert S. Gorab, M.D. is the chief medical officer at the Hoag Orthopedic Institute (HOI) in Irvine, California. He tells OTW,

“Our study, just published in The Journal of Arthroplasty, found that after unicompartmental knee arthroplasty (UKA), day of surgery discharge for appropriate patients can be both safe, efficient and even increase patient satisfaction. We took 160 consecutive patients with appropriate risk profiles and performed all the procedures on an outpatient basis. We found that there were no readmissions, no re-evaluations for nausea, no falls, and no acute post-surgical complications. We had a broad age range—people in their 40s all the way up to 83 years of age. And the average length of stay was less than three hours!

The success of these procedures can largely be attributed to the strong educational process that we have at our facility. There are both nurse practitioners and physician assistants that work through the educational process with the patient; they review safety issues and provide education for the family. In all, they spend approximately an hour and a half with each patient the week before surgery in order to optimize the entire process. Some patients also receive pre-surgical physical therapy, such as gait training with ambulatory aids.

I believe that in order to successfully perform these partial knee replacement surgeries on an outpatient basis you need a facility with solid orthopedic infrastructure that performs a reasonable volume to handle these larger procedures. The administrative team, in cooperation with the physician leaders, must spend time standardizing surgical protocols and recovery pathways to optimize results. We also have a physical therapy department in our office that sees the patients after surgery and before they go home to ensure they are safely discharged.”

20% Have Severe Thigh, Hip Pain After Hip Replacement

Despite improvements in hips implants, thigh and groin plain remain challenges for many young, active patients. Ryan Nunley, M.D., assistant professor of orthopedics at Washington University in St. Louis, tells OTW,

“We have just presented our work indicating that the incidence of thigh and groin pain in young, active hip replacement patients is underreported. However, we found that when you ask about these issues in a blinded way (using a mailed survey) they’re more honest about the pain. A large percentage of these patients have thigh pain after hip replacement and 10-20% have severe thigh pain and lateral hip pain; they just learn to live with it over time.

The native hip socket is not a perfect hemisphere, so we put in a metal hemisphere that may overhang and rub against the tendon if we don’t get the fitting just right. On the femoral side most surgeons are currently using uncemented tapered stems with conventional length implants which might account for the rate of thigh pain.

Several companies are coming out with shorter stems, the thought being that perhaps if the stem didn’t go down as far into the bone then there may be less thigh pain. We are currently studying this at our institution, comparing shorter stems to longer devices to see if the former improve functional outcomes.

As in so many surgical situations, it is about managing expectations. When patients are told that they could have thigh pain or lateral hip paint then they expect it and report higher satisfaction rates. Our current implants for hip replacement are much improved, but thigh and groin pain are a real challenge for some patients. It’s especially important to develop better implants because young, active patients are the fastest growing segment of the hip arena.”

Disc Herniation and Pain: New Understandings of a Very Complex Disease Process

Irving M. Shapiro B.D.S., Ph.D. is the director of the Division of Orthopaedic Research at Thomas Jefferson University in Philadelphia. He tells OTW, “My colleague Dr. Risbud and I have just published a review article in Nature Reviews Rheumatology and a series of articles in the Journal of Biological Chemistry and The American Journal of Pathology on the events that trigger degenerative disc disease and the molecular changes that are linked to the generation of radicular pain. Both of these processes are initiated by an increase in levels of inflammatory cytokines especially TNF, IL-1 α, IL-1β, IL-6. These agents provoke the synthesis of matrix digesting enzymes especially MMPs and ADAMTSs which degrade matrix macromolecules within the nucleus pulposus. With loss of matrix constituents, there is often tearing or herniation of the annulus fibrosus, leading to vascularization and chemokine-dependent migration of immune cells into the disc. These cells further amplify the inflammatory state of the disc, and elicit a rise in levels of neurogenic molecules including neurotransmitters and neuromodulators. These molecules influence the activities of nociceptive neurite sprouts from the dorsal root ganglion and cause radicular pain.”

Dr. Risbud added, “While the immediate approach to preventing disc pain is to prevent the release of inflammatory molecules, a more subtle approach might be to limit immune cell invasion into the herniated disc.”

Michael Bronson, M.D. Named Honoree by Arthritis Foundation

Dr. Michael Bronson, vice chairman of the Department of Orthopaedic Surgery and chief of the Joint Replacement Center at the Icahn School of Medicine at Mount Sinai, has been named as the Medical Honoree by the Arthritis Foundation at their annual Jingle Bell Run/Walk on Saturday, December 7, 2013.

Dr. Bronson is being honored by the Arthritis Foundation for his continued efforts to assist those who live with arthritis. He will serve as the key medical spokesperson for the disease itself, treatment and quest for a cure. Dr. Bronson will be raising awareness about the disease and money through with the goal of helping New York City event organizers reach the fundraising goal.

Dr. Bronson is the founding surgeon of the Joint Replacement Center and LeFrak Center for Patient Education at the Icahn School of Medicine at Mount Sinai, one of the leading centers of its kind in the country and the only one of its kind in New York City. Dr. Bronson is one of the nation’s leading orthopedic surgeons specializing in the field of joint replacement. He has been published extensively and lectured around the world and has appeared on national and local television and radio. He has been interviewed extensively in The New York Times, USA Today, U.S. News and World Report, the Associated Press, Bloomberg and other publications.

ACL Reconstruction: Independent Femoral Drilling Needed

“Focus on what’s important, ” says Mark D. Miller, M.D. of the University of Virginia (UVA). Dr. Miller, the S. Ward Casscells Professor of Orthopaedic Surgery at that institution, tells OTW,

“All of the recent sensationalism in the lay press regarding ‘new ligaments, ’ PRP, and other ‘advances’ need to wait for the science to catch up with the hype. The field needs to focus on more important things, like getting ACL [anterior cruciate ligament] reconstruction right. At UVA we are studying techniques to ensure the correct location of tunnels for ACL grafts. We are conducting lab and clinical research to evaluate ideal tunnel locations. We have just completed a series of three high tech CT cadaver studies which demonstrated the need for independent drilling of the femoral tunnel instead of the traditional drilling through the tibial tunnel (trans-tibial). Trans-tibial drilling does not consistently put the femoral tunnel in the footprint of the ACL, and that is what is required for an anatomic ACL reconstruction. Independent femoral drilling does bring new challenges, however, and we have developed ways to protect the medial femoral condyle and to ensure that the femoral tunnel is long enough. We are also researching the ideal tibial tunnel location in ACL reconstructions; several recent studies (including our own) have suggested that we need to move our tibial tunnels more anteriorly.

The biggest obstacle to new techniques being popularized is that it requires people to learn new techniques. Sadly, a lot of surgeons are unwilling to change the way that they have done things in the past. We are in the process of planning more research to prove that anatomic ACL reconstruction yields the best long term results. As pay for performance, bundled payments, preferred providers, and other new insurance issues arrive, we all see that the future of remuneration depends upon results, and adopting new techniques is an important part of that concept. Those surgeons who don’t keep up to date with advances may take some time to be convinced of the value of it. We should all embrace the concept of ‘lifelong learning.’”