‘Revolutionized’ post-op process makes outpatient joint replacement effective for some

This story first appeared in Healthy You - November 2024, The Gazette’s quarterly health publication.

Long hospital stays and even longer time on bed rest is no longer the standard for joint replacement surgery patients.

Surgeons are utilizing cutting edge technology, pain management methods and postoperative recovery plans to get patients back on their feet quicker with outpatient surgery. Dr. David DeMik, an orthopedic surgeon with Physicians’ Clinic of Iowa in Cedar Rapids, said the game has changed as innovation continues to create new possibilities in medicine.

“Historically, hip and knee replacement was a procedure that required you to spend multiple days in the hospital. People used to think you had to sit in bed after joint replacement surgery for days,” DeMik said. “We’ve learned that this isn’t the best way. Overall, post-op care has been revolutionized.”

Patients who do not have other serious health conditions, such as heart disease, are the best candidates for outpatient surgery, DeMik said. For patients with other medical conditions of that severity, it is preferred they remain under observation by medical professionals as they recover, at least early on.

DeMik notes that inpatient surgery is always an option for any patient.

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The benefits of getting patients out of the hospital or care center have become more apparent in recent years with an emphasis on home recovery spurred by the COVID-19 pandemic. The pandemic created unique conditions that encouraged healthcare facilities to get patients in and out in a timely manner to limit the risk of infection and to keep beds open.

According to Dr. Andrea Stitgen Policano, who is also an orthopedic surgeon with Physicians’ Clinic of Iowa, studies have found knee and hip replacement patients are more likely to avoid complications due to infections if they recover at home.

The Centers for Medicare and Medicaid Services found this to be true among elderly joint replacement patients who were operated on under its Comprehensive Care for Joint Replacement pilot program.

“It’s important that we’re able to offer (outpatient surgery) to people so you don’t have to be in the hospital. We have lower infection rates, and it’s cheaper for patients,” Stitgen Policano said. “Beds in the hospital are OK, but it’s not the same as being in your own bed.”

The typical hospital stay for inpatient surgery prior to the COVID-19 pandemic was one to two nights, Stitgen Policano said.

The revolution did not arrive suddenly. Progress has been made over the course of years and on multiple fronts. Leading the way is the advancement in pain control.

Joint replacement procedures have taken on a different approach to the use of pain medication. A greater understanding of the harm and risks related to opioids have played a role in the medical community looking to other medicines, including over-the-counter pain relievers like Tylenol.

“Instead of just using narcotics alone, which was often what was used in the past, we now have a bunch of different medications used to treat pain,” Stitgen Policano said. “Anti-inflammatories, Tylenol, nerve-type pain medicines. We kind of attack pain from a bunch of different angles instead of strong narcotics.”

Pain relieving medicine is also administered to soft tissue around the area of the surgery, targeting pain at the source.

“Anesthesia gives everyone a nerve block before surgery, which can last 24 hours after, which can help,” Stitgen Policano added. “Also, spinal anesthetic in general causes less nausea. Newer medicines help minimize blood loss. So people are generally pretty comfortable after surgery.”

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The technique of surgeons has improved as well. Surgeons strive to make smaller incisions requiring less recovery. This is made possible, in part, using robotics and preoperative scans of the joint.

Stitgen Policano described the process of integrating preoperative CT scans of the knee or hip she will operate on into a computer program. After completing this step, she can “fine tune” the positioning of the replacement joint to ensure it is properly placed.

Greater efficiency in the procedure has trimmed down the time a patient spends under the knife. DeMik said many knee and hip replacements can be completed within less than two hours in the operating room. It is uncommon for a surgery to take three hours or more.

The prosthetic replacement joints themselves, and the way they are attached, continue to be modernized. For instance, press-fit or cementless knee replacements have gained popularity in recent years. These replacements wedge into the patient’s actual bone snugly, DeMik said, mimicking the native bone. Press-fit knee replacements use porous material that allows for new bone growth. Because they do not use cement to fix the replacement in place, there is no concern about cement breakdown which can cause complications.

The team at the Physicians’ Clinic of Iowa begins preparing patients for their home recovery early in the process. After determining outpatient surgery is best for them, they will meet with a physical therapist, learn about the medications they will be taking and participate in a pre-joint-replacement class. During this class, they learn how to use devices like canes and walkers, what to expect about the recovery process and how they should prepare their home.

“Having good family and social support at home is important,” DeMik said. “The most important thing is making sure the patient is comfortable with it. We want to set people up for success after surgery.”