St. Joseph's Health Musculoskeletal Minute

Welcome back to St. Joseph's Health Center's Musculoskeletal Minute! This video blog features doctors from St. Joseph's Hospital Health Center in Syracuse, NY, speaking on orthopedic topics of interest. You will see a new video blog out every few weeks.

Dr. Brett Greenky, orthopedic surgeon at St. Joseph's Hospital Health Center, speaks on obesity and its effects on orthopedic health.




Board Certified in Orthopedic Surgery and Assistant Clinical Professor

Education:
MD - Upstate Medical University
MS - Biology, Long Island University
BA, Biology, Northwestern University

Residency:
Upstate Medical University

Fellowship:
New England Baptist Hospital

Areas of Expertise:
Total hip, knee and shoulder, replacement, hip resurfacing, revision total joint surgery

Operation Walk Syracuse: Preparing for Panama

Operation Walk Syracuse is a group of orthopedic specialists (surgeons, medical doctors, nurses, anesthesiologists, and physical therapists) who travel to countries that lack ample access to desperately needed hip and knee replacement surgeries. The surgeries are performed at no cost and patients receive the same state of the art services that our patients receive here at home. This post highlights the “pre-trip” the group made to Panama recently, preparing for their longer trip in November 2012. Last year the group traveled to Nepal, performing more than 75 hip and knee replacements.

Thousands of miles closer, a fraction of the travel time, one hour difference in time, and the luxury of clean, running water, ample electricity, and sound building structures--this is Panama City, Panama.  We joked casually as we were chauffeured from the airport in Panama City to the modest hotel that would serve as home base during our pre-trip visit to St. Tomas Hospital.  We were preparing for our upcoming annual Operation Walk trip in November, 2012.  We (Dr. Brett Greenky, Mike O’Hara, and I) discussed the stark contrast of Panama City in comparison to Kathmandu, Nepal our 2011 Operation Walk Syracuse destination.  We speculated about the hospital, the working conditions, the medical staff, equipment challenges, and our potential patients.  A literal world of difference from the far away and exotic land of Nepal, this mission should be a virtual walk in the park from a comparative standpoint. 

Our small “scouting” team was warmly greeted by the Panamanians and hospital staff, and eagerly embraced and integrated into the Operation Walk Team visiting Panama City for their annual trip.  Operation Walk Denver, a long time established Operation Walk group, had graciously permitted us to coordinate our “pretrip” visit with their scheduled mission trip to enable us to draw from their vast experience as an established team, as well as to permit them to show us the lay of the land at St. Tomas Hospital. 

True to our beliefs, the differences were vast—a modern city with a fairly well equipped hospital rivaling many in the US in terms of the structure and facility features.  Lacking, however, was the capacity to provide the people of Panama with life altering joint replacement surgery primarily due to the supply and demand.  There simply aren’t enough joint replacement surgeons in Panama to meet the surgical needs of their people.  It is for this very reason that Operation Walk teams are warmly embraced and welcomed into this country.  The surgery missions are viewed by both government and hospital officials as a conduit for meeting the needs of their people; in essence, a salvation for them.

Our “perceived” differences between Kathmandu and Panama City rapidly dissipated as we filed into the patient screening clinic that had been assembled in anticipation of our arrival accompanying the Operation Walk Denver team.  As we wound our way through the waiting room crowded with potential patients and their families, applause erupted and cheers echoed from the walls from the hundreds of people crowding the room.  The American team offering the promise to relieve the pain and suffering for some, and restoring the ability to walk for others, had arrived.

The next six hours flew by in what seemed like mere minutes.  Grateful patients and their families were ushered into screening rooms and evaluated by teams comprised of surgeons, medical doctors, anesthesiologists, and nurses.  We encountered elderly people crippled from pain who had limbs misaligned by the long term effects of osteoarthritis.  We met young people, eyes filled with hope for a better future, who had fused hips and/or knees with little or no mobility due to advanced rheumatoid arthritis that had been left untreated due to the lack of availability of disease modifying medications which are readily accessible in the US but not available in this country.

The potential patients were all impeccably dressed in Sunday best for their appointments with the Operation Walk team, wanting to demonstrate respect and admiration for the Americans who had come to offer them hope and relief.  We quickly learned from the Denver team and from the Panama physicians that their lifestyle reality is actually dramatically different from the way they presented to us.  Many live in condition  of complete squalor and poverty, but their pride and respect for Operation Walk inspires them to present themselves immaculately coiffed and wearing what might be their only untattered garment. 

Most of the patients were candidates for bilateral hip or knee replacements, and whenever medically feasible, procedures on both sides would be performed.  For those patients only able to tolerate a single procedure, they were offered the hope of having the second surgery done when we, Operation Walk Syracuse, returns in November.  The same held true for those patients who had medical conditions such as heart disease or diabetes that had to be brought under control prior to undergoing a surgical procedure.  These patients were all considered to be in our “bullpen” and in the queue for surgery in November upon our return. 

So, back to the differences—Nepal versus Panama City—the city, the hospital, the environment couldn’t not have been more in contrast, but the differences end there.  Glance into the eyes of the people, old or young, patient or family member, and we were witness to the same basic need and hope for relief from suffering. It transcends several continents and many thousands of miles.  Once again as we embark on this new journey to Panama City, we are forever humbled by the honor and privilege of caring for those less fortunate brothers and sisters in our world. 

A patient in Panama, who will receive total knee replacement surgery. 

How Long Should You Be Hospitalized After Joint Replacement Surgery: Not too short….not too long…..just right

Once upon a time, there was a little girl named Goldilocks.  She went for a long walk in the forest.  Soon, she came upon a house and knocked on the door.  When no one answered, she entered.

On the table in the kitchen there sat three bowls of porridge.  Goldilocks was hungry so she set about tasting the porridge from the first bowl.

“This porridge is too hot!” she exclaimed.   So, she moved to the second bowl and tasted.  “This porridge is too cold, “she declared.  So, she tasted the last remaining bowl of porridge.  “Ahhh, this porridge is just right, “she happily proclaimed and ate it all up.

When it comes to how long a patient remains hospitalized after total hip or knee replacement surgery, the scenario is not unlike the situation faced by Goldilocks in the forest.  Length of stay, the “official” terminology used to describe the measurement of the duration of a single episode of hospitalization, is the period between the time that a patient is admitted to the hospital, to the time that the patient is discharged.  As joint replacement surgery advances in terms of procedural technique and care provided to patients, the surgical outcomes have also dramatically improved.  As the result of improved patient outcomes, the length of stay (LOS) for patients after joint replacement surgery has been declining as well.

Much attention has been given to the cost of hospitalization and the impact of these escalating costs on the American healthcare system.  As a result, the length of time in the hospital or (LOS) for patients has come under close scrutiny and is often a marker associated with hospital finances.  In terms of joint replacement surgery, LOS has been a focus of our program’s efforts for reasons outside of the financial realm.

Patients who are able to be discharged to their homes with adequate support systems in place, and with home physical therapy and nursing services, have been found to achieve the best outcomes associated with their joint replacement procedures. Reduced level of pain, optimum mobility, prompt return to previous level of functioning and activity (motion and function), and the avoidance of surgical wound infection are all associated with discharge to the home.

For the reasons just cited, we encourage our patients to return to their homes for convalescence whenever that is possible.  Preparation and discharge planning for this goal is initiated prior to admission to the hospital for the surgical procedure.  For those patients where this is not an option, arrangements are made for a temporary stay at a facility providing short term rehabilitative services.  Nearly 70% of our patients are discharged directly to their homes.

When it comes to exactly how long a patient should remain in the hospital after joint replacement surgery, we subscribe to the “Goldilocks” philosophy: 

·         The post surgical hospitalization should not be so short that the patient leaves prior to being able to accomplish critical tasks such as independent ambulation with an assistive device or adequate control of pain. (The porridge is too hot).

·         Nor should the patient remain in the hospital so long that advancement in their recovery is thwarted by the restrictions of a hospital environment, or that they are exposed to the risk of infection for longer than necessary.  (The porridge is too cold).

·         The ideal joint replacement patient is leaving the hospital at a time that has “optimized” what the hospital environment, staff, and services can do for them, and further recovery advancement will occur at home or a short term rehab center.  The hospital time (like the porridge) is “just right”.  For most hip replacement patients this is between three and four days, and for knee replacement patients between two and three days. 

At St. Joseph’s the length of time that patients do remain in the hospital has progressively shortened over time due to the advancements in surgery and postoperative  care protocols.

Year	Ave Hip Replacement LOS	Ave Knee Replacement LOS
2008	3.71 days	2.85 days
2009	3.64 days	2.73 days
2010	3.64 days	2.64 days
2011  (Year to Date)	3.57 days	2.64 days
**national ave hip replacement LOS = 3.7 days in 2008 **national ave hip replacement LOS = 9.1 days in 1992

We are committed to ensuring that patients receive the appropriate care in the hospital for the necessary period of time, and then to assist them in a seamless transition to their homes or the next location of care.

A recent study published in The Journal of the American Medical Association  in April of this year reported on a longitudinal study that described the clinical characteristics and associated outcomes of patients undergoing total hip arthroplasty between 1991 and 2008.  Their findings support the fact that the length of stay in the hospital declined during this time period.  The study also cautions that although the length of stay has decreased, there has also been an increase in the rates of discharge to short term rehabilitative facilities and in re-admission to the hospital.

It is because of the delicate balance between too short and too long a period of time in the hospital that we subscribe to the philosophy of an optimized individual time and recognize that one size does not fit all patients.  Most likely, you will find your discharge time to be when the “porridge is just right”, and that time is collaboratively determined by both you and your doctor.

Reference:

Cram, P., Lu, X., Kaboli, P.J., et. al. Clinical Characteristics and Outcomes of Medicare Patients Undergoing Total Hip Arthroplasty, 1991-2008.  Journal of the American Medical Association. 2011; 305 (15): 1560-1567.