Joint Replacement Surgery: Solo Sport or Team Event?

Deciding to have total hip or knee replacement surgery and the timing of the surgery  is a personal and individualized process which can only made by the person experiencing the pain,  mobility and function deterioration.  Once the decided should “go it alone” or develop a carefully crafted plan to surround yourself with family and friends to assist you to reach your goals?  A recently released study supports previous findings that having a dedicated family member, significant other, or friend providing support every step of the way before, during, and after surgery positively impacts surgical outcomes.

This study included nearly 2000 patients who experienced joint replacement surgery.  The findings suggest that patients with strong social support, especially in the form of a “coach” experienced optimal outcomes including:

·         Shorter hospital stays

·         A greater likelihood to be discharged to their own home

·         Were more likely to achieve transfer out of bed and ambulation target goals

·         Reported feeling more ready and confident at the time of discharge

·         Were more likely to rate the overall quality of their care as excellent.

The findings replicate those of other studies which also found that preoperative education, as well as the use of coaches, positively impacts the quality and timeline for postoperative recovery from joint replacement surgery.

This particular study not only specifically explored the impact of a coach on outcomes, but also drilled down further to identify those time intervals that were most positively influenced by an active coach participating in the surgical experience:

·         Family or friend presence during the preoperative classes

·         Family or friend presence in the preoperative holding area while awaiting surgery

·         Family or friend presence during the last physical therapy session.

One additional finding was that the patient’s decision to use a coach for social support closely correlated with the view of his or her surgeon in this regard.  If the surgeon emphasized the importance of this role to the patient, this emerged as an important priority to the patient during the planning process.

One message is pervasive.  Once you have made the important decision to move forward with joint replacement surgery it is also important to identify those family members and friends who can function in the role of coach.  Discuss this with your physician early in the process.  When it comes to joint replacement surgery and rehabilitation these are no individual events, only team athletics.

Reference:

Theiss, M.M., Ellison, M. W.l, & Tea, C.G.  The Connection Between Strong Social Support and Joint Replacement Outcomes.  Orthopedics.  2011; 34(5):357.

LifeWings: A Commitment To Safety

The Orthopedic Team is eagerly anticipating the launch of the LifeWings Patient Safety Program at St. Joseph’s Hospital in early June.  Through our organized service line efforts we have made tremendous progress in improving operational efficiencies and patient outcomes over the years but also recognize that continued and sustained improvement requires ongoing effort and intervention.

Physicians, nurses, and other support team members will participate in intensive training sessions specifically designed for St. Joseph’s Hospital by LifeWings Partners.  LifeWings is a team of physicians, nurses, pilots, and former astronauts that have adapted for healthcare the teamwork training framework used by commercial aviation.  Through interactive exercises, experiential examples, evidence-based strategies, and tools and checklists we will learn how to avoid the mistakes that are occasionally made by teams and improve the safety for our patients.

We recognize that the system and environment of care at St. Joseph’s can be purposely and methodically redesigned to achieve results even better than those produced now.  We applaud the investment that St. Joseph’s Hospital has made to bring this program to us.  It truly demonstrates the commitment to creating and sustaining a culture of safety for our patients.

Unicompartmental Knee Replacement: A Bone Sparing Alternative for Some Knee Arthritis Sufferers

Alternative Names:  Partial Knee Replacement, Unicondylar Knee Replacement, Unicompartmental Knee Replacement, Unicompartmental Knee Arthroplasty, Minimally Invasive Partial Knee Replacement

More than 500,000 people in the United States undergo total knee replacement each year.  Some of these patients and an additional gorup of other indivudals with knee arthritis might be candidates for partial knee replacement. 

Knee Anatomy

Three bones join together to form the knee joint

·         Thighbone (femur)

·         Shinbone (tibia)

·         Kneecap (patella)

The knee components are held together by muscles, ligaments, and soft tissue.  The shock-absorbing material inside the joint that cushions during weight-bearing activities is called the cartilage.

The knee is comprised of three separate section:

·         The medial compartment (inside part of the knee)

·         The lateral compartment (outside part of the knee)

·         The patellofemoral compartment (front part of knee between the kneecap and thigh bone)

Knee Arthritis

Osteoarthritis, or wear-and-tear arthritis, often results in symptoms such as stiffness, pain, and/or a sensation that the knee has “locked” during walking or other activity.  The cartilage in the knee degenerates over time until the surfaces are rubbing directly with each other without any cushioning (bone on bone).

Rheumatoid arthritis is an inflammatory process resulting in damage to the surface of the knee joint.  Partial knee replacement (PKR) is not indicated in rheumatoid arthritis.

Unicompartmental arthritis is wear and tear disease that affects only one of the three compartments of the joint instead of the entire knee.

Partial Versus Total Knee Replacement

Knee replacement surgery is intended to relieve knee pain and to imporve the function and motion of the knee. 

A total knee replacement (TKR) involves the complete repalcement of all three components in the knee.  Unicompartmental, or partial knee replacement, allows the surgeon to resurface (or replace) only the damaged compartment of the knee while preserving the health y bone in the other two compartments.

Patients suffering from osteoarthritis that is isolated to only one part/compartment of the knee might be candidates for partial knee replacement.  The healthy parts remain untouched during the surgery.  Patients also have the opportunity to undergo a standard total knee replacement in the future if the arthritis progresses and additional surgery is needed. 

Historical Perspective

Partial knee replecement actually predated Total Knee Replacement.  In the 1960’s when the idea of resurfacing an arthritic knee joint was first successfully accomplished, it was with a partial design.  It was only after the intial success of these designs that surgeon developers linked together two partials to make the first “Total Knee”-- the Duopatellar.  Over the years “total” knee designs have become more and more anatomic following the lead of nature.  At the same time partial knee replacement was overshadowed by the success of the “total” design despite the fact that it works so well in certain circumstances.  The continued improvement in material science has increased the longevity of both partial and total knee components.  Partial knee replacement, when applied to the correct patient, can have superior fuctional results when compared to”total” knee replacement.  The operative procedure remains more technically demanding for the surgeon, and is therefore usually provided only by orthopedic surgeons who are Joint Replacement Specialists.

The Procedure

Although the surgeon is able to predict with a high degree of accuracyby review of the x-ray if a patient is a candidate for PKR, the first step in the actual surgical procedure is to examine the three compartments of the knee directly to verify that cartilage damage is present in only one compartment of the knee.  If the damage is more significant than was visible on the preoperative x-ray, the surgeon will perform a total knee replacement instead.  He or she will discuss this possibility during the preoperative visit.

The term minimally invasive is often thought to relate to incision size.  In the hands of a skilled surgeon, the incision size is approximately half the size of the incision made during total knee replacement.  In terms of a partial knee replacement, the descripion of minimally invasive also correlates most closely to:

·         Preservation of two of the three compartments in the knee joint

·         Preservation of the stabilizing ligaments of the knee

o   Anterior cruciate ligament (ACL)

o   Posterior cruciate ligament (PCL)

During total knee replacement surgery these ligaments are usually cut or loosened.  Keeping these intact helps retain a more normal sensation of movement and range of motion.

If the intraoperative examination supports partially resurfacing the knee:

·         The damaged bone is removed and replaced with implants (prostheses) made of plastic and metal

·         The ends of the thigh and shin bones are cut and reshaped

·         The metal implants are secured in place with a fixative substance called bone cement

·         A plastic insert is placed between the two metal components to enable the surfaces to freely glide

Advantages of PKR

·         Quicker recovery and return to normal activities of daily living

·         Smaller incision

·         No disruption of the knee cap

·         Less pain

·         Improved range of motion

·         Little to no blood loss

·         Reports of a more natural feel in the knee

Disadvantages of PKR

·         Potential for additional surgery in the future (if other compartments become damaged by osteoarthritis)

As possible with any surgical procedure, complications can rarely develop:

·         Blood clots

·         Infection

·         Nerve injury

·         Persistent pain

·         Implant failure

Activity

Most patients can resume normal activities after partial knee replacement when they have regained adequate strength and flexibility.  Most exercise and activity are acceptable after surgery including walking, swimming, biking, gardening.  Activities that result in repetitive joint trauma such as running, jumping, or twisting should be avoided.

Conclusion

Partial knee replacement can achieve excellent results when performed on the appropriate population of patients.  This procedure may be an option for patients who are experiencing significant lifestyle limitations as the result of osteoarthritis isolated to one part of the knee.

If you believe that you may be a candidate for PKR talk to your doctor to determine what treatment is best for you.  Since this procedure is technically more challenging and surgeon experience is a key driver of positive surgical outcomes, don’t be hesitant to discuss with your surgeon his or her experience with this procedure.

References

AAOS:  http://orthoinfo.aaos.org/topic.cfm2topic=A00585

Berger RA, Meneghini RM, Jacobs JJ, et al.  Results of unicompartmental knee arthroplasty at a minimum of ten years of follow-up.  Journal Bone Joint Surgery Am.  2005; 87(5): 999-1006.

Smith & Nephew:  www.RediscoverYourGo.com

The Power of Teams

Anyone who knows us well, knows our sentiment about “our team.” Being branded a team does not in itself make a team, in fact, far from it. The word “team” is overused and in fact often misused.  At worst, people can be brought together structurally and be nothing more than folks functioning independently without common goals or vision.  Conversely, assemble people who share a common belief in their own ability to create and contribute to exceptional patient outcomes and there you find constituent parts that work as a unified whole.   Take a close look at our team and you will quickly recognize how highly interdependent we all are to achieve the results that we do. Everyone wins on our team, most importantly the patient. The Total Joint Replacement Program at St. Joseph’s Hospital consists of clinical and nonclinical people from our office, the hospital, and homecare providers.  All of us are critically important to the care that our patients receive and the outcomes that they achieve.  The whole is greater than the sum of the parts.

Throughout the years scientists have researched why migratory birds such as geese fly in a V-shaped formation.  Recently a team of scientists from France had the opportunity to study great white pelicans that had been trained to fly behind aircraft and boats in preparation for a feature film.  The scientists found that the heart rates of these birds dramatically decreased when they were flying together and that they were able to glide for longer periods of time, thus reducing the energy they exerted during their journey.  These findings suggest that flight formation evolved as a means to allow birds to reduce their energy expenditure.  Birds flying in a V had lower heart rates and experienced less air resistance than birds flying solo.  The bird in the lead position of a V formation will experience greater air resistance, will work harder, and fatigue more quickly than the other birds.  The flight formation (or team process) then compensates for this.  When the lead bird wearies, it falls out of the lead and allows another bird to take its place.  This exchange takes only a second or two and is barely evident from the ground.  The process of the lead bird changing out each time it becomes exhausted continues throughout the entire migratory journey, with each new bird offering strength along the way.  This formation permits all the birds to benefit individually while they work harmoniously as a team.

Like those migratory birds, we all share a portion of ourselves with each other. Each of us is willing to pitch in and do whatever is needed. We share a sense of common goals, open communication, mutual trust, and individual accountability. It truly is a Herculean effort to accomplish what we do.

Thanks Team!

References:

“Bird Flight Explained,” BBC News World Edition, December 16, 2002.

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.

Designing for the Future

Momentum continues to build in orthopedic services at St. Joseph’s Hospital.  We launched our orthopedics master planning process this week.  Challenged by a growing orthopedic service, an existing orthopedic unit in an aging physical plant, and the need to integrate our orthopedic plan with other facets of the overall hospital master facility strategic plan, we enthusiastically gathered to initiate the process that will carry our expanding program into the future.

We asked ourselves many candid questions.  What is the future vision for the care delivery model and physical plant environment for joint replacement and other orthopedic patients?  How do we optimize the areas rendering services to orthopedics patients today and in the near future, while the longer term plan is developed and implemented?  These are tough questions with no easy answers.   We are, however, completely committed to advancing the care in a manner that is most meaningful to our patients--from their perspective.  We intend to create a unique patient and family experience that will result in safe, effective, timely, and efficient health care focused on quality outcomes and a high level of patient satisfaction.

To accomplish this we are assembling a multidisciplinary team of individuals closest to our patient processes—physicians, nurses, physician assistants, physical therapists, transporters, nutritional services staff, housekeepers, volunteers, and even past joint replacement patients themselves. The group and many others will work closely together during the next six months to develop short, mid, and long range plans to accomplish our goals for the physical plant and model of care delivery for our patients.

What will this most likely look like?  Dr. Anthony DiGioia has pioneered a patient and family-centered collaborative orthopedic model of care delivery at the University of Pittsburgh Medical Center.  In his experience, focusing on the patient first results in outcomes that cannot be refuted.  The environment in which his patients and their families receive services is an important contributing factor to achieving these desired outcomes.  Our vision for design of the ideal orthopedic center or institute will focus on elements that will support these concepts. 

The design of our orthopedic units will focus on measures to provide a comfortable and at-home feeling for our patients and their families.  Our vision includes a high complement of private rooms that will have in-room amenities such as Internet access, family chairs that convert to beds for overnight stays, small freezers for ice packs, and ample space for easy navigation with crutches, walkers, and canes.  Satellite gym/fitness centers will be on the unit for ease of access and group therapy activities.  Patients and family members will be able to access café-style room service for meals at a time that is convenient for them and consistent with their individualized needs.  A family room complete with kitchen and dining areas will support a sense of community and camaraderie amongst the patients and families navigating the surgical and recovery experience together.  The gathering of these individuals promotes the wellness concept associated with the surgical experience and is intended to be inspirational to the recovery process. 

The project promises to be innovative and exciting.  As it unfolds and develops we will provide periodic updates in this blog.  The best is undoubtedly yet to come for orthopedics at St. Joseph’s!

Satisfaction With Outcome After Hip and Knee Replacement Surgery: "It's Not the Keds"

Think back to your youth when you dreamed of being the fastest runner, the basketball player who could magically became airborne as if tiny springs propelled him higher into the air, or the quarterback who was so agile that he could zigzag around countless enemy linemen attempting to thwart his journey to the end zone.  If you were like so many of us, you enthusiastically badgered your parents until they succumbed to your request for the canvas-top sneakers known simply as “Keds.”  Your expectation was that these magical sneakers would make your athletic prowess soar to legendary heights and transition you into a star athlete.  Sometimes athletic dreams were achieved, but more often than not sports abilities remained unchanged post Keds acquisition.  The reason for this is quite simple.  One’s athletic talents, abilities and motivations are intrinsic to each individual, and are often completely independent from influences outside of one ’s self, i.e. “the Keds.”  The ability of an athlete to achieve amazing feats is internally driven.  Similarly, patient outcomes and the satisfaction associated with how well a patient does after hip and knee replacement surgery is most closely aligned with his/her personal motivations and goals.

Patient satisfaction with the outcome of a hip or knee replacement is very high, with only a small number of patients relating dissatisfaction with the results after the procedure.  Several studies have explored this topic and the findings are quite interesting.  Of even greater interest is the correlation between postoperative patient satisfaction and surgeon satisfaction with procedure outcomes.

Patients and surgeons most likely evaluate surgical outcomes from different perspectives. From the patient perspective, satisfaction results when there is an improvement in pain, lessened joint stiffness, improved physical function, and most importantly, an ability to return to the desired lifestyle and level of activity.  These are all subjective findings.  From the surgeon’s perspective, satisfaction is measured by more objective outcomes such as the absence of complications, radiographic (x-ray) verification of appropriate prosthesis placement and alignment, and a low revision rate.  Although it is true that patients and surgeons have divergent but overlapping criteria of success after joint replacement, commonality does exist in the most important elements.  Return to a desired level of function, reduced pain, and increased mobility are shared endpoints for both patients and their surgeons.

Patients and surgeons might have differing opinions of success after total joint replacement surgery.  

When measuring the success of hip and knee replacement surgery, it is important to recognize these differences.  In addition, patient satisfaction is also most likely influenced by patient expectations (and fulfillment of those expectations) and demographic characteristics such as age and education, gender, and ethnicity.  The expectation of complete pain relief after surgery, as well as the expectation of a low risk of complications, has been found to be the best predictors of improved functional outcomes and overall satisfaction following joint replacement surgery.

Patient expectations may be the single most predictor of patient satisfaction.  When considering hip or knee replacement surgery, keep in mind that patients and surgeons might not share the same definition of success and satisfaction.  It is essential that you discuss your expectations with your surgeon prior to the procedure so that you can ensure that your goals are realistic and attainable after joint replacement surgery.  Expectations are a key to appreciated success.  

So, remember when considering hip or knee replacement surgery, it’s not the Keds that will determine how well you do, it is you.

Noble, P., Conditt, M., Cook K., & Mathis, K.  The John Insall Award:  Patient Expectations Affect

Satisfaction with Total Knee Arthroplasty.  Clinical Orthopaedics & Related Research 2006; 452:35-43.

Brokelman, R. B., Van Loon, D. J., & Rijnberg, W. J.  Patient versus surgeon satisfaction after

           total hip arthroplasty.  The Journal of Bone and Joint Surgery 2003; 85-B; 495-498.