ASC TOTAL JOINT REPLACEMET

Transcription

1 ASC TOTAL JOINT REPLACEMET Mark A. Hartzband, MD Hartzband Center for Hip & Knee Replacement Holy Name Medical Center Hackensack University Medical Center DISCLOSURES Zimmer - Design, Consulting BACKGROUND Mini-Incision Posterior Approach Developed in

2 MINI INCISION FIBER METAL TAPER EXPERIENCE (1/00-5/00) Incision Length: Mean: Range: Length Of Stay: 7.26 cm 6-8 cm 2.89 days Transfusion Rate: % autologous 1% non autologous Avg. Operative Time: 37.5 min. MINI INCISION FIBER METAL TAPER EXPERIENCE Complications Angina 1 Atrial Fibrillation 1 DVT 4 Dislocation 0 Nerve Palsy 0 Infection 0 MIS SURGICAL TECHNIQUE Technically demanding More Tactile Less direct visualization (femur) 2

3 Days 09/24/ MIS HIP Length of Stay Hackensack University Medical Center Patient OBSTACLES TO SAME DAY TJA in HOSPITAL Insufficient availability of PT (?) Financial disincentive to hospital (?) Time honored institutional resistance to change Ingrained staff bias ASC INITIAL EXPERIENCE 1 st Case 6/30/ TJA Patients 575 THA s mini posterior - 9 two-incision 228 TKA s - mini quadriceps incision 3

4 ASC INITIAL EXPERIENCE Age range: 21yo 73yo mean: 53yo Comorbidities range: 0 5 mean: 1.5 Surgical Time range: 27 min 69 min mean: 39 min ASC INITIAL EXPERIENCE Complications 1 emergency room visit overnarcotized 2 hip dislocations both revised and discharged on same day 4 I&D for hematoma 1 TKA, 3 THA 3 early THA infections (culture+ hematomas) treated by direct primary exchange ASC INITIAL EXPERIENCE NO emergency hospital admissions NO transfers to inpatient rehabilitation 4

5 ASC INITIAL EXPERIENCE 3 OR Unit (2 or 3 at my disposal) Multiple Anesthesiologists Full X Ray with Flouro on premises Physical Therapy Unit on premises Adequate autoclaves & central supply Working relationship with a blood bank ASC INITIAL EXPERIENCE 5x / week home PT readily available Visiting Nurse Service readily available Frequent office contact! Early office follow up ANALGESIA PROTOCOL Peri-operative Post-operative Out-patient 5

6 PRE OPERATIVE Patients get cocktail: Celecoxib 400 mg Percoset (5/325mg) - 2 tabs Famotidine 20mg Pregabalin 100mg Scopolamine Transderm Patch (Novartis) -1.5mg behind ear -remove prn post op confusion! +/- Oxycontin 10 or 20mgs + NORMOVOLEMIC HEMODILUTION PERI OPERATIVE No Foley catheter Prior to incision: Reglan (metaclopramide) 10mg Zofran (ondansetron) 4mg Decadron 8mg Appropriate Antibiotic Tranexamic Acid (prior to tourniquet deflation in TKA) 6

7 INTRA OPERATIVE (initial) Hyperbaric Bupivicaine Spinal Anesthetic -Problem: occasional extended duration of anesthesia INTRA OPERATIVE (TODAY) Hyperbaric mixture of Lidocaine 5% with 7.5% dextrose - Solution is diluted 1:1 with CSF and injected slowly INTRA OPERATIVE Heated IV fluids KEEP PATIENT WARM! Local infiltration of 0.25% bupivicaine with epinephrine (1:200,000) - avg. 1cc/ kg. Bupivacaine Liposome Injectable Suspension (TKA only) Heparin 1,000 units-1,500 units IV prior to incision Transcollation Cautery (Aquamantys) 7

8 OUTPATIENT PROTOCOL Percoset (5/325mg) po q4h Celecoxib 200mg po bid Pregabalin 50mg po bid Coumadin 10mg, 5mg, & then LMWH (THA) or ASA 325mg po bid (TKA) Famotidine 20mg po daily Venous Compression Stockings Stool Softeners POSTOP / OUTPATIENT REGIMEN Mechanical compression device (RR only) -Foot Pump for TKA -SCD for THA Cryotherapy (Recovery room & home) ANTI COAGULATION PROTOCOL Create a system that works within the framework available to you 8

9 BECOME PREDICTABLE BEFRIEND OR STAFF Develop highly motivated, interested and talented team(s) Train them and let them train you BEFRIEND ANESTHESIA Develop highly motivated, interested and talented team(s) Seek out people willing to try something new 9

10 ENSURE ADEQUATE SUPPLY LINE Sign on implant vendor as integral team member - Ensure adequate implant inventory and instrumentation Streamline operating set up (drapes, instruments, etc.) Arrange sufficient supply of power tools PRE OP EDUCATION Begins with initial consultation Office Patient Educator Printed Literature Video- DVD Office Web Site DISCHARGE PLANNING Must be open minded and flexible Arrangements must be made well in advance 10

11 STARTING OUT Thin patient Small-medium canal diameter Minimal deformity Atrophic arthritis Crowe I or 2 Younger Motivated ARS Consistently successful ambulatory TJA requires that the surgeon be 1Fast 2Predictable 3Maximally minimally invasive 4Very busy ARS Which of the following is most important in patient selection for outpatient TJA? 1. Patient motivation 2. Patient support system at home 3. Manageable post op environment 4. All of the above 11

12 ARS Obstacles to performing ambulatory TJA in a hospital setting include 1. Institutional resistance to change 2. Ingrained nursing staff bias 3. Inadequate availability of sufficient physical therapy 4. All of the above ARS Which of the following is required to ensure successful outpatient TJA? 1. Minimal arthritic deformity 2. Muscle sparing surgical approach 3. Early office contact and follow up 4. Local use of Bupivicaine Liposome injectable suspension STARTING OUT Progress gradually and intelligently Achieve consistent same day success in-hospital BEFORE moving to an ASC 12

13 BOTTOM LINE Familiar surgical technique Not a steep learning curve Multiple patient benefits Potential benefits to the entire healthcare delivery system WELCOME TO THE FUTURE! THANK YOU 13