The debate is always the same: “We do it the traditional way because that is the way we have always done it” vs. “It is safer for patients, the new ways are not time tested and there are more complications.”
No matter what the advance in medicine and surgery may be, these arguments are always used to delay the inevitable march toward efficiency and quality. It’s the taxi vs. Uber argument. We all know the answer — but the road to it is full of potholes.
Total knee replacement, in which the ends of the bones in the knee are replaced with metal and plastic, is a godsend for older people with severe three-compartment (inside, outside and front-of-the-knee) arthritis. But it is not perfect, and it is expensive. Fifty percent of total knee patients have pain at 10 years. Very few have normal-feeling knees. And when the repaired knees fail, they are very hard to salvage.
In my opinion (and in the view of many knee surgeons trained to use the new, more accurate robots), partial knee replacement, in which only the worn-out side of the knee is resurfaced, should replace 80 percent of the total knee surgeries that are performed. Partial knees feel normal, permit a full range of sports, have fewer complications, show faster recoveries and are less expensive. With the advent of robotic guidance, the old concerns about the accuracy and difficulty of the procedure have been resolved.
Many of the issues of inpatient vs. outpatient knee replacement can be resolved by performing more partial knee replacements, which have less bleeding and risk instead of replacing the whole knee.
The other advances are in the areas of pain control, bleeding control, home nursing and physical therapy. The new bleeding control drugs eliminate the need for a tourniquet in most cases. The lack of a tourniquet decreases both pain and muscle inhibition post-surgery. The targeted drugs also diminish post-op bleeding and swelling, thereby speeding healing.
One of the main reasons patients stay in hospitals after total knee replacement is related to pain and the complications of treating pain with narcotic drugs that make people nauseated, woozy and inactive. These drugs reduce breathing and lead to chest congestion and pneumonia.
Most of this is eliminated in an outpatient setting with regional anesthetics and preemptive anesthesia. (Preemptive anesthesia describes a cocktail of non-narcotic medications and injections that block the pain fibers before any incision is made.) If the brain doesn’t receive pain signals until a day or two after surgery, those pain levels are reduced. Patients are therefore more active, which decreases the risk of blood clots and other complications.
Immediate physical therapy, along with home nursing, provides the supervision needed to avoid other types of complications. By starting the rehabilitation program before surgery and continuing on the first day after surgery, patients develop confidence in their legs. They elevate their heart rates on stationary bikes (using single-leg cycling) and blow off the effects of surgical anesthesia. The increase in heart rate increases testosterone, adrenaline and pheromones and markedly improves their well-being. A home nursing visit can optimize these recovery tools and provide guidance on pain control. The use of Toradol and Tylenol in sufficient doses often obviates the need for narcotics, though they can be made available when necessary.
The main issue lies in deciding which patients are best suited for outpatient knee surgery. Clearly, people with significant health issues — those placed at risk by the surgical experience — need inpatient care. Hospitals are wonderful places for the very (or potentially) sick. For all others, a surgery center specializing in outpatient knee care is ideal.
Dr. Kevin R. Stone is an orthopedic surgeon at The Stone Clinic and chairman of the Stone Research Foundation in San Francisco.