Any good orthopedic surgeon believes he's in complete control of how well knee replacement patients will fare after he replaces old bone with new titanium, but (between you, me and the OR wall) some of the keys to achieving excellent outcomes are largely out of his skilled hands. It takes constant communication with patients, effective pain management, instrument and staff standardization, and technology-assisted implant placement.

1. Constant contact

Keeping patients informed about what will happen on the day of surgery and during their recovery motivates them to be active participants in their care. It's never been easier now that you can easily email or text patients. Brett R. Levine, MD, MS, a hip and knee reconstruction and replacement specialist at Rush University Medical Center in Chicago, Ill., partners with a text-messaging service that lets him send essential information to patients before and after surgery.

"My team and I studied about 100 patients to determine their most common questions and concerns," says Dr. Levine. He then created customized text messages to each one. Now his patients receive automated reminders and information about, for example, how they should prepare for surgery and what to expect afterward. He's even able to send them videos of exercises and physical therapy routines to keep their recoveries on track.

The messaging service also provides patients with answers to questions about relatively minor post-surgery concerns that in many cases they used to call him about or for which they ended up in the ER for unnecessary treatment.

2. Multimodal analgesia

The current opioid epidemic and good clinical sense point to limiting the use of opioids to manage post-op pain, but you should avoid the push to do away with the powerful painkillers altogether.

"A completely narcotic-free recovery is not impossible for some knee replacement patients, but the majority require a conservative use of opioids," says Keith Berend, MD, orthopedic surgeon at Joint Implant Surgeons in New Albany, Ohio.

Multimodal drug cocktails differ from provider to provider, but each regimen is designed to stay ahead of pain and attack it from various pathways. Dr. Berend augments a judicious use of opioids by administering acetaminophen, long-term Cox-2 inhibitors and tramadol before and during surgery.

Single-shot analgesics placed around the surgical site (such as bupivacaine liposome) and regional blocks help patients get back on their feet soon after surgery and ready for same-day discharges. The adductor canal block is placed at the mid-thigh and primarily impacts the saphenous nerve. It has shown promise in managing post-op pain in knee replacement patients and effectively reduces opioid consumption in the 48 hours after surgery. Also, unlike the femoral block, it preserves quadriceps strength to avoid the temporary weakness in patients' legs that can impact faster ambulation, according to one study (osmag.net/jAWgR7).

Also consider adding cold-therapy analgesia, says Joseph Nessler, MD, a joint replacement specialist at St. Cloud Orthopedics in Sartell, Minn. For example, recirculating cold therapy machines provide strong and continuous ice therapy to the joint area.

Patients receive automated text reminders about how they should best prepare for surgery, what to expect afterward — even physical therapy videos.

3. Precision implant placement

Precision is essential when placing implant components in order to optimize joint stability and alignment, and requires detailed pre-op planning. Missing the optimal placement by a single degree or shaving the bone by a mere 1 mm too much can lead to premature implant failure and suboptimal joint function. Many surgeons can use conventional instrumentation and cutting blocks to make precise cuts and place implants with incredible accuracy, but many more might not have the skills and experience to achieve excellent clinical outcomes without robotic assistance.

During robotic-assisted procedures, surgeons register anatomical landmarks of the patient's knee to the robotic platform and rely on the robotic handheld device to guide cuts in the femur and tibia, so the implant components are placed precisely where they need to be based on the patient's unique anatomy.

"We model our knees pre-operatively using an anatomical creation based on a 3D CT scan of the patient," says Dr. Nessler. "That has improved the precision of the procedures."

There's another way to achieve precise joint replacement outcomes: template-directed instrumentation (TDI) involves capturing digital radiography of a patient's joint and sending the images to a component vendor, which prepares 2 to 3 trays of customized instruments based on the expected size of the tibial and femoral implant components that the surgeon will use.

Dr. Levine says template-directed instrumentation eliminates the need to bring 5 or 6 trays of conventional instrumentation into the OR to ensure implants are placed accurately and can lead to shorter case set-up times and room turnovers.

4. Strive for consistency

The more variables — different implants, various instruments and rotating members of the surgical team — the greater the chance of a less-than-stellar outcome, a critical delay or even a devastating error. Implant standardization should always be encouraged.

"We convinced our surgeons to sit down and agree to a single vendor for all of our total joints," says Barbara Gosselin, RN administrator, Premier Ortho-pedics Surgery Center in Albany, Ga. "Standardization here allowed us to reduce our instrument trays from 8 down to 4."

Standardization at St. Cloud (Minn.) Surgical Center, where Dr. Nessler operates, includes physicians using 80% to 90% of the same instruments and impacts how they staff ORs. The center also created core teams to optimize communication and coordination during cases. Not only does the ASC have a core group who handles general orthopedic procedures, it also has a group that focuses solely on total joints.

"With the core grouping," says Dr. Nessler, "we never have to wonder if we're going to walk into the OR and find strangers working with us." OSM