Some total joint outcomes are too good. "I once replaced the knee of a guy who was hiking almost 15 miles a day 3 weeks after surgery," laughs Joseph Nessler, MD, a surgeon at St. Could (Minn.) Orthopedics. "Now, he was a competitive athlete, but that's unusual. I feel like I need to add a disclaimer to the end of my clinic appointments with prospective patients — results may vary."

Your typical knee replacement patient likely won't be backpacking to their post-op physical therapy appointments, but younger patients are more motivated than ever to head home on the day of surgery and return to normal life activities soon thereafter.

Through last July, surgeons at the St. Cloud Surgical Center, where Dr. Nessler does many of his joint replacements, had performed 300 total knees and 490 unicompartmental-knees. All but 6 of the patients went home on the day of surgery thanks to a team-wide approach to multifaceted patient care that begins long before the day of surgery and extends several months into recovery.

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Patients scheduled for surgery at the St. Cloud Surgical Center are strongly encouraged to attend a nurse-run educational seminar held at the facility. It's an opportunity to familiarize themselves with the center, meet the staff who'll be taking care of them and go over care instructions in a relaxed and friendly atmosphere.

The educational session prepares patients for the day of surgery and, perhaps more importantly, creates a mindset that same-day discharge is possible as long as they buy into the facility's extensive care plan that's designed for successful recoveries.

Kari Scholz, RN, BSN, CAPA, quality improvement and PACU manager at St. Cloud Surgical Center, helps to ensure patients have the equipment they'll need to move around and recover at home, including a walker and raised toilet seat. They tell patients to remove tripping hazards from walking pathways, teach them how to navigate stairs with a knee that's not back to full strength and make sure a chair is available with a seat level at least level with the back of the knee. They confirm that patients' feet can touch the floor when they're sitting on the edge of their bed, that they cook preplanned meals to eat during the first few days of recovery and establish a base camp where they'll have easy access to a phone, computer and television remote.

"We require a caregiver to be present for the first 24 hours, prefer someone is present to assist in their recovery the first 3 days they're home," says Ms. Scholz.

Patients also meet with physical therapists, who provide a prehabilitation program for strengthening the muscles around the knee in the weeks leading up to surgery and preview the rehab program they'll begin the day after surgery.

Relying on robotics

Surgeons at the St. Cloud Surgical Center do nearly all of their uni-knees and total knee replacements with the help of robotic assistance. The facility invested in a robotic platform 2 years ago and has since invested in 2 more platforms due to high demand and excellent outcomes.

Dr. Nessler says 10% to 15% of patients who undergo knee replacement are dissatisfied with the results, experience swelling and pain, even when post-op X-rays show the implant was properly placed. "That's due to subtle, low-grade instabilities in the joint, which is a secondary complication of inaccuracies associated with mechanical implantation," says Dr. Nessler.

Robotic assistance solves that issue. Dr. Nessler points to the accuracy with which he's able to place implants thanks to the technology guiding him to make exact bone cuts based on 3D pre-op scans of a patient's unique anatomy. He's able to place a perfectly sized implant in the joint's centerline to maintain the kinetic balance of the joint's ligaments. The implant won't feel loose after surgery, eliminating a common post-op complaint among patients.

Dr. Nessler also points out that the precision provided by robotic assistance lets him make real-time adjustments by referring to the 3D scan and making accurate bone cuts based on the patient's specific anatomy. Surgeons who rely on mechanical alignment, he says, might have to make recuts in the bone or release more soft tissue to make sure the implant is placed in a balanced knee. Avoiding the release of soft tissue results in less post-op pain, according to Dr. Nessler.

"I essentially no longer have to do soft tissue releases after I've made my bone cuts," he says. "That lets me place implants in 25 to 35 minutes after making an incision. That's pretty remarkable."

The approximate $1 million price tag hanging from a robotic arm is a big nut to swallow on the front end, but the technology lets you add more cases because of savvy patients who want their procedures performed in facilities outfitted with cutting-edge technology, according to Julie Tonsager, ADN, operating room manager at St. Cloud Surgical Center. "It's a significant initial expense, to be sure, but when we look back at adding the technology, it's paid for itself," she says.

Part of that return on investment involves capturing uni-knees in the marketplace. Ms. Tonsager says the precision offered by robotics gives St. Cloud's surgeons the confidence they need to perform the technically demanding procedure many surgeons simply avoid.

Pain control

When patients arrive in pre-op at the St. Cloud Surgical Center, they receive 10 mg of IV dexamethasone, 1,000 mg of IV Tylenol, 400 mg of celecoxib and 300 mg of gabapentin. Most patients, unless they're intolerant to it, also receive a single dose of long-acting oxycodone. Postoperatively, patients receive a combination of hydrocodone and Tylenol, and are given a prescription for 7 days of opioids to manage breakthrough pain. Prescriptions can be refilled after a clinic consultation if pain persists, but the initial week-long supply limits unused pills that increase the risk of abuse.

Anesthesia providers place adductor canal blocks and surgeons inject Exparel at the incision site to further limit post-op discomfort and prepare patients to ambulate soon after surgery and timely discharges. Tranexamic acid is administered to control intraoperative bleeding. In addition, surgeons use plasma cautery to seal blood vessels instead of electrocautery, which results in more pain during the healing process.

The multimodal pain control efforts ensure patients are ready to ambulate soon after surgery and prepare them to begin post-op physical therapy as they limp, then walk — and maybe hike — down the road to successful recoveries. The staff and surgeons at St. Cloud Surgical Center understand it takes a total team effort and buy-in from patients to achieve excellent outcomes.

"Our educational efforts and multifaceted care program inspire patients to take ownership in their own care," says Ms. Scholz. "It encourages them to want to do well, and makes for a seamless transition from here to home." OSM

Surgeons at the St. Cloud Surgical Center do nearly all of their uni-knees and total knee replacements with the help of robotic assistance. The facility invested in a robotic platform 2 years ago and has since invested in 2 more platforms due to high demand and excellent outcomes.

Dr. Nessler says 10% to 15% of patients who undergo knee replacement are dissatisfied with the results, experience swelling and pain, even when post-op X-rays show the implant was properly placed. "That's due to subtle, low-grade instabilities in the joint, which is a secondary complication of inaccuracies associated with mechanical implantation," says Dr. Nessler.

Robotic assistance solves that issue. Dr. Nessler points to the accuracy with which he's able to place implants thanks to the technology guiding him to make exact bone cuts based on 3D pre-op scans of a patient's unique anatomy. He's able to place a perfectly sized implant in the joint's centerline to maintain the kinetic balance of the joint's ligaments. The implant won't feel loose after surgery, eliminating a common post-op complaint among patients.

Dr. Nessler also points out that the precision provided by robotic assistance lets him make real-time adjustments by referring to the 3D scan and making accurate bone cuts based on the patient's specific anatomy. Surgeons who rely on mechanical alignment, he says, might have to make recuts in the bone or release more soft tissue to make sure the implant is placed in a balanced knee. Avoiding the release of soft tissue results in less post-op pain, according to Dr. Nessler.

"I essentially no longer have to do soft tissue releases after I've made my bone cuts," he says. "That lets me place implants in 25 to 35 minutes after making an incision. That's pretty remarkable."

The approximate $1 million price tag hanging from a robotic arm is a big nut to swallow on the front end, but the technology lets you add more cases because of savvy patients who want their procedures performed in facilities outfitted with cutting-edge technology, according to Julie Tonsager, ADN, operating room manager at St. Cloud Surgical Center. "It's a significant initial expense, to be sure, but when we look back at adding the technology, it's paid for itself," she says.

Part of that return on investment involves capturing uni-knees in the marketplace. Ms. Tonsager says the precision offered by robotics gives St. Cloud's surgeons the confidence they need to perform the technically demanding procedure many surgeons simply avoid.