Raring to Go After Joint Replacements

Orthopedics

By: Ravi Bashyal

Published: 4/24/2020

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Rehab technologies and advanced care get patients back up to speed sooner after surgery.


We've made tremendous progress in rehabbing and recovering outpatient hip and knee replacement patients. In the not too distant past, total joint patients could expect an inpatient hospital stay of two to three nights, after which they might be discharged to an inpatient rehabilitation facility before returning home. Numerous innovations — from app- and tablet-based home rehab programs to improved surgical techniques and robotic-assistance platforms — have let us reduce that time span. Patients who undergo surgery in the morning are up and walking within an hour of leaving the operating room and heading home that same afternoon. Rapid recovery, minimal pain and a quick return to a joint's prior level of function are hallmarks of our outpatient total joint service line, which requires a collaborative effort among all members of the patient care team and involves tapping into technology that helps patients return to normal life activities sooner.

  • Home-based recovery. Digital rehab platforms have great potential because they can lower the touchpoint barrier for more frequent interaction between provider and patient, allowing patients to participate more and receive more feedback during rehab. These technologies use various devices — including patients' smartphones and tablets as well as in-home, connected rehabilitation devices — to educate and coach patients through rehab activities, record exercise data that clinicians can view and analyze, and provide telehealth capabilities.

Plus, technologies like accelerometers can relay how many steps the patient is taking, or how much their knee is bending, and automatically send alerts to a provider's phone. Interactive rehab technologies also cut costs and save time for providers and patients alike by enabling patients to rehab at home, at their own convenience, as opposed to traveling to appointments with a physical therapist.

  • Surgical techniques. The minimally invasive techniques we use are muscle-sparing approaches, meaning the major muscles are retracted as opposed to cut. This allows for faster healing with less inflammation and pain, resulting in a more rapid return to function.

You don't want to perform a minimally invasive operation that may have a more limited field of view if that ultimately doesn't allow for the implant components to be put in the right position. At the same time, you want to get the patient up and moving more quickly and avoid cutting important muscles, tendons and other structures solely for the sake of visualization. That's where technologies like patient-specific instrumentation for knee replacement come into play.

Well in advance of surgery, we use a combination of imaging modalities, including X-rays and MRI, to generate a computerized model of the knee. We then plan the entire surgery virtually well before making an incision. This work allows us to accurately size the implants, precisely plan bone cuts and create a game plan for the operation.

JUST RIGHT Ravi Bashyal, MD, blends preoperative planning with the diversity of available implants to reduce patients' postoperative discomfort.   |  NorthShore University HealthSystem

When preoperative planning is complete, we simply hit a button to transfer that data to the instrumentation's manufacturer, who then uses a 3D printer to create a sterilized mold that is customized to that patient's specific anatomy. This mold then fits directly onto the patient's bone during their operation, and incorporates all the planning and sizing data into a guidance system. This customization allows the surgeon to make precise cuts to the bone that utilize all the data analyzed and inputted during the digital planning. All of this translates into an operation that is more accurate, less invasive and more efficient than many of its predecessors.

Some studies have shown that patient-specific instrumentation in total knee replacement not only decreases operative time, but also improves the accuracy of bone cuts, resulting in a more rapid recovery that leads to earlier discharge. While this innovation is not yet widely available for hip replacements, there are other modalities and technologies that are allowing for improvement in that space.

  • Robotic assistance. Another enabling surgical technology we use for both hip and knee replacements is robotics, which allow us to do much of the same type of patient-specific planning, but also offers the flexibility to adjust in real time. Preoperative imaging is used to generate a three-dimensional plan on a computer. During surgery, we use a robot arm to help execute those plans.
  • Optimized implants. The manufacturers we work with have evolved to develop longer lasting implants with better kinematic capabilities. For example, there is a great deal of focus on reproducing a more natural and normal arc of motion when replacing the knee joint. Your native knee is not a simple hinge joint that bends back and forth. Instead, as you go from extension to flexion and back again, numerous subtle rotational movements occur around the joint — in addition to and in conjunction with the simple hinge-type bend. If the replaced knee cannot mimic these more subtle and natural movements, it's possible the patient will be less satisfied with the outcome.

Part of creating a more natural feeling knee is related to accurate surgical cuts and precise component sizing and placement as I have described above. However, in addition to all this, the implant itself also needs to be designed in a manner that when placed accurately, will reproduce the natural motion and kinematics of a native knee. Simply put, longer-lasting, better-fitting implants reduce pain and recovery times.

By simultaneously refining both surgical accuracy and implant design, we've experienced a dramatic improvement in outcomes. By combining newer implants that have a more "natural" feel and motion arc with precise and thoughtful preoperative planning and customization, we can provide the patient with a state-of-the art joint replacement that they are more likely to be happy with.

Partnerships of care

Patients must be fully engaged partners in their recovery and rehab. Like the surgery itself, that involves preparation well before we ever set foot in the operating room. In fact, the process starts in the office as we work to identify the patients who are best suited to undergo joint replacement as an outpatient procedure. That means patients with multiple medical comorbidities and those without significant social support at home are not necessarily optimal candidates.

One of the most important factors of success is ensuring the patient has a friend or loved one who can also serve as their partner in care. Same-day joint replacement isn't right for all patients, but with the proper support structure in place and a thoughtful preoperative experience that focuses on positive mindset and accurate expectations about recovery and pain, it can be the perfect fit for many. OSM

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