Same-Day Hips Are a Recipe for Success

Orthopedics

By: Steven Dellose

Published: 9/3/2020

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Expect case volumes to surge as more total joint procedures move to the outpatient setting.


Hip replacements may be thought of as elective surgery, but not for the patients who need a new joint. After trying to manage their chronic pain with anti-inflammatories, physical therapy or injections, many patients are at their wits' end and desperate for a remedy. With their quality of life suffering, surgery is often the best and only solution. Now it's easier than ever for orthopedic facilities to offer that option.

A same-day total hip replacement seems like a daunting surgery to perform. It can be, but tremendous strides have been made in the quality and efficiency of this life-altering procedure. There's an ever-growing list of outpatient facilities that are performing these surgeries with great success thanks to new techniques and comprehensive patient care.

If you're interested in adding same-day hips — or want to ramp up your current caseload — here's how to make it happen.

Dedicated doctors

Your facility must be staffed with high-volume orthopedic surgeons who have a long track record of doing these procedures efficiently and safely. My partner and I each perform 800 to 1,000 hip- and knee-replacements and revisions each year. Collectively, that's the largest annual volume of primary and revision joint replacement surgeries in the state of Delaware.

UNDER THE KNIFE Emerging technologies and techniques allow most surgeons to replace a hip in about an hour.

One major reason we're able to perform such a high-volume of cases is specialization: I don't perform upper-extremity procedures and our joint replacement team is made up of sub-specialized, fellowship-trained surgeons.

Same-day total hips take a lot of extra work and commitment from the surgeon's perspective. The pre-operative process and post-operative follow-up protocols are much more involved, but the extra steps are necessary to make sure patients aren't admitted to the hospital or suffer avoidable complications.

You should also consider working with a reputable consulting partner who can help you set up the comprehensive clinical pathway needed to perform these procedures successfully on an outpatient basis, including standardized preoperative protocols and a robust postoperative follow-up process.

The average time it takes to complete a hip replacement depends on the surgeon. It typically takes our surgeons about 35 minutes. But admittedly, that's fast. In general, a hip replacement will take about an hour for most surgeons to complete. In terms of surgical technique, surgeons can access the hip in various ways:

  • Anterior approach. This isn't a new technique, but it has undergone a recent resurgence due to marketing. The minimally invasive approach uses a small incision on the front of the hip, allowing the surgeon to replace the joint by moving muscles along their natural tissue planes without detaching any tendons. While the approach has been around for decades, it recently has been publicized in a manner that it is "new and different."
  • Posterior approach. With this approach, the patient is positioned on their side. The surgeon then makes an incision — which goes through muscle and detaches some muscles from the "ball and socket" of the hip joint — along the buttock area, just beside or behind the hip joint.
  • Anterolateral ?approach. This is my preferred technique. It lets me operate through a single small incision and work between muscle groups, which minimizes trauma to soft tissue in the joint. This approach is one of the reasons patients can ambulate soon after surgery and prepare for discharge in just a few hours.

There are no long-term benefits associated with one approach over another. Surgeons should ultimately use the one they feel most comfortable with in order to achieve excellent results.

Pain management advances

HEALING HELP Patients should undergo a preoperative evaluation with a physical therapist, who can set expectations for post-op rehab requirements.

In the outpatient setting, we typically perform four cases a day. If a patient has surgery at 9 a.m., they're usually ready to go home by 1 p.m. That's due in large part to advancements in post-op pain control. It's now standard practice to include a multimodal approach, meaning we give ?patients ?different medicines that treat their pain in different manners to decrease the amount of opioids used post-operatively. This approach has been very successful, and we have been able to substantially decrease the amount of opioids used as a result.

We're also doing a much better job of managing patients' pain because of the precision of anesthesia. We use regional anesthesia (spinal) and then perform a peri-articular block with a mixture of long-acting local medications and pain medicines. The combination of multimodal analgesia and regional anesthesia allows us to treat the patient's pain post-operatively more effectively and has helped us to initially decrease a patient's stay at the hospital and now to perform the procedures on an outpatient basis.

Before surgery, patients receive a preoperative evaluation that includes a physical therapy session, during which they become familiar with what will be required of them to help advance the healing process after surgery. Patients go to physical therapy the day after surgery and typically schedule sessions three days a week for two to six weeks post-op. It really is a remarkably quick recovery process, and patients feel immediate relief from their pain following the procedure.

Patients who undergo successful hip replacement surgery — especially in their older age — typically outlive their implants.

Worth the effort

Hip replacement is a game-changing treatment for patients who often consult with a surgeon on the heels of several failed conservative interventions. Many patients who opt for surgery have already tried several treatment options before their surgeons recommend finally fixing the underlying cause of their joint discomfort.

We still have some restrictions for Medicare patients, but private insurers are pushing younger patients to have their procedures performed in outpatient ORs. From a financial standpoint, it makes a lot of sense to do these procedures that way, because it saves the healthcare system, insurance companies and patients a lot of money.

Typically, a total-hip replacement performed as outpatient costs half or less than half of what it does as an inpatient procedure — without sacrificing the quality of the care patients receive. This provides a lower cost benefit for the payer and allows patients to greatly reduce their copays and out-of-pocket expenses.

Total hip replacements can be performed fairly quickly and provide immediate relief for patients who have likely been suffering for years with debilitating joint pain. Patients are very grateful to live life with pain-free joints, and it's a very successful endeavor for surgical facilities from a business standpoint. It's really a feel-good type of medicine and it's great to give quality of life back to patients.

It takes a high level of commitment from all providers involved to make a hip replacement program work, but the benefits to your facility, the healthcare system and, of course, patients are undeniable. OSM

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