Optimizing Patients for Optimal Total Joint Outcomes

Wound Closure Patient Safety Patient Experience Pain Management Infection Prevention Anesthesia Orthopedics

By: Jared Bilski | Managing Editor

Published: 8/3/2022

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A multidisciplinary effort that focuses on patient education, effective pain control and safe care is a must.


About 45 minutes before surgery, Joseph Nessler, MD, will stop by pre-op to mark the correct surgical site of his total joint patients. He’ll say hello, note his initials where he intends to cut and ask if the patient has any last-minute questions. Then he’ll do something subtle that he believes makes a major impact in the patient’s mindset going into surgery. Dr. Nessler, an orthopedic surgeon who performs hip and knee replacements at St. Cloud (Minn.) Surgery Center, will tell each patient, “OK, they’re going to take you back to the OR soon, and then a few hours after that we’ll have you up and walking around.”

The choice of wording — combining “a few hours” with “up and walking around” — and the simple reassurance of his comment works wonders on most patients psychologically, according to Dr. Nessler. When they come in for surgery, they’re very nervous about going under the knife and having their procedure done, then suddenly their surgeon is talking to them about getting up and walking around. “It sets their mind to already thinking about recovery, before they even have the surgery,” he says.

The expectation that patients will go home the day of surgery must be communicated to and understood by every member of the care team. Same-day discharge after joint replacements must be considered the norm, says John Crawford, MD, an orthopedic surgeon at OrthoTennessee in Knoxville. “Everyone has to be on the same page and approach patient care with the same expectation.”

Every provider who touches the patient must deliver a consistent message.
— John Crawford, MD

Drs. Nessler and Crawford agree that any facility’s efforts to achieve optimal total joint outcomes must begin long before the day of surgery and include everyone involved in the surgical process working together to send the same message to patients. “Same-day joint replacement success requires a multidisciplinary approach,” says Dr. Crawford, whose facility performs approximately 1,000 total joints each year, 95% of which are done on an outpatient basis. “Every single person who touches the patient, from the moment they make the decision to have surgery until they come back for their two-week follow-up, must work together to instill confidence in the patient and deliver a consistent message.”

That approach requires a significant amount of planning and scripting, and Dr. Crawford says it’s imperative for surgeons, nurses and anesthesia providers to sit down together and hash out the tiniest details of a standardized care plan — something that’s easier said than done. “Surgeons want to be in total control of their patients, but they don’t have the time to ensure that everything that needs to get done actually does,” he says. Hence, the essential team-based meetings where everyone sits down to look at what’s working and what’s not. “You need to ask, ‘Where are the problems?’” says Dr. Crawford. “‘What are the issues that are causing us to underperform in terms of complications or readmissions?’”

Both surgeons say optimizing patients for their procedures is an all-encompassing proposition that covers the following focus areas.

• Prehab and patient education. The clinical team at St. Cloud understands the importance of doing everything in its power to set patient expectations as early as possible. That’s why it has a robust prehab program, complete with education modules and a nurse educator who tells patients exactly what they must do before their procedures to become medically optimized for surgery and what to do postoperatively during recovery to achieve the best possible outcome. “Because our patients don’t spend time in the hospital learning how to ambulate, they’re taught the exercises they can and can’t do during rehab, how to use assistive devices and all they’ll be asked to do in recovery,” says Dr. Nessler.

SET UP FOR SUCCESS Many providers rely on prehab programs and dedicated nurse educators to prepare patients for successful outcomes.

The can’t-do aspect of the prehab is just as important as the can-do component because of the pain control aspect of the procedure. Enhanced regional blocks and periarticular infiltrations are often so effective that patients feel so good during the first couple days post-op that they can easily overdo things, says Dr. Nessler. “I try and instill in patients the idea that we can make them feel better, but we can’t speed up biology,” he says. “We still need to give the muscles and ligaments time to settle down and go through the inflammatory process that comes with surgery. We don’t want them to do too much and cause too much bleeding around the joint.”

In addition to educating patients, you also need to prime their caregivers and support system for what to expect during the recovery period. This is a critical and often overlooked component of patient optimization that can easily lead to unnecessary issues. “You need to make sure there’s someone around during the first full night post-op in case the patient isn’t doing as well as they expected or is feeling a little anxious,” says Dr. Nessler, who adds that this person should be informed and educated as to how the recovery will progress to avoid panicking in response to an expected development and taking the patient to the emergency department for unnecessary follow-up care.

• Anesthesia experts. Dr. Crawford’s facility has a readmission rate of less than 1%, and he gives the bulk of the credit for this standout statistic to his high-performing anesthesia team. “The single biggest key to building a successful outpatient total joints program is anesthesia and the optimization of postoperative pain, and that really starts with regional anesthesia.” he says.

All his facility’s total joint patients receive regional anesthesia as a supplement to their intraoperative course of anesthesia, says Dr. Crawford. The emphasis on anesthesia is something that’s shared by Dr. Nessler, who also points to preoperative modalities in conjunction with the regional or general anesthesia a patient receives as a key to keeping pain at bay. “At our facility, this includes a combination of steroid medications, non-steroidal anti-inflammatories, preoperative nerve blocks and then additional intraoperative modalities such as periarticular infiltrations with different pain cocktails,” he says. These cocktails, notes Dr. Nessler, differ from surgeon to surgeon but generally follow a similar formula. “They typically include longer-acting local anesthetics administered with anti-inflammatories,” he says, adding that Enhanced Recovery After Surgery (ERAS) pathways associated with total joint cases often include an additional postoperative steroid dose, which helps with inflammation and pain — and has the added benefit of potentially preventing nausea and vomiting.

• Wound irrigation. You can’t truly optimize patients for the best possible total joint outcomes without touching on some of the protocols that are geared toward preventing the ultimate outcome-killer: surgical site infections. Dr. Nessler and his team do everything in their power to prevent this complication by performing wound irrigation with an antibacterial lavage at the end of surgery for every patient — not just the high-risk individuals. The product he uses contains chlorhexidine gluconate (CHG), doesn’t require additional irrigation with saline after its application and has an impressive kill rate. Dr. Nessler estimates St. Cloud has had universal irrigation via a wound lavage in place for around eight years. He’s tried other products, including a dilute betadine lavage, before switching over to the CHG product because it better suited his needs. “When it comes to selecting a wound irrigation product, the decision comes down to effectiveness and ease of use,” says Dr. Nessler.

Top total joint programs all have a group mentality when it comes to optimizing patients for successful outcomes. As Dr. Nessler puts it, “Everyone involved in the program — surgeons, nurses, techs, anesthesia providers, patients and caregivers — must be focused on the same end goal: Knowing the patient is going to have surgery and be ready to go home safely, not within days, but within hours.” OSM

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