WASHINGTON, DC (Feb. 24) - Building on advances in minimally invasive total joint replacement techniques, surgeons are starting to offer arthroplastic procedures on an outpatient basis, according to Richard A. Berger, MD, orthopedic surgeon at Rush University Medical Center in Chicago, Illinois. The first surgeon to perform minimally invasive total hip arthroplasty as an outpatient procedure, Dr. Berger spoke Wednesday at the 72nd Annual Meeting of the American Academy of Orthopaedic Surgeons. He has performed almost 500 knee and hip replacement surgeries on an outpatient basis, and reports that he has had no readmissions, no infections, and that the patients confirm good anesthesia and pain control.

According to results from a randomized study of outpatient knee arthroplasties that was also presented at the meeting, patients showed increased range of motion (118 degrees at 5 days) compared with those who underwent the traditional long-incision procedure. While "very few" surgeons currently perform these surgeries on an outpatient basis, Dr. Berger tells CIAOMed that "in the future, the standard of care will be a small incision and also [will involve] a much shorter hospital stay...either the same day or overnight, except for really infirm patients."

Dr. Berger indicated that minimally invasive procedures are muscle-sparing, resulting in a swift recovery, and that surgeons have perfected regional anesthesia, leading to less postoperative nausea and hypotension, and enabling patients to go home sooner. Other innovations, including intraoperative rehabilitation and improved radiographic imaging, have helped the procedures evolve.

Minimally invasive surgeries improve patient satisfaction and function

In quadriceps-sparing minimally invasive knee arthroplasty, patients recover three times as fast, have one-third less pain, one-third the length of hospital stay, and lose 30% less blood than patients who undergo the traditional long-incision procedure, according to the co-designer of the procedure, Alfred J. Tria, MD, clinical professor of orthopedic surgery at St Peter's University Hospital and the Robert Wood Johnson Medical School, both in New Brunswick, New Jersey. Patients also achieve a 10-degree improvement in range of motion at 1- to 2-year follow-up examinations.

In addition, the minimally invasive procedures lead to more satisfied patients, says Lawrence D. Dorr, MD, medical director of the Dorr Arthritis Institute of the Centinela-Freeman Hospital System in Inglewood, California, who conducted a study of 210 hip replacement patients in his practice. Surveyed preoperatively, patients said they expected better pain relief, functional improvement, and an improved sense of well-being as a result of minimally invasive surgery as compared to the traditional open procedure. "Minimally invasive surgery makes them comfortable, and they also have confidence that they will recover quickly, and in fact they do," reports Dr. Dorr.

This patient confidence is validated by results reported from an ongoing randomized trial comparing minimally invasive surgery to long-incision hip replacement. Six weeks after surgery, patients who underwent minimally invasive arthroplasty walked and functioned better than their counterparts who underwent the long-incision procedure. They also used fewer pain killers and reported less pain.

Caution advised

Enthusiasm for minimally invasive procedures is high, according to Thomas S. Thornhill, MD, John B. and Buckminster Brown Professor of Orthopaedic Surgery at the Harvard School of Medicine and orthopedist in chief at Brigham and Women's Hospital in Boston, Massachusetts. However, Dr. Thornhill cautions that, whereas he does less-invasive and minimally invasive surgeries and is a supporter, "so much of our [work] so far has been data-free."

Peter M. Bonutti, MD, assistant clinical professor in the Department of Orthopaedic Surgery at the University of Arkansas and orthopedic surgeon at St. Anthony's Memorial Hospital in Effingham, Illinois, says that many in the field are trying to equate minimally invasive surgery with outpatient surgery.

"We all try to reduce hospital stays, but I don't know that outpatient joint replacement is the driving direction of joint arthroscopy, because there can be surgical and medical complications, and if we send patients home too early, they have a higher risk for complications at home, which is more dangerous than if they occur in the hospital," Dr. Bonutti observes.

He points to studies that have shown that arthroplasty patients who are released early have double the readmission rate and increased mortality compared to those who stay in the hospital following surgery. "Clearly, pushing people out of the hospital is not where we want to go," he says.

William J. Maloney, MD, professor and chairman of the department of orthopedic surgery at Stanford University School of Medicine in Stanford, California, says that while select patients can go home the same day of arthroplasty, the average Medicaid patient cannot. "The 75-year-old with diabetes and hypertension whose heart doesn't function well [requires postoperative observation]", he says.

Reference:

Press Briefing on Less- and Minimally Invasive Joint Replacement. 72nd Annual Meeting of the American Academy of Orthopaedic Surgeons; February 23-27, 2005. Washington, DC.