Same-day Joint Replacement

Episode 34 - Same-day Joint Replacement

Dr. Chehab: [00:00:00] Welcome to IBJI's OrthoInfor m where we talk all things orthopedics to help you move better, live better. I'm your host, Dr. Eric Chehab. With Ortho Inform, our goal is to provide you with an in-depth resource about common orthopedic procedures that we perform every day. Today. It's my pleasure to welcome Dr. Mark Hamming, who will be talking about same day joint replacement surgery. So Mark, thank you for being here on ortho form and welcome. 

Dr. Hamming: Thank you, Eric. Great to be here. 

Dr. Chehab: , give us a little bit of background. I'm sure the listener would like to know, , about your educational background, your training, your interest in orthopedics.

Dr. Hamming: Sure. , I'm originally from around here in northern suburbs of Chicago. I grew up, , in with a lot of exposure to orthopedics, being that my dad and uncle. We're some of the original members of IBJI and had a practice up there. And then my brother and I have gone on to, , do orthopedic training and then join them.

And so it's been, , a nice, , nice to work with them in a kind of a seamless transition for the hamming. I guess [00:01:00] 

Dr. Chehab: it's a family business. Yes. And you, your training, , you did your undergraduate at Northwestern? 

Dr. Hamming: I did. Yep. Yep. And then I, . Went down to Rush for Rush Medical College for my medical school.

And then I did, , my orthopedic surgery training down at Duke University. And then I did a one year fellowship in sports medicine at the, Steadman Clinic in Vail, Colorado. I. 

Dr. Chehab: Yeah. And people may not know how prestigious Duke and, and, and the Steadman clinic are. I mean, these are major comp accomplishments to be accepted into these programs.

Well, thanks. And then when did you come back into the area? What year did you arrive back in the area? 

Dr. Hamming: I came back in 2014. , I've been here a little over 10 years now. And, . Yeah, it's been great and it's coming home so it feels good. 

Dr. Chehab: And your practice, how has that evolved over the past 10, 11 years?

Dr. Hamming: Yeah, it's, I like a little bit of diversity in the practice, , I felt like I, I obviously do a fair amount of sports medicine, , given , my fellowship in that, but I also do a fair amount of. Of, or arthroplasty as well. I feel like I got a nice broad training at [00:02:00] Duke and they prepared me to do whatever I really wanted to do and so I can make my practice my own and I'm not pigeon and holding kind of one specific area.

And so I do, , a significant volume of total joint replacements as well as some fractures in other kind of general orthopedic procedures too. 

Dr. Chehab: And the joint replacement, , which, , joints. 

Dr. Hamming: Total knee arthroplasty, total hip arthroplasty, as well as shoulder arthroplasty. 

Dr. Chehab: Okay. And, , we're here to talk about same day joint replacement.

And when I was a resident, which was a little bit before you and maybe when you were a resident, , there wasn't a such thing as same day. Yeah. Joint replacement. , most of the time it was almost, in fact, every time I can recall it was an inpatient procedure. Yeah. And patients would stay. Four days, five days.

Was that the same when you were in training? 

Dr. Hamming: Same with me. , we were hoping to get patients mobilized and on their feet and outta the hospital by three days, but like you said, it's not uncommon for people even up to a week or so. Okay. 

Dr. Chehab: Yeah. So maybe you were farther ahead than I was.

If you were getting 'em out in three days and we were four days and I was a few years before, but that kind of speaks to the point where this has [00:03:00] been moving to and, with same day joint replacement surgery. It seems to, would have a very broad appeal, , for patients because instead of spending three or four days in the hospital, they can go right home the same day.

Dr. Hamming: Absolutely, Eric. I mean, I think patients in general like to recover in their comforts of their own home, familiar surroundings. They're not in the hospital where there's. What we call no nosocomial infections, where there's, , different sick people around you. , they're not getting interrupted by the blood pressure cuff and the beeping of the machine and all , the IV fluids and everything like that.

So in general, if it's safe to do and people are motivated to do it, it's a great option for many patients. 

Dr. Chehab: So we obviously got to this point now where. You mentioned you're doing a majority of your joint replacements as an outpatient. 

Dr. Hamming: Yeah. I'd probably say a good two thirds are going home the same day.

Dr. Chehab: Yeah. Yeah. So , how do we get to this point? , obviously it's because it's safe. I mean, that's the first and more foremost. 

Dr. Hamming: Yeah. Obviously basic tenant of medicine do no harm. And so we're, [00:04:00] we've gotta make sure something's safe before we implement it. And that's why it's been a transition. I think over time it, the people have continued to push the boundaries in terms of what is appropriate and what's safe and what's best for the patient.

, and this has been well studied too. So this isn't just a movement in terms of this is what the insurance companies want, or this is what the surgeons want. This is really what. Is safest for the patient too, in, in the appropriate patient that's been selected. 

Dr. Chehab: So it's definitely, it's an outcomes based decision, correct?

Correct. The outcomes tend to be better in terms of fewer complications, earlier motion and mobility among the patients. And so why do you think you mentioned. With the hospital, there's a chance of acquiring infections from other patients and from being interrupted and whatnot, and being touched a lot by other people and not being in the surroundings of your own home.

That certainly makes sense from an infection standpoint. And then going home also affords patients almost the necessity of having to move around. Which is therapeutic, 

Dr. Hamming: [00:05:00] correct. We want early mobilization in most joint replacements, so we want people to get up, get moving. It decreases risk of blood clots, things like that.

And like you said, nobody's coming in to take your bed pan and you just lay in bed all day and delivering your food, right to your tray in front of you. So by necessity, you do have to get up and get moving a little bit, which. Is the name of the game in joint replacement recovery. 

Dr. Chehab: Right.

It's your benefit to be moving earlier on. 

Dr. Hamming: Exactly. 

Dr. Chehab: Yeah. Okay. And , when did, what year did you begin doing outpatient joint replacements? About? 

Dr. Hamming: That's a great question. Probably around, I would probably say six or seven years ago is my guess. 

Dr. Chehab: Okay. 

Dr. Hamming: Yeah. 

Dr. Chehab: So maybe we can frame this discussion in terms of.

N first, how does the patient prepare for an outpatient total joint? , what's the day of the surgery like? And then let's do the post-op recovery. 

Dr. Hamming: Yeah. 

Dr. Chehab: And break it down into that. So how do you prepare? Patients when a patient comes in your office and they may be a candidate for an outpatient total [00:06:00] joint, , what's the preparation?

, and then we can also discuss who is an appropriate candidate. 

Dr. Hamming: Absolutely. So, yeah, that's probably the first step is to help decide if somebody is an appropriate candidate. So a lot of factors go into that. I look personally at their medical history and to see if that's something that's appropriate.

, if somebody is, . It has a lot of medical comorbidities and it would be safer to do it in the environment, whereas there's more, uh, medical personnel around, such as a hospital setting, then that's what we're gonna do. But if they are relatively healthy and motivated, so I talk to the patient, is this something you want to do?

Is this something you're motivated to? , some people aren't. And so it also, that, that plays, I think, a huge role. You also have to look on at their support system and if anybody's home with them. If what their environment in their ho house looks like. Are they on a fourth level? , walk up or a walk up condo or is this the ranch house and that, that sort of thing.

So I think all those important things play into that. [00:07:00] Nothing is absolute though. Like I've had patients that live typically alone and they go home the same day and they do have stairs. I mean, it all depends on the patient, but a lot of it is, it's a combination of all those factors. 

Dr. Chehab: So just to reframe this, patients make the choice.

Dr. Hamming: Yes. 

Dr. Chehab: And there are certain people who may be a good candidate. Based on their overall health and folks who don't have significant medical problems. Such as what? Heart disease or a history of blood clots or what would be some of the things that would make you, in your mind say, maybe this person's better to be in the hospital than being at home?

Dr. Hamming: Yeah. History of a lot of blood clots. Maybe they're prone to going into AFib a lot. Some heart disease or some heart. Yes. , so yeah, those are some of the, yeah. 

Dr. Chehab: Okay. And then, and then obviously the home environment. If they can navigate it, whether it's a ranch or walkups, it's really their feeling that they can navigate it after a replacement.

But ultimately, it's a patient decision to. Have an outpatient [00:08:00] same day total joint replacement. 

Dr. Hamming: Yes. And sometimes we rely even on the physical therapist too, to work with them ahead of time to help teach them strategies and to help them be confident to know this is something they can do, or this is something that maybe we should pivot and think about the hospital.

Dr. Chehab: Okay, great. So part of the patient selection. And then as you prepare them, what are some of the things that help patients get their ducks in a row? Before they have their outpatient total joint, 

Dr. Hamming: so then we then rely on their medical specialist. Certainly. So even if I, we, I think it's a good idea.

The patient thinks it's a good idea. We gotta make sure that her, their medical, , primary care doctor as well as any medical subspecialist feel comfortable with it and feel like that's a good idea for them too. And probably initially there was a little bit more hesitancy from some of the primary care doctors, but, , it's become so ubiquitous now.

It really hasn't become too much of an issue. Yeah. Yeah. 

Dr. Chehab: , and then what about like equipment, for instance, people have a hip replacement. Do they need high chairs or, or are there anything that patients are doing preoperatively to prepare for their same day joint replacement? 

Dr. Hamming: [00:09:00] Yes. And then so they get a lot of the durable medical equipment is what we call it.

An elevated toilet seat, a grasper to help get things off the ground. And there's. We've got a program and a packet that kind of helps you get prepared and ready for that. 

Dr. Chehab: And in essence, that's not any different than if the patient stayed in the hospital and then went home.

They're still gonna need this equipment, but it's just good to have it before they get home that same day. 

Dr. Hamming: Right. Exactly. We're preparing them from the get go. 

Dr. Chehab: Yeah. Yeah. Okay. And any other preparation that generally you would do, , that may be a little bit specific for outpatient joint replacement as compared to in hospital?

Dr. Hamming: I think that's pretty much it. Yeah. 

Dr. Chehab: So it's not nothing too onerous. No. And 

Dr. Hamming: then, 

Dr. Chehab: and then let's move to the day of the surgery. 

Dr. Hamming: So the day of the surgery, they typically arrive , at the surgery center about two hours or so before the, which is typical for anyone. , they will.

We get everything going with the IV and , some preoperative medications. So we often give them some analgesics ahead of time to help with the pain control in anticipation of it. And I think that's one of the things that's moved this [00:10:00] forward and we can talk about that in a little bit, but just the overall perioperative pain control in order to help them facilitate this early mobilization.

But and then we do the surgery. And roughly on average we tell people joint replacements take approximately two hours or so. Um, obviously there's a lot of factors that go into it. Some are an hour, some are three hours, that's just a rough timeframe. And then you go to the recovery room and they're there typically for a couple hours.

You recovering, they work you into some fluids and eventually get you eating again. Make sure you're urinating , and your pain is controlled. We typically have a physical therapist come and work with you in the recovery area, so they actually get you up, get you moving. They usually do the stairs with you before you even leave the surgery center, so there's a whole session or even two sessions sometimes before you leave, so it's not like you're up and out of the door immediately.

Dr. Chehab: Right. God, that's amazing. , again, when I was a resident, it was day three. Maybe the physical therapist would take patients up and down the stairs in the stairwell. Yeah. And, but it's done because it's safe. , and like you [00:11:00] mentioned, the analgesia, the pain management is so much better.

Dr. Hamming: Yes. 

Dr. Chehab: And that's probably one of the big things that has advanced it. Again, harking back, , as a resident, patients had the PCA, the patient controlled analgesic, which was an IV and a pump, and they could press a button and when they press the button, they were administered pain medication and. Patients became relatively reliant on it to the point where it was hard to get 'em off the pump, get the IV out of the arm, and allow them to move around more ear earlier on.

And so the PCAs actually fell out of favor because they were tethering people to the bed. They weren't allowing patients to get up sooner, and there was just better ways to manage the pain than getting squirts of opiates. And , explain some of. I think that's been a big driver that allows outpatient total joint to happen.

So what are some of the advances in analgesia and in pain management that have brought us to the point where patients can safely, effectively, with, have their pain managed so that they can go home, be comfortable, and be mobile? 

Dr. Hamming: [00:12:00] Yeah, I think probably if you re rewind 15, 20 years ago. Pain management was all about and opioid use and moral opioid use.

It was all narcotics. Now we like to think of it as what's called a multimodal approach, so we're using multiple D, we're attacking the pain pathway from multiple different angles. So you know, it starts when they hit the door at the surgery center, so they're getting some preoperative pain.

Control . In anticipation so that those chemicals are , in you to help with the pain. During the surgery, they do a nerve block. Usually if it's a, like a total knee replacement, they'll do a local nerve block in your thigh to help with the pain there, in addition to a spinal nerve.

Nerve blocks. , something that goes in the back to help numb you a little bit from the waist down. Now those are temporary. The spinal typically last two to three hours or so, so it, they've timed it so they're using, , medications that will wear off. Relatively quickly, right at the time the surgery is done or shortly thereafter.

So then you're able to get up and get going again, 

Dr. Chehab: some of the [00:13:00] peripheral nerve blocks versus the central nerve block in the spine, in the back, the peripheral nerve blocks, are those affecting the muscles or are they just affecting the sensory pathways, , to the knee or the hip? 

Dr. Hamming: They can do either, but depending on which surgery and everything.

But typically it's more the sensory because again, we want those muscles to get going and get firing 

Dr. Chehab: and get the muscles working. Yes. So that they can really get on their feet. Exactly. In the recovery room. Exactly. Yeah. Okay, so multimodal. Pain management is a one of the key advances in joint replacement surgery that has allowed for this more rapid recovery, safe recovery, and again, getting patients more mobile and, and, and back into their home environment where they seem to thrive more so than they do in a hospital setting.

Dr. Hamming: Absolutely. Then, yeah, then in the postoperative, , period, then we talk again. It's not just opioids or narcotics, we're, we do, uh, a higher dose Tylenol and obviously these are all patient. Specific if their kidneys and liver are okay, but, a powerful anti-inflammatory. We do a little bit of the narcotic, but it's coming at this pain [00:14:00] pathway to really get at it from all angles and use less opioids, which also helps.

, if you're not as drowsy and you're not as, as nauseous and everything, you can get up and get going too. 

Dr. Chehab: Yeah, I think people underappreciate how terrible the side effects of opiates can be. 

Dr. Hamming: Yeah. 

Dr. Chehab: Between not being able to pee, having trouble, , with constipation, having nausea, feeling dopey, like they aren't pleasant for some people and, and they're not getting that euphoric whoopee, we're having a good time on opiates.

Dr. Hamming: Absolutely. 

Dr. Chehab: Absolutely. , and then, let's do , a hypothetical. If you had , a family member who needed a joint replacement and they were to say, hey Mark. Should I do this as an outpatient or should I do it, , in the hospital? What are some of the discussions you would have to say, Hey, I think you'd be a good candidate for the hospital, or you'd be a good candidate for the outpatient, uh, setting.

Dr. Hamming: Sure. Well, I'd do my mental. Kind of checklist on what I know about them, obviously, and their medical history. , but I think one of the biggest things is patient motivation to do it. So if they want to do it, if, is this something [00:15:00] they do want to go home? Is this something that they don't feel comfortable with?

That would be my, what my discussion with them is, Hey, do you feel comfortable doing this? And do you go home? I think it's safe for them. But. You've gotta be, you gotta have the patient on board. 'cause it's all about patient expectations too. 

Dr. Chehab: Yeah. Yeah. 

Dr. Hamming: If I told you, Eric, like, you're gonna go run, you would wanna know if I'm gonna make you do a 10 mile run or one mile run.

But you can pace yourself and you know what you're gonna do. And if you're like, yeah, I want to do the you, I want to do it this way, then you're gonna be ready to do it. 

Dr. Chehab: It won't be 10 miles. And then so I'll be, if someone asked me, I'd be like, sign me up for the outpatient. 

Dr. Hamming: Yeah. 

Dr. Chehab: And. As someone in the know.

Dr. Hamming: Yeah. 

Dr. Chehab: , and so I have , a very strong bias that I would have. If it were me or anybody in my family towards an outpatient center for the reasons of that, we had mentioned previously lower infection risk, being in a home environment, and I'd be motivated to get on my feet just because I know how important it's from as an orthopedic [00:16:00] surgeon to get people moving after joint replacement.

And I'm far more inclined to move if I have to get outta bed to do it myself as opposed to someone doing everything for me. 

Dr. Hamming: Yeah, absolutely. I think you have all those benefits and then you still have the safety net for some reason. If things aren't going quite as planned or smoothly and somebody needs the hospital setting.

It's always there. It's always there. It's very rare. I'm, I mean, I, I can think of only a handful of people and it, , we do hundreds of joints a year, but, , where they actually get transferred to the hospital. But it is there and it occasionally happens and it's not the end of the world.

You just make that transition to the inpatient setting and you can still get the benefits of that if necessary. 

Dr. Chehab: Yeah. , this is once again. A big iteration in joint replacement where again. Before we were training, it was two weeks in the hospital when we were training. It's days in the hospital.

Now it's hours in the surgery center. 

Dr. Hamming: Yeah. 

Dr. Chehab: What do you think the next iteration in joint replacement is going to be? 

Dr. Hamming: Oh, that's a great question. , I think there's always gonna be some role for some [00:17:00] patients to do it in the hospital. Yeah. Basically you, some people need the extra medical support.

Medical support. Um, but I do think that it's gonna continue. To become more prevalent to do it in an outpatient setting. I don't think it's, I think some people worry about chronologic age. I think that will continue to become less of a factor. Some people, I mean some patients think, oh, I'm too old, even for a joint replacement and everything.

I think we're gonna find as can people, , continue to realize it's not really about the chronologic age, it's about how. What you're, how healthy you are, how strong you are, how fast you can mobilize and everything. And keeping people down for less time only allows them to bounce back sooner. So, 

Dr. Chehab: yeah.

Yeah. I have to say it's been wonderful to see it. Just as an observer of patients, , who get joint replacements, how quickly they have been able to recover compared to previously, how safe it is to be going home and again, avoiding some of the risks that we used to think were mitigated by being in a hospital setting, but actually may have been [00:18:00] exacerbated.

, increasing some of those risks interestingly. Um, so Mark, do you think it matters what approach, , is made? For a patient to be an appropriate candidate for a total hip, for instance, does it, is an anterior approach or posterior approach is one better suited for the outpatient setting than the other?

Dr. Hamming: That's a great question, Eric and I do get that, that asked that all the time and , I think it does not make a difference. I think you can do either approach in an outpatient setting. , I was, in my residency we did five different approaches, 

Dr. Chehab: right. 

Dr. Hamming: And. So I was trained how to do, we all have our own preference for various reasons, but I don't think it impacts whether you're a candidate or whether you can do the outpatient setting.

Dr. Chehab: Now, when patients arrive home, they're clearly not on their own. Um, what are some of the resources that are provided to patients so that, , they're guided through their recovery on the backend after an outpatient total joint? 

Dr. Hamming: Yeah, they're not on their own. You're right. So in addition to at least the first night, having somebody stay with them and make sure they're [00:19:00] okay.

Like a family member. Like family member. Yeah. Yeah. They, or a friend. Um, some people, the most people get a home health nurse that would come in and help them with some logistics of dressing and whatnot. There's also in-home therapy, so oftentimes my patients would go home. Let's say they, they were discharged from the surgery center at.

2:00 PM their therapist is gonna work with them at home even at 5:00 PM that day. That same day. And then they continue to come and work with them doing off often a week or two of in-home therapy, even prior to going to an outpatient therapy, a building a mile away or whatever.

Sure. Now we have had a fair amount of people. As things continue, people continue to mobilize and feel better. Initially we've had a fair amount of people that are even going straight to outpatient these days and not even needing really the in-home therapy, but the, I would probably say more people than not are still doing the in-home therapy for a week or two and then transitioning outpatient.

But both are very reasonable. 

Dr. Chehab: So there are lots of resources for patients on the backend. They get their surgery. We've been [00:20:00] talking about going home, mobilizing, doing things on your own. But the fact of the matter is they have lots of help and there are people who visit them, nurses who visit them.

Physical therapists who visit them that allow them to recover almost like they would in a hospital where the physical therapist is rounding on your bed and spending the 20 to 30 minutes with you, you probably get a little bit better therapy because they're in your home and can see what the needs are and can address 'em directly.

Dr. Hamming: Absolutely. I mean, it, it takes a village type mentality, but I do think it, it does help to have all those people there and you've got a full team for you. Even outside your own network, of family and friends. Um, 

Dr. Chehab: so any other parting thoughts about outpatient joint replacement that you would want the listener to know?

Someone who might be weighing the pros and cons of outpatient versus hospital surgery? Like what are some of the, the pearls you might provide for that? 

Dr. Hamming: Yeah. I think it's, uh, it's still ultimately a personal decision, so you've gotta be. Ready? Any joint replacement, you're gonna have pain.

I mean, that's the one thing I drive home with my patients and I don't like to sugarcoat it. Like it's, you're [00:21:00] gonna have some pain. You have to expect it. You're, you have to tackle it and be ready to just to manage it. And that's what it's all about. Uh, we're not gonna make anybody like a hundred percent pain free, feeling like, there's nothing ever happens.

Yeah, exactly. But if they can know what's that? Hey, this, I'm gonna have a little bit of pain. We're gonna use some medication to help with it. We're going to do all these different things to , help me manage it and get through it. It's gonna keep getting better day by day. And I think that's the most important thing is if you feel comfortable with it, then yeah.

, the literature, the medical literature supports it. It's saying it's as safe if not even safer, , for the right patient. Yeah. Absolutely. 

Dr. Chehab: Yeah. Okay. My guest today is Dr. Mark Hamming. , mark, thanks so much for being on Ortho Inform. 

Dr. Hamming: My pleasure. Thanks for having me, Eric.