Major joint reconstructions in day surgery What is the limit? John Fox (Australia)

Major joint reconstructions in day surgery

What is the limit?

John Fox (Australia)

From Any Lecture / Presentation

• You will only remember four facts.

First Fact you will remember…is

From any lecture you will only remember four facts… Three to go.

Background

• Orthopaedic surgeon in Sydney• Major Teaching Hospital Appointment - Westmead• 8 years at the Cleveland Clinic, Cleveland Ohio • 2 years in Boston, Massachusetts • Fellowship trained in major adult reconstructive surgery• (Major hip, knee, shoulder and elbow reconstructions)• Conceived, designed and with a number of other

colleagues am a shareholder of Castle Hill Day Surgery • I have very much a vested interest in pushing the limits

of the Day Surgery within the bounds of safety and appropriateness.

Major joint reconstructions in day surgery – what is the limit?

What is a Major Joint ?What is a Reconstruction ?

ShoulderElbowHip

Knee

What is a Major Joint ?

What is a ‘Reconstruction’ ?

Shoulder reconstruction = ligament reconstruction or tendon repair

• Rotator Cuff Repair• Capsular Shift

Rotator Cuff Repair

Capsular Shift

Shoulder Reconstruction

Shoulder reconstruction = ligament reconstruction

• Rotator Cuff Repair• Capsular Shift

Not Controversial !

Elbow Reconstruction

Elbow reconstruction

=

Ligament reconstruction

Not Controversial !

Shoulder / Elbow

What about REPLACEMENT ?

•Shoulder Replacement

•Humeral Head Replacement

•Elbow Replacement

Not Controversial !

Total Shoulder Replacement

Humeral Head Replacement

Shoulder Elbow Replacement

•Shoulder Replacement

•Humeral Head Replacement

•Elbow Replacement

Not Controversial !

ShoulderElbowHip

Knee

What is a Major Joint ?

Primary Arthroplasty

USA

• Joint replacement is being done on an ambulatory basis.

Australia

• Some selected cases / places

Total Hip Replacement

Hip Resurfacing

HIP

• No hip ‘ligament’ reconstruction

• Unipolar Replacement

• Bipolar Replacement

• Total Hip Replacement

Unipolar eg Moore’s

Hip Bipolar Replacement


Second Fact

Japanese Hornetaka ‘yak-killer hornet’

Scientific name:Vespa mandarinia


• Paradox in the literature

“One of the most significant advancements in total hip replacement is the recognition that the procedure can be done with less invasive techniques which allow the patient to recover faster. This has even progressed to the point that some patients are able to have their surgery accomplished as an outpatient procedure. ”


• New implants designs

• New materials – Metals – Plastics– Ceramics

• New biologically active coatings

Total Hip Replacement - Proponents

The less invasive approach

• minimally invasive techniques resulting in less trauma to the tissues benefits for the patient

• most obvious, the scar is significantly smaller. • faster recovery from surgery of “smaller” magnitude. • Eg knee arthroscopic surgery, laproscopic cholecystectomy,

appendicectomy, hernia repair some more tumor operations. • When joint replacement surgery is accomplished with smaller

incisions, the patients will require fewer blood transfusions, have shorter hospital stays and will return to work or recreation sooner.

• Patients report that a joint replaced with these new techniques is significantly less painful than with the previous larger surgical exposures.

• Minimally invasive hip replacement can be performed either through two incisions each 1½ to 2 inches long or one 3 to 3½ inch incision


• The natural extension of minimally invasive surgery is to do the operation on patients as outpatients. In this situation, the patient receives appropriate education before surgery and then comes to the hospital the morning of surgery. After the operation, the patient is able to leave the hospital on crutches and be driven home to recover.


Criteria:• The patient is in a stable medical condition.

– Minor medical conditions should be well controlled: hypertension, asthma, thyroid conditions, stomach or gastrointestinal problems.

• Contraindications: diabetes, altered mental function (dementia, Parkinson’s disease), unstable cardiac status, renal failure, sleep apnea, and significant prostate obstruction.

• The patient is willing to attend physical therapy before coming to the hospital. The patient must learn the use of crutches and the appropriate dislocation precautions before surgery.

• There is an appropriate caregiver to help take care of the patient at home for the first few days after surgery.

• The patient desires to have the operation as an outpatient. Obviously this would not be imposed on anyone.


Conventional Minimally Invasive

Total Hip Replacement - Berger

• Richard A. Berger, MD, Rush–Presbyterian Chicago, Illinois

• 250 patients who had received total hip replacements through his two-incision method.

• 100 have gone home the same day of surgery• Total hip replacement surgery can be done

safely and consistently with two 1.5-inch incisions, and most patients can go home the same day

• Presented American Academy of Orthopaedic Surgeons.

Berger

• 100 consecutive patients (74 men and 26 women)• 92 patients discharged same day• the rest were sent home the following day• “In a press briefing” Dr. Berger said • only about 5% of hip replacements - less invasive• knows of no other surgeon doing it as a same-day

procedure. • predicted that within five years, all hip replacements

would be done less invasively• the shorter rehabilitation and more appealing scar• "Right now, I could do it on 90% of the patients who walk

through the door."

Total Hip Replacement – Red Flags Rising

• David S. Hungerford, MD, Johns Hopkins University, Baltimore, – There are no rigorous data showing that less invasive surgery is

any better than procedures using a slightly longer incision. – "For this to be widespread, you have to convince skeptics like

me," he said, adding that he was concerned that patient demand was being driven by device manufacturers' "hype."

• Thomas P. Sculco, MD, Surgeon-in-chief at the Hospital for Special Surgery, New York City– cautioned that smaller incision hip replacement — especially on

an outpatient basis — required experience and carefully selected patients and noted that Dr. Berger's patients were younger and healthier than the average hip replacement patient.

Total Hip Replacement - Opponents

• Key factors • Optimal fixation of the components is essential to the

long term success of the total hip arthroplasty. • Optimal fixation provides patients with predictable and

durable results. • The recent emphasis on minimally invasive surgery has

focussed attention on short term goals such as the rapid rehabilitation and early discharge of the hospital.

• The ultimate goal of total hip arthroplasty however, is the long term pain relief and function. Minimally invasive surgery should not compromise long term outcomes for short term achievements

Hozack

• Safe and adequate medical exposure is required for proper component placement and for obtaining optimal fixation.

William Hozak- Professor of Orthopaedic Surgery Rothman Institute, Thomas Jefferson University, Philadelphia PA

Woolson

• “In the absence of evidence why bother? A literature review of minimally invasive total hip replacement surgery”.

– Instructional Course Lectures from the American Academy of Orthopaedic Surgery

– Prof Woolson MD, Stanford University California

Woolson

• Is the small-incision total hip replacements minimally invasive ?

A small skin incision requires the application of high forces on the soft tissue for exposure of the joint

Woolson

• A review of the literature provides no convincing evidence of any significant advantages of small incision THR compared to a standard incision THR, other than a shorter surgical scar.

Woolson

• The two incision technique have shown higher rates of – fracture – nerve palsy

• “surgeons must weigh safety concerns against patient demand in hospital economics in deciding whether to use these procedures”

• “Patients should be informed about the few documented advantages and possible higher risk with the small incision technique.”

Literature• Digioia, Ploksey, Levison, et al Mini incision technique for total hip

arthroplasty with navigation – J Arthroplasty • De Beer Petrocelli, Alzal et al – Single incision minimally invasive

total hip arthroplasty. – J Arthroplasty.• Chimento Provine et al – Minimally invasive total hip arthroplasty, a

respective randomized study – J Arthroplasty.

– No statistical significance between small and standard incision total hip replacement in the specific clinical indicators for trauma, invasiveness, post operative, narcotic requirement or length of hospital stay.

– No difference in the transfusion requirements in these patient groups.

– Two studies have showed evidence of more subcutaneous tissue necrosis, poor wound healing after the mini incision procedures.

Incidence of Fracture

• Burger Jacobs Meneghini et al reported low risk of femoral fracture of 1%,

However

• Berry, Burger, Callahan 2.8%

• Archibeck and Pagano 7 – 9%

• There has been 4% early revision rate for postoperative fractures

• Higher than average risk of lateral femoral cutaneous nerve palsy (2.5-3.2%)

– Pagnano MW, Mayo Clinic,

Summary

• The literature does not show any convincing evidence or significant advantage of the small incision (either one or two incision or the mini incision techniques to standard techniques of total hip replacement.

• The only advantage identifiable is the smaller incision.

KNEE

• Ligament reconstruction– Anterior Cruciate Ligament– Posterior Cruciate Ligament

• Unicompartmental Replacement

• Total Knee Replacement

Unicompartment Replacement

MI TKR

Conventional Minimally Invasive

Upper extremity

• Upper extremity reconstructions and replacement are not controversial

• Overnight stay

Lower Extremity replacement

• Very Healthy • Only minor medical conditions and well

controlled• Pre-Admission Patient Education

– crutches education– dislocation precautions

• The patient desires to have the operation as an outpatient

Lower Extremity replacement

• Overnight stay + Rehab

– Total Knee Replacement – Unicompartmental Knee Replacement

• Urge caution

– Total Hip Replacement

Knee Arthroscopy

Four Facts

• Four facts

• Vespa

• No convincing evidence for Minimally Invasive Surgery of the hip

• Nurses are more observant then surgeons

Major joint reconstructions in day surgery What is the limit? John Fox (Australia)

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