Aug 28, 2018
Researchers expect a 77 percent growth in joint replacements over the next decade as increasingly younger patients have the procedure. Dr. Savyasachi Thakkar discusses the benefits of outpatient joint replacement, which allows patients go home within 24 hours of surgery.
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: Thank you for joining us today. We’re talking with Dr. Savyasachi Thakkar, an orthopaedic hip and knee reconstruction surgeon at MedStar Orthopaedic Institute at MedStar Washington Hospital Center. Welcome, Dr. Thakkar.
Dr. Thakkar: Thank you very much for having me.
Host: It’s estimated that there will be 77 percent growth in joint replacements over the next decade. Increasingly younger patients are seeking joint replacement—people in their 40s, 50s and 60s who are working and active and can’t afford to slow down. Advances in joint replacement techniques allow for shorter hospital stays and quicker recovery than ever before. Dr. Thakkar, how is it that a total joint replacement can be performed as an outpatient surgery?
Dr. Thakkar: Oh, that’s a fantastic question. So, up to ten years ago, we didn’t quite understand how to perform surgery with the adequate pain control that we have now. So, I think that what’s changed the last ten years is how to attack pain management from a multimodal perspective and try and get patients outside the hospital within 23 hours. So, we call that an outpatient joint replacement. At the MedStar Washington Hospital Center we perform several such surgeries—we perform partial knee replacements, partial hip replacements, total knee replacements, and total hip replacements within that 24-hour window. Some patients are candidates to leave the very same day if they’re healthy, they’re active, they have a low BMI, which is a body mass index, and they are non-smokers and otherwise have a very good social support system at home. So, if all those things and all those parameters match up, we’re able to get them home the very same day or sometimes have an overnight stay and get them home the next day, understanding very well that they have to have a robust coaching system at home, maybe a friend, maybe a family member who can care for them. And they also have to have all their needs addressed beforehand. So, at our institution, we have the social workers who are called the post-acute care coordinators, or the PAC coordinators, that coordinate the patient’s perioperative care with regards to physical therapy, with regards to transportation needs, all in one setting, done before surgery.
Host: So, aside from some of the benefits that you mentioned—the shorter hospital stay, the ability to go home quicker - what are some of the other major ways that patients benefit from same-day or outpatient therapy?
Dr. Thakkar: You know, one of the biggest things that patients can experience with a same-day program is that they have surgery at a very well-established surgery center or a hospital and then they can recover in the comforts of their own home. So, they can have physical therapy come out to their house for approximately two weeks after surgery, and that reduces the number of falls that they have, to try and leave their house and transport themselves to a physical therapy institution. The other thing is that they can control the cleanliness, they can control their pain a lot better because they’re not being woken up at all hours of the night for vital checks, for blood pressure tests, and even to draw their blood. So, the recovery is a lot healthier, it’s a lot quicker and it’s a lot more effective.
Host: How does the process of outpatient total joint replacement compare to traditional joint replacement?
Dr. Thakkar: Traditional joint replacements and outpatient total joint replacements differ in the perioperative care. So, the surgical procedure is very similar for both...both settings. But, once you have patients that want to stay in the hospital, we have to plan for inpatient rehab needs, we have to plan for them to get to a rehab center. All of these things increase the cost to the healthcare system and to the individual. They increase the risk of infection because patients are now in less controlled environments. They also lead to patients who have higher pain scores than patients that have outpatient joints just because patients are not in their normal realm of life, which is where they want to be, either before or after surgery. So, I think that traditional joint replacements are applicable to a certain subset of patients now that are elderly, that don’t have support systems at home, that are less active. But, for the more active, the...the younger patient population, I think that outpatient joints are the way to go.
Host: How long is the recovery process for a younger, more active individual, say in their 40s to 60s, as compared to one of the older patients maybe that had to go through the traditional route?
Dr. Thakkar: So, what I like to tell patients, either knee replacement or hip replacement patients, is that on average they take about 6 weeks of physical therapy to recover from surgery. Now, for that younger, more active individual, it could be on the order of 3 to 4 weeks. For the elderly, that could be about 7 to 8 weeks. So, the average is about 6 weeks for each individual. Now just this morning in my clinic, I saw several patients that have had these procedures about 6 weeks ago, and most of them are raring to go back to work. Most of them got out of the hospital overnight. So, we’re starting to see that a larger proportion of patients want to get back into the daily stream, or their daily activity, just because they miss it and they feel like they need to get away from the distraction of having surgery and reduce their outliers, and reduce their pain, by going back to work sooner.
Host: Will these individuals be able to recover 100% of their previous activity before their joint began to deteriorate?
Dr. Thakkar: Absolutely. So, joint deterioration happens over a number of years. The symptoms may only present for a few months or a few years, but the deterioration has been in place for a number of years. That is associated with several other problems, such as, losing muscle mass, losing the ability to perform activities of daily living, to enjoy life as it may, and those things take about 3 or 4 months to get back to 100% normalcy. But, for the most part, patients, when they are rid of their pain, they experience such relief that they are able to tackle life and life situations at a much faster pace.
Host: As a academic medical center, MedStar Washington Hospital Center and the Orthopaedic Institute really take a lot of stock into and a lot of collaboration with each other as a team. Could you talk a little bit about your team-based approach to care for your orthopaedic patients?
Dr. Thakkar: Absolutely. So, that’s a fantastic question. At the MedStar Washington Hospital Center at the MedStar Orthopedic Institute, as a whole, we have several specialists devoted to patients with arthritis. So, let’s start with the providers themselves. Dr. James Tozzi and myself, we focus on primary and revision hip and knee replacement surgeries. We also have Dr. Wiemi Douoguih and Dr. David Johnson, who focus on primary knee replacement surgeries. Along with that, we have a team of physical therapists that evaluate the patients in the preoperative setting, immediately after surgery and then 6 to 8 weeks after surgery on a continual basis. We have specialized nursing devoted to orthopaedic patients on our orthopaedic floors and we also have social workers that are geared towards caring for patients just with knee and hip replacement surgeries without any distractions and they’re used to caring for such patients with complex medical needs, with complex social situations. The other advantage of being in a tertiary care facility like ours is that we have access to neurosurgeons, to cardiac surgeons, to all kinds of physicians and all kinds of specialists, so that if a patient were to have a complication in the perioperative setting, it can be easily addressed. And, a final point is that in a tertiary care hospital, if we have to convert a patient from being an outpatient setting to staying overnight, or maybe even staying for 2 nights, it’s very easily accomplished. Now, this is in contrast to numerous surgery centers that are mushrooming across our communities where they do not have such facilities, they do not have such expertise, and that can lead to drastic complications.
Host: How does the volume at the MedStar Orthopaedic Institute compare to other centers within the region?
Dr. Thakkar: I think that the MedStar Orthopaedic Institution, as a whole, is a much busier orthopaedic practice just because we see patients that need simple hip and knee replacements and also need complex revisions. So, from a volume perspective and from a complexity perspective, we are significantly higher in terms of the number of procedures that we perform than other comparative situations or other comparative hospitals. On average, at the MedStar Washington Hospital Center alone, we’re performing about 600 to 700 joint replacement procedures each year, and these are primary joint replacement procedures. With regards to revisions, we’re probably performing about 200 or 300 revision procedures, so an average of about 1000 procedures. Now, if you account for all the MedStar Orthopaedic Institute practices that are in the area, we’re looking at lines of about 3- or 4,000 joint replacement procedures performed each year.
Host: That’s several a day, if you just go by the calendar year.
Dr. Thakkar: Yes, absolutely. I mean, I operate 2 days a week and on average I’m doing between 7 and 10 or 7 and 12 cases per week, so that number adds up very quickly.
Host: Are you doing any research currently on total joint replacement that you'd like to share with the DC community?
Dr. Thakkar: Yeah, I think that joint replacements have come a very long way, and especially the last decade. So, there’s several areas of focus on research for joint replacement patients. One of them is optimizing protocols for such patients, whether they be in-hospital protocols or outpatient protocols. Second are pain management strategies. Pain management is also making leaps and bounds with regards to joint replacement patients, and I think that addressing the multimodal issues that patients have is significant, so we’re doing research on that. We’re also focused on looking at pre- and postoperative nerve ablation for patients that may have chronic pain issues. We have pain management specialists that can go in and ablate with radiofrequency the skin nerves around the incision sites where we’re going to make the incision for our surgeries. By doing so, they reduce the overall narcotic burden that these patients see in the postoperative setting. We’re also looking at advanced technologies like robotics or computer-assisted navigation to help us reduce our operative time, to help us reduce blood loss and the need for blood transfusion, so we’re calling this bloodless surgery for our patients. And, that also helps us optimize our outcomes. And, finally, we’re looking at alternative bearing surfaces. A bearing surface is where the bones are capped with different materials, and they help form the new joint. So, alternative bearing surfaces will give patients better pain control, better mobility and also longevity with regards to their prosthesis.
Host: So, the bloodless surgery—that one really stuck in my ear when you said that. Is that something that you currently offer to patients?
Dr. Thakkar: Absolutely. So, what I like doing for a lot of patients, and a lot of patients will have bilateral knee or bilateral hip problems. In those situations, I will use a surgical navigation device, which is also known as a GPS device or a computer-assisted navigation. That allows me to work outside of the bone on the joint surface as working inside of the bone. Working inside of the bone leads to significant blood loss, and it also leads to significant risk of having blood clots either in the legs or in the lungs, and using this computer avoids these issues for these patients so that I can perform these safely without the risk of blood transfusion because their blood loss rates are low and also without the risk of blood clots.
Host: That’s fascinating. Could you share some success stories from your patient population regarding the same-day, joint replacement surgery?
Dr. Thakkar: Absolutely! So, I saw a very active individual. Unfortunately, she had a high BMI and she was refused to have surgery at multiple different institutions. However, when she came to me, she clearly demonstrated a need to get back to her lifestyle that she desired and she needed a knee replacement surgery. We brought her in for surgery. We performed the operation without any complications. In fact, she was so ecstatic with the pain control and the mobility that she received that she was eager to leave the very same day. However, it being, bad weather, she stayed overnight and she was able to leave the very next day, and had very good pain control and she hasn’t had any concerns. So, I think that patients overall do very well. I’ve also tried to perform bilateral total knee arthroplasties. Now, these patients need to stay in the hospital for a little bit longer, maybe a day, maybe 2 days. And, we recently did a story on a patient that was not able to cook for her family for the last several years, but just this Christmas was the first Christmas she was able to cook for them, and I think, in my mind, that’s a…a big success for this patient.
Host: Do you often see individuals who are turned away from other centers or refused surgery from other centers?
Dr. Thakkar: Absolutely. So, at the MedStar Washington Hospital Center and the MedStar Orthopaedic Institution overall, we have, like I mentioned, experts that can deal with multiple problems, so a lot of patients come to us who either have significant joint deformities or they’ve had several procedures that have been unsuccessful in the past, and we have to evaluate them to try and revise them and to try and provide a more stable functional prosthesis. And, we’ll frequently see those patients at our institutions because we have the ability to care for them for a multidisciplinary approach.
Host: What makes MedStar Washington Hospital Center the best place to seek same-day or outpatient total joint replacement?
Dr. Thakkar: At the MedStar Washington Hospital Center and the MedStar Orthopaedic Institution, we focus on individualized multidisciplinary specialized care that encompasses the entire perioperative care for a patient from the preoperative setting, during surgery, and in the postoperative scenario. We have specialists that can help patients and help each individual with their customized needs and provide the best possible outcome for this patient. And, I think that using a tertiary care facility to achieve this goal is remarkable because we have 24/7 support and we have residents on staff which are seeing patients at all hours of the night, taking phone calls, which is just not possible in outpatient situations.
Host: Thanks for joining us today, Dr. Thakkar.
Dr. Thakkar: Thank you very much.
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