Appeared as a sponsored section in the October 2017 issue of Business North Carolina.
By Suzanne Wood
It wasn’t that long ago that hip- or knee-replacement surgery involved a hospital stay of up to several weeks. It wasn’t any easier for patients after they were discharged, when an often painful and physical-therapy filled recovery could stretch into months. For some, returning home was delayed by a prescription for inpatient rehabilitation.
Most orthopedic patients travel a shorter and smoother road today. They brag about the ease of their hip or knee replacement, which often is completed the same day that they return home. That was the case for one of North Carolina’s best-known residents, Duke University men’s basketball coach Mike Krzyzewski. He had a total-knee replacement in August. But instead of the standout he is along the sidelines, this accomplishment made him just one more in a growing crowd.
The first hip-replacement surgery was completed in 1960, and the first knee replacement followed eight years later, according to Rosemont, Ill.-based American Academy of Orthopaedic Surgeons. Rockville, Md.-based Agency for Healthcare Research and Quality, the fact-finding arm of U.S. Department of Health and Human Services, reports that more than 600,000 total knee replacements and 300,000 total hip replacements are performed each year in the United States.
But as more baby boomers enjoy their 70s and the oldest Generation Xers enter their 50s, demand for hip and knee replacements is growing. Researchers in an AHRQ-funded study estimated that about 7 million Americans had had a total hip or knee replacement by 2010, including more than 600,000 individuals who had both procedures. That number is expected to jump to 11 million by 2030, when it will be one of the most common elective surgeries in the U.S.
While demand for these surgeries is increasing, instances of complications, hospital stays and recovery times are decreasing. That’s not because of one magic pill, but a combination of pre-operation patient management, better surgical techniques and new anesthesia and pain-management options. “I tell my patients, ‘It’s a great time to have orthopedic surgery,’” says Scott Hannum, an orthopedic surgeon at Wilmington-based EmergeOrtho and chairman of Wilmington-based New Hanover Regional Medical Center’s orthopedics department, where he and his colleagues operate. “We’re doing so much better than we were even five years ago when it comes to knee and hip replacements. It’s an evolution on multiple fronts.”
One of the primary reasons that knee and hip replacements are safer and less debilitating is the growing reliance on evidence-based medicine, which uses findings from the latest research to direct clinical decisions. More hospitals and medical groups are using data, often collected through Medicare’s relatively new bundled-payment system, that standardizes care and reimbursement for procedures. It requires hospitals to keep comprehensive electronic records of each patient’s care, so Medicare knows exactly what is being billed.
Some hospitals track procedure-related data independent of Medicare, developing their own rules for procedures such as joint-replacement surgery, says
L. Andrew Koman, chairman of Winston-Salem-based Wake Forest Baptist Medical Center’s Department of Orthopedic Surgery and an orthopedic surgery professor at Wake Forest School of Medicine. “We’ve been doing this for five years systemwide, and at Davie Medical Center, which is in our system, 100% of surgical procedures are dictated by these algorithms.”
Koman says an evidence-based approach helps surgeons predict how a knee- or hip-replacement procedure will affect a patient. He says data shows that patients with certain conditions, such as unmanaged diabetes or morbid obesity, are more likely than healthy patients to develop complications such as infections, poor wound healing or heart attack. It’s important that patients be in the best possible position going into surgery. “Failure in a total joint replacement surgery is a disaster,” he says.
Surgeons that use hard-and-fast data, such as the A1C test for blood sugar or body-mass index for obesity, appear less arbitrary and more helpful when the results show a patient that he or she isn’t a good candidate for joint replacement. But that doesn’t mean they can’t become one. Orthopedic surgeons often counsel these patients, helping them address concerns before performing replacement surgery. Depending on the surgical group or hospital’s practices, these patients may be assigned an in-system internist who joins their care team, or are referred to their primary-care physician. In some cases, morbidly obese patients opt for gastric bypass surgery as a means to quickly reach a weight that’s safe for surgery. Many patients embrace this help as the push they need to finally enact important lifestyle changes. “I can’t tell you how many colleagues have said to me about a shared patient, ‘Hey, how did you get so-and-so to quit smoking?’” Hannum says.
It wasn’t that long ago that hip- and knee-replacement patients received general anesthesia, necessitating the placement of a breathing tube to ensure their airway remained open. But that’s become the exception. Anesthesiologists are turning to spinal blocks to numb only the operation site, much like a dentist numbs only a portion of the mouth for a tooth filling. Data has shown regional anesthesia is as effective and often safer than general anesthesia. The blocks are paired with a mild sedative that isn’t strong enough to render the patient unconscious. And with fewer drugs and no breathing tube, complications such as confusion and sore throat, are eliminated, says David Casey, an orthopedic surgeon with Pinehurst-based FirstHealth of the Carolinas and a former Army surgeon who served four tours in the Middle East. He says these patients get out of bed sooner than those who receive general anesthesia, meaning most can return home the same day.
Most people are surprised to learn that the typical joint-replacement patient can lose from 500 to 1,000 milliliters — the equivalent of one or two 16.9-ounce bottles of water — of blood during surgery. But the rich vascular supply to joints makes that a real possibility. That means those patients often required a post-operation blood transfusion, extending their hospital stay and opening the door to more complications. Tranexamic acid is changing that. First available three years ago, it keeps blood clots from breaking down. Casey says it reduces blood loss during surgery to 50 to 200 milliliters, reducing the need for a transfusion.
Surgical techniques are improving joint replacements, too. And like cardiac surgeons, who have perfected the use of catheters to place stents in arteries or mechanical valves in hearts without splitting open a patient’s chest, or general surgeons, who use scopes to maneuver tiny tools through small incisions in a patient’s abdomen, orthopedic surgeons are working with less on purpose. John Shields, professor of orthopedic surgery at Wake Forest Baptist Medical Center and an orthopedic surgeon at Davie Medical Center, says the key to success is using the smallest incision possible given a person’s unique anatomy, health status and degree of disease. Smaller incisions cause less tissue damage and heal faster, he says.
Casey says smaller incisions are making a big difference in hip replacements. While the time-tested posterior approach requires a surgeon to access the joint through the patient’s lower back, he says an anterior approach provides access through a smaller incision near the patient’s groin. Its advocates claim it spares more muscle. The procedure was developed more than two decades ago but has gained popularity among his colleagues in the last five years. But Casey cautions that a successful recovery depends on more than just the location and size of the first cut. “What matters most is how technically proficient they are in inserting the implant.”
Orthopedic patients also are benefiting from more pain-management options. Prescription narcotics were once seen as the only painkillers strong enough to provide dependable and lasting relief. Tim Harris, a surgeon with Raleigh-based Wake Orthopedics, a physician practice of WakeMed Health and Hospitals, says today’s multimodal approach, which blends pharmaceutical and nonpharmaceutical options, minimizes the risks associated with certain drugs, including addiction, and ensures patients remain comfortable for longer.
The multimodal approach begins in the operating room with a local anesthetic, in many cases the drug Exparel. The numbing effect from this drug can last up to 72 hours, helping patients through the period when they’re most likely to experience the greatest discomfort. Other non-narcotic drugs used today to treat postoperative pain include gabapentin, which is primarily used for neuropathy — numbness most often in the hands and feet — and prescription strength nonsteroidal anti-inflammatory drugs and acetaminophen, he says.
There’s one more benefit to the multimodal approach, says Cliff Sutcliff, president of Winston-Salem-based Novant Health’s Clemmons Medical Center. Patients who use it are more likely to experience easier recoveries because they can start at-home exercises or physical therapy sooner than those who are experiencing discomfort. “After they leave the hospital, the goal is to get patients to rehab as soon as possible. The faster they get moving, the faster they can get better.”
Given the longevity of joint implants — about 25 years — more octogenarians will likely be having their second knee and hip replacements when the youngest baby boomers and oldest Gen-Xers have their first. But as time marches forward, there is one more group of joint-replacement candidates that’s growing, and they aren’t dealing with the osteoarthritis and other degenerative diseases in their knees and hips experienced by older folks. For these younger patients, their weight is the problem.
Atlanta-based Centers for Disease Control and Prevention says almost 38% of Americans age 20 and older are obese. When joints carry more weight than they are designed to handle, Casey says, it doesn’t take 80 years for them to weaken. But with today’s emphasis on patient management at the outset, people with body mass indexes too high for surgery still have to reach more desirable weights before they are eligible for joint replacement. People can’t prevent arthritis, but they can delay its effects as long as possible by maintaining a healthy weight and exercising. After all, joint replacement surgery is elective. It’s the last choice for patients who have run out of options for improving their quality of life. As Christopher Barsanti, chief of orthopedics at Greenville-based Vidant Medical Center and a surgeon with Orthopedics East, puts it, “Our job is to keep people out of the [operating room].”
Barsanti says he never would have imagined during his residency 30 years ago that patients would be leaving the hospital 12 to 24 hours after surgery. Today, almost all his patients go home that soon. “Who knows what is going to go on 10 to 15 years from now? I always think that we’ve gone as far as we’re able to, but [researchers and device companies] always come out with more.”
Charlotte surgeons are building a better prosthetic hand
A shark cut short Tiffany Johnson’s June trip to the Bahamas. She was snorkeling when it attacked, biting her right arm. Local emergency-room surgeons stabilized the wife and mother of three from Concord as best as they could before sending her to Charlotte, where two orthopedic surgeons tried to save her arm and hand. When they couldn’t, they fitted her with the next best thing — a prosthetic that she can control with her mind.
Glenn Gaston and Bryan Loeffler practice with Charlotte-based OrthoCarolina Hand Center and OrthoCarolina Research Institute. They’re improving their patients’ quality of life with technology that was considered science fiction until recently. Their work with myoelectric hands, which use biological controls to operate mechanical pieces, is part of a movement to make prosthetic limbs stronger, more comfortable and intricately controlled.
Loeffler and Gaston’s work began in the cadaver lab, where they tested a theory: What if the small muscles that move individual fingers could move the fingers on a prosthetic hand? After ensuring they could preserve enough blood supply and nerves to make their theory reality, the two surgeons collaborated with the Hanger Clinic, part of Austin, Texas-based prosthetics and orthopedics provider Hanger Inc., on how much bone to remove to ensure the prosthetic componentry maintained a normal hand length.
The two doctors made headlines last year when they fitted a patient with the world’s first working myoelectric hand. The recipient was a young man who lost three fingers at the knuckle on one hand in an industrial accident in May 2016. They transferred muscle from the recovered fingers to the back of his hand and wrist, keeping the all-important nerves and blood vessels intact. The patient now uses those muscles to control his prosthetic fingers.
Gaston says it didn’t take long for the motivated patient to be able to perform tasks with his new hand, such as pick a flower or hoist a 20-pound weight. Those actions would be awkward or impossible with conventional prosthetic hands. “He really inspired us,” Loeffler says. “He was really the genesis of a new clinic we’ve just opened for patients with amputations of their upper extremities. Philosophically, the approach to amputation has been, ‘Cut it off and move on.’ We view losing a limb entirely differently, as more reconstruction. Our goal is to provide something that’s comfortable, that incorporates a level of dexterity and is as controllable as possible.”
That work was the basis for Johnson’s procedure, a targeted muscle reinnervation. Loeffler and Gaston extracted muscle tissue from her damaged hand and transferred it to what was left of her arm. Once Johnson’s prosthetic hand and forearm were complete, she started learning how to use them, even though it would be two or so months before the remaining portion of her arm would be healed enough to wear the device. At one point, she could move her new hand while it was on an adjacent table.
The future looks even brighter for prosthetics. Gaston says technological advances with sensors could allow patients to experience sensations — such as temperature, pressure or pain — with their devices. While the benefits of such additions would be welcomed by patients now, their availability won’t be time sensitive. “We can do these surgeries right away, and we can do them years later,” Loeffler says. “As long as they have enough existing nerve endings, we can make it work.”