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There’s no denying that COVID-19 changed everything, and while a number of those changes were unsettling, some were for the bet- ter. Such was the case in the world of orthopaedics. According to Michael Lawson Swank, M.D., orthopedic surgeon with Beacon Orthopaedics and Sports Medicine, before the pandemic, hospitals sent 50% to 60% of patients home in the same day following a joint surgery when 80% to 90% could have been discharged in the same day. “It was just inertia, really,” says Swank, who found that patients felt more comfortable with that plan since the coronavirus loomed. Whereas patients once fought to stay in the hospital because they thought they would receive better care, now the fear of going home too soon is less than the fear of staying and getting COVID-19.
“In that respect, COVID-19 was an accomplice I didn’t expect to have,” says Swank. “It set the stage for people to rethink how they view health care and risk.”
Within a few months of the coronavirus invading our country, Swank was performing exclusively outpatient joint surgeries where patients weren’t spending the night.
“It’s not this 23-hour admission stuff that hospitals made up as a less-than-a-full-day surgery,” says Swank. “It’s literally going home within three to four hours post-surgery and this includes patients up to 80 years old.”
This change in practice has major implications for health care because total knee replacements tally as the No. 1 surgical cost for Medicare.
“Ultimately, if we can do these things out of the hospital in an outpatient setting, we’re saving Medicare millions of dollars a year,” says Swank, who is the medical director of Cincinnati Orthopaedic Research Institute. Patients were initially skeptical, however, and right- fully so. In order to do this safely, Beacon has put in place standardized protocols that include treatment pathways, pain management and changes to anesthesia.
Swank employs muscle-sparing techniques — he doesn’t cut any muscle during the time of surgery. And, because he uses spinals and local blocks instead of full anesthesia, patients don’t wake up in pain or nauseated, which are typically two of the big problems following surgery. By avoiding those two major immediate post-op complications, patients are able to safely go home the same day.
While moving the procedure to outpatient surgery with faster recovery and rehab and less pain may send a message that the surgery is no big deal, that’s not true.
“This is a life-changing event,” says Swank. “Your joint is not the same as it used to be. It requires maintenance just like your car requires maintenance. It’s not a passive process.”
Patients come to Beacon because they want their joints fixed, and that requires both doctor and patient effort, Swank emphasizes, offering this analogy:
“All I do is put a hinge on your door so your door can move properly,” says Swank. “The hinge I put in doesn’t make your door move. The patient has got to make the door move. The problem is that people focus too much on the hinge and not enough on moving the door.”
Swank tells his patients it’s a 50/50 deal, meaning that while he must get his part right, they, too, have to put in the effort to ensure they can return to a life of independence and autonomy.
The joint replacement process involves:
- Prehabilitation (getting patients in the best shape prior to surgery)
- Acute phase recovery (getting patients back to range of motion/ walking/off ambulatory aides)
- Strength building (this lasts six weeks to a year and is for recovering lost strength).
- Maintenance (daily lifetime care, including walking and two simple stretches).
“Patients need to walk 30 minutes a day and do simple stretches in order to take care of their joint and keep themselves out of my office,” says Swank.
To help the process along, Beacon assembles a multidisciplinary team consisting of a nurse navigator, anesthesiologists and therapists. To help guide the patient through the perioperative episode of care, Beacon’s staff utilizes a web- and app-based software program to communicate with their patients to ensure they have seen their primary care physicians, completed their labs, gotten in their daily steps, and have seen their therapists.
Because the first six weeks post-surgery are really to restore motion, they have decreased the number of visits in the first six weeks but extended the visits to help patients through the strength-building phase when they require more help. Therapists are monitoring the patients longer and the patients can send physicians messages through the app about how they are doing.
“We can track these patients using a multidisciplinary, real-time record of what’s happening,” says Swank. “We’ve added this tracking and monitoring system so we can broaden our outreach even though we’re seeing people less frequently.”
Beacon uses customization techniques for implant fit and position by getting their patients CAT scans or MRIs ahead of time so that they can precisely fit the implants to the patients as opposed to making judgements about the patient at the time of surgery. Regarding hips, Beacon uses an interoperative computer program based on an X-ray that allows their team, in real time, to get leg length measurements, acetabular cup positions and femoral stem positions.
“All of these things are designed to decrease pain, reduce blood loss and allow for faster rehabilitation because there is not as much trauma, and we are fitting implants to the patients even better,” says Swank, who likens it to fitting a coat.
“When the fit is better, the feel is better. And when the feel is better, you’re likely to move better,” he explains.
Swank estimates that since COVID-19 started, he has performed between 500 and 600 outpatient joint surgeries. Where doubt once sat, gratitude has bloomed — complaints have decreased, patients are doing better, and there is less confusion among providers because they are controlling the whole narrative.
“Many of my patients were skeptical of going home the same day, but they came back and said, ‘Man, this is way better than I thought!’” says Swank, who suspects that COVID-19 will permanently change a number of protocols, and in this instance, that’s a good thing.
“It goes back to the idea that the goal is not to fix something but rather to get someone back to walking and moving more comfortably so that they can maintain their independence, their quality of life and improve their overall health.”