The latest surgery techniques

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Ballarat Orthopaedics & Sports Medicine

Rapid Recovery Surgery

Rapid recovery surgery is a philosophy that incorporates anaesthesia, local infiltration analgesia drugs injected around the joint during the operation, medications, mechanics and mindset to achieve the fastest recovery possible. Although not an instant recovery, we continue to strive towards improved outcomes for our patients. Rapid recovery techniques assist in reducing the length of hospital stay, facilitating a faster return to normal activity, and reducing the risk of complications.

PATIENT EXPECTATIONS

A common misconception amongst patients and their families, is that patients undergoing joint replacements need to be in hospital for a week, and often need rehabilitation. We find though that 70% of patients are able to go home after one night in hospital, and a further 20% go home the next day. Improved mobilisation reduces the risk of blood clots, chest and other infections. Our approach to pain management and early mobilisation achieves better outcomes and a positive hospital experience.

There is an international trend towards day surgery for joint replacement surgery. We believe we have all the necessary controls in place to do this in Ballarat, although during our pilot program, will be doing only Ballarat based patients for total joint replacements. We have already been doing partial joint replacements for Ballarat and out of town patients.

ESTIMATING DISCHARGE DAY FOR JOINT REPLACEMENTS

We have been using our own scoring system to determine patients who are suitable for day surgery. Medical conditions need to be mild and well controlled, you need to live relatively close by, have someone at home, or someone prepared to stay the first night, you need to be reasonably mobile prior to surgery, not depressed or anxious, and calm about the idea of day surgery.You, or your carer, need to be able to apply compression stockings to wear during the day, and the surgery routine joint replacement. A physiotherapy session is required to confirm your ability to use a crutch to walk after surgery.

We find that folk that aren’t perfect in all of those regards are better being done in a hospital with an overnight bed available, or even book a bed for the night.

Patients that don’t come close to achieving three items might be wise to have rehabilitation after surgery. We consider and score every patient, and have a discharge plan prior to admission to hospital. We have a good number of patients in their late 80s & early 90’s go directly home only two days after surgery.

OUR APPROACH TO BLOOD THINNERS

Injection treatments (e.g. clexane) for two to five weeks was popularised twenty years ago. The evidence for its effectiveness has been seriously questioned. For normal patients, a small dose of aspirin is just as effective, and seems to reduce cardiac and stroke events. A paper published in Denmark indicates that normal patients, with a hospital stay of less than five days, should cease any injection treatment on discharge.

We define normal patients as not having a history of blood clots, or a family history of blood clots, and no known blood clotting disorders. For higher risk patients, we stratify the risk and provide more aggressive treatment.

For normal patients we use low dose aspirin and class two compression stockings. For hip replacements we rarely see DVT’s. In knee replacements, small DVT’s are seen 20% of the time, and are treated with the same compression stocking, and the same aspirin dose.

AVOIDING NARCOTICS AFTER JOINT REPLACEMENT

Whilst the operation is being performed, your surgeon will inject around the joint with a combination of drugs. This ensures when you wake, you will be relatively comfortable, and you will be able to begin to mobilise two hours after surgery. In addition, some pain relieving & anti-inflammatory tablets and a pain patch (Norspan) will be used. We have found for almost all patients, we can avoid using short acting narcotics. Avoiding narcotics reduces hospital stay, constipation, sleep disturbance and chronic pain problems.

RAPID RECOVERY OUTSIDE OF JOINT REPLACEMENT

The philosophy of Rapid Recovery Surgery also extends to other surgery including injury management. Ankle fractures were historically treated with the patient using crutches for six weeks before weight bearing was permitted. With the introduction of new techniques, weight bearing can commence once the wounds have healed (about two weeks) and the joint can be exercised through a range of movement. At six weeks the majority of injuries can be “ready to go”. Achilles ruptures, wrist fractures, shoulder surgery, and virtually all orthopaedic treatments benefit from this approach.

References:
LB Oldmeadow, H McBunney, V Robertson.
Predicting risk of extended inpatient rehabilitation after hip or knee arthroplasty. J Arth 2003;18-6:775-9
EO Pearse, BF Caldwell, RJ Lockwood, J Hollard,
Early mobilisation after conventional knee replacement may reduce the risk of postoperative venous thromboembolism. JBJS (Br) 2007, 89-B: 316-22
Eva N Glassou, Alma B Pedersen, and Torben B Hansen
Risk of re-admission, reoperation, and mortality within 90 days
of total hip and knee arthroplasty in fast-track departments in
Denmark from 2005 to 201. Acta Orthopaedica 2014; 85 (5): 493–500 493

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