Orthopedic surgeon Ian Katz, MD, of Johnstown-based Western Pennsylvania Orthopedics, recently spoke about what he sees for the future of orthopedic outpatient centers with respect to hip and knee replacements.
Q: What are the most important innovations in outpatient total knee and hip replacements today?
IK: Actually, I'd say that the most important innovations in outpatient total knees and hips today isn't in the field directly, per se. The main improvements have been within anesthesia. If you look between last year and the last few before that, not much has changed. It's the exact same surgical approach in many cases — the exact same prosthesis, but what has changed are these anesthesia practices that allow for better nausea and pain control. Early ambulation. The mitigation of bloodloss. What has allowed us to let the patients go home earlier are these things and that's important to outpatient surgery.
Q: What new technologies or devices could make a big impact on outpatient hip and knee replacements in the future, in your opinion?
IK: The technological changes in implants have been very small — tweaks, really. We haven't seen dramatic changes in knee and hip prosthesis for years. Each manufacturer makes fine little tweaks, but it's the same prosthesis whether you're doing it inpatient or outpatient. They're so minor and so spread out over time, that there's no way to attribute a real, big change. But, again, with anesthesia, and the regional blocks they do, that's something that could improve drastically and affect a lot of outpatient centers. They don't need a general anesthetic; you can anesthetize the leg in a very localized area so you're not having pain. You can do the surgery without any pain and the patient can be immediately awake, mobilized and they don't have to stay overnight.
Q: How are patients responding to less time in the hospital?
IK: Some love it. Younger patients in general are much happier to go home sooner. Some don't like it as much, usually the older patients who like the comfort of being kept for a few days.
Q: How can orthopedic surgeons optimize their outpatient total joint procedures? What do they need to know about transitioning cases from inpatient to outpatient?
IK: The most important thing in transitioning from inpatient to outpatient, in my opinion, is appropriate patient selection. For some patients, outpatient or short stay is definitely the right way to go. For others, it's the exact wrong way to go. The best way to insure success of your transition is choosing the right patients. You choose the wrong ones, they get admitted or they come back and the last thing you want is a high rate of re-admission. It's not for everybody.
Q: Where do you see the biggest opportunities in knee and hip replacement outpatients in the future?
IK: The biggest opportunity is collaboration between surgeons, patients, physical therapists and anesthesiologists. Everybody has to be on the same page. If anybody drops the ball then it isn't a success.
Q: You would say that patients would like more input ?
IK: The case is certainly true for younger patients. They're on the Internet, they're doing home research, they're tech-savvy, they like to be involved in their care and decision making. Those patients like input. The older patients, not so much.
Q: Do you think more knees and hips will be performed in outpatient ambulatory surgery centers five years from now?
IK: It all depends on legislation and regulation from government and insurance companies. If they regulate or legislate in certain ways, then answer is no. But if outpatient centers can be allowed to thrive, I bet we'll see in a spike in the near-future. . I do think that the number will come down after that, however. In five years, I expect the number of outpatient orthopedic knees and hips to be above where it is today but lower than it will be in two years from now.
Q: What do you account for the drop in the future?
IK: I think too many people will try it. It's not for everybody and some will abandon it.
I would actually caution patients and physicians that it's not for everybody. If you have a patient who's in their 80s and suffering from a lot of comorbid medical problems like heart problems, obesity and diabetes, it's probably not for them. If you have a patient who is 45 fit and active , it is probably a good choice for them. It's not for every for surgeon, it's not for every hospital, it's not for every patient.
Q: What should surgeons do if they're dealing with a borderline patient, say somebody who is 65 years old and has a few complications?
IK: If you're in doubt, admit the patient for a day or two to avoid readmissions. You err on the side of being conservative in those cases. Doing an inpatient or outpatient knee or hip replacement should have the same results. The key to success to a hip and knee replacement, is putting it in proper balance and alignment, not whether you do it at a hospital or an outpatient surgery center. It's not where you do it; it's how you do it.
Dr. Katz is board-certified with American Board of Orthopedic Surgery and served as former chief of Orthopedic Surgery at the University of Pittsburgh Medical Center-Lee Hospital in Johnstown, Pa.