Total Joints at a Freestanding ASC? Why Not?

Chris McClellan, DO, Altoona, Pa.

October, 2013

Last January, our team here at Advanced Center for Surgery looked at the 500 or so total knees and hips I perform each year and asked ourselves, "Why aren't we doing more of these outpatient, in our ASC?" We couldn't find a good reason, and so we began. Now we've done 50 of them.

Some readers may find this shocking. Total joints as an outpatient ASC procedure? But take a look at the big picture, and see if you don't agree.

A decade or so ago, total knees involved 8-inch incisions, large incisions of the quadriceps muscle and tendon, patellar eversion and significant blood loss. Most patients got general anesthesia only, and suffered severe pain and PONV post-op.

But all that has changed. Today, we use minimally invasive surgery with minimal trauma to the quadriceps and tendon. Blood loss is minimal because the surgery is so quick; we can complete knees in about 35 minutes, and that will improve. Total hips have undergone a similar evolution.

Importantly, we no longer use general anesthesia. Our top-notch anesthesia team uses a low dose spinal anesthetic for the procedure, a single-shot sciatic block and a continuous nerve block at the femoral plexus. Studies show this approach reduces pain, PONV, respiratory depression, PE and ileus.

The program has been amazingly successful:

  • All 50 of our patients have gone home after 3 to 4 hours of recovery, vs. the traditional 2-3 days. Patients are up and walking in the PACU. They go home to a program of aggressive physical therapy, made possible by their anesthesia. A nurse preinspects the home and monitors the patients there for 3 days. There have been no falls.
  • Day 1 post-op pain scores are virtually always under 3, and frequently 0; there are very few complaints of breakthrough pain. The continuous nerve block lasts for 2 to 3 days, by which time the most intense pain has subsided.
  • It's early, but so far there've been no significant complications. One patient experienced PONV. But we've had zero post-op infections and zero DVT. Being out of the hospital helps with the former, and the aggressive PT helps with the latter.
  • Patient satisfaction is sky-high. No patient has said "I wish I had my procedure done in the hospital." The more common response is, "I would definitely do this again and refer my friends."

There are important financial implications, too. At our ASC, we can do total joints for about a third of the cost of hospitals. Just by cutting out the hospital stay, we save about $5,000. We are in negotiations with insurers about how to cut costs even further by streamlining payments to the various providers -- a step toward bundled payments.

I don't want to mislead anyone: There are many challenges to a program like this. Your surgeon has to be efficient. Your anesthesia team must be very skilled with ultrasound-guided nerve blocks and continuous catheter placement. Your home health team must have a plan for making sure patients can recuperate safely.

Still, we believe a revolution is underway. In the U.S., we do about a million total knees and hips each year, at a cost of more than $20 billion. Health reform is about improving outcomes and decreasing costs, and that's exactly what our surgical group and ASC are implementing. This is great for our local community and it will be outstanding for U.S. health care. I don't see how anyone can argue that point.

Dr. McClellan is a board-certified orthopedic surgeon at University Orthopedics Center. Special thanks to David Berkheimer, CRNA, for assistance with this article.


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