Archive July 2017 XVIII, No. 7

Same-Day Hip Success

Today's total hip replacement patients are back in their recliners before they know it.

Dan O'Connor, Editor-in-Chief

same-day hip surgery MINIMAL TRESPASS Smaller-incision, muscle-sparing surgical techniques for joint replacement contribute to a successful surgery and recovery.

HAIRY BUFFALO
Multimodal Pain Management

Buffalo's multimodal pain management regimen includes steroids, regional blocks, anti-inflammatories and the "Hairy Buffalo," a cocktail consisting of: tranexamic acid (2 grams), liposomal bupivacaine 20 mg (22 gauge needle), morphine 10 mg, bupivacaine 0.25% with epinephrine 10 mg and peripheral nerve stimulation by NSS (Neuro-Stim System). Total volume: 80 cc for hips.

Hip replacement patients also receive extended-release opioids (OxyContin 20 mg BID or MS Contin 30 mg BID), short-acting opioids (Percocet 5/325 mg or Norco 5/325 mg every 4 hours), anti-inflammatory (Celebrex 200 mg BID or Mobic 15 mg daily), CTE prophylaxis (enteric coated aspirin 325 mg BID x 4 weeks), treatment for constipation (Senna-S daily [softener and laxative] or Mag Citrate 150 mL BID), antibiotics (Keflex 500 mg QID for 1 day), treatment for urinary retention (Flomax 0.4 mg once) and antiemetic (Zofran 4 mg every 8 hours). The ASC discontinues post-op opioids 3 months following surgery.

— Dan O'Connor

Jeannette Moretti, RN, remembers what hip replacement was like 15 or 20 years ago, back in the old days when total joint surgery was very invasive, pain control was primitive and the patient was immobile for days. Admitting these patients the night before surgery and for 3 or 4 nights afterward was necessary. Surgery took a minimum of 3 hours and required 10 to 12 instrument trays. Following hospital discharge, some patients would require further care at a rehabilitation facility.

My, how times have changed. Fast forward to today and it's get hip, go home.

Patients arrive 2 hours before surgery. It's wheels in, wheels out in 90 to 100 minutes. Depending on the implant, you can get by with 4 to 8 size-specific instrument trays. And thanks to muscle- and tendon-sparing surgical techniques and innovative pain management protocols, patients are back in their recliners before they know it. They spend 2 hours in PACU and 1 overnight in an off-site recovery suite before they're discharged home.

"It's come a long way since I first started doing hips 20 years ago in the hospital," says Ms. Moretti, director of the Buffalo Surgery Center in Amherst, N.Y., which has developed one of the country's top same-day joint replacement programs and recently christened a 28,000-square-foot multi-specialty surgery center with 4 ORs dedicated to total joints and a $200,000 OR table that's specifically designed for an anterior approach during hip replacement, a muscle-sparing technique that leads to the faster recoveries.

Buffalo Surgery Center launched its same-day total joints program nearly 3 years ago, one of the first freestanding facilities to offer same-day discharge. Of Buffalo's total joint volume in 2016, hips represented 46%, while knees were 54%.

Of the 340,000 hip replacements performed annually in the U.S., it's becoming increasingly common for patients never to step foot inside a hospital. Buffalo's surgeons rehearsed and honed their same-day total joint protocols in the hospital — working on ways to send patients home even though they weren't — and then conducted start-to-finish dry runs at the surgery center until they'd mastered all the elements needed for same-day discharge: reliable pain control, exquisite surgical technique and at-home rehab programs.

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