Blog

Rapid Recovery in Total Joint Arthroplasty


Dr. Shah is an author in the latest edition of Rapid Recovery in Total Joint Arthroplasty.

Rapid Recovery

Anesthesia Considerations

03 April 2020
Over the past decade, there has been a growing interest in performing primary total joint arthroplasty in an outpatient setting. One of the most important factors in making this a reality is the development of rapid recovery anesthesia protocols and utilization of multidisciplinary care teams focused on getting the patient discharged home as quickly and safely as possible. With an increasing number of total hip and knee replacements being performed at freestanding surgery centers, the immediate safety net of a hospital is no longer available. Careful patient selection and appropriate anesthesia administration tailored to the outpatient setting have become paramount. Anesthesiologists now play a greater role in screening patients, minimizing narcotic administration, and facilitating early ambulation. It is critical that both the surgeon and the anesthesiologist understand the shared goals of treatment in order to give them the best chance to provide a positive and safe experience during outpatient surgery for their patients.

Follow-Up Care Just a Click Away


Actively engaging patients in their care remains a key driver in
improving outcomes and lowering costs. Surgical patients can now
use their smartphone to stay on track—and ask for help—before and
after a procedure, all at the click of a button.


GetWell Loop is a mobile app that offers easy, two-way
communication, both to and from the surgeon’s office. Advocate
Aurora Health surgeons in Illinois use the tool to connect with
their patients before surgery, during their inpatient stay and after
discharge. During the first 90 days following discharge, when
readmissions are most likely to occur, patients receive automated
“check-in” text messages to see how they are recovering.


Since launching a GetWell Loop pilot in 2016 across orthopedic
surgery settings in Illinois, this innovative tool has engaged patients
to partner with their surgeon to achieve better outcomes.


The tool now covers all surgical specialties and is used to connect
with patients as part of the Medicare Bundled Payment Program—
ensuring care is coordinated following an inpatient hospital visit.
To date, nearly 2,000 patients have been invited to use GetWell Loop,
with 73 percent of these patients activating and routinely using their
account. Of these patients:

  • Over 83 percent report they were able to avoid unnecessary follow-up office visits
  • 93 percent report they are “extremely likely to recommend” their providers

GetWell Loop’s automated daily engagement feature encourages
patients to become active stakeholders in their own health.
It empowers them to reach out for information or advice they feel
they need, when they need it. Remote guidance and monitoring
keep surgical patients on track toward a successful recovery.


Addressing the Opioid Crisis


Following surgery, many patients head home with prescriptions
for opioid painkillers. The American Society of Anesthesiologists
recommends using prescription painkillers sparingly after surgery.
To avoid the potential for opioid addiction, surgical patients need to
be properly educated about the risks and benefits of opioids—before
their surgery takes place. GetWell Loop is helping in this effort, as
health care organizations can customize the content of this digital
app to meet their own patients’ needs. With this in mind, Advocate
Aurora Health created several short videos on the topic of opioids
that surgical patients are encouraged to view on GetWell Loop.


These short videos include easy-to-follow instructions explaining the
proper use of drugs after surgery and how to dispose of any unused
opioids. These videos are now available to all Advocate Aurora Health
surgical patients—in both Illinois and Wisconsin.


Keeping Patients on Track for a Rapid Recovery


Ritesh Shah, MD, Orthopedic Surgeon, adopts new advances that
allow many joint replacement patients to walk out of the hospital 90
minutes after surgery and resume their active lives in days or weeks.
Such rapid recoveries are made possible because of new advances in
surgery, anesthesia, physical therapy and importantly—proper patient
preparation and education.


Closely following these “rapid recovery” patients once they leave the
hospital is crucial to the healing process and the success of joint
replacement surgery. Dr. Shah believes the GetWell Loop has made
keeping tabs on surgical patients more efficient.


“It is a very helpful tool to engage patients after they leave the
hospital setting,” he says. “I can check on how they are doing at
home, address any concerns they may have in a timely manner and
follow their outcomes as the treating physician.

Does It Matter: Total Hip Arthroplasty or Lumbar Spinal Fusion First? Preoperative Sagittal Spinopelvic Measurements Guide Patient-Specific Surgical Strategies in Patients Requiring Both


Background

In patients requiring both total hip arthroplasty (THA) and lumbar spinal fusion (LSF), consideration of preoperative sagittal spinopelvic measurements can aid in the prediction of postfusion compensatory changes in pelvic tilt (PT) and inform adjustments to traditional THA cup anteversion. This study aims to identify relationships between spinopelvic measurements and post-THA hip instability and to determine if procedure order reveals a difference in hip dislocation rate.

Methods

Patients at a single practice site who received both THA and LSF between 2005 and 2015 (292: 158 = LSF prior to THA, 134 = THA prior to LSF) were retrospectively reviewed for incidents of THA instability. Those with complete radiograph series (89) had their sagittal (standing) spinopelvic profiles measured preoperatively, immediately postoperatively, and 3 months, 6 months, 1 year, 1.5 years, and 2 years postoperatively. Measured parameters included lumbar lordosis (LL), pelvic incidence (PI), PT, and sacral slope (SS).

Results

No significant differences in dislocation rates between operative order groups were elicited (7/73 LSF first, 4/62 THA first; Z = 0.664, P = .509). Compared to nondislocators, dislocators had lower LL (−10.9) and SS (−7.8), and higher PT (+4.3) and PI-LL (+7.3). Additional risk factors for dislocation included sacral fusion (relative risk [RR] = 3.0) and revision fusion (RR = 2.7) . Predictive power of the model generated through multiple regression to characterize individual profiles of post-LSF PT compensation based on perioperative measurements was most significant at 1 year (R2 = 0.565, F = 0.000456, P = .028) and 2 years (R2 = 0.741, F = 0.031, P = .001) postoperatively.

Conclusion

In performing THA after LSF, it is theoretically ideal to proceed with THA at a postfusion interval of at least 1 year, beyond which further compensatory PT change is minimal. However, the order of surgical procedure revealed no statistical difference in hip instability rates. In cases characterized by large PI-LL mismatch (larger or less predictable compensation profiles) or large SS or LL loss (considerably atypical muscle recruitment), consideration of full functional anteversion range between sitting and standing positions to account for abnormalities not appreciated with standing radiographic assessment alone may be warranted.

Read the full article here.

CME: Total Joint Arthroplasty in the Ambulatory Setting


The number of hip and knee joint replacement surgeries performed in an outpatient setting is expected to grow 73% from approximately 1.1 million today to approximately 1.9 million by 2026. There will be a significant migration of these cases from the inpatient to the outpatient setting.

Join us for a free one-day CME seminar to learn about the various components needed to successfully manage the transition from inpatient to ambulatory surgery. 

Attendees will learn about the important role of the surgeon champion, the innovative anesthesiologist, and the motivated patient. This knowledge will help surgical teams reduce costs, improve the patient experience, and lower the risk for healthcare acquired infections.

Course Chairman: Ritesh Shah, MD, Orthopedic Surgeon of the Illinois Bone & Joint Institute

Keynote Speaker: Richard A. Berger, MD, Associate Professor at Rush University Medical Center

VIEW AGENDAAmbulatory Surgery Center administrators

To learn more click here.

Suburban Women’s Magazine: Rapid Recovery is A Reality for Patients Seeking to Return to Active Lifestyles


Dr. Shah is a nationally recognized orthopedic surgeon whose mission is to get active joint replacement patients back on their feet as quickly as possible. As a leader in his field, Dr. Shah teaches colleagues worldwide about new advances in same day hip and knee replacement, hip arthroscopy, and joint revision surgery. 

Dr. Shah’s typical otherwise healthy hip and knee replacement patient walks with a cane about one hour after surgery, returns home after ninety minutes, and is back to a light workload in a few days or weeks. Such rapid recoveries are possible because of new advances in surgery, anesthesia, physical therapy, and patient preparation. Recovered patients typically go back to skiing, hockey, and tennis. One former hip replacement patient is a horse trainer at Arlington Park; a hip arthroscopy patient is currently a professional race car driver. 

Dr. Shah is also an expert in hip arthroscopies. This procedure relieves hip pain in younger patients with cartilage tears and may prevent otherwise inevitable joint replacement surgery later. 

Dr. Shah shares, “Patients often wait far too long to have their hip and knee pain evaluated. This unfortunately leads to limiting various activities that impact quality of life and promote muscular and skeletal weakness further aggravating discomfort. Avoiding activity due to pain often leads to weight gain as well. We perform a very thorough assessment that will give the patient a road map for their care that makes return to function a priority and may combine several approaches that may or may not include surgical intervention. The average person will struggle with hip and knee pain for over 3 years before seeking treatment. We seek to return our adult Ritesh Shah, M.D. patients of all ages back to full function as quickly and effectively as possible. Patient experience matters to us very much, and we make detailed education a priority so that anxiety is reduced and confidence in the process is there.” 

Dr. Shah largely credits his results to a team- approach to orthopedic care. The practice objective of “Rapid Recovery Reality” is only possible because of a leading-edge anesthesiologist, a consistent and expert operating team, and leading physical therapists both in home and outpatient settings. 

Dr. Shah is a graduate of University of Chicago Pritzker School of Medicine, completed his residency at Northwestern University Feinberg School of Medicine and received specialized training through his Fellowship at Washington University School of Medicine where he gained additional expertise in Joint Preservation, Resurfacing, and Reconstruction. 

Dr. Shah is affiliated with Illinois Bone and Joint Institute and is on staff at Advocate Lutheran General, Advocate Illinois Masonic and North Shore University (Evanston) Hospital. 

A Tennis Player’s Total Right Hip Replacement


Tennis is my passion and I have been playing for 46 years and I am a solid 4.5 player still.  I was told that I was bone on bone (along with two bone spurs) 5 years ago. At that time I went for meetings with three other hip/knee surgeons, two at Northwestern and one at Rush.  All told me that I needed immediate replacement. They also told me that there was no guarantee that I could play at the same level again after replacement. That scared the heck out of me.  I decided to wait.

Mid-year in 2017, I was limping and pretty sore after any tennis or long walking.  I had heard about Dr. Shah from someone at my tennis club. I went to see him and heard answers that I could have only dreamed of!  Outpatient and home the same day. Back on the Tennis court in 3 weeks making sure to be safe (hitting, not running). I interviewed three of his hip replacement patients and got rave reviews. (they were all tennis players and coaches).   I had my hip replacement on Dec 27th,2017.  It was very cold and icy outdoors so I played it safe and staying indoors and did two weeks of PT at home before going to the Physical Therapist location.  It was amazing to be able to sleep with both legs flat on the bed again and not having to change positions every 45 minutes during the night. As promised, I was back on the tennis court at 3 weeks, standing and hitting tennis balls and feeling pretty happy.  After six weeks, I started to include lateral movement on the court and at eight weeks, I was drilling at almost where I had left off. I continue to do strengthening exercises as everything continues to get stronger!

The attached picture here was shot on April 15th, 3 ½ months after hip replacement and I had just played 90 minutes of doubles.

I can’t say enough great things about Dr. Shah and his team and have already sent two new patients over to him who were very grateful after their surgeries!   

A Marathon Runner’s Bilateral Hip Labrum Tear Story


I am a competitive amateur marathoner who had completed 21 marathons prior to my injury. I began having muscle pain in my stomach and groin area and I thought it was just a muscle pull. The pain was manageable with naproxen but it progressively got worse so I went to my GP. He thought it may be a hernia so he in turn sent me to a surgeon.  The surgeon promptly told me I did not have a hernia, but just a muscle strain and prescribed PT for 6 weeks. The pain got a little better so I just kept running and taking naproxen.  After the pain got worse with more weekly mileage I returned to the surgeon who told me that I still did not have a hernia. The insurance company finally agreed to pay for an MRI that revealed I had torn cartilage in my right hip due to a natural impingement I was born with but did not manage to affect me until I was 48 years old.

I then saw an orthopedic surgeon out of a practice through a major Chicago hospital (many of whom are team doctors to local Chicago sports teams). He told me that he could repair the tear but that I could never run again and if I tried I would be facing full hip replacement surgery in a year or less. I was devastated by this news but thought it would be prudent to get a second opinion. I saw Dr. Shah and he told be that my MRI revealed that I did still have a significant amount of healthy cartilage left and that he felt I had a good chance of returning to running. I did some follow up homework on Dr. Shah with a friend of mine who is a radiologist and he said he had heard good things about him from peers and his patient success rates for my type of procedure were excellent so I scheduled my surgery with him.

Following the surgery Dr. Shah told me that it had been a successful hip scope and that I had 70% of my cartilage left.  I patiently went through the slow process of physical therapy including 3 weeks on the passive motion machine for 4 hours a day, always wearing the hip brace, riding an upright bike 3 days after surgery, walking on crutches for 6 weeks, using an elliptical trainer after 7 weeks and not running until 3 months. I was able start running a few miles a day at first after 3 months and by 4 months post-op I was up to 40 miles per week. 6 months out from surgery in the summer I ran one of my fastest 10k races in several years!  

Then into my fall marathon training my left hip had the same impingement and I tore the cartilage in that one. This time I did not have to go through unnecessary PT and was able to schedule the surgery immediately. I went through the exact same rehab protocol and was running again at full speed in 4 months! Because I caught the injury sooner Dr. Shah reported that I had 90% healthy cartilage in this hip. 7 months after surgery I was peaking at 70 miles per week in the early spring and went on to run my first marathon in over 2 years! I won my age group and had no pain whatsoever in either of my hips. I ran another marathon in the fall and also won my age group and have been running pain free since. Just last week I was in Arizona and had 3 separate long hikes in challenging locations like the Grand Canyon and was able to stay in step with my 20 year old daughter.

I know that there are doctors out there that are not as experienced in reattaching torn cartilage to people's hips and it saddens me to think that there are a lot of runners and other athletes out there with unnecessary total hip replacements that will never have their full active lifestyle back. Obviously everyone's conditions and injuries are different so their outcomes may be worse than mine but just make sure you ask your prospective physician not only how many of these types of procedures they do a month but, more importantly, what their patients outcomes are post-op. Then ask to speak to patients they have worked on who have been able to resume their sport to see how things went for them. 

I cannot thank Dr. Shah enough for his expertise and counsel. He even recommended I started taking yoga to make my tight runner's body more flexible and that in turn has helped me with some back pain I had been experiencing. I now have running back in my life and could not be happier. I am not running as fast as I did when I was 35 but I am still very competitive for my age and get to do what I love- running with my own hips and participating in any physical activity I desire.  

Jack Goldberg

President

BirdDog Media, LLC

IBJI Wins the Award for the Best Physical Therapy in the Entire North Shore!


Congrats IBJI Physical Therapy!
IBJI was voted the Best Physical Therapy in the entire North Shore for the 2019 Choice Awards, presented by 22nd Century Media. Votes are taken over four weeks from their readers in all seven of their newspapers. IBJI staff were happy to accept the award. Staff had a great time at the award ceremony, meeting other winners and watching a performance by a juggler! Be sure to read pages 12, 13 and 20 in 22nd Century Media's publication and check out the pictures below! Keep up the great work team!

Orthopedics Blue Ribbon ARTICLE Award


Dr. Shah was recently awarded a Blue Ribbon ARTICLE Award for his work in changing the way we manage blood clot prevention after total joint replacements. 

Aspirin Alone Is Not Enough to Prevent Deep Venous Thrombosis After Total Joint Arthroplasty


Abstract

Thromboembolic events after total joint arthroplasty are potentially devastating complications. This study evaluated the efficacy of 4 different anticoagulants in preventing deep venous thrombosis and pulmonary embolism after total joint arthroplasty. The demographics and anticoagulant use (warfarin, enoxaparin, and aspirin with and without outpatient mechanical pumps) for patients who underwent primary unilateral total joint arthroplasties performed by a single surgeon from January 2013 to October 2014 were retrospectively reviewed. All patients underwent lower extremity ultrasound at the 3-week postoperative visit. A total of 613 primary unilateral total joint arthroplasties met the study inclusion criteria. There were 288 primary total knee arthroplasties and 325 primary total hip arthroplasties. The patients were 62.2% female, having a mean age of 67.6±10.6 years and a mean body mass index of 30.2±5.9 kg/m2. There were 119 patients in group 1 (aspirin alone), 40 patients in group 2 (aspirin plus pumps), 246 patients in group 3 (warfarin), and 208 patients in group 4 (enoxaparin). The overall 3-week symptomatic and asymptomatic deep venous thrombosis and symptomatic pulmonary embolism rates in the entire cohort were 5.7% and 0.3%, respectively. The venous thromboembolism rate was significantly affected by the anticoagulant of choice (P<.01). Compared with aspirin alone, warfarin decreased the risk of venous thromboembolism (P<.01). Increasing age led to increased risk of venous thromboembolism (P=.05). This study indicated that aspirin chemoprophylaxis alone was not as efficacious as warfarin and enoxaparin in preventing asymptomatic and symptomatic venous thromboembolism found during routine postoperative surveillance with lower extremity ultrasound. Aspirin alone may be inadequate and should be augmented with an outpatient mechanical pump as part of multimodal prophylaxis. [Orthopedics. 2019; 42(1):48–55.]

Read Full Article Here