En español | After playing football in high school, running track year round as an NCAA All-American and later coaching track, Lee McGinnis eventually paid the price in his hips. “It got to the point where I couldn't even work out anymore, the pain was so bad,” says McGinnis, 71, a retired college English instructor in Wheaton, Illinois. Told in spring 2020 that he would need both hips replaced, McGinnis worried about the timing. As his wife, a retired nurse, says, “In the middle of a pandemic, no one wants to be in the hospital."
Fortunately, his orthopedic surgeon also explained that McGinnis could have joint replacement surgery as an outpatient in the hospital. On May 29, McGinnis had his right hip replaced at Central DuPage Hospital. On Aug. 17, he returned for his left. To facilitate his ability to go home the same day of both operations, he was given spinal anesthesia instead of general anesthesia. He was sent home with both a cane and a walker.
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Beyond that, he says, “my doctor told me we could do as good a job with rehabilitation at home as in the hospital.” Indeed, after doing exercises on his own and later attending physical therapy sessions, McGinnis is back to walking, bicycling and playing golf again.
The COVID-19 pandemic has hastened the trend toward more outpatient total knee and hip joint replacement surgeries at hospitals throughout the country. At the Northwestern Medicine Regional Medical Group (which includes Central DuPage Hospital), in the six months before the COVID-19 pandemic 14 percent of hip and knee joint replacement surgeries were done as same-day surgery; in the six months after the pandemic began that figure jumped to 27 percent.
NYU Langone Health in New York City saw a similar increase. “One of the unintentional consequences [of the pandemic] is patients who were previously apprehensive about going home the day of surgery now want to go home the same day to recover in their own environment,” says William Macaulay, M.D., chief of the Division of Adult Reconstructive Surgery in the Department of Orthopedic Surgery there.
Pain control shifts key to the outpatient procedures
What's made same-day operations possible, doctors say, are changes in surgical protocols — such as the use of minimally invasive techniques — and a better understanding of pain-control measures. High on the list is the ability to use a short-acting spinal anesthetic, rather than general anesthesia. With this approach, “there's less risk of a blood clot and less risk of nausea and vomiting post-surgery,” says William Sterba, M.D., an orthopedic surgeon at Northwestern's Central DuPage and Delnor hospitals. “The surgeries are about an hour in length, and with a short-acting spinal anesthetic, by the time the patient gets to the recovery room, they're starting to wiggle their toes.”
Sterba says such “early mobilization” of the patient is always a goal, but the swifter surgery also offers a cognitive benefit. “If you're given a short-acting anesthetic, your brain is able to shake that off fairly easily,” notes Matthew Squire, M.D., an orthopedic surgeon and codirector of the joint replacement service at the University of Wisconsin-Madison's UW Health. Given the ongoing opioid epidemic, surgeons are minimizing the use of narcotic pain medications, instead sending patients home with instructions for using nonsteroidal anti-inflammatory drugs and other pain-relieving agents.
These trends seem to have positive effects for many patients. A study in the September 2020 issue of Arthroplasty Today compared the results of hospital-based same-day discharge and inpatient total hip replacements, and found that while both sets of patients had comparable postsurgical pain scores, those who had outpatient surgery reported better physical and mental functioning after 12 weeks; those who went home the same day also had lower readmission rates.
How to know if you might recover at home
Deciding who is a candidate for outpatient hip or knee replacement surgery is done on a case-by-case basis. “The ideal candidates are between 45 and 75 and have good social support in their homes,” Squire says. This is especially important when it comes to assisting with mobility for the first week or two after surgery. On the other hand, patients who have multiple comorbidities — such as heart disease, lung disease or poorly controlled diabetes — aren't good candidates for such outpatient surgeries because they need to be monitored closely postoperatively.
Even after the pandemic passes, some experts believe outpatient total joint replacement surgery will continue to grow. “I think this is a trend that's here to stay,” Macaulay says. “Once the general public sees people doing this, they're going to feel more comfortable about it.”