23 hour or Outpatie atient nt ASC outpatient Rehab Patients - - PowerPoint PPT Presentation

Inpatient Surgery Hospital Day 1 Hospital Day 2 Hospital Day 3 Inpatient Rehab

ASC 23 hour or

• utpatient

Outpatie atient nt Rehab

 Patients don’t need prolonged

hospitalization

• More functional
• Pain control
• Blood management

 Patient centered approach  Cost effective

 Organization  Patient selection  Preparation  Execution

 ASC director  Insurance issues  Materials management/Vendors  PACU/23 hour stay  Rehabilitation

 Appropriate total joint candidate  Insurance  Medical clearance  Communication and Education  Motivated to improve  Important decision in the early

cases performed at ASC

 Patient education is paramount!  Prehab  Medical staff education

• Anesthesia
• Nurses
• Surgical staff
• Therapist

 Instruments

• Sterilization
• Multiple sets
• Power equipment
• Bed set-up
• Fluoroscopy

 Implants

 Pain management

• Preoperative
• Intraoperative
• Postoperative

 Home equipment  Rehab

 Hospital back-up plans

 Simulate first  Team approach

• Anesthesia
• Nurses
• Therapists
• Surgeon
• Surgical staff

 Dr. Domb

• Performs Hip

Arthroscopy and THA at ASC

• Two techniques

 Traditional  MAKO robotic-assisted technology

 Patient Selection!

• Assessment of pain

prior to procedure

• Evaluation of

comorbid conditions and current health status

• Insurance pre-

approval process

• Research evaluating

clinical outcomes

Hip Arthroscopy: What is Treatable Today?

 Labral tears  Femoro-acetabular impingement (FAI)  Instability  Borderline Dysplasia  Gluteus Medius Tears  Snapping Hip

Labral Base Refixation in the Hip: Rationale and Technique for an Anatomic Approach to Labral Repair

Robert Fry, M.D. Benjamin Domb, M.D.

Simple Stitch

Labral l Base e St Stit itch

• Labrum everted + bunched
• No contact with femoral

head

• No suction seal

1. Triangular shape preserved 2. Restore transitional zone 3. Restore suction seal

Domb, Giordano, Philippon Arthroscopy 2013

Large Full Thickness Tear Double-Row Suture-Bridge Repair

Tendon Trochant er

• 3D virtual pre-op implant planning
• Navigated stem placement
• Haptically guided acetabular

preparation & placement

• Combined Version
• Hip Length
• Hip Offset

 More accurate

positioning of implants with:

• Robotic arm guidance
• 3-D visual feedback
• Real-time data

 Decreased likelihood

• f mechanical failure

 Improved outcomes

(scree creen shot – femur/ r/tibia) ibia)

• 1. Plan & Broach

Femoral Stem

• 2. Combined Anteversion

Assessment

• 3. Pre-operative

Cup Planning

• 4. Robotic Cup

Placement

• 5. Quantified Surgical Report

2 1 m 37°

 Inputs:

• Patient CT Scan
• 3D Bone Models
• Size of Implant
• Center of Rotation
• Inclination
• Version
• Native Femoral

Version

Inputs: → 3D Templating → Neck length is selected based on patient anatomy Outputs: ← Planned neck resection plane ← Complete visualization of the planned implant positions ← Measurement of final broach position

• Femoral version is

difficult to control in a cementless, broach-

• nly, system
• Therefore, the

planned cup version is updated intra-

• peratively based on

the femoral version achieved during broaching

(Dorr, CORR 2009) (Jolles, JoA 2002)

Software Provides: ← Complete visualization of the planned implant positions ← Predicted hip length ← Predicted offset

Resected bone 0.5mm 1mm

• 1. Visual Feedback:

Green/White/Red

• 2. Tactile Feedback:

Haptic Stiffness (0.5-1mm)

• 3. Audible Feedback:

Beeping (0.5-1mm)

• Robot haptically

guides both reaming & impaction

• Real-time

numeric & graphical representation of the progression of reaming & impaction

Conical Haptic

• Initial Reaming

Line Haptic

• Reaming, Impaction

 Continued assessment of THA outcomes

based on:

• Component placement
• Leg length discrepancy
• Global offset
• Predictive vs actual positioning
• Comparative studies or various approaches

 Published articles in:

• CORR
• Journal of Arthroplasty
• Orthopedics

 Analgesia in THA

involves multimodal analgesia

 Postoperative opioid-

related events can slow recovery and increase patients’ length of stay

 Long-acting local

anesthetics can reduce early postoperative pain at the surgical site

 Decreasing opioid

use while maintaining adequate pain control could reduce:

• opioid-related events
• increase patient time

to first ambulation

• decrease length of

stay

 Research comparing the effectiveness of liposomal

bupivacaine with bupivacaine following total hip arthroplasty.

 Study group= 27 consecutive patients who received liposomal

bupivacaine

 Control group=previous 30 consecutive patients who received

bupivacaine alone

• All patients received a combination of celecoxib 400 mg PO,

pregabalin 75 mg PO and 1gm of IV acetaminophen prior to procedure

• The study group received 20 cc of liposomal bupivacaine,

combined with 40 cc 0.25% bupivacaine HCl with epinephrine and 20 cc of preservative free normal saline

• The control group received 60 ml of 0.25% bupivacaine HCl with

epinephrine

 The study group median length of stay was 1.9 days;

the control group median length of stay was 2.5 days (p = 0.05).

 Both groups had average VAS scores of 2.8 during

the first 24 hours after surgery and 3.3 during the time frame of 24 to 48 hours after surgery

 The study group average morphine equivalent use

during the first 24 hours after surgery was 24.0 mg, and the control group 53.4 mg (p <0.05)

 From 24 to 48 hours from surgery, the average

morphine equivalent use in the study group was 41.1 mg, and the control group 64.9 mg,

 Liposomal bupivacaine administration during

THA appears:

• to decrease the need for opioid use post operatively
• to decrease length of stay

 The results of this study justify the need for

a well-designed RCT utilizing liposomal bupivacaine as part of multimodal analgesia during THA

• RCT started September 2014
• 11 patients enrolled to date

 Patient preparation  Simulation in hospital  Staff preparation  Team approach  Good experiences will generate

more opportunities

Questions?