Becker's ASC Review

68 12th Annual Spine, Orthopedic and Pain Management-Driven ASC Conference + The Business of Spine - call (800) 417-2035 Whenever possible we try to get preapproval from all insurance carriers prior to the patient having surgery. We have a good success rate with getting these surgeries approved. Q: What do you do to prevent complications? Dr. Hope: In order to successfully perform total joint arthroplasty as an out- patient procedure, one must address and prevent the complications that have made it historically an inpatient procedure. These include bleeding, venous thromboembolism, uncontrolled pain, nausea and urinary retention. A comprehensive preoperative optimization program can boost hemoglo- bin to the desired range, which when combined with aggressive periopera- tive blood management protocols makes the need for blood transfusions rare. Routine use of antifibrinolytics, advanced cautery devices and tourni- quet-less techniques minimize perioperative blood loss. Avoiding over-aggressive chemoprophylaxis for VTE decreases postoperative bleeding. A multimodal pain management protocol emphasizing non-steroi- dal anti-inflammatory drugs, periarticular injections and regional anesthetic techniques can minimize pain during the first 72 hours, and avoiding paren- teral narcotics results in less sedation, nausea and constipation. I have found that an adductor canal block gives similar pain relief to the stan- dard femoral nerve block with dramatically less quadriceps weakness. Most patients with an adductor canal block can ambulate more than 100 feet on the night of surgery without a knee immobilizer, which helps avoid falls. Pre-emptive antiemetics along with minimizing narcotics greatly reduce postoperative nausea and vomiting. Careful fluid management, avoiding long-acting spinal anesthetics and minimizing narcotics decrease the prob- lem of urinary retention. Most patients who qualify for outpatient TJA would also tend to have not yet developed bladder outlet obstruction. Q: Can total joints be done efficiently in an outpatient setting? Why or why not? Dr. Riordan: Yes. Advances in medical management and preoperative risk assessment, surgery, pain management, nursing, home therapies, education, medications and equipment combine to yield a safe path for these outpatient procedures. Dr. Hope: Efficient outpatient arthroplasty requires an adequate facility, an experienced surgical and anesthetic team and ample equipment. The surgery center must have enough room to prepare the patients, at least two large ORs, and a recovery area large enough to accommodate the patients for several hours while they are mobilized and monitored. The surgeon and team must be expeditious and predictable. Minimizing variance in set up, surgical and clean up times will facilitate the optimal use of two surgical rooms. Ideally, the surgical time should be slightly less than the set up and clean up so the surgeon can move from room to room with minimal down time. Another issue is the complexity of the surgi- cal trays. Clearly they must provide the needed tools, but multiple pans take time to open and also burden the sterilization process. For a total knee arthroplasty, I routinely open four pans for a case: one pan with all the blocks and trials, a power pan, an instrument/retractor pan and my navigation tray. Total hip arthroplasty requires two trays for trials and reamers, a power pan and the instrument/retractor pan. THE CLOSEST TO NONE IS ONE SINGLE PORTAL ARTHROSCOPY 21% Less Post Operative Pain SPA patients experienced less pain when compared with patients who underwent Dual Portal Arthroscopy surgery.* 26% Less Knee Swelling SPA patients reported less swelling at one month than Dual Portal Arthoscopy patients.* 42% Did Not Take Pain Pills The percent of SPA patients that did not take any pain pills after surgery.* www.SinglePortalArthroscopy.com *Please reference the Single Portal Arthroscopy Clinical WhitePaper for detailed information and data from the clinical study. Stryker Endoscopy | 5900 Optical Court | San Jose, CA 95138 | t: 1 800 624 4422

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