ambulatory total knee replacements

Revolutionizing knee replacement surgery

By: Jaclyn Tersigni

Greg Nemez assumed he’d be in the hospital for a week following his knee replacement surgery. The 56-year old realtor from Mississauga had been struggling with severe pain resulting from ACL injuries and wear-and-tear that stemmed from competitive sports and a tackle football injury at age 15. He had reparative surgeries in the ’70s and ’80s, but in the last year, the discomfort became overwhelming.

He was relieved when he learned he could have the surgery within months. He was amazed when he found out his surgery would be a same-day experience, known as ambulatory surgery.

“I’d never heard of anything like it before,” says Nemez. “When they said I’d be in and out in one day, I was shocked.”

On April 9, Nemez became the fifth patient to participate in the day-surgery joint replacement program at Women’s College Hospital (WCH). It’s the first program of its kind in Canada, and one that promises to subvert the traditional model of joint replacement surgery, which sees patients stay in hospital for an average of four days, delaying their return to everyday life and costing the Canadian healthcare system close to $1 billion each year. The program will reduce healthcare costs and free up desperately needed hospital beds, while also improving the patient experience; patients will be able to heal in the comfort of their own home where, as research shows, they prefer to be.

The program is part of a WCH pilot project, whose mandate includes the development of innovative solutions to improve health services country-wide.

In 2017, Carlo and Angela Baldassarra made a significant donation to support surgical innovation. The funds supported the formation of a new working group comprised of various researchers, surgeons, anesthetists, nurses, physiotherapists and pharmacists that began looking for tangible ways to improve the healthcare system.

Dr. David Urbach is the surgeon-in-chief and medical director of perioperative services at the hospital. “The motivation was that we were trying to figure out where we could make a real difference in the health system,” says Dr. Urbach. “We didn’t necessarily set out saying, ‘Oh, we need to work to improve joint replacement surgery.’ Instead we said, ‘What’s happening out there? What’s a common operation that uses beds in hospitals where we, as an ambulatory hospital, can be on the forefront of revolutionizing how healthcare is delivered?’”

What Dr. Urbach discovered, along with fellow group leader and orthopedic surgeon Dr. David Backstein and their team, was that joint replacement surgeries were the most common planned operations that landed patients in hospital beds unnecessarily for days following the procedure. More than 100,000 hip and knee replacement surgeries take place in Canada every year and, with patients staying an average of four days for knees and seven days for hips, the procedures are responsible for occupying a significant number of hospital beds that could be used to provide more care and shorten wait times.

“Where we can make a big impact on the sustainability of the system is if we can allow hospitals to use their beds for people who are actually sick and need acute medical care. Those are the people who should be in those beds,” Dr. Urbach says. “If you can preserve those hospital beds by taking care of everybody else in a different environment, then you’ve got all these extra resources in a system that’s quite strapped and under stress.”

As it turns out, a significant percentage of knee and hip replacement patients don’t actually need active medical care following their procedure. What often keeps joint replacement patients in hospital is management of pain and nausea.

Establishing a model for ambulatory surgery meant that Dr. Urbach and the working group had to develop solutions for two challenges: First, how can patients get on their feet sooner while also staying comfortable? And second, how can their recovery be monitored and reassurance be provided in a non-hospital environment? To answer those questions, the group made site visits to a hospital in the U.S., where sameday joint replacement is routinely performed. “That reassured us that this can be done and that it can be done safely,” Dr. Urbach says. They also investigated what the best practices were for anesthesia that would provide better pain management for patients, with less reliance on oral painkillers, so patients can recover more quickly in the comfort of their own home.

With collaboration with Women’s College Hospital, Dr. Wong is pleased to offer highly selected patients the option of going home the same day after their total joint replacements, without the need for inpatient admission. Advantages of same day discharge included faster recovery, lower risks of complications, such as,infection and blood clots. Patients’s satisfaction is also higher. Who would not like to recover in the comfort of their own home? 

This new and highly innovative program is made possible by utilizing the latest anaesthetic and surgical techniques. A seamless transition of care from hospital to home is also facilitated by the use of mobile devices and dedicated teams of nurses and doctors. Welcome to the future of total joint replacements.