Local physicians and health care professionals discuss what you need to know about joint replacement procedures.
What is joint replacement?
The phrase “joint replacement” or “total joint replacement” might bring to mind a picture of cutting out one knee and popping in another. This is not what’s done. “It’s really more of a resurfacing procedure,” says Dr. John Diana, president of the Napa Valley Orthopaedic Medical Group and vice chief of staff at Queen of the Valley Medical Center in Napa. “You smooth off the end of the bone (in the knee) and cap it with metal on either side of the joint, and then you put a plastic insert in between.” In the case of hip replacements, he explains, they may resurface the socket and replace the ball itself with a metal one or, in some cases, retain the ball and cap it with metal. The result, when all goes well, is relief from pain, restored mobility and the possibility of resuming the desired active lifestyle. For many, it gives a whole new lease on life.
Louise Cavallo, office manager for Sonoma internist Dr. Clinton Lane, was going in for surgery as this article was being prepared and agreed to share her experience with NorthBay biz. As she waited in the pre-op room in Sonoma Valley Hospital for her anesthesiologist to begin her preparation, she was in high spirits and said she’s filled with hopes for a new life, free of joint pain. “I want to dance!” she laughed.
She admitted to being a little anxious, but was confident because her hospital “has awesome doctors and the care is just terrific,” and because her orthopaedic surgeon is Dr. Michael Brown, who replaced the hip of a coworker; that friend is thrilled with the result. As she prepares to begin what will be a months-long process toward full mobility, Cavallo, who is barely in her 60s, knows she’s on the brink of a life transformation. And she’s not alone.
“Some of the statistics are indicating that 78 million baby boomers, who may be starting to feel their knees and hips going, are demanding a more active lifestyle,” says Evan Rayner, CEO of Healdsburg District Hospital. “They’re becoming candidates at a younger age, just based on their active lifestyle.” Also, he points out, older seniors are living longer, expanding the population base in the higher age ranges as well. “The American College of Orthopaedic Surgeons predicts a more than 105 percent increase in orthopaedic surgical volume over the next 10 years, and more than 335 percent volume in the years ahead due to the growth of an aging population,” he says.
Kristine Sheerin, a physical therapist and patient navigator in Santa Rosa Memorial Hospital’s orthopaedics program, says she already sees the change. “Our average candidate’s age is anywhere between 65 and 70, she says. “When you ask them what their goals are, it’s typically to do an activity that includes travel or sports. Not just, ‘I want to walk around without pain.’ They want to get back to sports that include things like skiing, hiking or golfing, take more active vacations and possibly return to work. This is a very active population with high expectations, which is new.” She says that 25 years ago, the average joint replacement candidate was in his or her 80s, retired and without such high expectations. “Now, we’re getting patients in their 40s and 50s who expect to return to their employment.”
Time for new knees?
“It’s definitely not for people who just have a sore hip or knee,” says Novato-based orthopaedic surgeon Dr. Ray Bonneau. “This is for people with more end-stage disease, who get to the point where they say, ‘I’ve given up golf,’ ‘I can’t travel anymore,’ ‘I can barely get down the walk,’ ‘This is really ruining my life,’ or, in the final stage, ‘I get no exercise. I’m gaining weight.’ At this point, it’s starting to wreck their body.”
What’s actually happening is, when the cartilage—the spongy tissue that acts as shock absorbers between the bones—starts to wear thin due to osteoarthritis, injury or other conditions, then the pressure wears on the bones and causes pain. People generally see a doctor at that point.
Dr. Brown likes to tell people that, when a patient comes in with joint pain, his first task is to find out what’s really wrong. “The right diagnosis is crucial,” he says. Then he may try a series of nonsurgical techniques and, only when it’s really time, will he recommend surgery.
Dr. Diana agrees. “The mantra is to exhaust the nonoperative measures first, because even though these devices are lasting longer, if someone’s 40 and we’re anticipating they’ll live another 40 years or so, we don’t have 40-year data on these prostheses.” Still, the longevity of today’s implants seems impressive. “If you look at the 20-year data on the knee side,” he says, “there’s anywhere from 85 to 90 percent survival of the prosthesis. This means that in a 20-year timeframe, only one in 10 patients will need to undergo additional surgery to change the original replacement.”
Recent advances
“We used to tell a person, ‘This will only last about 15 or 20 years, so you’ll have to have it redone,’” says Dr. Bonneau. “Now, the replacements can last a whole lifetime, so it’s a rarity to have to have it redone. And that’s due to changes in the materials.”
As Dr. Bonneau tells it, the initial hip replacements were made of a material like teflon, which would wear over time. When they wore out, the bond that joins the prosthesis to the bone would loosen and they’d need to be redone. Then came a ceramic-type surface. “The thing about ceramics is they’re highly polished and will last a long time. But they’re basically like a toilet bowl, so people could hit them and have catastrophic failures [as a result of cracking],” he says. “So that obviously wasn’t the way to go. So then they went to metal-on-metal hip replacement—and those are some of the failures, where you’ve heard of people who’ve had their hips recalled.”
Meanwhile, a polyethylene material was developed and improved into a highly cross-linked molecule that has a lower wear rate. This is mated with oxinium, which looks like glass but is actually metal. So it has the wear rate of metal-on-metal but doesn’t create trace ions and particles in the joint (which, because their long-term effects on the body are unknown, can be worrisome). “So with the new prostheses, we can’t say, ‘I guarantee this,’" he says, “but we tell people, ‘We expect this to last your whole life.’”
Another big change is in the procedure itself. “Traditionally, hips and knees used to be 18-inch incisions,” says Dr. Bonneau. “We now do them with 5- or 6-inch incisions, which is minimally invasive.” He says people sometimes ask him, ‘Well, if you can do that now, why couldn’t you do it back then?’ He explains that there are now myriad new tools that make this kind of precision possible, and each surgical team needs to be trained on the use of the tools. So the success of the technique remains in the hands of the surgeon and the team who supports him or her. “When I’m doing a surgery, I barely say anything. I put my hand out, and boom—they put the next instrument in it.”
Pain control
When you think “anesthesia,” you may envision the mask over your face, the foul ether smell and then waking up groggy and disoriented. No more. Let’s go back to our patient, Louise. Before she’s taken into the operating room, her anesthesiologist, Dr. Keith Chamberlin, CEO of Anesthesiology Consultants of Marin, sits beside her with his clipboard, asking a series of detailed questions about her history, preferences and generally how she’s feeling so far. She admits she’s a little anxious about “going under” but by the time he gets up, she looks confident and has a full picture of the kind of orchestrated continuum of pain control she’s about to experience.
“The whole idea is to provide excellent intraoperative as well as postoperative pain control so the patient can engage in physical therapy in a meaningful manner,” says Dr. Stephen Licata, also of Anesthesiology Consultants of Marin and president-elect chief of staff at Sonoma Valley Hospital, whose total joint replacement program he helped develop. “And it works well!”
He explains that, when the patients first come in for a knee replacement, they’re given a “cocktail” of Tylenol, Celebrex (a nonsteroidal anti-inflammatory agent) and Oxycontin (a long-lasting narcotic), which they continue in the postoperative peroid. Then when they go into the OR, they’re given a sedative and then a femoral nerve block, which numbs sensation in the anterior aspect of the knee and leg. Not everyone does this, but, as Dr. Licata explains, it’s a way of keeping the knee pain-free while the patient can be alert and healthy.
So how does it work? “It’s like when you go to the dentist and he injects local anesthetic into the alveolar nerve prior to having a tooth extracted, rendering the jaw numb so you don’t feel pain,” he explains. In the case of the knee replacement, it’s the femoral nerve that’s targeted, because it enervates the area where they’re making the surgical incision. “If you look at pain from a knee replacement, which is one of the most painful things you can have done,” he explains, “about 85 percent of the pain is caused by this femoral nerve.” So the nerve block takes care of this during the operation and the days immediately following. “We render that whole area nice and numb,” he says, “then we thread a small catheter that lies adjacent to the femoral nerve, tape that in place and, postoperatively, the patient has this little infusion pump that constantly bathes that nerve in local anesthetic, providing exceptional postoperative pain control.”
He says they don’t block the back part of the knee, which is enervated by the sciatic nerve, because that would interfere with immediate postoperative movement and therapy. During the surgery, the surgeon injects a local anesthetic that renders the back part of the knee numb and provides some additional postoperative pain control.
He says they don’t block the back part of the knee, which is enervated by the sciatic nerve, because that would interfere with immediate postoperative movement and therapy. During the surgery, the surgeon injects a local anesthetic that renders the back part of the knee numb. “So when the patient wakes up and that local anesthetic wears off, they’re good to go.”
Why is it important, other than for humanitarian reasons, to have excellent pain control? “There’s a practical reason, too,” says Dr. Bonneau, who also works with Dr. Licata and Anesthesiology Consultants of Marin, “If two people wake up from surgery, and the patient on gurney number one says, ‘Hey, I feel great!’ and the other wakes up and says, ‘Oh, this is killing me,’ it’ll take about six months for that second patient to catch up with the first. Everything goes slower—physical therapy will go slower, the wound will heal more slowly. So we’re really, really careful about how people wake up.”
Navigating the process
The day after the operation, Louise is sitting up in bed, chatting brightly with Janet Alexander, R.N., who’s been her educator and guide throughout the process as Sonoma Valley Hospital’s nurse navigator. “I feel fabulous,” says Louise. “On a scale of one to 10, my pain is about a three or four, and I feel wonderful.” Her husband, Alan, standing by, says he hadn’t worried at all, “because Janet was with us through the whole process.” She will continue to guide—or navigate—Louise through the next stages of her recovery, until she’s no longer needed.
“The patients love being navigated,” Alexander says. “They get so much one-on-one attention. If they have a question, they’ll call. There’s lots of TLC.
Alexander, along with a physical therapist and occupational therapist, teach a preoperative class called “Joint Camp,” educating people about joint pain, the surgery and what to expect during and after hospitalization and then continues with them throughout the process. Dr. Brown, who brought ideas from his previous total joint program, and Dr. Licata, who helped set up the total joint program at Marin General Hospital, worked with Alexander and other team members to establish SVH’s total joint program. Alexander is also grateful for valuable input from Courtney Hurwitz, who created the role of patient navigator at Santa Rosa Memorial (a role Sheenin now fills while Hurwitz is on maternity leave). Brown, Licata and Hurwitz offered many valuable suggestions when the program was being designed.
“There’s always a fear of the unknown when it comes to operative procedures like joint replacement,” Alexander continues. “But we’ve found that by educating patients in our joint program, they feel empowered and less frightened. I guide them, step-by-step, through the process beginning when they’re scheduled for surgery and through follow-up after they go home. We recognize that surgery isn’t a pleasant experience. But that doesn’t mean their hospital experience can’t be very positive.”
Most hospitals follow their patients carefully through the process, though not all have a designated navigator. Palm Drive Hospital in Sebastopol, for example, is of such a scale that navigation happens naturally. “We’re a small community hospital,” says Perioperative Services Director Pam Reed, “so the orthopaedic surgeon we use is right next door to the hospital, and the patients just walk over. They meet the pre-op nurse, they’re introduced to the hospital, they see where they’re going to check in and where they’re going to stay. From there, they go to the physical therapy department and meet their therapist, and they’re shown what kinds of therapy they’re going to be getting right after surgery. So it’s a really comprehensive program. We do a lot of teaching and individual patient attention up front, which we can do, because we’re small.” As she explains it, in a very small hospital, everything is easier. Parking is easier, finding your way around is easier, it’s quieter, “for elective surgery, it really is a great choice.”
Choosing your experience
At the most basic level, prospective patients should look for an accredited facility that does a sufficient volume and has a joint replacement team and rehabilitation component, advises Dr. Gary Stein, orthopaedic surgeon with Santa Rosa Orthopaedics. “A surgeon should be board certified, do a reasonable volume and have joint replacements as a primary component of his or her practice.”
All those interviewed agree that the best recommendations tend to be from word of mouth. “Here in Marin, Sonoma and Napa,” says Dr. Stein, referring to counties known for their affluence, activity and health-conscious cultures, “word of mouth counts. You’ll have a friend or family member or someone you know who says, ‘I’ve had this procedure and it changed my life. I had a great experience.’”
Then, says Dr. Stein, you should have a recommendation from your primary physician. “They’ll know. They see patients afterward and get direct feedback of how the patients have done after they’ve had their surgery and what the experience was like.” Along with taking the advice of your own, local doctor, is the recommendation—shared by all the doctors interviewed for this story—that you have your surgery close to home. “Joint replacement isn’t just in and out,” says Dr. Stein. There’s follow-up and supervision that has to occur—during the rehab process, especially. You want to make sure the surgeon and members of his or her staff who were involved in your care are going to be available if you have questions or needs, because there are things that come up after you go home. If your surgeon’s in a remote location, that’s not ideal.”
Nor is it necessary to go to a metropolis for joint replacement competence. “People really don’t have to go to San Francisco or some farther away place to get this done,” says Dr. Bonneau. “It can certainly be done in their community now.” He says people often think they need to go to the big city hospital for care when really, that’s only necessary for rare cases. “If you have a brain tumor, San Francisco’s the place to go. But to be honest, to go for a routine joint replacement—that’s not what they specialize in, it’s not their purpose.” He even goes so far as to say that’s a misuse of their competency. “Sometimes people are pounding a round peg into a square hole when they try to do that.”
What about the Internet?
In our age of instant information, many people feel empowered by being able to research highly specialized information on their own. The problem, all the surgeons interviewed agree, is that it’s sometimes hard to distinguish between information and advertising, and thus people think they must have something advertised as the latest thing. “So I tell people, they’re not buying a cell phone or a flat-screen TV,” says Dr. Bonneau. “Think of it more like you’re buying an airplane or scuba diving gear. You don’t want antiquated junk, but you don’t want to get experimented on either.”
Another issue to consider, some suggest, is that some physicians have a personal interest in a particular technique or material. This needs to be disclosed to the patient. Some of the implants and advertising are profit-driven, and that can confuse the issues when evaluating what’s really the best course of treatment.
Can you believe the ads?
In Napa, Marin and Sonoma counties, there are a number of qualified joint replacement specialists and programs. Some, like Dr. Bonneau in Novato, prefer to do their marketing in the direct manner of educational talks, informative websites and delivering the kind of service that creates excellent word of mouth referrals. Some make use of print and billboard advertising along with educational presentations. Others, like Dr. Brown in Sonoma and Dr. Diana in Napa, advertise mostly through talks, recommendations and word of mouth, with website and print support.
Excessive advertising on the part of prosthesis companies seems irksome to some of the surgeons interviewed. “One of my pet peeves,” says Dr. Stein, “is they do a lot of direct-to-consumer advertising: ‘You need this lifetime knee,’ or ‘…this custom-designed knee,’ or ‘You need the robotic knee’—and that’s a lot of misinformation. People really need to discuss their options with their surgeon,” he says. “The surgeons are trained to do this and are the ones who have experience with the implants, so they’re the best ones to decide what’s best for a patient.”
“I’d much rather have a surgeon who’s going to take the time to do the procedure correctly, with a good team, than experiment with some new device that a company’s marketing with no proven long-term effect,” says Dr. Diana
“[At Queen of the Valley], we offer patients a variety of options, including the newest knee replacements—custom knee implants designed specifically for each patient and his or her unique anatomy,” he continues. “The custom knee implant reduces surgery time and provides patients with an even better fit, which can improve long-term outcomes.” Blue Shield of California recognized its program as a Blue Distinction Center for knee and hip replacement for delivering quality care, impressive outcomes and rates of readmission and complication after surgery that are well below the national average.
Dr. Brown agrees. “When people come to me with marketing materials or information they’ve found on the Internet, it means they don’t have a close relationship with their primary care physician. And I personally think that’s unfortunate.” He says what he does is carefully explain what his goals are in surgery, what his experience is, what innovations he uses and how the total joint team works together to provide patients a comprehensive experience, from the education at the start to the operating room, the floor, the skilled nursing or home care and on to the rehab departments.
“You have to be careful not to embrace every new technology that comes out,” says Dr. Stein, “because they don’t always live up to their expectations, and, sometimes, they’re harmful to people. So you want to use things that have been proven and tested and that are improvements but not necessarily always the first wave. There’s a learning curve on the new techniques as well, which can mean complications early on when a surgeon is learning those techniques.”
“A lot of times you’ll see a companies marketing an implant, or some minor variation of a technique,” agrees Dr. Diana. “One company, for example, was marketing a ‘gender knee.’ There wasn’t any data out there that said those prostheses were better, lasted longer or actually achieved any of the goals, and yet the companies marketed and marketed, including direct to the consumer, and I had tons of patients coming in and thinking that was the best. Because I predominantly used this manufacturer’s implant at the time, I felt I had to discuss the fact that this particular ‘model’ really didn’t have any long-term data to support a better outcome.”
And the cost?
Without going into the gruesome details of a typical medical bill, Dr. Diana summarizes the affordability of joint replacement: “If you’re on Medicare, with a supplement, it’s covered,” he says, “including a skilled nursing stay, if you need to do that. The private insurances cover most of it, but there’s often some scattered amounts of costs from $200 to $2,000, but generally, not more than that.” So what may be in the neighborhood of a $50,000 surgery may end up costing the patient anywhere from $2,000 to nothing—for a whole new lease on life.
Bottom line
If you’re considering a joint replacement, take the advice of these experts: First, see your trusted primary care physician and let him or her refer you to a trusted orthopaedic surgeon. Let your surgeon give you a careful and thorough diagnosis of your issue. He or she may recommend a series of nonsurgical steps before deciding the time is right for replacement. The surgeon will know the right techniques to use for your particular case and the right materials for your implants. He or she will have a trusted team and will work with an accredited facility, which will have a comprehensive program for joint replacement.
We live in an area of excellent small, community hospitals and highly skilled and trusted surgeons. Dr. Bonneau in Novato, Dr. Stein in Santa Rosa, Dr. Brown in Sonoma and Dr. Diana in Napa all will say you’ll do well to choose your local, community hospital for your care. So talk to your doctor, your surgeon, and interview the team. If there’s a nurse navigator, like Janet Alexander or a patient navigator, like Kristine Sheerin, set up an interview. See if what they emphasize is what matters most to you. If anesthesia techniques are important to you, ask your surgeon about that as well.
“At the end of the day,” says Rayner, whose Healdsburg District Hospital boasts Health Grades awards for 2009, 2010 and 20112 for superior patient satisfaction, “It’s all about patient satisfaction and superior outcomes.”
High Efficiency Surgical Technique and Economics of Joint Arthroplasty
By Thomas M. Coon, M.D.
With the aging of the baby boomer generation, the expected growth in demand for total joint arthroplasty is huge. Projections show a 673 percent increase in the need for total knee arthroplasty (TKA) by the year 2030. In the same timeframe, our joint replacement surgeons are getting older, with fewer surgeons entering the field than are leaving due to retirement. One way to improve patient access to these life-changing procedures is to enhance the efficiency of surgical teams and operating rooms, thus allowing more surgeries to be performed in any given timeframe.
Surgical efficiency begins with the surgeon, who must practice each movement of the operation and develop mastery of technique and economy of motion, thus letting other team members predict with great accuracy the surgical time. This efficiency allows the second key team member, the anesthesiologist, to perform his or her portion of the process in a timely way so that, immediately upon finishing the first surgery, the surgeon can proceed directly to a second, identical operating suite and find a prepared patient ready for the next operation. In this fashion, the surgical team can move back and forth from one operating room to the other, all the time aided by a highly trained staff dedicated to patient comfort and safety.
The Coon Joint Replacement Institute introduced the high efficiency surgical technique and the two-room operating model in 2004, and has refined it over the last seven years. A study of statistical results found that surgeon waiting time between cases was reduced from 75 minutes in 2003 to 11 minutes in 2006. This equates to an added 540 hours of available operating time for the same surgeon (assuming back-to-back cases), thus offering the possibility of increased access to care for a large number of patients. Some critics argue the two-room model leaves the second OR sitting idle, but our study showed an increased availability of OR time of 867 hours in only one year of the study. This increased potential usage of stressed hospital facilities has great potential economic impact.
In addition, the introduction of computer aided surgical techniques, such as computer navigation and robotics, can reinforce the surgeon’s skills and reduce the chance of error. Historically, TKA has been plagued by inaccuracy, and many studies show in excess of 20 percent of TKAs placed in malalignment. The addition of computer navigation has reduced errant alignment dramatically, with 98 to 99 percent of TKAs aligned within one degree of perfection in most studies. With diligence and practice, these enabling technologies can be introduced to the operating theater and enhance the quality and reproducibility of high efficiency surgical techniques.
The meaning for patients
On the patient care front, the use of minimally invasive surgical techniques results in less pain and faster recovery. When combined with advanced, multi-modal pain management protocols, patients are more comfortable, ambulate more quickly and effectively, and can be discharged home from the hospital sooner, which further reduces cost pressures on the health care system.
We’re currently working with implant vendors and technology companies to provide simplified, high-efficiency instruments and alternative implant technologies that could lead to even further reductions in operative time and improved system efficiencies. Reductions in cost for processing and procurement of instruments and implants hold promise for reductions of health care costs in the future. Additionally, further cost reductions can be achieved through creative business associations and alliances, which may further enhance the economies of scale.
Thomas M. Coon, M.D., is founder of the Coon Joint Replacement Institute at St. Helena Hospital, which performed 1,200 minimally invasive joint replacements in 2011. For more information, please visit www.napavalleyjointcare.org or call (877) 747-9991.
