- August 27, 2018
Hi my name’s Chris Grayson and I’m one of the adult reconstruction specialists at Florida Orthopsedic Institute. We’re the largest group in the state of Florida consisting of over 40 physicians covering 10 locations throughout the Tampa Bay area and operating at many of the hospitals throughout Hillsborough and Pinellas County. We consist of fellowship trained specialists covering nearly all of the sub specialties of orthopedics also offering a full range of services for patients such as C.T. scan physical therapy MRI. First a little bit about myself. I’m originally from Baton Rouge, Louisiana and stayed there through undergrad where I went to LSU. Tiger Stadium is in my opinion the best place to watch a football game in America. Went to Shreveport where I went to the LSU Medical School and completed my medical training. From there I was fortunate enough to match into an orthopedic residency at the University of Florida and Shands Hospital spent five years as a Gator in enemy territory and decided to pursue my love of joint replacement by performing an extra year of fellowship to become a specialist in the hip replacement at the University of Indiana in Indianapolis outside of work.
I enjoy spending time with my family. My two daughters Hannah and Layla and enjoy cooking Louisiana foods such as such as the gumbo prepared there. And today we’re gonna talk a little bit about some of the recent advancements in hip replacement surgery so we’re gonna mainly focus today on the surgical treatment of arthritis all arthritic conditions are treated without surgery until that fails. But ultimately the pain and disability from arthritis will necessitate surgical treatment in some patients. Unfortunately arthroscopic surgery is not able to put cartilage back in the joint and since arthritis is the loss of cartilage in the joint it does not help patients with arthritis. The mainstay of our modern treatment for hip arthritis is a hip replacement hip replacement is performed three hundred thousand times per year and is a fabulous surgery that greatly decreases patients pain and disability and improves their function.
It’s used to treat many different types of patients with osteoarthritis rheumatoid arthritis, avascular necrosis, congenital problems such as hip dysplasia and even patients who have had prior fractures involving the pelvis and femur. The benefits of joint replacement are that it improves pain reduces stiffness and gives patients the ability to regain control of their life and continue to participate in the activities they love to understand how far we’ve come with joint replacement. I think it’s first we have to look back at where joint replacement started. Modern joint replacement began in the 60s as a similar surgery to what we do today. The implants weren’t as technologically advanced and less refined materials were used. This was a much more invasive surgery requiring larger incisions taking significant longer amount of time and often requiring longer hospital stays. However in the hands of master surgeons patients still had good results.
The early joint replacement protocols sometimes included bed rest for up to 21 days. Patients did the majority of their recovery in the hospital and we often kept patients from putting full weight on their legs for six weeks after surgery pain control considered consisted mostly of narcotic medications and was often poor. As we improved 20 around 20 years ago we shorten this day to three to five days. Many patients still were discharged in nursing facilities and did the majority of their recovery in both the hospital and the nursing home. They would stay in the nursing home for up to three weeks after surgery so often spending almost a month away from home. Some patients still were not allowed to put full weight on their legs and used a walker for up to six weeks after surgery.
We also were paying little attention to risk factors which led to complications after surgery. Currently modern joint replacement involves short stays in the hospitals with most patients going home the day after surgery or staying two nights in the hospital. Patients put full weight on their leg immediately after surgery they get up with physical therapy the same day. We have advance multimodal pain control techniques that make makes patients both more comfortable and more alert throughout their recovery period. Patients are able to get therapy at home for the first two weeks after surgery and are able to be more comfortable during their recovery. So you can see this was a big difference from where we started in the 60s. We’ve come a long way and I think it’s important to look at how we got there. Currently recovery starts before we ever book the surgery.
We have been able to perform studies define risk factors which put patients at risk of bad outcomes. Things such as obesity diabetes malnutrition heart disease kidney disease and anemia, all set patients up for poor outcomes such as infections and wound issues by paying attention to these risk factors. We’re able to help correct the problems prior to surgery and give patients less complications many of the hospitals I work out have also instituted weekly meetings where we discuss the patients before they ever come into the hospital. We talk about the surgery that could be performed talk about each patient as an individual and anticipate problems that might occur during their recovery. This allows us to instead of reacting to problems to anticipate them and deal with them before they occur. Prior to surgery we give numerous medications in order to help the patient be more comfortable after surgery.
These medications help reduce pain reduce nausea and make the patient more alert post-operative multiple different types of spinal anaesthesia now used in order to reduce the pain narcotic medications have lots of problems with them. They can confuse patients they can cause constipation. So by giving nerve blocks in spinal anaesthesia we are able to reduce the amount of narcotics patients need both during surgery and in the recovery after surgery. This results in more comfortable patients that wake up from surgery more alert and are able to get to therapy more quickly during surgery we have developed new equipment new techniques and improved blood conservation in order to give patients better outcomes. Excellence as defined in other fields we have you can see in professional sports. Ted Williams who’s the last major league player to hit 400 first season and Steph Curry who averaged 43 percent and three point shooting are both considered the top of their fields.
These are professionals in what they do doing very difficult things who are only successful around 50 percent of the time. I don’t think most patients would be happy with an orthopedic surgeon whose only successful 50 percent of the time. However in a study from Harvard we found that that’s about how well we were doing when we looked at the component positioning when we looked at where the as a tabular component the cup of the hip replacement was placed. We were only hitting our goal 50 percent of the time. Most of the time this didn’t result in complications such as dislocation or patients needing to go back to surgery but we weren’t enacting the plan we were setting out to do. So some of the solutions we came with were the use of intra operative x rays, the use of new technologies such as computer navigation, and robotic assistants and even the use of new surgical approaches to facilitate better x ray intra operatively.
One of the first steps I made in order to improve my implant positioning was transition into a direct interior approach the direct anterior approach is a surgery from the front. It’s gained a lot of notoriety and there’s been a lot of advertisements based on it. Some proponents cite less muscle damage although other studies showed that there’s not much difference. And some studies have also shown that there is a faster recovery. I think it’s important to know that after six weeks there isn’t much difference in the outcomes and all hip replacement approaches do equally well. My decision to switch to the direct anterior approach was to be able to gain accurate x rays interoperability in order to know exactly where my components were to be placed before the patient left the operating room. Traditionally we would get an x ray in the recovery room where it was too late to change anything without taking a patient back to surgery by getting X-rays in surgery. I’m able to make any adjustments that need to be made before the patient leaves the operating room.
Computer Navigation is the next generation of technology from plane x rays. This allowed us to supply points to the computer and the computer created a virtual map of the patient’s anatomy. This then allowed us to use special instrumentation to place the components exactly where we wanted them to be. One of the first improvements in technology we made was the use of computer navigation with computer navigation systems. The surgeons supplied points along the patient’s anatomy to the computer so the computer could create a virtual map of the patient’s bones. This allowed the computer to then use special instrumentation to give guidance on implant positioning to the surgeon. The goal was to allow us to customize the fit of the components to the patient. Instead of customizing our instead of making the patient’s body fit the component however the problem with the computer navigation was that if the surgeon gave imprecise information to the computer it was able it would not give us an accurate plan and the components would still be slightly malplaced.
From there the next or the next jump in technology was with robotics. This allowed us to use a preoperative C.T. scan to have a virtual to have a known map of the patient’s anatomy to compare the two compare the information the surgeon gave the computer during surgery and ensure accurate placement. This also allows us to do preoperative planning based on a 3D model and use a robotic arm to ensure that the computer are to ensure that the components are accurately placed exactly where the surgeon wants them. Well when a study was done on how accurate the Mako robot was with hip and with hip cup implementation we found that we were able to put the cups within the safe zone 100 percent of the time. Much better than the 50 percent done with traditional instrumentation robotics allow us to have more accurate component positioning and gives us me as the surgeon a chance to do precise adjustments to the components in order to in order to give the patient a very accurate and successful surgical outcome.
We’re able to reduce leg length discrepancies and dislocations by having an accurate component positioning. Blood conservation has also been a great change in total hip replacement previously almost 30 percent of our patients ended up needing blood transfusions. However by becoming more selective with the patients we give blood transfusions to and using new medications we have almost eliminated blood transfusions from hip replacement after surgery. I have become a big believer in the well patient model. I treat my patients as if they’re recovering from an injury instead of being sick. I want patients to wear to rehab quickly and to focus on recovery and not to think of themselves as sick. Patients have early physical therapy. They put full weight on their legs. We have improved pain control so they’re more comfortable and alert and we discharge patients quickly and safely by discharging them based on goals and not time again by reinforcing the patient is recovering from an injury and not sick.
We able to make them transition through the hospital stay more quickly to have be more comfortable during their stay. We do this by eliminating the use of catheters encouraging patients to wear normal clothes eat their meals at the side of the bed and not in bed and generally act like they would at home. This helps them progress through the hospital stay stay in the hospital a shorter amount of time and be more comfortable while they’re there with physical therapy. Everyone is able to put full weight on their leg immediately after surgery. It starts the same day as surgery. Many my patients think that sounds a little crazy but the therapist will be in there within hours of you completing your hip replacement so that you can get up and start walking. We found that as we transition from surgery or physical therapy the day after surgery to the day of surgery we’ve been able to improve outcomes in and help people recover more quickly on the first surgical are the first physical therapy appointment patients are often scared they’re nervous they don’t know if the if the joint replacement is going to hold their weight or what’s going to happen so we’re not expecting you to walk up and down the hall but to get up move around a little bit and start gaining some confidence that your new hip is going to support you.
With multi-modal pain control we’ve been able to make patients more comfortable during the hospital stay. We use a combination of medicines instead of just narcotics by using multiple medications we’re able to reduce complications by using a large amount of one medication. This allows for patients to be more comfortable to customize their pain control to what they would prefer and to leads to less confusion constipation and falls. Historically patients were on an I.V. pump for narcotics they as well as taking short acting oral narcotics. What this did was it kept patients chasing their pain and often groggy and asleep. It led to higher rates of constipation and confusion. With modern pain control methods we start paying control prior to surgery we use nerve blocks and numbing medications to help keep patients more comfortable. And we use a combination of anti inflammatory his long and short acting narcotics and Tylenol in order to reduce the amount of narcotics the patient needs.
All this all serves to keep the patients comfortable without needing as much narcotics leading to less problems with constipation addiction and all the negative side effects of opioids prior to modern day joint replacement. Patients were often kept in the hospital for a minimum of three days. We kept patients in the hospital for a artificial time requirement which often treated some patients or which often meant that some patients were in the hospital too long and some patients weren’t in the hospital long enough. I’m not a fan of time requirements in any facet of my patient care because each patient behaves differently and needs to be treated as an individual by using new methods and ensuring that patients are discharged based on obtaining goals that ensure they’ll be safe at home.
We’re able to often get patients home more quickly traditionally also patients went to a nursing home for three weeks.
However what we found was that patients who went to rehab facilities or nursing homes had a higher chance of readmission to the hospital and a higher chance of infection by getting patients home in a safe manner. We’ve reduced these complications and allow patients to have better outcomes ultimately with modern joint replacement you can expect short stays in the hospital more comfortable recovery return to your activities in a in an expedient fashion safely going home instead of a rehab center and working with the therapist at your house in the first two weeks allowing you to be in charge of your own pain control and transition back to your normal life more quickly. You can expect better outcomes less pain better functional results and happier patients. Thank you for your time. Hope you enjoyed my talk and found it informative. Please visit our website for more information about Florida Orthopedic Institute’s hip replacement program.