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Knee replacement surgery in a day hospital – Part 2 of 2

Post 3

Covid-19 sparks opportunity and innovation 

In July I performed the first total knee replacement surgery in a day hospital in the Western Cape, and possibly in South Africa. This drastic step was as a direct result of the Covid-19 pandemic, which has forced surgeons, understandably, out of the operating theatres in acute hospitals.

Orthopaedic surgeons across the globe are increasingly starting to perform day case total joint (hip and knee) arthroplasty on eligible patients. Day case patients are discharged on the same day as their surgery. There are several benefits to this for patients as well as for the healthcare system – namely cost-saving and freeing hospital beds for critically ill patients.

A Royal College of Surgeons of England review titled The safety and efficacy of day-case total joint arthroplasty predicts that the demand for joint arthroplasty in patients younger than 65 will increase by more than 50% by 2030. This makes it is imperative that we find innovative ways to treat our patients to ensure the best possible outcome.

In my experience, and based on international studies, there are several factors to take into account when considering day case total joint arthroplasty.

Pain management

Crucial to successful day case knee replacement is excellent pain management. It is one of the areas I have focussed on over the past 15 months as I worked on getting my knee surgery patients mobilising sooner and minimising their length of stay in hospital.

The main reason patients don’t want to move after an operation is because they have pain. I make sure that my patients are pain free so that they can start walking within a few hours of their surgery. Firstly, this means that during the surgery I infiltrate the knee with analgesics. If this is done correctly, the patient shouldn’t have any pain.

Secondly, because my patients go home so soon after their surgeries, they have to manage their own pain medication, rather than having it administered to them by hospital staff. To make sure they can do this effectively, I have implemented a tick sheet system so that patients know exactly when to take which pain medication and at what dosage.

This remarkably simple solution has paid off, giving my patients the power to manage their pain. And in the case that they do experience pain, I can look at their tick sheet to work out what the problem is.

Weighing up the risks

As with anything, there risks both with having patients spending several days recovering in an acute hospital as well as with doing total knee replacement surgery in a day hospital. In both these scenarios, some of the biggest concerns post-surgery are leaking wounds, deep vein thrombosis, and infection.

Several studies, including the A Royal College of Surgeons of England review, found that “prolonged hospital stay is associated with higher morbidity and mortality”. Patients face increased risk of developing complications such as clots, deep vein thrombosis and pneumonia during a longer hospital stay because they’re not very active. On top of that, the unfortunate reality is that during the pandemic, the longer patients stay in a hospital, the more likely they are to be exposed to Covid-19.

As mentioned in the first article of this series, the outcomes of a day case arthroplasty patient are probably going to be good because the patient selection criteria are so strict. Therefore, the largest risk of performing day case surgery in a day hospital is due to complications from the anaesthesia. Day hospitals aren’t equipped with ICUs, which means that a patient experiencing any serious complications would need to be transferred from the day facility to an acute hospital.

The logistics of knee replacement surgery in a day hospital

Performing a total knee replacement in a day hospital required meticulous planning. I chose a theatre team that I had worked with before and who are used to doing knee replacements. The team at the day hospital, Summerhill Surgical Centre, in Somerset West, were excited to host us and moved mountains to prepare their facility for us.

Because the day hospital isn’t equipped to do big arthroplasty surgeries, we arranged to get the saws and cement in, and my instruments were brought over from the Mediclinic where I normally perform these operations. The implants arrived a day before the procedure. I visited Summerhill several times in the days leading up to surgery to check that everything was ready and to make sure that the staff knew what to expect.

It was this level of planning, commitment and collaboration from everyone involved that helped make this surgery a success.

Post-operative support is crucial

Critical to a patient’s recovery after total joint arthroplasty as a day case is their support structure. A review by the Canadian Medical Association Journal titled Management of patients undergoing same-day discharge primary total hip and knee arthroplasty stated: “A strong social support system is essential for assistance (both physically and mentally) in the perioperative period.”

International healthcare systems, such as the UK’s NHS have at home care programmes, where nurses keep contact with patients who have been discharged. This allows the patient to recover in their own surroundings, minimising their risk of hospital-acquired illness, freeing up hospital beds for other patients, while still receiving a level of professional care.

In the absence of this type of support in South Africa, my patients have direct access to me. I also make a point of following up with my patients regularly. While this approach is more labour-intensive, it is incredibly rewarding. Our patients mobilise more quickly when they’re at home, because they aren’t confined to a hospital bed and they feel motivated to move around. Their general wellbeing and demeanour is also much better at home.

Day case arthroplasty – the new normal

Doing a total knee replacement in a day hospital was exciting and the result of exceptional teamwork and pain-staking preparation and planning. However, within the next few years this probably isn’t going to be the exception, but rather the ‘new normal’. We were heading in this direction anyway; the Covid-19 pandemic merely fast-tracked things. A knee replacement remains a good operation, but the way Covid-19 numbers keep surging means we must find ways to continue improving our patients’ quality of life in a way that doesn’t put them at unnecessary risk of contracting the virus.

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