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Knee replacement surgery in a day hospital

Post 5

A first for the Western Cape 

Covid-19 has had a lasting impact on hospitals and the field of medicine in general. In 2020, most South African hospitals, including the Mediclinic where I work, put a stop to all elective surgeries and most procedures that weren’t related to Covid-19 or emergencies. A significant number of the knee and hip replacement surgeries that I perform are elective, and this meant my operations where almost completely slashed.

While this is frustrating to surgeons as well as our patients, it is a completely rational response to the pandemic which has seen both public and private hospitals overwhelmed by severely ill Covid-19 patients. The burden on our staff is enormous and the onslaught of the pandemic is relentless.

But amidst the frustration and devastation wrought by Covid-19 comes opportunity and innovation. In July 2021 I performed the first total knee arthroplasty (total knee replacement) in a day hospital in the Western Cape and possibly the country. My patient was discharged from the hospital a mere 20 hours after her surgery. In most cases, patients stay in an acute hospital for around four days after a knee replacement.

Teamwork for decreased length of hospital stay

In July, one of my patients was frustrated during a consultation to find out that she would only be able to have her knee replacement surgery several weeks later in an acute hospital due to the Covid-19 restrictions on operating theatres. Doing a knee replacement in a day hospital was an idea I had been toying with for a while, given the successes I’d already had in decreasing patients’ length of stay. When I pitched it to her, she was immediately keen to be the first patient to undergo a total knee replacement in a day hospital.

I had been building up to this moment for a long time. Out of concern that the patients I have been able to operate on over the past 15 months would be exposed to Covid-19 during a prolonged stay in hospital, my team and I have worked hard to discharge these patients as quickly as safely possible.

We have been working together to get these patients standing and walking soon after their surgeries. From my side, this involved optimising my surgery techniques, and a meticulous pain management schedule. The anaesthetists, physiotherapists, and everyone else involved in the patient’s hospital stay and recovery have had to be on board with the plan. Doing this I had already managed to ensure that most of my patients are discharged after only a day in hospital.

Day case total joint arthroplasty across the globe

Several articles have been published about day case total joint (knee and hip) arthroplasties that are increasingly being performed internationally because of the pandemic. Day case surgery is when a patient is discharged on the same day as their operation. The Bone and Joint Open, in an article titled Day-case total hip arthroplasty: a literature review and development of a hospital pathway noted: “We have seen unprecedented demands and changes within our healthcare systems during the Covid-19 pandemic… This pandemic has presented rare opportunities to revise and re-engage elective arthroplasty pathways aimed at improving patient care and healthcare efficiency.”

These articles all highlight that the outcomes for day case and outpatient arthroplasty patients are very similar to inpatients. A Royal College of Surgeons of England review titled The safety and efficacy of day-case total joint arthroplasty found that the readmission rate for day case patients was 1.9% versus 2% for inpatients.

Patient selection and education

Crucial ingredients for success for day case arthroplasty is careful patient selection and education. One of the reasons that day case arthroplasty has been largely successful so far is because the patients are so carefully selected, with many surgeons using a scoring system to determine who is eligible. Surgeries on these patients are less ‘risky’ and they are more likely to experience good outcomes.

Some of the factors taken into consideration when selecting patients for day case arthroplasty includes their age, health, and support system. Patients with comorbidities such as cardiovascular diseases, pulmonary diseases, uncontrolled diabetes, or obesity, to name a few, aren’t eligible for day-case surgery because they are at a higher risk of postoperative complications and need to be monitored in a hospital.

Studies, as well as my own experience, show that patient education is essential when planning for day case arthroplasty. In a review by The Canadian Medical Association Journal titled Management of patients undergoing same-day discharge primary total hip and knee arthroplasty, the authors point out that “careful education of patients, by surgeons and primary care physicians, can help to dispel myths about outpatient (day case) total joint arthroplasty and thereby optimise success”.

The way that we speak to and prepare our patients pre-operatively is most probably the biggest change my team and I have made over the past 15 months. We tell our patients that they will be up and walking soon after the operation and that they will be able to go home within a day. The patient also needs to be comfortable with such a short hospital stay.

Our day case surgery

The patient I performed the first day hospital surgery on was a perfect candidate. Her health and age counted in her favour, as did her willingness to participate in something new. She knew what to expect and was enthusiastic at the thought of being mobile so soon after a total knee replacement. The combination of these factors led to her successful surgery at Summerhill Surgical Centre, a day hospital in Somerset West.

We operated in the morning and our patient was walking an hour and a half after surgery. While she was ready to be discharged in the afternoon on the same day as her surgery, hospital staff opted to keep her overnight as a precaution. She was discharged early the next morning and is recovering wonderfully.

An outsider’s perspective

Annemi Stone, a sales consultant for Corin South Africa, from which I source my implants, gave her views on the total knee replacement that I performed at Summerhill.

“What Dr Hardcastle did is ground-breaking, and I think it’s the future of knee surgery. Dr Hardcastle had already been working to get his patients home quicker over the past year. Doing knee replacement surgery in a day hospital was a natural next step. He coaches his patients emotionally so that their expectations are to go home very soon after surgery. The surgery he did in the Summerhill day hospital had an amazing outcome.

“Covid-19 forced Dr Hardcastle to think out of the box and take a leap of faith. It takes guts to do something like this. Dr Hardcastle is young and upcoming and is willing to try new things. He is practising new age orthopaedics. We don’t know of anyone else in the country who has attempted this.

“I think that this is the future of knee surgery and better for patients overall. There are other surgeons that are open to trying this now, eager to follow in Dr Hardcastle’s innovative footsteps.”

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