New Center for Outpatient Hip and Knee Surgery Improves Access
Dennis Harris struggled with hip pain for years. When things got so bad that he couldn’t walk anymore, he came to Cedars-Sinai for hip replacement surgery. Harris said he was confident the operation would help but initially assumed that he would be in the hospital for several days. "I thought that I was going to be out of commission for months," he said.
Instead, the 59-year-old Koreatown resident was discharged within 24 hours—and he was walking for miles and working out at the gym 10 days later. He is thankful to be pain-free. "I'm like a kid in the candy store as far as life is concerned right now," Harris said.
His story is a glowing example of the benefits of what are known as outpatient, same-day or “24-hour” total hip and knee replacement surgeries. Advances in minimally invasive surgery, anesthesiology, imaging technology and pain control have combined to make outpatient joint replacement suitable for many patients.
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More recently, outpatient surgeries—meaning those allowing for discharges the same day or within 24 hours—have surged in popularity as COVID-19 has made some patients wary of extended stays in a hospital. While accommodating those patients, the trend toward outpatient surgeries also helps institutions such as Cedars-Sinai free up more beds for patients with COVID-19 or other major ailments.
Amid those developments, Cedars-Sinai opened its Center for Outpatient Hip and Knee Surgery on Dec. 7, 2020, to increase the number of outpatient joint replacements it can perform. The aim is to provide the convenience of a surgery center with the support of a world-class medical center, according to the two hip and knee arthroplasty surgeons leading the effort, Brad Penenberg, MD, and Sean Rajaee, MD, who operated on Harris.
Penenberg said that when he began performing hip and knee replacements more than 25 years ago, patients would remain in the hospital for anywhere from several days to up to two weeks. Minimally invasive surgery began to emerge two decades ago. Drawing on that and other advances, Penenberg and the Cedars-Sinai arthroplasty team of surgeons began performing total hip replacements on an outpatient basis eight years ago, and total knee replacements six years ago.
At Cedars-Sinai, more than 90% of patients getting hip replacements and more than 80% receiving knee replacements can be discharged within 24 hours, including many who go home without an overnight stay.
"People would immediately think that it's a 35-year-old or a 40-year-old or a really healthy 50-year-old who could go home on the same day, but we've had people in their 80s go home the same day."
On the other hand, Rajaee noted, the outpatient surgeries aren't suitable for everyone, especially those with serious comorbidities. Rajaee recommends speaking with your surgeon about whether you would be a good outpatient candidate.
Tom Jovicich, DMD, a 60-year-old oral surgeon, had his left hip replaced the week the center officially opened in early December. He was discharged the same day.
His hip problem stemmed from sports injuries. Although Jovicich wasn't in great pain, the deterioration in the joint slowed him down physically and curtailed his activities. Still, he wasn't about to get the surgery if it meant a long hospital stay.
"I've always been a believer in 'get in, get out and minimize your footprint.' I never have had to stay in a hospital overnight. I never want to stay in a hospital overnight," said Jovicich.
The outcome of his surgery, Jovicich said, "exceeded his expectations." At times, he has wondered, "Why didn't I do this earlier?"
Harris said he could have left the medical center the same day he was operated on but was given permission to stay overnight and depart the morning after his hip surgery.
"It just made me feel better," he said, to know that he would have medical personnel nearby if any complications arose.
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The next morning, he walked without a crutch or a cane up and down the hall in front of his caregivers. Harris said he felt so good that he "held back" a bit while his caregivers were watching. "I didn't want them to think I was going to overdo it" once he was discharged, Harris explained. "But the reality was, I was walking fine."
Harris' struggles with crippling pain began with a work accident three decades ago that smashed one of his ankles and led to a cascade of orthopaedic problems, including the bad hip that Rajaee replaced in June.
Rajaee, an assistant professor of Orthopaedic Surgery, said the number of people needing hip and knee replacements or reconstructions is rising rapidly as the population ages and more people stay active as they grow older. "In general, what we're talking about are the conditions of hip arthritis and knee arthritis," he said. "Their joints are wearing down."
While the numbers of candidates for joint replacements have swelled in recent years, surgical techniques have improved. Surgeons have developed ways to avoid cutting muscle and to reduce damage to other soft tissue while also minimizing blood loss. Digital radiography, or imaging, techniques that were pioneered at Cedars-Sinai have brought added precision to the operations.
Perhaps most importantly, anesthesiologists have moved away from general anesthesia to more targeted regional anesthesia, so that only a limited part of the body is numbed.
Previously, "It was often the general anesthesia that kept patients in the hospital for additional days after surgery," Penenberg said, pointing to temporary side effects such as low blood pressure, dizziness and nausea. Regional anesthesia's side effects are milder and shorter-lasting, enabling patients to get back on their feet more quickly.
Recent studies, including a June paper by New York University's Langone Orthopedic Hospital researchers, have found that surgeries with same-day discharges achieve results that are as good, or even better, than traditional operations.
Nonhospital surgical centers in some cases have been quicker to seize the opportunity to perform these surgeries on a same-day basis.
A key task for the new Center for Outpatient Hip and Knee Surgery in the Pavilion will be matching one of the strengths of the small surgery centers—ensuring that the necessary physical and occupational therapy, pharmacy and other services are promptly available to prepare patients for swifter discharges.
At the same time, a big advantage that Cedars-Sinai will offer patients, Rajaee said, is that "your surgery is going to be in a building that's still attached to a Level I trauma center that has vascular surgeons, cardiologists—all of these types of doctors—minutes away."
Penenberg agreed. A big hospital can be daunting for some patients, he said, but "the benefit is, you get all of the backup in the world in terms of a world-class medical center should there be a need for any unanticipated medical services."
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