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Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole (Host): As physicians are able to make great strides and advances in surgical technique, anesthesia, and pain control, it's now possible that total joint replacement can be done as an outpatient.

Welcome to UAB MedCast. I'm Melanie Cole. And joining me today is Dr. Scott Mabry. He's an orthopedic surgeon at UAB Medicine. Dr. Mabry, it's a pleasure to have you join us. As you're new to UAB, before we talk about outpatient total joint replacement, tell us a little bit about yourself and how you came to UAB Medicine.

Dr Scott Mabry: Well, thanks for having me, Melanie. It is very exciting to be back at UAB. I was actually here as a resident physician for five years before I went off to St. Louis last year for my hip and knee replacement fellowship at Washington University. I'm initially from Tennessee, so from the south, and definitely wanted to come back to the southeast. And UAB was just such a great opportunity, great experience. And I think the things that we're doing from a joint replacement standpoint are at the forefront of where I'd want to be in my career. So, I was definitely happy to join back on.

Melanie Cole (Host): UAB is at the forefront of many types of medicine careers, so thank you for telling us that. Now, tell us a little bit about the evolution of total joint replacement. What's different now? Why are we able to do outpatient total joint replacement when this used to be a pretty big surgery? But now, it's being done in so many different ways. Can you tell us a little bit about it?

Dr Scott Mabry: Absolutely. And that's a great point you bring up. Just that there has been such evolution in joint replacement over time. It's allowed us to have these same-day surgeries and the advances in our technologies and our protocols. The basics of a joint replacement really hasn't changed over the years. It's still where you take out arthritis and you replace the ends of the bone with metal with plastic between. That's the forefront of joint replacement. That's where it's always been.

The real change has been with the materials that we use. These materials whereas they used to last five, 10 years, they're now integrating into the bone better. Their plastics are wearing out at a much slower rate. So, these are now lasting 25, 30 years and 80-90% of them are surviving that long. So from that standpoint, we aren't getting very good outcomes with our joint replacements. From a same-day joint perspective, the real change has been with our postoperative pain management protocols, as well as some of our physical therapy protocols. Our anesthesia colleagues have done a great job of instrumenting spinal anesthetic, which are epidurals, the same kind of epidurals that you would have during childbirth, where the legs are numbed up. It's short-acting. So by the time we're finished with the joint replacement, the legs are warming up, and they're able to start moving again. So, physical therapy can then start immediately after surgery.

We also do pain blocks for the knees and local infiltrate of pain medications in the hips, so that by the time the patients are waking up from these surgeries, they're not having the same kind of pain they had years ago where they would lay in bed for days on a pain pump before finally getting out of bed with physical therapy. So, these two advancements have really gone a long way into getting these patents up immediately after surgery comfortably, and then getting them home the same day.

Melanie Cole (Host): Great points that you brought up, and I'd like to expand for a second on that as we look at this emerging model. Who do you think that it's driven by? Do you feel this is both patients, obviously physicians, because you are looking at better pain control management, physical therapy and, you know, stewardship for opioids, but also the insurance companies to reduce their costs? Is this better for the physicians? Speak about the advantages a little bit.

Dr Scott Mabry: Sure. And I think this is beneficial to all three of those different categories. I think ultimately it has to be driven by the patient. The patients, especially after COVID, really didn't want to spend any more time in hospitals than they had to. With the pandemic and the risk of being in the hospital, a lot of patients just wanted to come in for their treatment and get home as quickly as possible. And from a joint replacement standpoint, we did note that spending more time in the hospital after your surgery didn't really provide much benefit and, honestly, could have increased the infection risk and some other complications from being stuck in a bed for three to four days after surgery. So, I think ultimately it's the patient's comfort level and the patient's benefit that we're striving for.

From a surgeon perspective, like I mentioned, the joint replacement surgery itself isn't any different for us if we did it for a same-day patient or for someone that's going home. But I do think it's beneficial for the surgeons because then we get to see our patients do better with the lower complication profile if they're able to go home that same day. And then, just kind of like other surgeries that we've had in orthopedics in the past as it becomes more mainstream, as our protocols improve and patients are able to go home same day or next day at a safer and higher rate, then you'll see that insurance companies will start to follow suit and kind of expect these surgeries to become a same-day type of surgery. And we've even seen that in the last few years as the hip and knee replacements have been taken off of the inpatient-only list from an insurance carrier perspective.

Melanie Cole (Host): Well then, speak about patient selection. Tell us the criteria someone would have to meet. And while you're doing that, speak about the strategies that you employ to optimize their recovery after an outpatient total joint replacement. Speak about patient selection, why that's such an important aspect for better outcomes.

Dr Scott Mabry: Absolutely. The patient selection is the most important part of planning a same-day surgery. The number one thing is going to be patient motivation and a patient support system. If a patient doesn't meet those two requirements, have someone at home that can help them out in that first week or two, doing some minor things around the house or even just getting up and down from the bed to the bathroom in the middle of the night or the patient's not motivated to go home that same day. And then, it's very hard to push this surgery or this procedure on someone. That's when you start to see some of the complications, some of the returns of the hospitals, because maybe the patient wasn't selected properly. Then, they have a higher risk of coming back to the hospital for some reason or another.

From a medical standpoint, there really are three things that would prevent patients from being a good candidate for an outpatient or same-day surgery joint replacement. Number one, it would be something like lung disease, COPD, something that where the patient requires multiple medications, has a potential risk of anesthesia, maybe even is on home oxygen. Those patients should probably be monitored in the hospital at least for a day or two. Same is said for some of the patients that have had previous heart issues, heart disease, heart attacks in the past, possibly they've had stents or pacemakers put in. Those are the patients that we really want to try to push in and out of the hospital. We want them to take their time, make sure nothing around that perioperative area is going wrong with their heart.

And then thirdly, it would be patients that have had a previous blood clot or deep vein thrombosis, pulmonary embolism, something that required them to be on higher anticoagulant doses. That risk of bleeding after the time of surgery is probably a little higher than we'd want to risk sending someone out immediately postoperatively.

So, the people that benefit the most from these protocols are the patients that are highly motivated with a good support system at home. Those are the patients that are adequate candidates for the same-day surgeries for joint replacement. They're the ones that are less likely to have to come back into the hospital for a social situation for a medical problem that arises. And at UAB, we are actually in the process of implementing a new perioperative optimization.

In addition to the standard anesthesia pre-op clinic where the anesthesiologist would evaluate the patients and clear them, we're actually looking at a variety of patient factors in these clinics from diabetes management, weight loss management, heart, lung, chronic medical condition management. And from here, we can actually gauge, A, if patients are candidates, but B, if patients have the motivation or have the desire to be outpatient surgery candidates, in addition to seeing them in our own clinic and working them up that way. So, I think this is just another step to ensure that we are adequately selecting correct patients for same-day joints, and that will only help with our successes here at UAB.

Melanie Cole (Host): It certainly will. That's excellent. So, I'd like you to share some considerations with other providers to help achieve their better outcomes. Now, you just mentioned that postop clinic, obviously multidisciplinary, many providers involved. But what are some of the things that you would like other providers that are thinking about doing these outpatient total joint replacements? Equipment, staff? Can you give any tips, tricks, things that you have found that have worked so well with these motivated patients that are selected for this type of procedure?

Dr Scott Mabry: Yes. I think that the first and most important thing is that conversation with the patient. You really want to make sure that you're on the same page, that your goals of having them go home the same day align with their goals. So, that is probably number one the most important conversation to have.

From a protocol and provider perspective, I think it's that multidisciplinary approach between us, the preoperative clinic, the anesthesiologist. That way, we can make sure that we're getting these patients selected correctly. And then, on the day of surgery, we're also doing our protocols to help them move along that day. And that includes scheduling these patients early in the day, having them get the preoperative spinal anesthetic, the pain block, the infiltrates of local anesthetic during surgery. And then, also speaking with our therapists, so after surgery, these patients are prioritized getting their therapy as soon as that spinal anesthetic wears off so that they can get multiple rounds of physical therapy before mid-afternoon when they would be going home. That and then the perioperative nursing staff, who also is vital in this process where they're able to help the patients as they may need a little bit more pain control or help coordinate with the therapist to get them up and down, out of bed as well.

Melanie Cole (Host): Such great points. As we wrap up, Dr. Mabry, tell other physicians what you'd like them to know about outpatient total joint replacement, what you're doing there at UAB Medicine. Tell us about your success rates and your outcomes. Let them know why it's so important to refer to the experts at UAB Medicine.

Dr Scott Mabry: Yeah, I think if you do have someone that's interested in a same-day total joint replacement or joint replacement in general, they should probably be evaluated by a facility such as UAB and UAB Highlands where we are doing these procedures. Pretty much all of our partial knees go home the same day. And a lot of variety of our total knees and total hips go home the same day. I believe our rate is somewhere around 30%. We could definitely expand that as patient interest increase as well.

From that standpoint though, I think that just getting the patients in to talk to us and have that conversation. It's a frank conversation and some people are interested, some aren't. But either way, we're happy to evaluate them, anyone with arthritis. And here at UAB, we manage our arthritis operatively, non-operatively and in concert with some of our non-operative physicians as well. So, we're always happy and grateful for any referrals that come in from the UAB departments in general or from the community at large.

Melanie Cole (Host): Thank you so much, Dr. Mabry. You are a great guest. Please come and join us again to discuss anything else that you would like to discuss in the orthopedic world at UAB Medicine. And for more information about the outpatient total joint replacement or to refer a patient to UAB Medicine, you can call the MIST line at 1-800-UAB-MIST or you can visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole.