How joint replacement became a fairly routine outpatient procedure
Advances in total joint replacement surgeries can be divided into two distinct time periods—before and after Sir John Charnley.
The earliest attempts at hip replacement took place in Germany in the late 19th century, with mixed results. Doctors attempted to use ivory in place of the decaying femoral heads of patients whose joints were destroyed by tuberculosis. But the trial-and-error approach to replacements lasted until 1953, when English surgeon George McKee created a one-piece mold that showed a strong long-term survival rate, but became unpopular due to the effects of the metal particles.
That’s when Sir John Charnley, a British World War II veteran, dedicated his career to the idea of improving and later perfecting the art of hip replacement. Charnley, now recognized as the father of hip replacement, passed away in 1982, but still has numerous students practicing in the field. Charnley’s low friction arthroplasty became popular in 1961 and still closely resembles the models used today. It consisted of three parts; a metal femoral stem, a polyethylene acetabular component and acrylic bone cement, which was borrowed from dentists.
Today, almost 100,000 Americans are undergoing total hip replacements each year. Techniques have modernized and become more standardized, but Dr. Carnley’s method remains the gold standard.
Changes over the Years
Back in 1961, Dr. Charnley refused to operate on anyone under the age of 50 nor anyone over 200 pounds, as the artificial hip structures were not thought to be durable enough to hold up for the entire lifespan of someone under age 50, or strong enough to support individuals above a certain weight.
These days, there are no absolutes in either category. Recommendations are based upon an individual’s pain tolerance and level of disability, not a specific age. However, as life expectancies increase, the focus shifts to creating implants with greater durability and less susceptibility to bearings that wear out with time.
As far as a comparison of useful materials, a recent National Institutes of Health paper outlined three primary compositions, and their respective plusses and minuses:
- Metal-on-polyethylene: This combination is the most popular, leading to the greatest volume of evidence behind their usage. They also combined a predictable lifespan with cost efficiency. On the downside, polyethylene debris can lead to loosening of the joint over time.
- Metal-on-metal: A reduction on wear-and-tear due to the similar materials leads to greater durability than polyethylene. Larger femoral head creates lower dislocation rate; however, the metal ions have a potential carcinogenic effect.
- Ceramic-on-ceramic: Lower friction and debris; but cost can be prohibitive and tends to make noise with movement.
The Move to Outpatient Surgery
As recently as 10 years ago, the idea for many state-of-the-art joint replacement programs was to have patients up and moving around the day after surgery. If all went well, the patient could expect to be released the following morning. At the time, doctors and nurses talked about the challenges of preparing often-elderly patients for the reality that they would be back home only a couple days after surgery, as many patient felt they couldn’t possibly handle that degree of independence so soon after the procedure.
Therefore, you can imagine the challenges in today’s environment, which encourages hip replacements to be done on an outpatient basis, meaning a same-day return to the home.
At a recent APTA Combined Sections Meeting, researchers showed how education via physical therapists can be part of a protocol that leads to positive outcome for patients undergoing total joint replacements. The Hospital for Special Surgery, located in New York City, led a study finding that patients benefit from individual educational sessions provided by a physical therapist and access to a custom web portal prior to knee or hip replacement surgery.
When compared to those who did not participate in the educational sessions or have access to the web portal, patients were more satisfied with their pre-surgery education and felt better prepared to leave the hospital after joint replacement.
“It has been shown that pre-operative education is most beneficial when provided one-on-one,” said Joshi. “The sessions are customized to address a patient’s specific needs regarding pre-operative preparation and what to expect in the hospital and during rehab and recovery. We also assist patients with setting realistic goals regarding outcomes, and they are able to ask any questions they may have in a private setting.”
Staff members begin gathering extensive patient histories about three to four weeks pre-surgery, while patients attend joint classes to learn what their reasonable expectations should be before and after surgery. Lastly, patients are invited to tour the facility in which their surgery—and possibly, their rehab—will take place.
Program coordinators work closely with patients and their families to coordinate these classes and schedule all necessary prep, surgical, and follow-up appointments. Ideally, each patient will work with one main staff coordinator who will lead communication throughout the process.
Many doctors believe that patients who have longer, more arduous recoveries from joint replacement end up staying in the hospital because they weren’t mentally prepared to recover quickly. If the hospital and its staff create the expectation of a same-day release, the patient will naturally become more comfortable with this ideal outcome.