Total hip and knee replacement performed on outpatient basis for certain patients

Advances in orthopedic surgery allow patients to recuperate entirely at home

It hardly seemed possible: Mere hours after undergoing major surgery to have her right hip replaced at the JGH in June, Anne Murphy was back at home and looking forward to a good night’s sleep in her own bed.

With her daughter driving, she’d come to Montreal that morning from the village of La Conception (not far from Mont Tremblant), had her operation, spent some time in the hospital’s recovery room, and was home again by late afternoon, having sat comfortably in the car for more than two hours during the return trip.

“The only way I can describe it is ‘incredible,’” says Ms. Murphy, 72, who began taking small, careful steps in the hospital a couple of hours after her operation. By mid-August, she was well on her way to normal, effortless movement.

Dr. David Zukor (right), Chief of the Division of Orthopedic Surgery, performs a total knee replacement by relying on a robotic arm (at left, wrapped in plastic) to guide him in removing precise portions of bone from a patient’s knee. Joining him is Dr. Mohammed Al Hassan, a Fellow from Saudi Arabia who specializes in joint replacment surgery. (Click on the photo to enlarge it.)

“If I’d had to spend a night in the hospital, it wouldn’t have been the end of the world,” she says. “But knowing I wouldn’t have to be away from home even for one night made me feel so much better.”

Ms. Murphy’s operation was performed by Dr. David Zukor, Chief of Orthopedic Surgery, who says his Division has consistently tried to minimize the time spent by patients in the hospital after a total hip or knee replacement.

However, only recently has the healthcare team succeeded in making the operation an outpatient procedure that requires no overnight hospital stay for certain patients. A trial run of the new system was completed this past May, with the first official procedure performed on an outpatient basis in June, followed by another 10 as of mid-August.

For Ms. Murphy, this was a significant contrast to the total replacement of her left hip at the JGH in 2021. After that operation, she spent three nights in the hospital, because post-operative medication caused a sharp drop in her blood pressure.

However, she says, after the hip replacement in June, the spinal anesthetic wore off quickly—“It was as if I’d been tuned like a Swiss watch!”—and she experienced no ill effects.

Outpatient surgery is voluntary

According to Dr. Zukor, patients must voluntarily agree to be part of the outpatient system. They must also be in generally good shape—for example, those who are frail or very elderly are excluded—and must have adequate support at home.

The new outpatient system was the next logical step after the improvements that Dr. Zukor had overseen during the previous several years in a Division where roughly 600 total hip and knee replacements are performed each year.

Since early 2020, the objective has been to get patients up and moving as soon as possible—ideally, within hours of the operation.

The effort was initiated by Dr. Zukor and Emanuela Ciarlelli, the former Head Nurse in Orthopedics (now Head Nurse for the operating rooms). They were backed up by a healthcare team that included nurses, orderlies and physiotherapists.

“It might mean patients would only take a couple of steps or sit in a chair or walk to the commode or the bathroom, but the point is, the mind-set was different,” Dr. Zukor says. “We were getting down to having the patients stay in hospital for just one or two days.”

Dr. Zukor also worked with anesthesiologists, especially Dr. Ken Kardash, to minimize the use of certain pre- and post-operative medications—notably, morphine and other opioids—so that patients would be better able to take their first steps much sooner.

In the new outpatient process, nurses encourage the patients to start moving as soon as the anesthetic wears off. To be discharged, patients must walk a certain distance, climb a certain number of stairs, keep food down and be able to urinate.

A key element of the at-home recuperation process is the continuity of support provided by professionals in the Recovery@Home program. This level of care is as rigorous as what in-patients receive after surgery, but in this case, it happens in a home setting which becomes a virtual hospital ward.

On the evening that patients have returned home after that day’s surgery, they get a phone call from a nurse to make sure they are feeling well, taking their medication, moving reasonably easily and experiencing no unusual pain.

The phone calls continue on a regular basis for the next three days, supplemented by in‑person visits from a CLSC nurse. In addition, patients are given a phone number that immediately puts them in touch with a nurse if a problem arises or if they have follow-up questions.

“Since the operation and the discharge happen so quickly in a single day, it’s important for us to stay in close touch with these patients,” says Julie Valiquette, a Senior Clinical Advisor in the Rehabilitation and Multidisciplinary Services Directorate.

“Streamlining the process is a definite advantage,” she continues, “but that doesn’t change the fact that the patient is under stress after surgery and needs guidance and support.”

Julie Savard, a Clinical Nurse Coordinator for the ERAS program (Enhancing Recovery After Surgery), agrees, adding that Recovery@Home serves as “an important safety net. It provides comfort and a sense of security at a time when the patient needs it most.”

Ms. Valiquette and Ms. Savard were instrumental in creating the post-operative pathway for outpatients in orthopedic surgery, working in close collaboration with Viki Doucette, Unit Chief for Virtual Care, and her team.

Introducing transparent dressings

Dr. Zukor is also proud of having switched to a transparent dressing that does not have to be removed in order for the wound to be inspected. This dressing—known as an “active dressing” for its ability to enhance healing—stays in place for 12 days and enables the patient to experience much less discomfort, since no adhesive material is regularly pulled off the sensitive skin near the wound.

In addition, a patient with a transparent dressing can shower as soon as three hours after the operation, since the wound’s exposure to—and possible contamination by—the environment is minimized.

“After that, whatever the patient chooses to do depends on the patient,” Dr. Zukor explains. “They all start walking right away and some even drive right away. Some who are highly motivated, like dentists, lawyers and certain self-employed people, have returned to work after just two weeks—maybe not full-time, but they do go back.

“Total recovery takes the usual three months, but the point is that we’re doing it on an outpatient basis.”

In Ms. Murphy’s case, the success of the new system also has a lot to do with the quality of the care she received. “It couldn’t have happened without Dr. Zukor and everyone on his wonderful team,” she says.

“After the operation, Dr. Zukor kept coming to see me and asking if I was comfortable. He instilled such confidence in me and he made everything feel so personal. It’s no exaggeration to say that he gave me back my life.”