Same-day hip replacement is a new procedure which allows patients to receive an endoprosthesis without having to spend the night in the hospital. Such accelerated treatment is possible by combining the highly-efficient minimally invasive anterior approach total hip replacement method with meticulously organized hospital logistics. In New York City, Dr. Roy I. Davidovitch was the first surgeon to perform same-day hip replacements in early 2015. He has since used the technique on about 110 patients.
MedicalExpo e-magazine: What are the key characteristics of the anterior approach?
Dr. Davidovitch: For the anterior approach, a six to ten centimeter long incision is made in the front of the hip. You enter the joint through a natural muscular interval between the tensor and the rectus muscle, so you only have to cut the capsule in order to expose the hip sufficiently. This causes only minimal soft tissue trauma. Also, to help with postoperative pain management, we inject a cocktail of pain medications directly into the wound. On average, the entire procedure takes about one hour.
ME e-mag: Does it require a different implant or any other special material compared to the traditional posterior approach?
Dr. Davidovitch: The implants are exactly the same. There are only modifications to the retractors and some of the instruments in order to accommodate the different angles. Also, to position the patient during the operation, I use a Hana operating table because it allows us to hyperextend, abduct, adduct and externally rotate the femur in the hip joint, while placing the components. I wouldn’t say, though, that this is absolutely essential, because the operation can also be performed safely without it. However, I feel that it is more reliable and reproducible to use that table.
ME e-mag: What are the advantages of this technique over the posterior approach?
Dr. Davidovitch: The data have shown that patients who had anterior approaches tend to get up faster, have less scarring, reduced post-op pain and a lower risk of hip dislocation. The hip is very stable and, in contrast to the posterior approach, there are no limitations on bending, sitting, turning, or other precautions afterwards. I have had patients who had both—first a posterior approach and then an anterior approach operation. Without exaggeration, every single one of them has told me that it was a night-and-day experience. However, the advantages of the anterior approach only last the first six to twelve weeks. After about three months, you really can’t see any differences in outcome, for example, based on the way patients walk.
ME e-mag: How did you first come to send patients home the day of an anterior approach operation?
Dr. Davidovitch: It was sort of a natural evolution. I realized that I could do same-day, when I noticed the length of stay for my patients drop over the years. Once I got to one day, I was rounding on these patients the morning after surgery and found them looking completely well, getting out of bed by themselves and walking around. I saw that the only thing keeping them from leaving was logistics. They were just waiting for things such as therapy sessions or medications to be set up. So, if we could do all that up front and ensure their safety, we could send them home the same day. The preoperative care is really extremely important when you are doing same-day surgery—even more so than the postoperative care, I would say.
Patients who had anterior approaches tend to get up faster, have less scarring, reduced post-op pain and a lower risk of hip dislocation.
ME e-mag: What exactly does the preoperative care for this procedure entail?
Dr. Davidovitch: In order for patients to qualify for same-day discharge, we first need to determine that they don’t have any active cardiac, pulmonary or hepatic disease. The other very important thing is to make sure they have support at home, at least for the first night after discharge. We call that person the coach. It doesn’t have to be a healthcare professional at all. Just somebody who is there to help them out and make things easier. After these assessments, the patients, together with their coaches, have sessions with the anesthesiologist, a nurse and a physical therapist. They learn about the operation and what to expect afterwards, how to use crutches or get up and down stairs.
ME e-mag: What’s the typical post-operative experience for a same-day discharge patient?
Dr. Davidovitch: Most patients who are going home on the same day will have the surgery sometime between 8 am and noon, and leave anywhere between 4 and 8 pm. Afterwards, if the patients feel good, are hemodynamically stable, and their pain is controlled, we send them home together with their coach. However, any patient that we are concerned about for whatever reason, we keep in the hospital for a night and monitor them. The patients usually leave the hospital with forearm crutches or a walker, and all the medication they need. We then send a nurse and a physical therapist to their home about two or three times a week for the first two weeks. So far, we have had no readmissions, and I have many patients who go back to work within two to three weeks.