1. Major joint reconstructions in day surgery What is the limit? John Fox (Australia)

3. From Any Lecture / Presentation You will only remember four facts. First Fact you will remember…is From any lecture you will only remember four facts… Three to go.

4. Background Orthopaedic surgeon in Sydney Major Teaching Hospital Appointment - Westmead 8 years at the Cleveland Clinic, Cleveland Ohio 2 years in Boston, Massachusetts Fellowship trained in major adult reconstructive surgery (Major hip, knee, shoulder and elbow reconstructions) Conceived, designed and with a number of other colleagues am a shareholder of Castle Hill Day Surgery I have very much a vested interest in pushing the limits of the Day Surgery within the bounds of safety and appropriateness.

5. Major joint reconstructions in day surgery – what is the limit?

6. What is a Major Joint ? What is a Reconstruction ?

7. Shoulder Elbow Hip Knee What is a Major Joint ?

8. What is a ‘Reconstruction’ ? Shoulder reconstruction = ligament reconstruction or tendon repair Rotator Cuff Repair Capsular Shift

9. Rotator Cuff Repair

10. Capsular Shift

11. Shoulder Reconstruction Shoulder reconstruction = ligament reconstruction Rotator Cuff Repair Capsular Shift Not Controversial !

12. Elbow Reconstruction Elbow reconstruction = Ligament reconstruction Not Controversial !

13. Shoulder / Elbow What about REPLACEMENT ? Shoulder Replacement Humeral Head Replacement Elbow Replacement

14. Not Controversial !

15. Total Shoulder Replacement

16. Humeral Head Replacement

18. Shoulder Elbow Replacement Shoulder Replacement Humeral Head Replacement Elbow Replacement Not Controversial !

19. Shoulder Elbow Hip Knee What is a Major Joint ?

21. Primary Arthroplasty USA Joint replacement is being done on an ambulatory basis. Australia Some selected cases / places

22. Total Hip Replacement

23. Hip Resurfacing

30. HIP No hip ‘ligament’ reconstruction Unipolar Replacement Bipolar Replacement Total Hip Replacement

31. Unipolar eg Moore’s

32. Hip Bipolar Replacement

33. Total Hip Replacement Second Fact

34. Japanese Hornet aka ‘yak-killer hornet’ Scientific name: Vespa mandarinia

36. Total Hip Replacement Paradox in the literature “One of the most significant advancements in total hip replacement is the recognition that the procedure can be done with less invasive techniques which allow the patient to recover faster. This has even progressed to the point that some patients are able to have their surgery accomplished as an outpatient procedure. ”

37. Total Hip Replacement New implants designs New materials –Metals –Plastics –Ceramics New biologically active coatings

38. Total Hip Replacement - Proponents The less invasive approach minimally invasive techniques resulting in less trauma to the tissues benefits for the patient most obvious, the scar is significantly smaller. faster recovery from surgery of “smaller” magnitude. Eg knee arthroscopic surgery, laproscopic cholecystectomy, appendicectomy, hernia repair some more tumor operations. When joint replacement surgery is accomplished with smaller incisions, the patients will require fewer blood transfusions, have shorter hospital stays and will return to work or recreation sooner. Patients report that a joint replaced with these new techniques is significantly less painful than with the previous larger surgical exposures. Minimally invasive hip replacement can be performed either through two incisions each 1½ to 2 inches long or one 3 to 3½ inch incision

39. Total Hip Replacement - Proponents The natural extension of minimally invasive surgery is to do the operation on patients as outpatients. In this situation, the patient receives appropriate education before surgery and then comes to the hospital the morning of surgery. After the operation, the patient is able to leave the hospital on crutches and be driven home to recover.

40. Total Hip Replacement - Proponents Criteria: The patient is in a stable medical condition. –Minor medical conditions should be well controlled: hypertension, asthma, thyroid conditions, stomach or gastrointestinal problems. Contraindications: diabetes, altered mental function (dementia, Parkinson’s disease), unstable cardiac status, renal failure, sleep apnea, and significant prostate obstruction. The patient is willing to attend physical therapy before coming to the hospital. The patient must learn the use of crutches and the appropriate dislocation precautions before surgery. There is an appropriate caregiver to help take care of the patient at home for the first few days after surgery. The patient desires to have the operation as an outpatient. Obviously this would not be imposed on anyone.

41. Total Hip Replacement - Proponents

42. ConventionalMinimally Invasive

43. Total Hip Replacement - Proponents ConventionalMinimally Invasive

44. Total Hip Replacement - Berger Richard A. Berger, MD, Rush–Presbyterian Chicago, Illinois 250 patients who had received total hip replacements through his two-incision method. 100 have gone home the same day of surgery Total hip replacement surgery can be done safely and consistently with two 1.5-inch incisions, and most patients can go home the same day Presented American Academy of Orthopaedic Surgeons.

45. Berger 100 consecutive patients (74 men and 26 women) 92 patients discharged same day the rest were sent home the following day “In a press briefing” Dr. Berger said only about 5% of hip replacements - less invasive knows of no other surgeon doing it as a same-day procedure. predicted that within five years, all hip replacements would be done less invasively the shorter rehabilitation and more appealing scar "Right now, I could do it on 90% of the patients who walk through the door."

46. Total Hip Replacement – Red Flags Rising David S. Hungerford, MD, Johns Hopkins University, Baltimore, –There are no rigorous data showing that less invasive surgery is any better than procedures using a slightly longer incision. –"For this to be widespread, you have to convince skeptics like me," he said, adding that he was concerned that patient demand was being driven by device manufacturers' "hype." Thomas P. Sculco, MD, Surgeon-in-chief at the Hospital for Special Surgery, New York City –cautioned that smaller incision hip replacement — especially on an outpatient basis — required experience and carefully selected patients and noted that Dr. Berger's patients were younger and healthier than the average hip replacement patient.

47. Total Hip Replacement - Opponents Key factors Optimal fixation of the components is essential to the long term success of the total hip arthroplasty. Optimal fixation provides patients with predictable and durable results. The recent emphasis on minimally invasive surgery has focussed attention on short term goals such as the rapid rehabilitation and early discharge of the hospital. The ultimate goal of total hip arthroplasty however, is the long term pain relief and function. Minimally invasive surgery should not compromise long term outcomes for short term achievements

48. Hozack Safe and adequate medical exposure is required for proper component placement and for obtaining optimal fixation. William Hozak- Professor of Orthopaedic Surgery Rothman Institute, Thomas Jefferson University, Philadelphia PA

49. Woolson “In the absence of evidence why bother? A literature review of minimally invasive total hip replacement surgery”. –Instructional Course Lectures from the American Academy of Orthopaedic Surgery –Prof Woolson MD, Stanford University California

50. Woolson Is the small-incision total hip replacements minimally invasive ? A small skin incision requires the application of high forces on the soft tissue for exposure of the joint

51. Woolson A review of the literature provides no convincing evidence of any significant advantages of small incision THR compared to a standard incision THR, other than a shorter surgical scar.

52. Woolson The two incision technique have shown higher rates of –fracture –nerve palsy “surgeons must weigh safety concerns against patient demand in hospital economics in deciding whether to use these procedures” “Patients should be informed about the few documented advantages and possible higher risk with the small incision technique.”

53. Literature Digioia, Ploksey, Levison, et al Mini incision technique for total hip arthroplasty with navigation – J Arthroplasty De Beer Petrocelli, Alzal et al – Single incision minimally invasive total hip arthroplasty. – J Arthroplasty. Chimento Provine et al – Minimally invasive total hip arthroplasty, a respective randomized study – J Arthroplasty. –No statistical significance between small and standard incision total hip replacement in the specific clinical indicators for trauma, invasiveness, post operative, narcotic requirement or length of hospital stay. –No difference in the transfusion requirements in these patient groups. –Two studies have showed evidence of more subcutaneous tissue necrosis, poor wound healing after the mini incision procedures.

54. Incidence of Fracture Burger Jacobs Meneghini et al reported low risk of femoral fracture of 1%, However Berry, Burger, Callahan  2.8% Archibeck and Pagano  7 – 9%

55. There has been 4% early revision rate for postoperative fractures Higher than average risk of lateral femoral cutaneous nerve palsy (2.5-3.2%) –Pagnano MW, Mayo Clinic,

56. Summary The literature does not show any convincing evidence or significant advantage of the small incision (either one or two incision or the mini incision techniques to standard techniques of total hip replacement. The only advantage identifiable is the smaller incision.

58. KNEE Ligament reconstruction –Anterior Cruciate Ligament –Posterior Cruciate Ligament Unicompartmental Replacement Total Knee Replacement

59. Unicompartment Replacement

60. MI TKR

64. ConventionalMinimally Invasive

65. Upper extremity Upper extremity reconstructions and replacement are not controversial Overnight stay

66. Lower Extremity replacement Very Healthy Only minor medical conditions and well controlled Pre-Admission Patient Education –crutches education –dislocation precautions The patient desires to have the operation as an outpatient

67. Lower Extremity replacement Overnight stay + Rehab –Total Knee Replacement –Unicompartmental Knee Replacement Urge caution –Total Hip Replacement

68. Knee Arthroscopy

69. Four Facts Four facts Vespa No convincing evidence for Minimally Invasive Surgery of the hip Nurses are more observant then surgeons