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Preoperative Evaluation/Patient Issues/Total Knee Replacement

QUESTION:

We are a small Ambulatory Surgery Center in Ft. Myers, Florida. Recently a surgeon requested time to do a total knee replacement (TKR) here. He said that this was done routinely in many places. I could not verify that with my literature search. To me it seemed in the experimental stages, requiring continuous infusion pumps, etc. Do you have any data, position, or opinion on doing TKRs in an ambulatory setting? We have no facilities to neither give blood nor provide prolonged pain control.

-- From Paul DeLeeuw, M.D., Ft. Myers, FL

REPLY:

First, Medicare will not reimburse for a total joint in an ambulatory setting. The other third party payors (e.g., Blue Cross / Blue Shield, Aetna, etc.) will, but the determining factors become the cost of the prosthesis, physical status of the patient, and (of course) postoperative analgesia care of the patient.

I have discussed this topic with many of our orthopedic surgeons, and we are first going to do a unicompartmental minimally invasive knee arthroplasty in our centers. These patients routinely go home on the first postoperative day from the hospital (with a psoas compartment catheter in place) and do very well. The reimbursement for the center would be reasonable, and we could do the procedure for about one half the cost of doing it in the hospital, which should be attractive the insurance company.

Also, we are fortunate to have a rehabilitation facility down the street from our center, and many of our patients are already going there after their total joint replacements (performed as inpatient surgery). I have in-serviced the staff at that rehabilitation facility, and have sent a few patients there after other procedures with nerve block catheters in place. This practice is permissible (from a reimbursement standpoint), since it is an admission "down," and not "up" to a higher level of care. It is illegal to admit to a higher level of care from an ambulatory setting.

The blood loss associated with a total knee replacement is surely a concern, since most ambulatory centers do not have protocols in place for transfusions. This is why I think it reasonable to start with a unicompartmental knee arthroplasty first thing in the morning, with both a psoas compartment catheter and a single shot sciatic block in place.

For these patients, in order to minimize symptom variability (especially PONV), I preferentially use propofol as a total intravenous anesthetic. Avoiding volatile agents can decrease PONV, as well as unplanned admissions. Propofol in my experience allows for faster emergence and decreases nursing interventions in the PACU thereby increasing nursing efficiency. The combination of propofol with the stated nerve blocks allows for patients to return to baseline cognitive function sooner in PACU which pleases both the patient and loved ones caring for patient. When I use nerve blocks (especially continuous nerve blocks) and total intravenous anesthesia with propofol, I also avoid intraoperative midazolam and narcotics, in order to facilitate all of the above.

After observing the patient in the recovery unit for a few hours, the patient can either be sent home if they have an appropriate caregiver, or to an assisted-care facility if necessary.

One cannot underestimate the critical importance of patient selection in this process.

-- From Don Siwek, M.D., Sarasota, FL

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