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Photo of Dr. David Hedden and Paul HughesResearch & Innovation
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An innovative approach to hip-replacement
surgery allows some patients to be released
from hospital mere hours after their operation
Dr. David Hedden (left) says Paul Hughes was the perfect candidate for outpatient joint replacement surgery.
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By Susie Strachan
Summer 2018

Paul Hughes had been living with minor back and leg pain for a couple of years.

Finally, it got to the point where it was really starting to undermine his quality of life.

An avid golfer since he was a kid, the Winnipeg man, who is now in his mid-fifties, found it difficult to walk the links during his games.

"I never missed a golf game, but the pain was starting to slow me down," says Hughes, who is a senior manager at Maple Leaf Foods. "Every time I moved my left leg, the pain would fire up, especially in the knee."

At one point, he sought care from a physiotherapist. But the physiotherapist suggested the real problem wasn't Hughes' back or knee - it was his left hip.

That came as a bit of a surprise. "There was very little pain, if ever, in the hip itself," he says.

Eventually, Hughes was referred to Dr. David Hedden, a surgeon with the Concordia Hip and Knee Institute. It didn't take long for Hedden to conclude that Hughes needed a hip replacement.

"(Paul) had terrible arthritis of his hip, and was having a great deal of difficulty walking and doing normal functions," says Hedden.

The only question was: How long would Hughes have to stay in hospital following the operation?

Photo of Paul Hughes
Paul Hughes holds up an X-ray showing his artificial hip replacement.

Traditionally, a patient undergoing hip-replacement surgery might have to spend two to three days in hospital following their operation.

But Hedden and his colleagues at the Hip and Knee Institute and Grace Hospital had recently embarked on a pilot project to test a new approach to the procedure, one that allows patients to be discharged from hospital mere hours after surgery.

And, as it turned out, Hughes checked all the boxes for the pilot project.

"He was relatively young, healthy and mobile, had good supports at home," says Hedden. "I felt he would be a perfect candidate for our pilot outpatient hip-replacement surgery."

Launched in the fall of 2017, the pilot project - officially known as the Outpatient Joint Replacement Program - is designed to determine whether this innovative approach to surgery will improve the patient experience and enhance efficiencies within the health-care system.

It's just one example of how the Region is constantly looking for innovative ways to enhance care and reduce costs at the same time. Another good example of this approach in action can be found at the Misericordia Eye Care Centre, where staff recently introduced no-sedation cataract surgery. Under this program, low-risk patients are offered the option to undergo surgery without sedation, which saves the patients time. By performing 1,500 no-sedation cataract surgery cases in its first year, MHC ophthalmology surgeons were able to add 200 additional cataract surgeries with the savings.

Patient selected for outpatient hip replacement surgery must fit specific criteria, including:

  • BMI less than 40
  • Minimal medical co-morbidities
  • Opioid-tolerant patients must be weaned to a different form of pain medication.

With regard to the outpatient replacement, officials say about 50 patients have undergone the procedure at Grace Hospital or Concordia between September 2017 and June of 2018.

The key to the outpatient pilot project lies in how the patients are selected, according to Laurie Walus, Manager of the Prehabilitation Clinic, the Hip and Knee Resource Centre, and the Winnipeg Regional Health Authority's Surgery Program.

"There are a number of criteria the patient must fit," says Walus, including a BMI under 40, have minimal co-morbidities, not use a walker or cane, not have an anaphylactic response to antibiotics, and live within 30 minutes of an emergency department. In addition, they mustn't smoke and drink alcohol extensively, she says.

Once identified on the medical side, each patient has to agree to attend mandatory classes before their surgery, take part in an exercise program, arrange for equipment and assistance at home, and fill their post-surgery medication prescriptions in advance.

"Each person must have the their home ready, and have someone stay with them for the first 48 hours, as we know that if medical complications arise, they do so within that first 48 hours," says Hedden.

Outpatient hip-replacement surgery has become a real option for patients today, in part because surgical training and techniques have evolved significantly over the last 20 years. As a result, surgery is much faster - typically 30 to 45 minutes - and there is less trauma inflicted on the patient.

Diagram of arthritis of the hip joint

The most significant changes are in the perioperative protocols that now focus on minimizing pain and side-effects of pain medications as well as patient education and early mobilization. Patients are given pain medication before the surgery starts and multiple drugs at lower doses are used after surgery to maximize effect and minimize side effects.

"We are now also using injections of local anesthetic into the tissues around the joint during surgery as well as a drug that stabilizes blood clotting which minimizes bleeding. The combination of all these interventions is what has ultimately enabled us to start doing total joints as a day surgery," says Hedden.

The surgeons do a soft tissue repair to keep the hip very stable. "We preserve the capsule of the hip joint," he says, in order to improve hip stability, which is one of the criteria before the patient can go home.

Doctors use a spinal anesthetic. This not only requires less recovery time, but also means patients are pretty much pain-free for the first six to eight hours. Post-surgery, patients are given pain medication and anti-emetic drugs, so they don't experience nausea and vomiting.

The main advantage for patients in the outpatient program is the ability to recover at home, according to Walus. "Home is best," she says, adding that the 3,000 joint replacement patients treated each year spend three to five days in hospital, with knee replacement patients having the longer stay. The same- day hip patients spend about 12 hours in hospital, from the time they are checked in to the point of discharge.

"Patients come out of surgery and go into the recovery ward," says Hedden. "Once we can get them up and walking slowly, many of them remark that they notice an immediate change in the level of pain from their hip. That deep, gnawing pain from hip arthritis is gone."

In fact, says Hedden, many patients feel they have less pain after surgery than they did from their previously malfunctioning hip.

"I woke up after my surgery, and the anesthetist asked me how I felt," says Hughes. "I said it felt like a quick nap. In fact, it was less painful than going in for dental surgery - certainly more relaxing. The people in the room made it relaxing."

What surprised him was how long it took before the nurses would let him try to stand.

"I went into the operating room at 7:30 a.m., and it was noon before I could get up. I couldn't wiggle my toes on that side, and they wouldn't let me go anywhere before that happened. After that, things went quickly."

Once he did get out of bed, a physiotherapist and an aide took him for a walk around the second floor at Concordia. He was outfitted with a safety strap around his waist and given a walker to use. The physiotherapist was walking with him, and the aide followed with a wheelchair, in case he needed help. He also practiced going up and down a set of steps.

But most importantly, his hip felt better almost immediately. He was discharged and went home and straight into bed. After the surgery, Hughes used a walker for two days and a cane for three weeks. He didn't leave the house for the first week.

"The hardest part was trying to put a sock on my left foot," he says wryly. "The second hardest was keeping the hip dry when I had a shower."

He followed the prescribed program of 12 different exercises, increasing the length of time each day, because he found that if he skipped exercising, his strength and flexibility regressed. "After about nine weeks, everything fell into place," he says. "There was no pain. I had full flexibility. It felt great, and I started to think I could get back out on the golf course."

Photo of a hip joint and socket
A hip joint and socket similar to the one implanted in patient Paul Hughes.

The outpatient pilot project came about as a team effort, says Walus. A group of orthopedic surgeons, anesthesiologists, physiotherapist, nurses, a pharmacist and other health-care providers wanted to learn more about this method of outpatient hip surgery.

"Six people, including myself, and a representative from the doctors, nurses, anesthetists and physiotherapists and managers went to a surgical centre in New Albany, Ohio, to learn about their program," she says. "We have since adapted the program to run here from Concordia and the Grace."

To this date, 35 people have undergone outpatient surgery at Concordia and 15 at the Grace. A surgeon will only perform one operation per day, usually the first on the surgical slate in the morning. This allows the hospital nurses and physiotherapists time to determine when the patient is ready for discharge. "We do a more intensive look at each patient, as they are going home and will be caring for themselves, along with the help of a relative or friend," says Walus.

The pilot project will take into account the case of each patient in their journey from the pre-surgery education through to their post-surgical care at each hospital, and then how they fared at home. The costs associated with the pilot will be tallied to see if there are financial savings compared to keeping a post-surgical patient in hospital.

Both the hospital staff and the patients are being surveyed about their experience. On the patient side, most responses have been positive. Each patient was contacted the day after their surgery, and again when they meet with their surgeon six weeks after the surgery.

All joint replacement patients can attend a series of education classes, including:

  • Considering joint replacement
  • Nutrition and exercise
  • Pain management
  • Total knee / hip replacement
  • Before surgery preparation

People are eligible to take the first class before their appointment with an orthopedic surgeon. All other classes take place after the person has been place on the wait list for surgery.

All classes take place at the Hip and Knee Replacement Centre, located at the Hip and Knee Institute at 1155 Concordia Ave.

"When we did the survey of the first 28 people, we found that 24 didn't have any issues going home. Some had an issue with dizziness or vomiting from the medication, but for the most part, people were glad to be recovering in their own home," says Walus. "In general, people really liked the communication they received about the program, the education sessions and the information on how to plan for a home recovery."

Each hospital holds a bed for the patients after their discharge. "We tell the patient, that once they meet all the discharge criteria, they can go home. But if they have any trouble, they can come back and their bed will be waiting," says Walus. "That helps ease any anxiety about discharge. People say they found that to be reassuring."

Out of the first 50 patients, only three did not go home the same day of their surgery, and were kept overnight, says Walus. The reasons included issues such as urological problems.

Walus believes that, after the pilot project has been wrapped up, about 200 people a year will be able to become part of the outpatient joint surgery option, as it moves into program status. "We are looking at splitting those numbers between Concordia and Grace, and pursuing adding same-day surgery for outpatient knee surgeries."

Hedden notes that most of his patients are suffering from mechanical problems in their hips. For women, it's often due to having a shallow hip socket which often wears out at a younger age. In men, it's the opposite. Their socket is often too deep, and they catch the edge of the socket, and after a number of years of doing so, it wears out the hip.

Some patients do have traumatic injuries, and then there are patients who are overweight. Some of it is genetic, with patients having a family history of this problem. "We do see a small number of people with inflammatory arthritis such as rheumatoid arthritis," he says.

In order to keep your hips from needing surgery in the future, Hedden says the best course of action for those with structurally-normal hips is to maintain a healthy body weight and exercise regularly. "Being overweight is putting yourself at risk, as is being sedentary," he says. "The heavier you are, the more force there is across that joint. Eventually, it wears out."

Many people thinking jogging or running or other active sports can damage their hips, he says. "That's actually not the case," he says. "If you have a structurally-normal joint, and you are physically active, the cartilage, the bone, the ligaments, they all get stronger. You actually protect that joint from developing joint disease."

Hedden himself has a new hip. He used to be a runner, but stopped when a too-deep hip socket wore out. One of his fellow surgeons did the operation. "I was offered to have my hip done elsewhere, but I said, 'Why would I do that?' This is one of the best teams I've ever had the opportunity to work with."

Joint replacement surgeries began at Concordia in the early 2000s and the Grace has added a number of joint-replacement surgeons over the past several years. Hedden says he's very happy with the way the two joint replacement teams are working together.

"In the future, we'd love to pool our resources more," says Hedden. "We do research together and develop techniques together. This surgery outpatient program is a great example of what we can achieve working together as an orthopedic team."

As for Hughes, he has returned to work and his new left hip is performing better than expected. He saw Hedden approximately 10 weeks post-surgery, and also had a quick consultation with a physiotherapist. After 11 weeks, he was back on the golf course.

"I've played at least one game every week since!"

Susie Strachan is a communications specialist with the Winnipeg Regional Health Authority.

Hip replacement surgery

In hip replacement surgery, the damaged bone and cartilage are replaced with ceramic, metal or plastic surfaces to restore hip movement and function. The artificial hip is called a prosthesis.

The total hip replacement prosthesis consists of 2 parts:

1. Femoral component (stem) that fits into the femur or thigh bone.

2. Acetabular component (cup) that fits in to the pelvic bone.

The surgical procedure for total hip replacement

An incision is usually made over the top of the thigh bone (femur) measuring between six to eight inches. The muscles that hold the hip in place are partially detached and the surgeon exposes the end of the thigh bone and the socket.

The damaged cartilage and bone in the socket are cleaned away and the new cup is fixed in place. The ball at the end of the thigh bone (femur) is removed.

The inside of the femur is prepared for the metal stem which is fixed in place. A liner is placed in the socket and the new ball is placed on the stem. The hip is put back in place and then tested for movement and stability. The wound is then closed. The surgery usually takes 45 to 90 minutes.

Source: Winnipeg Regional Health Authority

Read more

The Hip and Knee Resource Centre has information online for those considering joint replacement surgery: http://wrha.mb.ca/prog/hipknee