There are a growing number of surgeons around the country that are moving some of their total joint replacement procedures out of the hospital and into outpatient facilities.
Tune in as Dr. Alon Antebi discusses latest advances in outpatient total joint replacement. He is an orthopedic surgeon who specializes in trauma and joint reconstruction and a member of the medical staff at Palmdale Regional Medical Center.
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Outpatient Total Joint Replacement
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Learn more about Alon Antebi, DO
Alon Antebi, DO
Dr. Alon Antebi is Chief of the Orthopaedic Department at Antelope Valley Hospital in Lancaster, California, and Chief of the Joint Program at Ridgecrest Regional Hospital in Ridgecrest, California. He is also a member of the medical staff at Palmdale Regional Medical Center in Palmdale, California; Henry Mayo Newhall Memorial Hospital in Valencia, California; Providence Holy Cross Medical Center in Mission Hills, California; and Antelope Valley Surgical Institute (AVSI) in Lancaster, California.Learn more about Alon Antebi, DO
Transcription:
Melanie Cole (Host): As physicians are able to make great strides and advances in surgical technique, anesthesia, pain control, it is now possible that total joint replacement can be done as an outpatient. My guest today, is Dr. Alon Antebi. He's an Orthopedic Surgeon who specializes in Trauma and Joint Reconstruction, and he's a member of the medical staff at Palmdale Regional Medical Center. Welcome to the show, Dr. Antebi. With total joint replacement, sometimes the surgeries can be performed as outpatient procedure in a hospital setting or at an outpatient surgery center, yes?
Dr. Alon Antebi (Guest): Sure. Good morning. So, what I’ve been doing now for the last two or three years is I’ve noticed that a lot of the patients I operate on in the hospital are doing so well that most of them if not all we're going home the next day. We were like why not push the envelope and then have people leave the same day especially if they’re younger, healthier, and with less comorbidities and less medical problems? I started doing that, and with the advent of modern anesthesia, pain control – pre-emptive pain control that we give patients even before they even go into surgery and before their body ever sees pain -- we are able to kind of quote-unquote, fool the body and these people, they do very well. They’re mobilized right after the surgery, and they go home within a few short hours after the surgery. Some of the total joints that we are doing outpatient include total hip replacements, total knee replacements, as well as total shoulder replacements.
Melanie: Are there certain candidates for whom this is not an option? Speak about how you select patients that might be suitable for outpatient total joint replacement.
Dr. Antebi: Sure. What we look for is people on the healthier side. First of all, let’s talk about the insurance. Right now, people who are Medicare beneficiaries, we are not able to do at an outpatient facility because Medicare does not have a code where the surgery center would be able to Medicare for that procedure. Right now, we are limited to doing currently just commercial based insurance or workman’s compensation patients as an outpatient facility. Just recently, in the last couple of months in the new year, Medicare has kind of downgraded total knee replacement at a hospital where right now, a total knee procedure – a total knee replacement is almost considered an outpatient procedure at the hospital. They still do not have a code for you to be able to do it at the surgery center, but they downgraded the knee. Where people before, used to stay two or three days after a knee replacement at a hospital, now, the doctor and the medical team has to document why this patient has to stay in the hospital after a knee replacement.
In regards to the selection of a patient, usually, these patients because they are not Medicare beneficiaries – they are usually younger, usually under the age of 65. We see people with arthritis in their 40s, 50s, and early 60s, and these are the patients that we usually select. We also look for patients that are not morbidly obese. We look for a BMI hopefully less than 20 to 22, preferably somewhere below 20. In addition, their overall health – do they have heart disease? Are they oxygen-dependent? Are they severe diabetics? Have they had a heart attack or a stroke before? We try to classify these patients to be overall healthy – they may have little, controlled diabetes, controlled hypertension – these patients would still be candidates for outpatient total joint replacement. Health and obviously, insurance are big predictors for who we can bring to an outpatient surgery setting and perform an outpatient total joint replacement on.
Melanie: What other strategies are you using to optimize patient recovery after this total joint replacement outpatient?
Dr. Antebi: Sure. I think it all starts before the patient goes to the operating room. One of the things that a lot of surgeons are doing now is what we call preemptive pain control. Before the patient even goes to the operating room, they receive a cocktail of medication for pain and inflammation that already hits their system before their body even sees any trauma from surgery. Then during the surgery, the anesthesiologist plays an important role in the spinal and the general, and then myself, I inject a different cocktail – now, this is going into the surgical area around the muscle, around the tendons, around the capsule, around the ligaments, and around the nerves around where we’re operating. After the surgery, the patient gets a couple of other medications, again to all help with the pain. So, 99% of patients that leave the surgery suite and they have no pain. They literally have no pain.
It’s not until 24 hours to 48 hours later, when all of these medications start to slowly wear off – in addition, they’re taking oral medications as well – that they may have a little soreness. But you’ve got to remember, these patients were in pain, to begin with. This is why they subject themselves to surgery because they want to get out of pain. A lot of patients are really fascinated by the fact that – oh my gosh, they see me two weeks later and they’re like, “Doc, I’m not even taking any more pain medication.” They have no more pain.
The advent of preemptive pain medication during surgery as well as after, in addition to early mobilization of the patient – get them up, get them walking, get them moving – prevents stiffness of the joint and decreases pain, as well. By the time they get home, within a couple of days, they’re walking unassisted with no worker or a cane.
Melanie: And then where does physical therapy happen?
Dr. Antebi: Usually, what happens is, before the surgery even takes place, these patients already have physical therapy set up that will come to the house for the first two, possibly three weeks. They don’t have to worry about getting in a car and driving somewhere. In addition, a therapist and a nurse will come to the house – a nurse will come to make sure the wound is doing okay, your vitals are okay, you’re not anemic, and if we need to, we can take blood at home to check to make sure that your blood level and all of your counts are correct. If there is anything that is incorrect, then I will get – or my team will get a phone call, and at that point, we will instruct the patient either to do – either to come to the office, or go to the hospital, go to the emergency room, or possibly just take some iron over the counter depending what the situation is. Those instances are fairly rare.
In addition, after the therapy at home is done, and the patient is more mobile – at the two-week mark, they’re already leaving their house and coming to my office for their first visit. Depending on how they’re doing at that point, at that point, we’ll maybe write a prescription for them to go as an outpatient physical therapy. Depending on what’s going on and their mobility, they may be able to drive in two weeks and actually go to therapy themselves or be taken by one of their family members until they’re a little bit more mobile and then start driving on their own to outpatient physical therapy. That usually goes on for about four to six weeks after the surgery.
Melanie: What a great point. In summary, Dr. Antebi, what would you like to tell people who are considering total joint replacement and have questions about outpatient availability?
Dr. Antebi: Sure. Definitely, do your homework in regards to having a total joint replacement. There are different ways of doing surgery, especially when we’re evolving hip replacement. One of the advents of recent, modern hip replacement, is the anterior approach, which is a minimally invasive procedure that you can definitely have as an outpatient procedure. You want to make sure the surgeon that you see is competent or experienced in doing these procedures. I think that if you are a healthy candidate, motivated, and want to have a quick, and speedy recovery, then outpatient total joint surgery is definitely an option for you.
Melanie: Thank you so much, for being with us today. You are always a really great guest. You’re listening to Palmdale Regional Radio with Palmdale Regional Medical Center. For more information, please visit PalmdaleRegional.com that’s PalmdaleRegional.com. Physicians are independent practitioners who are not employees or agents of Palmdale Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. Individual results may vary. There are risks associated with any surgical procedure. Speak with your physician about these risks to find out of total joint replacement might be right for you. This is Melanie Cole. Thanks so much, for listening.
Melanie Cole (Host): As physicians are able to make great strides and advances in surgical technique, anesthesia, pain control, it is now possible that total joint replacement can be done as an outpatient. My guest today, is Dr. Alon Antebi. He's an Orthopedic Surgeon who specializes in Trauma and Joint Reconstruction, and he's a member of the medical staff at Palmdale Regional Medical Center. Welcome to the show, Dr. Antebi. With total joint replacement, sometimes the surgeries can be performed as outpatient procedure in a hospital setting or at an outpatient surgery center, yes?
Dr. Alon Antebi (Guest): Sure. Good morning. So, what I’ve been doing now for the last two or three years is I’ve noticed that a lot of the patients I operate on in the hospital are doing so well that most of them if not all we're going home the next day. We were like why not push the envelope and then have people leave the same day especially if they’re younger, healthier, and with less comorbidities and less medical problems? I started doing that, and with the advent of modern anesthesia, pain control – pre-emptive pain control that we give patients even before they even go into surgery and before their body ever sees pain -- we are able to kind of quote-unquote, fool the body and these people, they do very well. They’re mobilized right after the surgery, and they go home within a few short hours after the surgery. Some of the total joints that we are doing outpatient include total hip replacements, total knee replacements, as well as total shoulder replacements.
Melanie: Are there certain candidates for whom this is not an option? Speak about how you select patients that might be suitable for outpatient total joint replacement.
Dr. Antebi: Sure. What we look for is people on the healthier side. First of all, let’s talk about the insurance. Right now, people who are Medicare beneficiaries, we are not able to do at an outpatient facility because Medicare does not have a code where the surgery center would be able to Medicare for that procedure. Right now, we are limited to doing currently just commercial based insurance or workman’s compensation patients as an outpatient facility. Just recently, in the last couple of months in the new year, Medicare has kind of downgraded total knee replacement at a hospital where right now, a total knee procedure – a total knee replacement is almost considered an outpatient procedure at the hospital. They still do not have a code for you to be able to do it at the surgery center, but they downgraded the knee. Where people before, used to stay two or three days after a knee replacement at a hospital, now, the doctor and the medical team has to document why this patient has to stay in the hospital after a knee replacement.
In regards to the selection of a patient, usually, these patients because they are not Medicare beneficiaries – they are usually younger, usually under the age of 65. We see people with arthritis in their 40s, 50s, and early 60s, and these are the patients that we usually select. We also look for patients that are not morbidly obese. We look for a BMI hopefully less than 20 to 22, preferably somewhere below 20. In addition, their overall health – do they have heart disease? Are they oxygen-dependent? Are they severe diabetics? Have they had a heart attack or a stroke before? We try to classify these patients to be overall healthy – they may have little, controlled diabetes, controlled hypertension – these patients would still be candidates for outpatient total joint replacement. Health and obviously, insurance are big predictors for who we can bring to an outpatient surgery setting and perform an outpatient total joint replacement on.
Melanie: What other strategies are you using to optimize patient recovery after this total joint replacement outpatient?
Dr. Antebi: Sure. I think it all starts before the patient goes to the operating room. One of the things that a lot of surgeons are doing now is what we call preemptive pain control. Before the patient even goes to the operating room, they receive a cocktail of medication for pain and inflammation that already hits their system before their body even sees any trauma from surgery. Then during the surgery, the anesthesiologist plays an important role in the spinal and the general, and then myself, I inject a different cocktail – now, this is going into the surgical area around the muscle, around the tendons, around the capsule, around the ligaments, and around the nerves around where we’re operating. After the surgery, the patient gets a couple of other medications, again to all help with the pain. So, 99% of patients that leave the surgery suite and they have no pain. They literally have no pain.
It’s not until 24 hours to 48 hours later, when all of these medications start to slowly wear off – in addition, they’re taking oral medications as well – that they may have a little soreness. But you’ve got to remember, these patients were in pain, to begin with. This is why they subject themselves to surgery because they want to get out of pain. A lot of patients are really fascinated by the fact that – oh my gosh, they see me two weeks later and they’re like, “Doc, I’m not even taking any more pain medication.” They have no more pain.
The advent of preemptive pain medication during surgery as well as after, in addition to early mobilization of the patient – get them up, get them walking, get them moving – prevents stiffness of the joint and decreases pain, as well. By the time they get home, within a couple of days, they’re walking unassisted with no worker or a cane.
Melanie: And then where does physical therapy happen?
Dr. Antebi: Usually, what happens is, before the surgery even takes place, these patients already have physical therapy set up that will come to the house for the first two, possibly three weeks. They don’t have to worry about getting in a car and driving somewhere. In addition, a therapist and a nurse will come to the house – a nurse will come to make sure the wound is doing okay, your vitals are okay, you’re not anemic, and if we need to, we can take blood at home to check to make sure that your blood level and all of your counts are correct. If there is anything that is incorrect, then I will get – or my team will get a phone call, and at that point, we will instruct the patient either to do – either to come to the office, or go to the hospital, go to the emergency room, or possibly just take some iron over the counter depending what the situation is. Those instances are fairly rare.
In addition, after the therapy at home is done, and the patient is more mobile – at the two-week mark, they’re already leaving their house and coming to my office for their first visit. Depending on how they’re doing at that point, at that point, we’ll maybe write a prescription for them to go as an outpatient physical therapy. Depending on what’s going on and their mobility, they may be able to drive in two weeks and actually go to therapy themselves or be taken by one of their family members until they’re a little bit more mobile and then start driving on their own to outpatient physical therapy. That usually goes on for about four to six weeks after the surgery.
Melanie: What a great point. In summary, Dr. Antebi, what would you like to tell people who are considering total joint replacement and have questions about outpatient availability?
Dr. Antebi: Sure. Definitely, do your homework in regards to having a total joint replacement. There are different ways of doing surgery, especially when we’re evolving hip replacement. One of the advents of recent, modern hip replacement, is the anterior approach, which is a minimally invasive procedure that you can definitely have as an outpatient procedure. You want to make sure the surgeon that you see is competent or experienced in doing these procedures. I think that if you are a healthy candidate, motivated, and want to have a quick, and speedy recovery, then outpatient total joint surgery is definitely an option for you.
Melanie: Thank you so much, for being with us today. You are always a really great guest. You’re listening to Palmdale Regional Radio with Palmdale Regional Medical Center. For more information, please visit PalmdaleRegional.com that’s PalmdaleRegional.com. Physicians are independent practitioners who are not employees or agents of Palmdale Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. Individual results may vary. There are risks associated with any surgical procedure. Speak with your physician about these risks to find out of total joint replacement might be right for you. This is Melanie Cole. Thanks so much, for listening.