Oct 11, 2016


Dr. Miller: Better pain management leads to shorter stays after your hip replacement. We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller, is on The Scope.

Dr. Miller: Hi, I'm Dr. Miller and I'm here with Dr. Chris Peters. Chris is a professor of Orthopedic Surgery here at the University of Utah. Chris, tell us a little bit about pain control in the operative period and shortly afterwards. I think that's been really improved to the point that it's reduced the amount of time that a patient is staying in the hospital after a joint replacement.

Dr. Peters: Yeah, I think you're right, Tom. One of the things that we've seen that's been fascinating over, probably the last five to ten years in the joint replacement world is that although we've had improvements in say, the parts that we put in and an improvement in the longevity of the prosthesis that we use, one of the most profound changes that has occurred over that time period is really changes in how we manage patients from a pain perspective, from an anesthetic perspective, and then from a early recovery perspective after their joint replacement.

So what we've seen is, whereas five or ten years ago, patients would come in at the hospital the day before, they would have their surgery and then get a ton of narcotic medications and kind of be sick and nauseous and have urinary retention immediately after their surgery, we now use various different combinations of medications, as well as nerve blocks, regional anesthesia, things that have made the experience of the patient right around the time of surgery significantly better, much less pain.

This has actually led to shorter hospital stays, and really a better ability for the patient to get up and walk and be mobile and be comfortable in the first few days and the first few weeks after their joint replacement.

Dr. Miller: So there are a number of new techniques, and I think you probably work with the anesthesiologist to put these blocks in, and I've seen some of the miracles that they've done in terms of reducing pain after surgery. Or even in other patients who've had traumas, it's pretty remarkable. So for instance, if you go back 20 years, how long was a patient staying in the hospital, say, following a hip replacement compared to now?

Dr. Peters: Yeah, that's a great question, and unfortunately, I was around to see that time but . . .

Dr. Miller: There was a lot of stuff you were around to see.

Dr. Peters: But you know . . .

Dr. Miller: I wish it wasn't true but it's true.

Dr. Peters: So 20 years ago, a normal length of stay for hip replacement patients, a patient was in the range of four or five days. And much of that time was spent managing pain. We've seen a tremendous change such that today, most of our hip replacement patients go home the next day after surgery. During the 24 to 36 hours they're here with us, they're quite comfortable.

Most of our patients, especially with hip replacement, literally get out of the operating room and they say the pain they came in with is gone and they are surprised at how little pain they're experiencing. This is really due to, again, this combination of therapies that we use to manage pain in that immediate post-operative period.

Dr. Miller: That's just remarkable. I mean, even after they go home, they're still experiencing much less pain than they would previously?

Dr. Peters: They are. Some of that has to do with refined surgical techniques as well, so we make smaller incisions and we do less surgical dissection and the operations are much more refined. But much of it is due to the multi-model agents that we use to control pain in those first few days after the operation.

Dr. Miller: Now, controlling pain is one thing but are they able to participate in physical therapy faster?

Dr. Peters: Yes, and that's the other thing that's been just a really pleasant surprise over the last five years or so is, we used to worry about getting patients up, say, on the first day or even the second day after surgery because perhaps they were too fragile or they weren't coordinated enough to actually get involved in therapy. We learned that that was really backwards.

So now, we get patients up on the day of their operation, whether it's a hip or a knee replacement, their doing physical therapy that afternoon. Really, across the country, we're in a position now with hip and knee replacement where many patients are actually able to go home either the same day of surgery or the next day after surgery.

Dr. Miller: A couple of other questions related to that, I would assume that if you're getting people up sooner and getting them home, you would see fewer complications related to a surgery. I mean, in the old days, we would see certain types of complications such as blood clots in the legs. Is that less now that they're getting up and being mobilized sooner?

Dr. Peters: Yeah, you're exactly right. So again, that's a little bit paradoxical but we were a little bit worried that sending patient home on the day after surgery that maybe we would miss something that we would have caught in the hospital, and it's actually the opposite. We're seeing less problems when patients go home earlier. So we've learned that early mobility, and early mobility is really dependent on being comfortable during your early mobility, leads to less complications, things like blood clot and pneumonia, urinary retention. We see significantly less of that as we get patients up sooner.

Dr. Miller: Another effect of this would be lower cost in the long run because they're in the hospital a shorter period of time.

Dr. Peters: Sure. Although our payers haven't quite caught up with that but the, I think, absolutely, when you look at it from a societal perspective, they're using less resources and that's going to be less expensive.

Dr. Miller: Now, when these people get to home and they're recuperating, are they able to get back to work a little bit sooner or is that true?

Dr. Peters: Absolutely. That's again, an incredibly important facet to patients when they come to consider a hip or knee replacement. Many or most want to get back to work, they need to get back to work. In the old days, we might tell patients to plan on three months prior to going back to work. Today, we can get patients back fairly reliably within the first two to six weeks after surgery.

Dr. Miller: Final question, and this crossed my mind during the interview is, since you are treating pain so much more effectively, presumably with some narcotics but with other types of intervention and getting them off pain medicines, I think a bit sooner, are we seeing fewer patients addicted to narcotics?

Dr. Peters: Well, it's hard . . .

Dr. Miller: That's a difficult question for that. But maybe I should say, do you think we're seeing patients relying on narcotics for pain control, a fewer patients relying on pain control?

Dr. Peters: Absolutely. Our goal, really, is to try and get patients off of narcotics as early as possible after their operation. Most patients need some but we're seeing, our routine is more two weeks of narcotic medication. After that, most patients are doing just fine on an anti-inflammatory and/or Tylenol.

Dr. Miller: In the old days, it might have been, maybe, a month to six weeks and even longer sometimes.

Dr. Peters: Correct. Yeah.

Dr. Miller: I think we know the longer that one is taking a narcotic, analgesic to control pain, the risk of prolonged need for that medication is higher.

Dr. Peters: Absolutely. Then what the other effects of that are patients are able to drive earlier, and therefore, they're able to get back to work. Essentially, they're able to be independent much sooner than they used to be.

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