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The outpatient: The morning in surgery, the night at home
By Jason Lesley
“After the second store, I had to leave,” she said. “You can only walk so far.”
She felt a grinding sensation when she walked and feared falling on steps or being pulled down by her dog. “The doctor said there’s absolutely no cartilage in the left knee, so it was time,” said Novi, who lives with her husband Ronald in Murrells Inlet.
Novi was referred to Dr. Michael Bohan of Carolina Orthopaedics. Neighbors told her that Bohan had done their surgeries and she shouldn’t worry. “I felt comfortable right away,” she said. When cortisone shots failed to provide much relief from her arthritis pain, she made the decision to have total knee replacement. Bohan saw her as an ideal candidate for outpatient surgery.
“It’s not for everybody,” Bohan said. “We pick them very specifically, very carefully. They have to be active, young, healthy with no medical problems. They have to have a good support system at home, a spouse or responsible adult willing to be the nurse. The feedback on those who have gone through it is tremendous. There’s a stigma about being in the hospital — infection, the food or whatever — where people don’t want to be there unless they have to be.”
Novi, 62, retired as a teacher in Pittsburgh, five years ago when she was offered a package of benefits that included health insurance for her and her husband until they are eligible for Medicare at age 65. Her Pennsylvania state insurance also made her a candidate for outpatient knee replacement because Medicare only covers joint replacement in hospitals. A survey by the hospital supply company Stryker estimated a savings of $4,000 on minimally invasive outpatient hip replacements. Carolina Orthopaedics estimates the cost is about a third of inpatient procedures at a hospital. Dr. Brian Blair, a Carolina Orthopaedics surgeon, performed the first outpatient knee replacement in Georgetown or Horry counties in November on a 49-year-old man.
Bohan said he expects Medicare to change its policy about outpatient joint replacement in the coming years. The option is still in its infancy.
The Advisory Board, a research and consulting firm that specializes in health care and higher education, found just over 1 percent of 29,321 knee replacements were done as outpatient surgeries in the first quarter of 2014. The length of hospital stays after joint replacement has decreased dramatically over the past decade: from nine days to one or two.
Bohan said advances in pain management have made outpatient joint replacement possible. The spinal anesthesia lasts only about an hour once the surgery is complete. That’s when a catheter inserted near a nerve in the patient’s thigh begins to deliver pain medication. “It helps you get over the first couple days,” Bohan said.
Despite the assurances of her neighbors and the doctor, Novi had trouble sleeping the night before her surgery. It will be awhile before she sleeps through the night. She arrived at the surgery center by 7:30 a.m. and soon got into bed to begin preparations. Her husband sat in a chair beside her as nurse Travada Marsh adjusted an intravenous drip and anesthetist Keith Wood explained her spinal block and assured her that she wouldn’t feel anything. Confident and relaxed, Bohan checked on his patient. He finally got a smile from Novi and wrote his name in black marker on her left leg, the one getting a new knee. He gave Novi his cell phone number if she needed him later.
After Novi’s bed was rolled into surgery, the doctors and nurses were zipped into surgery outfits that resemble space suits. An incision the length of Novi’s knee, let assistants pull the skin back so Bohan could remove the arthritic knee with a power saw and hammer and chisel. Novi was in a semi-sleep with her view of the surgery blocked by a drape, but she said she remembered hearing a saw.
Once the old knee was out, Bohan used another power saw to even the patient’s leg bone to allow the artificial knee to be perfectly flush. Screws and glue hold the knee in place. Bohan waited for the glue to dry before he injected pain medication into the patient’s femoral nerve and stitched the inside of her knee. His assistants finished the outer stitches, and Novi went to recovery. The procedure took just under two hours, a little longer than average, but routine nonetheless. She was back home by late afternoon.
She began the first of her three-day-a-week rehab sessions at Carolina Orthopaedics Monday morning with physical therapist Jeff Taylor. It was a relief, she said, to be with others in various stages of recovery. She had started rehab exercises at home but wasn’t sure she was doing them correctly.
“Yes,” Bohan said, “therapy is great in that it gives the patients a sense of community. They can see that other patients are having some of the same symptoms. They are also encouraged by those patients that are further along in their rehab in that there is light at the end of the tunnel.”
It takes time to trust the artificial joint. “Push it straight,” Taylor said to Novi. “It’s not going to break. Your knee is more durable than mine.”
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