For years, the conventional wisdom regarding full knee replacements has been to wait until the patient is 60 years old because of a preference to do a single surgery. However, advances in equipment and procedures are changing this viewpoint.
"We have fine-tuned some of the process," says Scott Orr, MD who practices with Ortho Sports Associates. "Using robotics and computers, we can take less bone now, which allows more room if we have to do revision work later. So when we convert a partial knee replacement to a total, it's not as complex as it used to be."
That means people in their 40s and 50s who suffer from arthritic knee pain do not need to delay surgery. "They can hold off and spend a decade in pain while waiting for a total knee replacement, or they can a have partial replacement for those 10 years and then convert for a total replacement, if they need it," Orr says, adding that partial replacements hold a 93 percent success rate at 10 years.
Waiting only inhibits a patient's movement, which generally decreases their quality of life, as well as their rehabilitative abilities from loss of activity. "Patients rehab better with good muscle tone than with a locked stiff knee because they've been living in a recliner for years," Orr says.
The pain medications, like opioids, that a patient might take during that extended time also present the potential hazard of addiction.
Because of the advances in knee replacement procedures, outpatient surgery is now an option. Some patients are unsure of the outpatient alternative, feeling that they will get more care in a hospital setting. However, a 2018 study at Rush University Medical Center found that joint-replacement patients felt more satisfied with the outpatient alternative. "They go home to their own bed and sleep better when a nurse is not waking them up. People's inflammatory markers decrease when they sleep," Orr says. "And they get moving quicker, have less nausea, better pain control, which helps them heal faster."
The greatest obstacle with outpatient surgery for most patients is the perceived lack of contact with a medical professional in those first few days. Orr views this differently. "In the hospital, the doctor comes by once a day and you have one shot to ask your questions," he says. "But as an outpatient, if you have the platform, they can message a nurse or doctor all day." They also still have daily interactions with a medical professional who visits their home for a week to manage their therapy, wound exposure, and medications.
Patients may not also realize that the home environment can be as safe and even healthier than a hospital or rehabilitation center because the communal facilities tend to offer greater exposure to nosocomial infections.
But not all patients qualify for outpatient surgery. "Besides needing to pass the 57 factors in the Outpatient Arthroplasty Risk Assessment (OARA), some people are just not set up for it," Orr says. "If you're 67 and healthy, but live on farm by yourself, I'm not sending you home that first day."
"But when possible, the outpatient route is better. They do better and it's fiscally responsible," Orr says. In the Southeast, outpatient costs for knee replacement runs about $30,000 less than for the inpatient procedure.
Currently, over 600,000 knee replacements are performed annually with the average patient age of 67. "I recently read that by 2026, more than half of the joint replacements will be done as outpatient. The CMS should be excited because of the savings," Orr says.
CMS has hit snags in defining the parameters for outpatient total knee arthroplasty, ultimately limiting it to hospital outpatient departments, leaving out ambulatory surgery centers.
But in their 2020 proposed changes released this summer, CMS plans to release total knee arthroplasty from the Inpatient Only List. BlueCross and BlueShield of Alabama, like most major health insurance carriers, follows the path of set by CMS. So although Blue Cross also currently covers outpatient knee replacement surgery only through hospitals, they too may begin to cover surgical centers which will drastically lower healthcare costs while offering patients greater accessibility.