As demand rises for hip and knee replacements in a more mobile population, the drive toward leading-edge surgical techniques that safely shorten patient recovery has gained momentum. At NYU Langone Hospital—Brooklyn, a team approach emphasizing patient selection and careful planning has maintained quality outcomes while mobilizing and getting patients home more quickly.
Setting the Stage for Successful Outcomes
To bring the same-day joint replacement surgeries pioneered at our Manhattan patient facilities to patients in other communities, NYU Langone Hospital—Brooklyn appointed hip and knee reconstruction specialist Joshua C. Rozell, MD, assistant professor in the Department of Orthopedic Surgery, who specializes in minimally invasive approaches.
The success of same-day techniques, Dr. Rozell says, relies in part on a holistic approach that begins with preoperative patient education using a detailed “playbook” with comprehensive information on the procedure and how to prepare. “I set these expectations from the first visit through postoperative care so patients understand what’s ahead,” he explains. “If the patient isn’t educated about rehabilitation, the recovery timeline, and potential postsurgical issues, they are more likely to return to the emergency department or be readmitted after surgery.”
It is also important to ensure that the multidisciplinary team is prepared and working in tandem—from the nursing and operating room staff to the anesthesiologist, physical therapist, and surgeon—toward quality outcomes.
Early Discharge Aided by Forward-Thinking Techniques
Dr. Rozell brings a range of surgical techniques to optimize knee and hip replacements for same-day discharge and faster recovery. In the knee, this involves a tourniquet-less, computer-navigated procedure. The computer navigation helps to accurately and reliably restore a patient’s leg alignment and knee kinematics to allow more natural movement after surgery, and avoiding a tourniquet reduces postsurgical muscle dysfunction.
“Without a tourniquet, blood continues to flow through the musculature of the leg, the quadriceps may return to normal functionality faster, and we tend to see fewer nerve-related problems,” says Dr. Rozell. A growing body of evidence supporting the approach points to an equal safety profile along with the benefits.
For most total hip arthroplasty procedures, Dr. Rozell performs an anterior approach using a standard operating table. The approach spares soft tissues, allows intraoperative imaging to confirm alignment and implant position, and permits a clinical assessment of leg lengths to ensure appropriate restoration of hip mechanics—nuances that some studies suggest can help patients return to activity more quickly.
Beyond the surgical techniques for both knee and hip procedures, adds Dr. Rozell, the use of a short-acting spinal anesthetic also supports same-day discharge by enabling early mobilization. “We also incorporate tranexamic acid to significantly reduce the need for blood transfusions after surgery,” he notes.
“It’s really a combination of all of these factors—the preparation and patient education, the surgical collaboration, technical innovation, and anesthesia selection—that together enable same-day discharge and optimized recovery.”—Joshua C. Rozell, MD
“It’s really a combination of all of these factors—the preparation and patient education, the surgical collaboration, technical innovation, and anesthesia selection—that together enable same-day discharge and optimized recovery,” says Dr. Rozell.
Stratifying Same-Day Discharge Candidates
The factors supporting same-day discharge are not universally applicable to knee and hip replacement patients, adds Dr. Rozell. He puts a strong emphasis on evaluating and selecting patients who could be good candidates. “When I first visit with a patient, I try to get the gestalt of who they are—how healthy they are, how motivated they will be after surgery in terms of mobilization, activity level, and what social supports they have in place,” he says.
Although the approach has had increased adoption since its first implementation in Manhattan, Dr. Rozell is one of few surgeons in Brooklyn to provide same-day discharge for total hip and knee arthroplasty. In that community, patients may live alone or have other obstacles to safe early discharge, such as multi-staircase buildings or language barriers. Since these factors can challenge patients’ ability to adhere to postsurgical protocols and physical therapy, any doubt about a patient’s health literacy, safety, or pain management capacity leads to an overnight stay or inpatient admission.
The evolution in practice to extend the benefits of same-day discharge to more patients has led to an overall reduction in length of stay for orthopedic procedures at the hospital, while quality outcomes remain steady. For total knee and hip arthroplasty, the reduction in average length of stay, from two to three days to zero more regularly, has led to efficiencies in patient care and fewer hospital-related complications.
“We’ve carved days, if not weeks, out of patients’ length of recovery by giving them a head start with the resources they need to recover at home,” concludes Dr. Rozell. “For those candidates whose condition and social factors support outpatient procedures, it’s a tool we want to use more and more, to balance maximum safety and efficiency with high-quality surgical outcomes.”
Rehabilitation Strategies Support a Changing Mindset
For same-day discharge candidates, postsurgical care and physical therapy begin before surgery itself. A clinical care coordinator speaks to the patients preoperatively, discussing expectations and discharge plans and arranging home therapy. Dr. Rozell works closely with Manuel Wilfred, DPT, PhD, assistant supervisor at Rusk Rehabilitation at NYU Langone Hospital—Brooklyn, to plan patients’ mobilization in as little as 90 minutes after leaving the operating room. The goal is to both initiate therapy and discharge the patient on day 0.
“My team will be there first to get the patient sitting up, getting out of bed, and starting to walk—and some patients can even make it 50 to 60 feet while still in the post-anesthesia recovery unit,” says Dr. Wilfred. A second session that same afternoon incorporates stairs to make sure the patient can return home safely. Then the patient is discharged, with home physical therapy initiated about 24 hours later.
“The idea is that it’s a supported discharge—we’re sending physical therapy and nurses to make sure the home environment is safe so they’re able to thrive there,” Dr. Wilfred adds. “All of this is possible with the highest levels of coordination among our multidisciplinary team of orthopedic physician assistants, case managers, social workers, nurses, and physical therapists, who are all focused on the same goal for our patients.”