Reid B. Brown, M.D. Louisville Bone and Joint Specialists.

Rapid Rehab Joint Replacement Surgery

Reid B. Brown, M.D.Louisville Bone and Joint Specialists

Does Rapid Rehab Matter?


Physical TherapyRehab Facility


COST DISTRIBUTION VARIATION IN COST

Post-Acute

Care

Index

Procedure

Post-Acute

Care

Decrease LOS !!!

Discharge HOME !!!

DOES RAPID RECOVERY MATTER?

POST ACUTE CARE COST SNF DISCHARGE HIGHEST READMISSON RATE

What Rapid Rehab is not?

< 24 HOUR DISCHARGE

What is Rapid Rehab?

• Comprehensive program that safely guides the patient on a quick road to recovery

• Pre-Operative

• Intra-Operative

• Post-Operative

MIS

Rehab & Education

Pain Management

Rapid RecoveryOutpatient / 23Hr

RAPID REHAB • Pre-Operative

Education, Education, Education

• Intra-Operative Pain Control

Surgical Approach

• Post-Operative Discharge Home

Communication

Pre-op Management

• Team Work Approach

– Preop Education

– Preop Medical Clearance

– Mid-level Providers

– Social Workers

– RN Coordinators

– Physical Therapy

What Rapid Rehab Requires?

Because Bullets Can Only Go Through So Many Bodies

PRE-OPERATIVE

EDUCATION

EDUCATION

EDUCATION

EDUCATION

Discharge planning

begins in the office

Expectation set as OP

or D/C POD #1

Pain Management• Pre Op

– Cox 2 inhibitor (Mobic)• Intra Op:

– Dexamethasone– IV Tylenol– IV Tranexamic Acid– Exparel tissue injection– IV Zofran

• Post Op:– Avoid IV Narcotics– IV Torodol– Cox 2 inhibitor– Norco q 4-6 hrs

Intra – Op Management

Indications and Usage

• EXPAREL is a liposome injection of bupivacaine indicated for administration into the surgical site to produce postsurgical analgesia

Administering EXPAREL in Special Populations

• No dosing adjustment for hepatic impairment

• No dosing adjustment required for renal impairment

• Safe and effective in elderly patients

Administering EXPAREL

• EXPAREL is intended for single-dose administration via infiltration only– EXPAREL is not recommended for epidural or intrathecal administration;

regional nerve blocks; or intravascular or intra-articular use

• EXPAREL should be administered using a 22 gauge or smaller bore needle

• EXPAREL is a ready-to-use suspension, or the volume can be expanded to accommodate larger surgical sites

EXPAREL Uses DepoFoam® to Release Bupivacaine Over Time

• By utilizing the DepoFoam product delivery platform, EXPAREL delivers therapeutic levels of bupivacaine over time

• DepoFoam is a multivesicular liposomal product delivery technology that encapsulates drugs without altering their molecular structure and then releases them over a desired period of time1

1. Lambert WJ, Los K. DepoFoam multivesicular liposomes for the sustained release of macromolecules. In: Rathbone MJ, Hadgraft J, Roberts MS, Lane ME, eds. Modified release drug delivery technology. 2nd ed. New York: Informa Healthcare; 2008.

• DepoFoam utilizes membrane components that are based on natural and well tolerated sources and are cleared by normal metabolic pathways

• DepoFoam is <3% lipid, biodegradable, and biocompatible

Pharmacokinetics Demonstrate Plasma Levels of Bupivacaine That Can Persist for 96 Hours

Peak Duration

EXPAREL 266 mg P1: 0-2 hoursP2: 24-48 hours 96 hours

0 24 48 72 96 0

100

50

150

200

250

300

Plas

ma

Bupi

vaca

ine

Conc

entr

ation

(ng/

mL)

Time (Hours)

Initial peak due to 3% extraliposomal bupivacaine

Second peak due to slow release of bupivacaine from DepoFoam

Expanding the Volume of EXPAREL

• EXPAREL can be given undiluted

• If needed, the volume of EXPAREL can be expanded by adding up to 280 mL of preservative-free normal (0.9%) sterile saline (for a total volume of up to 300 mL)

• EXPAREL must not be diluted with water or other hypotonic agents as it will result in disruption of the liposomal particles

Following withdrawal from the vial, EXPAREL may be stored at controlled room temperature of 20°C to 25°C (68°F to 77°F) for up to 4 hours prior to administration

Label all prepared syringes of EXPAREL to avoid confusion

Exparel

Exparel + Marcaine + Saline – Total Volume = 100cc

Injection Instructions

• EXPAREL should be injected slowly into soft tissues of the surgical site with frequent aspiration to check for blood and minimize the risk of intravascular injection

• EXPAREL should be administered using a 22 - 25 gauge needle

Ensuring a meticulous technique that coversthe whole surgical site is critical to improvingpostsurgical analgesia.Inject every cell

Two Storage Options for EXPAREL: Refrigeration

• Vials should be stored refrigerated between 2°C to 8°C (36°F to 46°F) for up to 2 years– It is recommended to store vials in the product carton to protect from

temperature swings during refrigeration• EXPAREL should not be frozen as reflected by the temperature indicator or exposed to

high temperatures (greater than 40°C or 104°F) for an extended period• Check the freeze indicator and discard product if it has been triggered

The freeze indicator turns from green to white when exposed to freezing temperatures

Please refer to full Prescribing Information for EXPAREL available at www.EXPAREL.com.

Two Storage Options for EXPAREL: Controlled Room Temperature

• EXPAREL may be held at a controlled room temperature of 20°C to 25°C (68°F to 77°F) for up to 30 days in sealed, intact (unopened) vials

• Vials should not be re-refrigerated

• As a convenience to the hospital pharmacist, each vial label includes space to record the date when the vial has been removed from refrigeration

Tranexamic Acid

• Given IV by anesthesiologist• Not new (40 years – trauma, uterine bleeding)• Inhibitor of fibrinolysis (clot breakdown)

TXA

TXA

Tranexamic Acid – Is It Safe?

• CRASH-2 Study (Clinical Randomization of Antifibrinolytic in Significant Hemorrhage 2) – 20,000 patients, 274 patients, 40 countries– Trauma patients with significant blood loss– Randomized to TXA or control group

15% reduction in death due to bleedingNo increase in DVT / PE

Shakur, Lancet 2010

Decreased Blood Loss• Transfusion Rates– 2269 pts : 6.5% 0.3% (Wind, J of Arthroplasty 4/13)

• No diff in DVT/PE

– 645 pts : 19.8% 4.39% (Harris, J of Arthroplasty 8/14)


– 591 pts : 17.5% 5.5% (Tuttle, J of Arthroplasty 2/14)


• My Experience − 600 pts : 26/300 (8.6)% 2/300 (0.67%)


TXA - Decreased Cost

• Transfusion rate 17.5% 5.5%– Savings $83.73 / patient– 9.3% less discharge to nursing home

J of Arthroplasty 8/14

TXA - Decreased Cost• Transfusion• Length Hospital Stay• Pharmacy Costs• Reoperation (hematoma/ Wash Out)

$879 Savings per case

$15,099$15,978Control Tranexamic Acid

Gilette, J of Arthroplasty July ‘13

Tranexamic Acid

• Decreased Blood Loss• Decreased Cost

Higher Hb, Less Bleeding into Joint

• Improved Function ?• Decreased Infection Rate ?

Post-Op Management

Post-operative

• No PCA’s

• No IV Pain Meds !!!

• Oral only pain meds

Narcotic Naïve – Hydrocodone 5mg

Narcotic Hx – Oxycodone 7.5mg

Add Torodol and Meloxicam (nl renal function)

PAIN MANAGEMENT

“Rapid Rehab Protocol”

• D/C all tubes/lines/monitors– Oxygen– Pulse oximiter– IV (saline well)

• Prepare for d/c Home• Regular Clothes• Ambulate in Hallway / Stairs

Rapid Rehab Candidates

• Any medically suitable patient:– THA, Hip Resurfacing, TKA, UKA– Motivated patient, suitable support (coach)– Any surgical approach

avoid unnecessary: retraction, cutting, stretching tearing of tissues• Best Candidates for Outpatient:– Anterior Approach THA– Unicompartmental Knee Replacement

Direct Anterior Total Hip(DA THA)

Louisville Bone and Joint Specialists

Anterior Approach


Capsular Anatomy


Anterior Approach

Reproduction of Patient Anatomy

• DA vs. mini Post: Reduced LOS, less use of assistive device at 2 & 6 weeks, better VAS scores, less narcotic use

- Zawadsky MW, JOA 2013 (in press)

• DA vs. Post: Functional recovery quicker @ 2wks, no difference @ 6 wks- Rodriguez JA, CORR Aug 2013

• DA vs. mini AL: DA lower VAS scores early postop period- Pogliacomi F, Acta Biomed. Aug 2012

RECOVERY AND REHABILITATION

• DA vs mini Post: DA quicker time to ambulation & quicker disuse of walking aids, no difference in leg length, component position (anteversion or abduction), WOMAC, or HHS. **randomized**

- Taunton MJ, AAHKS Paper #33 Nov 2013

RECOVERY AND REHABILITATION

• DA vs. Post: less stiffness, improved early gait mechanics, no difference in pain, gait, and function @ 6 mos

- Maffiuletti NA, Orthop Clin North Am. Jul 2009

• DA vs. AL: showed early, sustained (3 months) improvement for cadence, stride time and length, walking speed, hip gait ROM.

- Mayr E, Clin Biomech. Dec 2009

- DA vs. AL: improved SF-36 and WOMAC scores at 1 yr- Restrepo C, JOA Vol 25 (5) 2010

GAIT BIOMECHANICS

- DA vs. Post: lower VAS scores, more normal stair climbing, improved walking at 6 wks, higher HOOS scores at 3 mos, no difference any outcome scores 3 mos

- Barret W, JOA v.28 2013

• DA vs. Post: improved ER / IR, improved walking velocity 1 yr.- Rathod P, JOA 2014 in press

- DA vs. AL: quicker time to single leg stance, quicker 50m walking time, less use of assistive device, improved gait

- Nakata K, JOA v. 24 (5) 2009

GAIT BIOMECHANICS

• 25 patients each group, MRI performed @1 yr

• DA THA

– Less frequent & less injury glut. med & min

– Less bursal fluid

– Less fatty atrophy

– No difference in TFL

MUSCLE DAMAGE

MUSCLE DAMAGE

CK

Serum CK level

Unicompartmental Knee Replacement(UKA)

Outpatient TJA / Rapid Rehab

• Here now• Future of TJA• Wide range of procedures• Applicable to the majority of patients

SafeMore Cost Effective

Better Outcomes

Thank You

Reid B. Brown, M.D. Louisville Bone and Joint Specialists.

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