Heather Benjamin: Thank you for joining us for tonight’s educational webinar on orthopedic outpatient surgery. Tonight’s speaker is Dr. Mark Gittins, OrthoNeuro’s orthopedic surgeon.

Dr. Gittins is a board-certified orthopedic surgeon specializing in sports medicine and arthritis, with extensive experience in outpatient joint reconstruction, including robotic-assisted knee joint replacement and direct anterior hip replacement.

Dr. Gittins: So, my task tonight is to talk about the outpatient world. I’m going to speak about why it’s occurred and some of the political reasons behind why this has happened, and why we’ve done it. 

Then we’ll talk a little bit about what arthritis is and why people need this. And then, at the end, we’ll show a short video—it’s actually one of our patients who has undergone an outpatient procedure. 

So, with outpatient total joints, you know, it is an up-and-coming trend. And we’ve been one of the pioneers on it and done some of the original investigations on it and why this is good and why it’s safe. 

So, the real reason this started to catch fire in the governmental world is that it’s simply a money deal. It saved money. 

We were doing these nine years ago because we knew, at that point, that it’s just simply better for the patients. They had better outcomes than just doing better because of the surgery. 

But, as a result of the Affordability and Accountable Care Act, which was attributed to Obama, the goal is to try to save some money.

And so, one of the ways that they looked at that was to make changes in the way that Medicare—which would be Medicare, Medicaid, or CMS—basically interacts. 

So, here’s how the country is divided up. So we’re with Wisconsin and Illinois, and Indiana. That’s our section. They’re all compared to each other. But obviously, New York and California are going to be different than us in the Midwest. 

With our CMS patients, we looked at what was happening and how the dollars were being spent. And so, we had three new classifications of what the typical CMS, Medicare, and Medicaid services were. And I was fortunate enough to go and actually testify on this topic to them. 

But, we see the number one issue between what we call the “young-old patients,” the younger people into the CMS, is that of hip and knee arthroplasty. Basically, arthritis-type surgeries were accounting for 34% of all the health care dollars being spent in this, what we call, “young-old group” or the young people in CMS. 

When we looked at the people in the middle of the CMS bundle, again, some of those people got sick because of septicemia. You may have heard of that. Those are people in the ICU, so they had very long stays.

But, then we saw people again for hip and knee replacement. So, now we’re up to the 84-year-old age group that is still having these issues. 

And then we looked at people over 85. And again, although some of those people get sick because their hearts were out or they got urinary tract infections, still, a lot of people are spending dollars, although only 15% of the total amount is spent on CMS, with hip and knee arthroplasty. 

So, when we met with the government, we went through a number of things and looked at safety and efficiency. And so, in 2017, knee replacement was the first one to go. And so, total knee replacements went to outpatient surgery. 

Now, what is outpatient? It’s more of a billing issue than anything else for the hospitals and hospital administrators. But it does mean that the patient comes in, has their procedure done, and goes home the same day. So that’s what we’re talking about when we’re talking about outpatient surgery. 

So, it really puts the focus on the procedure, the anesthesia, how safe it is, and how fast we can get people back into the rehabilitation. 

In 2017, we started doing full total knee replacements. We are already doing partial knee replacements prior to that. And again, we’ve been doing this going into our 10th year. 

What also came out of that study is that in 2020, hips are now outpatient. So, as we speak right now, the hips are done in an outpatient fashion where they come in. They have their surgery done, and they go home the same day. 

That will be done in the surgery center, probably, just kind of guessing how Medicare CMS works, in January of this upcoming year. All of these will be done in surgery centers and the outpatient areas of the hospitals. 

So, that’s what we’ve seen. It’s putting a lot of pressure on the hospitals. It’s putting a lot of pressure on the consumer, which is the patient. And the surgeons are having to step up to try to meet this.

Bu,t I think, fortunately, the surgeons have been the driver of all this, and we’ve seen better outcomes. Patients are doing better. They simply have better outcomes, use less pain medicine, and are happier with their procedure. 

So, when we talk about arthritis, many people come in and speak to us, saying, “Am I a candidate for surgery? Do I need surgery? What is osteoarthritis?

I was talking to numerous patients today, and basically, osteoarthritis is the number one cause that we see. Over half of America are affected at some time during their life with this degenerative bone disease. It’s the most common cause of disability. And, we see over 50% of people in the United States with this. 

Obviously, the US has certain things that accelerate this. Issues with diabetes and metabolism issues with obesity may accelerate this. But, just like any other type of disease, they are somewhat mild, moderate, or severe. 

And, you can see the pictures on the right. It’s just a wearing of the cartilage on the end of the bone. So, if it’s just a little bit worn, then we’ll call that mild. And again, those people may have started with a sports injury when they were in high school or cheerleading class or something, or a gymnastics class. 

As they go through life, they progress. Then they wear more of the joint off, which you may see here. Therefore, they may lose a little bit of motion. They may not be able to run as far. They have a little bit more pain. 

What we, as surgeons, look for is the pattern. What is the pattern of arthritis? Is it all in one area? Is it in this area? Is it all the compartments of the knee? How is that affecting the person? 

As this progresses, and again, there is no cure for arthritis—it’s just how do we live with it? How do we deal with it at this point? Again, we see a lot of disability. People can’t do certain parts of their job anymore.

They have pain at night, they get swelling, they have difficulty going up and down stairs, or they have to use the rail. They have trouble getting out of a chair. And again, what’s happened is usually the arthritic pattern disseminated itself across the whole joint. 

So, the treatment, as you can maybe guess—mild, moderate, and severe—is different. And so, when you have early changes of the mild, you know, we want to make sure that if we have a weight challenge or metabolic issue, we’re controlling that and pushing it down as far as we can. 

Those people are usually helped with simple, anti-inflammatory medicine such as Advil or Aleve, and you can buy those over the counter. Tylenol works really well with those, too. So, that’s something you can add to the anti-inflammatory medication.

Trying to stay active is a good thing. So, we usually recommend, perhaps maybe not running, but more cycling, water therapy, or dance therapy. Those are things that include rhythm and balance and strength. And that is what we start with. 

On the moderate side, then you can consider doing some lubricant injections. Some people still use some corticosteroids, although the literature is somewhat pushing a change in that and that we’re not seeing as much corticosteroid use as we did in the past. 

Then again, if people have failed those, been through physical therapy, done their exercises, used their anti-inflammatory medications, and they’re still noticing a change in their activity level, then those are the people that surgery can be beneficial for. 

That’s how it is usually progressed, depending on the disease and how the disease progresses. Again, these are just some of the options that I mentioned. 

Probably the most common is the Advil and Aleve. The steroid injections of cortisone injections are still occasionally used. It used to be our gold standard because that’s all we had, but it may have had some deleterious effects to the joint. 

Braces are something you can use. TENS units, again, are not harmful. They block some of the pain. Stem cells—you may see some of that on TV. Again, we do not see a lot of FDA approval on that at this point. 

Hyaluronic acid or lubricant, or chicken injections—they just have to be cleared with your insurance. Those are some of the things that we can do for the mild and the moderate levels. 

And again, with these mild and moderate, depending on your on your age and depending on the type, you may be a candidate for a scope, especially if you have mechanical symptoms, such as locking or catching, or a torn meniscus. So, that’s usually for younger mild patients with arthritis. 

But, as you progress, as I was saying earlier, you may be a surgical candidate. The surgical things are, again, the more severe states where you’ve worn the cartilage completely off, and you get these raw pink spots, which is really bone. So, then you may hear the term “bone on bone,” and that’s what’s happened. You’ve worn the cartilage, and you simply get bone on bone. 

These photos just demonstrate some of the techniques that we use. We have all kinds of scans, whether they are CAT scans or MRI scans. 

And now the big push is that most of the companies are having some type of robotic surgery work. We’re able to use a robot to help reconstruct the joint where this wear of the cartilage down to the bone has occurred. 

Again, we see really excellent results in knee and hip arthroplasty. And these are basically lifelong results. We try to get these in and they usually last 20, 30, or 40 years. So, you want to try to make sure you’re working with people that do that many, that are used to participating in the programs and have a program for doing this. 

Partial knee replacement—you have to be the right person with the right pattern of arthritis for that. We certainly now know, if you look at some other joint registries out there, that the partials tend to do much better for the majority of surgeons doing them if they’re using some type of robotic instrumentation to put them in accuracy. The reproducibility is much higher.

This is what it looks like when you do things with a robot. You can see how everything lines up perfectly straight. So this is what a partial knee replacement looks like. Therefore, again, we’re more accurate or more reproducible. So each case looks like the next case. 

As far as getting the leg aligned, this is one of the machines we use. This is called a Blue Belt, which is now moving forward to what’s called a CORI. 

The names are important only to the surgeons, but it shows that we start thinking in different types of precision and accuracy. So, now we start thinking in half-millimeter and half-degree increments. That’s 20,000 of an inch. Extremely accurate. We’re able to align joints and get them very, very straight and erect, with the tracking and the pressure on each side of the joint being equal. 

This is how it looks. As you can see, these high-speed burs that spin at about 80,000 RPMs. They connect with the robot and the computer, and it gives you a custom knee just for your leg. 

This is an animated version of what that may look like. This is what these outpatient cases look like in hip and knee arthroplasty. We’re able to show what the knee looks like in real time, so we don’t have to take any special X-rays. 

We’re able to see how the joints can actually move. You can see the pictures there. Before we even do the surgery, we’re able to adjust the components to make sure that it fits just perfectly to you. Again, making adjustments within 20,000 of an inch. 

This is registered on the tip of this cutting device, which is going in and out. It’s very safe. It’s very reproducible. So, we’re fortunate enough to have a lot of visitors come in and see us and try to replicate this program. 

But this is how the one piece portion of bone is just simply sketched out. And then the worn, very hard bone is then simply removed. And the cutting device is able to put these in perfectly to fit each person’s knee. Each case is done differently. 

And then these pieces are just cemented onto the knee. And with that, the patients are able to get up and walk and go up and down steps and go to the restroom. And usually, they’re out of the center by lunchtime. 

So, it’s a very smooth procedure, and people are able to recover at their own homes. And again, this is just some of the technology. It’s very much driven by the technology and the math of all these surface contract points that we can put into the robot. 

And then, we have all these colors that help the surgical team know exactly where they’re cutting into to get this leg aligned perfectly. 

There are a lot of questions that patients ask. We’ll go through these as we go on. For example, “Does this allow for a shorter stay?” Yes. “Does it control blood loss?” We think—yes, because we’re not doing as much. We’re able to produce smaller scars, and then we think we get people back to their lifestyle pretty quickly. 

So, we’re seeing most of our patients in less than three weeks going back to work, going golfing, and that type of stuff. Not everybody, but most. 

That’s what we see as for what arthritis is and what’s happening. So, this last little video is one I want to show you. It’s one of our patients that had an outpatient hip replacement. 

When people say, “What’s outpatient?” It’s something that we’ve been doing for a long period of time. CMS has just started in the last few years, first with total knees and now with total hips, bringing this into the realm where it’s almost required, unless there are certain medical conditions for all of our people. 

So, here’s one that I’ll let you watch, and you can enjoy the journey of this patient. 

Theresa: Well, I have had a history of orthopedic problems in my lower limbs for a long time. When I followed up with Dr. Gittins, then I found out that arthritis had really started affecting my hip as well. 

Gradually, I had been less active. And then a couple of years ago, I retired. And so, now I want to be able to do the things that I want to do, when I want to do them. And it’s just not as easy to do that right now.

Gary: Being an outpatient, there are a lot of benefits to it. You’re in and out. You’re back in your own comfortable bed or back in your home. And so, I think the healing process just is that much easier for you when you’re at home.

Theresa: Hey, I’m all for outpatient. Yeah! 

What I’m expecting today is to go home for lunch, and I think everything will go very smoothly. And I’ve been looking forward to this, so I’m ready to get it started.

Dr. Gittins: Just to recap what we talked about in the office—anesthesia will be with Dr. Betts and his team. They will be in here in just a little bit. They’ll talk to you about a number of different things for this. 

We just completed the right total hip on an outpatient basis. Everything went smoothly. 

Nurse: Okay, I’m going to sit you up a little bit. You did great! How does that hip feel? Do you have any pain?

Theresa: No.

Dr. Gittins: Superstar. I love it. A+. Excellent. Good.

Theresa: I’m not at all hesitant to go home and think that I’m going to have any kind of a medical emergency. They did not push me out the door when I faltered a little bit. You know, they just held steady right there until I was ready to go to the next step. And, that’s what happened. 

I’m looking forward to going home, getting comfortable, and just letting the recovery start.

Dr. Gittins: So, that’s just a kind of a hint of what we’re doing and what outpatient is, because it brings all kinds of questions of what outpatient really is. 

And so, I’m going to go through some questions here, and that will probably spur some other questions. So, one of the questions is, “What age do people typically start experiencing arthritis?”

It really is a genetic issue. And, so, if your family is prone to it, you’ll start seeing it earlier. If you have an injury, like an athletic injury where you tear your ACL or you lose a meniscus, those people will get it sooner. Some people never get it. 

We do see over half the people in the United States do get it at some point. So, you really can’t change your genetics. But what you can do is live a healthy lifestyle, eat a well-balanced diet, and try to have a good exercise program. 

Those are the things that we can see. Keep weight challenges to a minimum. Those are the things that we see tend to give people the best shot at not experiencing arthritis during their lifetime. 

Another question is, “What determines whether you get a partial or total knee?” Well, I think it’s a great question, and it really depends on your surgeon and what they’re comfortable doing. That’s one factor. Some people are not comfortable doing partials. It’s a more finicky, more difficult procedure. 

The other thing from the patient’s standpoint is: What type of arthritis do they have? Do they have inflammatory arthritis? Is their ACL okay? What is their pattern of arthritis? Where is their pain? So, I think you need to talk to your surgeon and look at your X-rays. 

We have seen an uptick, especially with the robotic world, of partial knees coming on board, although many of the totals now are done with robots too. 

Another question is, “Can I choose to have the surgery done with the robot?” And that would probably be similar to what I said on the first one. It depends on what your surgeon is comfortable with and whether there’s a robot at the facility or not. Not every facility has one. 

Robots are just wonderful computers. But, they’re not going to replace surgeons. You still have to be careful. You have to know how to use them. They can get you in trouble, as well as not having a robot can get you in trouble. 

So again, I usually ask people to make sure that if you’re doing that—that you have somebody that has the experience that’s used to using them. Ask questions and be a good consumer of your health care. But there are a number of procedures where it is beneficial.

“How long does a total knee replacement take?” So, I think they usually take around an hour—45 minutes to an hour is about the amount of time it takes. With all the planning done prior to surgery, the surgery itself should be pretty smooth. It should be almost like a dance—a one, a two, a three. If the steps are followed, it should be pretty smooth. 

And the idea with this whole outpatient world is to have that coordinated with your anesthesia team because there are different types of anesthesia that we use. And if you do that and have a coordinated team, then you’re able to get up and walk. 

And you saw the illustration that we have, people are doing stairs within an hour after surgery. So it’s amazing how we can get these people with the hip and knee replacements back up and moving so quickly. 

So, part of it is your anesthesia team; part of it’s having a team that’s used to doing outpatient work. Some people are still learning how to do it. We have a lot of visitors that are at that level. So, just make sure that you’re asking questions and you know how many they do. 

“What can’t I do after a knee replacement?” I don’t put a lot of restrictions on my patients. I think you’ve got to have realistic expectations of what you can do.

I don’t see many people coming in that are candidates for knee replacement and wanting to run marathons and such, because they usually have some other body issues—maybe in another joint that’s not quite ready for surgery yet. 

I have people that bike and ski and do endurance bicycle racing. It’s usually the pounding type of exercises that I encourage people maybe to look at different options for. But, you know, they can ski, they can hike, they can golf, they can dance, and they can speed walk. So I really don’t put many restrictions at all. 

The reason we do the surgery is so people can have an active lifestyle. That’s when you start seeing that you’re losing some of your lifestyle. You can’t do stuff with the kids. You can’t go golfing. You’re hurt at night. You can’t do the stairs. You can’t keep up with your spouse or whoever you’re walking with. And that’s when you really need to have an evaluation and consider options that may be best for you. 

“What other surgeries are now being done outpatient?” Shoulder replacements and spine surgery were in question. It really goes back to the insurances and what’s allowed. But CMS is now allowing certain spine surgeries to be done outpatient.

And again, the reason is that if the team is coordinated with their anesthesia and the surgeon, we see better results with the spine surgery done outpatient. So, certainly, some of spine surgery is done. Shoulder surgery is done a lot outpatient, like rotator cuff repairs, even fractures, labral repairs for dislocations—that’s all done outpatient. 

CMS, at this point, has not allowed total shoulder replacement in the outpatient arena yet. Although the private insurers—so you think it private insurers, something like Anthem, UHC, Medical Mutual of Ohio—we call those the private insurers. They do allow them to be done outpatient. 

So, it just depends on your surgeon’s comfort, your comfort, the anesthesia, and what insurance you have. That’s what we’re seeing in the outpatient world. And again, it certainly has opened up. 

There was a big push in the outpatient world since the pandemic that we’ve all been living through started because nobody was going to the hospital. But the arthritic disease was not going away. And so, lots of people are going to the outpatient world. 

Fortunately for us and several other people that had been doing it, it was nothing new. It’s just business as usual. For some people, they had to learn how to do it in their centers. So, there was a little bit of a learning curve. 

But what we’re seeing is that that trend is not going to go away, and it’s probably going to increase where you’ll see probably close to 70-75% of all the surgeries go into the outpatient world because we do have a coordinated team. We have protocols. Anesthesia works well with the surgeons and the recovery room staff. 

I think there are a lot of benefits to doing it this way. And I think we’ll see more of that expand, especially as we get some newer medications and newer techniques that are always expanding. But I think we’re doing pretty well with it right now. 

“Does osteoporosis interfere with a successful outcome?” That’s a good question. So osteoporosis sounds like, when you listen to the word, sounds like osteoarthritis, but they are two separate diseases. 

So, osteoporosis is really thinning of the bone. That’s different than osteoarthritis, which is wearing out of the joint. People can have very, very good results that have severe osteoarthritis and have osteoporosis. So there’s not a direct correlation. 

They are two separate diseases. You can have osteoporosis and not even have arthritis. So it’s something that you factor in as a surgeon because you’re only as good as the quality of bone that you’re working with. But there are ways to get things done and keep the two diseases somewhat separate. That’s really the definition of the other diseases. 

The next question is, “What would eliminate me from being able to have outpatient joint surgery?”So, we kind of have a list of who’s not a candidate because almost everybody is a candidate. 

And the term that goes with this is you need to really optimize the patient prior to surgery. So, you just don’t take him to surgery. You look at what the surgery is, you look at the medical conditions, and then you alter those. 

The list of things that don’t go to surgery includes somebody who’s on dialysis, because most outpatient centers don’t have a dialysis unit there. Somebody who has 24-hour-a-day oxygen therapy may not be a good candidate. 

People that have had solid organ transplants—so somebody with a kidney transplant or heart transplant—might not be good outpatient cases. So there are extreme things like that. 

If your diabetes is out of control, we just say, “Well, you just need to get your diabetes under control,” and we get the specialists and the endocrinologist to help us out with that. So those are the people that are not candidates for outpatient. 

Other than that, you optimize the patients so they can get there. So, having coronary stents or having a previous heart attack doesn’t disqualify you from having outpatient surgery. 

Having a blood clot does not disqualify you. You just have to talk to your surgeon and know the protocols and what you can do and what you can’t do with that. 

Heather Benjamin: I have a question for you. You always say, “You’ll know when you know” as far as when to have surgery. Can you expand a little bit on that?

Dr. Gittins: So, when we say that, it’s really the patient’s choice. These are elective procedures. I don’t tell people they have to have surgery. When they get to the point where they’re losing function in any fashion, then it’s time to have it. 

There used to be the thought, “Well, you have to be 55. You have to be 60.” So, I think that’s robbing people—life’s short. You never know what’s going to happen the next day. So I think if you’re having loss of function, you’re having discomfort, and your x-rays show that you’re an osteoarthritis person, and if your surgeons recommend it, you might want to consider it. 

Some people say, “Well, I never had pain. I’m just uncomfortable.” Well, to me, that’s up to you to decide. 

Any time one says, “I can’t walk as far. I can’t walk as fast. I’m hurting at night. I’m taking more pills. I’m stiffer. I can’t get into my car as well. I’m having trouble getting out of a chair. I can’t get off the floor. I’m afraid to babysit the grandkids because I don’t know if I can keep up with them. I hesitate to go to the zoo with people because of the walker. I can’t go to the fair because of the walking involved.”

So that’s what I mean by, “You’ll know when you know.” You don’t want to just masquerade the options to solve the issue of the arthritic pain. They are so good now. There’s just no reason to wait anymore. 

My dad just went through a revision at 86 years old so he can play softball three nights a week again. So that’s where I come from. That’s living life. I think that’s what you want to do. 

So, you just don’t want to be tucked in a corner and not be enthusiastic about life and being able to move. It’s all about moving. And arthritis is a curse that takes that away. So, that’s what I look for on that.

The one thing I’ll leave with you all with is a request and something for fun. Heather works in multiple jobs, and so do I. And OrthoNeuro supports research and a number of universities. And so, one of the ways that we collaborate with research is through something called The Orthopedic Foundation

And the Orthopedic Foundation works tirelessly all year long about doing research on neurological disease as an orthopedic disease. And it’s currently going on. But this year is a big fundraiser for all arthritis research. So I invite you to come and participate in that fundraiser. 

We’ll have some special VIP guests that have had arthritis, and some VIP announcers. And it’s a polo match fund get-together matched with all the community. So, look for that website and come out and say hi. Heather will be there. I’ll be there. I hear that some famous mascots might be there. 

So, I encourage you to all come out if you get a chance and have a wonderful time. If you’ve never seen anything that crazy, it’s a great, exciting sport. But it’s even a better cause. I mean, to do the research and see the people that you’re impacting by supporting it is a great thing. So I’ll leave that one promotional thing with you all.

Heather Benjamin: Thank you, Dr. Gittins. Thank you all for participating in tonight’s webinar. 

If you have any more questions about orthopedic outpatient surgery, be sure to contact OrthoNeuro today! We have many offices within Columbus, OH for your convenience. Our specialists look forward to giving you the peace of mind that you deserve.

Request A Callback

Take The First Step Today.

Call: (614) 890-6555