The time when new mothers were confined to bed for a week or two to “rest” after delivery is long gone. But until recently, middle-aged and elderly patients suffering from osteoarthritis (OA) who underwent total knee or hip joint replacements (total joint arthroplasty or TJA) have been instructed by their doctors to do the same.
Until a few decades ago, such patients were doomed to spend their lives in wheelchairs. The development of artificial joints from metal alloys, ceramics and strong plastic parts have created an orthopedic revolution. But surgical recuperation from OA – a degenerative joint disease involving “wear and tear” on the cartilage “cushion” between the joints, leading to pain, swelling and stiffness – was typically slow and painful.
Today, a rapid recovery approach from such operations has been adopted by hospitals around the world, including Israel. A public symposium on the subject was held on July 21 at Jerusalem’s Shaare Zedek Medical Center and attended by a full house in its 350-seat Hedi Steinberg Auditorium. Many of them had already undergone such surgery or were scheduled to have such an operation soon – or have relatives with OA who face such a procedure.
Dr. Amir Rubin, head of the hospital’s joint replacement unit who studied the sub-specialty in Australia, organized the Shishi Bari (Healthy Friday) event and invited seven other professionals from the orthopedic department and a driving instructor who described how happy he was to have had the surgery and recovered quickly.
SZMC director-general Prof. Jonathan Halevy, who greeted the audience, said that every day, the hospital receives 50 or 60 emergency orthopedics cases, more than any other Jerusalem medical center.
“Our job is not only to treat but also to prevent and rehabilitate,” he added, as it does for cardiology patients as well. “Our Dr. Rubin is a pioneer in promoting proper care before joint surgery and after it.”
Prof. Amos Peyser, chairman of the orthopedic surgery department, noted that such operations have become much more common because Israelis are living longer – about 12 months more every decade. “Modern orthopedics gives answers to all kinds of problems that it couldn’t before. When the joints have degenerated, we at first try simpler treatments. Only if surgery can’t be avoided do we recommend it.”
Rubin noted that in a single year, more than 10,000 knee and hip replacements are conducted in Israel to treat OA and the numbers have increased by 10% each year. It is the most common operation in the country after circumcision and the removal of cataracts from the eye.
Rubin and the hospital recently published a softcover, 81-page, Hebrew-language book titled Hahlama Muetzet (Rapid Recovery: The Comprehensive Guide to Recovery from Hip and Knee Replacement Surgery), which outlines a new perspective on the difficulty of recovery from joint replacement and suggests a methodology for addressing it. Patients who read it weeks before surgery have an easier time because they don’t have to face the unknown.
Rubin noted that the body – especially the immune, nervous and endocrine systems – perceive joint replacement surgery as an open fracture. In an attempt to “fix the fracture,” the body creates an intense biological response that, among other things encourages the patient to rest to ensure uninterrupted regeneration of the tissue.
The patient’s reaction to the surgery, drugs and the avoidance of movement can cause an inflammatory reaction and hormonal and nervous system changes, but in fact, he said, the only tissue that needs to heal is the skin, and there is no need to wait for the skin to heal in order for the joint to function fully.
ISRAELI TJA patients must currently wait between six and 18 months for surgery in public hospitals here (unless they suffer an acute hip fracture, which can be life-threatening and require immediate surgery). To reduce costs, continued Rubin, rapid-recovery programs have been researched and developed to reduce recovery time and thus open up beds.
This reduced hospitalization from 10 to 14 days to only four to six days. There are hospitals in Europe and elsewhere that discharge TJA patients on the same day! This changes the requirements previously considered necessary for joint replacement, eliminating the need for a night staff and enabling the procedures to be performed in medical settings that do not have an intensive care unit.
Not only has this saved money, but recovery is easier for the patient, complications have been reduced and even rare deaths have been reduced by up to 70%.
A 2011 article in the journal Acta Orthopaedica found that rapid recovery programs for TJA reduced the death rate. Studying 4,500 patients who had the surgery, the British researchers showed that patients needed fewer transfusions, could go home faster and that complications and deaths were much reduced.
In an article in the Journal of Arthroplasty last year, which followed up 549 patients, the New Jersey researchers found that complications during the first three months after surgery using the rapid recovery technique were significantly reduced.
A number of Israeli hospitals have gradually implemented some of the components of rapid recovery, but Shaare Zedek under Peyser and Rubin have strongly promoted a program that includes a large number of critical recovery elements, including psychological ones that enable the patients to feel healthy, strong and motivated.
As human bodies haven’t changed, how can patients who used to be confined to hospital beds for up to two weeks be sent home so fast? Rubin explained that the “biological burden” on the body is reduced by preparing the patient physically and emotionally for the surgery. In addition, smokers are encouraged to kick the habit before surgery; if those who don’t quit completely reduce by half the number of cigarettes they smoke, that alone can drastically cut the time for the skin wound to recover. Patients with anemia are given iron to strengthen the body, and patients are encouraged to exercise – including walking, to build up their leg muscles. Diabetics are encouraged to improve their sugar balance to improve outcomes of the surgery.
As for post-surgery, hospitalization is reduced by getting out of bed within hours of the operation and giving the proper painkillers as well as persuading the body that the pain is not so bad. SZMC is the first Israeli public hospital where physiotherapists mobilize patients on the same day as the surgery. Rubin presented a video clip showing a TJA patient actually dancing a few days after surgery.
Since the rapid recovery methodology was implemented, a significant percentage of patients has been released in less than 48 hours, Rubin related. “For the first time, a patient was released 12 hours after the operation; efforts are underway to make day surgery for joint replacement routine.”
A PRELIMINARY review of the results from last year has shown great satisfaction among the patients and significant savings on hospitalization costs without an increase in complications, Rubin reported. But these positive results require real multidisciplinary, holistic teamwork in the hospital – nurses, doctors, physiotherapists, occupational therapists and social workers all cooperating together to help the patient.
Dr. Michael Toybenshlack, who performs the surgery along with Rubin, Dr. Moshe Lifschitz and Dr. Victor Vaisbrud, added that presurgical counseling to improve patients’ expectations is very important in rapid recovery.
“We want them to exercise. They don’t have to run a marathon, but there are ways to make their leg muscles stronger before both hip and knee surgery.”
Lifschitz said that in every operation, there are at least two orthopedic surgeons and sometimes three to carry it out. Positive results for hip surgery have reached 96% and 85% for knee operations.
Itta Lee Tov, the nurse who coordinates the surgery, explained that one prepares for TJA as if you were going on a voyage.
“We ask patients to bring to us all the medications, including dietary supplements, that they take. We balance their blood pressure, sugar and hemoglobin. We eliminate drugs that are no longer needed. We also make sure they drink a lot of water and eat more protein and fiber,” she said.
“We treat fungal infections and improve their hygiene. We also use a new protocol to ask them to quantify their pain between 0 and 10 so we can treat it. We give painkillers so they can be active without suffering debilitating side effects. They are allowed to wear clothes from home so they can feel normal. The nurse is available to help inpatients and answer their questions any time of the day or night.”
Physiotherapist Reut Shemesh said there are no physical limitations after knee-joint replacement surgery, but those who have had hip joint replacements are asked not to make quick movements. Both are encouraged to use a walker and then make numerous steps or even climb stairs quickly after surgery.
“By the second day, they walk about 40 meters if they can. When they go home, they can get a physiotherapist from their health fund to continue to work with them at home. They can also practice exercises on their own.”
Occupational therapist Dr. Danit Langer showed simple devices that can help patients put on socks, shoes and dress more easily. There is also equipment to help in the bathtub and toilet. She also offers counseling on couples’ returning to intimacy as before the operation.
Tsehayenesh Tadesa, a department social worker, said that patients worry about being a burden on family members.
“It’s natural to worry. They can get help from someone from the health fund or the National Insurance Institute for the first two weeks to wash and dress, then ask help for housework and chores in the coming weeks. The pace of full recovery is different for each person. We explain social services available to each patient.”
Finally, Shaul Habaz, a middle-aged driving teacher, explained that he had really been suffering due to the erosion of cartilage in his knee.
“I was in severe pain. I could hardly move. I went to Shaare Zedek and was encouraged to do physical activity. I read Dr. Rubin’s book and felt somewhat better for a year, but then I decided to go ahead and have an operation. The next day, I was able to sit by myself, put on my trousers and shoes and walk. I soon went home. Two weeks later, I started to drive, and three weeks after the surgery, I was back on the job.”
Today, he walks 10 kilometers daily to keep in shape. “I do everything. Don’t be afraid of surgery. I strongly recommend it.”