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Total Approach to Hip and Knee Replacement

December 11, 2018
Total Approach to Hip and Knee Replacement

One hundred leg lifts a day. Jim Griffith and David Kiihnl say performing these exercises prior to total knee replacement surgery sped up their recoveries. The ambitious regimen, championed by Mark Snyder, MD, medical director of Good Samaritan Hospital’s Orthopedic Center of Excellence, was just one of many strategies that got Jim, 72, and David, 70, back on their feet.

Jim knew that the methods of Dr. Snyder, a volume leader in joint replacements in the Tri-State area, worked. In 2007, Dr. Snyder performed Jim’s first total knee replacement surgery, replacing his damaged right knee joint with a prosthesis.

A Vietnam war veteran and air conditioner salesman, Jim often crawled into tight spaces on the job. His knee, originally injured in Vietnam, became debilitated as arthritis progressed—making his occupation difficult and painful. “I worked in hundreds of homes a year, including those of nurses and doctors,” says Jim. “TriHealth Orthopedics and Dr. Snyder’s name kept coming up.”

Two months after Dr. Snyder performed Jim’s first knee replacement procedure, which involved a three-day stay at Good Samaritan Hospital and intensive physical therapy, Griffith says his mobility was nearly 100 percent. “I was able to do a full squat. It hurt, but I could do it,” says Jim, fit and trim due to regular home workouts.

Zeroing in on Complications

Jim’s active lifestyle continued into retirement until his left knee began acting up in 2017. This time, he didn’t hesitate and scheduled an appointment with Dr. Snyder. “Jim had severe arthritis and a meniscus tear,” says Dr. Snyder. “A total knee replacement was the best approach for long-lasting results. The only time we do a less invasive arthroscopic procedure to correct a meniscus tear in people with knee arthritis is if they have knife-like catching or locking episodes,” clarifies Dr. Snyder.

Though Jim felt prepared for replacement surgery the second time around, he was heartened to learn that Dr. Snyder was part of an integrated TriHealth program designed to make the recovery process even better. Known as Zero in on Zero (ZIOZ), the program focuses on reducing ten of the costliest and most debilitating adverse effects that can follow lower joint replacement surgery.

This includes eliminating unnecessary blood transfusions by screening and treating preoperative anemia; lessening blood clots through the use of mobile compression devices and low dose aspirin; and reducing opiate dependence with multiple pain control methods before, during and after surgery.

When a patient has a medical risk that might impact the outcome of joint replacement surgery, Good Samaritan Hospital has systems of care in place. “By working collaboratively with our centers of care, obesity is improved, smoking stops, diabetes is better managed and sleep apnea is diagnosed and treated,” Dr. Snyder affirms. “This synergy is what makes Good Samaritan Hospital unique.”

Empowering Patients

Dr. Snyder says patients of the Orthopedic Center for Excellence, which earned the Joint Commission’s Gold Seal of Approval® for Advanced Certification for Total Hip and Total Knee Replacement in 2017, are educated about potential problems pre-surgery and provided with tools to solve them.

Jim attended an educational joint replacement class prior to his second surgery in 2018, something he hadn’t done the first time. “I was given protein shakes and energy bars to promote good nutrition. I followed exercise and medication recommendations. When I came out of the OR and woke up, I was amazed. The pain level was not there,” says Jim who was discharged the next day.

Dr. Snyder says all ten of the ZIOZ pathways were applied to Jim. This included using a multi-layer, water tight closure without surface staples, a new surgical technique that greatly reduced wound infection. “Our pathways are like bridges over a raging river,” says Dr. Snyder “Patients must literally step on stones laid before them.”

Pain, a constant problem for orthopedic patients, must be managed carefully. “Patients have less pain if they prepare themselves before surgery with the right non-narcotic medications. That way, drugs are in a patient’s system controlling pain pathways when they have surgery. During the procedure, we treat patients with a spinal anesthetic and long-lasting tissue and nerve blocks. Most of our patients are narcotic-free within the first week.”

Return to Family and Fitness

For Jim, adherence to the ZIOZ pathways made a world of difference. He not only restored his fitness level quickly and safely, but says he is now better able to care for his wife during her cancer treatment.

Family involvement was also the driving force behind the April 2018 knee replacement surgery of David Kiihnl, a Cincinnati-based business consultant. After struggling to walk to the beach with his grandchildren during a Florida vacation, David turned to Dr. Snyder. He was diagnosed with advanced arthritis and a knee replacement was scheduled after injections proved short-lived.

Like Jim, David was well-schooled in ZIOZ pathways. “Dr. Snyder is an expert in what he does, but that’s only one part of the process. I knew I had a responsibility to do my part and follow instructions. Dr. Snyder told me early on, ‘If you do what you need to do and I do what I need to do, all you’ll require after surgery is a bottle of Tylenol and ice packs.’ He was right.”

David was impressed with clinicians at Good Samaritan Hospital and their commitment to the ZIOZ pathways. “I wanted to continue the process in outpatient rehabilitation with a physical therapist who understood Dr. Snyder’s recovery expectations,” he says. While David could have gone to a physical therapy practice minutes from his home, he opted to drive thirty minutes to TriHealth’s outpatient physical therapy department at Good Samaritan.

Because he had “prehabbed” his knee with exercises before surgery, David found outpatient PT less taxing than his peers who did not follow Good Samaritan’s protocols. “I used a walker for a short time and bypassed the cane all together,” he says. Today, David is walking distances with ease and finding playful joy again with his six grandkids.

Local, National and International Impact

Like his two patients, Dr. Snyder is confident that the ZIOS program works. It includes a Level 3 American Joint Replacement Registry through the American Academy of Orthopaedic Surgeons, which provides valuable data about outcomes, complications and patient feedback. Data collected in a Good Samaritan Hospital legacy registry about patients revealed that when integrated pathways for 10 adverse events were simultaneously enacted, rates of complications, readmissions and revisions in 2,000+ primary hip and knee arthroplasties in 2011–2017 plummeted below national averages.

It’s a model that Dr. Snyder believes has far-reaching potential. “The integrated clinical pathway method is a way for every doctor, every hospital, every patient in the United States and the world to more rapidly achieve safer and more optimal outcomes at the lowest possible cost.”