New Technologies

Accelerated Recovery Technique

Knee replacement surgery has evolved over the last several years to a less invasive procedure, but it is associated with a significant amount of pain. Just recently, this author has combined multiple modalities to significantly decrease the amount of pain associated with knee replacement recovery. We are calling this the Accelerated Recovery Technique and the components of this are listed below.

1. Platelet gel is used to decrease swelling, decrease pain and improve tissue healing. This substance has amazing and multiple beneficial affects. Since using this, this author has decreased his transfusion rate from approximately 33% to around 3%. In other words, 97% of our total knee patients do not need a blood transfusion. This has given us the best profile for blood utilization in the entire hospital and in the entire surgical staff of this hospital system. Not only that, but we have seen a significant decrease in the swelling, the pain that the patients have and also improved tissue healing.
2. A subcuticular closure is also a part of this whole process. Instead of using a standard suture technique with staples on the skin, we have switched to closing the cuticular layer of skin with a subcuticular absorbable suture and then using Dermabond glue on the skin and covering that with Steri-Strips. This has virtually eliminated wound healing problems. The importance of this particular aspect of the process is that eliminating wound healing problems will virtually eliminate the instance of early postoperative infections.
3. A proprietary technique using 1/4% plain Marcaine of up to 1 cc per kilogram with a maximum of 80 cc, combining that with 5 mg of Duramorph in a 10 cc vile and injecting the knee with four separate aliquots during the procedure has significantly reduced our pain in these patients. Specifically, 20 cc of this mixture is injected into the joint before the knee is prepped. This is done from a lateral portal, parapatellar. A second aliquot is then injected above and superior to the area of the proposed knee incision from mid coronal plane to mid coronal plane, perpendicular to the axis of the incision. This is another 20 cc of this mixture. A third aliquot is injected into the posterior capsule and here we actually can use 30 cc, as we have 10 cc from the addition of the Duramorph to the 80 cc of the Marcaine. Therefore, 30 cc is injected, 15 on each side in the medial and lateral compartments posteriorly of the knee before prosthesis implantation. The remaining 20 cc mixture and fourth aliquot is then injected into the subcuticular and subcutaneous tissues after wound closure.
4. Cryotherapy has been used extensively in these surgeries in the past with good results. It significantly reduces pain and swelling by achieving a reduction in these two particular problems. It enhances the recovery from knee surgery significantly.
5. Minimally invasive techniques including quadriceps sparing approach to the knee has significantly decreased pain and given the patient a faster functional recovery.

By significantly reducing the amount of narcotics, a myriad of postoperative complications can be avoided. These include atelectasis, urinary retention, and ileus, among others. By reducing these three alone, we can also decrease indirectly the instance of deep venous thrombosis and pulmonary embolism. These two complications are most closely associated with DVT and pulmonary embolism and this has actually been studied and proven in literature. Mental status changes are also kept to a minimum by avoiding intervenous narcotics. Typically, what we have seen with this combination of techniques is that we can give the patient oral medications only in the postoperative period and avoid in 80% of he patient intervenous narcotics. Not only that, but a length of stay of 1.5 to 2 days is the norm.

This author feels that this unique blending of these particular techniques is proprietary, has essentially never been done before, and it will be a standard technique in the future for the knee replacement patient as it will allow us to decrease our postoperative complications, decrease our bleeding, nearly avoid the use of narcotics, and eventually lead to outpatient surgery for these particular operations.

Sincerely,

H. Morton Bertram, III, M.D.
HMB/msikc/qakm

TOP

<<RETURN TO PREVIOUS PAGE