New Technologies: Accelerated Recovery Technique (ART)

Knee replacement surgeries evolved over the last several years to a less invasive procedure, but it is associated with a significant amount of pain. Just recently, we have developed a technique that combines multiple modalities to significantly decrease the amount of pain associated with knee replacement surgery. We are calling this the Accelerated Recovery Technique (ART) and the components of that technique are listed below:

1. Platelet gel is used to decreased swelling and pain and improves tissue healing. This substance is amazing and multiple beneficial affects. Since using this, the author has decreased 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 busy hospital system. Not only that but we see a significant decrease in the swelling and the pain that patient's have is less and we have had improved healing of the wounds.
2. A subcuticular closure is also part of this process. Instead of using a standard suture technique with staples in 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. 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. We use a proprietary technique using 0.2% ropivacaine up to 100 cc maximum, combining that with 5 mg of Duramorph and 0.2 cc of epinephrine 1-1000. The sequence of these injections as of January 2010 is 1 aliquot as a field block superior to the incision from mid coronal plane to mid coronal plane. The second aliquot is done from inside the knee. The knee distracted with a lamina spreader first on the lateral compartment and lateral collateral ligament, posterior cruciate ligament or remnant, and the medial compartment and medial collateral ligament. The third aliquot is into the vastus medialis muscle and the fourth aliquot is into the synovium in the suprapatellar pouch of the knee. The platelet gel that we have harvested from the patient before the surgery is injected into the deep wound and deep posterior capsule at the time of closure with platelet rich layer going deep and after the capsular closure a platelet pore layer in the subcu.
4. Cryotherapy has been used extensively in these surgeries with excellent results and significant reduces the pain and swelling and when we can do that it really helps the pain. It enhances the recovery from the knee surgery significantly.
5. We have combined this with what we call a preemptive edema management program by using a grade I compression stocking on patient's whose legs will accommodate this and this is applied the afternoon of surgery or the next morning. Using this for the first couple of weeks significantly decreases the pain because it decreases the swelling of the extremity.

By significantly reducing the amount of narcotics, a myriad of postoperative complications can be avoided. These include atelectasis, urinary retention and an ileus, among others. By reducing these three alone we can decrease indirectly the instance of deep venous thrombosis and pulmonary embolism. More importantly, by getting the patient up and walking the day of surgery, we decrease our rate of deep venous thrombosis by 80%. Mental status changes are also kept to a minimum by avoiding intravenous narcotics. In a review of almost 900 patients at Naples Community Hospital over the last three years, the instance of intravenous narcotic usage on these patients has been less than 2%. Typically, what we have seen with a combination of these techniques is that we give the patients only oral medications in the postoperative period. Their length of stay has been decreased and the patient's recovery has been facilitated even up to three months out.

This unique blending of these particular techniques is proprietary, is unique, and in the future will be a standard for knee replacement surgery, allowing us to decrease postoperative complications, decrease bleeding, and nearly avoid the use of narcotics.