Total Joint Rehabilitation: Introduction (13:11)

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Paul Levy introduces himself, began his career as a staff nurse at the University of Pittsburgh Medical Center Shadyside, and reviews his credentials. This lecture will review the pathophysiology of joint disease, history of joint disease, treatment options, pre-operative planning, post-operative assessments, pain management, complications, post-hospital planning, and CMS payment bundling.

History of the Total Joint: Pre- World War II (14:53)

Arthritis has occurred in older individuals for centuries. Treatment methods have improved with time. Levy traces the history of joint surgeries from the 19th century including Girdlestone procedures, joint resection, amputation, intertrochanteric osteotomy, interposition arthroplasty, and hip fusion.

History of the Total Joint: Latter 20th Century (17:18)

Levy traces the history of joint surgeries from the mid-20th century including hemiarthroplasties, chromium-cobalt alloys, research from the National Health Service, and modern techniques. The American Academy of Orthopedic Surgeons defines total joint arthroplasty as a surgical procedure in which parts of an arthritic or damaged joint are removed and replaced with a prosthesis. CMS bundling is creating fixed costs for joint replacement surgeries and post-operative care; participants discuss whether the United States is performing too many replacement surgeries and should consider more conservative approaches.

Bone Disease Pathophysiology (15:07)

Levy reviews hip, knee, shoulder, elbow, disk replacement, and ankle arthroplasty. A new knee prosthetic preserves the integrity of the ACL and MCL ligaments. Learn about osteoarthritis and rheumatoid arthritis in various joints.

Trauma and Fractures (14:21)

Levy discusses underlying causes and treatments in fractures. Osteoporosis affects mostly women, but the American Academy of Family Practitioners advocates all individuals who suffer a potential fragility fracture receive a DEXA scan.

Treating Bone Disease: Non-Surgical (15:37)

Look at the indications, cater to the individual's needs and risks, and get the patient active as soon as possible; Levy discusses treatment modalities including exercise, traction, and medications. Under the ADA, patients could sue their doctors for refusing to perform surgeries because of weight-related issues. The greatest issue with body mass index is post-operative infection.

Bone Disease: Surgical Treatments (05:12)

Research does not show any difference between arthroscopies and total joint replacements and suggests that meniscectomies are degrading to joint health. Levy discusses other surgeries including ORIFs, IM nailing, and hip replacements.

Approaches to Total Hip Replacement (13:24)

Levy discusses anterolateral, direct lateral, anterior, posterior, and two-incision MIS surgical procedures and potential complications. The doctor's expertise and preference determine the approach. Longer incisions create additional recuperation, but shorter incisions tend to bruise.

Materials for Hip Replacement Surgery (16:57)

Surgeons typically use cobalt chromium and polyethylene prosthetics; Levy also discusses cross-linked polyethylene with gamma irradiation, ceramic, and metal on metal benefits and drawbacks. Eventually the prosthetic will pull away from the body because of abrasion and loosening; most replacements will fail in ten to fifteen years. Patient factors to consider include age, gender, weight, smoking, drinking, and sterilization.

Total Knee and Shoulder Replacement Approaches (12:15)

Levy outlines the traditional, minimally invasive, quad-sparing knee, reverse total shoulder, lumbar disk, and bone replacement surgical procedures and potential complications. Research suggests partial knee replacements may be a better less invasive technique for senior citizens. Shoulder dislocations happen in patients who are non-compliant.

Fixation of the Prosthesis (09:34)

Surgeons usually decide whether to fixate or in-grow the prosthesis during the surgical procedure; polymethyl methacrylate and methyl methacrylate mix along with other additive properties into cement in a vacuum tube. Hematomal mesenchymal tissue begins to grow within twenty-four hours. Prosthetics come with a rough texture in order to aid bone growth.

Cash Flow and Insurance (13:42)

By 2030 Medicare will be broke; Maryland is a rate-setting state for surgical procedures and hospitals disperse the payments. Blood tests, EKG's, and x-rays are paid prior to surgery. Observation status and ED visits get paid out of the bundle but do not penalize the hospital.

Better Accountability for Surgical Procedures (13:49)

Levy emphasizes poor communication between hospital employees; sending patients to pre-habilitation helps obtain a baseline helps target post-operative complications. Medicare requires patient-reported outcomes reported at 30 days, 90 days, and one-year post surgery. Levy discusses benefits and drawbacks of CMS bundling and the future of medicine.

Reversible Risks for Surgical Procedures (15:14)

Levy discusses how weight, patient education, improved communication between professionals, and Hemoglobin A1C optimization aid in patient outcome. Doctors argue they cannot force someone to attend a class prior to surgery. Medicare only pays for rehabilitation if there is an acute medical complication.

Video about Bundled Payment (10:16)

A single fixed payment is sent to the hospital to coordinate bills and divest the income to the professionals who participated in the surgery. Patients find an improved quality of service, simplified billing, and better coordination among medical professionals. Start therapy immediately post-surgery to avoid complications.

Pre-Operative Planning (06:31)

UPMC requires a history, physical, blood work, chest x-ray, EKG, and dental screening pre-operatively. WebMD and Wikipedia are not fact-checked. Emmi, Medline, and pre-habilitation are good educational tools.

Day of Joint Surgery (12:39)

Enhanced recovery after surgery protocols gives clinicians a guideline to achieve early recovery after surgical procedures. Instruct the patient on the location of registration, the itinerary for the surgery, and PT and OT expectations. Levy describes when to implement Buck's Traction and emphasizes obtaining a CMP.

Perioperative Considerations for Joint Surgery (15:46)

Most non-profit hospitals and socialized medical programs are in debt. Levy reviews benefits, drawbacks, and potential complications of different types of anesthesia and pain management.

ERAS (08:57)

Enhanced Recovery after Surgery protocols includes dietary changes, use of Zofran and increased movement. Levy describes pressure points for different positions.

Anterior Approach to Hip Surgery Video (14:10)

Watch an animated video of a total hip arthroplasty. The muscles are stretched and strained during surgery, causing pain. Every patient should be seen by a physical therapist the day of surgery.

Surgical Care Improvement Project (11:14)

SCIP initiatives pertaining to joint replacement include a prophylactic antibiotic, surgical selection, Venous Thromboembolism prophylaxis, Bactroban, urinary catheters, and cease antibiotics after 24 hours post-surgery. Levy describes different drug protocols. Withdrawal from beta-blockers increases the mortality rate by one year.

Post-operative Assessment (18:11)

ERAS is an oral-based protocol for pain control; studies show patients do better on pills rather than PCA. Levy reviews common assessment protocols including neurovascular, neuromotor, incision site, pain, neurological, and gait inspections. Charting saves nurses in malpractice suits.

Auto-transfusion and Blood Transfusion (09:30)

Transfuse blood within six hours from the time of collection. If patient shakes, slow down the rate. The OrthoPAT is a viable option for Jehovah's Witnesses. Levy discusses using Tranexamic acid as an alternative and requiring a CBC and BMP.

Physical Therapy for Joint Replacement (11:22)

Levy discusses assessment procedures to decide between a wheeled walker, crutches, or a cane. Toe-touch weight bearing means all the weight goes on one leg to help balance issues. Hip-precautions include devices, avoiding hip flexion above 90 degrees, and do not cross legs.

Sizing Devices (10:37)

Levy describes how to size walkers, crutches, and canes and using assisted devices. Move individuals in bed in orthopedics from the weak side to avoid crossing legs and cause the least pain. Usually, physical therapists do not see shoulder replacement patients until 12 weeks post-surgery.

Pain Management: Prescription Drugs (23:53)

The quality of pain management is directly related to the patient's functional recovery. Medicare requires patients to fill out HCAHPS, a patient satisfaction survey. Levy describes multimodal strategies and benefits and drawbacks to specific drugs to oral medication.

Pain Management: Devices and Supplements (23:21)

Levy describes benefits and drawbacks to techniques including the TEN's machine, TED hose, blood thinners, aspirin, nerve blockers, supplements, and braces. Get patients on a bowel regiment as soon as possible. Do not use trapezes; continuous passive motion machines should be implemented for pain management only.

Post-Operative Complications (19:45)

Levy describes how to diagnose falls, pulmonary embolisms, fever, infection, prosthetic loosening, fat emboli, pressure sores, and compartment syndrome. Blood clots should dissolve on their own. Do not give patients suffering from compartment syndrome an opiate.