Bones of the Bay: Episode 1

Javier Ortega: Hello, my name is Javier Ortega. We’re pleased to have you join us of Florida Orthopaedic Institute’s first Bones of the Bay Podcast. Today, we’ll be joined by Dr. Steven Lyons and Dr. David Donohue, two of FOI’s exceptional adult recon doctors.

Dr. David Donohue: Well, thanks everybody for tuning in. This is the inaugural podcast for FOI, Florida Orthopaedic Institute. My name is David Donohue. I’m an adult reconstruction surgeon and a trauma surgeon. I’ve been at FOI for four years. I do an awful lot of outpatient hip and knee reconstruction like my colleague, Dr. Lyons.

Dr. Steven Lyons: Thanks for the introduction. I’m Steve Lyons, and I’ve been at FOI now for 25 years, exclusively doing adult reconstruction, which, in other words, is really hip and knee replacement. I’m excited about our new venture now that we have going. Dave, why don’t you explain things a little bit further?

Dr. Donohue: Sure. It’s a very exciting venture. Basically, there’s two main settings in which you can do a hip or a knee replacement. There’s the hospital setting, which most people are very familiar with, and there’s the outpatient setting something that you’ll hear called an ASC, which is an Ambulatory Surgery Center. We’re opening a new ASC, that is exclusively for joint replacements. It’ll be very efficient. It’ll certainly streamline the process for ourselves and our patients. Hopefully, that’s going to be coming online here late in the summer. That’s what we’re here to talk about.

Dr. Lyons: Great. Well, the outpatient experiences really hailed to be a better experience overall. I think most would agree, surgeons and patients alike, like the fact that they can get their surgery done in an outpatient setting. I think there are some benefits to that, and the benefits really are that you have it done in a more comfortable environment. A lot of patients feel like they’re at home. They can go home quickly in a few hours. In some cases, we may even keep someone 23 hours if they need a little extra care, but there’s nothing like recovering in your own bed. I think just being home, in your own environment, in your comfort zone, that helps you recover a little bit quicker. I think the cost is undeniable. Why don’t you mention some of the cost issues.

Dr. Donohue: The cost is a big concern. I agree 100% with everything you said. If I had to recover from a hip or knee replacement, I’d want to be home as well. In the hospital, although a very safe and often convenient place to do this, there’s a lot of hustle and bustle there, and having a smaller place to do it often it gives you a sense of comfort and ease.

Every patient is a bit different, insurance policies are all very different, but, unequivocally, the cost of this operation at a surgery center versus a hospital is on the order of $10,000 or so less expensive. That, obviously, has varying impacts on the patients as far as their co-pays for the procedure, but in general, co-pays and overall costs are much lower at the ASC than they are at the hospital.

Dr. Lyons: Sure. I think families, that are really burdened by huge co-pays for their insurance plan, will find that this is a very nice alternative.

Dr. Donohue: Absolutely. I know if I was watching this podcast as a patient deciding if I’m going to have a hip or knee replacement, I’d wonder if you think about an ASC. Obviously, a hospital has got a lot of resources there. There’s lots of specialists, everything is right at your fingertips. What’s the big difference between doing this kind of surgery at a hospital versus an ASC?

Dr. Lyons: Well, I think it’s really convenient, Dave. It’s convenient, it’s ease of use. The complication rate is touted to be a lot lower than in the hospital. When you really think about it, you’re away from sick patients, you’re away from all the other patients that don’t really belong in an adult reconstruction arena. It may translate to better outcomes and certainly a lower rate of infection because you’re not really around sicker people.

Dr. Donohue Absolutely.

Dr. Lyons You’re around a healthier cohort of patients and everyone in the surgery center that were starting is focused on total joints. Everyone’s there for one goal. Everyone’s aligned, everyone, whether it’s physical therapy, the nurses, the physicians, the OR techs, everyone knows what they’re there to do. It all revolves around total joints, which is much different than when you’re in a hospital.

Certainly, Dave, as you well know, when you’re in a hospital, I can end up with a scrub tech that just was scrubbing an abdominal case or someone that’s really never even seen a total joint before and you, unfortunately, are the recipient of that particular help. So in the surgery center, which is a center of excellence, we’re all aligned in the same direction and I think it really matters to the bottom line and how you end up with what results you get.

Dr. Donohue: I couldn’t agree more. I can’t wait to start working there. When you work with a team that’s dialed in, it dramatically improves efficiencies, and as we know, as the efficiencies go up, complication rates go down. You mentioned a great point. A hospital is a place where sick people go. That’s not an ASC. This is not a place for sick people. It’s a place for people that have relatively isolated pathology, hip or knee arthritis, some indication to have this kind of operation down, and they can do it in a comfortable spot where they have a team that’s dialed in for their problem and they’re not around a lot of other patients that are dealing with lots of other more complicated elements.

Dr. Lyons: Right. What people really don’t understand is that the ASCs are credentialed by really the same folks that credential hospitals. They live by the same rules. You have the same requirements. They self-report. They do all the same things that hospitals do. It’s not like you’re on some island. This is something that is very legitimately policed, if you will, and evaluated on a regular basis, just as a hospital would be.

Dr. Donohue: Great point. Very safe place to have this operation done. Are there any differences when you’re doing a knee replacement or hip replacement at a hospital? Do you feel any different as the surgeon doing the case in the hospital versus the ASC or is it just about the same for you?

Dr. Lyons: Dave, I think it’s about the same for me. It’s just a different environment than you might be used to, but you have the same equipment. Everything is the same. The same tools that you’re routinely used to using are all brought in or reside there. In this case, with our center of excellence, all the surgeons that go there from FOI will have all of their requisite instruments that are important to them, and they think that are very instrumental in making a good outcome for the patient. They will live there and all the instrument pans from all the companies that we use will be there as well.

Really nothing changes. I don’t think the cadence would change. I think that help is going to be the same. As a matter of fact, there’s a few people that might even want to come over from a hospital setting to work in an ambulatory surgery center. It’s generally touted as a kinder, gentler place to work because everyone is mellow, they’re really focused on things, and there’s not a lot of chaos that might exist in the hospital when you have other specialties competing for the same operating rooms.

Dr. Donohue: Absolutely. It’s simply a peaceful place to work. I love working at the surgery center. It’s one of the coolest experiences I’m sure you’ll agree when you’re doing a case that you know is very formulaic and routine, like a hip or knee replacement. You don’t have to say a word, you can just enjoy the surgery, you can do your case, you can put your hand out without taking your eyes off the field, instruments and everything you need just come into your hand and it’s a perfect way to do a hip or knee replacement.

Dr. Lyons: Now Dave, when you’re doing outpatient surgeries, what time of recovery do your patients typically sit in the recovery room for?

Dr. Donohue: The recovery room is a matter of hours. They’re up walking as soon as the anesthetic clears. We’re usually doing these surgeries under a very light anesthetic or maybe a spinal anesthetic, so the amount of medications they’re getting is pretty minimal. It gets out of their system pretty quickly. Postoperative nausea is very minimal, and they’re able to walk quickly with therapy. As soon as they’re able to move around comfortably and when their pain is controlled, they’re able to keep down a little bit of food and water, they’re usually ready to go home. We give them a courtesy call at the end of the night to make sure they’re home okay and feeling well. The home health agencies have been arranged.

It usually is a matter of hours, which is really difficult for patients to believe after they have what is relatively large operation. Since it’s done in a setting where everyone is doing only those two surgeries, and it’s not just us in the OR and our support in the OR, it’s, as you mentioned earlier, everybody after that sees the patients that seeing hip and knee replacement patients all day that know when they’re safe to go home. They get them out very efficiently and very safely.

Dr. Lyons: Sure. What people really don’t realize is since Medicare thought of or change the ruling to totally in total hip is outpatient only procedures, a lot of other insurance companies that followed suit. Really, patients are unaware that that procedure either the hip or knee replacement is considered outpatient only in many situations. I think this opens up the door to really do this a lot safer than we’ve done in the past. What I found is that my patients spent about three or four hours in the recovery room. Certainly, when we want to get them up and walking and walk them usually twice to document that they’re walking safely.

Certainly, in my arena, we use Exparel or other intraarticular injections to help them decrease their pain in the knee. We use adductor blocks or other femoral nerve blocks to help decrease the pain. I think that might be surgeon dependent or anesthesia dependent and some surgeons might have differing ideas on what might be the best. In my situation, I use a pain management cocktail, usually Exparel or other things, and then I do an adductor block. That negates the need for a knee immobilizer to walk around right away, and, typically, my patients are walking an hour and a half after the surgery. They hang out a few hours and then they walk a few hours later to document that they’re safe, and then they go home, which is fantastic. Dave, one of the things I think we are alluding to but really haven’t talked about is how anesthesia is dialed in.

Dr. Donohue: Sure.

Dr. Lyons: I think one of the keys with the center of excellence that we have in our developing is that anesthesia is truly dialed into what we’re doing. I think the success of getting people home at a very reasonable timeline is really paramount on anesthesia knowing what we want doing really facile nerve blocks and allowing patients to go under general anesthesia or spinal with no nausea or very little nausea, and allow them to get up and walk right away. I think it’s really a key point that needs to be emphasized.

Dr. Donohue: Absolutely. I couldn’t agree more. It’s worth mentioning that it may be normal for a lot of these patients to have a bit of abnormal sensation in their leg when they are going home, and that is the residual effect of some of those pain control modalities that anesthesia is deploying to keep them comfortable. Those usually go away maybe 12, 24 hours after the surgery, but it’s a normal thing.

Dr. Lyons: Sure. Well, this Ambulatory Surgery Center is going to be 40,000 square feet. We have our operating rooms on the main floor and then the floor above the operating rooms is office space for patient visits. There’s I think room for about four surgeons at any given time that we can actually see patients in the office. What makes it even more convenient is not only can we operate on you at the facility, we can see you in the office afterwards. We can see you in the office beforehand. We have physical therapy on-site. It’s kind of a one-stop-shop and we can take care of everything under one roof.

Dave, I know I mentioned it earlier about getting patients out at a reasonable time, but have you ever thought that 23 hours is really needed in this arena to do the outpatient joint in other patients that might not be the best perfect candidate for it?

Dr. Donohue: I think so. That’s a good point. I’d say the vast majority of patients are able to go home the same day, but that it’s not for everybody that it whether it’s because of anxiety or various social constraints if there won’t be enough help available that night. Sometimes it is easier for somebody to stay overnight. There are some medical conditions, which I’m sure that we’ll talk about that don’t make it perfect candidate to go home the same day but still very reasonable to go home the next day.

That’s I’m sure you’ll agree is the current standard in most hospitals. If you’re going to the hospital and you can’t go home the same day, you can stay one night and go home the next day, just with observation of vital signs to make sure all systems are functioning properly before you go home. We can do the same thing at this new ASC. I think the vast majority of patients can still plan on going home the same day, but there is that option if they’d like to stay overnight that’s just fine.

Dr. Lyons: I’m really excited about it because it opens the door to a lot of patients that otherwise might not be able to go home same day.

Dr. Donohue: Absolutely.

Dr. Lyons: Typically, we get a lot of patients traveling from all over the state or from longer distances around the city. If you’re done later in the day, in regards to your surgery, it’s harder to get home in the middle of the night or as the sunsetting to avoid traffic and to get stuck in rush hour and stuff like that. I think what this will do is open up the possibility of having surgeries done a little bit later in the day, and we can kind of recover you overnight and let you go home the next morning.

Certainly, people may not have others to drive them home, and that would open up the availability to have help come take them home the next day. I think the 23 hours is going to be really key here, and certainly other medical conditions that require a little bit more monitoring, like you said, maybe whether it’s an AFib, some heart issues, respiratory issues are going to be really well-managed with the availability to do it for 23 hours.

Dr. Donohue: I couldn’t agree more. Are there any patients in particular that you think they’re not really a good candidate for an ASC hospital a safer place to do, anybody in particular?

Dr. Lyons: Well, I think the ones that are at the top of the list are people that are very sick with active cancer, with active severe heart conditions like congestive heart failure, people with really difficult knee situations or hip situations that require a lot more major implants or the possibilities of the surgery changing every 10 minutes to half-hour based on what we’re doing. Certainly, major infections, major trauma around joints probably wouldn’t be that great for it, and huge revisions, severe respiratory compromise with COPD, severe COPD or severe asthma, but light asthma, I think, would be fine. Diabetes is certainly not an issue because a lot of folks that have it as well as it’s well managed. It’s not a problem.

Dr. Donohue: That’s probably the same in my practice as yours is more and more as we’re learning these restrictions that really make it a little too dangerous to do a hip or knee replacement at all. We’re learning is that those constraints really don’t exclude many patients from an ASC anymore. If you’re having to go to the hospital to do it in general, like you said, it’s because it’s a complicated case.

For our viewers, a hip and knee replacement is a pretty straightforward procedure, where usually you don’t need that many trays or implants, but as you get into the revision world, the trauma world, the amount of implants and access that you need to various other modalities of treatment expands dramatically. That’s the reason to go to the hospital. The majority of people, I think, are perfectly safe to do it in an ASC.

Dr. Lyons Absolutely.

Dr. Donohue: Steve, we’ve talked a whole lot about doing hip and knee replacements at this new state-of-the-art facility. Are there any other joints or any other procedures for that matter that you can do at this facility, at an ASC?

Dr. Lyons: Sure. As far as I understand, certainly, we’re going to be doing hip and knee replacement, but shoulder and elbow replacement will also be available there, and also total ankle replacement at that point. The goal, as you said, the state-of-the-art facility is to make it a center of excellence for total joints, and that includes all the joints, certainly in the lower extremity and upper extremity. I think they’re all game.

Dr. Donohue: Absolutely. One of the newest frontiers, I guess you could say in hip and knee replacement and other joint replacements for that matter has been robotics. Do you use robotic-assisted surgery to perform robotic-assisted surgery at all?

Dr. Lyons Yes, Dave, I use robotics, when I think the patient really is amenable to it. Certainly, it’s debatable as to who’s really a candidate for robotics, I think most people would agree in a surgical setting that almost anyone can be a candidate, and may help us get things a little bit closer to the perfect zone, if you will, but it’s not 100% perfect, if you will, like in surgery anything, can have a little bit of outliers.

Dr. Donohue: Certainly, a robotic assistant won’t make a bad surgeon a good surgeon, but I think exactly, like you said, if you look at the literature, in the results from robotics, long-term outcomes have not been shown to be any different from the standard approach versus robotics, but it does seem to eliminate some outliers. I think it’s a useful tool. It certainly helps us quantify a lot of things that before was based more on our field during surgery. It’s a very interesting new technology.

Dr. Lyons: Sure. I think it’ll continue to evolve, and we’re happy to be part of the evolution and, certainly, we’ll offer robotics at our state-of-the-art facility. Dave, we’ve talked a lot about center of excellence at this ASC. Could you define for our audience a bit clearer what exactly a center of excellence is?

Dr. Donohue: Absolutely. It’s a great question. Basically, the center of excellence comes down to a few main points. Number one is patient safety. You could say that’s, that’s paramount at an ASC or a hospital, but certainly, in our center, patient safety is number one. The second are the efficiencies that are built into the system. We mentioned earlier that there are a lot of scrub techs involved, circulators in the operating room, nurses that are all helping us do the surgery. When they know exactly what we’re going to need, when we need it, the surgery goes faster and smoother, and complication rates go down.

The third is coordination of care. As we know, it’s not just you and I that are determining how well a patient does after a surgery. It’s dependent entirely, not entirely, but in large part on the nurses taking care of them after the surgery, home health nurses come in to take care of them at home, coordinating care with their medical physicians to make sure they don’t have any medical complications after the operation, and having somebody covered and all aspects like that really does make for a fluid experience. The most important thing and that what I think separates our ASC and from other centers where we can do this surgery is that everybody involved in the episode of care is focused on a singular procedure for that one patient. That’s what defines it as a center of excellence.

Dr. Lyons: Absolutely. That is, as like you mentioned, whether it’s the pre-op nurse, the intra-op nurse or the circulator, or scrub techs, the post-op nurse, the physicians they’re taking care of them, the therapist, as you alluded to, everyone is aligned to the same goal and I think it matters in the outcome. Certainly, Dave, what better place to have a surgery than a very clean comfortable environment that is equivalent to a five-star hotel experience?

Dr. Donohue: Indeed. Well, thanks again, everybody for tuning in. We hope this podcast has been informative and has answered your questions about hip and knee replacements. Thanks for joining us on our maiden voyage and we hope you tune in for future episodes.

Dr. Lyons: Great. For any other information about our doctors or the surgery center that we discussed, please go to floridaortho.com. Thank you.