For years, orthopedic surgeons have measured the success of joint replacement by where patients ultimately end up: pain relieved, function restored and an implant that holds up over time.
Eric Lepkowsky, MD, thinks another part of the outcome deserves more attention: how patients get there.
A knee replacement that produces an excellent result at one year can still demand weeks of pain, assistive devices and disrupted routines before the patient reaches it. Advances in surgical technique, robotics and postoperative care are increasingly targeting that window.
Dr. Lepkowsky, an orthopedic surgeon with Hempstead, N.Y.-based Total Orthopedics & Sports Medicine who serves as section chief of the arthroplasty division at St. Joseph Hospital in Bethpage, N.Y., has watched that transformation happen quickly.
“For years, we’ve basically been chasing the gold standard of a hip replacement as far as recovery is concerned,” he told Becker’s. Now, he believes knee replacement is beginning to close the gap.
The outcome at one year can miss the point
Dr. Lepkowsky recently began performing Jiffy Knee, a muscle-sparing approach to total knee replacement designed to preserve the quadriceps tendon and surrounding tissue. But he makes an important distinction about what approaches like it actually change.
He does not consider joint replacement minimally invasive. Implanting an artificial joint is, by its nature, invasive. What surgeons can increasingly control is how much trauma they create getting there.
“I think the focus should really be more on the fact that it’s minimally traumatic,” he said.
For Dr. Lepkowsky, that means being more deliberate about soft-tissue handling and limiting unnecessary disruption around the joint.
It is a distinction that also shapes how Dr. Lepkowsky thinks about robotics. Robotic systems allow surgeons to make small adjustments to implant positioning and bone cuts that can reduce the amount of soft-tissue work required. Yet studies comparing robotic and conventional knee replacement can struggle to show substantial differences once patients are six months or a year removed from surgery.
To Dr. Lepkowsky, that does not necessarily mean the technology failed to make a difference.
“If you look at these outcomes a year after surgery, they all do the same because, by then, everyone’s fully healed,” he said. The more revealing period may come much earlier.
Six weeks matters
Dr. Lepkowsky pointed to research he participated in during training that found higher early satisfaction among patients who underwent robotic rather than conventional knee replacement, with the difference eventually narrowing. He does not see that convergence as a reason to discount the early advantage.
“You can say, ‘Eventually they normalize,’ but to me, those six weeks matter,” he said. “Getting someone back to their activities, feeling happier and experiencing less pain sooner is just better.”
That argument extends beyond robotics. Anterior hip replacement, muscle-sparing knee approaches and evolving postoperative protocols may ultimately produce patients whose long-term outcomes resemble those achieved through other techniques. But if one pathway reduces the difficult period between surgery and recovery, Dr. Lepkowsky considers that meaningful.
The challenge is measuring it. Traditional endpoints do not necessarily capture when a patient stopped using a walker, returned to driving or no longer needed narcotic pain medication. Those are among the markers Dr. Lepkowsky watches in the first weeks after surgery.
And their significance differs from patient to patient. A 90-year-old hoping to move comfortably again has a different target than a construction worker returning to a physically demanding job. Dr. Lepkowsky recently operated on a stunt performer whose livelihood requires being thrown down stairs and hit by cars.
“My job is to get people to their goal, whatever that may be, as quickly as possible,” he said.
Same-day discharge is becoming less exceptional
Faster recovery is also changing what happens immediately after surgery.
Dr. Lepkowsky said every joint replacement patient he operates on at an ASC goes home the same day. At the hospital, about half of his patients currently do..
Some overnight stays, he said, have less to do with whether a patient is medically capable of leaving and more to do with logistics, including whether physical therapy can evaluate the patient before the end of the day. Older patients can also be more hesitant about returning home immediately.
The shift is particularly striking to him in New York, where he said some patients still expect rehabilitation facilities to be part of the joint replacement experience.
“I still have to convince people they don’t have to go to a rehab facility, let alone home the same day,” he said.
That expectation reflects how quickly the procedure has changed. When Dr. Lepkowsky was a resident, he said joint replacement patients routinely remained hospitalized for at least two days. Today, some leave directly from recovery. COVID-19 accelerated that transition by forcing healthcare organizations to reconsider which procedures and recoveries truly required hospital stays, he said.
Robotics has another outcome that studies may miss
Dr. Lepkowsky’s defense of robotics is not limited to patient recovery. He readily acknowledges his bias: He performs robotic joint replacement and believes in the technology. He also said some studies questioning its advantages raise legitimate questions about how those advantages are being measured.
Part of the value, he argued, accrues to the surgeon. He recalled performing four knee replacements on a recent operating day. All went well, but one case performed without access to a robot was more difficult and took longer than he believes it would have with robotic assistance.
That difference is unlikely to appear in a study measuring how the patient is doing a year later. But making an operation more predictable and efficient can matter to surgeons and healthcare organizations, he said, particularly if it allows physicians to treat more patients while reducing some of the physical and mental burden of operating.
“These things are all tools,” Dr. Lepkowsky said. “Tools that make us better.”
The history of joint replacement is already a history of such tools. Early knee replacements relied on freehand bone cuts before increasingly precise cutting guides became standard. Robotics, in his view, is another step in that progression.
“We can make it easier. We can make it more streamlined. We can improve earlier outcomes,” he said. “We can just be better.”
The recovery race is not slowing down
Dr. Lepkowsky is less certain about what comes after today’s muscle-sparing approaches.
There are only so many ways to access the knee, he said. A truly minimally invasive replacement, perhaps an implant capable of being introduced through an arthroscopic portal, still belongs closer to science fiction than routine orthopedic practice.
But the demand for a less disruptive recovery is already apparent to him. Since adopting the Jiffy Knee approach, Dr. Lepkowsky said he has been surprised by how far some prospective patients are willing to travel. He recently received an inquiry from someone in Ireland about coming to New York for surgery.
Whether that person ultimately makes the trip is less important, he said, than what the inquiry represents. Patients care about the weeks after surgery, even if long-term studies eventually show similar endpoints.
“That early period matters to people,” he said. “It should.”
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