Total joint replacement surgery is rapidly changing in the 21st century. Advancements in the execution and postoperative care of patients coupled with favorable long-term results of the procedures have resulted in expansion of the indications for total joint replacement to patients that in the past would have been considered too sick, too young or too active for the surgery. This scenario has imposed the following challenges to the practicing orthopedic surgeon:
1. The challenge of increasing safety of total joint replacement: With advancements in anesthesia, surgical technique and perioperative care of patients undergoing total joint replacement, safe and satisfactory results are obtained in the majority of cases. However, there are still patients in whom total joint replacement carries significant risks for complications. Patients who are debilitated, malnourished, immunosuppressed, or who suffer from significant cardiovascular, pulmonary, renal or hepatic disease are at a particularly higher risk [1]. The preoperative assessment and postoperative care of these high risk patients is more time and resource consuming than that of the majority of patients with no major medical comorbidities. The adult reconstructive surgeon of the 21st century faces the challenge of developing perioperative pathways for the safe and efficient care of these high risk patients. Such pathways should contemplate the selective, efficient and rational allocation of medical and technical resources based on the patient’s individual risk.
2. The management of patients’ expectations prior to joint replacement surgery: When considering hip or knee replacement surgery, patients have a pre-conceived image of their final result in terms of pain relief and function (“recovery expectations”). Similarly, after a thorough examination and discussion with the patient, the surgeon recommending joint replacement surgery also develops expectations for recovery for each individual patient. The physician’s expectations are based on multiple factors including his or her experience with other patients, the patient’s motivation, preoperative functional condition, medical history, current diseases, condition of other joints, etc. Ideally, the patient’s and physician’s expectations should be aligned. When a patient has expectations that are unrealistically high, the unmet expectation after surgery may diminish the patient’s perceived satisfaction. Conversely, a patient with preoperative expectations that are too low may not engage enthusiastically in the different phases of recovery and may have a sub-optimal result [2]. With the expansion of indications for total joint replacement to younger and more active patients, the surgeon faces the challenge of improving preoperative patient-physician dialogue to make sure that expectations are aligned. This will ultimately increase the patient’s perceived satisfaction.
3. The challenge of providing balanced patient education in light of the increased use of direct-to-consumer marketing in orthopedics: With the increased use of direct-to-consumer marketing by orthopedic manufacturers, the dialogue between the orthopedic surgeon and the patient has dramatically changed. Oftentimes, patients considering total joint replacement surgery come to their medical consultation after researching the subject on the internet, and therefore, may have misconstrued ideas on the most relevant aspects of the procedure. In extreme cases, patients may come looking for a surgeon that will implant the prosthesis that they feel will most likely fit their needs, based on information provided by commercially related websites. During their office visit, the orthopedic surgeon must not only gain the trust of the patient, but also redirect his or her attention to what is most relevant and possible in light of the patient’s circumstances. This dialogue can be distractive and confusing to the patient; however, it is one that must be faced in order to enable the patient to make an educated decision for his or her care.
Learn more about Dr. Alejandro Gonzalez Della Valle.
References:
1. Memtsoudis S, Gonzalez Della Valle A, Besculides S, Garber L, Laskin R. Trends in demographics, comorbidity profiles, in-hospital complications and mortality associated with primary knee arthroplasty. J of Arthroplasty 2009;24(4):518-527.
2. Ghomrawi H, Franco Ferrando N, Do H, Mandll, Gonzalez Della Valle A. How often Are Patient & Surgeon expectations for total joint arthroplasty aligned? 2010 AAOS Annual Meeting Poster Presentations #P140.
