---
title: 'Less Opioids After Total Joint Replacement Surgery'
type: 'lecture'
url: 'https://doc.social/lectures/less-opioids-after-total-joint-replacement-surgery'
published: '2020-12-02'
author: 'SwiftPath Program'
specialty: 'Hip and Knee'
topics: 'Hip and Knee'
transcript: 'yes'
---

# Less Opioids After Total Joint Replacement Surgery

## Summary

Dr. Andrew Wickline from Utica, NY discusses his approach of achieving 10 opioids or less after joint replacement surgery.

## Transcript

2,861 words · 16 min · 2 speakers · automatically transcribed (aws-transcribe) and not checked by a person; it may contain errors, particularly in names, drugs and dosages. The recording is the source.

[0:00] Speaker 1: Hi, I'm Doctor Craig McAllister, and I would like to welcome you to our educational series on Outpatient joint replacement during a COVID Pandemic.
[0:09] Speaker 1: I serve as the Chief Medical Officer and the president of SwiftPath and would like to introduce you to my friend and collaborator, Doctor Andrew Wickle.
[0:18] Speaker 1: With over 20,000 joint replacements to his credit, Doctor Wickline is one of the highest volume surgeons in New York State. In addition to his 700+ annual joint replacements, he has achieved one of the lowest complication rates and readmission rates in New York State and in the country.
[0:36] Speaker 1: He is the founder of the Total Joint Program at Saint Elizabeth Medical Center in Utica, New York, and is one of SwiftPath's early adopters. All of Doctor Wickline's patients participate in the SwiftPath program. Those patients were included in two of his recently published peer-reviewed studies. Those studies show how a robust patient education platform combined with state of the art surgical techniques.
[1:03] Speaker 1: Can lead to a significant reduction in opioid consumption compared to two patients undergoing traditional Joint replacement Surgery.
[1:12] Speaker 1: Please take 12 minutes to hear Doctor Wickle's discussion on aftercare in Outpatient joint replacement Surgery.
[1:20] Speaker 2: I think this is where the, uh, the biggest potential savings is, uh, in the entire bundle. And, uh, so I'm gonna go over, uh, my thoughts on this.
[1:31] Speaker 2: Here are my personal stats. I suspect we're all fairly similar, uh, but I'm I'm ready to, uh, have data in submissions, uh, showing that last year's total knees, uh, all 386 patients, 86% use 10 opioid pills or less, uh, the majority of which was tramadol, actually. Uh, I consider tram a single tramadol pill, one opioid.
[1:53] Speaker 2: We saw 85% of all total knees using zero post-discharge spend services including home health and therapy. Uh, in terms of the anti total hips, I use an Anterior approach. Um, there's a debate, of course, which is better. Uh, it's just what happens to be what I like to use. 97%, 10 pills or less. Uh, again, 70% tramadol, uh, 95% no therapy, uh, through 6 weeks.
[2:21] Speaker 2: And I believe those uh opioid usage numbers uh are the lowest in the nation. Uh, in addition, uh, this protocol led to a, uh, I, at the same time, I was in the BPCIA bundle. My target price was 18,000. I was able to do it for an average of 15,000 for Hip and Knee. Uh, and unfortunately, my hospital did not include my total knees, uh, as Inpatient. The majority of my total knees were done Outpatient.
[2:44] Speaker 2: So that average number is actually artificially high, um, because my typical total needs, it's about $13,000 for the entire 90 day bundle.
[2:56] Speaker 2: That's also associated with the lowest complication rate, uh, in New York State. Uh, that's from my hospital, uh, of which I do 80% of the work. Uh, again, from a therapy standpoint, 85% of total knees reached 115 degrees of flexion by 3 weeks, just following my simple, uh, discharge protocol, and that's 7 to 12 weeks sooner than the 2018 AAOS textbook.
[3:21] Speaker 2: Aftercare, I believe, starts 6 weeks preoperatively. Um, you know, on the left here is a picture where I was able to do some Joint replacement in India. Uh, they kind of still have the old, uh, model where you just come to the hospital, you show up, and they actually have Surgery the next day. There is no optimization, there's no thought process. Those patients are admitted and operated on the next day.
[3:45] Speaker 2: Here in the United States, I think Total joint replacement is not a decision that uh anyone really wants to make. Most people believe it's painful and dangerous, and there's fear and anxiety.
[3:57] Speaker 2: So again, education has to start before the Surgery to decrease that anxiety, and also helps set reasonable goals and expectations.
[4:06] Speaker 2: Um, the education should be provided in short bursts. We've already seen earlier today that patients don't really retain much of what, uh, they hear, particularly in one visit, so there should be multiple, uh, education pieces.
[4:20] Speaker 2: Uh, also, part of the education should really talk about narcotics. We should be open and honest about a 24 hour prescription leading to a 6% permanent addiction to opioids.
[4:32] Speaker 2: And uh again, having a, a standardized single textbook that is specific to you in the protocol that you use, I believe is key.
[4:40] Speaker 2: Uh, you need to train all of your staff and family. Uh, Dana down in Florida knows that when you call a certain, uh, theme park, no matter who answers the phone, they all answer it the same way. Hello, it's a magical day. How can I help you? That's what your staff, both in the hospital and in the Surgery center, and in your office, should all be saying.
[5:01] Speaker 2: My personal medical assistants actually operate with me. I ask them uh to uh switch, so each of them has a separate day, and um they come and operate with me, so they, they can hear about the things we're thinking about. They can um be more involved with the actual care of the patient, and they can answer questions more accurately.
[5:24] Speaker 2: Um, and again, I think, uh, someone alluded to earlier today, my patients call the handbook their bible, and I love it when they correct a staff member because it really shows their buy-in. Again, the acceptance of the plan needs to happen before the Surgery, uh, otherwise you can expect to, uh, use your safety net and derailment plan for this patient. Uh, I have a home exercise video, which we'll talk about shortly. So when patients meet with me, I make sure that they can discuss and tell me about those exercises.
[5:52] Speaker 2: And then there's a separate pre-op, uh, Physical therapy visit, and at the hospital or at the ASC there's another therapy visit that reiterates to both the patient and to the coach what they need to do.
[6:03] Speaker 2: I do think that, you know, if you're in a Business, you should underpromise and overdeliver. Um, and I, again, try to make sure I set those expectations at that decision for Surgery meaning one week prior to Surgery.
[6:16] Speaker 2: It's a chance for the surgeon to make the final call on moving forward with Surgery or delaying, uh, due to poor patient compliance or understanding or risk. I know a lot of Practices do it a little differently. They have, uh, uh, the patient first evaluated by the surgeon, and then the PA or the mid-level, uh, decides to do that HMP right before Surgery. I think it should be the Other way around. Um, you know, I guess that's a separate point we could discuss in a roundtable someday.
[6:44] Speaker 2: It's a chance for me to make a specific treatment plan for that patient, uh, looking at their comorbidities, and, uh, again, be able to gauge their ability to succeed. And lastly, to really make sure that that 58 year old male that wants to continue running the boilermaker here in Utica, New York, uh, understands that maybe Knee Replacement, it might not be the right option for them.
[7:08] Speaker 2: You need to, uh, again, under promise over deliver. Uh, so you need to tell them there's going to be at least 3 humps to get over. The day of Surgery, most patients are very comfortable. It's that, uh, 24, usually 36 hours where that, that peak swelling sets in, and so you have to get over that first hump. Uh, there's a second hump. I use a canal pump, uh, and so about 3 to 5 days post-operly in my practice, the second Pain hump to get over.
[7:35] Speaker 2: And then, when you follow each and every single patient for a year, you find out that around 8 to 10 days, there's about 10% of patients that the hematoma that drifts down into the calf becomes very, very painful. Uh, they have difficulty putting weight on the leg, and they are anxious if they don't know that this is going to happen, that there's something wrong. So again, you tell them to call you, you get that Ultrasound and run the fire drill, but if you tell them ahead of time, you've averted their anxiety.
[8:02] Speaker 2: And I am very clear to describe the word painful when I described these humps preoperatively, and most often after Surgery, they tell us it's uh uncomfortable. When they say it was uncomfortable and not painful, that's a win. You overpromised, uh, assume you underpromised and you overdelivered.
[8:19] Speaker 2: Need to make sure they understand that there are non-narcotic solutions when they encounter those humps.
[8:25] Speaker 2: So, uh, I think this is, uh, uh, uh, you know,
[8:29] Speaker 2: Very important. I, it was really eyeopening for me to do these two separate studies in the last year, looking at narcotic usage. I thought that, you know, somewhere between 30% and 50% use zero narcotics, and, you know, it turns out that's not really as good as I, uh, I thought it was. So, if you really capture every single patient and include your hospital dosage, uh, which these studies that are about to be published, uh, did, uh, you'll be surprised and you'll be able to make adjustments.
[8:56] Speaker 2: Uh, we did briefly talk about this periotic Pain control for that, that, uh, first hump. You know, everyone's using a perarticular Injection. I think that's a standard protocol.
[9:06] Speaker 2: But you really need to ideally hit that 36 to 48 hour window, um, whether it's this paintball catheter that I use, or the intra-articular uh liposomal bupivacaine, or maybe the off-label use of the adductor canal with the bupiviccaine that's uh got a published paper now. You do need to pick one, you need to collect data. And the goal is zero narcotics through 72 hours. The discharge plan, I think this part is important for a COVID-19 standpoint.
[9:34] Speaker 2: You know, my hospital and the governor said no one should be in the hospital for these elective surgeries. I don't disagree. There's no reason for them to be wandering down into the cafeteria for the 5 or 6 hours that the patients in the hospital.
[9:46] Speaker 2: But I do believe that the last 30 to 45 minutes where the patient is passing Physical therapy and may have some questions, and they need to understand how to use the paintball or how to uh take their medications, I think uh this is crucial and uh remember you are the physician, not the administrator. Uh, for my, uh, again, aftercare, uh, some current thoughts that I've been working on and believe in, uh, I do think there's some clear data that shows that, uh, uh,
[10:16] Speaker 2: Perioperative protein supplementation, uh, more reliably reduces, uh, tumor necrosis factor, alpha, IL-6, Other cytokines, and that may lead to less Pain. There's some data also that this may, uh, improve, uh, potential outcomes for those patients with, uh, uh, COVID-19 as well. I believe that's under investigation currently. And, uh, lastly, I'm working on, uh, some early, uh, Research with CBD oil to reduce those, uh.
[10:45] Speaker 2: Uh, cyt accounts. So, I'm gonna show you my, uh, simple uh exercise program. Again, I've been doing this now, uh, for 5 years, um, and that's, uh, the data that I'm presenting, uh, or publishing. Uh, the patients need to walk for
[11:02] Speaker 2: Just a short walk once an hour. That helps reduce pneumonia and the blood clot. So, I just tell patients kitchen and back, bathroom and back. They're going to do some uh Knee flexion exercises, so they sit in that chair, uh, and, uh, they bring the leg back as far as they can. They lock the foot down and they scoot their butt forward. Uh, so that helps get that flexion, and then we do the Knee straightening.
[11:25] Speaker 2: They do 10 ankle pumps an hour, and this is something I'm going to incorporate the heel hand. We're gonna do it 3 times a day, uh, to try to help get the last couple degrees of extension.
[11:37] Speaker 2: And overall, this is about 5 to 8 minutes per hour. They ask patients to do that. So you can see this here. So, 40 minutes ice and elevation, toes above the nose, uh, 5 to 8 minutes of the uh exercises, and at least 12 minutes at the liberty. Uh, it's, it's a tough uh schedule to get through the 1st 12 to 14 days, but after that, it's amazing.110, 115 degrees range of motion, uh, patient's doing well.
[12:05] Speaker 2: From a Hip standpoint, I do even less. Again, I just need the, the distance, the short distance walk and the ankle pumps.
[12:14] Speaker 2: So if any of you, I have a simple uh iPhone video. It's on my website, uh talking about the, the exercises. So, if um if you want to see that simple video on how to do it, uh, it's on my uh SwiftPath uh button. So you have to go to my website, click the button, click on exercise tabs, and again, I'm trialing the, the heel hang, uh in the very near future.
[12:36] Speaker 2: Discharge medications. I think all of us know Tylenol, some sort of anti-inflammatory, and the prednisone is something that I've been doing for about a year now. Uh, one of the reviewers for my paper thought this was the magic. Uh, I don't think so. I think it's maybe another 5% reduction in Pain. Um, and I think the real, one of the real keys is reducing swelling, and, uh, aspirin, in my opinion, uh, leads to less bleeding, less swelling.
[13:03] Speaker 2: And then, uh, gabapentin is something that I use. My, uh, as many of you know, my wife, uh, had the Cancer treatment last year. Uh, terrible burning in the arm, gabapentin made it 80% better, did not need narcotics. Uh, they wanted to give her opioids, uh, for her Surgery, and, uh, did not need them. Uh, I prescribed the gabapentin, big difference.
[13:24] Speaker 2: Um, I use it for my patients, and I know that the clinical, uh, practice guidelines say it doesn't work. Uh, on this one, I have to disagree, uh, with the ALS. I use tramadol. Uh, again, I only dispense 10 pills, uh, and oxycodone if that patient was a previous narcotic user, uh, and, uh, under 70, and if that patient feels that they will need a stronger meds. So, typically, the oxycodone is only used for that 58-year-old male that tends to be, uh,
[13:52] Speaker 2: Um, you know, he's in my age group, so it tends to be a baby, according to my wife.
[13:56] Speaker 2: Um, and since the initiation of my Hip and Knee study, it seems apparent that tramadol may work for approximately 90% of patients, but I don't have data to prove that yet. That's just my personal feeling.
[14:07] Speaker 2: Cryoablation, Vin, uh, uh, alluded to this earlier. Uh, for some, uh, unknown reason, I, I currently have the largest cryoablation practice in the US, um.
[14:17] Speaker 2: What we are seeing is about a 33% reduction in VAS Pain scores uh on the 1st 3 days. So, I, I think that's helpful. I think number 3 is the thing that really impressed me, seeing a patient 12 days post-op, no cane, uh, 115 degrees of bend, going furniture shopping in a giant store. Um, that's impressive after Total Knee Replacement.
[14:41] Speaker 2: Um, but, uh, the next line, uh, again, I'm a little concerned that, that perhaps those patients will do, do a little too much, lead to increased swelling, and I think that swelling can potentially lead to ankylosis.
[14:54] Speaker 2: Complications plan, this is also important. You need to have uh an after hours emergency phone. Doctor Lowry Barnes, uh, taught me that in 2013 at a meeting. Uh, and, uh, it really helps decrease cost and, uh, inappropriate trips to the ER, uh, during the weekdays, you have someone else to answer the questions in the office. Um.
[15:14] Speaker 2: Someone else mentioned this earlier in the presentations. I think number 4 is super important. You know, when you get to a certain point where you've said it over and over and over again, maybe you don't really remember what you've told that patient. Uh, and even your staff, who is less aware of this, uh, may start kind of acting like the questions are dumb questions. So, you really have to reiterate to your staff and all the personnel that, that no question is a dumb question for that patient, that's their first time.
[15:42] Speaker 2: So, in a wrap up, uh, by, by following this, uh, protocol, uh, it can decrease COVID-19 exposure, uh, 18 less visits, you know, 6 weeks times 3 weeks. Uh, that's where I get that $720.40 dollars copay, uh, uh, 18 times. Uh, the insurer, uh, or federal government can see an average of $2500 savings per, uh, case.
[16:06] Speaker 2: In my practice, it was also associated with quicker recovery than what's reported in literature. Uh, 9 days of missed work by a family member bringing mom or dad to, uh, the painful Physical therapy visit, uh, uh, is, uh, appreciated. And uh happier patients due to less Pain, uh, also means happier office staff. Thank you.