You Think You Need a Joint Replacement?
I have seen several articles and presentations about non-operative treatments for arthritis to help postpone or even prevent joint replacement surgery. But, there often comes a time when that just isn’t enough and joint replacement surgery is the best option. We see several patients every year at Arkansas Bone & Joint from all over Arkansas who come to the clinic ready to have a hip , knee or shoulder replacement saying they have put up with the pain as long as they can stand it and are ready to get the joint replaced. They have seen their primary provider who found bone to bone arthritis with deformity on the x-rays and were told they needed joint replacement surgery. Sometimes this occurs near the end of the year as patients are trying to get their surgery done before the last day of the year. Many have met their insurance deductibles and have made tentative plans to have their procedure performed during the holiday break. When I went into practice 27 years ago that was fine. We could schedule a patient for surgery and even admit them the night before to get pre-op labs and then do the surgery. They would be in the hospital for 3-5 days and then go home or to an Acute Rehab facility. Fast forward 27 years and that is no longer the case.
We now live in the world of CMS guidelines which govern the rules for most insurance companies . Patients have to get pre-approved for surgery and must adhere to a strict criteria to actually be scheduled for the desired procedure. Most of these patients are scheduled as outpatients now even though they usually stay in the hospital overnight and go home the next day. Once home the patients then go to outpatient therapy or use home health. We prefer outpatient therapy whenever possible as it gets our patients up and moving quicker and is more predictable. If a patient shows up now to schedule a joint replacement and hasn’t met the pre-op criteria, then surgery can be delayed. Sometimes the delay is for 3 months and beyond if the basic CMS guidelines have not been achieved in addition to the individual insurance company requirements. This can be problematic in patients with severe pain and end stage arthritis who must live with the pain and impaired mobility as they wait for the insurance company to approve the surgery. The guidelines were established to help improve outcomes and to allow for attempts at managing the arthritis with non-operative treatment. My hope with this article is to disclose the basic treatment criteria that should be done prior to attempting to schedule a joint replacement surgery with your orthopedic surgeon. Most of these treatments can be instituted by the patient or primary physician before seeing the orthopedic surgeon.
CMS criteria for Total Knee Replacement:
1.a trial of NSAIDs or the inability to tolerate these meds
2.use of a walking aid or external support (cane,walker or brace) for 3 months
3.Physical Therapy for 6-12 weeks or the inability to tolerate once started
In addition to these basic criteria we must address smoking status/cessation, obesity, diabetes, and cardiac clearance for heart patients.
CMS criteria for Total Hip Replacement:
1.a trial of NSAIDs or the inability to tolerate these meds
2.use of a walking aid (cane or walker - even for part-time use)
3.Physical Therapy for 6-12 weeks or the inability to tolerate once started
In addition we must also address smoking status/cessation, obesity, diabetes, and cardiac clearance.
Our Criteria For Total Shoulder Replacement:
1.a trial of NSAIDs or inability to tolerate
2.we offer injections of steroids to help relieve the pain or alternative injection
3.Physical Therapy for 6-12 weeks depending on insurance and response
4.a failure of other treatment alternatives to establish medical necessity
In addition we again address smoking status/cessation, obesity, diabetes and cardiac clearance.
Most of these criteria can be achieved before seeing the surgeon. For knee arthritis, patients can take over the counter NSAIDs (such as Alleve or Ibuprofen when allowed by your primary physician) if tolerated or alternative analgesics if necessary. They can get a simple brace for warmth and compression or even an ACE wrap if standard braces don’t fit their anatomy. They may get a cane or walker from a drug store, Amazon or a local medical supply store. Physical Therapy can often see the patient without a referral to do the required therapy unless the patient has Medicare or Medicaid. For hip arthritis the same rules apply except we don’t use a hip brace. For shoulder arthritis the rules are similar except we don’t use a walking aid or a brace.
Smokers are at a much higher risk for infection and wound complications after joint replacement and patients should stop at least 1 month prior to surgery. Poorly controlled diabetic patients also are at risk for wound problems and infection. Diabetic patients need to have good control of their blood sugar levels. I like to see blood sugar levels routinely < 200 with the AIC level at a reasonable level. If the diabetes is poorly controlled, then that will delay surgery until it is reasonably controlled. Severe Obesity is problematic as we see a higher incidence of wound problems, surgical challenges and slower initial recovery. I like my Direct Anterior hip replacement patients to have a BMI <35 otherwise I do the lateral approach which has a much slower recovery. Some insurance companies have strict BMI guidelines that often delay the approval if the patient is not on a successful weight loss program. Heart patients will need “cardiac clearance” from their cardiologist to have the surgery and get guidance for stopping any blood thinners or other meds prior to the surgery. All pending dental work should also be performed prior to the procedure as it may have an elevated risk for joint infection from oral bacteria that can get in the bloodstream from the dental procedure. I’ve seen it a handful of times in my career.
Many of our joint patients have seen us for years and we walk them through the process until nonoperative treatments have failed and the criteria have been met. We also see patients from all over the state who are sent to us to get an arthritic joint replaced. It can happen much quicker if these criteria have been addressed.
Jerry J Lorio, MD
Arkansas Bone & Joint
About Arkansas Bone & Joint:
We have 2 full-time physicians, Dr BJ Bailey and Dr Jerry Lorio. Dr Bailey is an ABOS certified Sports Medicine Specialist with specialty interest in Joint Reconstruction and Dr. Lorio has an orthopedic specialty interest in Joint Reconstruction and is ABOS certified through the Joint Reconstruction specialty exam. They both perform ASI (direct anterior) hip replacement surgery which is known for smaller incisions and quick recovery and they also perform hip revision surgery. They both perform Patient Specific Technique (PST) which offers quick recovery due to custom balancing of the knee joint to match the patients deformity and they also do knee revision surgery. Dr. Lorio likes to use the ROSA Robot as a measuring tool for each procedure. They both perform Total Shoulder Arthroplasty and Revision Total Shoulder Arthroplasty (used for rotator cuff deficient shoulders and certain fractures and deformities). They also perform a vast array of general orthopedic procedures such as fracture care, open and arthroscopic shoulder surgeries, hand surgery (carpal tunnel, ganglion, CMC arthroplasty, mass excision,tendon repair), foot surgery, knee arthroscopy and ligament reconstruction/repair, sports medicine injury care, and basic spine care. Between the two of them they offer procedures at Arkansas Surgical Hospital , Arkansas Heart Hospital - Encore and Saline Memorial Hospital. They cover emergency room call at Saline Memorial Hospital and Encore. After surgery, the patients are allowed to contact the physicians by cell phone after hours and on weekends for urgent needs.
We also have 2 full-time Physician Assistants, Jasmin Lease PA and Dia Watson PA who are both loved by our patients and provide a smooth continuity of care in our orthopedic practice. We also have 2 physical therapists, Derick Hampel DPT and Easton Freeman DPT and an Occupational Therapist , Cullen Bullard who runs the therapy department. We have in-house MRI, x-ray, nerve studies and DME. Our desire is to be a one-stop location for orthopedic care. We try to treat the patients in a way that we would want our family treated. If you have Orthopedic needs come see us and be a part of our family !