Mr Freedman - Orthopaedic Surgeon
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In contrast to traditional surgical pathways where patients typically spend 4-10 days in hospital after major hip or knee surgery, our patients are generally able be discharged 1-2 days after surgery. Our Rapid Recovery or Enhanced Recovery Program is designed to accelerate rehabilitation from your surgery.
It comprises a multifaceted approach to preoperative preparation, less invasive surgery and enhanced post op recovery that is used to reduce the physical and psychological stress of surgery and to optimise conditions for a complication-free recovery, shortened hospital stay and earlier return to work and physical function.
Key elements included in the Mr Freedman’s Enhanced Recovery after Joint Replacement surgery pathway are:
(a) Our patients are seen by a specialised preoperative physician before surgery to identity and optimise any existing medical conditions prior to surgery.
(b) Preoperative patient education: Patient who know what to expect from each phase of their care experience feel less anxiety, meet recovery goals faster and are empowered to achieve faster return to independent function.
(c) Preoperative hydration and enriched preoperative nutrition:
It used to be widely thought that prolonged fasting (> 6 hours) prior to surgery was necessary to avoid aspiration during anaesthetic but surgeons and anaesthetists interested in enhanced recovery now realise that lengthy fasting can make patients dehydrated and feel run down and unwell and have other deleterious physiological effects.
Mr Freedman and his anaesthetists now allow patients to drink clear fluids such as clear apple juice or black tea up to 2 hours prior to surgery. Patients are often allowed water even closer to their operation.
Preoperative administration of electrolyte and carbohydrate rich drinks such as powerade also assist in preventing hypoglycaemia. In addition to improving preoperative hydration and nutrition, care is taken to reinstitute eating and drinking as soon as possible (once safe) after surgery.
(d) Premedication: Surgeons and anaesthetists now realise that administration of certain medications prior to surgery can reduce the activation of pain pathways during surgery, which then leads to less pain after surgery. Less pain after surgery means less pain killers are required and by this, the side effects from pain killers can be greatly reduced. The premedication regime is tailored for each patient and will be directed by Mr Freedman’s experienced anaesthetists.
To reduce requirement for general anaesthesia most of our patients will receive a regional “block” to temporarily turn off pain nerves prior to surgery. Most patients will still receive sedation so that they’re lightly asleep (and not aware of proceedings) during the surgery but avoiding deep general anaesthesia (and the associated need to be on a breathing machine) allows for much quicker recovery of normal lung function after surgery.
(a) Physiologic Optimisation During Surgery and avoiding hypothermia (drop in body temperature) during and after surgery: Without specific attention to warming during surgery, a patient exposed for surgery can easily lose body heat. Low body temperature can affect various organ systems and lead to delays in recovery. With deliberate attention to patient warming techniques during surgery, normal body temperature (“normothermia”) can be well maintained. This facilitates faster recovery after surgery.
(b) Use of less invasive surgical approaches: We use less invasive surgical techniques, such as the Direct Anterior Approach for Hip Replacement to greatly reduce the surgical trauma.
(c) Minimisation of intraoperative blood loss: Careful surgical technique and revolutionary new medications such as Tranexamic Acid greatly reduce intraoperative blood loss. Less blood loss reduces the need for blood transfusion. We have not needed to give a single blood transfusion is our last 500 hip or knee replacement surgeries.
Minimising the administration of intravenous morphine and other opiate analgesia: Opiate pain killers (analgesia) are very effective pain killers but have a lot of side effects such as drowsiness, sickness and nausea. Preferential use of preventative techniques to avoid pain in the first place and sparing use of newer analgesics allows avoidance of opiates and thereby avoidance of opiate related side effects. We used advanced Local Infilatration Anaesthesia (LIA) techniques whereby local anaesthetic is infiltrated directly at the surgical site. This greatly reduces need for oral or intravenous pain killers later.
(b) Early removal of IV drips, urinary catheters or any other devices that could restrict patient movement:
Any drips or other lines that physically connect a patient to a device or the bed will restrict the capacity for early movement. Therefore all lines and drips are removed as quickly as possible so that the patient is free to get up, move about and mobilise as soon as possible.
(c) Early post-operative mobilisation:
Achieved through continuous passive motion (CPM) devices, early post op physiotherapy and patient up and walking within hours of surgery.
Use of new technologies such as active cold compression systems (e.g. GameReady) are used to reduce pain and swelling. Use of these cooling systems further reduces the requirement for pain medications.
When safe so that patients are able to recover in their own home environment. Hospitals are for sick people.
Most orthopaedic patients having elective surgery are otherwise well. The sooner you can be discharged away from the hospital environment (and exposure to actual sick patients) the less will be your risk if exposure to infection. Also, the sooner you are in your own familiar environment the more confident and active you will be.
Enhanced Recovery is a concerted, carefully designed collaborative program between Mr Freedman, your anaesthetist and the hospital nurses and physiotherapists. Much of the program will happen seamlessly in the background but Mr Freedman will be very happy to explain the elements to you before and during your surgical journey.