Chapters Transcript Video Module 3: Post-Operative Session Highlights Discuss any changes to be made in post-operative care protocols for patients undergoing elective surgery Explore techniques and technology to support reduction of length of stay and readmission. Hello and good evening. Thank you for joining our program. I'd like to welcome you to this webcast titled Resuming Elective Orthopedic Surgery. A New Processes Post Kobe 19 Guidelines Developed by the International Consensus Group. This is Module three of a three part series that assembles top surgeon leaders to discuss a comprehensive set of consensus guidelines and protocols for resuming elective surgery developed by the International Consensus Meeting Musculoskeletal Infection led by Dr Javad Part Easy, today's module we will be covering recommendations for post protocols for returning to surgery today. I'm very happy to introduce are moderator Doctor Divide Parties E of the Rockman Institute at Thomas Jefferson University Hospital in Philadelphia. Our esteemed Panelists include Dr Tim Alton Frump Reliance Orthopedics in Washington State, Dr John Cooper from Columbia University in New York City, Dr Michael Cross from the Hospital for Special Surgery in New York City and Dr Michel Malo from the University of Montreal in Quebec. Each of our speakers have disclosed any potential conflicts that they have. Thank you, Janine and James, thank you very much for all of you for being on this last and third module. We would like to thank three m k c r for their generous support of this particular educational activity and Blue Mehdi for putting together a fantastic program with their incredible skill in house. To be able to have these weapon ours thistles, the last of the modules. And this is going to be related to post operative care of patients during the elective orthopedic surgery. And we'll give you a little bit of a background and go through the questions. And I'm honored to have incredible steam faculty, all of whom are my friends. But more importantly, they're respected surgeons in the field of our capacity who have amazing knowledge that will share with us. So, as you know, before the 2020 our challenge that we're facing with and we're trying thio uh, dedicate our energy and effort was to try to address the issue of pay prosthetic joint infection, which is still continues to pose an incredible challenge to the orthopedic community. And as you know, back in July of 2018 the international consensus meeting up together, which after two years of effort came up using the Delphi method, came up with recommendations related to various aspect of care for prayer prosthetic joint infection, which was then published in various venues. And then, of course, 2020 hit all the wheels came off. Our attention turn to a new challenge, which was a challenge of covert 19 a virus that gets transmitted from animal to animal and then to the humans, and it gets transmitted through droplets. Three droplets can then land on four mites. Which person coming into contact with can obviously, uh, then get infected by the virus is and possibly through even aerosolized virus is in the air. That thing is transmitted and, of course, started from China back in November of 2019 and suddenly it affected just about every country around the globe, and we will still continue to be dealing with the issue. United States is in the midst of a second wave, with majority of the states having a very high rate of zero positive patients, and some of the countries have fallen victim to this issue. Particular countries with the older age have seen a very high rate of mortality Italy, United Kingdom being at the top and some of the other countries with the younger patient population like Iceland and South Korea. Not so much of mortality but nonetheless covered. 19 effects are patients. Our society and some of these patients, unfortunately, lose their lives. The mortality of SARS cov to fortunately is not as bad as some of the other pandemics that we have seen, but its variables to some of the recent ones. In particular the issue related to H one N one. When a pandemic hits, you have three options. Do nothing, in which case the virus will spread and affect just about everybody in the society. Try to mitigate the risk by implementing some strategies or you bring down the hammer, lock down every place and try to prevent the spread of the virus from one individual to another. And I think we saw the lock down the majority of the countries that happened, and during that time, all things all activities including elective orthopedic surgery, were all canceled. Up to about six million orthopedic procedures were put on hold due to the lock down during the pandemics, and during that time we had a chance to engage some of the faculty in the international Consensus group to come up with the Delphi method and come up with recommendations related to resuming life to surgery. How do we go back and start the procedures when the pandemic ends? And this culminated in the publication of an article, which is the subject of tonight's The Discussions that was published in General Bone and Joint Surgery. The American version, the International Consensus Group in in particular, the American Association of Heaven need Surgeons and their research group should be really, uh, thanks for the efforts to try to put this together. The article was published in J. B. J s and also on Ortho evidence, and it actually had four parts the general apart, preoperative part. Interrupt the part and the Post op the part. We've covered the other aspect, and tonight's discussion relates to the postoperative protocols when elective orthopedic surgeries resumed and the article was also published in also evidence and is available. So with that background, I would like to start the process and have our faculty to try Thio go through some of these post operative protocols. Each one of the faculty will weigh in and please feel free toe all the faculty to provide your insight related to each question. I will ask each question from one particular faculty. And again, we will have others also provide their insight when or if they wish. So let's start with Dr Alton. Uh, what steps should be taken of? A patient who underwent elective surgery tests positive for SARS, Kobe to in the postoperative period. I'm not sure if you've had experience with this issue, but what do we do with these patients? They turn positive in the postoperative period. Yeah. Thank you, Dr Barbara. Easy. We have had to deal with this in our clinic, and we've We've been a little better with it recently. I think we've been testing more people and haven't haven't run into it quite as much, but sort of early on when we weren't doing quite as good of a job in our clinic in terms of wearing PPE and protecting ourselves. I mean, there was a period where this was spreading around and we weren't all wearing masks yet. And then someone would come into the clinic, even pre operatively, and then they would get their screening test for surgery and they would come back positive, and so we'd have to go back and trace and see who they came in contact with and isolate those people and get them tested on. But I think some of these measures that we've made Thio protect our staff. Everyone wearing a mask wearing eye protection. Now, if we happen to have a patient come through the clinic before they have had a test on Ben, they come up positive. It really protects our staff. I think so. That's 11 sort of change that we've implemented that has been very effective. Um, in the postoperative period, if somebody who had a negative test gets an elective operation and somehow gets in contact with the virus and comes back positive, they still need to get their post operative care. Eso It's have to be careful in terms off, limiting exposure of our staff and the community by that now positive patient. So anything that we could do toe limit their touch points in the office, I think, are beneficial if we can avoid them coming in altogether. I think that's ideal. Telemedicine plays into that very nicely. Closing wounds with futures that don't have to be removed or staples that don't have to be removed is one potential advantage there. And as long as that person's not having a peri operative complication, just manage everything remotely until you know, they they're virus has sort of run its course, and then you can get him back plugged into the office. So, you know, I think it's important Thio to protect our staff if we don't know their status. And then, um, if they do come back positive, just try and keep them out of the office if you can. Great. Thank you to my I don't know if you've had experience with this or not and if any of the other faculty. So if I were to summarize what you're saying is that in the post operative period, if they test positive, you isolate them. Obviously put the health care workers who are dealing with that particular patient on high alert. And would you let these patients go home in the postoperative period and ask them, then quarantine in their own homes? Or do you keep them in the hospital until they terrorists, they test negative again? Um, we don't We don't keep them, um, in the hospital, we have them quarantine at home as long as they're, you know, sort of safe and doing well with the virus And don't require the elevated level of medical care for a hospital facility. Okay, so you will let them go home. Great. Thank you again, Tim. And we'll go to the next question. I'm gonna ask John Cooper to start the weigh in on this question. What changes should be implemented in the recovery room and the postoperative care of patients. What have you been doing, Janet? Colombia. So good. Good. Good question. And one that's relevant. Certainly when, when operating on patients so way reconfigured our recovery rooms to allow a little bit more space between patient days. We were already pretty close to 6 ft, but we certainly space that out a little bit more. Eso took advantage of space. It helps that are operative volume was lower than it was pre pandemic. In order to accommodate that change on gotta be careful when we scheduled surgeries that we have the number of pack you base to accommodate those patients. Uh, physically distance. Um, probably the biggest change that we made, though, is the duration of time patients spend in the pack. You we cut it down significantly. Way changed our protocols. Thio no longer require the spinal anesthesia to wear off before the patient could move on to other phase two of outpatient recovery or to the floor if they're being admitted overnight, Um, which made a big difference. We're done, you know, to about a 60 minute attack. You stay which allowed those days to be free. And and patients not the linger around, you know, exposed Thio larger group of patients coming in and out and staff coming in and out. Um, obviously cleaning protocols, the same ones that we use in the offices and the operating rooms toe really clean all surfaces and all touchpoints between patients were important. Um, and one that hasn't really been relevant thio much of what we've done. But some of the bigger spine cases. If the patient eyes intubated and has a difficult excavation, we try to do it in the operating room, um, or send them to the to the I C u still intubated rather than excavating in the pack You, which was sometimes done before we made that change. Um, in those kind of special circumstances. Great. Thanks, John. Yeah, I think we covered this previously Fortunately, most of the Arctic plus is done on the spinal anesthesia, So intubation excavations a relevant but because of the fear of their civilization of virus during intubation and exhibition that's been shown numerous studies. Obviously the anesthesia team need to wear PPE. But anybody in the room could also be subject to those air slides viruses. And because of that, this should be done in the operating room with minimum number of personal in the room present. But again, regional anesthesia is preferred whenever or if possible. Is that a fair statement? John? Very, very mind. That's almost almost 100% of our practice. Yeah, sorry. I just want to say to the were also, you know, we used to have a recovery is kind of big open day. We used to allow visitors post off, you know, to come into the recovery room every two hours and that we actually remove the visitor program. Tua's well on a everybody in a one most of you, Mike, Is it true that it says and elsewhere? Most of you call the patients on the phone? You don't go to visit the patient. I'm sorry. The patient families I should say patient families on the phone and you don't go to visit them in the in the waiting room. And most of the waiting rooms have actually been closed up. Is that true? That's correct. Yeah, are waiting? Room used to be very crowded and, you know, with the family waiting room. And we used to go back, you know, into the waiting room and speak to every patient. The way we've transitioned that now is that we actually are just calling patients on the phone. Most patients choose not to stay in the waiting room just to protect themselves. You know, we've socially distanced some chair, so if they feel comfortable, wait, they can. But most of them end up not. And so I you know, you'll get I call them on the phone. But we've also implemented a text messaging service. So the family member gets a text message. When they arrived, the recovery room and then when they transferred up to the floor. All right. All right. Perfect. Thank you, Mike. Since we have you, I'm gonna ask you the next question. Should patients were masking the postoperative period, Your independent Nick, and if so, what type. Does that really matter? Yeah, I think that the type is something we don't know a ton of information on Yeah, I think is generally recommended for the higher risk cases where they're visiting. You know, if they prefer to wear a 95 type mask, I think it may end up protecting the most. But, you know, just a regular surgical mask is always that we require at our institution. E. I think you'll see a variety of masks being worn and you know when they come back to see you. Some, some warn appropriately, and some you have to remind them that they have to pull it up over their face. But the work, um but yeah, everybody, every patient that comes back in the post operative period eyes wearing at least a surgical mask in similarly in physical therapy to we're requiring a patient's where mass during physical therapy. So if they don't have the surgical mask as soon as they enter the hospital. My hospital has thes surgical masks, and they asked all these patients who have their own homemade masks and the neck mask etcetera to discard those and where the surgical mask is it true that all of your hospitals also have similar policy? Yeah, we have the same policy. You'll see that some patients will keep the n 95 put the surgical mask on top of the n 95 which we allow them to do if they feel comfortable in n 95 mask. But, yes, we require any home clock mass that gets switched over to a surgical mask. You got it? No, thank you. That's fantastic. Dr. Melo, I'm gonna ask you this Should routinely performed post op radiographs be taken in the pack, you or somewhere else. What do you think? And what are you doing at your institution? Yeah, Thank you, Dr. Part of Easy. I mean, this is a good question. Uh, we used thio and still sometimes do routine post op radiograph in the pack you. But whenever possible, we do it in the operating room itself, or we would since usually nothing. You know, if you have nothing to be worried about, there is no need. Thio do it in the immediate post up period and we will do it at the next follow up visit. But since now our post up visit are limited because of our new reality. Now, uh, we haven't yet, uh, decided what would be the best way to do. But we certainly try Thio the consistent and to have a protocol that everybody will follow. So, uh, specifically preferable to do the post operator graph in the operating room if you need to on if it has to be done or you do it in the pack you area, then making sure that you you know all the rules that you know, we know they have to be followed. So that's where we're at now, right? Right. Great. Do anybody else do differently or do most of you agree with this statement? I assume most of you. Yeah. Yeah, we we've we've It's probably it's been an evolution, I think. When we you know, Cove in first started, we would really strict, you know, stick to this guideline and do any postoperative radiographs in the recovery room. And now that we're testing everybody pre operatively so everybody gets a PCR test prior to surgery. So we're kind of assume that most patients are are negative at the time of the operation. So we've been allowing postoperative radiographs now in the recovery room. Especially total hip replacements. Eso It's been an evolution. We started off very strict, but we've got less strict as we're testing more, our facilities are similar. Uh, go ahead. I'm sorry. Sorry. I'm just going to say that our facility is similar to Dr Crosses in that testing is really allowed us to get back to what we were doing before the pandemic with regards to our postoperative X rays. And we have been taking them in the recovery room like we were doing before, because we also have the PCR testing available. Right. So you're assuming I mean, not assuming. But you have tested those patients, and you know that they're negative for SARS. Cov too, right. But nonetheless, in the post in the pack, if they're taking all the X ray plates and the usual disinfection protocols are in place to try to minimize the risk of the spread of the virus for the next set of patients. Absolutely. Yeah. Perfect. Thank you. Great. Uh uh, Tim, we'll ask you the same. This question. Should the antibiotic of E t e prophylaxis be altered in these patients and they I'll tell you. The impetus behind us is there have been articles that show the risk of infection is higher in patients who have a source. Kobe, too, and infections with superimposed bacteria. And we also know that patients who are source Kobe to have a higher incidence of Venus stronger embolism. So this question sort of assumes that the patient hasn't been tested. Obviously have a patient who's tested and is negative is one thing. But if a patient either isn't tested or you're not sure about their status related to SARS, cov too. So could you answer this question in both ways? Negative patient and a patient that's either uncertain could be positive. What would you do for a negative patient who has been tested? I think that our best understanding would be to do what you would otherwise do in terms of your DVT prophylaxis and your antibiotic utilization. And so that's a medical decision based on your procedure and the medical co morbidity is, and I think you stick to doing um, what you do based on the literature in a patient who has not been tested and you don't know their status. Uh, my practice has been um, take a similar approach. Um, even with those concerns, I don't do anything really differently for them. You know, I don't anti coagulate them or aggressively on risk getting a hematoma or something like that, where they have to come back to the office mawr eso We have been doing basically the same protocol. Um, Mike and John Mike, do you guys do the same thing? Yeah, Way Dio. Exactly the same thing. I haven't not altered my DVT prophylaxis protocol for elective surgery patients or or the infection control protocol way put a lot of time and thoughts into designing a protocol that we thought was optimal. And because we're testing all of our patients uh, no need Thio Alter that on our end Three unknown patients again. I think testing is is critical. And if you can no patients positive before. That's great. If you're in an environment we're testing is not readily available on your operating on patients where the prevalence of SARS cov to is is, you know, is there and they're, you know, chances that you're operating on patients who are positive that asymptomatic. I think real consideration probably should be given to using it slightly more aggressive. Um, and that coagulant Thio help with prophylaxis just because of the higher potting risk that we can be there in these patients. So again, we're assuming that the patients are negative because we did cover this question. In the beginning. The majority of us test these patients prior to undergoing elective orthopedic procedures. And if they're negative, you don't alter the VT or the antibiotic prophylaxis. But if they are positive, yeah, let's assume if they are positive. Go ahead. Mike, I'm sorry. I was just gonna say I bring up the question to the group is you know, the patient whose antibody positive but pcr negative. Uh, you do. Is anything done differently? They're not necessarily Cove in 19 positive, but have positive antibodies that they've had it before. That's a great question, because you mentioned last week that your institution is testing everybody for antibodies. We're not, so we don't know. Um and I don't think a single one of my patients has, um, since I've come back has told me they're antibody positive. I'm also not asking that question. Um, but it's a It's a very good question that that Colombia don't have an answer to yet on haven't put a lot of thought into yet. What are you guys doing? Because you have that information. You know, the reason I ask is because I've had a couple of patients that were antibody positive that I then pcr negative. And then I put him on standard bt prophylaxis. And I've had to patients that have had either a DVT or pulmonary embolism. They weren't fatal, but the smaller pulmonary embolisms And then I've ended up having a re anti coagulate them with more potent agent for 3 to 6 months. So I I don't know the answer. That question. I just didn't know if anybody else was anything differently. I'm almost prone now to give mawr anti coagulation. If you're known antibody positive, even if PCR negative, just because I don't know that there's still a risk for a high risk for a lot. Yeah, we don't dio. Yeah, we don't do antibody testing either here, but it zone. Interesting question. I think that's an evolving science because because ultimately we're going to discover that a lot of our patients or individuals in the society must have being exposed to source. Kobe to without even knowing it. And the question is whether they are at a higher risk off VT during the procedure or their risk has passed because they have by definition contracted the infection and recovered from it. Great question. I'm sorry, John. Did I interrupted you. Do what? You're going to say something. No, I was going to say with, uh, you know, much like, I'm sure, many, many across the country doing Andi, You included way rich stratify patients. You know, according Teoh, one of the various algorithms, Uh, that's probably I think we actually use yours from 2016 that you published at Columbia. And, you know, about 10% of our patients risk stratified to that high risk group. And obviously, that calculator didn't include any body positive patients with SARS cov too, because that wasn't around then. But I would if I had that data, I would probably put them into the high risk category and give them a, you know, one of these novel, newer oral anticoagulants that I'm using for my high risk patients who risked ratified into that higher group. Yeah, that makes total sense. We've obviously all done emergency surgery in patients who are south Kobe to have done a couple of them. I think in these patients, I would be worried about just giving them pure aspirin. And I would put them on something a little more aggressive. But patients who were tested negative prior toe elective surgery, then I think there okay for both. Antibiotic Pra plex is a zealous VT. Great. So this is an interesting question, and very, very pertinent one, So it might spend a few minutes on this one. And I know John you published on this, and I'm glad that we've got some cases to show The question here asks, should any changes being made in the post op care protocol for patients undergoing elective Arte plastic? And that applies to just about everything there. Rehab there, uh, discharged their disposition wound care, etcetera. So why don't we have you start there, John, if you don't mind. Sure. So I mean, you're right. This is a very broad topic, and I, you know, have some slides on wound care in a minute. But I think before we get into that, there's a really important considerations about hospital stay about discharge disposition. Um, at our institution. We were about 88% of our patients after elective, our capacity were discharged home, either home with home care or just home. Um, and since we've come back to elective surgery, that rate has been 100%. I don't think we sent a single patient to a acute or sub acute nursing facility after again because of the because of the concerns for contracted covert correct because of both patient concerns and also, you know, our provider concerns. Um, it's a bit of a self selected population who is choosing to have surgery in this time. Um, but the's patients are choosing to go home, and if they're on the fence, we're pushing them strongly towards going home on. But it is not 100%. It's very close to 100% and in addition to that, are outpatient angioplasty practices has shot up tremendously. It was never something that I pushed, um, or made a priority. So it ended up for me in the 15% range of my practice, and now it's probably 60%. 65% is outpatients, um, with changes in how patients get their postoperative rehab, postoperative care. There's a lot of telehealth happening with physical therapy. There's a lot of self directed home exercises happening now, and those two things are the majority of our how our patients get their rehab. Now, Um, Aucas just came out with a nice resource for, um, both print out instructions of home exercises after hip or knee replacement on some nice videos. And so we share those with all our patients, and they have found it immensely useful in the post operative period. Way really cut back a lot from sending, uh, services home with patients where they have somebody coming into their home with them. And it's also cut back on our outpatient therapy as well, because patients are able to achieve the same goals with less touchpoints in person touch points. Great. So, John, you've done a lot of work on the wound care even prior to the pandemic. And now your work is even more relevant now. Can you take us through the risk stratification algorithms that you've developed for wound and then try to apply that into the era of the pandemics and educators on what you do right now? Sure. So So this this is a project that we put together a couple of years ago, Um, in and, you know, kind of in response to our observations that wound problems and readmissions from one problems happens. And they happen with some regularity after surgery. And if you went back and looked at who they were happening, Thio, uh, they were fairly predictably happening to patients with co morbidity these with specific vulnerabilities. And we thought, Well, gosh, if we can predicts who these patients are, who are at risk for these one complications more so than the average population. And if we have an intervention that might reduce the risk of complications and then we can overall improve our patient outcomes, decrease our ER visits decrease our unplanned readmissions in the 90 day postoperative period. Um, which was the goal of this Mainly driven by the, um, you know, patient satisfaction bundling, Um um, uh, efforts from a couple of years ago, but very relevant right now. What? We're trying to reduce touchpoints overall. So this we ended up publishing this in November 2018 in Arthur Plastic Today, which is an open access journal, so you can certainly, um, put this up in and get our paper pretty easily. Um, that Alexander Tone, who is now a resident with Dr Crossett HSS took took the lead on this on look back at, you know, hundreds and hundreds and hundreds of cases that we had done to try to find these predictive parts. Um, so we look for a lot of ah, lot of different risk factors, and from our retrospective data from years ago, we were able to identify, um, the patient co morbidity ease that put patients at higher risk for these wound complications. We were able toe come up with this algorithm, which was kind of risk. I'm sorry weighted based on these different risk factors. So, um, with b. M i and we found that patients who were both undernourished and also patients who were over nourished were rest or obligations. Um, these included, uh, obese patients, morbidly obese patients, and the risk went up with time. Uh, not surprisingly, diabetes was a risk factor. Uh, those with immunodeficiency are active smokers. Um, those who needed to be on ah, stronger anti coagulation anticoagulants. An aspirin on those who had prior open surgery. Andi found that if the risk score was greater than or equal to to that risk started to go up, and it really started to climb quite a bit after that. So we took this algorithm and we way we started applying it in 2017 where I started applying it in 2017 to my elective Arthur plastic practice. And in just a little bit over a year, um, I did 323 primary electric joints. And when I, uh, prospectively risk stratified them using this, this algorithm about a third of my patients stratified into the high risk category with two or more co morbidity. Ease, uh, two of them, about two thirds of them stratified into the lowest category on. And, um, when we had this risk stratification, we used that to determine which postoperative dressing we were gonna apply. Kind of a standard. Um, what what was our standard of care dressing, which was a silver impregnated hydro fiber dressing or a, um, negative pressure dressing, which is Ah, a more active incision management, uh, therapy, Um, certainly more expensive, But it had some good data at this time to reduce decisional complications, reduce infection rates, uh, in a number of different surgical populations. So, uh, when we did that, you can see that the risk of our wound complications in the low risk group with standard dressing was 6.5%. The risk of the wound complication in the high risk group with a negative pressure dressing was 7%. So statistically equivalent wound complication rates. Eso what? What we took from this is that, you know, taking a high risk group that historically was at a high risk ruling complications on simply doing everything is the same. But simply changing the wound dressing way were able to reduce their rate Thio that of a sort of kind of a normal population. So, John, right? So you were applying the negative pressure dressing to the high risk group and your inclusive dressing to the so called the Normal Risk Group. And here you suddenly you were able to bring the risk of, uh, wound related complications down to almost the same in both patient population. Statistically, the equivalent and the next slide shows kind of a break out of of this. So our historical data was from 2012 to 2014 and after we started stratified in 2017. You can see, looking at our total population, that risk went down. And you know, J as we all do, we all improve our practices or try to improve our practices a year over, year over year. So lots of little changes happened over this five year period. Um, so we didn't want to attribute this entirely to the dressing. Um, so way broke it out by subgroups. And if you look at our low risk group, um, who had, you know, we're getting these inclusive dressings before and after this gratification, we're still getting the same inclusive dressings. Their rate of one complications didn't change a whole lot. They improved a little bit, you know, 89% to 6.5%. But where the overall improvement came from was from this high risk cohort you'll see that are high risk. Cohort had a really high rate of leaving complications historically with inclusive dressings. And when we risk stratified them to a negative pressure dressing, um, they were effectively the same risk as any other healthy patients and the high risk group. John, just sort of recap from that slight. You showed us IBM I diabetics, aggressive anti coagulation, immune deficient patients and possibly patients who had multiple revisions in the same incision through the same decision. Multiple multiple open surgeries or active smokers, which, you know, have kind of fallen off from many of our elected practices. Right? So suddenly that creates has gone from 26% down to 7.3% which is, uh, which is fantastic. And this is old wound related complications. This is not infections. Uh, wound. Drainage is his. And this is a Yeah, that's fantastic. It's really great, Dr. Melo. The why didn't you cover the low risk patients? What are you doing with your lower space? So the high risk patients like Cooper tells us that a negative pressure dressing would really have a good benefit in this patient population. What about the regular group of patients? What are you doing for them? Yes, thank you, Doctor. Barbies. I mean, first, just, uh, quick return on the question itself, and I agree. I totally agree with Dr Cooper. I mean, post operative care protocols in our institution, and that has been probably the biggest challenge and evolution, as you all know, working in Montreal, Canada, This is a public health system. So, uh, with reviewed our protocols. And now we're what we used to be used to be a three day stay for standard total knee, our capacity procedure. Now, you know, we're down to two and further trying, you know, to reduce our length of states so early discharge is certainly really important in our new Khalid reality and everybody else that it has been mentioned regarding rehab protocol at home. And the people are asking now to go back home because of that new reality. So that certainly helps us a lot. So regarding the first case, I mean since last week session that I've received many questions in regard to our in regard to our protocol of one closer and closer addressing. So here's some brief remarks regarding that case of 65 year old female, which I did electoral near supplies, DeForest, arthritis. The only cool mobility is diabetes s O. I mean, we could argue if you know she is at high risk or not, but nothing else involved. So the first thing that I'd like you know to say as remark, is that as we mentioned last week, whatever technique of one closure you use. Make sure that you do it properly on you achieve a type closure and him most as is to prevent anyone discharge and further potential complications such as infection, as we all you know, afraid of. So this'd is this is a case I did lately and this is a type of closure now that I tend to use since our new Covic reality to decrease. As we said a touch point, the closure was done using intra operative suitors for the Arthur, Artemis and subcutaneous layer and then soup particular suitor with glue to seal the wound and stir strips and then the exclusive dressing using a particular as shown into the next short video. So the technique is quite simple technique of application that you make sure that you clip any hair for best addition that you allow the skin to dry, and then you smooth the border down of the dressing as you gently peel off the outer paper frame of the dressing and the knee right after that is ready to bend. As you can see, that dressing holds perfectly in place. And, uh, this is the only, uh, touch point that we will have in the operating room in the post op of postoperative period. Nothing else has to be done. The dressing itself allows for early range of motion. And this is certainly an excellent dressing for accelerated react protocol in Jordan in joint replacement in our capacity in the next case, Michael. Michael, do you let this booth do let these patients shower after surgery? That that's a great question. The answer is yes. So this, uh, this dressing is impermeable and but breathable. So, yes, certainly. They're allowed thio to shower, and it sticks perfectly to the skin. Uh, that, you know, we with We've seen excellent performance both for, you know, the patient and the surgeon using that dressing. So this is certainly a huge advantage. And one of the reasons why the patients, the patients like that dressing on days on for seven day, seven days, and you keep it up and then patiently tried to remove them, right? Exactly. A doctor Pervez. I mean, in the next example, case example. This is exactly what, like, you know, to show. So this is what it looks like in the post operative period for a low risk patient as we mentioned. Next slide, please. You can see what it looks like in the immediate post up and then post up the three and then at Post Update 10 at the time of dressing removal. So we keep it for 10 day. That case was done before the Cupid pandemic using staples, but the goal here is to show how the skin looks like at the time of dressing removal. There is no addition to wound non traumatic removal. Uh, you know, and the removal is done by the patient itself, as you mentioned, and the one in skin is completely dry. Eso that's it. That that that's, you know, addressing that works perfectly as specifically in the new in our new reality as we mentioned on now you've moved away from suit Staples, Thio observable futures. Uh, exactly Exactly. We tend we tend as I, as I showed in the first case. That's that's what we tend to do now. I mean, Thio have at, you know, less touch point as possible, and then you don't wanna be supreme. The patient back to the office for removal of Staples or have a nurse to go visit them. Great, Perfect. So we've covered the high risk group. John Cooper did a beautiful job of telling us who those are you giving us your wound? Closure and dressing. And now we have Tim talk about Praveen A in search of management. Thank you, John and Michael. Thank you for sharing. I've always learned from you guys hearing you talk, So I appreciate that information and what I have here is a case example of what I think John would classify as one of the high risk patients and something that I've had a lot of success with, similar to John in terms of managing their soft tissue on envelope. Just wanted to add a couple of things that I think are the take home points for my practice. How it's changed in this post, um, cove it era. The first thing is similar to the other speakers. We really try to not send people to skilled nursing facilities. Keep that rate is close to zero. It's possible we've limited the postoperative visitors as well in the hospital so that our elective Arthur plastic patients go to a specific ward in the hospital. They're allowed one visitor for a short period of time. There's no re entrance back onto the word, so they really limited not only shortening their stay but the number of people who come to the ward with them as well. Total hips. I try not to send them to physical therapy at all and have them do some basic exercises that we created with similar resource is to the Aucas Resource that John mentioned, Um, and then also pretty uniformly do a two week telemedicine visit. Now we have a lot of those visits with our physicians assistance. And so we tell people from the beginning because of Cove it because we don't want you to be exposed. We're going to do a telemedicine visit for your follow up, and that's been pretty uniformly adopted. And people are pretty amenable to that. I'll still see people back in the office at six weeks from time to time. Or obviously, if they have suitors that need to be removed, we'll see them back in a limited fashion. Um, s O. This is a 56 year old lady with a very large B m. I pushing 70 with just a horrible, horrible knee. You can see her soft tissue envelope there, Um, in the X ray, You know, you examine this me and you're not sure if it's stable various in August because you can't hardly even feel because this off tissue envelope is so large and she wanted to have a knee replacement. You'll see on the next slide that she has a large soft tissue envelope and she says, Yeah, Doc. But look, I hadn't done on the other side, and I made it through. So don't tell me that you're not going to do it because of my b m I. So we elected re elected to do it and, um, way put on the restore, addressing just, you know, further X rays here showing showing the arthritis. And this is the dressing here, the restores the larger sponge. And so this is the negative pressure addressing that you apply to your closed incision. And for these patients, I close in a similar way that Michael suggested with are throwing me closure with either symbols or like a running barbs future and then closing layers. And I use a running some particular future and then underneath of this dressing, there's just a thin layer of skin glue protecting the incision. And the thought here is that that dressing the large volume on surface area of that sponge covers the knee and not only splits the skin but potentially opens the lymphatic and helps get some of swelling out of their improving profusion to the skin edges on dso. The other picture there. It's just the appeal in place provisions that just covers the incision. All this trying to sort of altered that biology and decrease some of these soft tissue complications. So that's what I used before was just appealing place. Wanna now gone to using this Arthur form on? I've had really, really good results with it. You know, patients, uh, tolerated quite well. They shower straight away, and they're able to take it off themselves a t appropriate time because it is basically just a large bandage just stuck on there. And that's something that will cover with them via Tele Medicine. And they can shine their camera on the dressing, and we can talk him through it if needed. But I have seen similar results to what Dr Cooper described as well, and that's what I saw what this lady as well. Um, she had her two week visit, was doing fine. And then by six weeks, you know, she was feeling great, and we'll see that, you know, her soft tissue envelope healed up and sealed up quite nicely. So I think it is a powerful tool Thio use not only for you know, these high risk patients, but also especially, I would say, in this covert air where you really focus on decreasing touchpoints, decreasing wound healing problems on do those things that make folks come back to the office more frequently. So, Tim, can you tell us, how long do you leave the sun and does the patient remove this at home? Or do you have to send somebody to do this for them? Yeah. So the address of the indication for the dressing is that it stays on for seven days. And so I have two classes of patients. I try to sort of coach them up, if you will, pre operatively. And in the postoperative period, when they're in the hospital, I see them how easy it is to just take it off yourself. And I get pretty good buy in from patients and just explain to them that it's like a large Band Aid, and it just peels off. Just Aziza Lee s. So a lot of people are comfortable doing that with the telemedicine phone call. Some patients aren't, and those patients come into We have a cast room, and so we can have them come see one of the technicians in the cast room for addressing removal. If they would like to come into the office toe, have assistance with it. Okay. Great. Great. Perfect. Perfect. That's fantastic. Thank you. Again. Yeah. B m I of 68. I weight 68 kg A b m i. Well, if you need your knee replaced, come on out to Seattle Will take care of Yeah, that's, uh, e have got up to 75 kg. You in the cove? It developed, but yeah, that's that's 11 large b m I. That's fantastic. Good for you. That's great. So, Mike cross, we're gonna ask you the 7th 7th question. What consideration? Thank you, gentlemen. Really great about wound care because that's one of the major issues that we have to deal with. The majority of the readmission emergency room visits re operations are wound related. So that's why we have to spend a couple of minutes to really cover that area. And I think you did a beautiful job. Thank you again. Really? Great. So, Mike, what about insects and seeds and patients undergoing elective surgery during Cove It Are you worried about this? Is there an issues here or or or what? What do you do? You know, it's a good question. I think that, you know, in the cove, it first. Yeah, There. When? When Kobe first came about, there was a lot of concern for insects and, you know, now again, because we're testing everybody he patients that are getting elective surgery, a pcr negative. So I'm still using instead a post up for part of my multimodal pain. Now, patients that air pre op that air taking long term headsets pain if they have a high risk or if they bring it up to me at all of our concerns are concerned about it. I say, You know, the safest thing is, if you're concerned to just stop it. But this is one situation where I don't think there's great data more than a lot of misinformation floating around in the media but post op as long as the negative, Then I I still using it. And I assume Brian says this also includes aspirin. Like Mike. Fair to say, you treat them the same way. If they were in an aspirin, you know, e and anti plate e. Okay. Yeah. So instead, the typical insects, the classical and sets the cox one inhibitors cox two inhibitors, the selective non selective ones and even anti platelets like aspirin and Plavix. All the same, you would not shy away from using these either as part of your anti coagulation and or your multi model pain management. Is that fair? Okay, that's correct. Especially E r. Because they all test negative for service. Yep. That's great. Perfect. Fantastic. I think we've come to the end. Gentlemen, you've done an amazing job. It's been a pleasure sharing three of these modules with you. I'm going toe sort of get a little bit of, uh, I'm gonna miss you next week. This time I will probably call each one of you and have a beer with you over over the webinar. And again Casey I three and has done an amazing job of supporting this educational activity. Boom, Eddie. Incredible job. Everything seamless even for illiterate people like myself. They made it so easy. So we have a few minutes for question and answer. If there are any questions from the crowd would be glad to answer them. Um, if not, I think we will probably, uh, call it today. Here. Uh, Janine, I don't know if you have any questions that you have seen. I have not seen keeping a tab on the questions that have come through Dr Corvis. 111 last common, I think. You know, as I take a message, you know, everybody you know would agree. And that's all you know. We emphasis, you know, we put emphasis on I mean, whenever possible. I think every every patient thio for to resume elective elective surgery should be tested pre operatively. And I think this is probably the most important and one of the main take home message regarding, you know, our three sessions. Thank you very much. Yeah. Oh, Mike. Alexa. Great. Thank you. So we had three modules and they're all obviously going to be available on Humadi for anybody and everybody to review, But As you said, we cover the preoperative issues in the first module. Intra operative matters during the second module and now the postoperative. And you gentlemen were incredibly engaging. You had amazing insight. I enjoyed working with you. I've learned a huge deal from you, as always is the case. And I think if there are not any questions, we'll stop here. And I'm gonna wish you a great evening. And I hope you will all do well. And now I have to go back to the hospital to deal with the complication. All the best, gentlemen. Thank you very much. Good night, everyone. Thank you. Good night. On behalf of three AM, I'd like to thank doctors, part of easy Dr John Cooper, Michael Cross, Tim Alton and Michael Mellow for sharing their expertise and insights with us today. And also thank you to our attendees for being part of this program. You have any further questions? Please email them to medical education. Webinars at m m m dot com. Please provide us your feedback in the short survey that's appearing on your screen. Now this helps us understand your thoughts on the program as well as needs for potential future programs. Thanks again to the panel as well as all the participants for taking the time to join us this evening. Good night. Yeah. Published October 8, 2020 Created by