Kessler Institute

Cutting-Edge Joint Replacement and Rehabilitative Surgeries

Surgeons are combining advancements in technology with new approaches to care to provide more precise joint replacements and effective, patient-centered rehabilitation services.

There was a time not so long ago that a hip or knee replacement meant days – or even weeks – of recovery in a hospital or rehabilitation center. But thanks to today’s cutting-edge technology and advancements in joint replacement procedures and rehabilitative approaches, New Jersey’s hospitals are helping patients return to their lives faster than ever before.

“Interestingly, the actual surgery is very similar to the surgery that was done 15 years ago, but surgical implants have improved significantly … especially regarding how the implants move against each other,” explains Dr. David Rojer, medical director for the joint replacement center at Robert Wood Johnson University Hospital (RWJUH) in Rahway. “In the past, the metal and plastic pieces for the hip replacement wore out much more quickly, but over the past decade, we’ve seen dramatic improvements in the types of materials we’re using, specifically with high-grade plastics and specialized ceramics.”

Joint Replacements That Last Longer

For many patients, that means earlier interventions are now possible when hip or knee joints are preventing them from living their lives to the fullest. According to Jim Dunleavy, doctor of physical therapy and director of rehabilitation services at Trinitas Regional Medical Center in Elizabeth, the advancement of the prosthetic components has also significantly impacted how long they will last.

“Historically, surgeons tried to delay a total hip or knee surgery as long as possible so that a patient wouldn’t require a revision surgery later in life when a prosthetic component would inevitably wear out,” he explains. “Now, we’re able to offer the surgery to people much earlier in life because we’re very hopeful that these new metals and plastics will last much longer.”

Robotic Technology

Along with an improvement in materials, one of the most cutting-edge advancements is in the field of robotics, which is also allowing both patients and providers to have the peace of mind that a surgery will last for the duration of a person’s lifetime. Saint Peter’s University Hospital in New Brunswick is one of the state’s hospitals that’s already home to a robotic system – the NAVIO Surgical System – to assist surgeons during the procedure.

“The surgeon is still performing the actual operation, but the use of robotic devices allows us to be more precise,” explains Dr. Alfred J. Tria, chair of orthopedic surgery at Saint Peter’s University Hospital. “Precision will make the replacement last longer and allow the patient to have a quicker recovery – in fact, we anticipate that today’s joint replacements will last 30 years.”

At St. Joseph’s Health in Paterson, a robotic device called the Mako Robotic-Arm Assisted Surgery, which was acquired via nearby Stryker in Mahwah, is also helping surgeons provide enhanced precision, both in how the surgery is completed as well as in the planning process. Dr. Vincent K. McInerney, program director of the orthopedic residency program at St. Joseph’s Health, notes that in a total hip replacement, often the most difficult part of the procedure is the cup in the pelvis because it’s reliant on each individual’s spine and knee configuration. The knee also poses challenges because traditional replacement procedures often required the use of bone cement, which tends to break down over time, he notes. “Robotics takes the question mark out of a lot of these variables, and has allowed us to provide surgeries with incredible accuracy,” McInerney adds.

According to Dr. Greg Klingenstein, joint replacement surgeon at Marlton-based Virtua, the latest advancements in robotic technology have also allowed surgeons to provide customized surgeries with more precise leg alignment and knee tension. “With traditional cutting guides, we had one goal: Do our best to get it straight. But robotic technology has opened up all sorts of options for restoring the patient’s anatomy, and as you can imagine, having a robot resurface the bone is always going to be more accurate than trying to do it freehand.”

Minimally-Invasive Options

Virtua has been offering minimally-invasive total knee replacements for the past decade, and the hospital is now able to incorporate new technologies to improve results. For hip replacements, the use of computer-navigated surgery allows providers to attain a CAT scan of the hip with a three-dimensional model weeks prior to surgery. “I can plan out the surgery on a computer screen ahead of time – so there are no surprises once we’re in that operating room,” Klingenstein adds.

Surgeons are also utilizing a technique known as SuperPATH, which builds a traditional hip implant in place without cutting the surrounding muscles and tendons – and doesn’t require the surgeon to have to dislocate the hip during surgery. “There’s been a significant evolution in what we were able to do in previous years; patients can expect accurate, safe, reliable joint replacements because now a lot of the guesswork has been taken out of the equation,” Klingenstein says. “As a surgeon, everything I do is for the benefit of the patient, so these technologies give me the confidence that I’m doing the right thing every single time.”

Shorter Recovery Times

According to Dr. Rojer, the biggest improvement that providers are seeing post-surgery revolves around pain and bleeding control, swelling control, and early mobilization. RWJBH’s current pain control injections as well as pre-emptive anesthesia medications and post-operative pain medications allow patients to start walking within two hours of surgery with very little pain for the first 24 to 48 hours, and without the use of pain pumps, he says. As a result, more than 90 percent of patients are able to go home within two days.

“In the past, patients used to stay in bed much longer because they were in too much pain to ambulate, which led to an increased risk of blood clots and pulmonary problems. We control pain and mobilize patients sooner, so we don’t need to use blood thinners,” he explains. Now, he says, they’re able to use mechanical prophylaxis and low-dose aspirin. “With our new pain management protocols, we’ve been able to get 95 percent of our patients to stop using all narcotics by two weeks,” Rojer adds.

By using the latest medication and modern surgical coagulation devices to control bleeding, RWJUH has been able to lower its transfusion rate to less than 1 percent in patients who start with a normal blood level, and an advanced incisional wound system and plastic surgery closure has decreased the infection rate to less than 1 percent. “The major change is timing,” asserts Dr. John Schnell, section chief of orthopedics at RWJUH in Hamilton. “Because these procedures have become less invasive, and less painful, we’re able to begin the rehab process sooner and get the patient back on track to normalcy.”

Rehabilitative Care

In addition to the advancements in the actual surgery, the Garden State’s healthcare networks and rehabilitation centers are offering new approaches to the rehabilitative process.

Dr. Bruce Pomeranz, senior medical officer at the Kessler Institute for Rehabilitation (West Orange, Saddle Brook, and Chester), notes that rehabilitation services are still provided post-surgery at the patient’s home, in a nursing home, or in a rehabilitation hospital, but today’s approach increasingly focuses on tailoring the best options for each individual patient after his or her surgery. “It’s an approach where patients work with a surgeon and other members of their healthcare team to determine what’s best for them in terms of their care, which may include their overall health status, personal goals, and potential risk factors,” he explains. “It’s all part of our strategy to make sure patients regain their independence and enjoy the best outcomes as quickly as possible.”

In addition to a more customized rehabilitative process, the state’s healthcare networks have also placed a higher priority on getting patients up and out of bed as quickly as possible – an approach that benefits the patient, but that may also be driven, in part, by insurance limitations, notes Dr. Anthony Delfico, director of orthopedic surgery at The Valley Hospital in Ridgewood. “Most clinical research shows that patients do better when they’re forced to get up and move sooner, so as opposed to hospitalization and lying in bed and waiting for people to help them, patients are sent home where they have to help themselves, which has led to a lower risk of issues such as infection, blood clots, and bed sores,” he adds.

In many cases, patients are able to have their surgery in the morning and start walking later that same afternoon, before being sent home the following day. Along with many of the state’s hospitals, Valley offers patients the flexibility to have in-home physical therapy first, before seeking outpatient options.

“Now, it’s all about the patients taking responsibility for their own recovery. They need to set their own goals, because with the information and support we give them, they will be the ones who need to make it happen,” explains Dr. Michael F. Harrer, a board certified orthopedic surgeon who performs total hip and knee surgeries at the hospitals and surgery centers at Voorhees-based Jefferson Health.

To that end, surgeons are relying not only on new technologies for joint replacements, but a new approach to care that encourages patients to advocate for themselves when they’re not meeting their goals or making decisions about when they no longer require pain medication.

“Rehabilitation is always about helping patients recover, but the No. 1 goal is patient satisfaction,” Harrer concludes. “Undergoing a joint replacement surgery is a monumental decision that patients should never take lightly, so everything we do is about improving function and ensuring that our patients are happy and doing well.”

Englewood Health’s Interdisciplinary Approach to Orthopedic Care

Healthcare provider also earns recertification for total hip and total knee replacement.

For the majority of patients, general musculoskeletal injuries take about six to eight weeks to heal, but proper pre- and post-operative orthopedic care can significantly expedite the healing process. Over the past five years, Englewood Health has taken significant steps to improve quality of life, minimize pain, and maximize mobility for patients needing a hip or knee replacement or spinal surgery. To achieve these goals, the health system, comprising Englewood Hospital and the Englewood Physician Health Network, has committed to an interdisciplinary approach.

In 2016, Englewood Health launched the Comprehensive Joint Replacement Program, a Medicare-initiated care model that supports better and more efficient care for patients undergoing hip and knee replacements, the most common inpatient surgeries for Medicare beneficiaries. Bringing together representatives from 15 disciplines, the model encourages hospitals, physicians, and post-acute care providers to work together to improve the quality, safety and coordination of care from pre-surgical assessments to hospitalization and through recovery.

“Within 18 months of the program’s inception, the number of patients discharged from the hospital directly to their homes increased from 15 percent to 56 percent,” says Stephen Brunnquell, MD, president of Englewood Health Physician Network. “In the second year of the program, our complication rate was zero percent.”

In the same year, Englewood Health earned recertification by The Joint Commission for total hip and total knee replacement, and became the only hospital in New Jersey to be Joint Commission-certified in spinal fusion. Englewood Hospital also expanded its main operating room with four new state-of-the-art operating rooms dedicated to orthopedic and neurological surgery. 

Asit Shah, MD, PhD, chief of orthopedics at Englewood Health, says his team is constantly following the latest improvements in engineering. “Robotics are making their way into orthopedic surgery more and more,” he says. “And technology is constantly enhancing in-office optics and diagnostics. There are also new materials being introduced. Components like bond materials and artificial cartilage are definitely enhancing.”

Atlantic Health System Expanding and Excelling in Rehab Care

New facility and CMS reimbursement reveal dedication to patient care.

Morristown-based Atlantic Health System and Kindred Healthcare recently broke ground on the Atlantic Rehabilitation Institute, a modern, state-of-the-art inpatient rehabilitation facility in Madison. The institute, expected to be completed during the second quarter of 2019, will be a two-story, 38-bed rehabilitation structure that will provide patient-focused rehab care dedicated to the treatment and recovery of individuals who have experienced a loss of function from an injury or illness.

It will feature all-private rooms, a secured acquired brain injury unit with private dining and therapy gym, large interdisciplinary gyms, a therapeutic courtyard with golf, basketball and varied surfaces, a dialysis suite, and will offer specialty programs dedicated to neuro, stroke, brain injury, spinal cord injury and amputation. The building will also include a transitional living apartment designed to simulate a residential apartment, to prepare patients for their daily living tasks before they are discharged home.

“Our focus is expanding accessibility to high-quality healthcare for our patients,” said Amy Perry, senior vice president, Integrated Care Delivery and CEO of Atlantic Health System’s Hospital Division. “The combination of Atlantic Health System and Kindred, in a modernized, convenient location, puts top-caliber rehabilitation services within the communities we serve.”

Earlier this year, Atlantic Health System’s Morristown Medical Center received the second highest reimbursement in the country for its year one performance in the Centers for Medicare & Medicaid Services (CMS) Comprehensive Care for Joint Replacement (CJR) model. The reimbursement is based on quality and safety.

Under a program launched by CMS in 2016, hospitals performing hip and knee replacement surgeries were financially rewarded based on how well their patients did. For example, hospitals were reimbursed at a higher rate when patients were not readmitted to the hospital for complications related to their surgery, had the support they needed to recover well, and were able to return home quickly.

“Our team at Atlantic Health System completely redesigned the way we care for our patients undergoing hip and knee replacements, from the time the patient and doctor make the decision to proceed with surgery through recovery,” said Steven Maser, MD, medical director, Orthopedic Surgery, Atlantic Health System. “By taking a critical look at what a patient needed and working in tandem with the patient’s family and all of the medical professionals involved in care – nurses, surgeons, patient care navigators, skilled nursing facilities/rehabs, and at-home nursing care – we were able to develop a new model that streamlines care to ensure quality, and is more efficient.”

Four Atlantic Health System’s hospitals – Morristown Medical Center (which has the seventh highest CMS volume in the country for joint replacement surgeries), Overlook Medical Center, Chilton Medical Center, and Newton Medical Center – participated in the program.

The largest shift in the standardization of care was sending appropriate patients home to recover, versus the standard practice of sending them to rehabilitation or a skilled nursing facility. Under Atlantic Health System’s new model, there was a 117 percent increase in patients discharged home. 

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