BlueCross BlueShield PPOs, Aetna, Cigna, Oxford, United Healthcare, Medicare and Worker’s Compensation.
Unfortunately, because of the lack of standardization of x-rays in many physician’s offices as well as radiology centers, the quality of many x-rays that are performed do not allow visualization of the critical structures that are essential in order to make an accurate diagnosis. In addition, many of the x-rays that are taken here will be used as part of your preoperative planning should you ultimately decide to go forward with surgery.
The typical time period from evaluation and a decision to go forward with surgery and the date of surgery is approximately four weeks. During this period of time, insurance approval, authorization, pre-surgical planning, preoperative evaluation by one of the internists located at HSS as well as preoperative lab work all needs to be performed prior to the surgery. All of these steps typically take approximately three to four weeks following the consultation.
Unfortunately, the answer to that question is no. While we greatly respect the caliber of many physicians outside the HSS family, preoperative medical clearance must be done by one of our own physicians who will be available during the time period of your surgery and for the several days following the surgery should there be any need for urgent medical consultation.
Most laboratory studies and x-ray studies are performed and interpreted within 48 hours after the study is complete. However, each of these studies needs to be reviewed by our professional staff and at that point the results will be transmitted back to the patient within approximately four or five business days.
Dr. Padgett performs over 350 total hip and total knee replacements per year. Dr. Padgett has been in clinical practice for almost 20 years and has been a staff member at the Hospital for Special Surgery and attending surgeon since 1994.
Dr. Padgett performs all of his own surgeries and is present in the operating room from start to finish. However, being in a teaching institution, there will be orthopedic surgical trainees present and assisting in some of the surgical procedures as well as in some of the aftercare.
Following discharge from the hospital, patients are routinely seen at the six-week visit with another follow-up visit at the three-month visit after surgery.
Regarding both hips and knee replacements, the type of implant that is chosen to be used in any particular patient is based on the number of variables including patient’s activity level as well as their bone anatomy. In general, our priority is to try to mimic each patient’s own natural anatomy and match that for shape and design so as to replicate patient’s normal functional activity.
Typical orthopaedic implants are a combination typically of either a metal or ceramic on a polyethylene bearing. For hip replacements, the component which is inserted into the femur known as the stem may be either a titanium porous ingrowth prosthesis or a cemented prosthesis. The porous prosthesis requires a period of time for the bone to become attached to the implant to provide secure fixation and this process can take anywhere from four to six weeks. Cemented femoral components in total hip replacement are typically used when the quality of the patient’s bone is somewhat weakened and the predictability of bone ingrowth is somewhat lessened. The outcome of both of these types of fixation methods is excellent and the decision to use one over another will be based on patient’s own variables including age and quality of one’s bone.
Knee prosthetic devices are a metallic alloy which is placed on the end of the femur and a medical-grade plastic (polyethylene) placed on a metallic platform which is placed onto the tibia bone. In essence, this becomes a metal and plastic resurfacing of the end of the femur and the upper part of the tibia bone, the two big bones that make up the knee joint. Shape and specific design is again tailored to the patient’s own unique anatomy.
The most exciting news in joint replacement has been the development of improved bearing materials that began at the start of the new millennium. The new bio materials consist of improved medical-grade polymers known as polyethylene which have been in use since approximately the year 2000. Data at this point suggests minimal evidence of wear at 16 years after surgery in both hips and knees and would suggest that we are now optimistic about the prospect of joint replacement lasting decades.
Dr. Padgett does not perform hip resurfacing
Dr. Padgett has had past experience using in the anterior approach when this was employed in his practice several years ago. After using it for a period of time, he made the decision to abandon this approach and return to the posterior approach based upon his observation of no significant difference in patient outcome and many of the patients undergoing the anterior hip approach suffering from temporary or in some cases permanent loss of sensation on the lateral aspect of their thigh. These observations have been reported by other surgical centers and beyond six weeks all have confirmed there is no difference in impact on surgical approach in the eventual outcome following the surgery.
The overwhelming majority of patients will receive a spinal epidural for anesthesia. This will be administered by one of our highly trained anesthesiologists who are medical doctors who specialize in regional anesthesia. In rare instances, general anesthesia will be performed in a small number of patients who have had extensive prior spinal surgery.
Over the past several years, it has become increasingly apparent that inpatient rehabilitation is not required for the vast majority of patients. Recently performed study at the Hospital for Special Surgery evaluated the outcomes of patients discharged to home with home rehabilitation versus those discharged to an inpatient rehab facility and we were able to find no difference in any outcomes and, in fact, the patients that were discharged to rehab had a higher incidence of complications. We typically advise most people to go directly home following either hip or knee replacement and arrangements for visiting nursing services (VNS) as well as home rehabilitation will be made prior to discharge working with our discharge planning group here at HSS. Specific questions regarding aftercare may be directly addressed to our department of social services here at HSS and their phone number can be found on the website.
Despite improvements in total joint replacement, some patients ultimately will require revision. There are a number of reasons why patients undergo revision ranging from infection, breakage of the bone, loosening of the implant, instability, as well as conditions related to sources of unknown pain. The evaluation of a patient with a painful prosthesis involves a number of steps including a rigorous review of the patient’s history including when the pain developed, when the implant was inserted, thorough review of the operative report and postoperative recovery as well as an assessment of the patient’s current level of disability. In addition, old as well as new radiographs are required and then finally workup performed at the hospital including blood tests, advanced imaging such as CT scanning, MRI as well as possible aspiration of the joint which is removal of any possible fluid around the prosthetic implant to assess for possible infection.