KUALA LUMPUR, April 26 — Subang Jaya Medical Centre (SJMC) consultant orthopaedic surgeon Dr Siva Kumar Ariaretnam talks about SJMC’s breakthrough total knee replacement operation.
Are you excited about being the first in Malaysia to do a daycare total knee replacement?
I have been doing fastrack total knee replacement (TKR) for about a decade now consistently, so daycare surgery is just a validation of a whole process of improving outcomes. TKRs have evolved ever since I started doing them, in ways that I would never have imagined and I’m happy to be a part of evolution.
What is fastrack knee replacement?
Fastrack TKR basically gives the patient the ability to walk within a few hours of surgery and even climb stairs the same day.
This also culminates in the ability to walk quicker and return to work and activity sooner after surgery. Daycare surgery simply means that in addition to this the patient is admitted and discharged the same day.
As I understand, knee replacements are very painful, and they often need injections to control the pain of surgery. So how is pain controlled with fastrack TKR?
Yes, they are indeed painful procedures. The way I initially did them almost 20 years ago, the pain had to be controlled with various injections and the patient was on a knee immobiliser for 24 hours at least and made to walk (with a lot of difficulty) one to three days after surgery. The knee was bent and extended slowly on a continuous passive mobilisation machine known as a CPM.
These days, some patients operated on in the morning are able to walk by lunchtime and climb stairs by evening. They bend their knees as they are being wheeled out of the operating theatre. I do not remember using a CPM machine in the last 10 years.
So what has changed in your practice to allow you to do this?
The surgical approach, for one thing. 90 per cent of surgeons around the world use a gold-standard muscle-splitting approach to the knee. This is what I used in the first 10 years as well.
Now I use a muscle-sparing approach to the knee such that the muscles are retracted for the most part instead of cut to do the surgery. This greatly reduces the pain and allows rapid recovery and return to function after surgery.
I have developed a novel wound-closure technique I’m particularly passionate about. It’s flexible enough to allow full knee flexion (bend) immediately after surgery without giving way but robust enough not to result in wound dehiscence or breakdown after surgery.
Then, there is the ever-important factor of pain management. The pain is greatly reduced firstly by the surgical approach itself.
Secondly, I was fortunate enough to spend a year of fellowship training at one of the foremost joint-replacement centres in North America that has published extensively in periarticular injections in the knee to control pain after surgery. This involves not only the “what to inject”, but the “where and when to inject it”.
Last but not least is the management of bleeding and blood loss. This is important if you intend to send patients home early.
It would be disastrous if a patient goes home and has to be rushed back to the hospital at night for bleeding from the wound. In fact, this has also reduced my need for blood transfusion.
Now I can consistently say that I would not likely have to transfuse anyone with a starting haemoglobin level of 12g/dL, even for those with bilateral knee replacements.
Besides the reduction in pain and early return to function that you mentioned, do you anticipate any other benefits from making patients walk early?
Yes, in fact, one of the biggest benefits of early mobilisation is the reduction of some of the most dreaded complications of surgery which involves getting blood clots in the deep veins of the leg after surgery.
These are deep-vein thrombosis (DVT) which could also lead to the rare complication of pulmonary embolism (PE) which could lead to death.
In fact, I was involved in a significant study 15 years ago when I was doing another hip and knee fellowship in Sydney, Australia. We basically showed that if a patient was made to walk within 24 hours of a TKR (the morning after), the risk of developing DVT was significantly lower than those who walked more than 24 hours after surgery.
Also, those who walked at least five metres on the morning after had no DVT in the study population. I have since succeeded in making patients walk more than five metres and climb stairs within hours of surgery.
What made you so passionate about early mobilisation and fastrack TKR?
Initially, it had everything to do with pain. I was equally pained when I saw my patients in pain.
The worst hit I got to my confidence as a young surgeon was when a patient declined having her other knee replaced. She thanked me profusely for the first one, but said the pain was worse than childbirth, and the thought of going through that again itself could kill her.
I really took this badly and had to reflect and question my role as a surgeon. Then, about a decade later, I started treating a fair number of overseas patients. These patients wanted to return home early.
So, I had to ensure they didn’t have issues with pain and their wounds. Hence my quest to find the perfect wound closure.
I even use dressings that patients could remove themselves without needing to be changed, and skin closure methods that could just be peeled away without having to visit a doctor and have stitches removed.
Do you anticipate that many will opt for daycare knee replacement surgery?
No, since most patients want to stay for a few days after surgery. But I do get requests especially from self-paying patients coming for their second knees who ask if they can go home the same day because they found the other one or two days in the hospital redundant, and they could rest at home and save costs.
The hospital management back in the day did not allow admission on the morning of surgery and discharge on the same evening, more as a safety concern. So I admitted them in the morning, operated after lunch, walked them myself after dinner, and got the physio to get them to climb stairs the next morning and off home by noon!.
And I have been doing this for some patients for the last five to eight years. It is only since they have realised that daycare surgery is being done in some parts of the world, was I allowed to do this.
Also, it took some very forward-thinking administrators to get the infrastructure and the licensing for Home Connect; our in-house home-care nursing team I liaise with for my daycare patients for home visits the morning after.
They would visit them and examine the patient and organise a video-consult with me to speak to the patient and ensure that the patient is well and totally satisfied with the treatment and progress.
Is this a one-man show, or do you rely on a team to help manage your daycare knee replacements?
Absolutely not. I totally rely on a team, without whom I would not be able to do this.
Firstly, as I have mentioned, was forward-thinking administrators. Hospital managers are often unfairly criticised for being profit-driven, but I must say mine were willing to put a lot of cost losses aside to allow this project to take off.
And the Home Connect team I work with has been absolutely fantastic in connecting with my patients. My fabulous physiotherapists who visit my patients and are confident enough to take my patient for a walk along the corridor and up a flight of stairs and back.
And last but not least is my anaesthetist who is able to consistently wake my patients up after surgery looking and feeling fresh and not having post-operative nausea and vomiting (PONV).
In the past, one of the major deterrents for patients walking immediately after surgery is severe PONV, and of course, this will derail any plans of sending patients home early.
You spoke a lot about people and techniques. Do you use any of the new advances in technology to improve outcomes of surgery?
I am a cautious technophile. It’s important to know that tech is industry-driven.
I didn’t buy into computer navigation in the early years after doing a handful of cases because I found the risks outweighed the benefits. At the end of the day, I am responsible for my patients.
I did, however, adopt patient-specific instruments early, and was the first in the country, and possibly the region to do it. Similarly with other technologies I weighed the pros and cons and made a decision in the interest of my patients.
I am happy to say that I developed my fastrack surgical protocol using conventional surgery alone. However, I am now excited to have adopted robotic surgery (in its current form) in a big way.
I can see it improving outcomes significantly. In addition, I am able to do a lot of niche partial knee replacements that have been dormant in my armamentarium over the years only to be resuscitated with robotics.
While TKR should only be considered for those with end-stage arthritis, it is not the only solution for end-stage knee arthritis.
There are the various partial knee procedures and for those intending to continue to be physically active, there are joint-sparing surgeries even in end-stage arthritis.
Again, there are multiple robotic platforms out there but it’s important to choose the right one for my patient.
Do you think robots will allow surgeons to do fastrack TKR?
No. As I said, fastrack TKR is a culmination of surgical techniques from surgical exposure, soft-tissue balancing, pain management, controlling bleeding, wound closure, and even minor things like dressing materials and methods.
None of this is contributed by the robot. However, robots in TKR enhance the outcome of surgery. It is a useful tool in the hands of an experienced TKR surgeon.
Do you think robots are going to be a big addition to the knee replacement armamentarium in the future?
I think they will eventually. I am happy to have been introduced to the robot at the stage of my practice when I have more or less worked out everything else before I resort to using robots. Robots are only useful in making accurate bone cuts.
One of the founders of total knee replacement surgery once said “a knee replacement is a soft-tissue surgery with incidental bone cuts”. This is absolutely true.
As a surgeon, I can cut the bone accurately, but if I can’t balance the soft tissue, the outcome could be disastrous.