By Cari Wade Gervin
Monday, November 2, 2020
Andrew Wickline, MD, FAOSS, FAAHKS, uses a joint replacement program that minimizes opioid use to promote holistic healing and better outcomes.
Andrew Wickline, MD, with a robotic surgical system. He is now also using a different type of technique called kinematics alignment for personalized fit. The negative to the robot is that it shoe horns people into the same size fit no matter what their pre-existing pre-arthritic alignment was. Kinematic alignment allows for that. Genessee Orthopedics will be performing a trial of an augmented reality system in the near future.
Total knee replacement is one of the more painful surgeries.
“My patients used to say, ‘I’d rather have another child than do this again,’” says Andrew Wickline, MD, FAOSS, FAAHKS, an orthopedic joint reconstruction specialist at Genesee Orthopedics & Plastic Surgery Associates.
The level of pain associated with a total knee replacement typically results in a large prescription for narcotic pain medication post-surgery. With opioid use and addiction up across the state, however, Dr. Wickline created a different approach for his patients. He now uses multiple non-opioid choices and a game-changing home therapy plan he created.
“There’s somewhere between an 8% to 14% risk of permanent opioid addiction after a total knee replacement for a patient who didn’t use opioids before,” Dr. Wickline says. “That’s at least eight out of 100 people or at least 50,000 people a year nationally. That’s a frightening number.”
Dr. Wickline
“There’s somewhere between an 8% to 14% risk of permanent opioid addiction after a total knee replacement for a patient who didn’t use opioids before.”
— Andrew Wickline, MD, FAOSS, FAAHKS, orthopedic joint reconstruction specialist at Genesee Orthopedics & Plastic Surgery Associates
The Problem With Opioids
In 2018, opioids were involved in almost 47,000 overdose deaths — 69.5% of all drug overdose deaths. Although New York has not been hit as hard as some other states, the problem continues to grow.
“Once you become an opioid user, you end up costing the medical system double the average amount of cost for a year,” Dr. Wickline says. “For commercial payers, for example, the average cost is around $11,000. But if you’re an opioid user, it goes up to almost $20,000.”
Even just a 24-hour prescription of narcotics has a 6% risk of chronic opioid addiction. So, after studying the issue and working with patients, Dr. Wickline published a study — 23-hour TKA in 10 Opioid Pills or Less Through 90 Days: A Non-Selected Prospective Consecutive One Year Cohort — earlier this year outlining his approach.
Dr. Wickline (center) with Uday Myneni, MS, MBBS, MCH, and his resident team at the first annual arthroplasty conference in Hyderabad, India. Dr. Wickline performed the first anterior hip replacement with the HANA table, televised live to over 400 surgeons.Dr. Wickline’s Study
Published in the Journal of Orthopaedic Experience & Innovation in July and co-authored with Maryann Stevenson, RPh, the study focused on 386 patients who underwent a total knee arthroplasty (TKA).
During a four-month period, the patients received education, home-based physical therapy and a continuous adductor canal block with ropivacaine during surgery. Pain levels were recorded pre-surgery and through the first three postoperative days, then again at three weeks, six weeks and 12 weeks post-surgery.
The study found that 86% of patients were able to get through the 90-day period with 10 opioid pills or less. This is the lowest published opioid use in the nation, five times lower than the next best paper, which found people used 50 pills post-surgery on average. In addition, 85% did not need formal physical therapy, saving them around $720 and reducing their exposure to COVID-19.
“I have a lot of patients who live up in the Adirondacks, and they have no access to therapy,” Dr. Wickline says. “Patients who went to rehabilitation and had two hours of therapy every day had more pain and took more narcotics. My patients who live up north and had no access to therapy followed my simple exercises and experienced less pain.”
The formal study confirmed Dr. Wickline’s anecdotal experience, he says. His patients also experienced a 1.2% readmission rate through 90 days, one of the lowest in the nation based on CMS data. In addition, 64% of TKA patients were able to go home the same day as surgery, and 91% of patients left the hospital within 23 hours.
“By getting patients out of the hospital sooner, we prevent complications, lower the risk of MRSA and COVID 19, and lower the risk of C. diff-caused colitis,” Dr. Wickline says.
“What I saw with patients who went to rehab and had two hours of therapy every day, they had more pain and took more narcotics … than the patients who lived up north and had no access to therapy and just followed my simple exercises.”
— Dr. Wickline
Improved Outcomes, Faster
According to the study, Dr. Wickline’s patients reached 110 degrees of flexion on average within three weeks. That’s seven weeks earlier than the 2018 American Academy of Orthopaedic Surgeons textbook on rehabilitation states is normal.
Dr. Wickline stresses that his patients haven’t been cherry-picked to improve outcomes, either, which is documented in the study.
“The protocol fits everyone,” Dr. Wickline says. “If you have medical comorbidities, I might have to keep you overnight but the study shows that most patients can go home the same day. You can decrease your complications by following this protocol, and you don’t have to be a 57-year-old marathon runner with a bad knee and no medical history to qualify for this.”
Dr. Wickline’s protocol includes a daily progress plan he says is simple for patients to follow.
“Patients do a little bit of exercise each hour and then immediately sit down, elevate and ice to control the swelling,” Dr. Wickline says. “They get the range of motion, but they create the least amount of swelling, so the pain goes away quicker.”
Dr. Wickline says the exercises take five to eight minutes each hour. Combined with ice, elevation and NSAIDs, most patients’ pain is manageable, he says. And the protocol is also a great option for people who have struggled with addiction, whether with opioids or other substances.
“We had around 30% of patients who did not take any opioid medication after discharge,” Dr. Wickline says. He also offers cryoablation that can freeze the nerves around the knee for up to three months for patients who want zero opioids in or out of the hospital.
“Anxiety is a prime culprit in reaching for a pain pill,” Dr. Wickline says. “I have a very detailed education book on what to expect, so my patients know exactly what is normal during their joint replacement recovery.”
Visit andrewwicklinemd.com or call 315-735-4496 to learn more about outpatient joint replacement with the least opioid use in the nation.