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A Win-Win for Patients and the Health Care System

A Win-Win for Patients and the Health Care System

I’m looking forward to the years ahead and being able to do all of the things I love to do—from hiking to shopping to traveling. It will be so nice to be an active person again and not worry about how my knees are going to feel." Lisa Lewis

Photo: Lisa Lewis meets with Dr. Rico Gonzales and her care team at D-H Manchester.

Striding alongside Lisa Lewis through the busy corridors of Dartmouth-Hitchcock (D-H) Manchester on a sunny January morning, it's impossible to tell that she recently had knee surgery."It feels great," she says."A few months ago, there was no way I could walk through these hallways like this."

Lisa has just had a follow up visit with her orthopaedic surgeon, Dr. Ricardo Gonzales."It went very well," she reports."I still have a little bit of inflammation in my left knee, but we think it's because of the winter conditions and the extent to which the knee had been damaged before I had the surgery."

In September of 2013, Lewis underwent a partial knee joint procedure known as unicompartmental knee replacement at the Bedford Ambulatory Surgical Center (BASC). She had the same procedure done on her right knee (also by Dr. Gonzales) at Catholic Medical Center back in June of 2011. One of six fellowship-trained joint surgeons within Dartmouth-Hitchcock's academic health system, Gonzales is one of the most experienced in the region in performing partial knee replacement.

"Comparing the two care experiences, I wouldn't say that having it done in the hospital was worse than having it done on an outpatient basis—I received excellent care in both cases," says Lisa."But it was so nice to be able to go home after one day versus three."

Wear and Tear

Lisa, like many other people, suffers from osteoarthritis, a degenerative joint disease that afflicts about half of the adult U.S. population, according to the Centers for Disease Control. The prevalence is even higher, about two-thirds, for those who are obese.

"We refer to osteoarthritis as the 'wear and tear' type of arthritis since it's caused by the normal wearing away of cartilage, which acts as a shock absorber in the knee and allows the bones to glide smoothly past each other," explains Gonzales.

When approaching knee reconstruction, joint surgeons typically break the knee joint down into three compartments: the medial side (inside), the lateral side (outside) and the cartilage beneath the knee cap."The vast majority of people who get arthritis wear down the inside compartment of the knee first," he says."That's why many people with arthritis end up shifting their weight to the outside of the joint and eventually become bow-legged."

Suffering trauma or injuries to the knee often accelerates the process—that was the case with Lisa."I fell in 2001, and that's when the right knee started giving me problems," she recalls.

Changing Course

Compensating put more pressure on her left knee, and by 2003 she was experiencing pain and stiffness in both joints."That's when I had medial meniscus cartilage work done on both knees, at the recommendation of the surgeon I had at the time," says Lisa."The arthritis really started to develop after that."

In 2007, Lisa switched to Dr. Gonzales, who had a more conservative approach to care."I just love him; I can't say enough about him, his head nurse Nancy and the whole care team at D-H Manchester," she says."They're so personable, professional and thorough. And Dr. Gonzales won't do anything until it's time to do it. We tried other, non-surgical treatments first, like injections to help lubricate the joints and cortisone, but they only worked temporarily."

By 2011, she had developed a painful bone spur in her right knee as a result of her arthritis, which meant it was time for her first surgery."I was very well cared for in the hospital, but I felt like I spent three days not sleeping well and I was medicated perhaps more than I needed to be," Lisa remembers."The beginning of the recovery was a little bit slower, too, because I'd spent three days in bed, not doing anything."

Having the surgery done on an outpatient basis in 2013 did require a pre-operative procedure."One advantage of doing the surgery in the hospital is, if you find more extensive damage to the knee than expected you can take care of it in that setting," says Gonzales."When you're planning a 23-hour admission at an outpatient facility, you have to know for sure that it's going to be a partial procedure. So a month before, we have the patient come in and under local anesthesia we use a tiny scope with a camera to make sure the rest of the knee is in good shape."

Providing Value

For patients that meet the criteria, unicompartmental knee replacement offers a number of benefits."The beautiful thing about it is you keep your own ligaments, and because two-thirds of the joint is still your own knee it feels a lot more natural compared to a total knee replacement," Gonzales explains.

A number of credible studies have shown the procedure compares very favorably to total knee replacement, still considered the"gold standard," in terms of complication rates, recovery time and durability. In addition, outpatient unicompartmental knee replacements are typically one-fourth of the cost of the same procedure done in an inpatient setting.

"The BASC does a fantastic job, and the collaboration we have with them allows us to bring considerable savings to the health care system with these cases," says Gonzales."It's important to mention that we have no investment in their facility. I just feel like we're being good citizens by doing this. And most importantly, the patients love it."

Lisa will vouch for that."The staff at the BASC were very professional, pleasant and helpful," she says."The fact that they specialize in outpatient surgery means that you start walking safely the same day, go home earlier and start your recovery sooner."

"I'm very glad I had it done, in both cases," adds Lisa."I'm looking forward to the years ahead and being able to do all of the things I love to do—from hiking to shopping to traveling. It will be so nice to be an active person again and not worry about how my knees are going to feel."