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programs. Otherwise, the complex procedure can be a sharp learning curve for some. "It's a big step for someone who's only done an arthroscopy to go to a total joint," he says. Dr. Berger notes that surgeons also may want a surgical assistant available for these cases, something many smaller centers might not offer. You can contract these services or bring someone on payroll, although in some cases, a surgeon may hire his own. "For total joints, where you need someone to hold the patient's leg or retractors, it's important to have that staff available," says Dr. Berger. Changes in technique You'll also need the right docs on board to make your total joint pro- gram a success, including surgeons with experience performing mini- mally invasive joint replacements and anesthesia providers proficient in the latest techniques, says Dr. Berger. Dr. Berger suggests appealing to local surgeons who are already per- forming muscle- and tendon-sparing procedures, using a 3- to 4-inch incision on an inpatient basis. "If they're already doing that at an inpa- tient facility, moving to an outpatient center is an easy transition," he says. "But for a surgeon used to making a 12-inch incision that results in a lot of lost blood, he needs to learn how to do it differently." There are also training programs designed to help surgeons learn new tech- niques — some hosted by manufacturers who produce orthopedic equipment — but he says having "first-hand knowledge and a history of practicing this type of procedure usually works best." Surgical technique is only 1 part of the equation for a same-day joints program. "Just because you can do the surgery well doesn't mean it stops there," says Dr. Berger. Experts say that ensuring anesthetists are knowledgeable on the latest regional blocks and multimodal pain man- agement is one of the biggest keys to a successful total joint program. "The technique is largely the same, so long as a surgeon performs mini- mally invasive joint replacement," says Dr. Kohen. "The anesthesia 9 2 O U T P A T I E N T S U R G E R Y M A G A Z I N E O N L I N E | M A R C H 2 0 1 5