embrace the concept of multimodal pain management in the ambula-
tory setting," says Dr. Stoeckl.
His patients receive the NSAID celecoxib in pre-op. Anesthesia
providers then place adductor canal blocks, which provide analgesia
without significantly inhibiting motor function at the joint. Dr. Stoeckl
has embraced local bupivacaine liposome injections, which he calls
"game changers" for patient recoveries. He also gives patients tranex-
amic acid, which decreases hemarthrosis, bruising and swelling —
several factors that impact pain.
Excelsior set procedure-specific case volume threshold surgeons
must hit before performing the procedures in the surgery center. For
example, surgeons must perform 50 knee replacements a year before
shifting the procedures outpatient. Surgeons have to be confident they
can perform the cases in a timely fashion without causing significant
trauma to the extremity, notes Dr. Stoeckl. Interestingly, he uses a
standardized operative technique, so his inpatients also benefit from
the continued evolution of his outpatient experience and protocols.
Once surgeons figure out the clinical side of things, the real work
begins. "Ironing out the pain control and figuring out patient selection
is the relatively easy part — that's what we do," says Dr. Stoeckl. "The
hard part is figuring out all the details behind the scenes."
It takes a total team effort to get a patient to the facility, through sur-
gery and recovered safely and effectively, but at the same time you
need a surgeon champion to push the cause and get the staff ener-
gized to make it happen. "If it weren't for the people around me get-
ting behind the effort, I'd still be talking about it," says Dr. Stoeckl.
"It's easy to come up with the idea of total joints, but it takes a couple
years to operationalize it."
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