By Elesa Swirgsdin
Friday, June 17, 2022
Andrew Wickline, MD, is raising the bar on total knee and hip replacements with game-changing protocols that minimize the need for pain medications while maximizing results.
Total knee and total hip replacements typically lead to painful recovery periods filled with difficult physical therapy sessions. Not only does this deter some patients from getting a procedure that can vastly improve their quality of life, but it also raises the risk of patients developing an opioid dependency after surgery.
Andrew Wickline, MD, an orthopedic joint replacement specialist at Genesee Orthopedics & Plastic Surgery in New Hartford, located about 50 miles east of Syracuse, has proven this troubling trend doesn’t have to continue. After developing Therapy-Free Total Knee Replacement, a program that virtually eliminates the need for traditional physical therapy following a joint replacement, Dr. Wickline published the lowest opioid use rates in the country for this type of procedure, with high patient satisfaction and positive long-term outcomes.
His groundbreaking protocols have also led to the lowest patient costs and the lowest complication rate in the state of New York, even among patients with a high number of comorbidities.
Responding to Patient Needs
“At the end of the day, a huge part of a doctor’s job is customer service,” Dr. Wickline says. “I asked my patients, what can I do better? The answers made me think about why we do such aggressive physical therapy after joint replacements, and if there could be a better way. That was the inspiration for developing my therapy-free program.”
Many patients told Dr. Wickline that the joint replacement surgery itself wasn’t a bad experience, but the physical therapy prescribed during recovery was nearly unbearable, especially for total knee replacements.
“I heard things like, ‘I hate therapy. It was absolutely terrible.’ Or ‘My mom won’t go back to do the other knee because she doesn’t want to go through therapy again,’” Dr. Wickline says. “I started looking at what we could do differently.”
Some patients also had to travel long distances for physical therapy, which presented a significant obstacle to a successful recovery. After developing an at-home therapy plan for these patients, Dr. Wickline found that they experienced less pain, better range of motion, and a faster overall recovery than those who followed a traditional, intensive inpatient physical therapy program. This success has been seen with patients from Pakistan, southeast Asia, Canada, the Caribbean, Texas, North Carolina, New Jersey, Maine and Pennsylvania.
Andrew Wickline, MD
Siobhan Fitzgerald, RN, BSN, Nurse Administrator
Apex Surgical Center
Dr. Wickline began using a home-therapy method for all of his patients combined with a comprehensive education and optimization plan. The results showed not only an easier recovery, but patients needed drastically fewer narcotics for pain relief following surgery. In 2020, he published the results of his new study, in the Journal of Orthopaedic Experience & Innovation. It involved 386 patients who had total knee replacement. During a 12-week period, 86.3% of patients needed 10 or fewer opioid pills, while 18.9% used zero opioids.
Dr. Wickline’s results are 16 times less than the national average and five times less than the next best published opioid reduction paper from Mayo Clinic.
“I saw a new study that said the average across the country is 1,200 morphine milligram equivalents for the three-month period after total joint replacement,” Dr. Wickline says. “That’s around 160 oxycodone 5mg pills for 90 days — compared to 10 pills or less with my protocol. There is still a disconnect, and we need better opioid stewardship in New York and across the country.”
In 2021, more than 107,000 people in the United States died from opioid-related overdoses. According to some studies, between 8% and 12% of people who are prescribed opioids for pain after joint replacement may develop an addiction.
Dr. Wickline’s approach replaces the typical 90-minute physical therapy sessions three times a week with four simple 8-minute exercises once an hour. Using elevation and ice after the exercises also keeps swelling down, which further decreases pain.
“If you sprain your ankle badly, you’re not going to do a 90-minute workout three times a week,” he says. “It turns out that you don’t need to do aggressive, tortuous therapy if you control swelling. Formal therapy is best used to fine tune recovery at five to six weeks after surgery.”
More than 85% of patients in Dr. Wickline’s study did not need formal physical therapy, leading to an average personal savings of $720 in therapy copays and more than $3,000 savings to insurers. In addition, 64% of patients in the study went home the day of surgery and 91% were discharged within 23 hours. Currently, 95% of patients go home the same day their joint was replaced.
Patients who follow the program also experience significantly fewer complications.
“Our readmission rate is 1.2%. That is markedly lower than results published by some big institutions,” Dr. Wickline says. “That’s also where cost is kept down. If you get readmitted for a fracture, suddenly the cost for that patient has gone up dramatically. According to Medicare cost data, I have the lowest 90-day cost in the state, even though my patients have a higher number of medical issues.”
Contributing Success Factors
Dr. Wickline is among a small percentage of surgeons in the country performing tourniquet-free knee replacements. This practice lowers the risk of blood clots by 19%. It also reduces pain and infection risk and improves incision healing.
In addition, Dr. Wickline is the only site in New York offering personalized kinematic alignment and medial pivot knee replacement. It restores each patient’s normal anatomy of the knee and provides knee motion that most closely resembles that of the native join — without painful ligament releases that increase swelling.
Improving nutrition with branched-chain amino acid protein supplementation and specific anti-inflammatory diet changes also plays a significant role in an accelerated recovery program.
Lastly, Iovera cryoablation, a temporary freezing treatment around the knee, provides patients with three months of post-op pain reduction.
Total Hip Replacement Results
Dr. Wickline delivers similarly impressive results for patients undergoing total hip replacement. In 2020, he published another study in the Journal of Orthopaedic Experience & Innovation reporting the results of a six-week long study following 207 patients after their hip replacement. About 97% of these patients required 10 opioid pills or less, with the average being 3.5 pills per patient in the six weeks following surgery. Patients followed a home-therapy protocol and 95% were able to skip formal physical therapy at six weeks. He has used the muscle sparing anterior hip approach since 2007.
Preparing Patients for Success
Comprehensive patient education is a critical component of Dr. Wickline’s program.
“No one prepares for the Super Bowl the day before the game. They prepare for weeks ahead of time,” he says. “It’s the same with joint replacement.”
Dr. Wickline has written two separate patient books for knee and hip replacements, each about 65 pages long. The goal of the books — now in their 13th edition — is to help patients succeed with proper preparation prior to surgery. The books cover topics like nutrition, getting the living space ready, and what to expect every step of the way before and after surgery, as well as during recovery.
“They answer pretty much every question that a patient has asked over the last 20,000 plus surgeries,” Dr. Wickline says. “They are extremely comprehensive.”
The books are designed to be read at certain intervals prior to surgery, so that patients can, for example, change their diet four weeks before the procedure to set themselves up for a successful recovery. An app is currently in development for patients who prefer watching videos more than reading.
Dr. Wickline continues to study opportunities to optimize recovery protocols. His research focuses on the correlation between swelling and pain and is a main focus of his current research.
“The more you control swelling, the better the joint feels,” he says. “We’re doing 3D optical scanning where we’re looking at several different infection control protocols to see if they reduce swelling. We’re also performing bioimpedance testing to look at how much fluid is in the leg before and after surgery. It’s about creating a normative baseline so we can start adding or subtracting different things from the protocol to see what improves or worsens swelling.”
Dr. Wickline also participates in the geko Cross Therapy Registry for Edema, a clinical trial that collects data on how geko neuromuscular electrostimulation technology affects swelling.
Another research focus area centers on the effectiveness of various non-opioid pain management methods, such as pre-op cryoablation, which Dr. Wickline offers to help reduce post-op pain for up to three months without narcotics. He is involved in a study focusing on how long various pain relief methods last and what is most effective for patients with osteoarthritis.
Prominent Surgeons Adopt New Joint Replacement Protocol
After Andrew Wickline, MD, published his studies on therapy-free joint replacement, orthopedic surgeons around the country, as well as in other parts of the world, began to take a keen interest in his method.
“I was having great success with my total hip and total shoulder patients, but my total knee patients seemed to suffer,” says Chris Mellano, MD, orthopedic surgeon in Manhattan Beach, California. “I commonly heard patients say, ‘I hope I never have to do that again.’ I was searching for a way to make the experience easier and less painful.”
Dr. Mellano came across Dr. Wickline’s study on therapy-free knee replacement — and couldn’t believe what he was reading.
“A large percentage of patients used no narcotics after surgery, which is unheard of in my experience,” he says. “Most also did not require formal outpatient therapy, another astounding accomplishment.”
Dr. Mellano was further shocked to find that the patients in the study were not hand-picked to be ideal patients and instead included people of all ages, including those with multiple comorbidities.
Dr. Mellano decided to visit Dr. Wickline’s practice to observe his protocols firsthand. What he saw validated the published results and inspired him to adapt these new techniques into his own practice.
“The most important factor I learned was exceptional dedication to patient education,” Dr. Mellano says. “Patients went into surgery with a clear understanding of the procedure and how to optimize their outcome. On a surgery day, Dr. Wickline and his team efficiently performed multiple total joint replacements without sacrificing patient care in any way. I left feeling empowered by his example.”
After returning to his practice, Dr. Mellano began implementing many of Dr. Wickline’s protocols, including providing patients with educational guides.
“My results have been transformative,” he says. “The first five patients each took zero narcotics and told me that their outpatient total joint procedure was a wonderful experience.”
Dr. Mellano is not alone in his experience. Michael Engl, MPH, a board member of the elite European Knee Associates, who operates in northern Italy, recently traveled to New York to observe Dr. Wickline’s protocols in action.
“Here in Europe, total joint replacements that allow patients to leave the hospital after a few hours is very uncommon,” he says. “It was almost unbelievable. By visiting Dr. Wickline, I am convinced that the knowledge I gained is as high as that of attending international meetings. It was very inspiring to discuss the differences in our pathways.”
Stephen Howell, MD, knee arthroplasty surgeon at Adventist Health Lodi Memorial in Lodi, California, known for his role in helping develop the kinematic alignment method, was looking for a way to perform outpatient total knee replacements when COVID-19 stopped elective inpatient procedures.
“Since adopting Dr. Wickline’s protocols in July 2020, nearly all of our TKA procedures have been outpatient,” Dr. Howell says. “His pain program works synergistically with the kinematic alignment approach. These techniques complement and potentiate each other.”
Looking to the Future
Dr. Wickline hopes that more surgeons across the country will adopt his unique protocols into their practices to reduce the need for narcotics and improve patient outcomes. Several prominent surgeons have already incorporated his techniques into their own protocols, an encouraging sign (see sidebar on page 8).
“It can be hard to get people convinced because these methods are so different, and change can be scary,” Dr. Wickline says. “But the bottom line is if patients follow the program, they’re going to have great outcomes. The key is getting patients engaged. You just have to give them the winning game plan.”
Dr. Wickline earned the 2020 Excellence in Surgery award at the 9th Annual Excellence in Healthcare Awards presented by the Central New York Business Journal. Visit andrewwicklinemd.com to schedule an appointment. You can also call his personal assistant, Mrs. Lorilynn Szkotak, at 315-738-5069.
The Right Way to Curb Opioid Abuse by Americans
Did you know that your grandma could become addicted to opioids because of a knee replacement? It’s more likely than you might think. Knee replacements — with more than 1 million performed every year — nearly always require opioids for pain control. It’s no surprise that the proportion of older adults seeking treatment for opioid abuse nearly doubled in recent years, particularly as the number of joint replacements increased drastically.
Every pill surgeons order can cause substance abuse. A 10-day opioid supply carries up to a 20% risk of addiction. A 24-hour supply runs a 6% chance of addiction. By getting their wisdom teeth pulled, your teenager — consuming opioids for one day — could develop an addiction. Approximately 80% of heroin addicts first misused prescription narcotics.
I propose a radical solution …
Excerpted from an op-ed in the New York Daily News by orthopedic joint replacement specialist Dr. Andrew Wickline on how to immediately begin reducing opioid addiction. To read the full article, visit nydailynews.com and search for Wickline. Siobhan Fitzgerald, RN, BSN, Nurse Administrator