The Joint Package

In his bestseller “Better,” the medical author Atul Gawande writes an essay titled “The Score.”  In it he reviews the challenge obstetrics has had over the past century to decrease infant mortality.  Based on individual innovation and other sources of contribution, over time there became a series of things done in the time before, during, and after childbirth that eventually led to a significant decrease in this mortality.  He called the sum total of all these maneuvers the “The Obstetric Package.”  He pointed out that while some of these things were not rigorously proved with science, as a combination they successfully solved a serious issue in healthcare.  I have given quite a lot of thought to a “Joint Package.”  There are many interventions that we use to improve the outcomes of joint replacement.  Through my patient experience I present my idea for a package.

In this blog I have tried to give a perspective of a major operation that I experienced  from five separate perspectives- The Five P’s:

  1. Patient
  2. Provider
  3. Participant
  4. Podium
  5. Publisher

I have now seen this operation from the perspective of the patient, the provider (surgeon), participant in national conferences, podium lecturer at national conferences, and I publish articles on this operation.  That’s a lot of information to process.  What I would like to do is put together, to date, the things that i have learned that I feel need to go into the basic “package” of joint replacement.  There are a lot of players in this joint replacement game- patients, caregivers, doctors, hospitals, insurers, device companies, and equipment suppliers.  Everything seems to have an opinion and most of these stem from their view of the situation or how the decision affects their pocketbook. How many times did a surgeon order a piece of the equipment and the insurance company didn’t cover it because they said it was not “medically necessary.”   I have found there just aren’t enough time to write all the articles and present all the evidence to all of the insurance companies that have all their uneducated representatives to say al the right things.  Here is my personal go at putting together this joint package.  Call it recommendations or call it a Joint Replacement Patient’s Bill of Rights- whatever- just call it.

  1. Choose outpatient or inpatient situation
  2. Preoperative Physical Therapy Visit
  3. Joint Camp Education session
  4. Comprehensive Surgeon-Authored Patient Guide
  5. Preoperative delivery of equipment listed below
  6. Preoperative understanding of all financial risk
  7. Intraoperative/postoperative IV Ofirmev (acetaminophen/Tylenol)
  8. Intraoperative tranexamic acid (TXA
  9. Intraoperative injections in the joint with Exparel (liposomal bupivacaine)
  10. Postoperative multimodal pain education
  11. Incentive spirometer
  12. Compression stockings
  13. Walker/crutches/and cane
  14. Shower/bath seat
  15. Elevation pillow
  16. Reacher
  17. Leg lifter
  18. Home DVT SCD machine
  19. Anticoagulation medicine of choice
  20. Physical Therapy X 12 sessions and then again if necessary


Anything short of an insurer paying for all the above is to only partially insure the procedure.  This was my package- and it worked.  I works for me as a surgeon and a patient.  I appreciate that there are many protocols from the many surgeons around the country but what I presented above is a reasonable starting point based on my 5 P’s experience.






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