Dr. David Morawski – Surgery Centers vs. Hospital Stays

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Toree: Hi, I’m Toree McGee, and this is the Rapid Recovery Report, sponsored by ROMTech, the modern technology of rehabilitation.  We’ll be doing a weekly, biweekly, monthly, we’ll figure it out – it keeps changing – series on Thursdays, at 4:00pm Pacific and 7:00pm Eastern, where we talk to different guests, be it surgeons or patients, or experts here at ROMTech, to discuss wellness and health, and occasionally, we will also touch on the ROMTech PortableConnect, which is this cool device here.  

If you are new to us here at ROMTech, this is the PortableConnect, and this is what it looks like.  So, it’s a high-tech recovery device that’s geared to getting patients moving, and back on the road to recovery faster post-surgery and injuries.  So, if you want to learn a little more about us, you can always follow us, and check out our website at Romtech.com.  All of that info is below as well in our little description. 

Joint Replacement Specialist, Dr. David Morawski

Toree: So, I wanted to introduce to you guys here.  We have a really great guest here today.  Dr. Morawski is a board-certified physician, who specializes in orthopedic surgery and total joint replacement.  And he’s been performing knee and hip replacements for over 25 years.  He’s the leading expert in anterior hip replacement, minimally invasive muscle-sparing same-day total knee replacement and joint replacement surgery.  

He uses a variety of nonsurgical treatment methods, including activity modification, medication, physical therapy, bracing, injections, and pain management, biologics for treating of arthritis, including platelet-rich plasma, also known as PRP, and stem cell treatment are also used.

He wants to work on eliminating hospital stays altogether, and doing all surgeries in the surgical center, to now only perform in surgery centers and no hospitals by the time that he retires.  

So, welcome Dr. Morawski.  It’s great to have you here.

Dr. Morawski: It’s good to be here.  Thank you, Toree.  

New Joint Replacement Techniques

Toree: Thanks for taking the time.  So, we’re really interested in this first question here for you.  So, in our initial conversation offline, you’d mentioned that you’re working with some new techniques, like diminished bleeding technique, so could you explain what that is to us?

Dr. Morawski: Well, the techniques for joint replacements now have significantly decreased the bleeding.  So, there’s a lot of less bleeding techniques, like hypotension anesthetics, so that the blood pressure is low during surgery, which minimizes how much people bleed.  We also use medicine, IV that’s called tranexamic acid, which a lot of obstetricians used to use for females who had heavy menstrual cycles, and it would definitely help them with decreased bleeding.  So, we decided, why don’t we use this medicine, not so new, but use in a new application to decrease bleeding.  And we found, virtually, 98% of the time, we do not need blood transfusions anymore when doing a reconstruction of a hip or a knee. 

Toree: Wow, that’s amazing.  You had mentioned some newer anesthetic agents as well, so can you tell us about that?

Dr. Morawski: Well, there are a couple of things that we have found out.  First of all, I believe using a regional anesthetic, like a spinal anesthetic, is a lot safer, and it lowers the blood pressure.  And when my patients wake up after their one-hour or 30-minute procedure, form the sedation, their legs are still asleep.  And when their legs are asleep, they wake up, start drinking some coffee or tea, or orange juice, and eating some snacks, and then they feel their numbness go away in their feet, they might feel some discomfort, and then we can offer them some [inaudible 00:04:06], rather than significant strong medicine like morphine or Dilaudid.  

The other medicine, the anesthetic agent that is new in the last five or six years is a local anesthetic, that is a longer-acting local anesthetic or a Novocaine that I inject all around the soft tissue around the knee or the hip that lasts for 72 hours.  So, my patients get significant relief for that amount of time, which allows them to get up and move, and feel comfortable, for not only the first day, but the second and third days, which typically are the hardest painful days after a joint replacement.  So, by then, they’re home, they’re liking being home in their own environment, and they’re recovering much faster.

Toree: Wow, that’s amazing.  So, you have a passion obviously for faster and quicker recoveries for your patients.  So, you’re using several minimally invasive techniques that seem to get your patients up and moving faster than traditional surgical techniques.  So, do you want to tell us a little bit about that?

Dr. Morawski: Right.  Some of the other techniques that I think some surgeons are getting away from.  We used to use a tourniquet on our knees.  The knees would be without blood, or the whole foot would be without blood, and we found that that causes, when it takes an hour or less, even that amount of ischemia through the muscles, the skin, the nerves, they would wake up in a lot of pain.  So, we decided, well, if we can do this with lower blood pressure, tranexamic acid, less bleeding, and not use a tourniquet during the procedure, that would benefit the patients.  And it certainly makes it a lot more comfortable.

The other technique that I use is a minimally invasive muscle-sparing technique.  Instead of cutting through the tendon of the quadriceps, I go under the muscle, and lift it over to the lateral side, and then do the knee replacement, then the muscle slides back, and patients don’t have problems contracting that quad, which is what gives the patient the most function in their leg, so they can get up and walk quicker.  So, that I noticed, and I used to cut the tendon, and they used to not be able to lift their leg up for, sometimes, two weeks.  So, I think not cutting the muscle in the tendon is a significant advancement. 

Toree: Okay.  Wow, it’s so crazy to hear.  I mean, you know with surgery that you’re in there doing your thing, and really just touching every part, but it’s so interesting to hear somebody talk about, yeah, well, I just pick the muscle up and move it.  That’s crazy to me.

Hospitals vs. Surgery Centers

So, you’re an advocate for independent practice, private orthopedic practices, and eliminating the red tape, and obstacles that someone might experience in a hospital.  So, would you want to touch on that a little bit for us?

Dr. Morawski: Well, I think patients need to know, and those who are watching this podcast probably need to know that, today, a lot of orthopedic surgeons are being acquired by hospital systems.  And a lot of these hospital systems are fine, but the alignment of a lot of these hospital systems are to do things in the hospital, and maybe overcharge, or do it the expensive way.  In fact, they’re disadvantaged if they move things out of their hospital if they’re working for the hospital.  

So, as an independent, I ask my patients what do they prefer.  Would they prefer to have the surgery done in a hospital setting, or would they prefer to have it in an ambulatory surgery center, that’s a specialty center, where all we do is orthopedics?  And 9 out of 10 patients prefer to be outside of the hospital, come in, have their surgery, spend a few hours, two, three hours, waking up, doing some therapy, making sure they eat and drink, and avoiding, and their vital signs are stable, and they go home the same day, and sleep in their own bed. 

When you’re owned by a hospital, you’re pretty much like, well, you don’t need to do that.  We need to fill up our beds.  And why don’t you bring him in.  And there are different fees for inpatient versus an outpatient.  So, I think most people prefer the outpatient technique.  

So, I think that’s the difference.  So, I think if you’re seeing an orthopedic surgeon that is hospital based or owned, they’re probably not going to want to do it.  Now, they may still do it outpatient, but you’ll probably spend a longer period of time in the hospital. 

Toree: Interesting.  Well, that is going to lead me into my next question.  So, you believe strongly in the surgery center option, where patients are out the same day, after a procedure.  And I understand that, right now, it’s mostly hand surgeons and sports injury surgeons that use surgery centers.  Is that right?

Dr. Morawski: Right.  I think, typically, when I started this practice with my partners, and we built a surgery center in 1994, pretty much as a total joint surgeon in the practice, I did all my cases at the hospital.  So, it’s changed, and all the surgeons that did hand surgery, bunions, carpal tunnels, trigger finger, arthroscopic shoulders, maybe some rotator cuff repairs, ACL reconstructions, those were typically the cases being done.  

So, as of this morning, I did eight surgeries there at my surgery center.  One of them was an arthroscopy, and the rest were joint replacements, and they’re all going home.  I have one on Wednesday morning, a total hip, and then I have six on Saturday, all joint replacements.  And then tomorrow, I have seven joint replacements at a hospital.  

So, not all patients can be done in a surgery center.  Currently, we’re limited on some patients by their health.  Obviously, if they have cardiac conditions, or need to be observed, it’s unsafe, I believe, to maybe take those patients in an ambulatory setting.  You have to maybe have the safety net of the hospital, maybe an ICU.  So, certain patients need that.  But most prefer, and some just have to be done at the hospital, based on their insurance. 

Currently, my Medicare hips still have to be done at a hospital, but we’re working on that.  And I think coming in 2022, in the first quarter, we’ll probably have a mechanism to safely do our Medicare patients who have hip replacements, and want to go home the same day.

Toree: Now, is that like a Medicare stipulation, where they wanted to be in a hospital?

Dr. Morawski: No.  Medicare has now released primary hip and primary knee replacements off of the inpatient-only list.  Before 2020, all joint replacements could be done only in a hospital.  Then Medicare or CMS is the oversight for Medicaid and Medicare, they allowed us surgeons to pick patients to be done outpatient.  And initially, was outpatient, but in a hospital.  And then they released that in 2020 to knee replacements could be done.  And then in 2021, hip replacements.  So, even this year, we could do it, but we haven’t come up with our surgery center some of the logistics in our personal surgery center of keeping those patients a little longer, and so on.  So, I think we’re going to make that smooth transition. 

Toree: Okay.  I mean, what percentage of your surgeries now are taking place in the surgery center versus the hospital, give or take?

Dr. Morawski: I’d say about 50% are done in my surgery center.  But out of the other 50%, probably 80% are going home the same day from the hospital.  So, more than 80% of my patients go home the same day, whether they’re done in our surgery center, or the hospital.  And then there’s a few that are older, sicker, no home situation, so they have to go to a skilled nursing facility.  And sometimes, Medicare requires a two-night stay, before they can go to a skilled nursing facility.  So, there are some rules and guidelines, so even though they may be ready to go, they won’t get covered unless they stay two nights. 

Toree: Got it, okay.  That’s interesting.

Dr. Morawski: It is exciting.  I’m happy that I can now, near my end of the career.  I’m not in the beginning half.  I’m in the second half, or close to the 18th hole.  I’m not in the clubhouse yet.  But I think it’s going to be fun that maybe some day I’ll be able to say, “If you want me to do your surgery, I’m only going to be doing them in my surgery facility,” and not spending the whole day in the hospital anymore.

Toree: Yeah, that’s great.  I mean, specially being a surgery center that you and your partners built, I mean that’s going to make it even more special to be able to spend your time there, and make you want to be there more.

Dr. Morawski: It is.  It’s something special.  They have your own staff, who you hired and handpicked.  They work really hard.  I mean, just the fact that I’m offering a Saturday surgery, which is not typical.  Near the end of the year, people that really want to get in, they’ve met their deductible, so I’ve asked for volunteers, and I got my staff to volunteer.  We’ll have a little pizza party after we’re done, I’d say.

Toree: They must really love you, and love what they do.  So, shoot, sign me up if I need surgery.  I hope you’re still performing. 

Dr. Morawski’s Patients on the PortableConnect

Toree: Now, we know that you were one of the earlier adopters of the PortableConnect, and of course, we appreciate that.  We’re honored.  So, we wanted to find out how your patients have been responding to the PortableConnect so far.

Dr. Morawski: Okay.  Well, I know for a fact, a lot of patients.  Now, I’ve been doing it for over a year, so I probably have close to 250 patients this year that I’ve signed up for the PortableConnect.  And some of those patients, keep in mind, are patients that I may have done their other knee with the continuous passive motion machine, which is a machine that was just a lay on their bed, or the couch, and they would slow bend and straighten their knee, with no feedback.  They would just read a book, or surf the internet, or watch a movie, and there’s no input or active contraction.  

And I really found that that was a little bit disturbing, a lot of people didn’t like it.  It hurt their back.  They had to be six hours in it.  So, some of my patients now who had that and they’ve had the Connect range of motion, they love it.  They just feel that it’s so much more inviting.  They kind of think that I’m watching and supervising it, because I can actually go on my Apple or my phone, and sign in, and see how many people, how many times they’re using the machine, what their motion is, so I can kind of get an idea.  

And we have good staff now that service my patients, and they work with some of my patients get home health.  Some of my physical therapists that I use are very versed on it, so they’ve been helping the patients through any glitches with it.  It’s a little daunting for some of my older patients, having an iPad, a computer, hitting some things, but it’s really verbally connected.  It says what to do, the next step, it tells you where to hit the button.  So, I think it’s set up very well, and they’ve all enjoyed it.  

I think I use it now for some of my Medicare patients, we use it for 21 days.  My non-Medicare patients, we use it for five or six weeks.  And they can slowly advance it.  And I think they just get better quicker, and they feel like they’re more active in the participation.

Toree: Yeah, I’ve heard that feedback too.  Patients feel like they’re definitely contributing a little bit more to their speedy recoveries, by making the choice to be on the PortableConnect, and actually see the changes that are being made in their range of motion.  So, it’s exciting. 

And I’m not sure if any of our audience members have seen a passive motion machine that you were kind of talking about, but it’s also called the CPM.  And if you look it up, it’s a little scary.  It’s a little medieval-torture-device looking.

Dr. Morawski: Right.  It’s old.  I mean, it’s been around.  And things have advanced, the surgery has advanced, like we’ve mentioned, from hospital stays up to two weeks, now to home the same day.  But that CPM machine, when I was in resident, and when I was a fellow in the 80’s and early 90’s, that CPM was the only thing we had, and I was using up until a year ago the same thing.  And it was just outdated, and needed an advancement.  

And I think, definitely, the ROMTech does it.  And it has features, I think, that are going to be added on, like telehealth visits, so we can actually phone in, and talk to them in person while they’re on the machine, and kind of have them point their knee at the camera, so I can look at their incision, and check things.  I think that adds some extra important, more modern ways of keeping tabs with your patients, and connect with them. 

Advice on Getting a Joint Replacement

Toree: Yeah, absolutely.  Well, they love to hear it.  Good.  That’s great feedback.  So, what advice can you give somebody who’s considering a hip or knee replacement, and might not know where to start looking for information, and what misinformation to avoid?

Dr. Morawski: Well, I think that you should know, if you’re a healthy adult, first of all, the results vary based on patients.  So, some patients are very healthy, and they can get up and move, and they’re strong.  Some people are very disabled.  So, expectations have to be met, but if you’re going to optimize your health prior to the surgery, before you seek, if you know you’re going to need a new hip or a new knee, and other doctors have told you that, prepare yourself for it.

I have, on my webpage, a robust educational video for my patients.  It’s about an hour long.  I explain what they’re going to go through, what it takes, what kind of medicine they’re going to need, how we handle pain, blood clots, bleeding, and all those things.  So, they’re really well prepared, and that’s important.  

So, make sure your surgeon prepares you.  Talk to them about if you’re a candidate for an outpatient procedure, as you prefer.  It’s a lot easier.  It’s a lot safer, cleaner.  You don’t have to worry about the big hospitals, the infection rates, the COVID issues.  

And I think COVID pandemic, one thing that may have helped my profession in joint replacements is people not wanting to go to the hospitals, and seeking out the ambulatory setting for their surgery, rather than go to where the COVID units were.  So, I think it has helped people.  And then once things catch on, and other patients talk about what their experience is to other patients, then it’s a whole change in attitude and expectations.

So, if you’re going through it, check your area for maybe a specialty center, someone who does these minimally invasive.  And optimize your health.  Lose weight.  Make sure your diabetes is under control.  Tone up your muscles in your lower extremity, so you can get up and go when it’s time.  

Toree: Yeah.  Well, while we’re on some advice here, I know that you’re really active, and you travel with your family, and you play golf, all of the things.  So, those folks out there who might be having a hard time getting motivated to exercise or move more, not just for rehab, but for general health, do you have any advice that you can give them?

Dr. Morawski: Well, I’m in the business of motion, so my job is to make patients move.  Mental health is affected by our physical health and our ability to move.  If you’re sitting in a chair in a room, and you can’t get out and about because of your bad hip or your bad knee, it affects you in many ways.  Not just your overall health, your psychological health.  So, people feel better, they sleep better when they move, so I think movement is the key.  So, keep moving, people.

Toree: Yes, keep moving.  And now, you mentioned diet with diabetes and all of those things.  And I know you work a lot with patients that have arthritis, because that’s a big role in a lot of the joint replacement scenarios.  So, is diet really important when it comes to arthritic patients as well?

Dr. Morawski: Absolutely.  I think that’s one area we’re starting to get a little more knowledge about, teaching the proper diet.  We know there are foods that are inflammatory.  We know there are caffeine, alcohol, tobacco, nicotine.  Those are all things we ingest.  They’re medicines basically.  Our food is a medicine.  And sometimes, that medicine is inflammatory to our body.  And we know.  We’ve all heard of inflammatory bowel disease, irritable bowel, all those things are probably related to some of the food things that we put in there.  

So, there are many books out there.  And I encourage my patients to look up what they’re eating, and see if this is a healthy food, is it inflammatory to your body.  Not just your knees and joints and muscles, but possibly sinuses, causes congestion, bowels, causes irritable bowel, all those things.  So, diet is a big important thing.  And obviously, body mass index, trying to be out of the obesity range.  Try to get your BMI below 30, if possible.  Work hard on that spare tire that men get, and the thighs and hips that women get.  If you can do that, I think your joints will feel better too.

New Orthopedic Technologies

Toree: Yeah, I agree.  Well, thank you for spending so much time with us.  I have one more quick question for you.  And I know that you’re up to date on all of the newest, latest, and greatest in orthopedics.  So, are there any new innovations aside from the PortableConnect that you see coming in the new year for orthopedics?

Dr. Morawski: Well, I just spent Friday last week.  I flew up from Chicago to Philly to work on a couple cadavers.  Trying to try out a new robotic total knee system.  So, I’m working at a robot with Globus Medical, a company that I work with.  And I used their joint replacements.  

And I’m also working on a new acetabular shell that will eliminate nickel, and will eliminate cobalt chrome, which even in small increments can be toxic, so we’re working on a type of plastic and ceramic, rather than cobalt chrome.  So, those things are going to be hitting.  I’m also working on a new cement-less knee with the robot.  So, those things I’m working on with some other surgeons, some lead surgeons.  And I think that will probably be in the near future.  

I think there is still this debate whether cemented knee replacements should be done, versus uncemented.  I think now with 3D printing, the old cement-less knee replacements didn’t really work.  We went through that when they failed.  But now, they’re making them differently, so the industry has changed.  Now, we’re revisiting the uncemented knee replacement.  So, typically, I’d say 95% are all cemented.  We’re starting to see a trend towards the uncemented.

Toree: Wow.  Well, that’s really exciting stuff.  Well, maybe sometime next year, we’ll have you back on the show, and see what’s new. 

Dr. Morawski: Okay.  Would love to talk to you again, Toree.

Toree: Yeah, absolutely.  We’d love to have you back.  Everybody, you can go ahead and visit Dr. Morawski at www.fvortho.com.  And as always, you can find his information, as well as ours, on our website at Romtech.com, all of our socials, all of that good stuff. 

Thank you again so much, Dr. Morawski, for hanging out with us.  I had a blast with you today.

Dr. Morawski: Thank you.  Same here.

Toree: Alrighty.  Well, we’ll see you guys next time, and be sure to subscribe.  And yeah, have a great one. 

Disclaimer: The content discussed on this program is often medical in nature, and is used for informational purposes only.  No content discussed should be taken as medical advice.  Please consult your healthcare professional for any medical questions. 

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