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MD News – Engineering High-Quality Specialty Care: The Joint Replacement Program at Bronx-Lebanon Hospital Center.

Engineering High-Quality Specialty Care: The Joint Replacement Program at Bronx-Lebanon Hospital Center

Ira Kirschenbaum, M.D., Chair of Orthopaedic Surgery at Bronx-Lebanon Hospital Center, has helped develop a modern model for providing both primary and specialty orthopedic care in one seamless system.

Photo: Ira Kirschenbaum, M.D., Chair of Orthopaedic Surgery at Bronx-Lebanon Hospital Center. Photo © Don Dempsey, White Light Photography

Dr. Kirschenbaum joined Bronx‑Lebanon Hospital Center with the goal of expanding high-quality orthopedic services within the Bronx. He approached the project with perspective from three other practice environments: Kaiser Permanente, where he focused on the development of a nationally recognized joint replacement program; a large orthopedic group, where he served as a managing partner; and a solo practice, where he specialized in referral joint replacement. At Bronx-Lebanon Hospital Center, Dr. Kirschenbaum quickly assessed the entire environment and determined how he could apply the principles of nationally known centers — such as the Rothman Institute at Thomas Jefferson University Hospital, where he originally trained — to the Bronx.

“We faced two challenges: developing services for the primary care needs of the musculoskeletal system and providing access to high-quality specialty orthopedic care,” says Dr. Kirschenbaum. “We needed to reengineer the way orthopedic care was delivered.”

Recognizing the Model’s Communal Potential

In identifying the needs of the Bronx community as related to orthopedic care, Dr. Kirschenbaum and his colleagues discovered the similarities between their community and those around the country. The dilemma of supplying to a patient in the Bronx the same quality of care as delivered at national centers was not unique to Bronx-Lebanon Hospital Center. Thus, its solution would not be limited to the emerging joint replacement program.

Dr. Kirschenbaum examined every section of the continuum of care from both the patient experience and clinical points of view. He and his colleagues perfected the Department of Orthopaedics by asking critical questions about the ease and success of making an appointment, finding or being directed to the appropriately qualified physician, fully educating the patient before surgery, booking the surgery, performing the surgery with advanced equipment, facilitating a comfortable hospital experience, and managing comprehensive 
postoperative care.

“We started looking with a careful eye at what we had and how we could implement what we wanted to accomplish. We had to ask, ‘When you take it all apart, what are the features that define high quality of care?’” says Dr. Kirschenbaum. “I think we’ve developed an enviable process, but we’re constantly modifying. Now, we’re tweaking rather than constructing.”

The polished process has allowed the Department of Orthopaedics to be in line with national standards in operating room efficiency and infection control. On the days when Dr. Kirschenbaum or Margaret Meyer, M.D., Chief of Sports Medicine and Orthopaedic Trauma, perform hip or knee replacement 
procedures, five to eight joint replacements are completed in a day. The process also assures community physicians that their patients will be treated by the appropriate physician — a joint replacement specialist.

The Bronx Twist 
on National Principles

Patients who require a knee or hip replacement can be referred by their primary care physicians or a general orthopedist. Regardless of their paths to the Department of Orthopaedics, patients are scheduled for appointments within the Center for Hip and Knee Replacement. The program is managed by Gabriella Iodice, Director of Clinical Services for the department, who arrived at Bronx-Lebanon Hospital Center with Dr. Kirschenbaum. John Bonsu, P.A., directs the outpatient aspects of the program. Every patient has an initial and thorough evaluation in the form of an intake interview. Patients then undergo the necessary imaging tests, which are all available within BronxCare Orthopaedics at Bronx-Lebanon Hospital Center’s Concourse Division.

Dr. Kirschenbaum then meets with patients to evaluate their joint condition, reviewing their entire histories and X-rays. If deemed a candidate for surgery, the patient is entered into a sophisticated database that meticulously tracks each patient through preoperative care, surgery and postoperative follow-up. The database also provides a centralized, comprehensive wealth of information on every patient, available at any time to the faculty.

“Before surgery, patients are optimized medically by their primary care physician, as well as the program’s perioperative hospitalist, Dr. Eric Rosier, [M.D.], who specializes in preparing patients for surgery and is the same person who manages postoperative care. Dr. Rosier works closely with the referring physician to preoperatively evaluate patients medically,” says Dr. Kirschenbaum. “The program keeps the patient and the primary care physician in the loop at all times.”

The attending anesthesiologist also meets with the patient preoperatively. On the day of surgery, Dr. Kirschenbaum is joined in the operating room by a specially trained joint replacement surgery team, which includes orthopedic technicians and nurses who are dedicated to joint replacement. Day or night, there is no other team that assists Dr. Kirschenbaum and Dr. Meyer. The cohesion of the team facilitates efficiency and quality. Both surgeons utilize a case cart concept, wherein surgical trays are dedicated for a particular procedure. Following surgery, the Department of Orthopaedics takes on a significant role in a patient’s postoperative rehabilitation care, even when the patient is admitted into an extended care facility. Dr. Kirschenbaum and his colleagues ensure that quality care is always controlled by only referring patients to facilities that have been personally visited and evaluated by members of the Department of Orthopaedics.

The environment and physical therapy care must meet certain benchmarks before being considered an option for patients. Even in rehabilitation, the database tracks patients while Dr. Kirschenbaum and the entire team adhere to a consistent schedule of follow-up care. This process of standardization is flexible enough to provide uniform care for each patient and allow for customization as needed.

In addition to the seamlessness of the Department of Orthopaedics’ process, Dr. Kirschenbaum and his colleagues have equipped their services with compassion. Patients are accepted for evaluation regardless of comorbid diseases or the complexity of their cases. If a patient underwent a procedure at another hospital or medical center and requires a second operation, Dr. Kirschenbaum does not hesitate to treat the patient, provided that he or she is healthy enough for surgery.

“If someone needs our care, we offer our care,” says Dr. Kirschenbaum. “We’re selective about how we choose our surgeons. We’re selective about how we choose our staff. All patients have access to our services.”

A Brief History

Having begun his orthopedic training in 1985, Dr. Kirschenbaum has watched the field of joint replacement surgery evolve through many challenges to arrive at its current refined state. The first issue to solve, dating back to the 1960s and ’70s, was determining the correct quality of material to use for the implant itself — specifically which type of metal and plastic liner contributed to the best outcomes. By the late 1980s, the debate had shifted to the process of attaching the replacement to the bone. The favored materials had emerged as a combination of cemented cobalt and chrome for knee implants and noncemented titanium for hip implants. The question then became how to make the replacements last longer. This was the era of the bearing surface, which began around the early 2000s. By improving the strength of the plastic and through the use of special ceramics, prosthetics can last more than 20 years as compared to the 10-year life span that was the standard 20 years ago.

Transferring the Model

Two years into a successful debut of the reimagined approach to primary and specialty orthopedic care, the Department of Orthopaedics at Bronx-Lebanon Hospital Center is applying the model first used in the flagship clinical program — the Center for Hip and Knee Replacement — to each of its many subspecialties. Patients undergoing evaluation or treatment for injuries or conditions of the foot, hand or spine will matriculate through the same process of assessment. If they are candidates for surgery, they will become part of the same database for more efficient care.

The Game Day, Same Day sports medicine program will also experience the benefits of transitioning to the improved care model while maintaining its tradition of definitively treating high school and college athletes on the days of their injuries. Next year, the Department of Orthopaedics will further expand with the launch of a program focused solely on the orthopedic needs of women.

“In this current era, which we’re just touching on now, we’re asking, ‘Do we need to do a complete knee replacement, or are there some more minimally invasive approaches and alternatives we can use?’” says Dr. Kirschenbaum. “Though we never fully leave an era — we know what we have is good — the question now is, can we do less to achieve more?”

The Fourth Generation Procedure

The signature operation at the Department of Orthopaedics is a minimally invasive partial knee replacement. In fact, the team and Dr. Kirschenbaum have contributed to the technique to such a degree that it was featured in an American Academy of Orthopaedic Surgeons video. While the national average for the procedure stands at two hours, Dr. Kirschenbaum performs the operation in 45 minutes.

In the operating room, Dr. Kirschenbaum approaches only the part of the knee impacted by arthritis, leaving intact the other area of the knee that is normal. He makes a 2-inch incision in the knee and utilizes custom tools to expose the joint and access the arthritic portion of the knee. Dr. Kirschenbaum excises between 8 and 10 millimeters of bone from the tibia and roughly 7 millimeters from the femur. He then applies specially pressurized antibiotic cement to the bone to ensure the implants connect to the bone. The implant itself consists of metal and a high-molecular-weight, medical-grade polyethylene that covers only the arthritic section of the joint.

“We’ve solved the metal and fixation issues and are now solving the bearing issue,” says Dr. Kirschenbaum. “Here’s an alternative to a total knee replacement that can be performed in 25% of patients. Partial knee replacements can be a better option for many patients and have improved postoperative mobility and function.”

Many patients can return home after one day of inpatient recovery, though some choose to stay for up to three days depending on their general medical conditions. The average recovery time is three to six weeks. Some of Dr. Kirschenbaum’s best results were seen in an 80-year-old female patient who had both knees partially replaced and drove to his office within two weeks of surgery.

No Patient Left Behind

The Department of Orthopaedics performs roughly 1,500 operations a year. Those figures represent a five-fold increase since Dr. Kirschenbaum and his colleagues implemented their model of care. The delivery of a unique blend of primary and specialty care has ensured that patients in the Bronx, northern Manhattan, southern Westchester County and Washington Heights receive the crucial range of orthopedic care they need without traveling outside of the community.

“The idea of specialty care is not special care, but care of special problems. In a high-population area such as the Bronx, even a small percentage of patients who need orthopedic care means a lot of people,” says Dr. Kirschenbaum. “We don’t leave people behind in medicine, and access to specialty care ensures no one is forgotten.”

To learn more about the orthopedic services at Bronx-Lebanon Hospital Center, visit www.bronxcare.org and select “Orthopaedics” under “Our Services.

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