University of British Columbia (UBC) Orthopaedics Clinical Instructor Dr. Duncan Jacks is credited as the lead orthopaedic surgeon under the new Victoria Enhanced Recovery Arthroplasty (VERA) program. This program targets pain and anesthesia prior, during, and after surgery, ultimately reducing the pain felt after surgery and bringing down the patient recovery time. With hip and knee replacement surgeries continually on the rise, the VERA program seeks to fulfill the ever-increasing demand for joint replacements.
The pandemic was significant in the expansion of this program. With the backlog of surgeries resulting from COVID-19, the new and advanced protocols of this program, such as reduced patient recovery time, helped hospitals cut costs and meet this escalating demand for joint replacements.
Dr. Jacks says that as a surgeon, personally, it has been a very rewarding and eye-opening experience as he could see how well his patients performed when all the elements of the perioperative pathway like pain, vomiting, dizziness, and nausea were addressed.
A 71-year-old firefighter, Dan Kelly, said that he was in a state of shock when he left the Royal Jubilee Hospital in Victoria, just three hours after a total hip replacement surgery. He recounted that right after he got out of bed, he did a little jig and walked thirty feet to reach his bathroom just an hour after his surgery. He was in complete disbelief. By noon, he was up and ready to go home. Dan Kelly was one of the eight trial patients who had hip or knee replacement surgery under VERA over the past year.
Dr. Jacks says that under this program, patients who can be labeled as “reasonably healthy” are also given several medications before their operation to target the various pain pathways before the pain begins. Along with this, patients are also injected with anesthetic into the epidural space, outside the spinal fluid, instead of injecting it directly into the fluid. Anesthetist Dr. Jacques Smit explains that many patients receiving spinal anesthetic directly tend to spend more time in recovery, with 30% of them suffering from light-headedness and nausea. Thus, injecting the anesthesia into the epidural space helps their motor functions to recover almost immediately.
Dr. Jacks added that his team is also maximizing efforts to reduce soft tissue damage through different kinds of cutting techniques, and the usage of specialized sutures, dressing materials, and the administration of an epidural along with sedation, to minimize drainage from surgical wounds. Dan’s ability to walk an hour after his surgery resulted from his epidural being turned off, which brought his motor functions back almost immediately.
Altogether, these procedural changes have successfully produced excellent outcomes for the patients. Jacks explained that traditionally they would feel nauseous, dizzy, and groggy and would have to spend a good number of days in the hospital post-operation. Kelly, who had his first hip replacement surgery under the old method, states that it was very painful and that he was unable to move his leg properly for about two weeks. After undergoing surgery under the new program, Kelly treated his leg as “normal.” On that very night, he was able to sleep on the side of the hip surgery, and the next morning, walked out onto his deck for a cup of coffee. He didn’t even feel like he had an operation.
Surgical Methods from Montreal
Dr. Jacks adapted his brilliance from the methods of a Quebec surgeon and clinical researcher, Pascal-André Vendittoli, after being familiar with them during an orthopaedic conference a couple of years ago. He says that he was blown away by how fast the patients were mobilizing. Jacks feels that one of the toughest jobs as a surgeon is to see your patients struggling after an operation. So he arranged for his team to meet Vendittoli in an operating room in Montreal to observe a procedure in December 2018.
For the past five years, hospitals across Canada have been using Enhanced Recovery After Surgery (ERAS) principles, which originated in Denmark, to cure patients faster. Vendittoli said that he developed his surgical methods based on the same technique. He currently works at the Maisonneuve-Rosemont Hospital in Montreal.
Vendittoli proudly acknowledges that his hospital was the first to accomplish the same-day joint replacement surgery following the ERAS principles in 2016. Following this, his team has successfully trained eighteen other Canadian medical teams, including some surgical units in Alberta, Kelowna, B.C., Ontario, Quebec, and New Brunswick.
Program to be Expanded to Other Surgeries
In Victoria, Jacks says that this new program can prove to be revolutionary – increasing the demand for joint replacements and cutting costs for the hospital staff and patients due to less time spent in recovery, post-operation.
The team has gone on to expand this very successful program to other surgeons by developing a health care provider manual and a new standardized clinical order set. Dr. Jacks states that he is very proud of the exceptional teamwork displayed by his multidisciplinary group, which consists of surgeons, nurses, anesthesiologists, navigators, pharmacists, physiotherapists, CNLs, and other administrative staff. He also adds that this pilot project was a great example of a collaborative effort between their office staff at RebalanceMD and Island Health.
He proudly informs that he was successfully able to operate on two more patients throughout the summer, and all ten of his patients had left the hospital on the same day as their surgeries, without any complications.
Dr, Smit makes a very interesting analogy regarding the VERA approach, comparing it to research on high-performance race cars, which ultimately trickles down into the mainstream automotive industry. He explains that patients like Dan Kelly who can go home on the same day as their surgeries are like the Formula One cars; however, the advantages of using this technology can prove to be beneficial for patients who have previously stayed in hospitals for several days. Due to the new and advanced protocols, patients will now be able to go home faster, experience much less pain, and recover very quickly at home.