Advanced Knee Surgery at Cedars-Sinai Leads to Faster Recovery

Mohan Makkar's right knee pain had become so debilitating that he struggled to walk, withdrew from friends and found himself constantly irritable. Conventional treatments like corticosteroid injections weren't helping.

"I had tried many treatment options, but the pain was still interfering with my day-to-day life," Makkar said.

Makkar, 73, underwent conventional knee replacement surgery for his right knee in 2023. While the procedure ultimately relieved his pain and helped him regain mobility, the recovery was long and difficult. For weeks, he relied on a walker, needed prescription pain medication and avoided social activities as he slowly worked his way back to daily life.

However, for Makkar's second knee replacement-this time for his left knee-he benefited from a new approach to the procedure intended to speed recovery and lessen pain.

The new approach worked. This time, Makkar used a walker for only two days, met up with his friends within days and relied on Tylenol instead of prescription painkillers.

"This recovery felt so much easier," Makkar said.

People are living longer and outliving their joints. However, many patients avoid much-needed surgery because they expect a tough recovery, said Sean Rajaee, MD, chief of Arthroplasty at Cedars-Sinai Orthopaedics, and Makkar's surgeon for both of his procedures.

To help patients recover faster and walk sooner after surgery-which can reduce the risk of complications, such as blood clots, pneumonia and urinary tract infections-Cedars-Sinai launched an enhanced joint replacement recovery effort. As a result, nearly 80% of total joint replacement patients are walking and going home within 24 hours, up from 68% in 2022.

"Now that patients are hearing about improved techniques and smoother recoveries, there is a growing demand for faster care-and Cedars-Sinai is committed to meeting that need," Rajaee said.

Building a Better Recovery

To speed recovery time for total joint replacementpatients, Cedars-Sinai leaders developed guidelines to identify patients best suited for an enhanced recovery regimen. Surgeons consider factors such as overall health and age. Nurses screen patients to assess their home environment and whether they have reliable support after surgery.

Collaboration among surgeons, anesthesiologists, nurses and physical therapists is another key element of the program. Anesthesiologist Michael Kissen, MD, said teams regularly meet to discuss optimal treatment plans, including medication use, procedure timing and wound dressings, with the shared goal of getting patients up and moving within hours after joint replacement surgery.

"Every part of this pathway has existed for a while on its own, but coordinating all these processes and fine-tuning what we do through constant feedback and regular meetings is the novel concept behind creating this pathway," Kissen said.

Rajaeesaid educating patients also helps. During presurgical appointments, setting expectations about the recovery plan and explaining the benefits of the approach prepares patients mentally.

The new approach has worked so well that plans are underway to expand the approach to other procedures, beginning with robotic prostate surgeries.

Medical Advances Speed Healing

Advances in pain management play a major role in helping patients walk soon after surgery. Rather than relying solely on general anesthesia, anesthesiologists often use spinal anesthesia, a form of neuraxial anesthesia that numbs the lower body while avoiding many side effects of general anesthesia. Compared with general anesthesia, spinal anesthesia is linked with fewer respiratory complications, less postoperative pain and nausea, reduced need for narcotics, and earlier mobilization.

"Spinal anesthesia has been used safely for years," Kissen said. "What's changed is our shift to shorter-acting medications that last through surgery but wear off quickly, so patients can move and start therapy much sooner."

In addition to spinal anesthesia, anesthesiologists use regional anesthesia techniques, such as peripheral nerve blocks and nerve catheters, to provide longer-lasting pain control after surgery while minimizing opioid use. One commonly used approach for knee surgery is the adductor canal nerve block, which targets sensory nerves while sparing motor function. This allows patients to experience pain relief around the knee without limiting their ability to walk immediately after surgery. In some cases, a catheter is placed near the nerve so a pump can deliver local anesthetic continuously for two to three days after surgery.

Rajaee said robotic-assisted surgery also helps patients walk sooner by reducing tissue trauma and preserving healthy muscle.

Second Surgery, With Less Pain

When Rajaee performed Makkar's first knee replacement, he used a tourniquet, a common technique that reduces blood flow to the knee to allow surgeons to place an implant.

However, during the second procedure, Rajaee opted for a tourniquet-free approach, a newer method shown to reduce pain after surgery. He also used what's called a quadriceps-sparing midvastus approach, which avoids cutting through the main tendon attached to the large muscle on the front of the thigh, preserving the tissue.

Anesthesiologists added a low dose of ketamine to target pain pathways not relieved by narcotics during the second surgery. Makkar experienced a smoother recovery and was thrilled with his results.

"At my age, I am super happy I'm walking," he said.

Read more on the Cedars-Sinai Newsroom: Cedars-Sinai Slashes Anesthesia Emissions, Reducing Carbon Footprint