PD Dr Patrick Vavken is a leading orthopedic surgeon and traumatologist at the ADUS Clinic in Dielsdorf, where he serves as Chief Physician. With extensive training in Austria, the USA and Switzerland, he specializes in the treatment of shoulder and elbow conditions, as well as in sports medicine. His expertise encompasses both minimally invasive and joint-preserving procedures, with a particular focus on the treatment of joint instability and hypermobility, which often occur in children and adolescents.
PD Dr Vavken has a particular passion for regenerative and joint-preserving surgery, especially in the treatment of cartilage damage. His work aims to preserve joint function and improve his patients’ quality of life in the long term.
His international training and close collaboration with leading medical institutions, including Boston Children’s Hospital and Harvard Medical School, have given him a unique perspective and in-depth knowledge of sports medicine and the treatment of growth-related injuries. He applies this knowledge not only in the treatment of children and adolescents, but also to adult patients who benefit from his expertise.
Under Dr Vavken’s leadership, the ADUS Clinic stands for first-class medical care, characterized by a patient-centered and holistic treatment approach. His commitment to the continuous improvement of treatment processes and patient safety ensures that the clinic continues to operate at the highest level and provides its patients with optimal care.
The editorial team of the Leading Medicine Guide spoke to Dr Vavken about optimal outpatient orthopedics.
Orthopedic conditions affect the musculoskeletal system of the human body, which includes bones, joints, muscles, tendons and ligaments. Common orthopedic conditions include injuries caused by accidents or sporting activities, as well as degenerative conditions such as osteoarthritis or osteoporosis, which can develop over the course of a lifetime. These conditions often lead to pain, restricted mobility and a reduced quality of life. Thanks to modern medical advances, there are now a wide range of outpatient treatment options available, making it possible to treat many orthopedic conditions effectively and gently. These include minimally invasive procedures, physical therapies, and regenerative methods aimed at supporting the body’s natural healing process and avoiding surgical intervention where possible.
Over the last 10–15 years, medicine has changed significantly, leading to an increasing number of procedures being carried out on an outpatient basis.
Outpatient treatment in Switzerland
In Switzerland, outpatient treatment is fully covered by health insurance. The costs of inpatient stays are shared between insurance companies (45%) and cantons (55%). It is therefore clear that there is considerable political interest in the shift toward outpatient care.
“It is certainly true that most patients welcome outpatient treatment. They are reluctant to spend time in a hospital, accompanied by concerns about possibly catching an infection there. Outpatient treatments are, of course, also possible. I spent quite some time in the USA, and there 99.99% of treatments were carried out on an outpatient basis, which was also great for us doctors, as you could simply go home after the last patient of the day without having to plan for long rounds or inpatient issues,” explains Dr Vavken, before we really get into the topic and explore the question of why so many treatments are now possible on an outpatient basis at all:
“All in all, we doctors have all become much better. We can now administer deep anesthesia and wake the patient up at precisely the right moment, without them feeling unwell for days on end due to the amount of anesthetic. We also have a much better understanding and more options for effective pain management. For instance, in pain management using catheters, elastomer – a flexible, rubber-like material – can act as an elastic balloon within the pain pump, delivering the medication evenly into the catheter and thus into the patient’s body. From a purely surgical perspective, of course, a great deal has changed. Just consider, for example, how a cruciate ligament operation was performed 15 years ago – the entire leg was cut open from the hip to the ankle. Today, there are only two small incisions, and the operation no longer takes four hours, but just 45 minutes. Thanks to all these improvements in terms of operation time, pain and so on, surgery is no longer such a traumatic and dramatic experience as it was 10–15 years ago. On top of that, everyone would rather be at home than in a hospital. After all, you can recover on your own sofa in your own familiar surroundings.”
Technologies such as endoscopic procedures and robot-assisted surgery have made it possible to perform operations with greater precision and in a less invasive manner. These advances are supported by improved anesthesia technologies, which enable a safe and rapid recovery, often without the need for general anesthesia. Furthermore, healing techniques have improved. New wound care products such as advanced wound adhesives and fast-healing sutures help patients recover more quickly. Improved patient management strategies allow for effective monitoring even after the procedure, making outpatient procedures safer.
In orthopedics, numerous operations can be performed on an outpatient basis, made possible by the use of minimally invasive techniques and advances in medical care.
“Almost any orthopedic operation can be performed on an outpatient basis, but not automatically on every patient. If, for example, a young and fit athlete needs a new hip, a same-day outpatient procedure is theoretically possible. To illustrate this specifically: the patient would arrive at the hospital at 10 am on Wednesday, the operation would take place at 3 pm, and they could leave the hospital at 3 pm on Thursday. This would then comply with the 23-hour rule, under which this procedure would still be classified as outpatient. “For an overweight patient or someone with heart problems, such a procedure would not be possible, not even if only a minor meniscus operation were required,” explains Dr Vavken.
To minimize the complication rate and the risk of readmissions following outpatient orthopedic procedures, both preoperative and postoperative management strategies can be optimized.
Thorough preoperative planning is crucial prior to the procedure. This begins with a comprehensive patient assessment, during which medical history, existing conditions and potential risk factors are carefully examined. An individual risk analysis helps to identify patients for whom additional precautions or alternative treatment options should be considered. Providing the patient with detailed information about the procedure, post-operative care and potential risks also helps ensure that the patient is better prepared and follows post-operative instructions carefully.
“It is important to ensure that the patient knows what they must do and what they can do once they are at home after outpatient surgery. And as a doctor, you must also trust the patient to do this. This requires thorough information provision prior to the procedure. What is naturally lacking in the outpatient setting, of course, is empathy, so one has to think ahead here. And that also involves seemingly minor details. For instance, the patient shouldn’t turn up for outpatient knee surgery in tight jeans, because they wouldn’t be able to get back into them straight after the procedure. We must ensure that such matters are explained to the patient beforehand. For me as a surgeon, speaking from the other side, it doesn’t matter whether I’m operating on an outpatient, inpatient or short-stay basis. Ultimately, I have to ensure that I’ve done everything correctly and decide whether I can actually send the patient home. In this regard, the anesthesiologist actually has more to consider and faces greater demands, as they are responsible for stabilizing the patient and must also ensure that the patient wakes up safely and that the nausea that often accompanies the procedure is under control. The patient themselves naturally has certain expectations too – after all, they pay their health insurance contributions. Conversely, it is often the case that I really have to convince patients when it comes to admitting them to the ward if there are any uncertainties,” explains Dr Vavken.
Several strategies are important in the post-operative period.
“Typically, we carry out the first post-operative check-up, which also involves removing the stitches, around two weeks after the operation. The patient’s GP can also remove the stitches, as it is medically entirely sufficient for me to see the patient again only after six weeks. By then, the patient should have got through the initial phase of healing pain and may even have attended physiotherapy a few times – which gives me a much more productive basis for discussion with the patient. Should minor wound bleeding or irritation occur in the meantime, the patient can of course be seen at short notice. We put together so-called ‘packages’ for our patients so that they know what they should or can do and when. Each patient receives a concise PDF containing all the information they need. This starts with the registration form for the operation, followed by an information section, a medical certificate for sick leave, the prescription for the health insurance company, instructions for physiotherapy, and a recommended code of conduct for the patient. This way, the patient knows exactly how to handle plasters or painkillers, for example, when they are allowed to shower, drive a car, and so on. Around 90% of all questions are answered in these packages. The pack also contains a list of emergency contact numbers. “It is important that the patient does not feel left on their own. Often, the questions a patient has are quite simple and human,” explains Dr Vavken.
Post-operative pain and inflammation management plays a central role. Effective pain control, tailored to the patient’s needs, can help facilitate recovery and reduce the risk of complications. However, it can sometimes happen that a patient does need to be admitted to hospital after an operation.
Commenting on possible complications, Dr Vavken says: “Some patients experience circulatory problems after surgery, particularly the elderly. Their blood pressure may be too high or too low. Naturally, we do not send patients with such a blood pressure crisis home. Other patients, including younger ones, sometimes suffer an apnoea episode as a reaction to the anesthesia. These patients then need to be monitored for 24 hours and remain on the ward. When I used to work at Harvard (Boston) in the US, we performed 1,000 procedures a year – of these patients, two to three were admitted as inpatients, while all the others were treated as outpatients and sent home.”
A comparison between outpatient and inpatient procedures shows that both approaches offer advantages, but can have different effects on the healing process and quality of life.
Outpatient surgery is encouraged by the Federal Ministry of Health in Germany, and in Switzerland too, many operations are already performed on an outpatient basis. “However, I have the impression that there is still no good solution from a political perspective regarding the shift toward outpatient care, and that dealing with the issue is still being pushed aside to some extent. After all, it also concerns patients receiving acute care who are billed via the so-called ‘short-stay DRGs’. It is still unclear to hospitals how to deal with patients requiring short- or medium-term care. As long as a hospital earns more from in-patient admissions than from those treated on an outpatient basis, the hospital will do nothing to promote the shift to outpatient care. In my opinion, it would make a lot of sense to physically separate inpatient and outpatient facilities. We need a dedicated outpatient infrastructure. Here in Switzerland, we have some huge hospitals – that’s not what’s needed for outpatient treatment. It all needs to be better organized, including the billing system. The distribution of patients should also be improved, so that those requiring minor procedures are treated only on an outpatient basis, those requiring major procedures are referred to a suitable university hospital, and those requiring moderate procedures remain in hospital as normal. In this respect, specialist centers would also be important, as treating a mix of conditions of varying severity within a single facility is challenging. One problem, however, is that everyone wants to do everything, which is also down to funding and certainly calls into question the credibility of their respective areas of expertise,” Dr Vavken points out, adding:
“Here at the ADUS Clinic, 15–20% of all procedures are carried out on an outpatient basis. Now, in Switzerland (after 15 years of discussion), the Federal Council has adopted a uniform funding model for outpatient procedures. However, hospitals are underfunded in the inpatient sector, which leads to a liquidity problem. Under the new funding model, part of the money saved is to be invested in better inpatient care. Outpatient care definitely makes sense! Both patients and doctors are in favor of it. A sustainable approach is needed here, as healthcare costs cannot be reduced overnight. There must be outpatient centers – this works very well in other countries!” With this wish, we conclude our conversation.
Thank you very much, Dr Vavken, for these interesting insights into the shift toward outpatient care!
