Preservation First™

Preservation First refers to my surgical philosophy and approach to caring for my patients. I have supreme confidence in the human body and its ability to heal itself. Therefore, my approach is always to give the body a chance to heal and choose the least invasive approach to surgery. For example, I would much rather repair than replace a part of the body, and if I have to replace something, I will try my best to replace as little as possible. My goal is ALWAYS to do the smallest surgery possible, to give my patient the best outcome possible.

The Genesis of the Approach

Preservation First stems from my wonder and amazement of the ability of the human body to heal. I was trained at the best institutions in the world, and was taught a very dogmatic surgical approach: “If the patient has this, then you do this surgery.” This one size fits all approach is very convenient for the doctors, but in my opinion less so for the patients. The “tried and true” approach is generally based on research and experience that stemmed from decades ago, and was based on the technologies of the time. Well, times change, and new technologies evolve that introduce many more options that haven’t been considered. This doesn’t mean that every new technique or technology is best, and that is where 20+ years of experience comes into play. For my first 5-8 years in practice, I did what I was taught, and I was frustrated by the variability of outcomes. The patients who had more resources had better outcomes than those who had less, what we now know as health care disparities. These social determinants of health played too pivotal of a role in a patient’s post-operative courses. I always had the sense that there had to be a better way, one that was focused on the healing potential of the human body and one that was customized to the particular problem of that patient. In other words, not everyone needed the same surgical solution. After I had enough experience, I began to trust myself, and my approach slowly blossomed. I have been practicing with this Preservation First™ approach, and expanding my techniques, for the past 12 years.

Preservation First Procedures

Many say that if you can keep the human body intact, it is usually better. First of all, if the injury can be treated without surgery, and the body can be allowed to heal on its own, that is the best option! However, if surgery is indicated, then I would much rather do a smaller operation to anatomically arrange the tissues and give your body the chance to heal the injury, rather than doing a bigger surgery to try and replace the injured part. If there is a big injury, the solution does not always have to be all or none. By having a “Less is More” approach, I try to simply help the body to heal, rather than force it to heal. This approach has changed the way I perform many common procedures. Rather offer all of my patients the same procedure, I provide them with a spectrum of small, medium, and larger options depending on their injury or condition.

For knee injuries, such as ligament or meniscal tears, I make every effort to save as much tissue as possible before I will replace or remove tissue. This includes ligament preservation and meniscal repair. For shoulder injuries, such as acromioclavicular joint separation, I will perform a much smaller repair surgery and only utilize the more involved reconstruction procedure if absolutely necessary. For osteoarthritis of the knee my approach is similar. When surgery is indicated, the standard of care is to perform a Total Knee Replacement (TKR). However, many patients have arthritis that is localized to a specific part of the knee. In these situations, Partial Knee Replacement can be performed and typically these patients will have a quicker recover, with lower complications and a more normal feeling knee.

How Does This Impact Physical Therapy (PT)?

I am a firm believer in the importance of physical therapy (PT), and thus I begin PT immediately after surgery for all of my patients to avoid the stiffness that results from immobilization. It is exceedingly rare for me to immobilize a joint in a locked splint or cast after any surgery. Surgery is a controlled injury to the body, and as with any injury there will be bleeding, swelling and discomfort that can all lead to stiffness and disability. With the “Less is More” Preservation First approach, all of these problems are minimized, as is the need for narcotic pain medications. Nonetheless, it is critical after surgery to immediately begin to work on all of these things so as to minimize their deleterious effects and achieve optimal outcomes. We use a team based approach to our treatments, providing patients with multiple points of contact. Providing education is key, so that my patients fully understand what is going to be done to them and so that they can be the MOST IMPORTANT part of the team when it comes to recovery. Knowledge is power, and all of this education about the surgical and recuperative experience is critical in getting great outcomes for our patients.

What Research is Available for Me to Learn More?

Most of my research involves ligament preservation. To date, my team and I have published over 30 peer reviewed articles and 5 book chapters, on topics related to ACL Preservation and/or Ligament Preservation in general. A list of my articles can be found under “Meet Dr. DiFelice”.