The Keys to Safe, Successful Outpatient Total Joint Arthroplasty

    Postoperative management of total joint arthroplasty patients has come a long way in the past 30 or so years, from a week-long recovery in a hospital bed after surgery to walking within hours of the procedure and going home the same day.

    And now that the Centers for Medicare and Medicaid Services has removed total knee arthroplasty, and is planning to remove total hip arthroplasty, from the inpatient-only list, outpatient total joint arthroplasty is clearly here to stay.

    Speaking at ICJR’s course for senior residents and fellows, Advanced Techniques in Total Hip and Knee Arthroplasty, Gregory G. Polkowski II, MD, MSc, said that 4 advances in perioperative management have enabled surgeons to safely send total joint arthroplasty patients home soon after surgery:

    • Weight-bearing shortly after surgery
    • Blood management with the help of tranexamic acid
    • Multimodal pain management
    • Accelerated rehabilitation protocols

    Combined, these advances have facilitated earlier mobilization after surgery and earlier return home.

    Dr. Polkowski, from Vanderbilt University Medical Center in Nashville, Tennessee, noted that outpatient surgery is the natural progression in total joint arthroplasty, with multiple motivating factors:

    • Patient safety. By going home soon after surgery, total joint arthroplasty patients avoid the risk of hospital errors – one of the leading causes of death among hospitalized patients.
    • Patient satisfaction. Patients are generally happier at home, where they are in control. Things can move slowly at big hospitals, such as having patients wait hours in recovery because a room is not yet available, causing frustration for patients and their families.
    • Surgeon satisfaction. Surgeons have more control over staffing and processes when they work in an ambulatory surgery center (ASC), as well as economic incentives if they have a share in ASC ownership.

    Of course, there are also potential concerns, Dr. Polkowski said, including:

    • Patient safety. Patients who are discharged the same day as surgery could develop a serious medical complication at home.
    • Patient satisfaction. Patients who say they want to go home the same day as surgery may have a change of heart when it comes time for discharge; they may get nervous about going home so soon. Also, some patients can experience severe rebound pain at home, decreasing their satisfaction with the procedure.
    • Readmission risk. Medical or surgical complications, including intractable pain, can send patients to the emergency department.
    • Reduction in the surgeon’s value to the hospital. Hospitals make more money when total joint arthroplasty is performed as an inpatient, rather than outpatient, procedure. Outpatient surgery could also increase costs to the patient, depending on the type of insurance they have.

    Although there are limitations to the data available on outcomes, Dr. Polkowski said that in general, outpatient total joint arthroplasty is safe, with high patient satisfaction and low readmission rates.

    He sees 2 keys to this success:

    • Select the right patients for the procedure. When starting to offer outpatient total joint arthroplasty, surgeons should be conservative and begin with the healthiest patients, Dr. Polkowski said. This means avoiding patients with comorbidities such as diabetes and coronary artery disease, as well as those with chronic pain and a high degree of anxiety.
    • Ensure that patients are properly educated preoperatively and that their expectations are appropriately managed. Everything patients will need at home after surgery must be in place before the procedure. That includes practicing rehab exercises, how to use a walker and/or cane, and how to go up and down the stairs before surgery. The surgeon should also give the patient a back-up plan for pain control and establish lines of postoperative communication in case there are questions or problems.

    Click the image above to watch Dr. Polkowski’s presentation and learn more about outpatient total joint arthroplasty.

    Disclosures: Dr. Polkowski has no disclosures relevant to this presentation.