Outpatient Total Joint Arthroplasty


18 Outpatient Total Joint Arthroplasty


Michael Pollock BSc MSc1, and Brent Lanting MD2


1 University of Limerick, Limerick, Ireland


2 Division of Orthopaedic Surgery, Department of Surgery, University Hospital, London Health Sciences Centre, Western University, London, ON, Canada


Clinical scenario



  • A patient without significant co‐morbidities undergoing a primary total joint arthroplasty (TJA).
  • The patient has sufficient caregiver support at home.
  • The patient lives close to the operating hospital in case of emergency.

Top three questions



  1. In eligible patients undergoing TJA, does performing the procedure and discharging the patient on the same day of the operation result in an additional risk of serious adverse events or readmissions compared to the same procedures performed on an inpatient basis?
  2. In eligible patients undergoing TJA, does performing the procedure on an outpatient basis result in cost savings compared to the same procedures performed on an inpatient basis?
  3. In patients undergoing an outpatient TJA, what factors are necessary to ensure a successful procedure compared to the general population undergoing TJA?

Question 1: In eligible patients undergoing TJA, does performing the procedure and discharging the patient on the same day of the operation result in an additional risk of serious adverse events or readmissions compared to the same procedures performed on an inpatient basis?


Rationale


The primary concern with performing outpatient TJA is patient safety. As readmission rates are increasingly used as a performance indicator, there is concern that outpatient surgery may increase these rates. If TJA are going to be performed on an outpatient basis, it is imperative to ensure there are no additional risks of serious adverse events compared to the same procedures performed on an inpatient basis.


Clinical comment


The major deterrent for outpatient TJA is patient safety. Proponents against outpatient joint replacements advocate that the majority of complications following surgery occur within the time‐frame of the typical hospital stay.1 There is a fear that outpatient TJA will lead to additional adverse events and an increase in hospital readmissions. However, the majority of literature illustrates that outpatient joint replacements can be safely performed with comparable complication rates to similar inpatient procedures.


Available literature and quality of the evidence



  • Level IV: 1 systematic review.2
  • Level I: 2 randomized controlled trials (RCTs).3,4
  • Level III: 2 large observational studies.5,6

Findings


To assess the safety of performing outpatient total joint arthroplasty recent literature has quantified the rate of adverse events following outpatient arthroplasty as either acute (intraoperative or immediately perioperative) or postdischarge. A systematic review of outpatient total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA) reported that the rate of acute adverse events ranged from 0 to 25%, whereas the rate of postdischarge adverse events ranged from 0 to 7%.2 More importantly, this review reported that outpatient procedures did not lead to a higher complication rate compared to inpatient procedures.2


Two RCTs allocated study participants undergoing a THA to be either discharged on the day of surgery (outpatient) or admitted to the hospital overnight following surgery (inpatient).3,4 In both RCTs, there were no significant differences in rates of adverse events between study arms.3,4 Similarly, two large retrospective reviews concluded that outpatient THA can be safely performed in appropriately selected patients.5,6 Courtney et al. conducted a retrospective review of the National Surgical Quality Improvement Program (NSQIP) records between 2011 and 2014 pertaining to outpatient TJA.5 They found that of the 169 406 patients who underwent a primary TKA or THA 1220 were performed on an outpatient basis (0.7%). Outpatient TJA alone did not increase the risk of readmission (odds ratio [OR] = 0.652; 95% confidence interval [CI]: 0.243–1.746; p = 0.395) or reoperation (OR 1.168; 95% CI: 0.374–3.651; p = 0.789). Furthermore, they found that outpatient TJA was a negative independent risk factor for complications (OR: 0.459; 95% CI: 0.371–0.567; p <0.001).5 Nelson et al. conducted a similar study retrospectively reviewing 63 844 THAs between 2004 and 2015 tracked by NSQIP.6 Of these patients, 420 (0.66%) were performed as an outpatient. These authors reported that outpatients had no difference in any of the adverse events evaluated other than blood transfusion, which was less for the outpatient group compared to the inpatient group (3.69% vs 9.06%; p <0.001).6 This evidence supports the notion that outpatient TJA can be performed safely in appropriately selected patients. Li et al. remark that the essential components of a successful outpatient TJA program include proper patient selection, preoperative patient/family education, perioperative multidisciplinary coordination and opioid‐sparing analgesia, and early and effective postdischarge planning.7


Resolution of clinical scenario

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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Outpatient Total Joint Arthroplasty
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