Low Rates of Adverse Events Following Ambulatory Outpatient Total Hip Arthroplasty at a Free-Standing Surgery Center

Safety Considerations for Outpatient Arthroplasty

Since 2018, the number of total joint arthroplasties (TJAs) performed on an outpatient basis has dramatically increased. Both surgeon and anesthesiologist should be aware of the implications for the safety of outpatient TJAs and potential patient risk factors that could alter this safety profile. Although smaller studies suggest that the risk of negative outcomes is equivalent when comparing outpatient and inpatient arthroplasty, larger database analyses suggest that, even when matched for comorbidities, patients undergoing outpatient arthroplasty may be at increased risk of surgical or medical complications. Appropriate patient selection is critical for the success of any outpatient arthroplasty program. Potential exclusion criteria for outpatient TJA may include age greater than 75 years, bleeding disorder, history of deep vein thrombosis, uncontrolled diabetes mellitus, and hypoalbuminemia, among others. Patient optimization before surgery is also warranted. The potential risks of same-day versus next-day discharge have yet to be elicited in a large-scale manner.

Ambulatory Surgery Centers Reduce Patient Out-of-Pocket Expenditures for Isolated Arthroscopic Rotator Cuff Repair, but Patient Out-of-Pocket Expenditures Are Increasing at a Faster Rate Than Total Healthcare Utilization Reimbursement From Payers

PURPOSE

To categorize and trend annual out-of-pocket expenditures for arthroscopic rotator cuff repair (RCR) patients relative to total healthcare utilization (THU) reimbursement and compare drivers of patient out-of-pocket expenditures (POPE) in a granular fashion via analyses by insurance type and surgical setting.

METHODS

Patients who underwent outpatient arthroscopic RCR in the United States from 2013 to 2018 were identified from the IBM MarketScan Database. Primary outcome variables were total POPE and THU reimbursement, which were calculated for all claims in the 9-month perioperative period. Trends in outcome variables over time and differences across insurance types were analyzed. Multivariable analysis was performed to investigate drivers of POPE.

RESULTS

A total of 52,330 arthroscopic RCR patients were identified. Between 2013 and 2018, median POPE increased by 47.5% ($917 to $1,353), and median THU increased by 9.3% ($11,964 to $13,076). Patients with high deductible insurance plans paid $1,910 toward their THU, 52.5% more than patients with preferred provider plans ($1,253, P = .001) and 280.5% more than patients with managed care plans ($502, P = .001). All components of POPE increased over the study period, with the largest observed increase being POPE for the immediate procedure (P = .001). On multivariable analysis, out-of-network facility, out-of-network surgeon, and high-deductible insurance most significantly increased POPE.

CONCLUSIONS

POPE for arthroscopic RCR increased at a higher rate than THU over the study period, demonstrating that patients are paying an increasing proportion of RCR costs. A large percentage of this increase comes from increasing POPE for the immediate procedure. Out-of-network facility status increased POPE 3 times more than out-of-network surgeon status, and future cost-optimization strategies should focus on facility-specific reimbursements in particular. Last, ambulatory surgery centers (ASCs) significantly reduced POPE, so performing arthroscopic RCRs at ASCs is beneficial to cost-minimization efforts.

CLINICAL RELEVANCE

This study highlights that although payers have increased reimbursement for RCR, patient out-of-pocket expenditures have increased at a much higher rate. Furthermore, this study elucidates trends in and drivers of patient out-of-pocket payments for RCR, providing evidence for development of cost-optimization strategies and counseling of patients undergoing RCR.

Increased rate of out-of-network surgeon selection for hip arthroscopy compared to more common orthopedic sports procedures

Background

Demand for hip arthroscopy (HA) has increased, but shortfalls in HA training may create disparities in care access. This analysis aimed to (1) compare out-of-network (OON) surgeon utilization for HA with that of more common orthopedics sports procedures, including rotator cuff repair (RCR), partial meniscectomy (PM), and anterior cruciate ligament reconstruction (ACLR), (2) compare the HA OON surgeon rate with another less commonly performed procedure, meniscus allograft transplant (MAT), and (3) analyze trends and predictors of OON surgeon utilization.

Methods

The 2013-2017 IBM MarketScan database identified patients under 65 who underwent HA, RCR, PM, ACLR, or MAT. Demographic differences were determined using standardized differences. Cochran-Armitage tests analyzed trends in OON surgeon utilization. Multivariable logistic regression identified predictors of OON surgeon utilization. Statistical significance was set to p < 0.05 and significant standardized differences were >0.1.

Results

410,487 patients were identified, of which 12,636 patients underwent HA, 87,607 RCR, 233,241 PM, 76,700 ACLR, and 303 MAT. OON surgeon utilization increased for HA, rising from 7.98 % in 2013 to 9.37 % in 2017 (p = 0.026). Compared to RCR, PM, and ACLR, HA was associated with higher likelihood of OON surgeon utilization. Usage of ambulatory surgery centers (ASCs) was predictive of higher OON surgeon rates along with procedure year, insurance plan type, and geographic region. HA performed in an ASC was 13 % less likely to have an OON surgeon (p = 0.047).

Conclusion

OON surgeon utilization generally declined but increased for HA. HA was a predictor of OON surgeon status, possibly because HA is a technically complicated procedure with fewer trained in-network providers. Other predictors of OON surgeon status included ASC usage, PPO/EPO plan type, and Northeast geographic region. There is a need to improve access to experienced HA providers-perhaps with prioritization of HA training in residency and fellowship programs-in order to address rising OON surgeon utilization.

Predictors of Failure to Achieve Planned Same-Day Discharge after Primary Total Joint Arthroplasty: a Multivariable Analysis of Perioperative Risk Factors

INTRODUCTION

Failure to achieve planned same-day discharge (SDD) primary total joint arthroplasty (TJA) occurs in as many as 7% to 49% of patients in the United States. This study evaluated the association between 43 perioperative risk factors and SDD failure rates.

METHODS

A retrospective analysis of prospectively collected data from 466 primary TJAs with planned SDD to home was performed. Surgeries were performed at an academic tertiary care center comprising a hospital facility and a stand-alone ambulatory surgery center (ASC) on the same campus. Factors associated with failed SDD were identified using a multivariable analysis.

RESULTS

Only one of 316 (0.3%) patients who underwent surgery in the ASC failed planned SDD ( P < 0.001) compared with 33.3% of 150 patients who underwent surgery in the hospital. The ASC failure was because of pain that interfered with physical therapy. Sixty-two percent (n = 31) of hospital failures were attributed to medical complications, 24% (n = 12) to physical therapy clearance, 8% (n = 4) to not being seen by internal medicine or therapy on the day of surgery, and 6% (n = 3) to unknown causes. Failure was increased in patients with preoperative anemia ( P = 0.003), nonwhite patients ( P = 0.002), patients taking depression/anxiety medication ( P = 0.015), and for every 10-morphine milligram equivalent increase in opioids consumed per hour in the postacute care unit ( P = 0.030).

DISCUSSION

Risk stratification methods used to allocate patients to ASC versus hospital outpatient TJA surgery predicted SDD success. Most failures were secondary to medical causes. The findings of this study may be used to improve perioperative protocols enabling the safe planning and selection of patients for SDD pathways.

Older Age, Male Sex, and Early Start Time Lengthen the Recovery Room Stay Following Total Joint Arthroplasty in an Ambulatory Surgical Center

Background

Total joint arthroplasty (TJA) performed in the ambulatory surgical center (ASC) has been shown to be safe and cost-effective for an expanding cohort of patients. As criteria for TJA in the ASC become less restrictive, data guiding the efficient use of ASC resources are crucial.

Purpose

We sought to identify factors associated with length of stay in the recovery room after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed in the ASC.

Methods

We conducted a retrospective review of 411 patients who underwent primary THA or TKA at our institution's ASC between November 2020 and March 2022. We collected patient demographics, perioperative factors, success of same-day discharge (SDD), and length of time in the recovery room.

Results

Of 411 patients, 100% had successful SDD. The average length of time spent in recovery was 207 minutes (SD: 73.9 minutes). Predictors of longer time in recovery were increased age, male sex, and operative start time before 9:59 am. Body mass index, preoperative opioid use, Charlson Comorbidity Index, type of surgery (THA vs TKA), urinary retention risk, and type of anesthesia (spinal vs general) were not significant predictors of length of time in the recovery room.

Conclusion

In this retrospective study, factors associated with increased length of time in the recovery room included older age, male sex, and operative start time before 9:59 am. Such factors may guide surgeons in determining the optimal order of cases for each day at the ASC, but further prospective studies should seek to confirm these observations.

Safety of Outpatient Total Hip Arthroplasty Performed in Patients 65 Years of Age and Older in an Ambulatory Surgery Center

Studies regarding the safety of same day discharge (SDD) in patients ≥65 years of age undergoing total hip arthroplasty (THA) are lacking. A retrospective review of 69 patients undergoing SDD following primary THA in 2 free-standing ambulatory surgical centers (ASCs) was performed to evaluate for safety and complications. Sixty-six patients met SDD goals, while 1 patient required transport to a hospital for transfusion, and 2 patients underwent overnight observation in the ASC. This study reveals that with appropriate preoperative evaluation, patient selection, and education, THA in a free-standing ASC can be safely performed in patients ≥65 years of age.

Success of Same-Day Discharge Total Hip and Knee Arthroplasty: Does Location Matter?

BACKGROUND

Same calendar day discharge (SCDD) following total joint arthroplasty is desirable for patients and surgeons alike. The aim of this study was to compare the success rate of SCDD in an ambulatory surgical center (ASC) versus hospital setting.

METHODS

A retrospective analysis was performed on 510 patients who underwent primary hip and knee total joint arthroplasty over a 2-year period. The final cohort was divided into 2 groups based on location of surgery: ASC (N = 255) or hospital (N = 255). Groups were matched for age, sex, body mass index, American Society of Anesthesiologists score, and Charleston Comorbidity Index. Successes of SCDD, reasons for failure of SCDD, length of stay (LOS), and 90-day readmission and complication rates were recorded.

RESULTS

All SCDD failures were from the hospital setting (36 [65.6%] total knee arthroplasty [TKA] and 19 [34.5%] total hip arthroplasty [THA]). There were no failures from the ASC. The main causes of failed SCDD in both THA and TKA included failed physical therapy and urinary retention. Regarding THA, the ASC group had a significantly shorter total LOS (6.8 [4.4 to 11.6] versus 12.8 [4.7 to 58.0] hours, P < .001). Similarly, TKA patients had a shorter LOS in the ASC (6.9 [4.6 to 12.9] versus 16.9 [6.1 to 57.0], P < .001). Total 90-day readmission rates were higher in the ASC group (2.75% versus 0%), where all but 1 patient underwent TKA. Similarly, complication rates were higher in the ASC group (8.2% versus 2.75%), where all but 1 patient underwent TKA.

CONCLUSION

TJA performed in the ASC, compared to the hospital setting, allowed for reduced LOS and improved success of SCDD.

Inconsistent Classification of "Outpatient" Surgeries Leads to Different Outcomes Following Total Hip Arthroplasty in Medicare Beneficiaries: A Critical Analysis

BACKGROUND

With rising utilization of outpatient total hip arthroplasty (THA) in older patients including Medicare beneficiaries, the objective was to compare differences in definition including (1) patient demographics; (2) lengths of stay (LOS); and (3) outcomes of "outpatient" (stated status) versus "same-day discharge" (SDD) (actual LOS = 0 days) utilizing a nationwide database.

METHODS

A national database from 2015 to 2019 was queried for Medicare-aged patients undergoing outpatient THA. Total outpatient THAs (N = 6,072) were defined in one of 2 ways: either "outpatient" by the hospital (N = 2,003) or LOS = 0 days (N = 4,069). Demographics, LOS, discharge destinations, and complications were compared between groups. Logistic regression models computed odds ratios (ORs) for factors leading to complications, readmissions, and nonhome discharges. P values < .008 were significant.

RESULTS

Women (OR: 1.19, P = .002), diabetes mellitus (OR: 1.31, P = .003), general anesthesia (OR: 1.24, P = .001), and longer operative times (≥95 minutes) (OR: 1.82, P < .001) were associated with 'outpatient' designation versus SDD. Within the hospital-defined 'outpatient' cohort, 49.1% (983 of 2,003) were discharged the same day (LOS = 0 days), and 21.8% had LOS 2 or more days. The hospital-defined 'outpatient' cohort had greater odds of nonhome discharges (6.3 versus 2.8%; OR: 1.88, P < .001) compared to SDD surgeries. The incidence was higher for any complication among hospital-defined 'outpatient' designated patients compared to SDD (5.5 versus 3.9%, P = .007).

CONCLUSIONS

Outpatient surgeries may be misleading and often do not correlate with SDD, as over 20% remain in the hospital 2 or more days. Investigators should quantitatively define the "outpatient" status by actual LOS to allow standardization and results comparison.

LEVEL OF EVIDENCE

III.

Hip Arthroscopy Trends: Increasing Patient Out-of-Pocket Costs, Lower Surgeon Reimbursement, and Cost Reduction With Utilization of Ambulatory Surgery Centers

PURPOSE

To (1) report on trends in immediate procedure reimbursement, patient out-of-pocket expenditures, and surgeon reimbursement in hip arthroscopy (2) compare trends in ambulatory surgery centers (ASC) versus outpatient hospitals (OH) utilization; (3) quantify the cost differences (if any) associated with ASC versus OH settings; and 4) determine the factors that predict ASC utilization for hip arthroscopy.

METHODS

The cohort for this descriptive epidemiology study was any patient over 18 years identified in the IBM MarketScan Commercial Claims Encounter database who underwent an outpatient hip arthroscopy, identified by Current Procedural Terminology codes, in the United States from 2013 to 2017. Immediate procedure reimbursement, patient out-of-pocket expenditure, and surgeon reimbursement were calculated, and a multivariable model was used to determine the influence of specific factors on these outcome variables. Statistically significant P values were less than .05, and significant standardized differences were more than 0.1.

RESULTS

The cohort included 20,335 patients. An increasing trend in ASC utilization was observed (P = .001), and ASC utilization for hip arthroscopy was 32.4% in 2017. Patient out-of-pocket expenditures for femoroacetabular impingement surgery increased 24.3% over the study period (P = .003), which was higher than the rate for immediate procedure reimbursement (4.2%; P = .007). ASCs were associated with $3,310 (28.8%; P = .001) reduction in immediate procedure reimbursement and $47 (6.2%; P = .001) reduction in patient out-of-pocket expenditure per hip arthroscopy.

CONCLUSIONS

ASCs provide a significant cost difference for hip arthroscopy. Although there is an increasing trend toward ASC utilization, it remains relatively low at 32.4% in 2017. Thus, there are opportunities for expanded ASC utilization, which is associated with significant immediate procedure reimbursement difference of $3,310 and patient out-of-pocket expenditure difference of $47 per hip arthroscopy case, ultimately benefiting healthcare systems, surgeons, and patients alike.

LEVEL OF EVIDENCE

Level III, retrospective comparative trial.

Validation of Machine Learning Model Performance in Predicting Blood Transfusion After Primary and Revision Total Hip Arthroplasty

BACKGROUND

The rates of blood transfusion following primary and revision total hip arthroplasty (THA) remain as high as 9% and 18%, respectively, contributing to patient morbidity and healthcare costs. Existing predictive tools are limited to specific populations, thereby diminishing their clinical applicability. This study aimed to externally validate our previous institutionally developed machine learning (ML) algorithms to predict the risk of postoperative blood transfusion following primary and revision THA using national inpatient data.

METHODS

Five ML algorithms were trained and validated using data from 101,266 primary THA and 8,594 revision THA patients from a large national database to predict postoperative transfusion risk after primary and revision THA. Models were assessed and compared based on discrimination, calibration, and decision curve analysis.

RESULTS

The most important predictors of transfusion following primary and revision THA were preoperative hematocrit (<39.4%) and operation time (>157 minutes), respectively. All ML models demonstrated excellent discrimination (area under the curve (AUC) >0.8) in primary and revision THA patients, with artificial neural network (AUC = 0.84, slope = 1.11, intercept = -0.04, Brier score = 0.04), and elastic-net-penalized logistic regression (AUC = 0.85, slope = 1.08, intercept = -0.01, and Brier score = 0.12) performing best, respectively. On decision curve analysis, all 5 models demonstrated a higher net benefit than the conventional strategy of intervening for all or no patients in both patient cohorts.

CONCLUSIONS

This study successfully validated our previous institutionally developed ML algorithms for the prediction of blood transfusion following primary and revision THA. Our findings highlight the potential generalizability of predictive ML tools developed using nationally representative data in THA patients.

Artificial neural networks for the prediction of transfusion rates in primary total hip arthroplasty

BACKGROUND

Despite advancements in total hip arthroplasty (THA) and the increased utilization of tranexamic acid, acute blood loss anemia necessitating allogeneic blood transfusion persists as a post-operative complication. The prevalence of allogeneic blood transfusion in primary THA has been reported to be as high as 9%. Therefore, this study aimed to develop and validate novel machine learning models for the prediction of transfusion rates following primary total hip arthroplasty.

METHODS

A total of 7265 consecutive patients who underwent primary total hip arthroplasty were evaluated using a single tertiary referral institution database. Patient charts were manually reviewed to identify patient demographics and surgical variables that may be associated with transfusion rates. Four state-of-the-art machine learning algorithms were developed to predict transfusion rates following primary THA, and these models were assessed by discrimination, calibration, and decision curve analysis.

RESULTS

The factors most significantly associated with transfusion rates include tranexamic acid usage, bleeding disorders, and pre-operative hematocrit (< 33%). The four machine learning models all achieved excellent performance across discrimination (AUC > 0.78), calibration, and decision curve analysis.

CONCLUSION

This study developed machine learning models for the prediction of patient-specific transfusion rates following primary total hip arthroplasty. The results represent a novel application of machine learning, and has the potential to improve outcomes and pre-operative planning.

LEVEL OF EVIDENCE

III, case-control retrospective analysis.

Changes in Neuraxial Anesthesia Protocols and Improved Efficiency of Same-Day Discharge Total Knee Arthroplasty in an Ambulatory Surgery Center: A Retrospective Cohort Study

INTRODUCTION

This study evaluated the effect of bupivacaine versus mepivacaine spinal anesthesia and preoperative adductor canal block (ACB) on recovery, length of stay, pain, and complications of same-day discharge total knee arthroplasty (TKA) at a free-standing ambulatory surgery center.

METHODS

We performed a retrospective review of patients who underwent TKA between March 2018 and September 2019. The patients were grouped based on the neuraxial anesthetic regimen: bupivacaine with ACB, bupivacaine without ACB, and mepivacaine without ACB. Preoperative ACBs were discontinued in December 2018, and use of mepivacaine spinal anesthesia was initiated in March 2019. Length of stay in the postanesthesia care unit (PACU), time to controlled void and ambulation, postoperative pain, morphine milligram equivalents (MME), and transient neurologic symptoms were compared.

RESULTS

Ninety consecutive patients who underwent TKA were identified. Fifty patients received bupivacaine with ACB, 20 received bupivacaine without ACB, and 20 received mepivacaine without ACB. Mepivacaine spinal anesthesia led to a 93-minute shorter PACU stay (P < 0.001), 115-minute quicker time to void (P < 0.001), 60-minute earlier ambulation (P = 0.024), and 109-minute shorter total facility time (P = 0.003) but increased total MME (P = 0.049) despite nonsignificant difference in pain at discharge (P = 0.908) compared with bupivacaine. Patients receiving bupivacaine with and without ACB had a nonsignificant difference in pain scores at discharge, time to ambulation, and time to discharge (P ≥ 0.1). No transient neurologic symptoms or overnight stays were observed.

DISCUSSION

Mepivacaine spinal anesthesia for TKA safely facilitated more rapid same-day discharge through decreased times to controlled void and ambulation but with a slight increase in MME requirements. Discontinuing preoperative ACBs did not negatively affect PACU outcomes.

Ambulatory Surgery Centers Significantly Decrease Total Health Care Expenditures in Primary Anterior Cruciate Ligament Reconstruction

BACKGROUND

Anterior cruciate ligament reconstruction (ACLR) is a commonly performed orthopaedic procedure. The volume and cost of ACLR procedures are increasing annually, but the drivers of these cost increases are not well described.

PURPOSE

To analyze the modifiable drivers of total health care utilization (THU), immediate procedure reimbursement, and surgeon reimbursement for patients undergoing ACLR using a large national commercial insurance database from 2013 to 2017.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

For this study, the cohort consisted of patients identified in the MarketScan Commercial Claims and Encounters database who underwent outpatient arthroscopic ACLR in the United States from 2013 to 2017. Patients with Current Procedural Terminology code 29888 were included. THU was defined as the sum of any payment related to the ACLR procedure from 90 days preoperatively to 180 days postoperatively. A multivariable model was utilized to describe the patient- and procedure-related drivers of THU, immediate procedure reimbursement, and surgeon reimbursement.

RESULTS

There were 34,862 patients identified. On multivariable analysis, the main driver of THU and immediate procedure reimbursement was an outpatient hospital as the surgical setting (US$6789 increase in THU). The main driver of surgeon reimbursement was an out-of-network surgeon (US$1337 increase). Health maintenance organization as the insurance plan type decreased THU, immediate procedure reimbursement, and surgeon reimbursement (US$955, US$108, and US$38 decrease, respectively, compared with preferred provider organization; P < .05 for all).

CONCLUSION

Performing procedures in more cost-efficient ambulatory surgery centers had the largest effect on decreasing health care expenditures for ACLR. Health maintenance organizations aided in cost-optimization efforts as well, but had a minor effect on surgeon reimbursement. Overall, this study increases transparency into what drives reimbursement and serves as a foundation for how to decrease health care expenditures related to ACLR.

Total Joint Arthroplasty at a Novel "Hyperspecialty" Ambulatory Surgical Center With Extended Care Suites is as Safe as Inpatient Arthroplasty

Background

New "hyperspecialty" ambulatory surgical centers (HASCs) have been introduced to deliver safe and cost-efficient care, allowing patients to spend additional nights in an extended care suite before discharge. This study compared the 90-day complications and readmissions of total joint arthroplasty (TJA) at an HASC and inpatient TJA at a tertiary hospital.

Methods

We retrospectively reviewed 1365 primary, unilateral, TJAs (658 total hip arthroplasty, 707 total knee arthroplasty) performed at 4 HASCs in 2017-2021. Following their outpatient procedure, patients were discharged to an extended care suite staffed full-time by nurses and physical therapists. These patients were matched 1:1 with 1365 inpatient TJAs (628 total hip arthroplasty, 737 total knee arthroplasty) based on demographics, joint, and American Society of Anesthesiologists (ASA) score. Ninety-day complications and readmissions were compared.

Results

The mean age was 60.0 ± 9.8 years and 59.4 ± 8.1 years in the inpatient and outpatient groups, respectively (P = .106). There was no difference in ASA≥3 patients (16.4% vs 17.7%; P = .387) and operative time (86.9 ± 31.8 vs 88.7 ± 27.9 minutes; P = .118). Five patients (0.4%) in the outpatient group were transferred to an acute hospital. When comparing 90-day outcomes between the inpatient and outpatient groups, there was no difference in pulmonary embolism (0.1% vs 0.0%; P = .317), mechanical complications (0.3% vs 0.7%; P = .165), periprosthetic joint infections (0.5% vs 1.1%; P = .092), or readmissions (1.2% vs 1.5%; P = .513). A subgroup analysis of ASA≥3 patients yielded similar findings.

Conclusions

Patients undergoing outpatient TJA at a novel HASC had similar complication and readmission rates as those undergoing TJA at a tertiary hospital. Based on these data, such facilities seem appropriate for the care of outpatient TJA patients with ASA<4.

Safety Considerations for Outpatient Arthroplasty

Since 2018, the number of total joint arthroplasties (TJAs) performed on an outpatient basis has dramatically increased. Both surgeon and anesthesiologist should be aware of the implications for the safety of outpatient TJAs and potential patient risk factors that could alter this safety profile. Although smaller studies suggest that the risk of negative outcomes is equivalent when comparing outpatient and inpatient arthroplasty, larger database analyses suggest that, even when matched for comorbidities, patients undergoing outpatient arthroplasty may be at increased risk of surgical or medical complications. Appropriate patient selection is critical for the success of any outpatient arthroplasty program. Potential exclusion criteria for outpatient TJA may include age greater than 75 years, bleeding disorder, history of deep vein thrombosis, uncontrolled diabetes mellitus, and hypoalbuminemia, among others. Patient optimization before surgery is also warranted. The potential risks of same-day versus next-day discharge have yet to be elicited in a large-scale manner.

Impact of enhanced recovery pathways on safety and efficacy of hip and knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

Over the past decades, clinical pathways (CPs) for hip and knee arthroplasty have been strongly and continuously evolved based on scientific evidence and innovation.

AIM

The present systematic review, including meta-analysis, aimed to compare the safety and efficacy of enhanced recovery pathways (ERP) with regular pathways for patients with hip and/or knee arthroplasty.

METHODS

A literature search in healthcare databases (Embase, PubMed, Cochrane Library, CINAHL, and Web of Science) was conducted from inception up to June 2018. Relevant randomized controlled trials as well as observational studies comparing ERP, based on novel evidence, with regular or standard pathways, prescribing care as usual for hip and/or knee arthroplasty, were included. The effect of both CPs was assessed for (serious) adverse events [(S)AEs], readmission rate, length of hospital stay (LoS), clinician-derived clinical outcomes, patient reported outcome measures (PROMs), and financial benefits. If possible, a meta-analysis was performed. In case of considerable heterogeneity among studies, a qualitative analysis was performed.

RESULTS

Forty studies were eligible for data extraction, 34 in meta-analysis and 40 in qualitative analysis. The total sample size consisted of more than 2 million patients undergoing hip or knee arthroplasty, with a mean age of 66 years and with 60% of females. The methodological quality of the included studies ranged from average to good. The ERP had lower (S)AEs [relative risk (RR): 0.9, 95% confidence interval (CI): 0.8-1] and readmission rates (RR: 0.8, 95%CI: 0.7-1), and reduced LoS [median days 6.5 (0.3-9.5)], and showed similar or improved outcomes for functional recovery and PROMs compared to regular pathways. The analyses for readmission presented a statistically significant difference in the enhanced recovery pathway in favor of knee arthroplasties (P = 0.01). ERP were reported to be cost effective, and the cost reduction varied largely between studies (€109 and $20573). The overall outcomes of all studies reported using Grading of Recommendation, Assessment, Development and Evaluation, presented moderate or high quality of evidence.

CONCLUSION

This study showed that implementation of ERP resulted in improved clinical and patient related outcomes compared to regular pathways in hip and knee arthroplasty, with a potential reduction of costs.

The successful migration of total joint arthroplasty from the hospital inpatient to outpatient ASC setting

BACKGROUND

This study was undertaken to analyze the clinical results and complication rate of patients undergoing outpatient total joint arthroplasty by a single orthopedic group. All surgeries were performed in the practice-owned ambulatory surgery center (ASC).

METHODS

All patients indicated for outpatient total joint arthroplasty from 2016-2019 with complete pre and post-operative patient reported outcomes were enrolled in the study including hip, knee and partial knee replacements. Patient reported outcomes including HOOS, KOOS and VR-12 were collected at six months. Patient complication and satisfaction data was also collected.

RESULTS

There were 1007 patients enrolled in the study. At six months, THA HOOS and VR-12 scores improved to 82.2 and 54.5/45. TKA KOOS and VR-12 scores improved to an average of 74.3 and 54.0/43.6. At six months, UKA scores improved to an average of 73.6 and 55.1/41.2. All HOOS, KOOS and VR-12 PCS scores improvements were statistically significant (p < 0.001) and met MCID thresholds. A separate cohort of 1898 regionally tracked cases with comprehensive global complication data exhibited 111 complications (unplanned post-operative events generating a medical expense) including manipulation 13 (0.68%), DVT/PE 4 (0.2%), medical 45 (2.4%), wound 8 (0.4%), infection 8 (0.4%). Sixty-six outpatient cases (3.5%) experienced clinical complications requiring some form of additional treatment.

CONCLUSION

Outpatient joint arthroplasty performed in the ASC is safe and effective in appropriately selected patients with complication rates that compares favorably to inpatient procedures.

Total Knee Arthroplasty in Freestanding Ambulatory Surgery Centers: 5-Year Retrospective Chart Review of 90-Day Postsurgical Outcomes and Health Care Resource Utilization

INTRODUCTION

Migration of total knee arthroplasty (TKA) procedures from the inpatient setting to outpatient venues, especially freestanding ambulatory surgery centers (ASCs), requires the use of reliable patient selection algorithms and standardized perioperative pathways to facilitate favorable outcomes for patients.

METHODS

This retrospective chart review included consecutive TKA procedures performed over a 5-year period between January 2014 and January 2019 at 2 freestanding ASCs. The patient selection algorithm was developed on the basis of patient comorbidities to minimize the potential for adverse events. All procedures were performed by one of eight orthopedic surgeons who were identified a priori as adhering to similar multimodal pain management regimens, including the use of spinal anesthesia, general or monitored-care anesthesia, adductor canal blocks, pericapsular injection of liposomal bupivacaine, nonsteroidal anti-inflammatory drugs, gabapentin, tramadol, acetaminophen, and oxycodone on an as-needed basis. Outcomes, including surgical complications, healthcare resource utilization (HCRU), and patient satisfaction, were measured before discharge and at a 90-day follow-up visit.

RESULTS

Four hundred thirty-nine TKA procedures in 386 patients were identified for inclusion. Of these patients, 115 (29.8%) were performed in patients with the American Society of Anesthesiologists physical status IIIa. Mean (standard deviation) length of stay at the ASC was 500 (107) minutes, including 136 (47) minutes of surgery and 201 (78) minutes to ambulation. The overall rates of surgical complications and 90-day hospital admissions were low (1.4% and 0.7%, respectively), as was the need for additional HCRU, including additional surgical procedures related to index surgery, emergency department visits, and unplanned clinic visits or calls. At the 90-day follow-up visit, 96% of patients reported being pleased with their outcomes.

DISCUSSION

With careful patient selection, standardized perioperative pathways, and multimodal analgesia protocols, TKA procedures can be performed in the ASC setting with low complication rates, minimal postdischarge HCRU, and high rates of patient satisfaction.

LEVEL OF EVIDENCE

III.

Introduction of day case hip and knee replacement programme at an inpatient ward is safe and may expedite shortening of hospital stays of traditional arthroplasties

PURPOSE

We investigated the safety of primary hip and knee replacements with same day discharge (SDD) and their effect on length of stay (LOS) of traditional inpatient arthroplasties at our elective orthopaedic ward.

METHODS

200 patients underwent elective, unilateral primary day case total hip (THA, n = 94), total knee (TKA, n = 60) and unicondylar knee replacements (UKA, n = 46). SDD rates, reasons for failure to discharge, readmission, complication and satisfaction rates were recorded at 6-week follow up. Changes in LOS of inpatient arthroplasties (n = 6518) and rate of patients discharged with only one night stay treated at the same ward were tracked from 1 year prior to introduction of day case arthroplasty (DCA) program to the end of observation period.

RESULTS

166 patients (83%) had SDD while 34 (17%) needed overnight stay. Main reasons for failure to discharge were lack of confidence (4%) fainting due to single vasovagal episode (3.5%), urine retention (3%) and late resolution of spinal anaesthesia (3%). 5 patients (3%) had readmission within 6 weeks, including 1 (0.6%) with a partial and treated pulmonary embolism. 163 patients were satisfied with SDD (98%). After launching the DCA program, average LOS of inpatients was reduced from 2.3 days to 1.8 days and rate of discharge with only 1-night stay increased from 12% to around 60%.

CONCLUSION

Introduction of routine SDD hip and knee arthroplasty programme at an elective orthopaedic centre is safe and also may confer wider benefits leading to shorter inpatient hospital stays.

Outpatient total hip arthroplasty : the future?

With advancements in minimally invasive surgical technique, pain management and rehabilitation proto- cols, and prevention of post-operative complications, outpatient total hip arthroplasty became a realistic goal. This study reports our experience of performing outpatient total hip arthroplasty assessing its feasi- bility and safety. Between December 2015 and January 2018, 52 outpatient total hip arthroplasties were performed. We implemented a peri-operative management proto- col that included education, improved analgesia and rapid rehabilitation. Patients were asked about any complications they had experienced after surgery and about the perception of their experience as outpatient. Any early post-operative emergency department visits, acute office appointments or hospital re-ad- missions were registered. Fifty-one of 52 patients (98,1%) enrolled in the study met the discharge criteria and achieved their goal of going home on the day of surgery, and only one patient (1,9%) required an overnight stay. There were two visits to the emergency room, with one hospital re-admission (1,9%) on the night of the surgery. There were no major post-discharge complications in the short-term follow-up (minimum of three months). Only one patient (1,9%) reported a significantly negative experience. With this first Belgian experience reporting on out- patient primary total hip arthroplasty, our data demonstrate that early discharge does not result in excessive re-admissions or other post-discharge complications due to an early discharge. This study suggests that total hip arthroplasty can be performed safely and successfully in appropriately selected patients and that patients who experienced that ambulatory protocol declared themselves highly satisfied.

The learning curve for the direct anterior total hip arthroplasty: a systematic review

BACKGROUND

The direct anterior approach (DAA) for total hip arthroplasty (THA) is a muscle-sparing approach thought to have less post-operative pain and quicker recovery, with similar functional outcomes to other approaches. However, it is technically challenging and transitioning surgeons may experience increased complication rates. The purpose of this systematic review is to identify reported learning curves associated with the DAA.

METHODS

Three databases (MEDLINE, Embase, and Web of Science) were searched using terms including "total hip arthroplasty," "direct anterior approach," and "learning curve." Study characteristics, patient demographics, learning curve analyses, and complications were abstracted.

RESULTS

Twenty-one studies met inclusion criteria, with a total of 9738 patients (60% female), an average age of 63.7 years (range: 13-94), body mass index of 27.0 kg/m2 (range: 16.8-58.9), and follow-up of 19 months (range: 1.5-100). There were five retrospective cohort studies and 13 case series representing fair methodological quality. Six studies depicted a true learning curve, with mean operative time of 156.59 ± 41.71 minutes for the first case, 93.18 ± 14.68 minutes by case 30, and 80.45 ± 12.28 minutes by case 100. Mean complication rate was 20.8 ± 12.7% in early groups and decreased to 7.6 ± 7.1% in late groups.

CONCLUSION

This review demonstrated a substantial learning curve associated with the DAA to THA. Operative time plateaued after approximately 100 cases. Complication rates decreased substantially from early to late groups.

Blood Management in Outpatient Total Hip Arthroplasty

Based on a series of 407 outpatient total hip arthroplasties performed by a single surgeon, a standardized protocol for blood loss management in outpatient arthroplasty was developed consisting of a presurgical hematocrit of greater than 36%, administration of tranexamic acid, prophylactic introduction of albumin, hypotensive epidural anesthesia, monopolar electrocautery, and bipolar sealer. This protocol uses techniques that alone are not novel but together create a standardized and reproducible pathway that when implemented can increase the safety of outpatient hip arthroplasty.

Allergies, Preoperative Narcotic Use, and Increased Age Predict Failed Same-Day Discharge After Joint Replacement

BACKGROUND

Identifying predictors of failed same-day discharge (SDD) is critical for patient selection. We evaluated patient factors associated with failure of SDD in patients undergoing elective total joint arthroplasty (TJA) in a hospital setting.

METHODS

We retrospectively reviewed consecutive patients who underwent primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) between January 31, 2018 and February 1, 2020 by one of the 3 fellowship-trained arthroplasty surgeons. Patient demographics, comorbidities, and clinical data were collected. Analysis was performed to assess risk factors for failed SDD.

RESULTS

In total, 2615 TJAs (1425 TKAs, 1190 THAs) were performed over the study period. Two hundred seventy-one (10.4%) were SDDs (80 TKAs, 191 THAs). There were fewer TKAs than THAs (5.6% vs 16.1%, P < .001). Forty-five patients failed SDD (16.6%). Failure rates were similar in TKA and THA (18.8%, 15.7%, P = .54). The most common reasons for failure of SDD were hypotension (11, 24.4%), delayed resolution of spinal anesthesia (11, 24.4%), and nausea (5, 11.1%). Age over 70 years (P = .007), greater than 2 self-reported allergies (P < .001), and preoperative narcotic use (P = .01) were associated with failure of SDD. Gender, body mass index, American Society of Anesthesiologists class, and prior TJA were not significantly associated (P > .05).

CONCLUSION

Success of SDD was greater than 80%. Hypotension, delayed resolution of spinal anesthesia, and nausea accounted for 60% of failures of SDD. Patients >70 years, those with >2 self-reported drug allergies, or patients who used preoperative narcotics were at high risk for failure of SDD after THA or TKA.

Anterior Supine Intermuscular Total Hip Arthroplasty at an Ambulatory Surgery Center Versus Hospitalization: Cost and Adverse Events

This study compares anterior supine intermuscular total hip arthroplasty performed at an ambulatory surgery center with the same procedure performed in a hospital setting in regard to complications and costs. The ambulatory surgery center had significantly shorter postoperative stays and superior visual analog pain scores at 3 months. No differences were noted in operative time, blood loss, or complications. Costs were significantly different between groups, with significant cost savings noted in the ambulatory surgery center group.

The feasibility of outpatient conversion and revision hip arthroplasty in selected patients

BACKGROUND

Total hip arthroplasty (THA) continues moving to the outpatient arena, and may be feasible for some conversion and revision scenarios. Controversy surrounds appropriate patient selection. The purpose of this study is to report complications associated with outpatient revision and conversion THA, and to determine if comorbidities are associated with complications or overnight stay.

METHODS

From June 2013 through August 2018, 46 patients (47 hips) underwent conversion (n = 10) or revision (n = 37) THA at a free-standing ambulatory surgery centre. This represented only 6.3% of revision THA cases at our institution during the study period that were selected for outpatient surgery. Mean patient age was 58.0 years, and 52% of patients were males. 1 or more major comorbidities were present in 15 patients (32%) including 1 valvular disease, 7 arrhythmia, 2 thromboembolism history, 3 obstructive sleep apnoea, 3 chronic obstructive pulmonary disease, 2 asthma, 4 frequent urination, and 1 renal disease.

RESULTS

44 (94%) patients were discharged same day without incident, none required transfer to acute facility, and 3 stayed overnight (2 convenience, 1 for medical reasons - urinary retention). The patient kept overnight for medical reasons had no major comorbidities. 3 patients were placed on an extended course of antibiotics, including 2 with positive intraoperative cultures and 1 for cellulitis. There were no major complications, readmissions, or subsequent surgeries within 90 days.

CONCLUSIONS

Outpatient revision hip arthroplasty is safe in selected patients undergoing minor or partial revisions. Presence of medical comorbidities was not associated with risk of complications. Medical optimisation and a multimodal programme to mitigate risk of blood loss and reduce narcotic need facilitate the safe performance of arthroplasty in an outpatient setting.

Defining Outpatient Hip and Knee Arthroplasties: A Systematic Review

INTRODUCTION

The term "outpatient" has a variety of meanings regarding the location of arthroplasty and the duration of stay postoperatively. The purpose of this systematic review was to evaluate the literature and more accurately define the term "outpatient."

METHODS

A PubMed search (2014 to 2019) using the terms "outpatient AND arthroplasty" identified 76 studies; 35 studies that met the inclusion criteria were assessed to determine the definition of "outpatient." The level of evidence, type of arthroplasty, location of surgery (hospital or ambulatory surgery center [ASC]), approach used for hip arthroplasty, number of patients, number of surgeons, and length of time the patients were kept at the location after surgery were evaluated.

RESULTS

Arthroplasties analyzed were total hip (11), total knee (seven), unicompartmental knee (five), and hip and knee (12). Only 16.8% of surgeries defined as outpatient hip or knee arthroplasty were done in a freestanding ASC, and 44.2% of patients defined as outpatients were kept overnight for the 23-hour observation.

DISCUSSION

We propose "DASH" (Discharge from ASC to Home) as a new term to define arthroplasties done in an outpatient setting with the patient discharged home the same day.

Single-Stage Bilateral Total Hip Arthroplasty in an Ambulatory Surgical Center: A Report of Three Cases

In recent years, there has been increased interest in transitioning total joint arthroplasty procedures from inpatient settings to ambulatory surgical centers to decrease costs and eliminate the need for hospital stays. In addition, simultaneous bilateral total hip arthroplasty (THA) has been found to be favorable in certain patient populations when compared with staged bilateral THA. In this study, we report the results of a series of three patients who underwent single-stage bilateral THA in a free-standing ambulatory surgical center with excellent short-term outcomes and no 90-day complications.

Risk Factors for Discharge to a Non-Home Destination and Reoperation Following Outpatient Total Hip Arthroplasty (THA) in Medicare-Eligible Patients

Introduction:

The Centers for Medicare and Medicaid Services removed total hip arthroplasty (THA) from the inpatient-only (IO) list in January 2020. Given this recommendation, we analyzed Medicare-eligible patients undergoing outpatient THA to understand risk factors for nonroutine discharge, reoperations, and readmissions.

Materials and Methods:

The 2015-2018 American College of Surgeons–National Surgical Quality Improvement Program database was queried using Current Procedural Terminology code 27130 for Medicare eligible patients (≥ 65 years of age) undergoing outpatient THA. Postoperative discharge destination was categorized into home and non-home. Multivariate logistic regression models were used to evaluate risk factors associated with non-home discharge disposition. Secondarily, we evaluated rates and risk factors associated with 30-day reoperations and readmissions.

Results:

A total of 1095 THAs were retrieved for final analysis. A total of 108 patients (9.9%) experienced a non-home discharge postoperatively. Patients were discharged to rehab (n = 47; 4.3%), a skilled care facility (n = 47; 4.3%), a facility that was “home” (n = 8; 0.7%), a separate acute care facility (n = 5; 0.5%), or an unskilled facility (n = 1; 0.1%). Independent factors for a non-home discharge were American Society of Anesthesiologists Class >II (odds ratio [OR] 2.74), operative time >80 minutes (OR 2.42), age >70 years (OR 2.20), and female gender (OR 1.67). Eighteen patients (1.6%) required an unplanned reoperation within 30 days. A total of 40 patients (3.7%) required 30-day readmissions, with 35 readmissions related to the original THA procedure. Independent risk factors for 30-day reoperation were COPD (OR 5.85) and HTN (OR 5.24). Independent risk factors for 30-day readmission were HTN (OR 4.35) and Age >70 (OR 2.48).

Discussion:

The current study identifies significant predictors associated with a non-home discharge, reoperation, and readmission in Medicare-aged patients undergoing outpatient THA.

Conclusion:

Providers should consider preoperatively risk-stratifying patients to reduce the costs associated with unplanned discharge destination, complication or reoperation.

Unplanned Emergency Visits and Admissions After Orthopaedic Ambulatory Surgery in the First 2 Years of Operation of a University Ambulatory Surgery Center

BACKGROUND

Ambulatory surgeries have increased in recent decades to help improve efficiency and cost; however, there is a potential need for unplanned postoperative admission, clinic visits, or evaluation in the emergency department (ED).

PURPOSE/HYPOTHESIS

The purpose was to determine the frequency, reasons, and factors influencing hospitalizations, return to clinic, and/or ED encounters within 24 hours of ambulatory surgery. The time frame for data collection was the first 2 years of operation of a university sports medicine ambulatory surgery center (ASC). We hypothesized that the percentage of encounters would be low and primarily because of pain or postoperative complication.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A retrospective review was performed of all patients undergoing ambulatory surgery at an ASC during the first 2 years of its operation (November 2016 to October 2018). Data including age, sex, Current Procedural Terminology code, procedure performed, American Society of Anesthesiologists classification, body mass index, medical history, and tobacco use were collected. Patients seeking care in the ED, inpatient, or outpatient setting within the first 24 hours after surgery were identified and the reasons for these encounters were categorized into 1 of 3 groups: (1) medical complication, (2) postoperative pain, or (3) other postoperative complication. Logistic regression models were used to assess risk factors for these encounters.

RESULTS

A total of 4650 sports medicine procedures were performed at the university ASC during the study period. A total of 35 patients (0.75%) sought additional care within 24 hours of surgery. Medical complications were the primary reason for seeking care (n = 16; 45.7%). Patients who sought treatment within 24 hours of surgery tended to be older, had more medical comorbidities, and were more likely to have undergone upper extremity (particularly shoulder) procedures. In the multivariable analysis, patients with higher ASA scores were more likely to seek additional care (P < .005) and there was a trend toward increased risk of seeking additional care with upper extremity surgery (P = .077).

CONCLUSION

Orthopaedic procedures performed in an ASC result in a relatively low percentage of patients seeking additional care within the first 24 hours after surgery, consistent with other reports in the literature. Upper extremity procedures, particularly those of the shoulder, may carry an increased risk of requiring medical treatment within 24 hours of surgery. Even in the first 2 years of operation of a university-based ASC, low rates of postoperative complications and unplanned admissions can be maintained.

Day-case total hip arthroplasty: a literature review and development of a hospital pathway

Aims

We present the development of a day-case total hip arthroplasty (THA) pathway in a UK National Health Service institution in conjunction with an extensive evidence-based summary of the interventions used to achieve successful day-case THA to which the protocol is founded upon.

Methods

We performed a prospective audit of day-case THA in our institution as we reinitiate our full capacity elective services. In parallel, we performed a review of the literature reporting complication or readmission rates at ≥ 30-day postoperative following day-case THA. Electronic searches were performed using four databases from the date of inception to November 2020. Relevant studies were identified, data extracted, and qualitative synthesis performed.

Results

Our evaluation and critique of the evidence-based literature identifies day-case THA to be safe, effective, and economical, benefiting both patients and healthcare systems alike. We further validate this with our institutional elective day surgery arthroplasty pathway (EDSAP) and report a small cohort of successful day-case THA cases as an example in the early stages of this practice in our unit.

Conclusion

Careful patient selection and education, adequate perioperative considerations, including multimodal analgesia, surgical technique and blood loss management protocols and appropriate postoperative pathways comprising reliable discharge criteria are essential for successful day-case THA.

Cite this article: Bone Jt Open 2021;2(2):93–102.

Outpatient Hip Safety in an Ambulatory Surgery Center Is Independent of Approach

BACKGROUND

There are few data comparing the direct anterior approach (DAA) and posterior approach (PA) for total hip arthroplasty (THA) in the outpatient setting. The purpose of this study is to compare 90-day complications between the 2 approaches. We hypothesized that they would be equally safe and effective.

METHODS

Retrospective review identified 432 THAs (346 DAA, 86 PA) performed at a single ambulatory surgery center (ASC). Outcomes compared included demographics, comorbidities, preoperative and discharge pain scores (visual analog scale [VAS]), overall time spent in the ASC, overnight stay, emergency room visits, admission, reoperation, and complications within a 90-day period.

RESULTS

There were no differences in mean preoperative VAS (DAA 4.7, PA 4.5), mean discharge VAS (DAA 0.8, PA 0.7), overall time spent in the ASC (DAA 9.0 hours, PA 9.3 hours), total number of overnight stays (DAA 0.9%, PA 1.2%), emergency room visits (DAA 1.7%, PA 1.2%), admissions (DAA 1.4%, PA 1.2%), reoperations (DAA 1.4%, PA 1.2%), or complications (DAA 3.5%, PA 2.3%).

CONCLUSION

There were no differences in the safety outcomes, and overall there were few complications in the 90-day period, regardless of the surgeon's preferred approach. This study indicates both DAA and PA are equally safe for THA in the outpatient setting, and the choice of surgical approach should be based on patient and surgeon preference.

Safety of Same and Next Day Discharge Following Revision Hip and Knee Arthroplasty Using Modern Perioperative Protocols

BACKGROUND

Advances in perioperative care have enabled early discharge and outpatient primary total joint arthroplasty (TJA). However, the safety of early discharge after revision TJA (rTJA) remains unknown and the COVID-19 pandemic will force decreased hospitalization. This study compared 90-day outcomes in patients undergoing aseptic rTJA discharged the same or next day (early) to those discharged 2 or 3 days postoperatively (later).

METHODS

In total, 530 aseptic rTJAs performed at a single tertiary care referral center (December 5, 2011 to December 30, 2019) were identified. Early and later discharge patients were matched as closely as possible on procedure type, sex, American Society of Anesthesiologists physical status classification, age, and body mass index. All patients were optimized using modern perioperative protocols. The rate of 90-day emergency department (ED) visits and hospital admissions was compared between groups.

RESULTS

In total, 183 early discharge rTJAs (54 hips, 129 knees) in 178 patients were matched to 183 later discharge rTJAs (71 hips, 112 knees) in 165 patients. Sixty-two percent of the sample was female, with an overall average age and body mass index of 63 ± 9.9 (range: 18-92) years and 32 ± 6.9 (range: 18-58) kg/m². There was no statistical difference in 90-day ED visit rates between early (6/178, 3.4%) and later (11/165, 6.7%) discharge patients (P = .214). Ninety-day hospital admission rates for early (7/178, 3.9%) and later (4/165, 2.4%) discharges did not differ (P = .545).

CONCLUSION

Using modern perioperative protocols with appropriate patient selection, early discharge following aseptic rTJA does not increase 90-day readmissions or ED visits. As hospital inpatient capacity remains limited due to COVID-19, select rTJA patients may safely discharge home the same or next day to preserve hospital beds and resources for more critical illness.

Perspectives and Consensus among International Orthopaedic Surgeons during Initial and Mid-lockdown Phases of Coronavirus Disease

With a lot of uncertainty, unclear, and frequently changing management protocols, COVID-19 has significantly impacted the orthopaedic surgical practice during this pandemic crisis. Surgeons around the world needed closed introspection, contemplation, and prospective consensual recommendations for safe surgical practice and prevention of viral contamination. One hundred orthopaedic surgeons from 50 countries were sent a Google online form with a questionnaire explicating protocols for admission, surgeries, discharge, follow-up, relevant information affecting their surgical practices, difficulties faced, and many more important issues that happened during and after the lockdown. Ten surgeons critically construed and interpreted the data to form rationale guidelines and recommendations. Of the total, hand and microsurgery surgeons (52%), trauma surgeons (32%), joint replacement surgeons (20%), and arthroscopy surgeons (14%) actively participated in the survey. Surgeons from national public health care/government college hospitals (44%) and private/semiprivate practitioners (54%) were involved in the study. Countries had lockdown started as early as January 3, 2020 with the implementation of partial or complete lifting of lockdown in few countries while writing this article. Surgeons (58%) did not stop their surgical practice or clinics but preferred only emergency cases during the lockdown. Most of the surgeons (49%) had three-fourths reduction in their total patients turn-up and the remaining cases were managed by conservative (54%) methods. There was a 50 to 75% reduction in the number of surgeries. Surgeons did perform emergency procedures without COVID-19 tests but preferred reverse transcription polymerase chain reaction (RT-PCR; 77%) and computed tomography (CT) scan chest (12%) tests for all elective surgical cases. Open fracture and emergency procedures (60%) and distal radius (55%) fractures were the most commonly performed surgeries. Surgeons preferred full personal protection equipment kits (69%) with a respirator (N95/FFP3), but in the case of unavailability, they used surgical masks and normal gowns. Regional/local anesthesia (70%) remained their choice for surgery to prevent the aerosolized risk of contaminations. Essential surgical follow-up with limited persons and visits was encouraged by 70% of the surgeons, whereas teleconsultation and telerehabilitation by 30% of the surgeons. Despite the protective equipment, one-third of the surgeons were afraid of getting infected and 56% feared of infecting their near and dear ones. Orthopaedic surgeons in private practice did face 50 to 75% financial loss and have to furlough 25% staff and 50% paramedical persons. Orthopaedics meetings were cancelled, and virtual meetings have become the preferred mode of sharing the knowledge and experiences avoiding human contacts. Staying at home, reading, and writing manuscripts became more interesting and an interesting lifestyle change is seen among the surgeons. Unanimously and without any doubt all accepted the fact that COVID-19 pandemic has reached an unprecedented level where personal hygiene, hand washing, social distancing, and safe surgical practices are the viable antidotes, and they have all slowly integrated these practices into their lives. Strict adherence to local authority recommendations and guidelines, uniform and standardized norms for admission, inpatient, and discharge, mandatory RT-PCR tests before surgery and in selective cases with CT scan chest, optimizing and regularizing the surgeries, avoiding and delaying nonemergency surgeries and follow-up protocols, use of teleconsultations cautiously, and working in close association with the World Health Organization and national health care systems will provide a conducive and safe working environment for orthopaedic surgeons and their fraternity and also will prevent the resurgence of COVID-19.

"Outpatient"-Same-calendar-day Discharge Hip and Knee Arthroplasty

As the length of stay for hip and knee arthroplasty has decreased over the years, "outpatient," or same-calendar-day discharge has become increasingly common. Outpatient arthroplasty offers several possible benefits over traditional inpatient arthroplasty, including potential for cost reductions, faster rehabilitation, improved patient satisfaction, and reduced reliance on hospital resources. Despite these possible benefits, concerns remain over feasibility and patient safety. To date, multiple studies have demonstrated that, for select patients, "outpatient" hip and knee arthroplasty can be safe and effective and yield complication and readmission rates similar to inpatient procedures at potentially significant cost savings. Successful outpatient pathways have emphasized careful patient selection, detailed patient education, enlistment of strong social support, utilization of multimodal analgesia and strong "episode ownership," and involvement on behalf of the surgical team. As outpatient hip and knee arthroplasty becomes increasingly common, continued investigation into all aspects of the surgical episode is warranted.

Is Outpatient Arthroplasty Safe? A Systematic Review

BACKGROUND

Advances in perioperative care and growing demand for hospital beds have progressively reduced the length of stay in lower limb arthroplasty. Current trends in population demographics and fiscal climate have also added to this change. Individual institutions have reported good outcomes with outpatient hip and knee arthroplasty. Debate remains regarding the safety of this practice, the optimal protocol, and the applicability in different subsections of population. The primary purpose of this review is to assess the complication and reoperation rates of outpatient arthroplasty.

METHODS

We performed a systematic review of all papers reporting on 30 and/or 90-day complication rates of outpatient total hip, total knee, and unicondylar knee arthroplasty published from January 1, 2009 to November 1, 2019. Patient demographics, anesthesia, analgesic protocol, selection criteria, and reasons for failed discharge were also extracted.

RESULTS

Nineteen manuscripts with a total of 6519 operations between them were analyzed as a part of this systematic review. Mean 90-day readmission rates were 2.3% (range 0%-6%) with 1.61% (range 0%-4%) rate. Overall rate of successful same calendar day discharge was 93.4%. Nausea/dizziness was the most common reason identified (n = 45) for failure of discharge.

CONCLUSION

The patients recruited for outpatient joint arthroplasty were younger, more active, and had suffered from less medical comorbidities than the more typical lower limb arthroplasty patient. There are significant differences in the reported complications between the studies reviewed. More research is needed to establish if an outpatient program can produce similar outcomes to a fast-track program. Further research is also needed to establish the optimal perioperative protocols.

Same-Day Discharge Following Total Joint Arthroplasty: Examining Trends, Discharge Dispositions, and Complications Over Time

Administrative database studies have reported on the safety of same-day discharge (SDD) following total joint arthroplasty (TJA); however, most patient cohorts have been defined by length of stay (LOS), and the proportion discharged directly home remains unknown. The purpose of this investigation was to (1) determine common dispositions for patients undergoing SDD TJA; (2) understand changes in discharge disposition over time; and (3) determine the safety of SDD TJA, stratified by discharge disposition. The PearlDiver Database was reviewed for patients who underwent SDD TJA (LOS of 0 days) from 2011 to 2016. Patients were stratified by discharge disposition, and rates and complications following SDD TJA were assessed accordingly. Chi-square analysis was performed to compare demographics and complications between patient groups stratified by disposition. From 2011 to 2016, there was an exponential increase in the annual rate of SDD TJA from 0.95% to 20.5%, respectively; however, the annual proportion of patients discharged directly home remained unchanged (approximately 68%), with the remaining discharged directly to an alternate care facility, most commonly inpatient rehabilitation. Patients discharged to an alternate facility were significantly older (P<.001), had significantly higher comorbidity scores (P<.001), and had significantly more complications (P<.001) than those patients discharged directly home. Although the annual rate of SDD TJA is increasing, up to one-third of patients are not discharged directly home-a proportion unchanged over time. Moving forward, administrative database studies examining SDD TJA must account for discharge disposition; moreover, there is a need to understand the practice of SDD TJA to an alternate care facility. [Orthopedics. 2020;43(4):204-208.].

After the COVID-19 Pandemic: Returning to Normalcy or Returning to a New Normal?

The novel coronavirus, severe acute respiratory coronavirus 2 (SARS-CoV-2), pandemic has delivered a profound and negative impact on the United States. The suspension of elective surgeries including arthroplasty will have a lasting effect on all stakeholders including patients, physicians, and healthcare organizations within the US healthcare system. Resumption of elective hip and knee arthroplasty will need to be carefully focused. The purpose of this work is to address potential strategies, concerns, and regulatory barriers in restarting elective hip and knee arthroplasty in the United States.

Can primary total hip arthroplasty be performed in an outpatient setting? Prospective feasibility and safety study in 321 patients in a day-surgery unit

INTRODUCTION

Total hip arthroplasty (THA) performed as day-surgery is an emerging and growing practice. The main aim of the present study was to assess the feasibility and safety of primary THA in an outpatient setting. The study hypothesis was that, within a specifically dedicated structure, such surgery is feasible and safe.

MATERIAL AND METHODS

A prospective observational study was performed in two centers, one private hospital and one university hospital, including all patients operated on by two senior surgeons between 2014 and 2017 for primary THA and eligible for day-surgery. The clinical pathway was governed by a pre-established protocol. Preoperatively, all patients took part in an information workshop, with their spouses and the surgeon. Postoperative phone interviews were held on D1 and D3, then out-patient consultations were conducted at 1 and 6 weeks. The main study endpoint was successful outpatient management, failure being defined as crossover or readmission within 1 week of discharge. Secondary endpoints comprised complications rate and satisfaction as assessed by patient and spouse at 6 weeks.

RESULTS

During the study period, 1,303 patients received primary THA. 338 (25.9%) were eligible for day-surgery, but 17 (5%) declined; the day-surgery series thus comprised 321 patients (24.6%): 166 men, 155 women; mean age, 61.2±9.7 years. Same-day discharge was not possible for 14 patients (4.5%): 9 due to persistent faintness, 2 to intraoperative femoral fracture, 1 to organizational issues, 1 to an uncomplicated fall, and 1 to hemoglobinemia<11g/100ml in a coronary patient. There were no readmissions during week 1. At 6 weeks' follow-up, there had been 3 adverse events: 2 dislocations, and 1 periprosthetic fracture. 312 patients (97.2%) were satisfied.

CONCLUSION

The present prospective study found no major adverse events in patients undergoing day-surgery for primary THA. However, patients should be selected, consenting, prepared and managed on a standardized clinical pathway.

LEVEL OF EVIDENCE

IV; non-comparative prospective study.

Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes From a Large Urological Group Practice

BACKGROUND

The definitive treatment for erectile dysfunction is the surgical implantation of a penile prosthesis, of which the most common type is the 3-piece inflatable penile prosthesis (IPP) device. IPP surgery in outpatient freestanding ambulatory surgical centers (ASC) is becoming more prevalent as payers and health systems alike look to reduce healthcare costs.

AIM

To evaluate IPP surgical outcomes in an ASC as compared to contemporaneously-performed hospital surgeries.

METHODS

A database of all patients undergoing IPP implantation by practitioners in the largest private community urology group practice in the United States, from January 1, 2013 to August 1, 2019, was prospectively compiled and retrospectively reviewed. Cohorts of patients having IPP implantation performed in the hospital vs ASC setting were compared.

MAIN OUTCOME MEASURE

The primary outcome measure was to compare surgical data (procedural and surgical times, need for hospital transfer from ASC) and outcomes (risk for device infection, erosion, and need for surgical revision) between ASC and hospital-based surgery groups.

RESULTS

A total of 923 patients were included for this analysis, with 674 (73%) having ASC-based surgery and 249 (27%) hospital-based, by a total of 33 surgeons. Median procedural (99.5 vs 120 minutes, P < .001) and surgical (68 vs 75 minutes, P < .001) times were significantly shorter in the ASC. While the risk for device erosion and need for surgical revision were similar between groups, there was no higher risk for prosthetic infection when surgery was performed in the ASC (1.7% vs 4.4% [hospital], P = .02), corroborated by logistic regression analysis (odds ratio 0.39, P = .03). The risk for postoperative transfer of an ASC patient to the hospital was low (0.45%). The primary reason for mandated hospital-based surgery was medical (51.4%), though requirement as a result of insurance directive (39.7%) was substantial.

CLINICAL IMPLICATIONS

IPP implantation in the ASC is safe, has similar outcomes compared to hospital-based surgery with a low risk for need for subsequent hospital transfer.

STRENGTHS & LIMITATIONS

The strengths of this study include the large patient population in this analysis as well as the real-world nature of our practice. Limitations include the retrospective nature of the review as well as the potential for residual confounding.

CONCLUSION

ASC-based IPP implantation is safe, with shorter surgical and procedural times compared to those cases performed in the hospital setting, with similar functional outcomes. These data suggest no added benefit to hospital-based surgery in terms of prosthetic infection risk. Weinberg AC, Siegelbaum MH, Lerner BD, et al. Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes From a Large Urological Group Practice. J Sex Med 2020;17:1025-1032.

Presurgical optimization and opioid-minimizing enhanced recovery pathway for ambulatory knee and hip arthroplasty: postsurgical opioid use and clinical outcomes

BACKGROUND

Enhanced recovery after surgery (ERAS) pathways offer approaches to achieve successful ambulatory primary total knee and total hip arthroplasty (TKA/THA) while meeting the "Triple Aim" of healthcare: patient satisfaction, population health, and value. We evaluated outcomes from an ERAS pathway designed to maximize patients' eligibility for ambulatory TKA/THA while reducing costs, complications, and postsurgical opioid use.

METHODS

This retrospective study included 220 consecutive unique commercially insured patients who underwent TKA (n = 113) or THA (n = 138) in an ambulatory surgery center between June 1, 2015 and November 16, 2017. The ERAS pathway encompassed early presurgical through home recovery periods. Key elements included presurgical patient engagement; creation of realistic expectations; optimization of modifiable medical, physical, and social factors; and creation of individualized multimodal opioid-sparing pain management. No home services were used. Adverse events and unplanned admissions within 30 and 60 days, satisfaction, and opioid use were analyzed descriptively.

RESULTS

All patients (mean [range] age, 58 [22-84] years; 49% women) had same-day discharge. Within 30 days, 7 (2.8%) patients experienced an adverse event, 3 (1.2%) had an emergency department or urgent care visit without admission, and 8 (3.2%) had an unplanned admission. Within 60 days, 3 additional patients had an emergency department/urgent care visit. Most patients (206 [82.1%]) did not require a second opioid prescription. Patient satisfaction was high.

CONCLUSIONS

This ERAS pathway may help meet the Triple Aim for outpatient joint replacement, expand the eligible patient population, and reduce postsurgical opioid use. Further research is warranted.

Ambulatory versus inpatient shoulder arthroplasty: a population-based analysis of trends, outcomes, and charges

Background

The purpose of this study was to evaluate the clinical outcomes and cost of shoulder arthroplasty (SA) performed in ambulatory surgery centers (ASCs) compared with SA performed in hospital-based surgery settings.

Methods

The State Inpatient Databases and the State Ambulatory Surgery Databases were queried for patients undergoing primary or reverse SA between 2010 and 2014 in 5 states in either the inpatient (IP), hospital outpatient department (HOPD), or ASC setting. Outcomes included all-cause readmissions, emergency department visits within the 90-day postoperative period, and charges. Covariates included patient demographic data and procedure details. Risk factors for readmission were calculated using logistic regression analysis.

Results

We identified 795 ASC (2%), 183 HOPD (0.5%), 38,114 (97.5%) SA procedures. The outpatient cohort was overall younger and healthier with a lower percentage of diabetes (14.1% vs. 20.2%), cardiopulmonary disease (11.4% vs. 20.4%), and obesity (10.7% vs. 15.6%). The US state and obesity were factors significantly (P < .0001) associated with readmission. The median IP charge was $62,905 (range, $41,327-$87,881) vs. $37,395 (range, $21,976-$61,775) for combined outpatient cases. When outpatient SA was stratified into ASC and HOPD cases, the median charges were $31,790 for ASC cases vs. $55,990 for HOPD cases (P < .0001). After adjustment for multiple covariates, the charges for combined outpatient SA surgery were 40% lower than those for IP SA surgery (P < .0001).

Conclusion

As the current health care climate shifts toward lower-cost and higher-quality care, this study demonstrates that SAs performed in ASCs have a comparable safety profile to and significant financial advantage over SAs performed in the hospital-based setting.

Patient Outcomes Following Total Joint Replacement Surgery: A Comparison of Hospitals and Ambulatory Surgery Centers

BACKGROUND

For several years, many orthopedic surgeons have been performing total joint replacements in hospital outpatient departments (HOPDs) and more recently in ambulatory surgery centers (ASCs). In a recent shift, the Centers for Medicare and Medicaid Services began reimbursing for total knee replacement surgery in HOPDs. Some observers have expressed concerns over patient safety for the Medicare population particularly if Centers for Medicare and Medicaid Services extends the policy to include total hip replacement surgery and coverage in ASCs.

METHODS

This study used a large claims database of non-Medicare patients to examine inpatient and outpatient total knee replacement and total hip replacement surgery performed on a near-elderly population during 2014-2016. We applied propensity score methods to match inpatients with ASC patients and HOPD patients with ASC patients adjusting for risk using the HHS Hierarchical Condition Categories risk adjustment model. We conducted statistical tests comparing clinical outcomes across the 3 settings and examined relative costs.

RESULTS

Readmissions, postsurgical complications, and payments were lower for outpatients than for inpatients. Within outpatient settings, readmissions and postsurgical complications were lower in ASCs than in HOPDs but payments for ASC patients were higher than payments for HOPD patients.

CONCLUSION

Our findings support the argument that outpatient total joint replacement is appropriate for select patients treated in both HOPDs and ASCs, although in the commercially insured population, the latter services may come at a cost. Until further study of outpatient total joint replacement in the Medicare population becomes available, how this will extrapolate to the Medicare population is unknown.

Outpatient Total Hip Arthroplasty Performed at an Ambulatory Surgery Center vs Hospital Outpatient Setting: Complications, Revisions, and Readmissions

BACKGROUND

Outpatient total hip arthroplasty (THA) utilization continues to grow. Literature suggests outpatient THA may result in low rates of complications and readmission. There are no studies comparing safety profiles of THA performed at ambulatory surgery centers (ASC) vs hospital outpatient (HOP) settings.

METHODS

Prospectively collected data were reviewed on all patients who underwent THA from 2013 to 2018. ASC and HOP subgroups were compared, investigating difference in demographics, comorbidities, American Society of Anesthesiologists subgroups, all complications, revisions, emergency department (ED) visits, and readmissions within the first 90 days of surgery. An additional subgroup analysis of patients younger than 65 years was performed.

RESULTS

Two surgeons performed 3063 THAs during the study period, including 965 outpatient cases (ASC = 335; HOP = 630). Thirty-seven (3.8%) complications occurred within 90 days. No differences were found between groups for 90-day complication rates (ASC = 13, 3.9%; HOP = 24, 3.8%; P = .48), revision rates (ASC = 0, 0%; HOP = 2, .3%; P = .30), all-cause reoperation rates (ASC = 1, 0.3%; HOP = 5, 0.8%; P = .35), ED visits (ASC = 3, 0.9%; HOP = 2, 0.3%; P = .23), or readmission rates (ASC = 2, 0.6%; HOP = 9, 1.4%; P = .25).

CONCLUSION

THA can be safely performed in both ASC and HOP settings with low 90-day postoperative complication, revision, reoperation, ED visit, and readmission rates. Based on the populations studied, we identified no statistically significant differences in rates of complications between ASC and HOP groups.

The effect of surgical setting on anterior cruciate ligament reconstruction outcomes

Objective: Ambulatory surgical centers (ASC's) have emerged as an alternative to the traditional hospital- based outpatient department (HOPD). We aim to determine the effect of surgical setting on adverse events following anterior cruciate ligament reconstruction (ACLR).Methods: The Humana Claims Database was queried for all patients undergoing ACLR in the HOPD or ASC setting, using the PearlDiver supercomputer. To eliminate selection bias in our study, the HOPD and ASC cohorts were propensity score matched on baseline demographics, comorbidities, and operative factors. Comparisons between the matched cohorts were made using chi-square tests. Logistic regression models were created to determine the effect of surgical setting on adverse events.Results: A total of 13,647 patients were queried in our study, 5,298 of whom underwent surgery in an ASC and 8,349 of whom underwent surgery in an HOPD. Analysis of the post-matched cohort revealed no differences between cohorts for mechanical failure, nerve injury, pulmonary embolism, septic joint, wound infection, revision surgery and readmission. Rates of deep vein thrombosis (1.18% vs 1.84%; p = .03) were significantly lower in the ASC group. On logistic regression, ASC was associated with decreased risk for deep vein thrombosis (.87, .83-.93) and pulmonary embolism (.85, .78-.95).Conclusion: ACLR performed in ASC is associated with reduced risk of venous thromboembolism and no difference in surgical morbidity and readmissions versus ACLR performed in HOPD. Development of a standardized algorithm for patient selection in the ASC setting is needed to preserve acceptability of ASC-based ACLR in cost-savings and patient safety models.

Enhanced recovery short-stay hip and knee joint replacement program improves patients outcomes while reducing hospital costs

INTRODUCTION

An attractive option to reduce hospital length of stay (LOS) after hip or knee joint replacement (THA, TKA) is to follow the Enhanced Recovery After Surgery principles (ERAS) to improve patient experience to a level where they will feel confident to leave for home earlier. The objective of this study was to evaluate the implementation of short-stay protocol following the ERAS principles.

HYPOTHESIS

We hypothesized that our ERAS THA and TKA short-stay protocol would result in a lower complication rate, shorter hospital LOS and reduced direct health care costs compared to our standard procedure.

MATERIAL AND METHODS

We compared the complications rated according to Clavien-Dindo scale, hospital LOS and costs of the episode of care between a prospective cohort of 120 ERAS short-stay THA or TKA and a matched historical control group of 150 THA or TKA.

RESULTS

Significantly lower rate of Grade 1 and 2 complications in the ERAS short-stay group compared with the standard group (mean 0.8 vs 3.0, p<0.001). No difference was found between the 2 groups for Grade 3, 4, or 5 complications. The mean hospital LOS for the ERAS short-stay group decreased by 2.8 days for the THAs (0.1 vs 2.9 days, p<0.001) and 3.9 days for the TKAs (1.0 vs 4.9 days, p<0.001). The mean estimated direct health care costs reduction with the ERAS short-stay protocol was 1489 CAD per THA and 4158 CAD per TKA.

DISCUSSION

In many short-stay protocols, focus has shifted from ERAS goals of a reduction in complications and improved recuperation to use length of stay as the main factor of success. Implementation of an ERAS short-stay protocol for patients undergoing THA or TKA at our institution resulted not only in reduced hospital LOS, but also in improved patient care and reduced direct health care costs.

LEVEL OF EVIDENCE

Level II.

Low complication rate after same-day total hip arthroplasty: a retrospective, single-center cohort study in 116 procedures

Background and purpose - Length of hospital stay (LOS) following total hip arthroplasty (THA) has been markedly reduced. Recently, same-day THA (SD-THA) was introduced, and previous studies have indicated satisfactory safety. However, studies are heterogeneous and only a few report results on SD-THA when using a posterolateral surgical approach. Thus, our aim was to evaluate the feasibility of and complications after SD-THA when using a posterolateral approach. Patients and methods - Consecutive patients scheduled for SD-THA between October 2015 and June 2016 were included. Eligibility criteria for SD-THA were: primary THA, motivation for same-day procedure, age > 18 years, ASA I or II, and the presence of a support person who could remain with the patient for 24 hours after surgery. A posterolateral surgical approach was used. Data were collected retrospectively from hospital records and the Danish National Patient Registry. Outcome measures were: complications during admission, LOS, causes of prolonged admission, and prevalence and causes of readmission at 90 days' follow-up. Results - 102 of 116 (88%) patients scheduled for SD-THA were discharged on the day of surgery. The remaining 14 patients were discharged the following day. Primary causes of prolonged admission were: dizziness/nausea, pain, and wound seepage. 7 patients had an estimated blood loss above 400 mL, but all were discharged as planned. No major complications occurred during admission. At follow-up, 3 patients had been readmitted due to pneumonia, wound infection, and dislocation, respectively. Interpretation - The results indicate that SD-THA performed with a posterolateral approach is feasible and can be performed with a low complication rate in a selected group of patients.

Adopting the direct anterior approach: experience and learning curve in a Chinese patient population

Background

There are concerns regarding the complications encountered during the learning curve when switching to a direct anterior approach (DAA) for total hip arthroplasty (THA). The purpose of our study is to report our outcomes and complications after adopting a new approach in a Chinese patient population.

Methods

From 2016 to 2018, a single surgeon’s first 100 cases with unilateral DAA for THA were reviewed. The patients were divided into 2 groups, the first 50 cases were designated as group A and the second 50 cases were designated as group B. The preoperative, intraoperative, and postoperative clinical data were analyzed. The cumulative summation method (CUSUM) was used to determine the learning curve.

Results

There was a significant decrease in the complication rate from 44% in the first 50 cases to 16% in the second 50. The first 50 cases showed a significant increase in operating time, length of hospitalization, fluoroscopy, and complications. There was no significant difference in implant position, postoperative leg length discrepancy (LLD), Harris score, or creatine kinase. CUSUM analysis showed that complication rates and operating time reached acceptable and steady state after 88 cases and 72 cases respectively.

Conclusions

Adopting DAA in a Chinese patient population has its own unique considerations and challenges. Even in the hands of an experienced surgeon, DAA is still a technically demanding procedure.

Outpatient Joint Arthroplasty: Transitioning to the Ambulatory Surgery Center

The performance of joint arthroplasty in an outpatient setting is expected to rise significantly over the coming decade, with predictions that greater than half of all primary joint arthroplasties will be performed in an outpatient setting by the year 2026. Financial pressures, bundled payment models, and improved understanding of patient recovery have led to discharging patients home the same day as the index procedure. Arthroplasty surgeons are starting to utilize ambulatory surgery centers (ASCs) to perform these outpatient arthroplasty procedures. Our duty as arthroplasty surgeons continues to be to protect our patients' overall care and safety during this transition from a traditional hospital model. Appreciating that postoperative treatment, disposition, physical space, and sterile processing department capabilities are different from traditional hospital models is paramount to success in an ASC. Differences between hospital and ASC models place additional staffing, financial pressure, and time pressure on the arthroplasty surgeon to select and prepare patients before surgery. Adequately preparing patients involves medical optimization, setting patient and family expectations, identifying appropriate caregivers, and establishing effective communication tools after surgery. It is imperative to develop protocols to deal with predictable discharge delays that include blood pressure, oversedation, postoperative urinary retention, postoperative nausea and/or vomiting, pain, and social issues. These protocols are best first developed in a hospital setting where they can be implemented and changed before starting in an ASC. Arthroplasty surgeons will continue to protect patients by developing protocols and preparing patients appropriately for care in an ASC.