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de Ladoucette A, Godet J, Resurg, Jenny JY, Ramos-Pascual S, Kumble A, Muller JH, Saffarini M, Biette G, Boisrenoult P, Brochard D, Brosset T, Cariven P, Chouteau J, Henry MP, Hulet C. Complication rates are not higher after outpatient compared to inpatient fast-track total hip arthroplasty: a propensity-matched prospective comparative study. Hip Int 2024:11207000241267977. [PMID: 39189627 DOI: 10.1177/11207000241267977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/28/2024]
Abstract
PURPOSE Concerns remain with regards to safety of fast-track (FT) and especially outpatient procedures. The purpose of this study was to compare complication rates and clinical outcomes of propensity-matched patients who received FT total hip arthroplasty (THA) in outpatient versus inpatient settings. The hypothesis was that 90-day postoperative complication rates of outpatient FT THA would not be higher than after inpatient FT THA. METHODS This is a prospective study of consecutive patients who received FT THA at various rates of outpatient and inpatient surgery by 10 senior surgeons (10 centres). The decision between outpatient and inpatient surgery was made on a case-by-case basis depending on the surgeon and patient. All patients were followed until 90 days after surgery. Complications, readmissions and reoperations were collected, and their severity was assessed according to Clavien-Dindo. Patients completed Oxford Hip Score (OHS) at the latest follow-up. RESULTS Compared to inpatient FT THA, patients scheduled for outpatient FT THA had no significant differences in 90-day postoperative complication rates (10.7% vs. 12.9%, p = 0.129). There were no significant differences between the 2 groups in 90-day readmission rates and reoperation rates, in severity of postoperative complications, and in time of occurrence of postoperative complications. CONCLUSIONS There were no differences in rates of intraoperative complications, 90-day postoperative complications, readmissions, or reoperations between outpatient and inpatient FT THA. These findings may help hesitant surgeons to move towards outpatient THA pathways as there is no greater risk of early postoperative complications that could be more difficult to manage after discharge.
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Affiliation(s)
| | - Julien Godet
- Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Resurg
- ReSurg SA, Nyon, Switzerland
| | | | | | | | | | | | | | - Philippe Boisrenoult
- Centre Hospitalier de Versailles - Hôpital André Mignot, Le Chesnay-Rocquencourt, France
| | | | - Thomas Brosset
- Cité Santé Plus, Alpilles Luberon Orthopédie, Cavaillon, France
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Strait AV, Ho H, Fricka KB, Hamilton WG, Sershon RA. Outpatient Total Joint Arthroplasty in the "Unhealthy": Staying Safe Using Institutional Protocols. J Arthroplasty 2024:S0883-5403(24)00749-6. [PMID: 39053661 DOI: 10.1016/j.arth.2024.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 07/12/2024] [Accepted: 07/17/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Recent expansion in the indications for outpatient total joint arthroplasty has led to debates over patient selection. The purpose of this study was to compare early clinical outcomes and complications of same-day discharge (SDD) hip and knee arthroplasties from a high-volume institution based on the American Society of Anesthesiologists (ASA) physical status classification. METHODS Prospectively collected data were reviewed for all SDD primary joint arthroplasties between January 2013 and August 2023. There were 8 surgeons who performed 7,258 cases at hospital outpatient (n = 4,288) or ambulatory surgery centers (n = 2,970). This included 3,239 total hip arthroplasties, 1,503 total knee arthroplasties, and 2,516 unicompartmental knee arthroplasties. The ASA 1 group comprised 506 subjects, compared to 5,005 for ASA 2 and 1,736 for ASA 3. The primary outcomes included emergency department (ED) visits, readmissions, complications, and revisions within 24 hours and 90 days of surgery. The ASA 3 group was older (ASA 1 = 55 versus ASA 2 = 63 versus ASA 3 = 66 years; P < .01) and had a higher body mass index (ASA 1 = 25.4 versus ASA 2 = 28.5 versus ASA 3 = 32.7; P < .01). RESULTS There were no differences between ASA groups in joint-related ED visits, readmissions, and complications within 24 h and 90 days of surgery (P > .05). Subjects in the ASA 3 group experienced greater 90-day revisions compared to the other groups (ASA 1 = 1 of 506, 0.2% versus ASA 2 = 15 of 5,005, 0.3% versus ASA 3 = 15 of 1,736, 0.9%; P = .01). Regarding systemic events, ASA 1 subjects experienced significantly greater 24-hour complications (8 of 506, 1.6%) and ED visits (5 of 506, 1.0%), and the ASA 3 subjects had a higher incidence of 90-day readmissions (19 of 1,736, 1.1%) compared to the other groups (P < .05). Within 24 hours of discharge, urinary retention and syncope were the most frequent complications that required additional health care utilization. CONCLUSIONS Medically optimized patients categorized as ASA 3 can safely undergo SDD hip and knee arthroplasty without increased risk of 24-hour or 90-day complications. Patient preference for outpatient care, reliable social support, and independent functional status are imperative for a successful outpatient program.
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Affiliation(s)
| | - Henry Ho
- Anderson Orthopaedic Research Institute, Alexandria, Virginia
| | - Kevin B Fricka
- Anderson Orthopaedic Research Institute, Alexandria, Virginia
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Katragadda BC, Suresh A, Azeez A. Can an Enhanced Recovery Protocol Result in a Safe and Effective Outpatient Simultaneous Bilateral Total Knee Arthroplasty? J Arthroplasty 2024; 39:1679-1684. [PMID: 38320663 DOI: 10.1016/j.arth.2024.01.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Outpatient total knee arthroplasty (OP TKA) is found to benefit patients as well as the health care system. Studies on OP TKA have been limited to unilateral total knee arthroplasty (TKA). This study aimed to determine if enhanced recovery after surgery (ERAS) protocols can result in performing simultaneous bilateral TKA (SBTKA) safely and effectively in the OP setting. METHODS This retrospective study compared patients who underwent SBTKA in an OP setting (OP group, n = 100) using an ERAS protocol from April 1, 2021, to June 30, 2022, and a propensity-matched historical group (inpatient group, n = 100) operated in an inpatient setting via conventional protocol from July 1, 2019, to June 30, 2020. The complication rate, readmission rate, visual analog score (VAS), range of motion (ROM), and Knee Society Score (KSS) were compared between the groups in the early postoperative and follow-up periods up to 1 year. RESULTS We found a comparable complication rate (4 versus 7%, P = .4) and readmission rate (2 versus 3%, P = .7). The VAS score was significantly lower in the OP group on day 1, day 2, day 7, and day 14 postsurgery (P < .001). The KSS and ROM were significantly better in the OP group after 14 days (P < .001). The VAS, KSS, and ROM were comparable between the groups at 1 month and later follow-up periods (P > .05). CONCLUSIONS An ERAS protocol in SBTKA patients resulted in safe same-day discharge with better early functional outcomes compared with conventional practices. The results from similar future studies can alleviate surgeon and patient concerns about OP TKA.
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Affiliation(s)
- Bharat C Katragadda
- Arthroplasty Unit, Department of Orthopedics, Sree Gokulam Medical College and Research Foundation, Thiruvananthapuram, Kerala
| | - Anoop Suresh
- Arthroplasty Unit, Department of Orthopedics, Sree Gokulam Medical College and Research Foundation, Thiruvananthapuram, Kerala
| | - Arshad Azeez
- Arthroplasty Unit, Department of Orthopedics, Sree Gokulam Medical College and Research Foundation, Thiruvananthapuram, Kerala
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Sershon RA, Ast MP, DeCook CA, Della Valle CJ, Hamilton WG. Advanced Concepts in Outpatient Joint Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00114-1. [PMID: 38364880 DOI: 10.1016/j.arth.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/01/2024] [Accepted: 02/07/2024] [Indexed: 02/18/2024] Open
Abstract
As the adoption and utilization of outpatient total joint arthroplasty (TJA) continue to grow, key developments have enabled surgeons to safely and effectively perform these surgeries while increasing patient satisfaction and operating room efficiency. Here, the authors will discuss the evidence-based principles that have guided this paradigm shift in joint arthroplasty surgery, as well as practical methods for selecting appropriate candidates and optimizing perioperative care. There will be five core efficiency principles reviewed that can be used to improve organizational management, streamline workflow, and overcome barriers in the ambulatory surgery center (ASC). Finally, future directions in outpatient surgery at the ASC, including the merits of implementing robot assistance and computer navigation, as well as expanding indications for revision surgeries, will be debated.
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Affiliation(s)
| | - Michael P Ast
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | | | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Patel S, Buller LT. Outpatient Hip and Knee Arthroplasty Can be Safe in Patients With Multiple Medical Comorbidities via Use of Evidence-Based Perioperative Protocols. HSS J 2024; 20:75-82. [PMID: 38356746 PMCID: PMC10863597 DOI: 10.1177/15563316231208431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/02/2023] [Indexed: 02/16/2024]
Affiliation(s)
- Sohum Patel
- Department of Orthopedic Surgery, School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Leonard T Buller
- Department of Orthopedic Surgery, School of Medicine, Indiana University, Indianapolis, IN, USA
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Murrell J, Khadabadi NA, Moores T, Hossain F. Identifying Preoperative Predictors for 24-Hour Discharge After Elective Hip and Knee Arthroplasties. Cureus 2023; 15:e50989. [PMID: 38143727 PMCID: PMC10748218 DOI: 10.7759/cureus.50989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2023] [Indexed: 12/26/2023] Open
Abstract
Introduction The resumption of elective medical services post-pandemic has brought to the forefront the importance of outpatient arthroplasty services in promoting efficiency and mitigating hospital-acquired infections. This study aimed to identify preoperative factors that predict the success of outpatient lower limb arthroplasty surgeries. Methods Our investigation involved a retrospective review of 606 patients who underwent elective hip and knee arthroplasty. We documented variables such as the hospital length of stay, patient demographics (age and gender), Oxford Joint Scores, body mass index, socioeconomic status, American Society of Anaesthesiologists' (ASA) physical status classification, comorbid conditions, the Functional Comorbidity Index (FCI), preoperative blood test results, implant types, scheduling details of the surgery, and rates of readmission within 30 days post-surgery. A two-step analysis using univariate and multivariate regression models was performed to pinpoint preoperative indicators that could predict same-day discharge following arthroplasty. Results Forty-five patients (7.4%) were discharged within 24 hours of surgery. Early discharge did not correlate with higher rates of readmission within 30 days (p>0.05). Neither weekend nor afternoon surgeries significantly extended the length of stay beyond 24 hours (p>0.05). No significant differences in the prevalence of comorbidities, FCI scores, socioeconomic status, or preoperative blood test results were found when comparing patients discharged within 24 hours to those who stayed longer. Multivariate analysis revealed that patients younger than 65 years (relative risk (RR) 2.41; 95% confidence interval (CI) 1.02-5.74) and those receiving partial knee arthroplasty (RR 8.91; 95% CI 3.05-26.04) were more likely to be discharged within 24 hours. Conclusions Outpatient arthroplasty is a viable option, especially for individuals younger than 65 years undergoing partial knee arthroplasty, independent of other patient-related factors, comorbidities, and specifics of the hospital episode.
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Affiliation(s)
- James Murrell
- Trauma and Orthopaedics, Walsall Manor Hospital, Walsall, GBR
| | | | - Thomas Moores
- Trauma and Orthopaedics, Walsall Manor Hospital, Walsall, GBR
| | - Fahad Hossain
- Trauma and Orthopaedics, Walsall Manor Hospital, Walsall, GBR
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White PB, Forte SA, Bartlett LE, Osowa T, Bondy J, Aprigliano C, Danoff JR. A Novel Patient Selection Tool Is Highly Efficacious at Identifying Candidates for Outpatient Surgery When Applied to a Nonselected Cohort of Patients in a Community Hospital. J Arthroplasty 2023; 38:2549-2555. [PMID: 37276952 DOI: 10.1016/j.arth.2023.05.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/18/2023] [Accepted: 05/24/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND There is a paucity of validated selection tools to assess which patients can safely and predictably undergo same-day or 23-hour discharge in a community hospital. The purpose of this study was to assess the ability of our patient selection too to identify patients who are candidates for outpatient total joint arthroplasty (TJA) in a community hospital. METHODS A retrospective review of 223 consecutive (unselected) primary TJAs was performed. The patient selection tool was retrospectively applied to this cohort to determine eligibility for outpatient arthroplasty. Utilizing length of stay and discharge disposition, we identified the proportion of patients discharged home within 23 hours. RESULTS We found that 179 (80.1%) patients met eligibility criteria for short-stay TJA. Of the 223 patients in this study, 215 (96.4%) patients were discharged home; 17 (7.9%) were on the day of surgery, and 190 (88.3%) within 23 hours. Of the 179 eligible patients for short-stay discharge, 155 (86.6%) patients were discharged home within 23 hours. Overall, the sensitivity of the patient selection tool was 79%, the specificity was 92%, the positive predictive value was 87% and the negative predictive value was 96%. CONCLUSION In this study, we found that more than 80% of patients undergoing TJA in a community hospital are eligible for short-stay arthroplasty with this selection tool. We found that this selection tool is safe and effective at predicting short-stay discharge. Further studies are needed to better ascertain the direct effects of these specific demographic traits on their effects on short-stay protocols.
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Affiliation(s)
- Peter B White
- Department of Orthopaedic Surgery, Northwell Health at Huntington Hospital, Hunginton, New York
| | - Salvador A Forte
- Department of Orthopaedic Surgery, Northwell Health at North Shore University Hospital, Great Neck, New York
| | - Lucas E Bartlett
- Department of Orthopaedic Surgery, Northwell Health at Huntington Hospital, Hunginton, New York
| | - Temisan Osowa
- Donald and Barbara Zucker School of Medicine/Hofstra, Hempstead, New York
| | - Jed Bondy
- Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania
| | - Caroline Aprigliano
- Department of Orthopaedic Surgery, Northwell Health at North Shore University Hospital, Great Neck, New York
| | - Jonathan R Danoff
- Department of Orthopaedic Surgery, Northwell Health at North Shore University Hospital, Great Neck, New York
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