Outpatient Total Joint Replacement

Historically, total joint replacement patients have recovered in an inpatient hospital facility

after surgery. The length of the average inpatient stay has steadily decreased over the last

several decades. In the past, it would not have been uncommon for patients to be hospitalized

for a week or more after the procedure. Modern recovery protocols have gradually decreased

the average amount of time in the hospital, though, with goals to return patients to their

homes earlier as long as there is no increased risk of post-operative complications. This trend

continues to this day and has transitioned to surgeons performing some total joint replacement

surgeries on an outpatient basis, meaning that patients have their procedure, recover in the

medical facility for a short period of time after surgery, and go home that same day after

passing a few requirements. The COVID-19 pandemic was a significant driving force in this

transition as well, since access to extended inpatient facilities was limited for such a long period

of time. Additionally, Medicare removed total joint replacement from the list of procedures

that could only be performed as an inpatient, which also paved the way for more outpatient

procedures. While some patients have expressed significant concerns regarding this plan for

recovery after surgery, many have now successfully undergone outpatient procedures without

increased complication rates. To better understand this potential treatment option for

patients, let’s explore the important aspects of outpatient total joint replacement.

Patient Selection

One highly debated topic and concern of both surgeons and patients is the safety of recovering

completely at home following surgery. Certainly, patients with significant health problems or

advanced age may not be ideal candidates for an outpatient procedure; however, defining a

clear and concise set of criteria for screening patients for the best candidates has proven

difficult. Research has led to some scoring systems, such as the Outpatient Arthroplasty Risk

Assessment score, which continue to be revised and updated to better predict a patient’s

likelihood of surgical risk. Medical conditions such as heart disease, some lung conditions, high

blood pressure, obesity, poor nutrition, chronic kidney disease, liver problems, and advanced

age remain important aspects of these scoring systems. Other characteristics of a patient, such

as living conditions at home, available assistance, and level of mobility before and after surgery

are also taken into account. Ultimately, each surgeon will have a unique set of criteria for

determining which patients are offered the opportunity for an outpatient surgery. While the

risks of surgery can only be estimated by these systems, surgeons frequently err on the side of

caution and proceed with an inpatient surgery if there are any significant concerns.

Pre-operative Care

Preparation for outpatient surgery begins well before the actual surgery. Since these patients

will not spend much time in the hospital setting, there will not be many opportunities for

patient teaching on the day of surgery. As a result, patient education becomes an important

part of the outpatient surgery planning. Patients may be asked to attend a joint replacement

class to provide additional details about surgery, expectations, and the surgical plan.

Alternatively, websites and handouts may be provided for those details as well. No matter

which type of education is offered, it is very important to review all of the information available

to avoid any surprises on the day of surgery.

Perioperative Care

All patients receive similar care around their joint replacement surgery regardless of whether

an inpatient or outpatient surgery is planned. However, certain aspects of care may be

emphasized or altered for outpatient procedures to avoid the most common reasons for

patients not being able to head home after surgery. For example, anesthesia providers will

frequently attempt to limit the dose of narcotics and other medications that are known to

cause significant post-operative nausea, vomiting, or difficulty urinating after surgery. In place

of those medications, others are used to provide the same level of care and make up part of the

multi-modal pain regimen that was discussed in last month’s blog. Nerve blocks are frequently

used in that regimen as well to provide additional pain control. Secondly, patients will likely

undergo the procedure under spinal anesthesia as opposed to general anesthesia. Spinal

anesthesia has lower complication rates, less bleeding, and can be accurately timed to provide

excellent pain control during the procedure and wear off shortly thereafter to allow patients to

walk after surgery. Thirdly, surgeons will avoid urinary catheters in most cases, as those can

result in difficulty urinating after surgery (especially in males). Lastly, care will be coordinated

amongst the entire surgical team to allow patients to briefly recover and then walk in the

recovery area to ensure they are safe to be discharged home.

As you can see, the perioperative care of outpatient joint replacement patients requires careful

organization and a dedicated team to make the experience run smoothly. Centers that perform

this well can easily reduce what was once a multi-week stay in the hospital down to a four-to-

five-hour procedure before returning home. Patients must realize, though, that any deviation

from the normal recovery protocol may result in the decision to admit the patient overnight in

the hospital for additional monitoring.

Complication Rates

The safety of outpatient total joint replacement has always been the main focus of research in

this field. Now that the level of experience with outpatient joint replacement has increased, so

have clinical studies looking at the success rates of this endeavor. One such study showed that

the complication rates following surgery were similar or even improved in patients undergoing

outpatient joint replacement. This study evaluated complications such as the rate of wound

complications, infection, blood clots, heart attacks, and the need to return to the hospital after

being sent home. 1 Another analysis calculated the rate of all complications for patients and

found a lower rate at 1.3% for outpatient procedures as compared to 1.9% for inpatients. 2

Thirdly, a study that combined several other studies to create a group of over 1,000 patients

showed that 94.5% of patients were able to be successfully discharged home when planning an

outpatient surgery and only 0.89% of patients needed to return to the hospital within the first

few days after discharge. 3 The conclusions of all three of these trials were that outpatient joint

replacement surgery is safe for carefully selected patients.

It is worth noting, however, that critics of these studies feel that comparisons of these two

groups may not be completely fair. Most early studies were very conservative regarding which

patients were considered for outpatient surgery, so patients with few health problems were

offered outpatient surgery while those with more significant health concerns were not.

Regardless, as more patients have been offered outpatient surgery over the years, the

conclusions stated above have held true so far.

Conclusions

As more data continues to be generated around the safety of outpatient joint replacement

surgery, surgeons and patients continue to be interested in pursuing this option for more

patients moving forward. The vast majority of patients, which was as high as 96% in one study,

are satisfied with their decision for outpatient therapy after the fact. 4 While the decision to

pursue an outpatient procedure may seem daunting or a bit scary at first, I hope the

information here will help provide some comfort that the process is well thought out and highly

coordinated by the entire joint replacement team.

1 Courtney, PM, Boniello, AJ, Berger, RA. Complications Follow- ing Outpatient Total Joint

Arthroplasty. An Analysis of a Na- tional Database. J Arthroplasty 2017;32:1426–1430.

2 Sher, A, Keswani, A, Yao, D, Anderson, M, Koenig, K, Moucha, CS. Predictors of Same-Day

Discharge in Primary Total Joint Arthroplasty Patients and Risk Factors for Post-Discharge

Com- plications. J Arthroplasty 2017;32:S150-S156.e1.

3 Hoffmann JD, Kusnezov NA, Dunn JC, et al. (2018) The Shift to Same-Day Outpatient Joint

Arthroplasty: A Systematic Review. J Arthroplasty 33:1265–1274 . doi:

10.1016/j.arth.2017.11.027.

4 Dorr, LD, Thomas, DJ, Zhu, J, Dastane, M, Chao, L, Long, WT: Outpatient Total Hip

Arthroplasty. J Arthroplasty. 2010;25: 501–506.