Total Joint Arthroplasty in a Stand-alone Ambulatory Surgical Center: Short-term Outcomes

July/August 2016

For decades, the average hospital stay following total joint arthroplasty (TJA) has been getting shorter. The historical standard was several weeks of hospitalization, yet improvements in perioperative care have reduced the average length of stay to a few days. Medicare recognizes a 3-day inpatient stay as the standard of care following hip or knee replacement. Yet continued advances in minimally invasive surgical techniques, short-acting general anesthetics, long-acting local anesthetics, and blood loss management have further improved the safety and recovery for TJA procedures. Thus, further reductions in postoperative hospitalization have been implemented around the country, with surgeons reporting successful same-day protocols, as defined by hospitalization discharge on the day of surgery. Although these studies have presented results of same-day TJA in the hospital setting, this study is the first to report on the perioperative adverse events and early outcomes of 51 consecutive TJA procedures performed in a stand-alone ambulatory surgical center (ASC). The ASC offers an ideal setting to perform such procedures in the properly selected patient population, obviating any form of postoperative hospitalization. Although 16 (31.4%) of 51 patients reported minor adverse events in the postanesthesia care unit, specifically nausea and/or pain, early intervention permitted 50 (98.0%) of 51 patients to be discharged home, on average 176 minutes after surgery, with 1 patient discharged to a rehabilitation facility as arranged prior to surgery. There were no major adverse events in the 90-day perioperative period, and although 1 (2.0%) patient was hospitalized for persistent incisional drainage, none required admission for pain. This study examines the strict eligibility criteria and perioperative analgesia protocols that permit successful outpatient TJA. [Orthopedics. 2016; 39(4):223–228.]

Ambulatory surgical centers (ASCs) offer surgeons an effective setting to perform procedures that do not require prolonged postoperative monitoring or an inpatient hospital stay. Advances in minimally invasive surgical techniques, short-acting general anesthetics, long-acting local anesthetics, and blood loss management have improved the safety and recovery for many orthopedic procedures. These changes to perioperative care have reduced the need for postoperative hospitalization in many surgical specialties. As a result, the number of procedures performed in the ambulatory setting has grown significantly. The health care market has been pushing for an increased quality of care at a lower cost. Ambulatory surgical centers provide an average 84% cost reduction in procedures as compared with hospital outpatient departments.1

The orthopedic community has mirrored the broader surgical trend in performing more outpatient procedures in ASCs. Total joint arthroplasty (TJA) has historically been considered an inpatient procedure that requires close postoperative monitoring. Use of TJA as treatment for degenerative joint disease has increased substantially in past decades in both elderly and younger patients.2–9 With increasingly younger patients, refinements in surgical technique and perioperative management have made the transition to outpatient TJA a realistic goal. In addition, outpatient TJA has the advantage of being a more cost-effective procedure.10,11

Several studies have demonstrated that TJA performed in an outpatient setting is safe, effective, and efficient.12–17These studies examined unicondylar knee arthroplasty (UKA), total knee arthroplasty (TKA), and total hip arthroplasty (THA). Their results showed no significant difference in morbidity or functional recovery in the properly selected patient population. However, these studies were all performed within the safety net of hospital outpatient departments. Thus, patients who do not meet discharge criteria are easily transitioned to inpatient hospitalization.

The purpose of this study is to report the authors’ experience performing TJA in 51 consecutive patients within a single stand-alone ASC using an integrated anesthesia and orthopedic protocol. Secondarily, the authors identified common perioperative challenges and postoperative outcomes.



Josh Sandberg

Josh Sandberg is the President and CEO of Ortho Spine Partners and sits on several company and industry related Boards. He also is the Creator and Editor of OrthoSpineNews.

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