Is Outpatient Arthroplasty Feasible?

    Length of stay (LOS) after joint replacement procedures has decreased dramatically over the last 20 years as a result of improved pre- and postoperative protocols, as well as improved surgical techniques. But is joint replacement as an outpatient procedure a realistic option?

    Yes it is, according to Adolph V. Lombardi, Jr., MD, who spoke on the topic at ICJR’s annual Winter Hip & Knee Course in Vail, Colorado. He and his colleagues at Joint Implant Surgeons, Inc., of New Albany, Ohio, have experience with outpatient arthroplasty, and have spent the past year honing their protocols and patient selection criteria.

    There are some roadblocks to outpatient arthroplasty, as described by Dr. Lombardi:

    • Patient fear/anxiety
    • Patients are afraid of the unknown, not knowing what is going to happen
    • Patients are afraid of the pain associated with the procedure
    • Risk factors
    • Patient co-morbidities
    • Medical complications as a result of the treatment
    • Side effects of the treatment
    • Narcotics/anesthesia
    • Blood loss
    • Surgical trauma

    To remove these roadblocks, Dr. Lombardi and his colleagues have identified the steps necessary for successful outpatient joint replacement procedures:

    Orthopaedic assessment. The orthopaedic assessment consists of the history and physical and determination of surgical intervention. It is important to motivate the patient, as well as to evaluate the home situation, such as whether the patient has support at home.

    Preoperative medical clearance. Preoperative medical clearance mitigates risks. Using the same group of internal medicine specialists to evaluate all patients ensures a team familiar with outpatient procedures and aware of factors that would make an outpatient procedure undesirable.

    Physical therapy preoperative assessment and and “pre-hab.” Pre-arthroplasty rehabilitation further educates patients about what is expected of them after the operation, such as how they are going to move their extremity, how to use a cane or crutches, and what to expect in the perioperative phase.

    Preoperative education. Preoperative education reduces fear and anxiety by informing the patient about the procedure, pain management protocols, and expected LOS. In Dr. Lombardi’s practice, each patient is given a “Rapid Road to Recovery” book so they can further educate themselves about the procedure and postoperative period.

    Preoperative analgesia and perioperative anesthetic. The anesthesiologist’s job is to make the patient comfortable. For total hip arthroplasty, Dr. Lombardi prefers a short-acting spinal without narcotics; for total knee arthroplasty, he prefers an adductor canal block with a sciatic nerve block plus local wound infiltration. His anesthesia, pain control, and blood loss protocol also includes:

    • General anesthesia
    • Tranexamic acid, 1g x 2
    • Pericapsular injectable cocktail: bupivacaine liposome suspension
    • IV acetaminophen, 1000 mg x 2
    • IV steroid dexamethasone, 10 mg/4 mg
    • Celcoxib pre- and postoperatively

    Efficient surgery. The surgeon should utilize proven techniques to minimize the duration of the procedure and minimize the impact of the surgery on the joint and surrounding tissues.

    Identifying the right patient for outpatient arthroplasty and incorporating the right program are crucial, Dr. Lombardi said, and include:

    • Medical screening
    • Acceptable cardiac history
    • Function independently with walker
    • Preoperative physiotherapy evaluation
    • Preoperative education
    • Written educational materials
    • Family support at home
    • Live 1 to 2 hours of the surgical center, or the surgical center has 23-hour stay capabilities

    Dr. Lombardi concluded that outpatient surgery in total joint arthroplasty is safe and  efficient for certain patients and procedures. It can provide significant cost savings for the patient, hospital, and health care system and can be profitable for the surgeon.

    Dr. Lombardi’s presentation can be found here.