Should Outpatient Hip and Knee Replacements Be Commonplace?
Article Summary
- Total joint replacement surgeries that used to require three months in the hospital are now routinely done on an outpatient basis.
- While safe, questions remain about total joint replacement patient selection and whether short hospital stays better serve patients.
- Miller School researchers are underscoring the need for providers to stay current with total joint arthroplasty literature.
The first patients to undergo total joint arthroplasty to replace arthritic knees or hips used to stay in the hospital for up to three months after surgery. Today, the majority of U.S. orthopedic surgeons offer the surgeries on an outpatient basis.
In a review article published in the Journal of the American Orthopaedic Surgeons (AAOS) Global Research & Reviews, authors Victor Hugo Hernandez, M.D., chief of the Division of Joint Replacement in the University of Miami Miller School of Medicine’s Department of Orthopaedics, and Brian Osman, M.D., chief of orthopaedic anesthesia at the Miller School and anesthesia director of quality assurance at UHealth Tower, reviewed recent literature looking at the developments and controversies around performing these common surgeries as outpatient procedures.
“Outpatient total joint arthroplasty is becoming a common option for many of our patients and others around the world,” Dr. Hernandez said. “That’s thanks to technological advances, including robotic surgery with mixed reality, surgical techniques that involve cutting less muscles and tendons, as well as a better understanding of pain management and optimal postoperative recovery.”
Trend Toward Outpatient Surgery
AAOS statistics show that in 2018, 47% of member orthopaedic surgeons performed outpatient hip arthroplasty, compared to 87% in 2022. The number of orthopedic surgeons performing outpatient total knee arthroplasty has also climbed from 47% in 2018 to 88% in 2022.
But while total joint arthroplasty has a strong track record of safety in the outpatient setting, questions remain about how to optimally choose patients and perform the same-day surgery versus total joint replacement that involves a short hospital stay.
Papers published in the last five years suggest discrepancies in optimal surgical methods, proper patient selection, pain management protocols, patient discharge readiness and surgical or anesthesia-related complications that may be unique to patients.
For example, the literature remains mixed on patient selection, including whether morbidly obese patients are candidates for total joint arthroplasty. That debate was ignited by the popularity of glucagon-like peptide-1 (GLP-1) receptor agonists for weight loss. There are reports that patients taking GLP-1 agonists are more likely to have residual solids in the stomach that pose danger during surgery and decrease the chances of being discharged the day of surgery.
Factoring in Patient Complexities
More complex surgeries are being performed on an outpatient basis on patients with complex conditions. Anesthesiologists must tailor their approaches as a result, according to Dr. Osman.
“The national societies are beginning to make recommendations focused on this subject,” Dr. Osman said. “For example, proper patient selection is key. Also, the implementation of enhanced recovery after surgery (ERAS) protocols, neuraxial anesthesia, multimodal opioid-sparing analgesia and peripheral nerve blocks have revolutionized the field of total joint surgery.”
To ensure that patients have the option of safe and successful outpatient joint arthroplasty, orthopaedic surgeons, medical doctors, anesthesiologists and physical therapists need to keep pace and with the latest evidence, according to Dr. Hernandez.
“As part of the world-class joint replacement program at the Miller School, we are constantly monitoring joint arthroplasty outcomes and researching ways in which to improve patient safety and the patient experience,” Dr. Osman said.
Coauthors of the review were Michele D’Apuzzo, M.D., professor of orthopaedic surgery and director of the Adult Reconstruction and Joint Replacement Fellowship Program at the Miler School, and Sina Ghaffaripoor Jahromi, M.D., assistant professor of anesthesiology at the Miller School.
Tags: anesthesiology, arthroplasty, Dr. Brian Osman, Dr. Michele D'Apuzzo, Dr. Sina Ghaffaripoor Jahromi, Dr. Victor H. Hernandez, Orthopaedic surgery, total hip replacement, total joint replacement, USNWR Ortho