Fast-track hip and knee arthroplasty...how fast?

Abstract

Fast-track (or enhanced recovery after surgery [ERAS]) programmes for total hip arthroplasty and total knee arthroplasty have evolved over the past 20 yr.1Kehlet H. Fast-track hip and knee arthroplasty.Lancet. 2013; 381: 1600-1602Abstract Full Text Full Text PDF PubMed Scopus (221) Google Scholar Their development has been driven by the questions, ‘Can the operation be done as an outpatient procedure?’ and if not, ‘Why is the patient in the hospital?’ based upon an analysis and modification of undesirable pathophysiological responses that delay recovery.2Wainwright T.W. Kehlet H. Fast-track hip and knee arthroplasty — have we reached the goal?.Acta Orthop. 2019; 90: 3-5Crossref PubMed Scopus (25) Google Scholar The data confirm that fast-track approaches can improve clinical and economic outcomes; however, their implementation has not been universal.2Wainwright T.W. Kehlet H. Fast-track hip and knee arthroplasty — have we reached the goal?.Acta Orthop. 2019; 90: 3-5Crossref PubMed Scopus (25) Google Scholar,3Memtsoudis S.G. Fiasconaro M. Soffin E.M. et al.Enhanced recovery after surgery components and perioperative outcomes: a nationwide observational study.Br J Anaesth. 2020; 124: 638-647Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar Although length of hospital stay (LOS) has been reduced over the past 10 yr within the English NHS, the national mean LOS remains 4–5 days and rates of outpatient arthroplasty continue to be low (data from Hospital Episode Statistics at https://digital.nhs.uk/data-and-information/data-tools-and-services/data-services/hospital-episode-statistics). In contrast, in Denmark4Petersen P.B. Jorgensen C.C. Kehlet H. Temporal trends in length of stay and readmissions after fast-track hip and knee arthroplasty.Dan Med J. 2019; 66: A5553PubMed Google Scholar and the USA,5Liu J. Elkassabany N. Poeran J. et al.Association between same day discharge total knee and total hip arthroplasty and risks of cardiac/pulmonary complications and readmission: a population-based observational study.BMJ Open. 2019; 9e031260Crossref PubMed Scopus (12) Google Scholar mean LOS has been reduced to about 2 days for both total hip arthroplasty and total knee arthroplasty, and outpatient arthroplasty is now well established in selected patients in many international centres.6Vehmeijer S.B.W. Husted H. Kehlet H. Outpatient total hip and knee arthroplasty.Acta Orthop. 2018; 89: 141-144Crossref PubMed Scopus (42) Google Scholar Importantly, the definition of outpatient surgery within these settings should not include an overnight stay, which is in contrast to other reports using a less than 23 h stay,6Vehmeijer S.B.W. Husted H. Kehlet H. Outpatient total hip and knee arthroplasty.Acta Orthop. 2018; 89: 141-144Crossref PubMed Scopus (42) Google Scholar thereby adding some confusion when interpreting the data. The concept of outpatient arthroplasty is not new. Studies demonstrating its feasibility in selected patients were first published more than 10 yr ago. More recently, preliminary observations support that such an approach is feasible in ∼15% of unselected patient cohorts within a socialised healthcare system, and with no apparent increase in complications or re-admissions.7Gromov K. Jorgensen C.C. Petersen P.B. et al.Complications and readmissions following outpatient total hip and knee arthroplasty: a prospective 2-center study with matched controls.Acta Orthop. 2019; 90: 281-285Crossref PubMed Scopus (30) Google Scholar Outpatient arthroplasty is therefore an attractive concept in the context of policy changes advocating value-based care models, particularly given the additional capacity and economic benefits it offers, although the economic benefit may be variable and depend on local factors.6Vehmeijer S.B.W. Husted H. Kehlet H. Outpatient total hip and knee arthroplasty.Acta Orthop. 2018; 89: 141-144Crossref PubMed Scopus (42) Google Scholar However, recent data from population-based observational studies from the USA and Canada based on the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database have shown that outpatient total hip arthroplasty and total knee arthroplasty were associated with higher odds of major and minor complications5Liu J. Elkassabany N. Poeran J. et al.Association between same day discharge total knee and total hip arthroplasty and risks of cardiac/pulmonary complications and readmission: a population-based observational study.BMJ Open. 2019; 9e031260Crossref PubMed Scopus (12) Google Scholar,8Nowak L.L. Schemitsch E.H. Same-day and delayed hospital discharge are associated with worse outcomes following total knee arthroplasty.Bone Joint J. 2019; 101-b: 70-76Crossref PubMed Scopus (14) Google Scholar compared with patients discharged after a one-night hospital stay5Liu J. Elkassabany N. Poeran J. et al.Association between same day discharge total knee and total hip arthroplasty and risks of cardiac/pulmonary complications and readmission: a population-based observational study.BMJ Open. 2019; 9e031260Crossref PubMed Scopus (12) Google Scholar or a 1–2 day stay.8Nowak L.L. Schemitsch E.H. Same-day and delayed hospital discharge are associated with worse outcomes following total knee arthroplasty.Bone Joint J. 2019; 101-b: 70-76Crossref PubMed Scopus (14) Google Scholar The USA study5Liu J. Elkassabany N. Poeran J. et al.Association between same day discharge total knee and total hip arthroplasty and risks of cardiac/pulmonary complications and readmission: a population-based observational study.BMJ Open. 2019; 9e031260Crossref PubMed Scopus (12) Google Scholar is the first very large comprehensive evaluation of population based data and includes a propensity matched analysis accounting for comorbidities amongst 226 481 total knee arthroplasty and 140 557 total hip arthroplasty patients, with a focus on the safety of outpatient arthroplasty. A smaller (n=4391) US private insurance database study also showed a higher risk of perioperative surgical and medical complications compared with standard inpatient total knee arthroplasty.9Arshi A. Leong N.L. D’Oro A. et al.Outpatient total knee arthroplasty is associated with higher risk of perioperative complications.J Bone Joint Surg Am. 2017; 99: 1978-1986Crossref PubMed Scopus (39) Google Scholar Although these studies may have several limitations, including residual confounding, the findings nevertheless are an important reminder that outpatient surgery may not equate to optimised care for every patient, and that ERAS protocols should be based on the concept of ‘first better – then faster’.2Wainwright T.W. Kehlet H. Fast-track hip and knee arthroplasty — have we reached the goal?.Acta Orthop. 2019; 90: 3-5Crossref PubMed Scopus (25) Google Scholar Consequently, there is a need for improved prediction methods for safe outpatient procedures.10Johnson D.J. Castle J.P. Hartwell M.J. D’Heurle A.M. Manning D.W. Risk factors for greater Ttan 24-hour length of stay after primary total knee arthroplasty.J Arthroplasty. 2020; 35: 633-637Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Within an optimised ERAS programme, selected high-risk patients may benefit from a planned longer stay in hospital as the best means of accelerating recovery and reducing complications, re-admissions, and morbidity.2Wainwright T.W. Kehlet H. Fast-track hip and knee arthroplasty — have we reached the goal?.Acta Orthop. 2019; 90: 3-5Crossref PubMed Scopus (25) Google Scholar Consequently, it may be prudent to keep some patients with specific comorbidities in hospital overnight even though they meet conventional discharge criteria. This is especially the case given that the benefits of discharging a patient home in the evening instead of the next morning are still to be determined from a safety vs economic perspective.6Vehmeijer S.B.W. Husted H. Kehlet H. Outpatient total hip and knee arthroplasty.Acta Orthop. 2018; 89: 141-144Crossref PubMed Scopus (42) Google Scholar Although apparently safe in several selected settings, we need more generalisable data, including complete post-discharge issues such as emergency department and general practitioner visits and use of skilled nursing or other facilities, home nursing care etc. Before more widespread recommendations for outpatient arthroplasty, there are several practical caveats that need to be considered. Firstly, the value of a change to outpatient practice should only be investigated in the context of an existing optimised fast-track programme, that is it should not be a justification for units without an existing properly implemented fast-track programme. Secondly, it may be more difficult to implement in some settings, such as hospital vs ambulatory surgery centres (ASC). However, preliminary data suggest an outpatient programme can be performed successfully in both settings.11Sershon R.A. McDonald 3rd, J.F. Ho H. Goyal N. Hamilton W.G. Outpatient total hip arthroplasty performed at an ambulatory surgery center vs hospital outpatient setting: complications, revisions, and readmissions.J Arthroplasty. 2019; 34: 2861-2865Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar In addition to these contextual factors, the most important challenge for future improvement within the outpatient ERAS setting is better understanding and control of undesirable perioperative pathophysiological responses such as pain relief, control of inflammatory responses and orthostatic intolerance, optimal blood management, and prevention of cognitive dysfunction.12Kehlet H. Enhanced postoperative recovery: good from afar, but far from good?.Anaesthesia. 2020; 75: e54-e61PubMed Google Scholar Future optimisation and reduction of these post-surgical sequelae therefore represent a prerequisite for further development and increased use of outpatient total hip arthroplasty and total knee arthroplasty. There is a need to be able to identify patients at risk of complication or re-admission preoperatively and before discharge. Of special importance will be the need to identify ways to predict high pain and inflammatory responders12Kehlet H. Enhanced postoperative recovery: good from afar, but far from good?.Anaesthesia. 2020; 75: e54-e61PubMed Google Scholar so that related pathophysiology can be modified to facilitate optimal post-discharge rehabilitation strategies.2Wainwright T.W. Kehlet H. Fast-track hip and knee arthroplasty — have we reached the goal?.Acta Orthop. 2019; 90: 3-5Crossref PubMed Scopus (25) Google Scholar Nevertheless, for high-performing total hip arthroplasty and total knee arthroplasty ERAS centres, outpatient surgery is a natural evolution, and the results have led to widespread enthusiasm for the approach across healthcare systems, industry, and media. However, for some patients it may remain better to prolong their hospital stay modestly. This may apply especially to sites without an already established successful fast-track protocol, where outpatient arthroplasty may not be possible or lead to increased re-admissions and morbidities. In addition, the outpatient approach should not be based upon increased use of post-discharge care facilities with secondary cost and safety challenges. To summarise, there is a delicate balance between implementation of established evidence for total hip arthroplasty and total knee arthroplasty ERAS care and moving too fast to more widespread implementation of the promising outpatient approach given the fact that more patients with comorbidities or need for revision surgery are being seen. We should be mindful to ‘walk before we run’ and remember that the ERAS concept is based on reduction of undesirable pathophysiological responses to surgery in order to enhance recovery, meaning ‘first better, then faster’. The authors declare that they have no conflicts of interest.