Outpatient Total Joint Arthroplasty: An Evolving Concept: Commentary on an article by Armin Arshi, MD, et al.: "Outpatient Total Knee Arthroplasty Is Associated with Higher Risk of Perioperative Complications".

Abstract

Commentary Total joint arthroplasty continues to evolve in modern surgical practice and has proven to be among the most effective, reproducible, and successful orthopaedic operations available. Historically, joint replacement surgery was associated with severe pain, prolonged inpatient hospitalization, and extended recovery times. The implementation of preoperative medical optimization, accelerated rehabilitation protocols, improved perioperative pain management strategies, contemporary anesthesia techniques, advanced implant technologies, and evolving surgical techniques into current patient-care episodes has decreased pain, allowed early mobilization, and reduced hospital stays while maintaining equivalent or improving patient outcomes1. A reasonable progression of these innovations would be to consider outpatient surgery for appropriately selected patients as has been done for many other orthopaedic procedures that were previously performed in an inpatient setting only. Additionally, with increasing demand for joint replacements and pressures to reduce health-care costs, outpatient surgery offers an opportunity to meet these challenges. As Arshi et al. mention in their study, several authors have reported safe and effective implementation of outpatient arthroplasty in highly selected patients treated at institutions following structured protocols and using modern perioperative management techniques. These articles have primarily emerged from high-volume centers with strict selection criteria, rigorous clinical pathways, and extensive resources. In their study, Arshi et al. identified a slightly increased risk of postoperative complications, including surgical site infections and stiffness, following outpatient arthroplasties performed in the general orthopaedic community. The trend toward increased complications in the large insurance database that they reviewed could potentially be related to suboptimal patient selection and breaches in strict comprehensive total joint protocols. The age at the time of surgery in the outpatient cohort was statistically identical to that in the inpatient cohort, with several patients who were older than 80 years of age undergoing outpatient surgery. This highlights several concerns regarding appropriate patient selection given the known increased risks of perioperative complications in the elderly population. Recommendations emanating from centers of excellence suggest that outpatient arthroplasty be offered only to patients younger than 70 to 75 years old with limited medical comorbidities and a high baseline level of function2,3. Furthermore, appropriate access to health-care resources is critical to effectively care for patients who are unable to be discharged to their homes or who experience an early postoperative complication. The prevalence of complications reported in this study could potentially be reduced with further modifications of the protocols and clinical care pathways. Although the study design made it impossible to know the details of the specific perioperative care utilized, the reported complications could logically be minimized with careful institution of a structured program for outpatient arthroplasty. This would include strict patient selection, preoperative education, timely delivery and an appropriate duration of antibiotic therapy, early initiation of postoperative therapy, and contemporary pain management strategies with preemptive administration of medications. Clinical care pathways need to be consistently reviewed and updated when barriers to safe patient care are identified. In summary, outpatient total joint arthroplasty will continue to emerge as an option for selected patients for whom structured clinical pathways are followed; however, it is unlikely to completely replace inpatient hospitalization for a substantial percentage of patients undergoing joint replacement. Further research is needed to clarify appropriate inclusion criteria and clinical care pathways. At present, careful patient selection, strict perioperative protocols, and adequate resources are necessary to safely incorporate outpatient arthroplasty into clinical practice.