Abstract
Length of hospital stay has been decreased to the point where the next logical progression in arthroplasty surgery is outpatient arthroplasty procedures. This trend has already happened for procedures formerly regarded as “inpatient” procedures such as upper extremity surgery, arthroscopy, anterior cruciate ligament reconstruction, foot and ankle procedures, and rotator cuff repair. Refinement of surgical techniques, anesthesia protocols, and patient selection has facilitated this transformation. Today, hip, knee and shoulder arthroplasty can be performed safely as outpatient procedures by implementing surgical and protocol refinements. Understanding and addressing, safely, the reasons that surgeons and patients believe they “need” a hospital admission is the cornerstone to outpatient arthroplasty. This program can be highly beneficial to patients, surgeons, anesthesia, ambulatory surgery centers, and payors as arthroplasty procedures shift to the outpatient space. It will always cost more to perform these procedures in hospitals therefore opening up significant opportunities. The less efficiently run hospital in-patient setting demands over-treatment of each patient to fit him or her into the mold of inpatient surgery. Patient satisfaction is very high in the outpatient setting. Patients can recover in their own home with reduced inpatient services and by utilizing outpatient physical therapy. The surgeon efficiently controls the local environment, and thus the overall patient experience and satisfaction are improved in the outpatient setting. The surgeon's role changes from commoditised technician in the hospital setting to coordinator of the entire care experience including pre-operative care, imaging, anesthesia, peri-operative care mapping, post-operative care, and enhanced coordination with therapy providers. An outpatient arthroplasty program involves multiple individuals and specialised protocols for pre-operative, peri-operative, and post-operative care. These include patient selection and education, anesthesia and analgesia, and minimally invasive surgical techniques. By implementing these protocols and a minimally invasive Watson-Jones approach, one study has reported 77% utilization of outpatient THA, 99% success with day of surgery discharge, and a 1% readmission or complication rate.
Outpatient arthroplasty is safe, it's better for us and our patients, and it is here now. In an outpatient environment the surgeon actually spends more time with the patients and family in a friendly environment. Patients feel safe and well cared for, and are highly satisfied with their arthroplasty experience. In a typical day a surgeon can perform 6–8 outpatient arthroplasty procedures with multiple interactions with each patient and their family throughout the day.
Avoidance of narcotics with peripheral and local blocks will increase the eligibility for outpatient surgery and decrease the need for overnight hospitalization. The singular focus on the patient and the avoidance of over-treatment will become the standard of care for total hip and total knee arthroplasty in much the same way as for other procedures once deemed “inpatient” surgeries.
