Abstract
Aims
The volume of ambulatory total hip arthroplasty (THA) procedures is increasing due to the emphasis on value-based care. The purpose of the study is to identify the causes for failed same-day discharge (SDD) and perioperative factors leading to failed SDD.
Methods
This retrospective cohort study followed pre-selected patients for SDD THA from 1 August 2018 to 31 December 2020. Inclusion criteria were patients undergoing unilateral THA with appropriate social support, age 18 to 75 years, and BMI < 37 kg/m2. Patients with opioid dependence, coronary artery disease, and valvular heart disease were excluded. Demographics, comorbidities, and perioperative data were collected from the electronic medical records. Possible risk factors for failed SDD were identified using multivariate logistic regression.
Results
In all, 278 patients were identified with a mean age of 57.1 years (SD 8.1) and a mean BMI of 27.3 kg/m2 (SD 4.5). A total of 96 patients failed SDD, with the most common reasons being failure to clear physical therapy (26%), dizziness (22%), and postoperative nausea and vomiting (11%). Risk factors associated with failed SDD included smokers (odds ratio (OR) 6.24; p = 0.009), a maximum postoperative pain score > 8 (OR 4.76; p = 0.004), and procedures starting after 11 am (OR 2.28; p = 0.015). A higher postoperative tolerable pain goal (numerical rating scale 4 to 10) was found to be associated with successful SDD (OR 2.7; p = 0.001). Age, BMI, surgical approach, American Society of Anesthesiologists grade, and anaesthesia type were not associated with failed SDD.
Conclusion
SDD is a safe and viable option for pre-selected patients interested in rapid recovery THA. The most common causes for failure to launch were failing to clear physical thereapy and patient symptomatology. Risk factors associated with failed SSD highlight the importance of preoperative counselling regarding smoking cessation and postoperative pain to set reasonable expectations. Future interventions should aim to improve patient postoperative mobilization, pain control, and decrease symptomatology.
Cite this article: Bone Jt Open 2022;3(9):684–691.
Take home message
Our results emphasize the importance of preoperative counselling regarding smoking cessation and postoperative pain.
Future research should be aimed at reducing dizziness and postoperative nausea and vomiting.
Introduction
Over the past 20 years, the average length of stay for total hip arthroplasty (THA) has decreased from seven days to approximately two days.1-5 Innovations in patient education, perioperative care pathways, surgical and anesthetic techniques, blood conservation, multimodal pain management, and accelerated recovery pathways were all instrumental in this paradigm shift.5-10 These efforts have led to the rise of ambulatory arthroplasty, allowing carefully selected patients to be safely discharged the day of surgery.8,11-17 In addition, the impetus of reducing healthcare costs has been a catalyst for the shift towards ambulatory arthroplasty.18-26 High patient satisfaction has been reported both in the hospital outpatient department (HOPD) and ambulatory surgery centre (ASC).27-29
When patients are not cleared to leave on the day of surgery, they lose the ability to recover in the comfort of their own home and the hospital incurs increased cost. Therefore, the main goal of this study was to elucidate the causes for failed same-day discharge (SDD) or “failure to launch” in preselected patients undergoing ambulatory THA. A secondary goal was to determine risk factors associated with failed SDD at the HOPD.
Methods
Institutional board approval was obtained prior to initiation of the study. A retrospective review of all ambulatory THAs performed between 1 August 2018 and 31 December 2020 at a tertiary orthopaedic speciality hospital (Hospital for Special Surgery, New York, USA) was performed. Ambulatory THA was defined as undergoing surgery and being discharged home on the same calendar day. Patients were deemed candidates for ambulatory THA according to comorbidities, social support, and patient preference (Table I). Patients who did not agree to be discharged the same day during the clinic visit and whose insurance company denied an inpatient stay, and therefore were scheduled as ambulatory, were excluded (Figure 1).
Table I.
Relative total hip arthroplasty outpatient candidacy criteria.
| Inclusion criteria |
|---|
| Procedures: unilateral primary total knee arthroplasty or simple revisions |
| Age 18 to 75 years |
| BMI 18.5 to 37.0 kg/m2 |
| Not currently using warfarin or enoxaparin |
| Appropiate social support: patient agrees and has a responsible adult to spend the night on the day of discharge |
| Case scheduled before 12 pm |
| Exclusion criteria |
| History of active ischaemia |
| Significant valvular disease or arrythmia |
| Uncontrolled or undiagnosed osbstructive sleep apnoea |
| Opioid dependence or addiction |
| Glomerular filtration rate < 60 ml/min |
Fig. 1
Flowchart of patient selection. THA, total hip arthroplasty.
In all, 278 patients with a mean age of 57.1 years (standard deviation (SD) 8.1) and a mean BMI of 27.3 kg/m2 (SD 4.5), of whom 45% were female, underwent THA with intention to be discharged on the same day (Table II). The majority of patient received neuraxial anaesthesia (98%), were American Society of Anesthesiologists (ASA) grade II (89%), and were never smokers (67%). Surgical approach breakdown, posterior compared to anterior, was almost an even split (51% vs 49%, respectively).
Table II.
Patient demographics and factors associated with successful same-day discharge.
| Variable | Overall (n = 278) | Successful SDD (n = 182) | Failed SDD (n = 96) | p-value |
|---|---|---|---|---|
| Age, yrs (SD) | 57.1 (8.1) | 56.8 (7.8) | 57.8 (8.7) | 0.293* |
| < 50, n (%) | 45 (16) | 30 (16) | 15 (16) | |
| 50 to 64, n (%) | 192 (69) | 127 (70) | 65 (68) | |
| 65 to 79, n (%) | 41 (15) | 25 (14) | 16 (17) | |
| Sex, n (%) | 0.100† | |||
| Female | 126 (45) | 76 (42) | 50 (52) | |
| Male | 152 (55) | 106 (58) | 46 (48) | |
| BMI, kg/m2 (SD) | 27.3 (4.5) | 27.3 (4.3) | 27.2 (4.9) | 0.872* |
| Non-obese, BMI < 30 kg/m2, n (%) | 202 (73) | 133 (73) | 69 (72) | |
| Obese (BMI ≥ 30 kg/m2, n (%) | 76 (27) | 49 (27) | 27 (28) | |
| ASA grade, n (%) | 0.116† | |||
| I | 25 (9) | 17 (9) | 8 (8) | |
| II | 248 (89) | 164 (90) | 84 (88) | |
| III | 5 (2) | 1 (1) | 4 (4) | |
| Smoking status, n (%) | 0.005† | |||
| Current | 13 (5) | 4 (2) | 9 (9) | |
| Former | 80 (29) | 47 (26) | 33 (34) | |
| Never | 185 (67) | 131 (72) | 54 (56) | |
| Laterality, n (%) | 0.138† | |||
| Left | 127 (46) | 89 (49) | 38 (40) | |
| Right | 151 (54) | 93 (51) | 58 (60) | |
| Anaesthesia, n (%) | 0.419† | |||
| Regional | 272 (98) | 179 (98) | 93 (97) | |
| General | 6 (2) | 3 (2) | 3 (3) | |
| Surgical approach, n (%) | 0.156† | |||
| Direct anterior | 135 (49) | 94 (52) | 41 (43) | |
| Posterior | 143 (51) | 88 (48) | 55 (57) | |
| Procedure start time, n (%) | 0.006† | |||
| Before 11 am | 217 (78) | 151 (83) | 66 (69) | |
| On or after 11 am | 56 (20) | 28 (15) | 28 (29) | |
| Procedure length, min, n (SD) | 82.4 (8.0) | 82.5 (6.9) | 82.2 (20.2) | 0.921 |
| Estimated blood loss, ml, n (SD) | 149.5 (40.5) | 148.6 (40.7) | 151.0 (40.2) | 0.640 |
| Intraoperative IV fluid intake, ml, n (%) | 1,364 (371) | 1,380 (386) | 1,330 (339) | 0.327 |
| Highest postoperative pain score, n (%) | 0.007† | |||
| 0 to 3 | 32 (12) | 26 (14) | 6 (6) | |
| 4 to 7 | 156 (56) | 108 (59) | 48 (50) | |
| 8 to 10 | 86 (31) | 46 (25) | 40 (42) | |
| Pain goal for discharge, n (%) | 0.006† | |||
| Minimal pain, 0 to 3 | 167 (60) | 99 (54) | 68 (71) | |
| Moderate to severe pain, 4 to 10 | 107 (38) | 81 (45) | 26 (27) | |
| Number of PT attempts on DOS, n (%) | < 0.001† | |||
| 1 | 165 (59) | 156 (86) | 9 (9) | |
| > 1 | 113 (41) | 26 (14) | 87 (91) |
-
*
Independent-samples t-test.
-
†
Pearson’s chi-squared test.
-
ASA, American Society of Anesthesiologists; DOS, day of surgery; PT, physical therapy; SD, standard deviation; SDD, same-day discharge.
Perioperative care protocols
Every patient underwent preoperative education regarding ambulatory discharge during the clinic visit to set appropriate expectations. Additionally, patients underwent a preoperative multidisciplinary pathway consisting of an educational webinar, virtual preoperative physical therapy (PT) assessment, and discharge planning with a case manager. Preoperatively, patients underwent risk assessment and medical optimization by an in-house specialist who routinely assess hip and knee arthroplasty patients.
The day of surgery, all patients were allowed to consume clear fluids up to three hours prior to surgery according to institutional guidelines. In the preoperative holding area, the patients set their tolerable pain goal. Blood conservation strategies consisted of a two-dose tranexamic acid (TXA) protocol, 1 gm IV prior to incision and 1 gm IV in the post-anaesthesia care unit (PACU). Intraoperative multimodal anaesthesia protocols consisted of neuraxial anaesthesia, ketamine (up to 50 mg), ketorolac 15 mg IV, acetaminophen 1 gm IV, and a surgeon-administered periarticular injection (PAI). Neuraxial anesthesia (spinal, epidural, or combined spinal epidural) drug and dose vary according to anesthesiologist preferences. Nausea and vomiting prophylaxis consisted of ondansetron 4 mg IV administered once intraoperatively. A single high dose of glucocorticoids (dexamethasone 4 mg IV) is administered to decrease the surgical stress response.30 Postoperative pain management consisted of IV ketorolac 15 mg once, IV acetaminophen 1 gm once, oral administration of oxycodone 5 to 10 mg q at four to six hours PRN, acetaminophen 1 gm q at six hours, and meloxicam 15 mg daily.
After surgery, patients were monitored in the PACU until discharge or admitted to the hospital for an overnight stay. Early mobilization was encouraged by PT after recovering full motor and sensory function approximately two hours postoperatively, discharge criteria include ambulating 150 feet, independent transfer from the supine and seated position to standing and negotiating stairs if needed. Additionally, patients should be able to independently perform a home exercise programme. Every patient who failed the first PT evaluation was seen a second time after a two- to three-hour period. Following the first postoperative void, one litre of normal saline solution is administered over one hour routinely. Transition to regular diet is encouraged two hours after surgery. Once all discharge criteria have been met both, patients and family members must verbalize their understanding of discharge instructions.
Statistical analysis
Patient demographics and perioperative data were reported using descriptive statistics. Continuous variables were reported as means and SD or median and interquartile range (IQR) for normally and non-normally distributed data, respectively. Comparisons between groups were investigated using independent-samples t-test or Mann-Whitney U test depending on data distribution. Categorical variables were presented as frequencies and percentages and compared using Pearson’s chi-squared tests. Univariate and multivariate logistic regression were used to identify factors associated with SDD. All tests were two-tailed, and p-values < 0.05 were considered statistically significant. Statistical analyses were performed using Stata version 15.0 (StataCorp, USA).
Results
Overall, 182 patients (65.5%) were successfully discharged the day of surgery, while the remaining 96 patients (34.5%) failed SDD. Of these 96 patients, 72 (82.2%) were discharged the next day (next day discharge (NDD)). A greater proportion of patients who went home the same day were never smokers (72% vs 56%; p = 0.005), had a procedure start time before 11 am (83% vs 69%; p = 0.006), had a tolerable pain goal for discharge > four (45% vs 27%; p = 0.006), and were cleared by PT on the first attempt (86% vs 9%; p < 0.001). A higher percentage of patients who were current smokers failed SDD (2% vs 9%; p = 0.005). Age, sex, BMI, ASA grade, surgical approach, and procedure length were similar between patients who went home the same day and those who stayed at least one night.
The most common causes for failed SDD were failure to meet ambulation goals (26%), dizziness (22%), and postoperative nausea and vomiting (PONV) (11%) (Table III). Interestingly, four patients (1.4% of the entire population) who had previously agreed to go home the day of surgery preferred to stay overnight, despite meeting criteria to be discharged on the same day.
Table III.
Reasons for failed same-day discharge (n = 96).
| Reason | n (%) |
|---|---|
| Failure to meet ambulation goals | 25 (26) |
| Dizziness | 21 (22) |
| Nausea/vomiting | 11 (11) |
| Uncontrolled pain | 8 (8) |
| Urinary retention | 7 (7) |
| Late case | 6 (6) |
| Other | 5 (5) |
| Hypotension | 4 (4) |
| Patient preference | 4 (4) |
| OSA monitoring | 3 (3) |
| Bradycardia/tachycardia | 2 (2) |
-
OSA, obstructive sleep apnoea.
According to multivariate analysis (Table IV), independent risk factors associated with failing same day discharge include being a current smoker (adjusted OR 6.24; p = 0.009), procedure start on or after 11 am (adjusted OR 2.28; p = 0.015), and having the highest in-house postoperative pain score ≥ 8 (adjusted OR 4.76; p = 0.004). A higher tolerable pain goal for discharge was a protective factor for being discharged the day of surgery (adjusted OR 0.37; p = 0.001).
Table IV.
Multivariate analysis of patient and perioperative factors associated with failed same-day discharge.
| Variable | Adjusted OR | 95% CI | p-value* |
|---|---|---|---|
| Age, yrs | 1.02 | 0.99 to 1.06 | 0.243 |
| Female sex | 1.63 | 0.90 to 2.95 | 0.109 |
| BMI, kg/m2 | 0.99 | 0.93 to 1.06 | 0.787 |
| ASA score | 2.04 | 0.78 to 5.28 | 0.144 |
| Posterior approach | 1.65 | 0.94 to 2.92 | 0.082 |
| General anesthesia | 1.27 | 0.20, to 7.91 | 0.799 |
| Smoking status | |||
| Never | Ref | ||
| Prior | 1.55 | 0.85 to 2.84 | 0.153 |
| Current | 6.24 | 1.59 to 24.54 | 0.009 |
| Procedure start on or after 11 am | 2.28 | 1.17 to 4.43 | 0.015 |
| Highest postoperative pain score | |||
| 0 to 3 | Ref | ||
| 4 to 7 | 1.93 | 0.71 to 5.24 | 0.199 |
| 8 to 10 | 4.76 | 1.64 to 13.78 | 0.004 |
| Pain goal for discharge | |||
| Minimal pain, 0 to 3 | Ref | ||
| Moderate to severe pain, 4 to 10 | 0.37 | 0.20 to 0.68 | 0.001 |
-
*
Multivariate logistic regression.
-
ASA, American Society of Anesthesiologists; CI, confidence interval; OR, odds ratio.
Discussion
SDD is possible as a result of optimizing patient factors and perioperative care pathways. Patient selection and optimization, advances in surgical and anaesthetic technique, and rehabilitation are all instrumental in achieving this goal. Therefore, it is crucial to understand the causes for failure to launch in order to further refine the optimization protocols for these highly efficient pathways.
While interpreting the results of this study, its strengths and limitations should be considered. The main strength of this study was the use of a standardized ambulatory THA pathway by high-volume surgeons at a tertiary orthopaedic hospital. Additionally, the study period incorporates the ambulatory THA pathway since its inception. Selection bias is inherently present in our study only including patients who are relatively healthy and motivated to go home the day of surgery. The limited numbers of patients in this study constraint the minimal difference detected between the groups. External validity is limited due to the heterogeneity in ambulatory pathways between institutions. Also, the HOPD has limitations in achieving SDD when compared to ASCs. The convenience of having the inpatient ward inhouse may increase the number of overnight stays.
In this retrospective cohort study of 278 pre-selected ambulatory THA patients, almost two thirds were safely discharged home the day of surgery from the HOPD. Prior studies assessing ambulatory THA performed at HOPD report failure to launch rates ranging from 0% to 72%.4,5,8,12,14,31-36 Notably, the investigation performed by Gromov et al8 was performed in an unselected population, leading to a 72% failure to launch rate. The study by Berger et al36 reported a 100% SDD rate, but only included the first case of the day.
Patient selection is key, with 91.3% of patients being discharged by postoperative day one. Recently, insurance companies have taken unilateral determinations on admission status. Therefore, we excluded patients whose inpatient stay was denied by the insurer to minimize confounding. These patients arrived to our institution with the expectation to stay at least one night. Rodriguez et al25 demonstrated that patients whose inpatient stay was denied and subsequently underwent outpatient surgery were twice as likely to be converted to an inpatient stay. The decision to undergo ambulatory arthroplasty should consider medical, psychological, social, and financial factors. An open dialogue between the surgeons and patients is crucial, highlighting the importance of shared decision-making principles.
At our institution, the most common causes for failure to launch as failing PT ambulation goals, patient symptomatology and preference, and cases starting after 11 am. Previous studies on this topic have also identified PONV, dizziness, pain control, and urinary retention as the main causes for failure to launch,4,5,8,12,14,34,37 all potentially avoidable to some extent with improvements in pathways and patient management. Fraser et al4 reported patient preference as the main reason for overnight stay, highlighting one of the limitations faced at the HOPD when compared to ASCs. We found failing PT ambulation goals was the main cause for failure to launch (26%); our goal for patients to walk 150 feet may be too ambitious as prior ambulatory arthroplasty report goals ranging from 50 to 100 feet.4,6,14,38 The exception being the study by Gromov et al,8 who had an ambulation goal of 70 metres (230 feet), and also reported failing PT as the main reason for failing SDD.
Early mobilization is essential in achieving SDD; however, it is well recognized that some patients may experience dizziness, nausea, and syncope. When combined dizziness and PONV accounted for 33% of our failure to launch rate even with routine use of antiemetic prophylaxis and goal-directed fluid management. Prior studies have reported orthostatic intolerance may occur in 42% to 76% of patients following arthroplasty.39,40 Common symptoms of orthostatic intolerance include dizziness, nausea, or even syncope. Data from goal-directed fluid management studies have shown that orthostatic intolerance may not be a hypovolemic problem, but caused by an impaired sympathetic response complemented by an increased parasympathetic response.39,41 Preliminary data suggests using low doses of ⍺1-drenoreceptor agonist may reduce orthostatic intolerance.42,43 In addition, reports from the anaesthesia and general surgery literature suggest the use of preoperative complex carbohydrate drinks reduces postoperative insulin resistance, positively impacting lean body mass and muscle function, and decreasing incidence of PONV.44-48 However, there is lack of data suggesting the same benefits are translated to the arthroplasty population. One randomized controlled trial following type 2 diabetic patients undergoing total knee arthroplasty compared preoperative complex carbohydrate drinks to IV 10% dextrose reported no reduction in PONV.49 The authors also found preoperative complex carbohydrate drinks did not increase hyperglycaemia, suggesting it may be safe in type 2 diabetics who do not use insulin. Future investigations are needed to elucidate the role of preoperative complex carbohydrate drinks and ⍺1-adrenoreceptor agonist in the ambulatory arthroplasty population.
No definitive conclusions can be drawn regarding the role that the ASA grade may play in the risk of failure to launch as our cohort suffers from selection bias. Other investigators reported ASA grade III and female sex to be risk factors for unsuccessful SDD.8,35 Notably, only 2% of our study population was ASA grade III. The causation of sex disparities are not well defined. Studies assessing sex differences in the inpatient arthroplasty population cite females verbalize the need for assistance more therefore changing the course of rehabilitation and lower functional independent measure (FIM) scores.50,51 In concordance with prior reports, age (range 28 to 79 years) and BMI (range 16.7 to 40 kg/m2) within the ranges seen in our selected population were not significant risk factors for unsuccessful SDD.35,36 We identified patients who currently smoke had a six-fold increase in the odds for failing SDD. While no prior studies have focused on the effects of smoking in SDD THA, there is evidence of increased costs, complications (medical and orthopaedic), lengths of stay, and risk of revision surgery.52-55 Currently, we counsel patients to stop smoking at least one month prior to surgery, but do not test for nicotine levels.
Our results show patients who reported a maximum pain score ≥ 8 were four-times as likely to fail SDD. Conversely, a higher tolerable pain goal prior to discharge increased the odds (adjusted OR 2.70; p = 0.001) of being discharged the day of surgery. Pain control is essential in achieving SDD. Our findings support prior studies reporting uncontrolled pain as a hindrance to successful SDD. Keulen et al35 demonstrated that patients who had a previous successful contralateral joint arthroplasty had higher a higher chance of achieving SDD; therefore, we believe there is room for improvement in setting appropriate expectations regarding postoperative pain in patients who are naïve to arthroplasty.
In conclusion, ambulatory THA is a safe and effective treatment for end-stage arthritis in pre-selected patients interested in going home the day of surgery. The most common causes for failure to launch were related to postoperative mobilization and symptomatology. Our results emphasize the importance of preoperative counselling regarding smoking cessation and postoperative pain. Future research should be aimed at reducing dizziness and postoperative nausea and vomiting.
References
1. Forrest G , Fuchs M , Gutierrez A , Girardy J . Factors affecting length of stay and need for rehabilitation after hip and knee arthroplasty . J Arthroplasty . 1998 ; 13 ( 2 ): 186 – 190 . Crossref PubMed Google Scholar
2. Meyers SJ , Reuben JD , Cox DD , Watson M . Inpatient cost of primary total joint arthroplasty . J Arthroplasty . 1996 ; 11 ( 3 ): 281 – 285 . Crossref PubMed Google Scholar
3. Liu SS , Della Valle AG , Besculides MC , Gaber LK , Memtsoudis SG . Trends in mortality, complications, and demographics for primary hip arthroplasty in the United States . Int Orthop . 2009 ; 33 ( 3 ): 643 – 651 . Crossref PubMed Google Scholar
4. Fraser JF , Danoff JR , Manrique J , Reynolds MJ , Hozack WJ . Identifying reasons for failed same-day discharge following primary total hip arthroplasty . J Arthroplasty . 2018 ; 33 ( 12 ): 3624 – 3628 . Crossref PubMed Google Scholar
5. Gogineni HC , Gray CF , Prieto HA , Deen JT , Boezaart AP , Parvataneni HK . Transition to outpatient total hip and knee arthroplasty: experience at an academic tertiary care center . Arthroplast Today . 2019 ; 5 ( 1 ): 100 – 105 . Crossref PubMed Google Scholar
6. Hoffmann JD , Kusnezov NA , Dunn JC , Zarkadis NJ , Goodman GP , Berger RA . The shift to same-day outpatient joint arthroplasty: a systematic review . J Arthroplasty . 2018 ; 33 ( 4 ): 1265 – 1274 . Crossref PubMed Google Scholar
7. Sculco PK , Pagnano MW . Perioperative solutions for rapid recovery joint arthroplasty: get ahead and stay ahead . J Arthroplasty . 2015 ; 30 ( 4 ): 518 – 520 . Crossref PubMed Google Scholar
8. Gromov K , Kjærsgaard-Andersen P , Revald P , Kehlet H , Husted H . Feasibility of outpatient total hip and knee arthroplasty in unselected patients . Acta Orthop . 2017 ; 88 ( 5 ): 516 – 521 . Crossref PubMed Google Scholar
9. Soffin EM , YaDeau JT . Enhanced recovery after surgery for primary hip and knee arthroplasty: a review of the evidence . Br J Anaesth . 2016 ; 117 ( suppl 3 ): iii62 – iii72 . Crossref PubMed Google Scholar
10. Wainwright TW , Gill M , McDonald DA , Middleton RG , Reed M , Sahota O . Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations . Acta Orthop . 2020 ; 91 ( 3 ): 3 – 19 . Crossref PubMed Google Scholar
11. Jaibaji M , Volpin A , Haddad FS , Konan S . Is outpatient arthroplasty safe? a systematic review . J Arthroplasty . 2020 ; 35 ( 7 ): 1941 – 1949 . Crossref PubMed Google Scholar
12. Weiser MC , Kim KY , Anoushiravani AA , Iorio R , Davidovitch RI . Outpatient total hip arthroplasty has minimal short-term complications with the use of institutional protocols . J Arthroplasty . 2018 ; 33 ( 11 ): 3502 – 3507 . Crossref PubMed Google Scholar
13. Sershon RA , McDonald JF , Ho H , Goyal N , Hamilton WG . Outpatient total hip arthroplasty performed at an ambulatory surgery center vs hospital outpatient setting: complications, revisions, and readmissions . J Arthroplasty . 2019 ; 34 ( 12 ): 2861 – 2865 . Crossref PubMed Google Scholar
14. Goyal N , Chen AF , Padgett SE , et al. Otto Aufranc Award: A multicenter, randomized study of outpatient versus inpatient total hip arthroplasty . Clin Orthop Relat Res . 2017 ; 475 ( 2 ): 364 – 372 . Crossref PubMed Google Scholar
15. Buller LT , Hubbard TA , Ziemba-Davis M , Deckard ER , Meneghini RM . Safety of same and next day discharge following revision hip and knee arthroplasty using modern perioperative protocols . J Arthroplasty . 2021 ; 36 ( 1 ): 30 – 36 . Crossref PubMed Google Scholar
16. Debbi EM , Mosich GM , Bendich I , Kapadia M , Ast MP , Westrich GH . Same-day discharge total hip and knee arthroplasty: trends, complications, and readmission rates . J Arthroplasty . 2022 ; 37 ( 3 ): 444 – 448 . Crossref PubMed Google Scholar
17. Arshi A , Leong NL , Wang C , Buser Z , Wang JC , SooHoo NF . Outpatient total hip arthroplasty in the united states: a population-based comparative analysis of complication rates . J Am Acad Orthop Surg . 2019 ; 27 ( 2 ): 61 – 67 . Crossref PubMed Google Scholar
18. Yayac M , Schiller N , Austin MS , Courtney PM . 2020 John N. Insall Award: Removal of total knee arthroplasty from the inpatient-only list adversely affects bundled payment programmes . Bone Joint J . 2020 ; 102-B ( 6_Supple_A ): 19 – 23 . Crossref PubMed Google Scholar
19. Iorio R , Barnes CL , Vitale MP , Huddleston JI , Haas DA . Total knee replacement: the inpatient-only list and the two midnight rule, patient impact, length of stay, compliance solutions, audits, and economic consequences . J Arthroplasty . 2020 ; 35 ( 6S ): S28 – S32 . Crossref PubMed Google Scholar
20. Burn E , Edwards CJ , Murray DW , et al. Trends and determinants of length of stay and hospital reimbursement following knee and hip replacement: evidence from linked primary care and NHS hospital records from 1997 to 2014 . BMJ Open . 2018 ; 8 ( 1 ): e019146 . Crossref PubMed Google Scholar
21. Schwartz AJ , Clarke HD , Sassoon A , Neville MR , Etzioni DA . The clinical and financial consequences of the Centers for Medicare and Medicaid Services’ two-midnight rule in total joint arthroplasty . J Arthroplasty . 2020 ; 35 ( 1 ): 1 – 6 . Google Scholar
22. Yates AJ , Kerr JM , Froimson MI , Della Valle CJ , Huddleston JI . The unintended impact of the removal of total knee arthroplasty from the Center for Medicare and Medicaid Services inpatient-only list . J Arthroplasty . 2018 ; 33 ( 12 ): 3602 – 3606 . Google Scholar
23. Molloy IB , Martin BI , Moschetti WE , Jevsevar DS . Effects of the length of stay on the cost of total knee and total hip arthroplasty from 2002 to 2013 . J Bone Joint Surg Am . 2017 ; 99-A ( 5 ): 402 – 407 . Crossref PubMed Google Scholar
24. Locke C , Sheehy AM , Deutschendorf A , Mackowiak S , Flansbaum BE , Petty B . Changes to inpatient versus outpatient hospitalization: Medicare’s 2-midnight rule . J Hosp Med . 2015 ; 10 ( 3 ): 194 – 201 . Google Scholar
25. Gooch K . United Healthcare’s policy will limit outpatient surgery payments to hospitals . 2019 . https://www.beckershospitalreview.com/finance/unitedhealthcare-s-policy-will-limit-outpatient-surgery-payments-to-hospitals.html ( date last accessed 23 August 2022 ). Google Scholar
26. Rodriguez S , Lebrun DG , Shen TS , et al. Predicting total knee arthroplasty outpatient discharge: surgeons versus insurance companies . J Arthroplasty . 2022 ; 37 ( 8S ): S766 – S770 . Crossref PubMed Google Scholar
27. Berend ME , Lackey WG , Carter JL . Outpatient-focused joint arthroplasty is the future: the Midwest Center for Joint Replacement experience . J Arthroplasty . 2018 ; 33 ( 6 ): 1647 – 1648 . Crossref PubMed Google Scholar
28. Edwards PK , Milles JL , Stambough JB , Barnes CL , Mears SC . Inpatient versus outpatient total knee arthroplasty . J Knee Surg . 2019 ; 32 ( 8 ): 730 – 735 . Crossref PubMed Google Scholar
29. Kelly MP , Calkins TE , Culvern C , Kogan M , Della Valle CJ . Inpatient versus outpatient hip and knee arthroplasty: which has higher patient satisfaction? J Arthroplasty . 2018 ; 33 ( 11 ): 3402 – 3406 . Crossref PubMed Google Scholar
30. Kehlet H , Lindberg-Larsen V . High-dose glucocorticoid before hip and knee arthroplasty: to use or not to use-that’s the question . Acta Orthop . 2018 ; 89 ( 5 ): 477 – 479 . Google Scholar
31. Alley MC , Shewmaker GS , Vaickus MH , Niu R , Freccero D , Smith EL . Early discharge after total hip arthroplasty at an urban tertiary care safety net hospital: a two-year retrospective cohort study . J Am Acad Orthop Surg . 2021 ; 29 ( 20 ): 894 – 899 . Google Scholar
32. Springer BD , Odum SM , Vegari DN , Mokris JG , Beaver WB . Impact of inpatient versus outpatient total joint arthroplasty on 30-day hospital readmission rates and unplanned episodes of care . Orthop Clin North Am . 2017 ; 48 ( 1 ): 15 – 23 . Crossref PubMed Google Scholar
33. Keulen MHF , Asselberghs S , Bemelmans YFL , Hendrickx RPM , Schotanus MGM , Boonen B . Reasons for unsuccessful same-day discharge following outpatient hip and knee arthroplasty: 5½ years’ experience from a single institution . J Arthroplasty . 2020 ; 35 ( 9 ): 2327 – 2334 . Google Scholar
34. Feder OI , Lygrisse K , Hutzler LH , Schwarzkopf R , Bosco J , Davidovitch RI . Outcomes of same-day discharge after total hip arthroplasty in the Medicare population . J Arthroplasty . 2020 ; 35 ( 3 ): 638 – 642 . Crossref PubMed Google Scholar
35. Keulen MHF , Asselberghs S , Boonen B , Hendrickx RPM , van Haaren EH , Schotanus MGM . Predictors of (un)successful same-day discharge in selected patients following outpatient hip and knee arthroplasty . J Arthroplasty . 2020 ; 35 ( 8 ): 1986 – 1992 . Crossref PubMed Google Scholar
36. Berger RA , Sanders SA , Thill ES , Sporer SM , Della Valle C . Newer anesthesia and rehabilitation protocols enable outpatient hip replacement in selected patients . Clin Orthop Relat Res . 2009 ; 467 ( 6 ): 1424 – 1430 . Crossref PubMed Google Scholar
37. Dorr LD , Thomas DJ , Zhu J , Dastane M , Chao L , Long WT . Outpatient total hip arthroplasty . J Arthroplasty . 2010 ; 25 ( 4 ): 501 – 506 . Crossref PubMed Google Scholar
38. Adachi RN , Wong KK , Buchner BR , Andrews SN , Nakasone CK . Tempering expectations for outpatient total knee arthroplasty for patients over 70 . J Arthroplasty . 2022 ; 37 ( 4 ): 704 – 708 . Crossref PubMed Google Scholar
39. Jans Ø , Bundgaard-Nielsen M , Solgaard S , Johansson PI , Kehlet H . Orthostatic intolerance during early mobilization after fast-track hip arthroplasty . Br J Anaesth . 2012 ; 108 ( 3 ): 436 – 443 . Crossref PubMed Google Scholar
40. Memtsoudis SG , Mörwald EE , Fields K , et al. Changes in the augmentation index and postoperative orthostatic intolerance in orthopedic surgery: a prospective cohort study . Can J Anaesth . 2018 ; 65 ( 9 ): 1012 – 1028 . Crossref PubMed Google Scholar
41. Jans Ø , Kehlet H . Postoperative orthostatic intolerance: a common perioperative problem with few available solutions . Can J Anaesth . 2017 ; 64 : 10 – 15 . Crossref PubMed Google Scholar
42. Smits M , Lin S , Rahme J , Bailey M , Bellomo R , Hardidge A . Blood pressure and early mobilization after total hip and knee replacements: a pilot study on the impact of midodrine hydrochloride . JB JS Open Access . 2019 ; 4 ( 2 ): e0048 . Crossref PubMed Google Scholar
43. Jans Ø , Mehlsen J , Kjærsgaard-Andersen P , et al. Oral midodrine hydrochloride for prevention of orthostatic hypotension during early mobilization after hip arthroplasty: a randomized, double-blind, placebo-controlled trial . Anesthesiology . 2015 ; 123 ( 6 ): 1292 – 1300 . Crossref PubMed Google Scholar
44. Svanfeldt M , Thorell A , Hausel J , et al. Randomized clinical trial of the effect of preoperative oral carbohydrate treatment on postoperative whole-body protein and glucose kinetics . Br J Surg . 2007 ; 94 ( 11 ): 1342 – 1350 . Crossref PubMed Google Scholar
45. Gianotti L , Biffi R , Sandini M , et al. Preoperative oral carbohydrate load versus placebo in major elective abdominal surgery (PROCY): a randomized, placebo-controlled, multicenter, phase III trial . Ann Surg . 2018 ; 267 ( 4 ): 623 – 630 . Crossref PubMed Google Scholar
46. Suh S , Hetzel E , Alter-Troilo K , et al. The influence of preoperative carbohydrate loading on postoperative outcomes in bariatric surgery patients: a randomized, controlled trial . Surg Obes Relat Dis . 2021 ; 17 ( 8 ): 1480 – 1488 . Crossref PubMed Google Scholar
47. Kehlet H . Enhanced postoperative recovery: good from afar, but far from good? Anaesthesia . 2020 ; 75 Suppl 1 : e54 – e61 . Crossref PubMed Google Scholar
48. Rajan S , Rahman AA , Kumar L . Preoperative oral carbohydrate loading: Effects on intraoperative blood glucose levels, post-operative nausea and vomiting, and intensive care unit stay . J Anaesthesiol Clin Pharmacol . 2021 ; 37 ( 4 ): 622 – 627 . Crossref PubMed Google Scholar
49. Shin S , Choi YS , Shin H , et al. Preoperative carbohydrate drinks do not decrease postoperative nausea and vomiting in type 2 diabetic patients undergoing total knee arthroplasty: a randomized controlled trial . J Am Acad Orthop Surg . 2021 ; 29 ( 1 ): 35 – 43 . Google Scholar
50. Holtzman J , Saleh K , Kane R . Gender differences in functional status and pain in a Medicare population undergoing elective total hip arthroplasty . Med Care . 2002;40(6):461–470. CrossrefPubMed Google Scholar
51. Vincent HK , Alfano AP , Lee L , Vincent KR . Sex and age effects on outcomes of total hip arthroplasty after inpatient rehabilitation . Arch Phys Med Rehabil . 2006 ; 87 ( 4 ): 461 – 467 . Crossref PubMed Google Scholar
52. Duchman KR , Gao Y , Pugely AJ , Martin CT , Noiseux NO , Callaghan JJ . The effect of smoking on short-term complications following total hip and knee arthroplasty . J Bone Joint Surg Am . 2015 ; 97-A ( 13 ): 1049 – 1058 . Crossref PubMed Google Scholar
53. Debbi EM , Rajaee SS , Spitzer AI , Paiement GD . Smoking and total hip arthroplasty: increased inpatient complications, costs, and length of stay . J Arthroplasty . 2019 ; 34 ( 8 ): 1736 – 1739 . Crossref PubMed Google Scholar
54. Singh JA . Smoking and outcomes after knee and hip arthroplasty: a systematic review . J Rheumatol . 2011 ; 38 ( 9 ): 1824 – 1834 . Crossref PubMed Google Scholar
55. Lim CT , Goodman SB , Huddleston JI 3rd , et al. Smoking is associated with earlier time to revision of total knee arthroplasty . Knee . 2017 ; 24 ( 5 ): 1182 – 1186 . Crossref PubMed Google Scholar
Author contributions
S. Rodriguez: Visualization, Investigation, Validation, Data curation, Writing - original draft, Writing - reviewing & editing.
T. S. Shen: Visualization, Investigation, Validation, Writing - original draft, Writing - reviewing & editing.
D. G. Lebrun: Investigation, Validation, Data curation, Writing - original draft, Writing - reviewing & editing.
A. G. Della Valle: Visualization, Investigation, Data curation, Validation, Writing - original draft, Writing - reviewing & editing.
M. P. Ast: Design, Visualization, Investigation, Data curation, Writing - original draft, Writing - reviewing & editing.
J. A. Rodriguez: Visualization, Investigation, Data curation, Writing - original draft, Writing - reviewing & editing.
Funding statement
The author(s) disclose receipt of the following financial or material support for the research, authorship, and/or publication of this article: patient donations.
ICMJE COI statement
The authors report that they have no disclosures to declare in relation to this work.
Acknowledgements
We would like to express our gratitude to Tricia Bonamo and Danielle Barone for their hard work implementing the ambulatory pathway. In addition, we would like to acknowledge this study was partially funded by the generous donation of Mr Kim Davis.
Ethical review statement
This study received institutional review board approval prior to initiation (no. 2020-2595).
Open access funding
The authors report that they received open access funding for this manuscript from Hospital for Special Surgery ARJR Perioperative Outcomes Group (POG).
Follow S. Rodriguez @samrodriguez_md
Follow M. P. Ast @drmikeast
© 2022 Author(s) et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/
