The purpose of our study is to examine the outcome of patients undergoing outpatient total hip arthroplasty with a BMI >35. Case-control matching on age, gender (46% female;54%male), and ASA (mean 2.8) with 51 outpatients BMI≥35 kg/m. 2. (mean of 40 (35–55)), mean age of 61 (38–78) matched to 51 outpatients BMI<35 kg/m. 2. (mean of 27 (17–34)) mean age 61 (33–78). Subsequently 47 inpatients BMI≥35 kg/m. 2. (mean of 40 (35–55)) mean age 62 (34–77) were matched outpatients BMI≥35 kg/m. 2. For each cohort, adverse events, readmission in 90 days, reoperations were recorded. Rate of adverse events was significantly higher in BMI ≥35: 15.69% verus 1.96% (p=0.039) with 5 reoperations in the BMI≥35 cohort vs 0 in the BMI<35 kg/m. 2. (p= 0.063). Readmissions did not differ between groups (p=0.125). No significant difference for all studied outcomes between the outpatient and inpatients cohorts with BMI≥35 kg/m. 2. The most complications requiring surgery/medical intervention (3B) were in the inpatient cohort of patients >35. The prevalence of Diabetes and Obstructive Sleep apnea was 21.6% and 29.4% for BMI>35 compared to 9.8% and 11.8%, for BMI <35, respectively. Severely obese patients have an overall higher rate of adverse events and reoperations however it should not be used a sole variable for deciding if the patient should be admitted or not

Microdiscectomy is the most commonly performed spine surgery in the world. Due to its technical simplicity and low complication rate, this was the first spine surgical procedure transitioning for one-day surgery. However, the economic assessment of this outpatient transition was never performed and the question on the real impact in the burden of spine care remains. This economic study aims to access the cost-utility of outpatient lumbar microdiscectomy when compared with the inpatient procedure. To do so, a cost-utility study was performed, adopting the hospital perspective. Direct medical costs were retrieved from the assessment of 20 patients undergoing outpatient lumbar microdiscectomy and 20 undergoing inpatient lumbar microdiscectomy, from a in a Portuguese NHS hospital. Utilities were calculated with quality-adjusted life-years were derived from Oswestry Disability Index values (ODI). ODI was assessed prospectively in outpatients in pre and 3- and 6-month post-operative evaluations. Inpatient ODI data were estimated from a meta-analysis. both probabilistic and deterministic sensitivity analyses were performed and incremental cost-effectiveness ratio (ICER) calculated. A willingness to pay (WTP) threshold of €60000/QALY gained with inpatient procedure was defined. Out results showed that inpatient procedure was cost-saving in all models tested. At 3-month assessment ICER ranged from €135753 to €345755/QALY, higher than the predefined WTP. At 6-month costs were lower and utilities were higher in outpatient, overpowering the inpatient procedure. Probabilistic sensitivity analysis showed that in 65% to 73% of simulations outpatient was the better option. The savings with outpatient were about 55% of inpatient values, with similar utility scores. No 30-day readmissions were recorded in either group. The mean admission time in inpatient group was 2.5 days. Since there is an overall agreement among spine surgeons that an uncomplicated inpatient MD would only need a one-day admission, an analysis reducing inpatient admission time for one day was also performed and outpatient remained cost-effective. In conclusion, as the first economic study on cost-utility of outpatient lumbar microdiscectomy, this study showed a significant reduction in costs, with a similar clinical outcome, proving this outpatient transition as cost-effective

The increased demand for total hip arthroplasty (THA) is having a significant impact on healthcare resources, resulting in increased interest in outpatient care pathways to reduce resource consumption. This study compared costs between patients who underwent outpatient THA using a Direct Anterior (DA) approach compared to a Direct Lateral (DL) approach to understand the effect of surgical approach on resource use. We conducted a prospective randomized controlled trial for DA patients undergoing primary THA. We compared patients in the outpatient arm of the trial to a prospective cohort of outpatient DL approach THAs. We recorded all costs including: equipment, length of stay in hospital, and laboratory or other medical tests. Following discharge, participants also completed a self-reported cost diary recording resource utilization such as emergency department visits or subsequent hospitalizations, tests and procedures, consultations or follow-up, healthcare professional services, rehabilitation, use of pain medications, informal care, productivity losses and out of pocket expenditures. We report costs from both Canadian public health care payer (HCP) and a societal perspective. The HCP perspective includes any direct health costs covered by the publicly funded system. In addition to the health care system costs, the societal perspective also includes additional costs to the patient (e.g. physiotherapy, medication, or assistive devices), as well as any indirect costs such as time off paid employment for patients or caregivers. We included 127 patients in the DA group (66.6 years old) and 51 patients in the DL group (59.4 years old) (p<0.01). There were no statistically significant differences in costs between groups from both the healthcare payer (DA= 7910.19, DL= 7847.17, p=0.80) and societal perspectives (DA= 14657.21, DL= 14581.21, p=0.96). In patients undergoing a successful outpatient hip replacement, surgical approach does not have an effect on cost from in hospital or societal perspectives

The coronavirus pandemic has reduced the capability of Canadian hospitals to offer elective orthopaedic surgery requiring admission, despite ongoing and increasing demands for elective total hip and total knee arthroplasty surgery (THA and TKA). We sought to determine if the coronavirus pandemic resulted in more outpatient THA and TKA in Nova Scotia, and if so, what effect increased outpatient surgery had on 90 day post-operative readmission or Emergency Department/Family Doctor (FD) visits. The study cohort was constructed from hospital Discharge Abstract Data (DAD), inpatient admissions, and National Ambulatory Care Reporting System (NACRS) data, day surgery observations, using Canadian Classification of Health Intervention codes to select all primary hip and knee procedures from 2005-2020 in Nova Scotia. Emergency Department and General Practitioner visits were identified from the Physician Billings data and re-admissions from the DAD and NACRS. Rates were calculated by dividing the number of cases with any visit within 90 days after discharge. Chi-squared statistics at 95% confidence level used to test for statistical significance. Knee and hip procedures were modelled separately. There was a reduction in THA and TKA surgery in Nova Scotia during the coronavirus pandemic in 2020. Outpatient arthroplasty surgery in Nova Scotia in the years prior to 2020 were relatively stable. However, in 2020 there was a significant increase in the proportion and absolute number of outpatient THA and TKA. The proportion of THA increased from 1% in 2019 to 14% in 2020, while the proportion of TKA increased from 1% in 2019 to 11% in 2020. The absolute number of outpatient THA increased from 16 cases in 2019, to 163 cases in 2020. Outpatient TKA cases increased from 21 in 2019, to 173 in 2020. The increase in outpatient surgery resulted in an increase in 90 day presentations to ED following TKA but not THA which was not statistically significant. For outpatient THA and TKA, there was a decrease in 90 day readmissions, and a statistically significant decrease in FD presentations. Outpatient THA and TKA increased significantly in 2020, likely due to the restrictions imposed during the coronavirus pandemic on elective Orthopaedic surgery requiring admission to hospital. The increase in outpatient surgery resulted in an increase in 90 day presentations to ED for TKA, and a decrease in 90 day readmissions and FD presentations for THA and TKA. Reducing the inpatient surgical burden may result in a post-operative burden on ED, but does not appear to have caused an increase in hospital readmission rates

Introduction. The Centers for Medicare and Medicaid Services (CMS) removed total knee arthroplasty (TKA) from inpatient-only status in 2018. Our goal was to measure the adoption of outpatient TKAs, the impact on re-treatment rates, and the economic implications for hospitals. Methods. We utilized 100% national Medicare Part A fee-for-service (FFS) patient-level claims data for 2017–2018. We excluded DRG 469 TKAs since they are unlikely to be outpatient candidates, which left 257,107 primary TKAs in 2017 and 264,393 in 2018. We examined the time trend in monthly case volume and 30-day retreatment rate (defined as percent of patients having a second TKA within 30 days of the first. We calculated the loss in revenue for a hospital by multiplying the decrease in payment rate between inpatient and outpatient by the outpatient and total 2018 TKA volume. Results. In 2017 0.2% of primary TKAs were performed outpatient. Following the rule change, 25% of cases were performed outpatient in Q1 2018. This stayed at 25% in Q2, increased to 27% in Q3, and then increased to 30% in Q4 2018. The 30-day re-treatment rate was 0.16% in 2017 and 0.15% in 2018. Across hospitals there was the following distribution in the decrease in payment rate from inpatient to outpatient TKAs in 2018: 10. th. percentile: $1,994, 25. th. : $2,612, 50. th. : $3,487, 75. th. : $4,918, 90. th. : $7,231. In 2018 outpatient TKA coding cost hospitals (saved CMS) $243M in Medicare FFS payments (an average of $89,000 per hospital). If all TKAs were performed outpatient hospital Medicare FFS payments would have been $965M lower ($353,000 per hospital) in 2018. Conclusion. Outpatient TKA volumes grew through 2018. This did not impact 30-day retreatment rates. Medicare FFS payment rates declined by a median of $3,487 per outpatient case. As more TKAs are performed outpatient, total Medicare payments will further decline. For figures, tables, or references, please contact authors directly

Percutaneous flexor tenotomy involves cutting the flexor digitorum tendons to correct claw toe deformity to treat apical pressure areas and prevent subsequent infection in patients with peripheral neuropathy. Performing this under ultrasound guidance provides reassurance of complete release of the tendon and increases procedural safety. This study is a retrospective case series evaluating the effectiveness, safety, and patient satisfaction of performing percutaneous ultrasound-guided flexor tenotomy in an outpatient setting. People with loss of protective sensation, a digital flexion deformity, and an apical toe ulcer or pre-ulcerative lesion who presented to our institution between December 2019 and June 2022 were included in this study. Participants were followed-up at a minimum of 3 months. Time to ulcer healing, re-ulceration rate, patient satisfaction, and complications were recorded. An Australian cost analysis was performed comparing this procedure performed in rooms versus theatres. There were 28 ulcers and 41 pre-ulcerative lesions. A total of 69 tenotomy procedures were performed on 38 patients across 52 episodes of care. The mean time to ulcer healing was 22.5 +/- 6.4 days. There were 2 cases of re-ulceration. 1 patient sustained a transfer lesion. There were four toes that went onto require amputation, all in the setting of pre-existing osteomyelitis. 94% of patients strongly agreed that they were satisfied with the outcome of the procedure. Costs saved were estimated to be $1426. Flexor tenotomy is a minimally invasive procedure that can be performed in the outpatient setting, and therefore without delay to treatment, reducing risk of ulcer progression and need for subsequent amputation. This is the first study to report on flexor tenotomy under ultrasound-guidance. Ultrasound-guided percutaneous flexor tenotomy is safe and effective, with high patient satisfaction and low recurrence rates. This performance in the outpatient setting ensures significant time and cost savings for both the practitioner and patient

Introduction. Total hip arthroplasty (THA) is an effective surgery for the treatment of advanced osteoarthritis but increasing numbers of these procedures are having a significant impact on healthcare budgets. One route to mitigate the increasing costs is outpatient THA, discharging patients on the same day as their surgery. The purpose of this study was to determine the cost of outpatient THA compared to standard overnight stay in hospital. Methods. This was a prospective-randomized controlled trial for patients undergoing primary THA through a direct anterior approach. Participants were randomized to be discharged on the same day as surgery, as outpatients, or on day one post-surgery, as inpatients, using a Zelen consent model. Adverse events were assessed, and participants completed self-reported cost questionnaires at two-, six- and 12-weeks post-surgery, and the WOMAC preoperatively and at 12-weeks post-surgery. We performed a cost analysis from health care payer (HCP) and societal perspectives. Results. 106 patients were enrolled in this study, with 50 randomized to outpatient and 56 randomized to inpatient THA. Seven patients from the outpatient group and five patients from the inpatient group crossed-over. Adverse event rate was similar between the groups with seven events in four participants in the inpatient group and three events in two participants in the outpatient group. WOMAC scores were not significantly different between the groups (p=0.12). From both a HCP and societal perspective, inpatient THA was more costly than outpatient THA. The cost difference was $3,353.15 for HCP (p<0.0001) and $3,703.30 for societal (p=0.003) in favour of outpatient THA. Conclusion. Our results suggest that outpatient THA is a cost-saving procedure when compared to inpatient THA from both HCP and societal perspectives. We will continue recruitment to investigate whether these results hold true in a larger sample as well as assess for cost-effectiveness, patient safety and satisfaction. Acknowledgements. This study was supported by the Opportunities Fund of the Academic Health Sciences Centre Alternative Funding Plan of the Academic Medical Organization of Southwestern Ontario (AMOSO). We also received funding from the PSI Foundation. For any tables or figures, please contact the authors directly

Aims. To identify variables independently associated with same-day discharge (SDD) of patients following revision total knee arthroplasty (rTKA) and to develop machine learning algorithms to predict suitable candidates for outpatient rTKA. Methods. Data were obtained from the American College of Surgeons National Quality Improvement Programme (ACS-NSQIP) database from the years 2018 to 2020. Patients with elective, unilateral rTKA procedures and a total hospital length of stay between zero and four days were included. Demographic, preoperative, and intraoperative variables were analyzed. A multivariable logistic regression (MLR) model and various machine learning techniques were compared using area under the curve (AUC), calibration, and decision curve analysis. Important and significant variables were identified from the models. Results. Of the 5,600 patients included in this study, 342 (6.1%) underwent SDD. The random forest (RF) model performed the best overall, with an internally validated AUC of 0.810. The ten crucial factors favoring SDD in the RF model include operating time, anaesthesia type, age, BMI, American Society of Anesthesiologists grade, race, history of diabetes, rTKA type, sex, and smoking status. Eight of these variables were also found to be significant in the MLR model. Conclusion. The RF model displayed excellent accuracy and identified clinically important variables for determining candidates for SDD following rTKA. Machine learning techniques such as RF will allow clinicians to accurately risk-stratify their patients preoperatively, in order to optimize resources and improve patient outcomes. Cite this article: Bone Jt Open 2023;4(6):399–407

The response to the COVID-19 pandemic has raised the profile and level of interest in the use, acceptability, safety, and effectiveness of virtual outpatient consultations and telemedicine. These models of care are not new but a number of challenges have so far hindered widespread take-up and endorsement of these ways of working. With the response to the COVID-19 pandemic, remote and virtual working and consultation have become the default. This paper explores our experience of and learning from virtual and remote consultation and questions how this experience can be retained and developed for the future. Cite this article: Bone Jt Open 2021;2(5):301–304

Introduction. External fixation (EF) devices are commonly used in the management of complex skeletal trauma, as well as in elective limb reconstruction surgery for the management of congenital and acquired pathology. The subsequent removal of an EF is commonly performed under a general anaesthetic in an operating theatre. This practice is resource intensive and limits the amount of operating theatre time available for other surgical cases. We aimed to assess the use of regional anaesthesia as an alternative method of analgesia to facilitate EF removal in an outpatient setting. Materials & Methods. This prospective case series evaluated the first 20 consecutive cases of EF removal in the outpatient clinic between 10/06/22 to 16/09/22. Regional anaesthesia using ultrasound-guided blockade of peripheral nerves was administered using 1% lidocaine due to its rapid onset and short half-life. Patients were assessed for additional analgesia requirement, asked to evaluate their experience and perceived pain using the Visual Analogue Scale (VAS). Results. Twenty patients were included in the study. The mean age was 46.6 years (range 21–85 years). Two thirds were male patients (N=13). Post procedure all patients indicated positive satisfaction ratings, each participant responding as either ‘satisfied’ (N=4), ‘very satisfied’ (N=15) or ‘highly satisfied’ (N=1). In addition, 85% of participants reported they would opt for this method of EF removal in future should it be necessary. VAS for pain immediately following completion of the procedure was low, with an average score of 0.45 (range 0–4), where a score of 0= ‘No pain’, and 10 = ‘worst pain possible’. Conclusions. We present the first description of outpatient EF removal using sole regional anaesthesia, with a prospective case series of 20 EF removed in fully awake patients. This novel technique is cost-effective, reproducible, and safe. This not only reduces the burden of these surgical cases on an operating list but also improves patient experience when compared to other forms of conscious sedation. By eliminating the use of Entonox and methoxyflurane for sedation and analgesia, this project demonstrates a method of improving environmental sustainability of surgery, anaesthesia and operating theatres

The brief answer is no….I do not believe that outpatient total joint arthroplasty is the emergent standard of care. However, for some patients and some surgeons I do believe that outpatient total joint arthroplasty can be performed safely and with greater comfort and convenience for the patient. Further, for the surgeon, it can provide greater control over the care environment if performed at an ambulatory surgery center. Patient selection is paramount in my opinion for safely performing outpatient total joint arthroplasty. While some have attempted to define specific criteria, our own criteria include patients with simple orthopaedic problems who are healthy, trustworthy and have a good support system of family or friends to assist them. As surgeons we must also be self-aware as the margin for error, particularly at a freestanding ambulatory surgery center, is narrow. Operative times should be reliably brief and blood loss should be minimal to allow for a safe discharge on the same day. Further the incidence of intraoperative complications such as fractures at the time of total hip arthroplasty or ligament injuries during total knee arthroplasty should be low. The surgeon should also be prepared with the equipment to address these common issues, if they do occur. In our review of the NSQIP data set we matched 1,236 outpatient TJA 1:1 with inpatients based on propensity scores. The risk of 30-day readmissions and complications was no different between groups, although inpatients had a higher rate of VTE and outpatients had a higher risk of re-operation. Risk factors for adverse events included patient age > 85 years old, diabetes and BMI > 35. Likewise in a review of results from my own practice, we have seen no difference in the risk of complications. As health care providers we must keep the safety of our patients paramount at all times. Further, we must be fiscally responsible to avoid costly complications, reoperations and readmissions. With conservative patient selection and careful surgical technique I believe that outpatient TJA offers an attractive alternative that is safe, cost effective and associated with high satisfaction for both patients and surgeons

Aims. Currently, there is no single, comprehensive national guideline for analgesic strategies for total joint replacement. We compared inpatient and outpatient opioid requirements following total hip arthroplasty (THA) versus total knee arthroplasty (TKA) in order to determine risk factors for increased inpatient and outpatient opioid requirements following total hip or knee arthroplasty. Methods. Outcomes after 92 primary total knee (n = 49) and hip (n = 43) arthroplasties were analyzed. Patients with repeat surgery within 90 days were excluded. Opioid use was recorded while inpatient and 90 days postoperatively. Outcomes included total opioid use, refills, use beyond 90 days, and unplanned clinical encounters for uncontrolled pain. Multivariate modelling determined the effect of surgery, regional nerve block (RNB) or neuraxial anesthesia (NA), and non-opioid medications after adjusting for demographics, ength of stay, and baseline opioid use. Results. TKAs had higher daily inpatient opioid use than THAs (in 5 mg oxycodone pill equivalents: median 12.0 vs 7.0; p < 0.001), and greater 90 day use (median 224.0 vs 100.5; p < 0.001). Opioid refills were more likely in TKA (84% vs 33%; p < 0.001). Patient who underwent TKA had higher independent risk of opioid use beyond 90 days than THA (adjusted OR 7.64; 95% SE 1.23 to 47.5; p = 0.01). Inpatient opioid use 24 hours before discharge was the strongest independent predictor of 90-day opioid use (p < 0.001). Surgical procedure, demographics, and baseline opioid use have greater influence on in/outpatient opioid demand than RNB, NA, or non-opioid analgesics. Conclusion. Opioid use following TKA and THA is most strongly predicted by surgical and patient factors. TKA was associated with higher postoperative opioid requirements than THA. RNB and NA did not diminish total inpatient or 90-day postoperative opioid consumption. The use of acetaminophen, gabapentin, or NSAIDs did not significantly alter inpatient opioid requirements. Cite this article: Bone Joint Open 2020;1-7:398–404

The discussion of outpatient unicompartmental knee arthroplasty (UKA) requires proof that it can be done safely and effectively, and also begs the question of whether it can be performed in an ambulatory surgery center (ASC) rather than a general hospital (which raises costs and is typically less efficient). Successful outpatient UKA requires carefully crafted algorithms/protocols, home support, preoperative planning and preparation, expectation management, risk stratification (not everyone is a candidate), perioperative pain management and buy-in from patients, support networks and the health care team. Relatively little data is available on the feasibility, safety and potential cost savings associated with this shift in care. We evaluated the costs and short term outcomes and complications of 150 consecutive UKAs performed in an ASC compared to those done in a general hospital both on an inpatient and outpatient basis. Determination of the setting of the outpatient surgery was made based on geographic preference by the patients; otherwise choice of inpatient or outpatient surgery in the hospital was left to the discretion of the surgeon and was primarily based on the patients' comorbidity profile and circumstances of home help. Total direct facility costs were calculated, including institutional supplies and services, anesthesia services, implants, additional PACU medications and services required, and costs associated with operating room use. Only total cost was evaluated, as it is the most consistent cost variable amongst the two institutions evaluated. The mean total direct cost of UKA in a general community hospital with an overnight stay was 1.24 and 1.65 times greater than the cost of UKA performed at the same hospital or an ASC on an outpatient basis, respectively. The mean total direct cost of outpatient UKA in a general hospital was 1.33 times greater than the mean total cost of UKA performed in an ASC. Semi-autonomous robotic technology has been introduced to optimise accuracy of implant positioning and soft tissue balance in UKA, with the expectation of resultant improvement in durability and implant survivorship. Currently, nearly 20% of UKA's in the U.S. are being performed with robotic assistance. It is anticipated that there will be substantial growth in market penetration over the next decade, projecting that nearly 37% of UKA's and 23% of TKA's will be performed with robotics in 10 years (Medical Device and Diagnostic Industry, March 5, 2015). First generation robotic technology improved substantially implant position compared to conventional methods; however, high capital costs, uncertainty regarding the value of advanced technologies, and the need for preoperative CT scans were barriers to broader adoption. Newer image-free robotic technology offers an alternative method for further optimizing implant positioning and soft tissue balance without the need for preoperative CT scans and with price points that make it suitable for use in an ASC. Currently, as a result of cost and other practical issues, <1% of first generation robotic technologies are being used in ASC's. Alternatively, more than 35% of second generation robotic systems are in use in ASC's for UKA, due to favorable pricing. In conclusion, UKA can be safely performed in the outpatient setting in select patients. Additionally, we demonstrated a substantial cost savings when UKA is performed in an outpatient setting and care is shifted from a general community hospital to an ASC. Finally, robotics can be utilised to optimise accuracy of implant placement and soft tissue balance in UKA, and newer image-free robotic technology is cost effective for outpatient UKA

Closed ankle fractures have been reported to account for 10% off all fractures presenting to the Emergency Department. Many of these injuries require acute surgical management either via direct admission or through defined outpatient surgical pathways. While both methods have been shown to be safe, few studies have examined the cost effectiveness of each clinical scenario. The purpose of this study is to compare cost and resource utilization associated with inpatient and outpatient ankle fracture surgery at a Canadian academic institution. This is a retrospective chart review of patients who underwent acute ankle fracture surgery at London Health Sciences Centre between 2016 and 2018. Thirty patients who underwent inpatient ankle surgery for closed, isolated ankle fractures at University Hospital were compared to 30 consecutive patients who underwent outpatient ankle surgery for similar fractures at Victoria hospital. Data pertaining to age at time of surgery, sex, BMI, fracture type, operating/recovery room time, and length of hospital stay were collected. All emergency room visits, readmissions and complications within 30 days of surgery were also recorded. Inpatient and outpatient cohorts were similar with respect to average age (48 vs. 44, P=0.326) and body mass index (29.8 vs. 29.1, P=0.741). There was a greater proportion of patients with an American Society of Anesthesia (ASA) Classification of 3 or greater in the inpatient surgery group (48% vs. 23%). The inpatient group spent an average of 1.2 days in hospital while waiting for surgery and a average of 72 hours in hospital for their entire surgical encounter. The outpatient group spent an average of eight days (at home) waiting for surgery while spending an average of 7.4 hours in hospital during their entire surgical encounter. Outpatient ankle fracture surgery was associated with a cost savings of 35.9% in comparison to inpatient ankle fracture surgery (P < 0 .001). There were no significant differences in the rates of emergency room visits, readmissions, or complications between cohorts. Preliminary findings suggest that outpatient ankle fracture surgery is appropriate for most patients, requires less hospital resources and is associated with similar rates of readmission and complications as inpatient surgery. An established outpatient surgical pathway may offer significant cost savings in the treatment of the common closed ankle fracture that requires surgical intervention

Outpatient total hip arthroplasty (THA) has remained controversial and challenging. Traditional hospital stays following total joint arthroplasty were substantial and resulted in increased rates of morbidity, significant pain, and severe restriction in mobility. Advancements in the surgical approach, anesthetic regimens, and the initiation of rapid rehabilitation protocols have had an impact on the length of recovery following elective THA. Still, very few studies have specifically outlined outpatient hip arthroplasty and, thus far, none have addressed the use of robotic-arm navigation in outpatient THA. This article describes in detail the technique used to perform outpatient THA with the use of robotic-arm assistance. We believe that outpatient THA using robotic-arm assistance in combination with tissue-preserving surgery, multi-modal pain and nausea management, early rehabilitation, and stringent patient selection yields a suitable alternative to inpatient joint replacement

An outpatient TKA program was developed by integrating advances in analgesia, rehabilitation, and minimally invasive surgical techniques with the objective of improving value in elective total knee arthroplasty (TKA) while maintaining quality standards. Previous studies have established the safety of outpatient TKA in selected populations, but the literature is devoid of outcome measures in these patients. Our goal was to investigate the quality of recovery, patient satisfaction, and safety profile in the first 90 days undergoing outpatient TKA. One hundred TKAs in 93 consecutive patients with end-stage arthritis of the knee candidate for primary TKA were enrolled in this prospective matched cohort study. Patients that underwent inpatient TKA (47 TKAs) were compared with patients that underwent planned outpatient TKA (53 TKAs). The following 28 day post-operative scores were recorded: quality of recovery (QoR-18) and pain scores by Numerical Rating Scale (NRS-11). Satisfaction with pain control (0 to 10) and quantity of opioid use was collected. Secondary outcome measures of 90-day complications, readmissions, and emergency department (ED) visits were recorded. Ninety-six percent of patients planned for outpatient TKA met our defined multidisciplinary criteria for same-day discharge. QoR-18 at post-operative day one was statistically higher in the outpatient TKA group. Otherwise, outcome measures were not statistically different between the 2 groups. Two patients required overnight admission: 1 for extended motor-block and 1 for vasovagal syncope. There were 7 ED visits in the in the outpatient group and 4 in the inpatient group. One outpatient was admitted for irrigation and debridement with liner exchange for an acute infection 2 weeks post-operatively. One inpatient required manipulation under anesthesia at six weeks post-operatively. Outpatient TKA in selected patients produced a post-operative quality of recovery and patient satisfaction similar to that of inpatient TKA. Our results support that outpatient TKA is a safe alternative that should be considered due to its potential cost-savings and comparable recovery

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

Introduction. Outpatient total joint arthroplasty (TJA) is emerging as a viable alternative to the historically accepted hospital based inpatient TJA in the United States. Several studies have focused on the financial advantages of outpatient TJA, however little research has discussed patient reported outcome measures (PROM) and the overall patient experience. This is a retrospective comparison of PROM data in patients undergoing outpatient vs. inpatient total hip arthroplasty (THA). Methods. An internal quality metric database analysis was performed on patients undergoing THA between 2/14/14 to 5/1/2015. Outpatients underwent THA at a newly opened ambulatory surgery center. Inpatients underwent THA in a hospital setting. Ninety-six outpatients and 152 inpatients between the ages of 29–65 years old were included. The Oxford Hip, VAS Pain, and Treatment Satisfaction Questionnaires were completed pre-operatively, and at 3- and 6-months post-op. The Treatment Satisfaction Questionnaire asked 8 questions including “how well did the surgery on your joint increase your ability to perform regular activities?” Patients chose from poor, fair, good, very good, and excellent. Chi-squared analyses determined differences in percentages between outpatient and inpatient PROM. Independent samples t-tests determined significant improvements between pre-op and 3 month post-op PROM scores. Results. Outpatients reported significantly greater improvements in functionality at 3 months post-operatively compared to inpatients (20.9 vs. 17.0 raw score improvement) as assessed using the Oxford Hip Score Questionnaire. Thus, outpatients showed a 23% greater improvement compared to inpatients. This was statistically significant (p<0.01). Outpatients showed a significantly higher improvement in VAS pain score compared to inpatients (84.5% vs. 66.2%, p<0.01) at 3 months post-op. Outpatients reported a significantly higher score (on a 100 point scale) when rating how normal their joint felt (85.0 vs. 76.8, p=.022) at 3 months post-op. A significantly higher percentage of outpatients reported their pain relief as “excellent” compared to inpatients (71.7% vs. 56.3%, p<0.01) at 3 months post-op. A significantly higher percentage of outpatients reported their ability to perform regular activities as “excellent” compared to inpatients (57.7% vs. 30.6%, p=.002) at 3 months post-op. A significantly higher percentage of outpatients reported their ability to perform regular activities as “very good-to-excellent” compared to inpatients (82.7% vs. 65.9%, p=.033) at 3 months post-op. A significantly higher percentage of outpatients reported that they “definitely would” have surgery again compared to inpatients (84.6% vs. 69.4%, p=.046) at 3 months post-op. Conclusion. Significantly greater PROM and VAS pain score improvements were reported by outpatient THA patients vs. inpatient THA patients of similar age between the pre-operative time point and 3-months post-op. Outpatient THA patients report a greater improvement on the Oxford Hip Score scale, VAS pain score, THA normal joint, and THA satisfaction questionnaire. The implementation of outpatient THA procedures shows greater overall patient satisfaction and improvement 3 months post-operation. This study demonstrates our initial experience with outpatient THA. The results have met and/or exceeded the inpatient experience with regards to patient reported outcomes measures

To our knowledge, we are the only centre in the UK where Achilles tenotomies (TA) for CTEV Ponseti correction are performed in outpatient clinic under local anaesthetic by an Advanced Physiotherapy Practitioner (APP) in orthopaedics. This study aims to present the outcomes and safety of this practice. Retrospective analysis of cases of idiopathic CTEV undergoing Ponseti correction January 2020 to October 2022. Demographic data: Pirani score and number of casts before boots and bar. Patients were divided into five groups: Group 1: TA performed by an Orthopaedic consultant under general anaesthetic (GA) in theatre. Group 2: TA performed by an Orthopaedic consultant under local anaesthetic (LA) in theatre. Group 3: TA performed by APP under GA in theatre. Group 4: TA performed by APP under LA in theatre. Group 5: TA performed by an APP under LA in outpatient clinic. Complications recorded: revision TA, infection, neurovascular injury or need for re-casting. Mean follow up 18 months. 45 feet included. Mean Pirani score 5.5, age started casting 33 days and total number of casts 6. No significant difference in demographic details between groups. 6, 4, 20, 5 and 10 tenotomies were performed in groups 1, 2, 3, 4, and 5 respectively. Complications were 1 revision tenotomy from group 2, one from group 4 and 1 renewal of cast from 3. This study demonstrates that TAs performed in outpatient clinic under LA by an APP is safe and feasible. No increase in complications were observed compared to TAs performed by orthopaedic consultants

Introduction. Outpatient total joint arthroplasty (TJA) is emerging as a viable alternative to the historically accepted hospital-based inpatient TJA in the United States. Several studies have focused on the financial advantages of outpatient TJA, however little research has discussed patient reported outcome measures (PROM) and the overall patient experience. The purpose of this study is to compare PROM data in patients undergoing outpatient vs. inpatient total knee arthroplasty (TKA) performed in the first year of a newly opened outpatient facility. Methods. An internal quality metric database analysis was performed on patients undergoing TKA between 2/14/14 and 5/1/2015. Outpatient TKA was performed at an ambulatory surgery center. Three-hundred and forty-three TKA patients (both inpatient and outpatient) between the ages of 37–65 years old were included. The Oxford Hip, VAS Pain, and Treatment Satisfaction Questionnaires were completed pre-operatively, and at 3- and 6-months post-op. The Treatment Satisfaction Questionnaire asks 8 questions including “how well did the surgery on your joint increase your ability to perform regular activities?” Patients chose from poor, fair, good, very good, and excellent. Chi-squared analyses determined differences in percentages between outpatient and inpatient PROM. Independent samples t-tests determined significant improvements between pre-op and 6 month post-op PROM scores. Results. Outpatients showed a significantly higher improvement in VAS pain score at 6 months compared to inpatients (74.5% vs. 61.6%, p<0.01). Outpatients rated their pain relief as “very good-to-excellent” significantly higher than inpatients (90.0% vs. 74.0%, p=.020) at 6 months post-op. Outpatients rated their ability to perform regular activities as “very good-to-excellent” more frequently as inpatients (82.0% vs. 59.3%, p=.004) at 6 months post-op. This difference was significant. A significantly higher percentage of outpatients reported “very good-to-excellent” meeting of expectations compared to inpatients (82.0% vs. 63.4%, p=.017) at 6 months post-op. No statistical difference was found between outpatients and inpatients in terms of Oxford Knee (function) scores at 6 months post-op. No statistical differences between the inpatient and outpatient groups were noted at the 3 month post-op time point. Conclusion. Significantly greater improvement was reported by outpatient TKA patients vs. inpatient TKA patients at six months post-op. Outpatients report a greater improvement on the VAS Pain score, and report a higher frequency of top-box ratings on the TKA normal joint and TKA satisfaction questionnaires. The implementation of outpatient TKA procedures shows greater overall patient satisfaction and improvement 6 months post-operation. This study illustrates that a de novo outpatient TJA pathway and facility can be successfully implemented with very high levels of patient satisfaction and patient reported success