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

In 2020, the COVID-19 pandemic meant that proceeding with elective surgery was restricted to minimise exposure on the wards. In order to maintain throughput of elective cases, our hospital was forced to convert as many cases as possible to same day procedures rather than overnight admission. In this retrospective analysis we review the cases performed as same day arthroplasty surgeries compared to the same period 12 months previous. We conducted a retrospective analysis of patients undergoing total hip and knee arthroplasties in a three month period between October and December in 2019 and again in 2020, in the middle of the SARS-CoV-2 pandemic. Patient demographics, number of out-patient primary arthroplasty cases, length of stay for admissions, 30-day readmission and complications were collated. In total, 428 patient charts were reviewed for the months of October-December of 2019 (n=195) and 2020 (n=233). Of those, total hip arthroplasties comprised 60% and 58.8% for 2019 and 2020, respectively. Demographic data was comparable with no statistical difference for age, gender contralateral joint replacement or BMI. ASA grade I was more highly prevalent in the 2020 cohort (5.1x increase, n=13 vs n=1). Degenerative disc disease and fibromyalgia were less significantly prevalent in the 2020 cohort. There was a significant increase in same day discharges for non-DAA THAs (2x increase) and TKA (10x increase), with a reciprocal decrease in next day discharges. There were significantly fewer reported superficial wound infections in 2020 (5.6% vs 1.7%) and no significant differences in readmissions or emergency department visits (3.1% vs 3.0%). The SARS-CoV-2 pandemic meant that hospitals and patients were hopeful to minimise the exposure to the wards and to not put strain on the already taxed in-patient beds. With few positives during the Coronavirus crisis, the pandemic was the catalyst to speed up the outpatient arthroplasty program that has resulted in our institution being more efficient and with no increase in readmissions or early complications

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

Over the past fifteen years, the average length of stay for total knee arthroplasty (TKA) has gradually decreased from several days to overnight. The most logical and safest next step is outpatient arthroplasty. Through the era of so-called minimally invasive surgery, perhaps the most intriguing advancements are not related to the surgery itself, but instead the areas of rapid recovery techniques and perioperative protocols. Rapid recovery techniques and perioperative protocols have been refined to allow for same-day discharge with improved outcomes. As mentioned, the single most important outcome from the minimally invasive movement has been the multi-modal approach to pain management of patients undergoing arthroplasty. Along with blood loss management, using tranexamic acid and hypotensive anesthetic techniques, this multi-modal program is the most important variable in reducing or avoiding side-effects. In any arthroplasty procedure, side-effects that need to be addressed include the negative effects of narcotics and blood loss. Anesthetic techniques, utilizing local nerve blocks, such as the adductor canal block and sciatic blocks for knee arthroplasty augment intraoperative anesthesia and provide postoperative pain relief and quicker mobilization. Additionally, pericapsular injection with a cocktail of local anesthetic helps significantly with pain relief and recovery reducing the amount of oral narcotic utilised in the early postoperative period. Many have utilised liposomal bupivacaine in these cocktails to successfully increase the period of pain relief. The use of multi-modal perioperative protocols can help avoid narcotics and helps avoid the side-effects of nausea. We also utilise an aggressive prophylactic antiemetic program with dexamethasone, ondansetron and a scopolamine patch. Patients without any significant cardiovascular history are given celecoxib preoperatively, which is continued for approximately two weeks postoperatively. Immediately postoperative, acetaminophen and additional dexamethasone are administered intravenously. The multi-modal protocols to address fear, risk, and side-effects will increase the eligibility for outpatient surgery and decrease the need for overnight hospitalization. By focusing on the patient and avoiding over-treatment, outpatient arthroplasty is quickly becoming the standard of care for total hip replacement in the same way other procedures transitioned from hospital in-patient surgeries to ambulatory procedures

To progress to a same day surgery program for arthroplasty, it is important that we examine and resolve the issues of why patients stay in the hospital. The number one reason is fear and anxiety of the unknown and of surgical pain. The need for hospital stay is also related to risk arising from comorbidities and medical complications. Patients also need an extended stay to manage the side effects of our treatment, including after effects of narcotics and anaesthesia, blood loss, and surgical trauma. The process begins pre-operatively with an appropriate orthopaedic assessment of the patient and determination of the need for surgery. The orthopaedic team must motivate the patient, and ensure that the expectations of the patient, family and surgeon are aligned. In conjunction with our affiliated hospitalist group that performs almost all pre-admission testing, we have established guidelines for patient selection for outpatient arthroplasty. The outpatient surgical candidate must have failed conservative measures, must have appropriate insurance coverage, and must be functionally independent. Previous or ongoing comorbidities that cannot be optimised for safe outpatient care may include: congestive heart failure, or valve disease; chronic obstructive pulmonary disease, or home use of supplemental oxygen; untreated obstructive sleep apnea with a BMI >40 kg/m2; hemodialysis or severely elevated serum creatinine; anemia with hemoglobin <13.0 g/dl; cerebrovascular accident or history of delirium or dementia; and solid organ transplant. Pre-arthroplasty rehabilitation prepares the patient for peri-operative protocols. Patients meet with a physical therapist and are provided with extensive educational materials before surgery to learn the exercises they will need for functional recovery. Enhancement of our peri-operative pain management protocols has resulted in accelerated rehabilitation. The operative intervention must be smooth and efficient, but not hurried. Less invasive approaches and techniques have been shown to decrease pain, reduce length of stay, and improve outcomes, especially in the short term. Between June 2013 and December 2015, 1957 primary knee arthroplasty procedures (1010 total, 947 partial) were performed by the author and his 3 associates at an outpatient surgery center. Seven percent of patients required an overnight stay, with a majority for reasons of convenience related to travel distance or later operative time. Importantly, no one has required overnight stay for pain management. 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

To progress to a same day surgery program for arthroplasty, it is important that we examine and resolve the issues of why patients stay in the hospital. The number one reason is fear and anxiety for the unknown and for surgical pain. The need for hospital stay is also related to risk arising from comorbidities and medical complications. Patients also need an extended stay to manage the side effects of our treatment, including after-effects of narcotics and anesthesia, blood loss, and surgical trauma. The process begins pre-operatively with an appropriate orthopaedic assessment of the patient and determination of the need for surgery. The orthopaedic team must motivate the patient, and ensure that the expectations of the patient, family and surgeon are aligned. In conjunction with our affiliated hospitalist group that performs almost all pre-admission testing, we have established guidelines for patient selection for outpatient arthroplasty. The outpatient surgical candidate must have failed conservative measures, must have appropriate insurance coverage, and must be functionally independent. Previous or ongoing comorbidities that contraindicate the outpatient setting include: cardiac – prior revascularization, congestive heart failure, or valve disease; pulmonary – chronic obstructive pulmonary disease, or home use of supplemental oxygen; untreated obstructive sleep apnea – BMI >40 kg/m2; renal disease – hemodialysis or severely elevated serum creatinine; gastrointestinal – history or post-operative ileus or chronic hepatic disease; genitourinary – history of urinary retention or severe benign prostatic hyperplasia; hematologic – chronic Coumadin use, coagulopathy, anemia with hemoglobin <13.0 g/dl, or thrombophilia; neurological – history of cerebrovascular accident or history of delirium or dementia; solid organ transplant. Pre-arthroplasty rehabilitation prepares the patient for peri-operative protocols. Patients meet with a physical therapist and are provided with extensive educational materials before surgery to learn the exercises they will need for functional recovery. Enhancement of our peri-operative pain management protocols has resulted in accelerated rehabilitation. The operative intervention must be smooth and efficient, but not hurried. Less invasive approaches and techniques have been shown to decrease pain, reduce length of stay, and improve outcomes, especially in the short term. In 2014, 385 primary partial knee arthroplasty procedures (7 patellofemoral replacement, 13 lateral, and 365 medial) were performed by the author and his 3 associates at an outpatient surgery center. Of those, 348 (95%) went home the same day while 17 (5%) required an overnight stay, with 11 for convenience related to travel distance or later operative time and 6 for medical issues. 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

Over the past fifteen years, the average length of stay for total hip (THA) and total knee arthroplasty (TKA) has gradually decreased from several days to overnight. The most logical and safest next step is outpatient arthroplasty. Through the era of so-called minimally invasive surgery, perhaps the most intriguing advancements are not related to the surgery itself, but instead the areas of rapid recovery techniques and peri-operative protocols. Rapid recovery techniques and peri-operative protocols have been refined to allow for same-day discharge with improved outcomes. In addition to Rapid Recovery techniques for the clinical care of the outpatient, one critical component to same-day total knee arthroplasty is the efficient performance and simplicity of the procedure itself. Simplified instrumentation and elimination of modularity can provide that efficiency and simplicity. All polyethylene tibial components have been mostly supplanted by modular metal-backed designs in recent years. However, mounting evidence suggests that survivorship of TKA with an all-poly tibia is superior to TKA with metal-backed, modular designs in all age groups except younger than 55, in which survival is equal to a modular design. Furthermore, this survival advantage was unaffected by obesity. Combining these excellent clinical results with the efficiency of a non-modular component can add to the efficiency and simplicity of the surgical technique. Therefore, in outpatient total knee arthroplasty, the all-poly tibia truly represents the less is more mentality

Introduction. Technology in Orthopaedic surgery has become more widespread in the past 20 years, with emerging evidence of its benefits in arthroplasty. Although patients are aware of benefits of conventional joint replacement, little is known on patients' knowledge of the prevalence, benefits or drawbacks of surgery involving navigation or robotic systems. Materials & Methods. In an outpatient arthroplasty clinic, 100 consecutive patients were approached and given questionnaires to assess their knowledge of Navigation and Robotics in Orthopaedic surgery. Participation in the survey was voluntary. Results. 98 patients volunteered to participate in the survey, mean age 56.2 years (range 19–88; 52 female, 46 male). 40% of patients thought more than 30% of NHS Orthopaedic operations involved navigation or robotics; 80% believed this was the same level or less than the private sector. A third believed most of an operation could be performed independently by a robotic/navigation system. Amongst perceived benefits of navigation/robotic surgery was more accurate surgery(47%), quicker surgery (50%) and making the surgeon's job easier (52%). 69% believed navigation/robotics was more expensive and 20% believed it held no benefit against conventional surgery, with only 9% believing it led to longer surgery. Almost 50% would not mind at least some of their operation being performed with use of robotics/navigation, with a significantly greater proportion of these coming from patients aged under 50 years. Conclusions. Although few patients were familiar with this new technology, there appeared to be a strong consensus it was quicker and more accurate than conventional surgery. Many patients appear to believe navigation and robotics in Orthopaedic surgery is largely the preserve of the private sector. This study demonstrates public knowledge of such new technologies is limited and a need to inform patients of the relative merits and drawbacks of such surgery prior to their more widespread implementation

Introduction. Technology in Orthopaedic surgery has become more widespread in the past 20 years, with emerging evidence of its benefits in arthroplasty. Although patients are aware of benefits of conventional joint replacement, little is known on patients' knowledge of the prevalence, benefits or drawbacks of surgery involving navigation or robotic systems. Materials and methods. In an outpatient arthroplasty clinic, 100 consecutive patients were approached and given questionnaires to assess their knowledge of Navigation and Robotics in Orthopaedic surgery. Participation in the survey was voluntary. Results. 98 patients volunteered to participate in the survey, mean age 56.2 years (range 19–88; 52 female, 46 male). 40% of patients believed more than 30% of NHS Orthopaedic operations involved navigation or robotics; 80% believed this was the same level or less than the private sector. A third believed most of an operation could be performed independently by a robotic/navigation system. Amongst perceived benefits of navigation/robotic surgery was more accurate surgery(47%), quicker surgery (50%) and making the surgeon's job easier (52%). 69% believed navigation/robotics was more expensive and 20% believed it held no benefit against conventional surgery, with only 9% believing it led to longer surgery. Almost 50% would not mind at least some of their operation being performed with use of robotics/navigation, with a significantly greater proportion of these coming from patients aged under 50 years. Conclusions. Although few patients were familiar with this new technology, there appeared to be a strong consensus it was quicker and more accurate than conventional surgery. Many patients appear to believe navigation and robotics in Orthopaedic surgery is largely the preserve of the private sector. This study demonstrates public knowledge of such new technologies is limited and a need to inform patients of the relative merits and drawbacks of such surgery prior to their more widespread implementation