Abstract
Aims
We present the development of a day-case total hip arthroplasty (THA) pathway in a UK National Health Service institution in conjunction with an extensive evidence-based summary of the interventions used to achieve successful day-case THA to which the protocol is founded upon.
Methods
We performed a prospective audit of day-case THA in our institution as we reinitiate our full capacity elective services. In parallel, we performed a review of the literature reporting complication or readmission rates at ≥ 30-day postoperative following day-case THA. Electronic searches were performed using four databases from the date of inception to November 2020. Relevant studies were identified, data extracted, and qualitative synthesis performed.
Results
Our evaluation and critique of the evidence-based literature identifies day-case THA to be safe, effective, and economical, benefiting both patients and healthcare systems alike. We further validate this with our institutional elective day surgery arthroplasty pathway (EDSAP) and report a small cohort of successful day-case THA cases as an example in the early stages of this practice in our unit.
Conclusion
Careful patient selection and education, adequate perioperative considerations, including multimodal analgesia, surgical technique and blood loss management protocols and appropriate postoperative pathways comprising reliable discharge criteria are essential for successful day-case THA.
Cite this article: Bone Jt Open 2021;2(2):93–102.
Take home message
Early literature demonstrates day-case total hip arthroplasty (THA) proves to be as safe, effective, and more cost-effective than inpatient THA, benefitting both patients and healthcare systems alike.
In a UK NHS-based system, initial results for day-case THA are promising, with low 30-day and 90-day readmission and complication rates.
Careful patient selection and education, adequate perioperative considerations, and appropriate postoperative pathways are essential for successful day-case THA.
Introduction
There is a strong consensus that total hip arthroplasty (THA) is one of the most successful elective operations, combining exceptional functional outcomes with low complication rates.1 With an ageing, more active population, the demand for THA is expected to rise globally, with a projected 400% increase from the early 2000s to 2030.2 This increasing demand for arthroplasty in the coming years can burden healthcare systems universally, particularly from a financial perspective.3 Additionally, a longer length of stay (LOS) in hospital post-THA has been associated with greater morbidity and mortality.4
‘Enhanced recovery’ protocols have been adopted to reduced LOS and have proven successful when compared to the more conformist recovery pathways.5 Although these pathways have led to a reduction in LOS to a few days, day-case or outpatient THA, whereby patients are discharged from hospital on the same day post-surgery, is comparatively less common internationally.
We have seen unprecedented demands and changes within our healthcare systems during the COVID-19 pandemic.6 As we now drive to reinitiate our full capacity elective services in an attempt to tackle an ever growing demand for lower limb arthroplasty,7 this pandemic has presented rare opportunities to revise and re-engage elective arthroplasty pathways aimed at improving patient care and healthcare efficiency. As we are now living in the era of integrated care systems, this will set a great example in transferring our care back to the community and reducing the burden on the secondary care services in the UK through a collaborative work involving all the stakeholders responsible in providing integrated care to our population.8
Early literature demonstrates day-case THA should be considered as a safe, efficient, and cost-effective practice, as it has been shown to be advantageous to both patients and healthcare systems alike. In this review, we present our institutional elective day surgery arthroplasty Pathway (EDSAP) and early results, coupled with an evidence-based summary of the most common interventions used to achieve successful day-case THA based on the evidence presented in the literature.
University College London Hopsitals (UCLH) day-case arthroplasty pathway
In order to achieve successful day-case THA, a number of strict protocols need to be in place that reduces the risk of an increased LOS. Pre-, peri-, and postoperative measures should be in place in order to facilitate day-case THA, as illustrated in our unit’s EDSAP standard operating procedure (Figure 1 and Tables I–IV).
Fig. 1
UCLH Standard operating procedure of elective day surgery arthroplasty and UCLH@home patient pathway.
Table I.
Multi disciplinary team members.
| Arthroplasty clinical nurse specialist |
| Matron for trauma and orthopaedics |
| Day surgery ward manager |
| Assistant general manager |
| General manager |
| Lead physiotherapist |
| Lead occupational therapist |
| Therapy assistant |
| Sister, pre-assessment clinic |
| Matron, theatres and anaesthetics division |
| Trauma clinical nurse specialist |
| UCLH@home matron |
Table II.
Inclusion and exclusion criteria for elective day surgery arthroplasty.
| Inclusion criteria | Exclusion criteria |
| Willing to participate | ASA ≥ 3 |
| Clinically safe to be treated at home | Any cardiac history |
| Proficient with walking aids | Significant prostate history |
| Living within the local borough | Haemoglobin < 120 g/l |
| Supported at home by relatives | Insulin dependent diabetes |
| Requires continuous positive airway pressure (CPAP) | |
| History of chronic pain | |
| Cognitive issues that preclude the ability to understand instructions | |
| Significant psycho/social issues that would prevent the patient from managing at home safely |
-
ASA, American Society of Anesthesiologists.
Table III.
Elective day surgery arthroplasty anaesthetic and prescription protocol.
| Anaesthetic protocol | Postoperative inpatient medications | Discharge medications |
PLAN A: Spinal anaesthesia
PLAN B: General anaesthesia using short acting drugs where possible. PLAN A & B:
|
|
|
-
*
If no penicillin allergy, otherwise consult microbiology guidelines.
-
NSAIDs, non-steroidal anti-inflammatory drugs
Table IV.
Elective day surgery arthroplasty discharge criteria.
The patient reviewed by UCLH@home by 17:00:
|
The COVID-19 pandemic has provided our institution with the opportunity to revise and re-engage our elective day-case arthroplasty pathway (Table V). As we close in on the winter months with undoubtedly increased pressures on our NHS system, we have already seen the benefits of day-case arthroplasty in our institution, as simultaneous elective operating lists have been cancelled due to bed shortages. Over the last few months in our early stages, we demonstrate varying success with day-case THA. Multiple patients successfully proceeded with day-case THA with high patient satisfaction, combined with few cases of failed day-case discharge. As with any novel service there is a learning curve, we would like to share these unsuccessful discharges as they are as important as the successful cases to learn how to avoid this in the future. Institutional approval was granted for auditing our pathway.
Table V.
Institutional elective day surgery total hip arthroplasty patient demographic, intraoperative, and perioperative data.
| Sex | Age, yrs |
BMI
(kg/m2) |
ASA grade | Preop diagnosis | Comorbidities | Procedure | Approach | Anaesthetic |
Operative
Time (hrs: mins) |
Blood loss (Hb drop, g/dl) |
Time to XR
(hrs: mins) |
Time to Discharge
(hrs: mins) |
Unsuccessful day-case discharge reason |
| M | 55 | 28.6 | 2 | OA | Mild COPD, hypertension, GORD | Right THA | Posterior | GA plus block | 01:10 | -7.0 | 01:52 | 08:50 | |
| M | 63 | 29.7 | 2 | OA | Hypertension, GORD | Right THA | Posterior | Spinal | 00:52 | -26.0 | 01:15 | 06:50 | |
| F | 54 | 24.5 | 2 | OA | Right THA 2017, asthma, migraines | Left THA | Posterior | GA plus block | 01:20 | -19.0 | 01:05 | 07:11 | |
| F | 53 | 31.2 | 2 | Hip dysplasia plus OA | Vertigo, haemorrhoids | Left THA | Posterior | Spinal | 01:47 | -09.0 | 23:35 | 123:47 | *Non-English speaker, complex operation: dysplastic hip, short, high BMI |
| F | 71 | 21.4 | 1 | OA | Left THA 2016, benign tinnitus | Right THA | Posterior | Spinal | 01:22 | -22.0 | 02:55 | 06:27 | |
| M | 78 | 23.7 | 2 | OA | Hypertension, Mild sleep apnoea, Hernia repairs | Left THA | Posterior | Spinal | 01:24 | -20.0 | 03:07 | 07:00 | |
| M | 63 | 36.5 | 2 | OA | Mild COPD, kidney stones | Left THA | Posterior | Spinal | 01:22 | -23.0 | 03:53 | 05:41 | |
| F | 39 | 39.3 | 2 | Hip dysplasia plus OA | GORD, anxiety, panic attacks | Left THA | Posterior | Spinal | 01:53 | + 3.0 | 22:22 | 31:51 | *Pain +++, anxiety, complex case; long operation time, high BMI |
| F | 58 | 29.8 | 1 | OA | GORD, current smoker, glaucoma | Left THA | Posterior | GA | 01:06 | -13.0 | 21:41 | 51:28 | *Recruited on the day of surgery, no available capacity for UCLH@home |
| M | 66 | 35.5 | 2 | OA | Hypertension, tinnitus | Right THA | Posterior | Spinal | 01:11 | -14.0 | 23:19 | 30:49 | *Recruited on the day of surgery, no available capacity for UCLH@home and no relative for supervision |
| F | 72 | 24.8 | 2 | OA | Corneal operations, postoperative DVT | Right THA | Posterior | GA plus block | 01:11 | -13.0 | 02:09 | 08:13 | |
| F | 55 | 22.6 | 1 | Hip dysplasia plus OA | Nil | Robotic-assisted right THA | Posterior | Spinal | 02:12 | -21.0 | 02:45 | 06:04 | |
| F | 54 | 22.5 | 1 | OA | Nil | Right THA | Posterior | GA | 01:05 | -13.0 | 03:26 | 08:52 | |
| M | 69 | 27.1 | 2 | OA | Bilateral TKA, TURBT | Robotic-assisted left THA | Posterior | GA | 02:19 | -14.0 | 02:50 | 05:41 |
-
*
Failed discharge on the day of surgery.
-
ASA, American Society of Anesthesiologists; BMI, body mass index; COPD, chronic obstructive pulmonary disease; DVT, deep vein thrombosis; GA, general anaesthesia; GORD, gastro-oesophageal reflux disease; OA, osteoarthritis; THA, total hip arthroplasty; TURBT, trans urethral resection of bladder tumour.
The process has compounded the necessity for stringent patient selection. Four out of 14 patients who were recruited failed day-case THA discharge due to inappropriate preparation (lack of UCLH@home team capacity) or patient selection (Table V).
Conversely, with appropriately selected patients this pathway provides an effective, efficient and economical service. We report a small cohort of successful day-case THA as an example in the early stages of day-case arthroplasty in our unit (Table V). Patient mean age was 61.3 years (SD 9.6), body mass index (BMI) 26.1 kg/m2 (SD 4.5), and ASA grade 1.6 (SD 0.5). Mean operative time was 85 minutes (SD 28), and haemoglobin (Hb) drop of 17.8 g/l (SD 5.8). Mean time from skin closure to postoperative radiograph was 2.5 hours (SD 0.9), and to discharge was 7.1 hours (SD 1.1). There were two cases of robotic assisted THA with successful day-case discharge. Following day-case discharge there were no readmissions or postoperative complications including re-operations, inadequate analgesia, infection, or venous thromboembolism reported in our cohort at 30- to 90-day follow-up.
While the initial results for this small cohort of day-case THA are promising, we examined the literature to extrapolate the evidence-based reports from which this pathway was designed and also identify elements to further improve this service in this review.
Search strategy
Our search strategy using NICE healthcare databases (title and abstract) was "hip arthroplasty" OR "hip replacement" OR "THA" OR "THR" AND "outpatient" OR "day case" OR "daycase" OR "same-day" OR "same day". Inclusion and exclusion criteria were used as defined in Table VI. Two authors (JT, WW) independently screened all search studies, any inconsistencies or disagreements were resolved by discussion and consensus. After completion of this process, 19 articles were selected (Figure 2).
Table VI.
Search strategy inclusion and exclusion criteria.
| Inclusion criteria | Exclusion criteria |
| Day-case arthroplasty being defined as discharge on the same day as surgery. Reporting on outcomes of day-case THA. Level I to IV evidence. |
Non-English language article. Case reports. Follow-up less than 30 days. Discharge on following calendar day to day of surgery. Studies reporting outcomes of hip and knee arthroplasty that did not clearly define THA outcomes and complications separately. |
-
THA, total hip arthroplasty.
Fig. 2
Flowchart of search strategy.
Evidence in support of day-case THA
Day-case THA has been shown to benefit patients and healthcare systems as it is considerably less expensive,3,9 with similar or improved complications rates and functional outcomes in comparison to inpatient THA pathways.3,10-27 A study comparing the complication rates and patient-reported outcome measures (PROMs) between inpatient and day-case THA showed that at 90 days postoperatively there were no significant differences in complication rates between the two groups, and the latter group experienced better PROMs at two years.13 Similarly, Coenders et al26 demonstrated significant improvement in all PROMs at one year following day-case THA, but also significantly lower 90-day complication and readmission rates in day-case THA compared with inpatient THA (4.61% vs 11.54% and 1.38% vs 4.46%, respectively). Moreover, Richards et al15 conducted a matched cohort analysis that showed lower 90-day complication rates in patients who underwent day-case THA compared to those that were treated as an inpatient post-operatively (8.82% vs 10.29%, respectively). In the largest study to date, although a non-comparative retrospective study, Berend et al27 reported on 1,472 day-case THAs at a single centre with low complication and readmission rate at 90 days (4.82% and 2.17%, respectively). Additionally, a meta-analysis of day-case THA (1,428 day-case vs 65,543 inpatient THAs) concluded lower complication and readmission rates in patients who had day-case THA compared to inpatient counterpart (3.0% vs 4.7% and 1.4% vs 3.0%, respectively).28 The complication and readmission rates associated with day-case THA published in the literature are summarized in Table VII.
Table VII.
Summary of day-case total hip arthroplasty studies in the literature.
| Author | Study design | No. of day-case THA patients | Follow-up (days) | Approach | Anaesthetic | Day-case complications (%) | Inpatient complications (%) | Day-case readmissions (%) | Inpatient readmissions (%) |
|---|---|---|---|---|---|---|---|---|---|
| Rosinsky et al13 | Prospective comparison | 91 | 90 | DAA | GA | 11.00 | 11.00 | 0 | 1.10 |
| Springer et al21 | Retrospective comparison | 45 | 30 | Posterior | GA/RA | 2.22 | 0 | 0 | 0 |
| Goyal et al14 | Prospective comparison | 112 | 30 | DAA | RA | 0.89 | 3.70 | 0.89 | 0.93 |
| Madsen et al22 | Retrospective comparison | 116 | 90 | Posterior | RA | 6.03 | N/A | 2.59 | N/A |
| Fraseret al23 | Prospectiveobservation | 106 | 365 | DAA | RA | 0.94 | N/A | 0.94 | N/A |
| Sershon et al24 | Retrospective comparison | 965 | 90 | DAA | RA | 3.80 | N/A | 1.14 | N/A |
| Klein et al20 | Prospective observation | 549 | 90 | Mini-posterior | RA | 4.92 | N/A | 0.55 | N/A |
| Larsen et al19 | Prospective observation | 29 | 42 | Posterior | RA | 0 | N/A | 0 | N/A |
| Hartog et al11 | Prospective observation | 27 | 42 | DAA | RA | 4.17 | N/A | 4.17 | N/A |
| Dorr et al18 | Prospective observation | 50 | 180 | Mini-posterior | RA | 1.88 | N/A | 1.88 | N/A |
| Toy et al25 | Retrospective observation | 145 | 90 | DAA | GA/RA | 3.44 | N/A | 0.69 | N/A |
| Berger et al12 | Prospective observation | 150 | 90 | Mini-posterior | RA | 2.00 | N/A | 0.67 | N/A |
| Otero et al16 | Retrospective comparison | 249 | 30 | Not stated | GA/RA | 5.62 | 4.96 | 2.02 | 3.55 |
| Nelson et al17 | Retrospective comparison | 420 | 30 | Not stated | Not stated | 7.86 | 13.43 | 1.43 | 2.97 |
| Aynardi et al3 | Retrospective comparison | 119 | 90 | DAA | RA | 1.68 | 0 | 0 | 0 |
| Paredes et al10 | Prospective observation | 72 | 90 | DL/AL | RA | 4.17 | N/A | 4.17 | N/A |
| Richards et al15 | Retrospective comparison | 136 | 90 | DAA | GA/RA | 8.82 | 10.29 | 1.47 | 1.47 |
| Coenders et al26 | Retrospective comparison | 217 | 365 | DAA | RA | 4.61 | 11.54 | 1.38 | 4.46 |
| Berend et al27 | Retrospective observation | 1,472 | 90 | DAA/DL | GA and RA | 4.82 | N/A | 2.17 | N/A |
-
DAA, direct anterior approach; DL, direct lateral; GA, general anaesthetic; N/A, not applicable; RA, regional anaesthetic.
Day-case THA has been shown to be significantly cheaper than inpatient THA in USA-based systems, although this has yet to be demonstrated in the UK NHS. Aynardi et al3 reported the overall cost in the day-case setting was significantly lower at $24,529 (SD 1,759) compared to $31,327 (SD 9,013) for the inpatient group. This cost-effectiveness was also shown in a further computer-based cost utility study comparing the costs of day-case and inpatient THA ($43,288 (SD 1,606) vs $48,155 (SD 1,673), respectively).9
Preoperative measures
Patient education
Adequate preoperative patient education is a fundamental component of the THA clinical pathway and has been shown to reduce LOS.29 Focused discussion sessions involve procedural benefits and risks, the model of day-case THA, analgesia, and postoperative physiotherapy. In our institution (UCLH), we start educating this cohort of patient from the time we list them for the procedure up until the day of the operation. Day-case THA education leaflets and joint schools are paramount for the service, and we have adapted these classes virtually for the COVID-19 pandemic.
Patient selection
In our protocol, we specified our inclusion and exclusion criteria for patients eligibility for day-case THA (Table II) to facilitate a fast-track service which allows for a predictable perioperative environment, good analgesic control, and rapid physiotherapy assessment before successful hospital discharge can be achieved. Major comorbidities have been highlighted in the literature such as cardiovascular disease, pulmonary disease, uncontrolled diabetes, coagulopathy, obesity, and corticosteroid use which may cause patients to be ineligible, as these conditions increase the risk of postoperative complications, which in turn increases LOS in hospital.30 Studies measuring the outcomes of day-case THA have largely been conducted in selected patients without any major comorbidities.3,10-14,19,20,22,31,32 The American Society of Anaesthesiologists (ASA) scoring system has also been used as an eligibility tool for day-case THA in a number of studies.11,19,22,32
Perioperative measures
Analgesia
In order to achieve day-case discharge, post-THA pain must be effectively managed so that patients can successfully mobilize. A multimodal pain-controlling approach combines various groups of analgesics and aims to minimize opioid use in order to reduce opioid-induced adverse reactions. Multimodal analgesia has been shown to successfully deliver more rapid functional recovery, reduced adverse drug reactions and reduced LOS in hospital post-arthroplasty.33 We prescribe pain relief medications as outlined in our institutional protocol (Table III). Also, educating patients about the importance of anticipatory analgesia, starting regular pain relief early and immediately after discharge must be the standard practice. Furthermore, we reinforce this during our routine UCLH@home day-one postoperative review at the patient’s residence/home.
Anaesthetic
The decision to use a general anaesthetic (GA)13,15,16,21,25,27 or a regional anaesthetic (RA) (spinal or epidural)3,10-12,14-16,18-27 for day-case THA is debateable. Rosinsky et al13 is the only study using exclusively a GA as the form of anaesthetic. Berger et al12 showed in their study involving 150 consecutive day-case THAs successfully discharged home on the same day, that a regional anaesthetic combined with adequate pre-emptive oral analgesia and anti-emetic therapy is an effective method of maximizing day-case discharge.
Surgical technique
While most day-case THA studies used muscle-sparing approaches,3,11-14,20,23 conventional approaches have also been shown to attain successful day-case THA.19,22 Furthermore, minimally-invasive approaches have been linked to more rapid recovery time, which is a factor that aids in successful day-case discharge post-THA.3,12,18 The reduced soft tissue trauma is the principal benefit of this approach and results in a reduced level of postoperative pain, greater mobility, smaller scar, and a reduced LOS.34 The most popular approach among the yielded studies within the literature search is the direct anterior approach (DAA). There is increasing interest in the DAA more recently as it reduces soft tissue trauma, which is thought to allow for a more rapid rehabilitation.34 In our institution, we predominantly use the posterior approach without any modifications as we believe that this service is about collaborative work and its success is multifactorial. Wound closure is as important as the surgical approach and surgical technique and meticulous closure is essential to reduce postoperative complications. We close the skin with 3-0 Monocryl to avoid having the need for the later removal of stiches or staples at the two-week postoperative review.
Management of intraoperative blood loss
Blood loss is common post-THA. Unlike inpatient arthroplasty, where the maximum drop in Hb has been shown to be seen after four days,35 there is no evidence in the literature to advocate the optimal timing for a Hb check following day-case THA.36 Preoperatively, selecting patients with an adequate Hb can curtail the need for a blood transfusion, which in turn can increase LOS. Moreover, the use of tranexamic acid has proven to be an effective method of achieving haemostasis intra-operatively.37 We routinely use tranexamic acid intravenously at induction (1 gram) followed by tranexamic acid wash prior to closure as a method of minimizing blood loss supported by the literature.10,13,15,20
Postoperative measures
Early rehabilitation
Early postoperative rehabilitation once the patient is alert and clinically stable is pivotal in order to attain successful day-case discharge post-THA. As mentioned previously, adequate pain control is vital to allow for patients to mobilize with physiotherapists postoperatively and a multimodal analgesic approach has been shown to aid with early mobility.33 Accordingly, general and spinal anaesthesia using short-acting drugs where tolerable, motor-sparing nerve blocks, or infiltration of local anaesthetic collectively facilitate early mobilization. Our unit predominately uses the posterior approach for THA and despite this, and in accordance with recent literature, we do not educate our patient’s on hip precautions.38 Multiple studies have demonstrated relaxed hip precautions do not increase the early dislocation rate following THA and potentially hinder both postoperative rehabilitation and patient satisfaction.38
Discharge protocol
There is no clear consensus established in the literature regarding specific criteria that has to be satisfied prior to day-case discharge following THA. In our protocol, we follow strict discharge criteria in order to maintain safety and run an efficient service (Table IV). Furthermore, to ensure safety, our protocol includes a mandatory postoperative day-one review by UCLH@home. Pain control is pivotal for discharging patients on the same day. The presence of an escort and the presence of family or friends to support at home is an essential criterion. Goyal et al14 describes a clear discharge criteria that included completing certain physical activities with the physiotherapists, being declared clinically stable enough to leave the hospital and also feeling subjectively comfortable with sufficient assistance at home. Fraser et al23 also adopted the same discharge criteria. However, like our protocol, other studies also took into account postoperative Hb levels as part of the discharge criteria.10,11
Limitations to the evidence of day-case THA
The introduction of any novel protocol is always paralleled with areas for improvement. In Goyal et al’s14 randomized controlled trial (RCT), they reported a high rate of patients (24%) recruited for day-case THA who were not discharged on the day of surgery due to common adverse events. Conversely, in the opposing arm of the same RCT, they reported 17% of patients who were scheduled to receive inpatient arthroplasty met inclusion criteria for day-case surgery and were discharged on the same day. This further emphasizes the meticulous selection criteria required for effective day-case arthroplasty pathways.
Additionally, when analyzing the literature, one must take into account potential selection bias when comparing day-case to inpatient THA. Due to the selection criteria for day-case THA, the majority of patients are highly motivated, have lower ASA grades, fewer comorbidities, lower BMI, younger age, and have good social support networks.31,39 Jaibaji et al,39 in their systematic review of day-case arthroplasty including 3,955 day-case THAs, had a mean patient age of 58.3 years compared to the UK national joint registry mean age of 70 years for THA.39 The asymmetry of baseline characteristics is associated with lower surgical risk favouring patients selected for day-case arthroplasty.28 Thus, it could be extrapolated that studies demonstrating superior or equivocal complication and readmission rates between day-case and inpatient THA could be secondary to selection bias;3,22,24,26 however, RCTs14 and propensity matched studies13,15,17,26 eliminating this bias have shown superior results favouring day-case pathways.
When evaluating financial benefits of day-case THA, previous studies have criticized reports lacking inclusion of outpatient visitations, complications or readmissions, support networks, and initial set-up expenses. Both studies included in our report included these,3,9 although, neither of the studies in their economic evaluation accounted for selection bias as described above associated with day-case THA vs inpatient THA. Working back from an NHS tariff-based system, increased financial remuneration is provided for managing patients with increased comorbidities following THA for hip fracture due to increased cost of care. Accordingly, this may negate the size of financial benefits reported in the above studies.40 Additionally, incorrect coding of day-case total knee arthroplasty in an institution demonstrated financial losses following its introduction, highlighting the constraints of the initial implementation of novel pathways.41
Due to the heterogenous nature of reporting studies, differences in surgical approach, anaesthetic technique, patient demographics, control groups, preoperative, perioperative, and postoperative protocols, and the limited number of studies (single RCT), the evaluation of the benefits of day-case THA compared with inpatient THA remains novel. Further prospective RCTs are required to truly define efficacy and morbidity of day-case arthroplasty pathways.42 Nonetheless, the evidence presented demonstrates a safe and effective pathway for appropriately selected patients with consistently low complication and readmission rates. In our institution, we benefited from this service by reducing costs and freeing up beds for the next surgical list, especially considering our limited green pathway beds due to the effect of COVID-19.
Day-case THA proves to be as safe, effective, and more cost-effective than inpatient THA, benefiting both patients and healthcare systems alike. In our UK NHS-based system, unsuccessful same-calendar-day discharge was seen in patients with complex surgical cases, language barriers or late recruitment with insufficient capacity of our day-case supporting systems (UCLH@home team). Careful patient selection and education, adequate perioperative considerations, including multimodal analgesia, surgical technique, and blood loss management protocols and appropriate postoperative pathways, are essential for successful day-case THA.
References
1. Learmonth ID , Young C , Rorabeck C The operation of the century: total hip replacement . Lancet . 2007 ; 370 ( 9597 ): 1508 – 1519 . Crossref PubMed Google Scholar
2. Ahmed SS , Haddad FS Prosthetic joint infection . Bone Joint Res . 2019 ; 8 ( 11 ): 570 – 572 . Crossref PubMed Google Scholar
3. Aynardi M , Post Z , Ong A , Orozco F , Sukin DC Outpatient surgery as a means of cost reduction in total hip arthroplasty: a case-control study . Hss J . 2014 ; 10 ( 3 ): 252 – 255 . Crossref PubMed Google Scholar
4. Maempel JF , Clement ND , Ballantyne JA , Dunstan E Enhanced recovery programmes after total hip arthroplasty can result in reduced length of hospital stay without compromising functional outcome . Bone Joint J . 2016 ; 98-B ( 4 ): 475 – 482 . Crossref PubMed Google Scholar
5. Ibrahim MS , Twaij H , Giebaly DE , Nizam I , Haddad FS Enhanced recovery in total hip replacement: a clinical review . Bone Joint J . 2013 ; 95-B ( 12 ): 1587 – 1594 . Crossref PubMed Google Scholar
6. Oussedik S , Zagra L , Shin GY , D'Apolito R , Haddad FS Reinstating elective orthopaedic surgery in the age of COVID-19 . Bone Joint J . 2020 ; 102-B ( 7 ): 807 – 810 . Crossref PubMed Google Scholar
7. Patel A , Pavlou G , Mújica-Mota RE , Toms AD The epidemiology of revision total knee and hip arthroplasty in England and Wales: a comparative analysis with projections for the United States. A study using the National joint registry dataset . Bone Joint J . 2015 ; 97-B ( 8 ): 1076 – 1081 . Crossref PubMed Google Scholar
8. NHS Integrated care systems . https://www.england.nhs.uk/integratedcare/integrated-care-systems/ (date last accessed 4 February 2021 ). Crossref PubMed Google Scholar
9. Rosinsky PJ , Go CC , Bheem R , et al. The cost-effectiveness of outpatient surgery for primary total hip arthroplasty in the United States: a computer-based cost-utility study . Hip Int . 2020 ; 1120700020952776 : 1120700020952776 . Crossref PubMed Google Scholar
10. Paredes O , Ñuñez R , Klaber I Successful initial experience with a novel outpatient total hip arthroplasty program in a public health system in Chile . Int Orthop . 2018 ; 42 ( 8 ): 1783 – 1787 . Crossref PubMed Google Scholar
11. Hartog YMden , Mathijssen NMC , Vehmeijer SBW Total hip arthroplasty in an outpatient setting in 27 selected patients . Acta Orthop . 2015 ; 86 ( 6 ): 667 – 670 . Crossref PubMed Google Scholar
12. 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
13. Rosinsky PJ , Chen SL , Yelton MJ , et al. Outpatient vs. inpatient hip arthroplasty: a matched case-control study on a 90-day complication rate and 2-year patient-reported outcomes . J Orthop Surg Res . 2020 ; 15 ( 1 ): 367 . 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. Richards M , Alyousif H , Kim J-K , Poitras S , Penning J , Beaulé PE An evaluation of the safety and effectiveness of total hip arthroplasty as an outpatient procedure: a matched-cohort analysis . J Arthroplasty . 2018 ; 33 ( 10 ): 3206 – 3210 . Crossref PubMed Google Scholar
16. Otero JE , Gholson JJ , Pugely AJ , Gao Y , Bedard NA , Callaghan JJ Length of hospitalization after joint arthroplasty: does early discharge affect complications and readmission rates? J Arthroplasty . 2016 ; 31 ( 12 ): 2714 – 2725 . Crossref PubMed Google Scholar
17. Nelson SJ , Webb ML , Lukasiewicz AM , Varthi AG , Samuel AM , Grauer JN Is outpatient total hip arthroplasty safe? J Arthroplasty . 2017 ; 32 ( 5 ): 1439 – 1442 . Crossref PubMed Google Scholar
18. Dorr LD , Thomas DJ , Zhu J , Dastane M , Chao L , Long WT Outpatient total hip arthroplasty . J Arthroplasty . 2010 ; 25 ( 4 ): 501 – 506 . PubMed Crossref Google Scholar
19. Larsen JR , Skovgaard B , Prynø T , et al. Feasibility of day-case total hip arthroplasty: a single-centre observational study . Hip Int . 2017 ; 27 ( 1 ): 60 – 65 . Crossref PubMed Google Scholar
20. Klein GR , Posner JM , Levine HB , Hartzband MA Same day total hip arthroplasty performed at an ambulatory surgical center: 90-day complication rate on 549 patients . J Arthroplasty . 2017 ; 32 ( 4 ): 1103 – 1106 . Crossref PubMed Google Scholar
21. 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
22. Madsen MN , Kirkegaard ML , Laursen M , et al. Low complication rate after same-day total hip arthroplasty: a retrospective, single-center cohort study in 116 procedures . Acta Orthop . 2019 ; 90 ( 5 ): 439 – 444 . Crossref PubMed Google Scholar
23. 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
24. 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
25. Toy PC , Fournier MN , Throckmorton TW , Mihalko WM Low rates of adverse events following ambulatory outpatient total hip arthroplasty at a free-standing surgery center . J Arthroplasty . 2018 ; 33 ( 1 ): 46 – 50 . Crossref PubMed Google Scholar
26. Coenders MJ , Mathijssen NMC , Vehmeijer SBW Three and a half years' experience with outpatient total hip arthroplasty . Bone Joint J . 2020 ; 102-B ( 1 ): 82 – 89 . Crossref PubMed Google Scholar
27. Berend KR , Lombardi AV , Berend ME , Adams JB , Morris MJ The outpatient total hip arthroplasty : a paradigm change . Bone Joint J . 2018 ; 100-B ( 1 Supple A ): 31 – 35 . Crossref PubMed Google Scholar
28. Bordoni V , Marelli N , Previtali D , Gaffurini P , Filardo G , Candrian C Outpatient total hip arthroplasty does not increase complications and readmissions: a meta-analysis . Hip Int . 2020 ; 1120700020948797 . Google Scholar
29. Yoon RS , Nellans KW , Geller JA , Kim AD , Jacobs MR , Macaulay W Patient education before hip or knee arthroplasty lowers length of stay . J Arthroplasty . 2010 ; 25 ( 4 ): 547 – 551 . Google Scholar
30. Higuera CA , Elsharkawy K , Klika AK , Brocone M , Barsoum WK 2010 Mid-America orthopaedic association physician in training Award: predictors of early adverse outcomes after knee and hip arthroplasty in geriatric patients . Clin Orthop Relat Res . 2011 ; 469 ( 5 ): 1391 – 1400 . Crossref PubMed Google Scholar
31. 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
32. Gromov K , Jørgensen CC , Petersen PB , et al. Complications and readmissions following outpatient total hip and knee arthroplasty: a prospective 2-center study with matched controls . Acta Orthop . 2019 ; 90 ( 3 ): 281 – 285 . Crossref PubMed Google Scholar
33. Halawi MJ , Grant SA , Bolognesi MP Multimodal analgesia for total joint arthroplasty . Orthopedics . 2015 ; 38 ( 7 ): e616 – e625 . Crossref PubMed Google Scholar
34. Siddiqui NA , Mohandas P , Muirhead-Allwood S , Nuthall T (I) a review of minimally invasive hip replacement surgery—current practice and the way forward . Curr Orthop . 2005 ; 19 ( 4 ): 247 – 254 . Google Scholar
35. Chen Z-Y , Wu H-Z , Zhu P , Feng X-B Postoperative changes in hemoglobin and hematocrit in patients undergoing primary total hip and knee arthroplasty . Chin Med J . 2015 ; 128 ( 14 ): 1977 – 1979 . Crossref PubMed Google Scholar
36. Lazic S , Boughton O , Kellett CF , Kader DF , Villet L , Rivière C Day-Case surgery for total hip and knee replacement: how safe and effective is it? EFORT Open Rev . 2018 ; 3 ( 4 ): 130 – 135 . Crossref PubMed Google Scholar
37. Shang J , Wang H , Zheng B , Rui M , Wang Y Combined intravenous and topical tranexamic acid versus intravenous use alone in primary total knee and hip arthroplasty: a meta-analysis of randomized controlled trials . Int J Surg . 2016 ; 36 ( Pt A ): 324 – 329 . Crossref PubMed Google Scholar
38. Brown ML , Ezzet KA Relaxed hip precautions do not increase early dislocation rate following total hip arthroplasty . J Am Acad Orthop Surg . 2020 ; 28 ( 10 ): e440 – e447 . Google Scholar
39. 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
40. Horriat S , Hamilton PD , Sott AH Financial aspects of arthroplasty options for intra-capsular neck of femur fractures: a cost analysis study to review the financial impacts of implementing NICE guidelines in the NHS organisations . Injury . 2015 ; 46 ( 2 ): 363 – 365 . Crossref PubMed Google Scholar
41. 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
42. Nowak LL , Schemitsch EH Same-day and delayed hospital discharge are associated with worse outcomes following total knee arthroplasty . Bone Joint J . 2019 ; 101-B ( 7_Supple_C ): 70 – 76 . Crossref PubMed Google Scholar
Author contributions
J. W. Thompson: Collected, interpreted, and analyzed the data, Prepared the manuscript.
W. Wignadasan: Collected, interpreted, and analyzed the data, Prepared the manuscript.
M. Ibrahim: Performed surgery, Generated standard operating procedure, Prepared the manuscript.
L. Beasley: Generated standard operating procedure, Delivered pathway.
S. Konan: Performed surgery, Generated standard operating procedure, Prepared the manuscript.
R. Plastow: Performed the surgery, Prepared the manuscript.
A. Magan: Performed the surgery, Prepared the manuscript.
F. S. Haddad: Performed surgery, Generated standard operating procedure, Prepared the manuscript.
Funding statement
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
ICMJE COI statement
S. Konan reports consultancy, payment for lectures including service on speakers’ bureaus, payment for development of education presentations and travel/accommodations/meeting expenses for Smith and Nephew and AO, all of which are unrelated to this article. F. S. Haddad reports editorial board membership by The Bone & Joint Journal and the Annals of the Royal College Of Surgeons, consultancy and royalties from Smith & Nephew, Corin, MatOrtho, and Stryker, and payment for lectures (including service on speakers’ bureaus) from Smith & Nephew and Stryker, all of which are unrelated to this article.
Acknowledgements
This study was part of a quality improvement project conducted at University College London Hospitals NHS Foundation Trust. The authorship would like to thank the entirety of the Trauma & Orthopaedics Department and Anaesthetic Department for their support in the pathway and study. Specifically, we would like to further thank Ms A Brooke, Dr C Goldsack, Dr S West, Mr S Oussedik, Mr J Witt, Mr R Patel, and Mr G Grammatopoulos for their contribution in creation of the Elective Day Surgery Arthroplasty Pathway Standard Operating Procedure.
© 2021 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/.
