Over the years, advances in arthroplasty have included improvements in surgical technique and perioperative pain protocols. As a result, outpatient total joint arthroplasty (TJA)—particularly total hip arthroplasty (THA) and total knee arthroplasty (TKA)—is becoming increasingly popular among both surgeons and patients, according to information presented at the 2015 AAOS Annual Meeting in Las Vegas.

“Less overtreatment, fewer unnecessary tests, and lower overhead contribute to cost savings in the outpatient setting,” said Keith R. Berend, MD, of Joint Implant Surgeons, Inc., New Albany, Ohio. “Surgeons also have more control of their environment in an ambulatory surgery center (ASC)—there is less bureaucracy and more accountability.”

Patients prefer the outpatient setting because it gets them home and back to performing their normal activities sooner. However, Dr. Berend pointed out, better outcomes among outpatient TJA patients are due more to patient selection than to the facility. “Outpatient TJA patients undergo a rigorous screening process. They are clearly healthier and younger than inpatient TJA patients; it’s not surprising that they have slightly better outcomes in terms of faster recovery and a lower rate of infection,” he said.

In addition to the patient’s overall medical health, several other factors need to be taken into account when deciding between an inpatient or outpatient TJA.

Patients come first
The biggest difference between patients in the inpatient and outpatient environment is insurance status, according to Dr. Berend. “There is no Medicare code for performing an outpatient TKA or THA. That eliminates most of the patients older than age 65,” he said.

As for younger patients, Dr. Berend added, “Do the patients with commercial insurance have the appropriate benefits? Is the hospital or ASC in network or out of network? That may determine the facility, and it may also change the patient’s responsibility with respect to payment.”

Another important consideration is the patient’s home situation. “How far away the patient lives may determine if he or she has to stay overnight,” Dr. Berend explained. “Similarly, whether or not the patient lives with others may determine whether the patient will require a longer hospital stay; it may also affect the patient’s rehabilitation needs. Finally, is the family member/caregiver comfortable with the patient’s having an outpatient TJA?”

When choosing between an inpatient and outpatient procedure, the patient is the first priority, stressed Dr. Berend. “We have to do what’s best for the patient. Surgeons need to keep that in mind when making the decision.”

Techniques
A number of surgical approaches for arthroplasty can be used effectively in the outpatient setting; surgeons should therefore use the approach and equipment with which they are most comfortable, Dr. Berend explained. For example, outpatient THA can be performed with the anterior, anterolateral, direct lateral, or superior approach.

“It’s not the surgical approach—or even the implant—that matters most in the outpatient setting. It is the efficiency of the operation, and the same holds true for outpatient TKA,” Dr. Berend said. “Efficient surgery, low tourniquet times, and low blood loss, with a good overall result, are the deciding factors that enable these patients to go home the day of surgery.”

Anesthetic technique in the outpatient setting differs slightly from the inpatient environment, particularly with respect to nerve blocks and narcotics. “For example, when performing a THA in an ASC, I use a lidocaine spinal block, an adductor canal block, and a sciatic nerve block. In the inpatient setting, I use a narcotic spinal block and an adductor canal block,” Dr. Berend explained.

Intangibles
Choreography and an experienced team are critical to efficiency in the outpatient setting, Dr. Berend stressed.

“In an ASC, the flow needs to be streamlined; you’ve got to think about your team. Nurses need to multitask—in addition to their nursing duties, they are also responsible for educating the patient and family about physical therapy and facilitating patient discharge,” he said.

The facility must be large enough to accommodate not only an operating room(s), but also additional equipment and recovery areas. “We use more equipment for TJA. A total hip surgical tray is quite a bit larger than, for example, a carpal tunnel tray. You need to take that into account, especially if you are going to do multiple joint replacements in one day,” Dr. Berend said.

Because patients tend to stay longer in the ASC following a joint replacement procedure compared to other orthopaedic procedures, the facility must have a private recovery area large enough for patients and their families.

He added, “In a surgeon-owned/partnered ASC, intangibles include the alignment of goals and expectations, shared decision-making, accountability, gain of control that many of us have lost, and a more agile and responsive environment.

“Outpatient TJA is here and now,” Dr. Berend concluded. “It is safe, effective, contributes to cost savings, and patients and surgeons love it.”

Additional presenters during Symposium O, “Outpatient Arthroplasty is Here Now” were Adolph V. Lombardi Jr, MD; Michael J. Morris, MD; John W. Barrington, MD; William G. Hamilton, MD; Michael E. Berend, MD; Jason M. Hurst, MD; Lawrence D. Dorr, MD; Richard A. Berger, MD; and Giles R. Scuderi, MD.

The authors’ disclosure information, including potential conflicts of interest, can be viewed at www.aaos.org/disclosure

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org

Bottom Line

• Outpatient TJA is becoming increasingly popular.
• When deciding between an inpatient and outpatient TJA procedure, the patient is the first priority.
• Surgical efficiency trumps surgical approach and implant type in the outpatient setting.
• Smooth workflow and an experienced OR team are also critical to success.