Outpatient Total Joint Arthroplasty: A Comprehensive Review of Feasibility and Safety in Carefully Selected Patients

Total joint arthroplasty (TJA) has traditionally been performed as an inpatient procedure, requiring patients to stay in the hospital for several days after surgery. However, the projected increase in primary total hip arthroplasty (THA) by 71% to 635,000 procedures and primary total knee arthroplasty (TKA) by 85% to 1.26 million procedures by 2030 in the USA 1 highlights the growing importance of outpatient procedures. Advances in surgical techniques, anesthesia, and pain management have made it possible for some patients to undergo TJA on an outpatient basis, allowing them to return home the same day as their surgery. This comprehensive review assesses the feasibility and safety of outpatient TJA in carefully selected patients, discussing patient selection criteria, perioperative protocols, and post-discharge care strategies.

Patient Selection Criteria

Appropriate patient selection is crucial to the success of outpatient TJA. The surgeon's judgment, considering the patient's entire medical and social history, is ultimately crucial in determining candidacy for outpatient TJA 2. Several factors must be considered when determining whether a patient is a suitable candidate for this approach. These factors include:

  1. Age: While advanced age itself is not a contraindication for outpatient TJA 3, older patients may have an increased risk of complications 4. Younger age is generally associated with better outcomes in outpatient TJA 5.
  2. Comorbidities: Patients with certain medical conditions, such as severe heart failure, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, kidney failure, or dialysis, may be at increased risk for complications and require close monitoring after surgery 3. Patients with well-controlled comorbidities may be eligible for outpatient TJA 6.
  3. Functional Status: Patients should be able to walk and move around independently without a cane or walker before surgery 3.
  4. Social Support: A strong support system is essential for safe discharge home and to ensure that patients can get to their physical therapy appointments 7. The literature has identified a strong social support system as essential for assistance (both physically and mentally) in the perioperative period, particularly the first night after discharge 8. Patients should have a family member or friend who can stay with them for the first few days after surgery to assist with meals, household chores, and transportation 9.
  5. Motivation: Patients who are motivated to recover and actively participate in their rehabilitation are more likely to have successful outcomes 7.

Factors Facilitating Outpatient TJA

Four main medical advances have made outpatient joint replacement possible 3:

  1. More effective anesthetics and pain control: Advances in regional pain control (numbing a specific part of the body) include spinal and epidural injections for hip or knee replacement, and brachial plexus injections that numb up the entire shoulder and arm area for shoulder replacement surgery. Injections of local anesthetic medications around the area of surgery (periarticular) provide longer-lasting pain relief and enable patients to use less opioid pain medication than in the past.
  2. More refined surgical techniques: Advances in surgical technique have shortened procedure times and reduced blood loss. A medication called tranexamic acid (TXA) has further reduced blood loss and made blood transfusions rare after total joint replacement surgery. These techniques have led to improved recovery after surgery.
  3. Improved pre-operative safety and patient selection: Over the many years of doing outpatient surgery, joint replacement surgeons have learned to identify which patients do well with outpatient surgery, and which patients should stay overnight at a hospital after surgery. Surgeons are therefore able to determine if patients are safe for outpatient surgery based on the patient's age, pre-existing health conditions (heart disease, lung disease, kidney disease, etc.), and home environment, including social support.
  4. More focused physical therapy (PT) and occupational therapy (OT) within hours of surgery: Over the past decade, more focused PT and OT has become the standard of care for hip, knee, and shoulder replacement patients. Study after study has shown that getting patients out of bed and walking around the same day, and in many cases just a few hours after surgery, leads to a quicker discharge home and a better, faster recovery with fewer complications.

Guidelines and Recommendations from Professional Organizations

Professional organizations such as the American Academy of Orthopaedic Surgeons (AAOS) and the American Association of Hip and Knee Surgeons (AAHKS) provide guidelines and recommendations for outpatient TJA. These guidelines emphasize the importance of:

  1. Proper patient selection: Selecting patients who are medically and socially appropriate for outpatient procedures 3.
  2. Multimodal pain management: Utilizing a combination of pain management techniques to minimize opioid use and optimize pain control 10.
  3. Early mobilization: Encouraging early mobilization to reduce the risk of complications and enhance recovery 3.

The AAOS also highlights the importance of patient education and shared decision-making in the context of outpatient TJA 3.

Perioperative Protocols

Perioperative protocols for outpatient TJA are designed to optimize patient outcomes and minimize complications. These protocols include:

Anesthesia

Spinal anesthesia is often preferred for outpatient TJA, as it is associated with fewer postoperative complications 11. However, general anesthesia may be used in certain cases, such as when spinal anesthesia is contraindicated or the surgery is expected to be longer or involve more blood loss 12. Both spinal and general anesthesia can lead to reliable same-day discharge with similar 90-day complication rates 13. General anesthesia can facilitate faster discharge from the ambulatory surgery center (ASC) compared with bupivacaine spinal anesthesia but may lead to higher levels of pain and incidence of nausea postoperatively 13.

Pain Management

Multimodal pain management strategies are used to minimize opioid use and provide adequate pain control 14. This may include a combination of non-opioid analgesics, regional anesthesia techniques (such as nerve blocks), and local infiltration analgesia 3. Optimal pain management for outpatient TJA requires a balance between adequate pain control and avoiding excessive sedation or muscle weakness 11.

Early Mobilization

Early mobilization is a cornerstone of outpatient TJA, as it helps to reduce the risk of complications such as deep vein thrombosis, pulmonary embolism, and pneumonia 15. Patients are typically encouraged to get out of bed and walk around within a few hours of surgery 16.

ERAS protocols recommend six core principles for managing outpatient TJA 17:

  1. Patient and family engagement
  2. Surgical best practices
  3. Multimodal opioid-sparing pain management
  4. Mobility and physical activity
  5. Fluid management
  6. Nutrition management

Post-Discharge Care Strategies

Post-discharge care strategies for outpatient TJA focus on ensuring a safe and comfortable recovery at home. These strategies include:

Physical Therapy

Outpatient physical therapy is typically recommended after surgery to help patients regain strength, range of motion, and functional mobility 18.

Monitoring for Complications

Patients are closely monitored for complications after discharge, and they are provided with instructions on when to contact their healthcare provider 19.

Discharge Criteria

Specific criteria must be met for discharge on the day of surgery, including:

  1. Steady gait with crutches
  2. No dizziness during mobilization
  3. Ability to use stairs, if required by the patient's home environment 20

Pain Management Strategies

Effective pain management is essential for successful outpatient TJA. A multimodal approach is typically used, which may include:

  1. Oral pain medications
  2. Non-opioid analgesics (e.g., acetaminophen, NSAIDs)
  3. Regional anesthesia techniques (e.g., nerve blocks)
  4. Local infiltration analgesia 21

Risks and Benefits of Outpatient TJA

Outpatient TJA offers several potential benefits compared to traditional inpatient procedures, including:

  1. Reduced risk of infection: Outpatient surgery centers typically have lower rates of hospital-acquired infections compared to hospitals 22.
  2. Faster recovery: Patients who undergo outpatient TJA may recover more quickly and return to their normal activities sooner 23.
  3. Increased patient satisfaction: Patients often report higher satisfaction with outpatient TJA due to the comfort of recovering at home and the reduced risk of complications 3.
  4. Lower costs: Outpatient TJA can be less expensive than inpatient procedures due to the shorter length of stay and reduced use of hospital resources 22. One study reported that outpatient TKA reduced costs by US$8,527 compared with patients admitted to the hospital for 3–4 days 25.

However, outpatient TJA also carries some potential risks, including:

  1. Increased risk of complications in certain patients: Patients with certain medical conditions or those who lack adequate social support may be at increased risk of complications after outpatient TJA 26. One study found an overall complication rate of 8% in outpatient TJA compared to 16% in inpatient TJA 27. Another study demonstrated a higher risk of perioperative surgical and medical outcomes in outpatient TKA than inpatient TKA, including component failure, surgical site infection, knee stiffness, and deep vein thrombosis 28. This study found a 5.8% failure to launch rate, where patients scheduled for same-day discharge could not be discharged 28.
  2. Need for careful patient selection: Not all patients are suitable candidates for outpatient TJA, and careful patient selection is essential to minimize risks 3.

Long-Term Outcomes

Studies have shown that long-term outcomes of outpatient TJA are comparable to those of traditional inpatient procedures in carefully selected patients 25. Patients who undergo outpatient TJA can expect similar improvements in pain, function, and quality of life 29.

Outpatient TJA Facilities

Outpatient TJA can be performed in two main types of facilities 3:

  1. Hospital operating rooms: Historically, most total joint replacements have been performed in hospital operating rooms.
  2. Ambulatory surgery centers (ASCs): ASCs are facilities specifically designed for outpatient surgery. Some ASCs are housed within hospitals but function independently, while others are free-standing facilities.

Both types of facilities have advantages and disadvantages, and patients are often better suited to one location or the other.

Conclusion

Outpatient TJA is a feasible and safe option for carefully selected patients. By adhering to strict patient selection criteria, implementing comprehensive perioperative protocols, and providing effective post-discharge care, surgeons can optimize patient outcomes and minimize complications. Outpatient TJA offers several potential benefits compared to traditional inpatient procedures, including a reduced risk of infection, faster recovery, increased patient satisfaction, and lower costs. While outpatient TJA is increasing in popularity, there are still questions about optimal patient selection and the best approach to same-day surgery 30. The results of a recent review suggest that outpatient or inpatient pathway selection for hip or knee arthroplasty should not be based on the superiority of functional outcomes alone 31. As the healthcare system continues to evolve, outpatient TJA is likely to become an increasingly popular option for patients seeking joint replacement surgery.

Works cited

1. Early mobilization after total hip or knee arthroplasty: a substudy of the POWER.2 study - SciELO, accessed February 17, 2025, https://www.scielo.br/j/bja/a/8dZkvLhHX8qC8NHQqYcZkZH/?format=pdf&lang=en

2. Recommended Patient- Selection Criteria for Procedures Performed in an Ambulatory Surgical Center (ASC) - California Orthopaedic Association, accessed February 17, 2025, https://www.coa.org/docs/WhitePapers/COA_Final.pdf

3. Outpatient Total Joint Replacement - OrthoInfo - AAOS, accessed February 17, 2025, https://orthoinfo.aaos.org/en/treatment/outpatient-joint-replacement-surgery/

4. Trends in Outpatient Total Knee Arthroplasty From 2012 to 2020 - PubMed, accessed February 17, 2025, https://pubmed.ncbi.nlm.nih.gov/37011701/

5. Can You Be Too Old For a Hip or Knee Replacement? - University Hospitals, accessed February 17, 2025, https://www.uhhospitals.org/blog/articles/2021/11/can-you-be-too-old-for-a-hip-or-knee-replacement

6. The outpatient total hip arthroplasty : a paradigm change - PubMed, accessed February 17, 2025, https://pubmed.ncbi.nlm.nih.gov/29292337/

7. Outpatient Joint Replacement - AAHKS, accessed February 17, 2025, https://www.aahks.org/position-statements/outpatient-joint-replacement/

8. Management of patients undergoing same-day discharge primary total hip and knee arthroplasty - PMC - PubMed Central, accessed February 17, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC6957327/

9. Outpatient Total Joint Replacement Surgery - South Shore Health, accessed February 17, 2025, https://www.southshorehealth.org/services-care/orthopedics/outpatient-total-joint-replacement-surgery

10. Clinical Practice Guidelines - AAHKS, accessed February 17, 2025, https://www.aahks.org/clinical-practice-guidelines/

11. Current Trends and Future Directions for Outpatient Total Joint Arthroplasty: A Review of the Anesthesia Choices and Analgesic Options - PubMed Central, accessed February 17, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC10481314/

12. Joint Replacement Anesthesia - Penn Medicine, accessed February 17, 2025, https://www.pennmedicine.org/for-patients-and-visitors/find-a-program-or-service/anesthesiology-and-critical-care/anesthesia-care-what-to-expect/joint-replacement-anesthesia

13. Spinal Versus General Anesthesia for Outpatient Total Hip and Knee Arthroplasty in the Ambulatory Surgery Center: A Matched-Cohort Study - PubMed, accessed February 17, 2025, https://pubmed.ncbi.nlm.nih.gov/38103803/

14. Pain management after total knee arthroplasty: PROcedure SPEcific Postoperative Pain ManagemenT recommendations - PMC, accessed February 17, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC9891300/

15. Early mobilization after total hip or knee arthroplasty: a substudy of the POWER.2 study, accessed February 17, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC9801188/

16. Set Measure ID: THKR-OP-2 - The Joint Commission, accessed February 17, 2025, https://manual.jointcommission.org/releases/TJC2025A/MIF0373.html

17. Clinical Pathway for Inpatient and Outpatient Hip and Knee Arthroplasty - Healthcare Excellence Canada, accessed February 17, 2025, https://www.healthcareexcellence.ca/media/k0mbozhc/erc_clinicalpathway_arthro_july2021_en.pdf

18. What to Expect with Outpatient Total Joint Replacement - OrthoVirginia, accessed February 17, 2025, https://www.orthovirginia.com/blog/what-to-expect-with-outpatient-total-joint-replace/

19. Outpatient Joints — Hip & Knee Book, accessed February 17, 2025, https://hipandkneebook.com/outpatient-joints

20. Study protocol for discharge on day of surgery after hip and knee arthroplasty from the Center for Fast-track Hip and Knee Replacement, accessed February 17, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC10028556/

21. Outpatient Total Joint Replacement: What You Need to Know - OrthoVirginia, accessed February 17, 2025, https://www.orthovirginia.com/blog/outpatient-total-joint-replacement-what-you-need/

22. Total Joint Replacement Without a Hospital - OrthoVirginia, accessed February 17, 2025, https://www.orthovirginia.com/blog/indications-and-advantages-of-outpatient-total-joi/

23. The Benefits of Outpatient Knee Replacement - Nathan Hammel, MD, accessed February 17, 2025, https://www.nathanhammelmd.com/blog/the-benefits-of-outpatient-knee-replacement-37226.html

24. Outpatient Total Joint Arthroplasty - PMC - PubMed Central, accessed February 17, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC5685972/

25. Outpatient total knee arthroplasty: is it worth considering? - PMC, accessed February 17, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC7144893/

26. Outpatient Total Joint Replacement: Is It Right For You? - OrthoVirginia, accessed February 17, 2025, https://www.orthovirginia.com/blog/outpatient-total-joint-replacement-is-it-right-for-you/

27. Complications Following Outpatient Total Joint Arthroplasty: An Analysis of a National Database - PubMed, accessed February 17, 2025, https://pubmed.ncbi.nlm.nih.gov/28034481/

28. Outpatient Total Joint Arthroplasty at a High-Volume Academic Center: An Analysis of Failure to Launch - PubMed, accessed February 17, 2025, https://pubmed.ncbi.nlm.nih.gov/38246314/

29. Assessment of Patient Satisfaction and Outcomes After Outpatient Joint Arthroplasty in Academic Medical Centers, accessed February 17, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC10776316/

30. Should Outpatient Hip and Knee Replacements Be Commonplace? - InventUM, accessed February 17, 2025, https://news.med.miami.edu/should-outpatient-hip-and-knee-replacements-be-commonplace/

31. A comparison of functional outcomes following inpatient versus outpatient hip or knee arthroplasty - PMC, accessed February 17, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC9344712/