Outpatient Lower Extremity Total Joint Arthroplasty: Where Are We Heading?

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Outpatient Lower Extremity Total Joint
Arthroplasty: Where Are We Heading?
Samik Banerjee, MBBS, MS (Orth), MRCS (Glasg); William G. Hamilton, MD; Harpal S. Khanuja, MD;
Jared T. Roberts, MD
By the end of 2050, the incidences of hip and knee arthroplasties
performed in the United States are projected to be more than
1.8 million and 4 million, respectively.1 In 2014 alone, more than
1 million elective lower extremity arthroplasties were performed,
with collective per procedure expenditures ranging from $16,500
to $75,000. This disbursement covered surgery, hospitalization,
and rehabilitative services.2 As the demand for hip and knee arthro-
plasties continues to escalate, orthopedic surgeons and hospital ad-
ministrators are striving to provide cost-effective improvements in
patient care.3-7 Given the large volume of total joint replacements,
even modest reductions in costs will translate into substantial sav-
ings in health care expenditures.
With the introduction of the Bundled Payments for Care Im-
provement initiative by the Centers for Medicare & Medicaid Ser-
vices, providers receive single payments for each procedure cover-
ing all costs related to acute hospital stay, the preoperative period,
and the period up to 90 days postoperatively. As per this initiative,
payments provided to hospitals are based on their previous year’s
benchmark. Going forward, hospitals will receive bonuses for re-
ducing average costs by 2% and penalties for failing to meet aver-
age costs. Thus, cost reductions are essential in health care organi-
zations.8
Major expenses associated with lower extremity total joint ar-
throplasties are affected by implant costs, in-hospital length of stay,
perioperative complications, readmissions, and discharge to reha-
bilitative services.9 In an effort to minimize costs and improve effi-
ciency, orthopedic surgeons have focused on reducing length of stay
and inpatient rehabilitation services. This has led to the evolution of
outpatient surgery. With advancements such as less invasive surgical
procedures, strategies to prevent blood loss, improved perioperative
pain control, and rapid rehabilitation protocols, outpatient hip and
knee arthroplasties have become a reality.10-12
In the past, some authors loosely used the term “out-
patient total joint arthroplasty” to encompass discharge within
23 hours of surgery.13 However, we believe that, when patients
stay overnight, this should be called short-stay surgery or expe-
dited recovery and that the term outpatient surgery should be re-
served for patients discharged home the same day as surgery.
Surgeons have used a variety of approaches—strict patient selec-
tion, preoperative counseling, preemptive analgesia with anti-
emetics, multimodal perioperative analgesic protocols that include
adductor canal peripheral nerve blocks, wound infiltration with lo-
cal anesthetics, less invasive surgical techniques, blood management
with tranexamic acid, and completion of surgery by mid-morning or
early afternoon—to enhance postoperative recovery, permit adjust-
ment of medications, and allow timely discharge.10,11,14,15 Despite
the appeal of outpatient arthroplasty, outcomes must be analyzed
prior to its universal implementation in this era of cost reduction and
savings and delivery of quality health care.
Patient Selection
Currently, most orthopedic surgeons believe that identifying
low-risk populations through strict criteria for eligibility will poten-
tially lead to increased patient satisfaction, increased rates of same-
day discharge, and decreased rates of complications. Although there
are no universally accepted selection criteria, the following have
The authors are from the Department of Orthopaedic Surgery (SB, JTR),
Albany Medical Center, Albany, New York; the Anderson Orthopaedic Re-
search Institute (WGH), Alexandria, Virginia; and the Department of Or-
thopaedic Surgery (HSK), Johns Hopkins University, Baltimore, Maryland.
Drs Banerjee, Khanuja, and Roberts have no relevant financial relation-
ships to disclose. Dr Hamilton is a paid consultant for DePuy and Total Joint
Orthopedics; is on the speaker’s bureau of DePuy; receives research support
from Biomet, Inova Health Care Services, and DePuy; and receives royalties
from DePuy and Total Joint Orthopedics.
Correspondence should be addressed to: Samik Banerjee, MBBS, MS
(Orth), MRCS (Glasg), Department of Orthopaedic Surgery, Albany Medi-
cal Center, 43 New Scotland Ave, Albany, NY 12208 (bashb02@gmail.com).
doi: 10.3928/01477447-20170302-02