Outpatient Total Knee Arthroplasty With a Minimally Invasive Technique

ArticleinThe Journal of Arthroplasty 20(7 Suppl 3):33-8 · November 2005with34 Reads
DOI: 10.1016/j.arth.2005.05.021 · Source: PubMed
Abstract
Fifty consecutive patients were enrolled in this prospective study. This was 37% of the 135 patients undergoing primary total knee arthroplasty (TKA) by one surgeon. The average patient age was 68 years (50-79 years). A comprehensive perioperative management pathway was developed and was implemented, which combined regional anesthesia with a minimally invasive, TKA technique in which the only incision in the capsule and extensor mechanism is a capsular incision from the joint line to the superior pole of the patella. Postoperatively, patients received oral analgesia. After specific discharge criteria were met, 48 patients (96%) chose to go home the day of surgery. No intraoperative complications occurred. There were 3 readmissions, none related to early discharge: gastrointestinal bleed at 8 days, superficial irrigation and debridement at 21 days, and a closed manipulation at 9 weeks. This study demonstrates that, in these selected patients, outpatient TKA was safe with no short-term readmission or complications related to early discharge. This comprehensive pathway may make it possible for this minimally invasive TKA to be done as an outpatient in specialized surgicenters in the future.
    • "Additionally, the difference may reflect an increased amount of pain when patients go home and have potentially increased activity as compared with an overnight stay in a hospital bed. Several investigators [1][2][3][4][5] 8] have written about pathways for the success of early-discharge THA and TKA and more recently [5, 8] have published on prospective evaluations of patients undergoing outpatient THA. Adult reconstructive surgeons nationally have adopted clinical pathways similar to those published by this group for inpatient THA as an evolution of the management of these patients undergoing elective surgery. "
    [Show abstract] [Hide abstract] ABSTRACT: Background Length of stay after total hip arthroplasty (THA) has decreased over the last two decades. However, published studies that have examined same-day and early discharge protocols after THA have been done in highly selected patient groups operated on by senior surgeons in a nonrandomized fashion without control subjects. Questions/purposes The purpose of this study was to evaluate and compare patients undergoing THA who are discharged on the same day as the surgery (“outpatient,” less than 12-hour stay) with those who are discharged after an overnight hospital stay (“inpatient”) with regard to the following outcomes: (1) postoperative pain; (2) perioperative complications and healthcare provider visits (readmission, emergency department or physician office); and (3) relative work effort for the surgeon’s office staff. Methods A prospective, randomized study was conducted at two high-volume adult reconstruction centers between July 2014 and September 2015. Patients who were younger than 75 years of age at surgery, who could ambulate without a walker, who were not on chronic opioids, and whose body mass index was less than 40 kg/m2 were invited to participate. All patients had a primary THA performed by the direct anterior approach with spinal anesthesia at a hospital facility. Study data were evaluated using an intention-to-treat analysis. A total of 220 patients participated, of whom 112 were randomized to the outpatient group and 108 were randomized to the inpatient group. Of the 112 patients randomized to outpatient surgery, 85 (76%) were discharged as planned. Of the remaining 27 patients, 26 were discharged after one night in the hospital and one was discharged after two nights. Of the 108 patients randomized to inpatient surgery with an overnight hospital stay, 81 (75%) were discharged as planned. Of the remaining 27 patients, 18 met the discharge criteria on the day of their surgery and elected to leave the same day, whereas nine patients stayed two or more nights. Results On the day of surgery, there was no difference in visual analog scale (VAS) pain among patients who were randomized to discharge on the same day and those who were randomized to remain in the hospital overnight (outpatient 2.8 ± 2.5, inpatient 3.3 ± 2.3, mean difference −0.5, 95% confidence interval [CI], −1.1 to 0.1, p = 0.12). On the first day after surgery, outpatients had higher VAS pain (at home) than inpatients (3.7 ± 2.3 versus 2.8 ± 2.1, mean difference 0.9, 95% CI, 0.3–1.5, p = 0.005). With the numbers available, there was no difference in the number of reoperations, hospital readmissions without reoperation, emergency department visits without hospital readmission, or acute office visits. At 4-week followup, there was no difference in the number of phone calls and emails with the surgeon’s office (outpatient: 2.4 ± 1.9, inpatient: 2.4 ± 2.2, mean difference 0, 95% CI, −0.5 to 0.6, p = 0.94). Conclusions Outpatient THA can be implemented in a defined patient population without requiring additional work for the surgeon’s office. Because 24% (27 of 112) of patients planning to have outpatient surgery were not able to be discharged the same day, facilities to accommodate an overnight stay should be available. Level of Evidence Level I, therapeutic study.
    Full-text · Article · Jun 2016
    • "However, the risk of pain after 1 year postoperative was significantly higher [28]. Protocols for OJA should focus on adequate analgesia and prevention for PONV [5, 10, 11, 15, 27, 30]. Some papers excluded patients with DM (type I and II) [16, 26]. "
    [Show abstract] [Hide abstract] ABSTRACT: Purpose General consensus of patient selection criteria for outpatient joint arthroplasty is lacking, which is paramount to prevent prolonged hospital stay, adverse events and/or readmissions. This review highlights patient selection criteria for OJA based on the current literature and expert opinion. Methods A search of the English and International electronic healthcare databases including MEDLINE/PubMed, EMBASE, AMED and the Cochrane library was performed in November 2015 to include studies published during the last 10 years. Furthermore, a survey of physicians from different specialties was performed. Results Fourteen studies described results regarding outpatient joint arthroplasty. Studies on outpatient hip and/or knee arthroplasty resulted in similar outcome in preselected patients. Patients who are able and willing to participate, with a low ASA classification (<III), undergoing primary arthroplasty, age <75 and with support at home during the first postoperative days are eligible candidates for outpatient joint arthroplasty. Patients with a high ASA classification (>II), bleeding disorders, poorly controlled and/or severe cardiac (e.g. heart failure, arrhythmia) or pulmonary (e.g. embolism, respiratory failure) comorbidities, uncontrolled DM (type I or II), a high BMI (>30 m2/kg), chronic opioid consumption, functional neurological impairments, dependent functional status, chronic/end-stage renal disease and/or reduced preoperative cognitive capacity should be excluded from outpatient joint arthroplasty. The expert opinion-based selection criteria were comparable to literature with a further extension of exclusion for patients with practical issue’s, urologic medical history and/or severe mobility disorders. Conclusion Based on the current literature, the presented patient selection criteria provide a basis for outpatient joint arthroplasty and can be useful when selecting patients. Together with a change in mindset, a multidisciplinary approach and literature-based protocols, outpatient joint arthroplasty can be applied in daily orthopaedic practice while ensuring patients’ safety. Level of evidence Clinical review, Level III.
    Full-text · Article · Apr 2016
    • "More complications <1 week postoperatively were seen after TKA rather than UKA during the outpatient procedure [4]. Previous series published by Berger et al. [5] showed fewer complications for outpatient TKA, in which they used more stringent inclusion criteria. Recently, Lovald et al. [24] concluded that preexisting comorbidities and particularly heart failure are major risk factors for AEs after outpatient and short-stay TKA. "
    [Show abstract] [Hide abstract] ABSTRACT: There has been increasing interest in accelerated programs for knee arthroplasty. We examined the efficacy and safety of an outpatient surgery (OS) pathway in patients undergoing unicompartmental knee arthroplasty (UKA). This case-controlled study evaluates patients operated for UKA in an OS pathway (n = 20) compared to rapid recovery (RR), the current standard (n = 20). We investigated whether patients could be discharged on the day of surgery, resulting in comparable or better outcome by means of adverse events (AEs) in terms of pain (numerical rating scale, NRS), incidences of postoperative nausea and vomiting (PONV) and opiate use (<48 h postoperatively), complication and readmission rates (<3 months postoperatively). Patient-reported outcome measures (PROMS) were obtained preoperatively and 3 months postoperatively. Postoperative pain (NRS > 5) was the most common reason for prolonged hospital stay in the OS pathway. Eighty-five per cent of the patients were discharged on the day of surgery, whereas 95 % of the patients were discharged on postoperative day 3 in the RR pathway. Overall, median pain scores in both pathways did not exceed a NRS score of 5, without significant differences (RR vs. OS) in the number of patients with PONV (4 vs. 2) and opiate use (11 vs. 9) <48 h postoperatively. At 3 months postoperatively, no significant differences were found for AEs and PROMS between both pathways. The results of this study illustrates that an OS pathway for UKA is effective and safe with acceptable clinical outcome. Well-established and adequate standardized protocols, inclusion and exclusion criteria and a change in mindset for both the patient and the multidisciplinary team are the key factors for the implementation of an OS pathway. Case-control study, Level III.
    Full-text · Article · Jul 2015
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