Search

The COVID-19 pandemic has had a drastic effect on the landscape of outpatient joint arthroplasty. By accelerating the migration to ambulatory surgery centers and hospital outpatient departments, protocols and techniques had to adapt quickly. In addition, the roles of technology and partnering with industry became more appealing in some cases to address specific voids and needs during this transition period. The COVID-19 pandemic abruptly affected the state of outpatient joint arthroplasty in 2020 with long-lasting effects that will continue to shape the practice of outpatient total joint arthroplasty for years to come.

Total knee arthroplasty is considered one of the most successful surgeries of modern medicine. While surgical outcomes have improved patient quality of life, the procedure has historically been associated with high levels of post-operative pain, disability, and a long hospital stay. Surgical technique, improved recovery protocols, and anesthesia changes have led to dramatic improvements in the recovery phase. This, in combination with financial pressures, has led to many of these patients now being discharged home the same day of surgery. While this can be accomplished in either the hospital or ambulatory surgery center (ASC) setting, there are potential advantages in the ASC with regards to cost, resource demand, and the patient experience. This article will explore specific topics related to the new trend of outpatient total knee arthroplasty.

The anterior approach (AA) for total hip arthroplasty (THA) is associated with more rapid recovery when compared to traditional approaches. The purpose of this study was to benchmark healthcare resource utilization and costs for patients with THA via AA relative to matched patients.This study queried Medicare claims data (2012-2014) to identify patients who received THA via an AA from experienced surgeons, and matched these patients to a control cohort (all THA approaches). Direct and propensity-score matching were employed to maximize similarity between patients and hospitals in the two cohorts. Hospital length of stay (LOS), the proportion of patients discharged to home or home health, and post-acute claim payments during the 90-day episode were assessed. Generalized estimating equations were applied to control for imbalances between the cohorts and clustering of outcomes within hospitals.A total of 1,794 patients were included after patient matching. Patients who received AA had significantly lower mean hospital LOS vs patients in the control group (2.06 ± 1.36 vs 2.98 ± 1.58 days, p .0001). The adjusted proportion of patients discharged to home was nearly 20 percentage points higher in the AA cohort vs the control cohort (87.3% vs 68.7%, p .0001). Post-acute claim payments for AA patients were nearly 50% lower than those for control patients ($4,139 vs $7,465, p .0001).AA patients had significantly lower post-acute care resource use when compared to control patients. Further research is warranted to evaluate the cost effectiveness of AA among surgeons of varying experience levels.

Joint arthroplasty is increasingly being performed in ambulatory surgery centers (ASCs). Enabled by enhanced recovery protocols and multimodal pain management, and incentivized by the implementation of value-based payment models, this trend is projected to continue, with more than half of total joint replacements predicted to be outpatient by 2026.

Background The study objective is to analyze subjects having a normal hip and compare in vivo kinematics to subjects before and after receiving a total hip arthroplasty. Methods Twenty subjects, 10 with a normal hip and 10 with a preoperative, degenerative hip were analyzed performing normal walking on level ground while under fluoroscopic surveillance. Seven preoperative subjects returned after receiving a total hip arthroplasty using the anterior surgical approach by a single surgeon. Using 3-dimensional to 2-dimensional registration techniques, joint models were overlayed on fluoroscopic images to obtain transformation matrices in the image space. From these images, displacements of the femoral head and acetabulum centers were computed, as well as changes in contact patches between the 2 surfaces throughout the gait cycle. Results Implanted hips experienced the least amount of separation, compression, and overall sliding throughout the entire gait cycle, but they did show signs of edge loading contact patterns. Conversely, the degenerative hips experienced the most compression, sliding, and separation, with the maximum amount of sliding being 6.9 mm. The normal group ranged in the middle, with the maximum amount of sliding being 1.75 mm. Conclusion Current analysis revealed trends that degenerative hips experience more abnormal hip kinematics that leads to higher articulating surface forces and stresses within the acetabulum. None of the implanted hips experienced hip separation.

The performance of joint arthroplasty in an outpatient setting is expected to rise significantly over the coming decade, with predictions that greater than half of all primary joint arthroplasties will be performed in an outpatient setting by the year 2026. Financial pressures, bundled payment models, and improved understanding of patient recovery have led to discharging patients home the same day as the index procedure. Arthroplasty surgeons are starting to utilize ambulatory surgery centers (ASCs) to perform these outpatient arthroplasty procedures. Our duty as arthroplasty surgeons continues to be to protect our patients' overall care and safety during this transition from a traditional hospital model. Appreciating that postoperative treatment, disposition, physical space, and sterile processing department capabilities are different from traditional hospital models is paramount to success in an ASC. Differences between hospital and ASC models place additional staffing, financial pressure, and time pressure on the arthroplasty surgeon to select and prepare patients before surgery. Adequately preparing patients involves medical optimization, setting patient and family expectations, identifying appropriate caregivers, and establishing effective communication tools after surgery. It is imperative to develop protocols to deal with predictable discharge delays that include blood pressure, oversedation, postoperative urinary retention, postoperative nausea and/or vomiting, pain, and social issues. These protocols are best first developed in a hospital setting where they can be implemented and changed before starting in an ASC. Arthroplasty surgeons will continue to protect patients by developing protocols and preparing patients appropriately for care in an ASC.