Abstract
The duration of hospitalization and subsequent length of recovery after elective knee arthroplasty have decreased. We hypothesized same-day discharge following either a unicompartmental (UKA) or total knee arthroplasty (TKA) in an unselected group of patients would not result in a higher perioperative complication rate than standard-length hospitalization when following a comprehensive perioperative clinical pathway, including preoperative teaching, regional anesthesia, preemptive oral analgesia, preemptive antiemetics, and a rapid rehabilitation protocol. We prospectively followed 111 of all 121 patients who had primary knee arthroplasty completed by noon and who agreed to be followed prospectively; 25 had UKA and 86 TKA. Of the 111 patients, 104 (94%, 24 with UKA and 80 with TKA) met discharge criteria and were discharged directly to home the day of surgery. Nausea requiring additional treatment before discharge was the most common reason for a delay in discharge. There were four (3.6%) readmissions (all with TKA) and one emergency room visit without readmission (in a patient with a TKA) within the first week after surgery, while there were four subsequent readmissions (3.6%) and one additional emergency room visit without readmission within three months of surgery, all among patients undergoing TKA. There were no deaths, cardiac events, or pulmonary complications during this study. Outpatient knee arthroplasty surgery is feasible in a large percentage of patients yet early readmissions may be decreased with a prolonged hospitalization.
Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.
Each author certifies that our institution has approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research, and that informed consent was obtained.
Appendix 1 [4]
Appendix 1 [4]
Pre-op
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Internist appointment for medical clearance
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Teaching Class
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Go through risks and benefits of surgery
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Explain rapid discharge protocol
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Session of physical therapy
Morning of surgery
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Celebrex 400 mg orally
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OxyContin 10 mg orally
Intra-op
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Epidural anesthesia with Fentanyl 5mcg/cc and Marcaine 0.1%
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Preventative measures for side effects include:
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Reglan 10 mg
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Zofran 4 mg
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Pepcid 20 mg
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Toradol 30 mg
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Twilight sedation with Propofol drip titrated to mcg/kg (per body weight)
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Local infiltration of surgical area with Marcaine 0.25% (per body weight)
Post-op
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Give post-op dose of OxyContin as soon as patient is in PAR
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10 mg for patients over 70 years old
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20 mg for patients under 70 years old
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Patients are given a fluid bolus of 500 cc of Lactated Ringers
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Remove epidural—2 hours after surgery
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Change surgical dressing and remove drains—3 hours after surgery
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Physical therapy session with WBAT—4 hours after surgery
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Discharge patient, if medically stable, comfortable on oral analgesia, and patient agrees
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Berger, R.A., Kusuma, S.K., Sanders, S.A. et al. The Feasibility and Perioperative Complications of Outpatient Knee Arthroplasty. Clin Orthop Relat Res 467, 1443–1449 (2009). https://doi.org/10.1007/s11999-009-0736-7
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DOI: https://doi.org/10.1007/s11999-009-0736-7