By Adrian T. Baddar, MD, FAAOS
Over the past two years, the COVID-19 pandemic has accelerated a movement to offer more total joint replacement surgeries on an outpatient basis.
More patients are out of bed and walk only about an hour after hip or knee arthroplasty thanks to less invasive operative techniques, improved surgical equipment, and highly effective multimodal pain control methods. Many can safely go home within four hours.
It isn’t unusual now for an orthopaedic surgeon to perform 80 or even 90 percent of their total joint replacements as same-day procedures, whether in an ambulatory surgery center or hospital.
Avoiding overnight hospital stays significantly reduces the risk of exposure to infectious pathogens, including COVID-19. Patients also can recover more comfortably in familiar settings and enter physical therapy almost immediately.
Each case requires a thorough evaluation of a patient’s health, motivation and support from family and friends. Typically, the best candidates for outpatient surgery are younger than 70, non-smoking and without serious comorbidities such as heart disease, COPD or obesity.
To be clear, this change never means rushing a patient to go home. Instead, strict discharge criteria require that pain be well controlled, that a patient is not at significant fall risk, and that they will receive attentive care during the early days of healing.
All post-operative patients must demonstrate an ability to get out of bed and move around safely themselves, typically with assistance from a walker. Those with stairs at home also must be able to navigate those under their own power.
The shift to outpatient settings results from a dramatic evolution in multimodal analgesia during the past five years. Rather than rely on general anesthesia and narcotics, most surgeons today use powerful combinations of non-opioid regional and local medications.
Preoperative patients typically receive acetaminophen or nonsteroidal anti-inflammatories to begin blunting pain. Surgeons then can utilize peripheral nerve blocks and periarticular injections in and around the joint, including numbing agents that last up to 72 hours.
The goal is for patients to go home alert and in minimal discomfort, even in the case of total knee replacements.
Not all patients are outpatient candidates, of course. People who are older, frailer, in poorer health or lacking a proper home environment for recovery will continue to benefit from a one- or two-day hospital stay and perhaps a period in a rehabilitation center.
Yet, given that today’s joint replacements require much smaller incisions and less tissue dissection and blood loss, even patients with certain chronic conditions – such as well-controlled high blood pressure or diabetes – could still qualify for same-day surgery.
In our practice, outpatient arthroplasty has proven to be safe, cost-effective and beneficial to many patients’ physical and emotional health. This option also places less burden on hospitals, which has been particularly valuable during this unpredictable pandemic.
I expect joint replacement procedures and pain medications will only become more sophisticated in the future – and, therefore, this trend will continue.
Dr. Baddar is a fellowship-trained orthopaedic surgeon with Hampton Roads Orthopaedics Spine & Sports Medicine, based in Newport News. hrosm.com