Can total joint replacements be done safely as an outpatient?
In recent years, orthopedic surgeons and outpatient facilities have both been advocating to provide outpatient Total Joint Replacements (TJRs) for patients who qualify. This saves on costs for both the patient and their insurance company, and is also a significant money-maker for outpatient facilities. Is it truly better for the patient, though? This is a growing trend around the country and one that has recently begun with an outpatient facility, The Orthopedic Surgery Center (OSC), that DPI Anesthesia has provided services for in Baton Rouge, Louisiana over the last 14 years. Let’s explore the patient qualifications, advantages and a specific protocol that we have been using successfully thus far.
The first and most important step in starting an outpatient TJR protocol is having strict criteria for patient selection. At OSC, our patients have:
- a BMI <40
- an ASA classification of 1 or 2
- are less than 65 years old.
The patients are screened at multiple pre-op visits to make sure they are motivated to do this procedure as an outpatient procedure and understand that we use an opioid-sparing technique. A chronic opioid user would not do well in this situation, as well as older and sicker patients with little family support. As you would expect, a compliant and motivated patient will minimize their potential complications by following the instructions laid out for them ahead of time. Proper patient selection is a major factor in good outcomes after TJRs.
What are the advantages to the patient having an outpatient TJR? One of the main advantages is largely alleviating the possibility of a hospital acquired infection; bacterial, viral, and fungal infections can result in blood stream infections, UTIs, pneumonias and surgical site infections. Having surgery and then being discharged to home within five to eight total hours greatly diminishes the chances of any of these happening due to exposure at the facility. The next advantage to having an outpatient TJR is enhanced recovery. By the time of discharge, the patient has already been to physical therapy and is developing a recovery routine that can help minimize the likelihood of a frozen joint, a situation that is not uncommon after a Total Knee Replacement. As an outpatient center, we focus on very minimal opioid use during and after the operation, as we feel that a less groggy patient is a more compliant patient and is better able to have early participation in their physical therapy routine.
Finally, what kind of protocol is required to do a successful opioid-sparing outpatient TJR? At OSC, we have found the following protocol to result in good outcomes:
- Start the night before surgery with 1000mg of Tylenol at bedtime.
- Prior to arrival in the morning, have the patient drink Gatorade until 2 hours prior to surgery. We have found that this reduces our incidence of nausea during the procedure.
- On arrival, we give 1000mg of Tylenol PO, 20mg of Pepcid IV, 200mg of Celebrex PO and Gabapentin 600mg PO. We perform an adductor canal block and IPACK block (infiltration between the popliteal artery and capsule of the knee) with 2mg of Versed IV.
- The patient is then brought to the OR for a spinal in which we use 12mg of bupivacaine.
- Once the spinal is placed and sets up, we run a propofol drip and work in a total of 30mg of IV ketamine throughout the procedure. We also give 10mg of IV Decadron once the patient is sedated and we give Zofran 4mg IV prior to heading to the PACU.
- In PACU, we try to avoid opioids if possible and once the spinal has worn off, we send the patient to our in-house PT service. Once PT is completed, we discharge them to home. Our last Total Knee Replacement was discharged from our facility at 11:40 a.m. We entered the OR at 7:00 a.m. for spinal placement and they were on the way home less than 5 hours later.
In summary, outpatient TJRs are becoming much more common across the U.S. and are being done more cost-effectively, with better patient safety and with a great chance for an improved outcome due to quicker access to physical therapy, as well as less likelihood for hospital acquired infection. The patient that participates in this procedure will be far less likely to become a chronic opioid user as well due to a thorough opioid-sparing technique. It is safe and has proven to be very effective for appropriate candidates.