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264
V. K. Alamanda and B. D. Springer
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23.1 Introduction
23.1.1 Scope oftheProblem—
Periprosthetic Joint Infections
Total joint arthroplasties represent some of the most
commonly performed surgeries in the United States.
However, periprosthetic joint infection (PJI) is a signicant problem associated with increased morbidity and
healthcare costs. The incidence of PJI after primary
total hip and knee replacements has been reported in the
literature to range from 0.5% to up to 2% (Bozic and
Ries 2005; Sculco 1993).
PJI has a signicant impact on the patient, the sur-
geon, and the healthcare system (Bozic and Ries 2005).
> The economic burden of PJI is expected to be in
excess of 1.62 billion $ by the year 2020 (Kurtz etal.
2012).
This is crucial to address as current estimates project
large increases in demand for total hip (growth of 174%
by 2030) and knee arthroplasties (growth of 673% by
2030) (Kurtz etal. 2007). Similar trends are also anticipated with revision arthroplasty surgery.
23.1.2 Modiable Versus Non-modiable
Risk Factors
It is imperative to appropriately recognize risk factor
variables as modiable versus non-modiable. While
the scope of this chapter is limited to identifying and
acting on modiable risk factors to improve rates of
PJI, non- modiable risk factors have also been recognized to affect rates of PJI.Specically, revision surgery
and non-same day surgery, i.e., surgery performed
>24h after admission, have been identied as negatively
affecting rates of PJI by Maoz etal. (2015). While it is
important to recognize, these risk factors are unfortunately beyond the control of the surgeon and their
patients.
23.1.3 Currently Available Guidelines
onSurgical Site Infections
The Centers for Disease Control and Prevention (CDC)
provided new guidelines that have important updates
and recommendations for the prevention of surgical site
infections(SSI). These include guidelines from the use of
antiseptic soap the night before surgery to maintaining
appropriate oxygenation and glycemic control in the
perioperative period (Berrios-Torres et al. 2017).
However, as noted by Parvizi etal., the lack of evidence
in many of the areas prevents it from being a comprehensive guide (Parvizi etal. 2017).
Thus, it is essential that we attempt to further understand and minimize the risk factors that can affect rates
of PJI.In this review, the effects of both patient as well
as perioperative modiable risk factors that can affect
PJI are analyzed.
23.2 Patient-Modiable Risk Factors
andCurrent Evidence
23.2.1 Diabetes
Diabetes and poor glycemic control have not only been
associated with increased risk of surgical site infection
in a variety of procedures but are also negatively implicated in PJI in multiple studies. Analysis of these studies
has shown diabetes to increase the odds ratio by 2.28
times in one of the largest series (Marchant Jr. et al.
2009).
Hemoglobin A1c (Hgb A1c) has been regularly used
as a prognostic indicator of long-term glycemic control
in patients and may take 3months to reect signicant
changes. Patients with good glycemic control should
ideally have Hgb A1C levels <7.0. Hgb A1c, a simple
test, has frequently been used as a routine screening test
which allows the provider to gain insight into the
patient’s glycemic control over the past 3 months
(Stryker etal. 2013).
> However, perioperative glucose levels may serve as a
better adjunct in predicting PJI as opposed to Hgb
A1c alone (Iorio et al. 2012). Additionally, other
markers such as serum fructosamine have also been
proposed to serve as an adjunct to measuring glyce-
mic control (Shohat etal. 2017).
The stress due to surgery results in an increased production of hormones antagonizing insulin and predisposes
patients to hyperglycemia. Thus, it is important that
perioperative glycemic control be strictly enforced. Surgical stress-related postoperative hyperglycemia, even in
patients without a diagnosis of diabetes, can increase the
risk of developing surgical site infection in a dose-related
manner.
> Thus, the authors recommend that blood glucose lev-
els be maintained between 110 and 180mg/dL (opti-
mal cutoff of around137 mg/dL) (Kheir etal. 2018) in
the perioperative period through frequent blood
sugar checks and initiation of diabetic management
protocols postoperatively (Gallagher etal. 2017).
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23.2.2 Obesity
Obesity has been correlated with higher rates of osteoarthritis and eventual increased use of arthroplasty
(Workgroup of the American Association of H, Knee
Surgeons Evidence Based C 2013). Studies have shown
that patient satisfaction and functional improvement in the
obese patient population is similar to the nonobese group;
however, obese patients are at higher risk of postoperative
complications, specically PJI (Mason etal. 2014).
Obesity predisposes patients to increased surgical dissections needed for exposure which results in higher surgical times. The poor vascularity of adipose tissue further
compounds this problem. The consensus opinion from
the workgroup of the American Association of Hip and
Knee Surgeons (AAHKS) evidence-based committee
emphasized delaying total joint arthroplasty in a patient
with a BMI >40, especially when associated with other
comorbid conditions such as poorly controlled diabetes
or malnutrition (Workgroup of the American Association
of H, Knee Surgeons Evidence Based C 2013).
Furthermore, a small minority of obese patients may
develop metabolic syndrome. This is composed of a
cluster of conditions arising from insulin resistance that
impairs normal leukocyte function. It is dened as hav-
2
ing a BMI >30kg/m
with central obesity, as well as two
of the following conditions: hyperlipidemia, hyperglyceridemia, hypertension, or diabetes (Gage etal. 2014).
Zmistowski etal. have shown an increased risk of PJI
(14.3% vs. 0.8%) in patients with uncontrolled metabolic
syndrome compared to patients with controlled disease/
the healthy cohort (Zmistowski etal. 2013).
> Patients with obesity should be screened for other
characteristics that may dene metabolic syndrome.
ferrin level of <200 mg/dL. Of these, preoperative
albumin has been found to be highly specic with a
high positive predictive value for PJI (Blevins etal.
2018).
Patients with preoperative malnutrition should be
encouraged to work with a dietician to help improve
their nutritional intake and help prepare them for the
catabolic demands required in the postsurgical period.
23.2.4 Smoking
Smoking, and its principal ingredient, nicotine, has been
associated with decreased oxygen delivery to tissues secondary to microvascular constriction. Duchman et al.
reported an increased risk of wound complications with
both current and former smokers in a large national
database study. Specically, they found current smokers
to have higher rates of wound complications than former smokers as it pertains to PJI (Duchman etal. 2015).
The deleterious effects, in particular PJI, seen with
smoking have also been conrmed by multiple other
studies (Teng etal. 2015).
> Studies have shown that smoking cessation programs
may help decrease complications associated with the
use of nicotine, even if introduced as late as just
4weeks before surgery (Lindstrom etal. 2008).
Thus, the authors recommend that patients undergoing
total joint arthroplasty have a minimum period of
4 weeks of smoking cessation prior to their surgery.
Smoking cessation can be conrmed via easily available
laboratory tests such as the serum cotinine assay (normal value of ≤10μg/L).
23.2.3 Malnutrition
A frequently unrecognized aspect of obesity involves
malnutrition and is associated with high caloric but
nutritionally poor diets.
> Malnutrition was found to be present in 42.9% of
obese patients in a prospective study evaluating the
role of malnutrition in total joint arthroplasty
patients (Huang etal. 2013).
Laboratory tests are easily available and can help to
identify patients at risk for malnutrition.
> These include a total lymphocyte count of <1500
cells/mm
3
, a serum albumin of <3.5g/dL, or a trans-
23.2.5 Vitamin D
Vitamin D has long been identied as playing a crucial
role in bone health. Vitamin D deciency, as dened by a
serum 25-hydroxyvitamin D concentration≤20ng/mL,
is unfortunately prevalent in the population of the United
States with an overall reported rate of 41.6% (Forrest
and Stuhldreher 2011). Studies have shown patients with
PJI to have low levels of Vitamin D.Animal models have
also demonstrated that reversal of Vitamin D deciency
can help improve rates of PJI (Hegde etal. 2017).
> Thus, the authors recommend that Vitamin D levels
be obtained preoperatively and if decient, i.e.,<
20ng/mL, supplementation be instituted.
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V. K. Alamanda and B. D. Springer
23.2.6 Staphylococcus Aureus Screening
Nasal swab rapid polymerase chain reaction has allowed
physicians to identify patients who are colonized with
methicillin-resistant Staphylococcus aureus (MRSA).
This helps eliminate the bacteria from the patient’s nasal
ora prior to surgery. Implementation of an institutionwide prescreening program allows for the identication
of the carrier status of S. aureus among patients; this
can then lead to a signicant reduction in postoperative
rates of surgical site infections (Kim etal. 2010).
It is the authors‘recommendation that patients
undergoing elective total joint arthroplasty undergo
screening for S. aureus through nasal swabs.
> The authors recommend that patients undergo appli-
cation of mupirocin nasal ointment twice daily to
both nares and a daily bath with chlorhexidine for
5days immediately prior to the scheduled surgery if
the nasal swab testing is positive.
> Additionally, patients screened positive for MRSA
should also receive a single dose of vancomycin along
with standard perioperative antibiotics during their
surgery.
disease-modifying antirheumatic medications
(DMARDS) do not need to be withheld prior to surgery.
> However, immunomodulating agents such as TNFα
inhibitors place patients at an increased risk for the
development of PJI and should be withheld one dosing cycle prior to surgery.
23.2.8 Urinary Tract Infections
A common type of nosocomial infection, urinary tract
infections (UTI), creates a reservoir of pathogens and
potentially increases patient morbidity during surgical
intervention. The role of UTI in the development of
PJI, however, remains controversial. Some authors have
noted the development of PJI in patients with UTI
(David and Vrahas 2000) while others have shown no
association between UTI and PJI (Koulouvaris et al.
2009).
> It is the authors’ recommendation that if the patient
has symptoms of UTI such as dysuria, urgency, and
frequency and has >1 × 10
(CFU)/mL of urine, surgery should be postponed.
5
colony forming units
23
23.2.7 Inammatory Arthropathies
Patients aficted with inammatory arthropathies such
as rheumatoid arthritis and lupus are at increased risk
of postoperative infection. Multiple systematic reviews
have validated the correlation between inammatory
arthropathies and periprosthetic infection. Pooled studies such as that by Kong etal. have shown that rheumatoid arthritis can increase the odds of PJI by 1.57 (Kong
etal. 2017).
Many of these patients are on multiple-drug regimens that may include immunomodulators. These medications often have signicant effects on wound healing
and infections. For example, tumor necrosis factor alpha
(TNFα) inhibitors are frequently used as a powerful
agent in the management of these diseases. However, by
modulating the immune system, they place patients at
signicant risk for developing infections. Momohara
et al. reported that patients on TNFα inhibitors were
found to be at higher risk for surgical site infections
(Momohara etal. 2011).
Guidelines jointly published by the American
College of Rheumatology (ACR) and the American
Association of Hip and Knee Surgeons (AAHKS) used
available evidence to make recommendations on which
medications should be continued and which medications should be stopped in elective total joint arthroplasty (Goodman et al. 2017). In general, traditional
> However, if the patient is asymptomatic but has
5
1×10
or more CFU/mL of urine, the authors recommend not withholding surgery and treating his
UTI with a routine course of postoperative oral antibiotics.
23.2.9 Poor Oral Health
Total joint replacement patients tend to have good dental hygiene in general (Wood etal. 2016). However, there
is not a lot of literature on the role of preoperative
screening as well as the association between poor dental
hygiene and PJI. Recent studies have questioned the
need to obtain routine preoperative dental screening for
hip and knee arthroplasty patients (Lampley etal. 2014).
> In general, the authors recommend a common-sense
approach—patients should have a dental exam and
clearance if they have evidence of decayed teeth,
abscess, gingivitis, or periodontitis and should have
routine cleanings done prior to surgical intervention.
23.2.10 Antibiotic Prophylaxis
Preoperative antibiotic prophylaxis is effective in reducing rates of surgical site infections and has been incor-
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porated in many surgical checklists (Fernandez et al.
2001). Routine prophylactic antibiotics should be dosed
in accordance with the patient’s weight and should
include a rst-generation cephalosporin such as cefazolin. Patients allergic to β-lactam antibiotics should
receive vancomycin or clindamycin in a timely fashion.
Prophylactic antibiotics should ideally be administered
as close to the time of the incision as possible.
> First-generation cephalosporin and clindamycin
should be administered within 1 h and vancomycin
within 2h of incision.
> The authors recommend that a single dose of vanco-
mycin be considered in addition to standard preoperative antibiotics for those who have been shown to be
colonized with MRSA or those who had a prior infection with MRSA.
23.3 Conclusion
The well-known saying, a stitch in time saves nine, is certainly applicable to PJI.Targeting modiable risk factors in the preoperative setting can help alter the risk
prole for PJI postoperatively. While enacting on these
variables may not completely eliminate the risk of PJI, it
can certainly help improve the odds.
Take-Home Messages
5 Periprosthetic joint infections pose high morbid-
ity; however, modiable risk factors can be optimized preoperatively to decrease risks.
5 Diabetic patients should have their glycemic con-
trol optimized preoperatively, and frequent blood
sugar checks and diabetic management protocols
should be implemented postoperatively.
5 Consideration should be given to delaying total
joint arthroplasty in patients with a BMI >40,
especially when associated with other comorbid
conditions such as poorly controlled diabetes or
malnutrition.
5 Patients undergoing total joint arthroplasty should
have a minimum period of 4 weeks of smoking
cessation prior to their surgery.
5 Strict antibiotic prophylaxis should be adhered to
including the use of rst- generation cephalosporins such as cefazolin. Patients with true allergies
to cefazolin should receive vancomycin or
clindamycin in a timely fashion.
Disclosure The authors have no funding sources and no
conicts of interest to report for this study.
References
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M et al (2017) 2017 American College of Rheumatology/
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Huang R, Greenky M, Kerr GJ, Austin MS, Parvizi J (2013) The
effect of malnutrition on patients undergoing elective joint
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Iorio R, Williams KM, Marcantonio AJ, Specht LM, Tilzey JF,
Healy WL (2012) Diabetes mellitus, hemoglobin A1C, and the
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27(5):726–729. e1
Kheir MM, Tan TL, Kheir M, Maltenfort MG, Chen AF (2018)
Postoperative blood glucose levels predict infection after total
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Kim DH, Spencer M, Davidson SM, Li L, Shaw JD, Gulczynski D
etal (2010) Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients
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23
Outpatient Total Knee
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Arthroplasty
JoshuaA.Greenspoon, CharlesP.Hannon, andCraigDellaValle
Contents
24.1 Introduction – 270
24.2 Outpatient Total Knee Arthroplasty – 270
24.3 Clinical Outcomes – 272
24.4 Conclusion – 272
References – 273
269
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© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
E. Hansen, K.-D. Kühn (eds.), Essentials of Cemented Knee Arthroplasty,
https://doi.org/10.1007/978-3-662-63113-3_24
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24.1 Introduction
There has been an increased interest in performing total
joint arthroplasty (TJA) in the outpatient setting over
the past decade (Berger et al. 2009; Kelly et al. 2018;
Kolisek etal. 2009; Meneghini and Ziemba-Davis 2017;
Springer et al. 2017). Advances in surgical technique
and pain management protocols have allowed for many
surgical cases to be safely and successfully performed in
the outpatient setting. Surgeons have been motivated to
perform procedures in an outpatient setting by several
factors including the ability to control more aspects of
patient care and the surgical environment, increased
patient satisfaction, and potential economic savings for
the patient and the healthcare system (Meneghini etal.
2018). As outpatient procedures have become more
prevalent, there is also a growing patient demand for
outpatient TJA.In order to achieve optimal patient outcomes and safety, a multidisciplinary approach led by
the surgeon must be utilized to create an outpatient TJA
program.
24.2 Outpatient Total Knee Arthroplasty
The American Association of Hip and Knee Surgeons
(AAHKS) released a consensus statement identifying
the following elements as key to successfully performing
outpatient TJA:
5 Patient selection
5 Patient education
5 Social support system
5 Clinical and surgical expertise
5 Evidence-based protocols for perioperative manage-
ment (Meneghini etal. 2018)
> Patient selection from both a medical and a social
perspective is key to safely and effectively perform
joint replacement surgery in the outpatient setting.
The patient as a whole is considered with regard to the
following:
5 Past medical history
5 Age
5 Body mass index (BMI)
5 Physical tness
5 Mental capacity
5 Social support system
5 Environmental factors
Scoring systems such as the outpatient arthroplasty risk
assessment (OARA) score or American Society of Anesthesiologists (ASA) can be utilized (Ziemba-Davis etal.
2019). The complexity of the surgical case is also evalu-
ated and outpatient surgery is typically reserved for
straightforward procedures that do not require extended
operative times or complex equipment. Ultimately, the
decision to perform surgery as an inpatient or an outpatient is a shared decision between patient and surgeon.
In general, patients selected for outpatient total joint
replacements tend to be healthier, younger, and more
physically t. The authors do not employ an absolute
cut-off for age or BMI.
> Particular attention is paid to cardiac history, history
of anticoagulation, sleep apnea, prior prostate surgery or history of urinary retention, and preoperative
narcotic use.
History of prostate surgery or urinary retention can
pose a challenge with discharge after surgery due to the
inability to void and preoperative narcotic use raises
concerns about the ability to effectively control pain
after surgery (Meneghini etal. 2018). All patients are
required to see an internist for preoperative medical
evaluation and clearance prior to surgery. If there are
any modiable risk factors, these are optimized prior to
surgical intervention. There is a low threshold to indicate a patient for inpatient total joint replacement if
concerns exist.
> As part of patient selection, the patient’s social situa-
tion is carefully evaluated. This includes type of residence, presence of stairs in the house, location of
bedrooms, and presence of a family member/caregiver that can assist in the postoperative setting.
Patients who must be able to go up several ights of
stairs to get into their home or to their bedroom within
the home may need additional physical therapy and thus
may be better suited for an inpatient procedure. Detailed
preoperative teaching is performed with both the patient
and caregiver in either a group or individual setting. The
teaching includes setting expectations for the day of surgery and postoperatively, outpatient-specic issues
including transportation after surgery, and perioperative pain management.
A strong working relationship with anesthesia col-
leagues is needed to design and implement an appropriate multimodal analgesic regimen. Our current pain
protocol is outlined in .
Table 24.1. In multimodal
anesthesia and analgesia, multiple analgesic medications are delivered in different routes and timing that
synergistically and additively target different aspects of
the pain pathway. Multimodal analgesia has been associated with better pain control, rapid recovery, and
shorter hospitalizations after surgery (Golladay et al.
2017; Kehlet and Dahl 1993).
24
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24
. Table 24.1 Multimodal analgesia protocol at our
institution
Preoperative 1. Acetaminophen (Tylenol) 1000mg PO
2. Celecoxib (Celebrex) 400mg PO
3. Pregabalin (Lyrica) 100mg PO
Intraoperative 1.
Postoperative 1.
> Multimodal analgesia starts before surgery with pre-
emptive analgesia to blunt the sensitization of the
peripheral and central nervous system from tissue
injury induced during surgery (Kissin 2000).
Periarticular injection (PAI) consisting
of ropivicaine 300mg, epinephrine
0.2mg, ketorolac 30mg, clonidine 100
mcg
2. Acetaminophen (Ormev) 1g IV
3. Ketorolac (Toradol) 15mg IV
4. Dexamethasone (Decadron) 10mg IV
Acetaminophen (Tylenol) 1g PO every
8hours scheduled
2. Celecoxib (Celebrex) 200mg PO every
12hours scheduled
3. Gabapentin (Neurontin) 200mg PO
every 8hours
4.
Tramadol (Ultram) 100mg PO every
6hours scheduled
5. Oxycodone (OxyIR) 5mg PO every
4hours as needed
We conducted a prospective randomized controlled
trial evaluating the quantity of opioid pills prescribed
after surgery and found that patients who received 30
oxycodone pills as opposed to 90 oxycodone pills had
signicantly fewer leftover pills (15 versus 73) (Hannon
2019). In addition, patients who received 30 oxy-
etal.
codone pills were associated with taking fewer oxycodone pills.
> Today, all patients including inpatient and outpatient
patients receive 30 oxycodone immediate release pills
upon discharge.
Clinical and surgical expertise including preoperative
planning is required to be successful in an outpatient
setting. Ambulatory surgery centers have inherent limitations with respect to inventory and sterile processing
capabilities relative to the hospital. Therefore, it is crucial to plan cases and communicate effectively with your
vendor and surgery center to ensure the necessary equipment is ready and available on the day of surgery. Strict
discharge criteria must be met prior to discharge including the following:
5 Hemodynamic stability
5 Ability to tolerate oral uids
5 Adequate pain control with oral pain medications
5 Voiding without difculty, and
5 Safe ambulation and clearance from physical
therapy
We utilize a spinal anesthetic and adductor canal block,
which have been shown to lead to improved ambulation
and pain control compared to an epidural alone (Kayupov etal. 2018).
> For many of our outpatient TKAs, we use a general
anesthetic to avoid any lower extremity weakness and
reduce the risk of urinary retention (Kayupov etal.
2018).
Intraoperatively, we administer a periarticular injection,
which provides pain relief and reduces opioid consumption after TJA (Ma et al. 2019). We also administer
intravenous acetaminophen, ketorolac, and dexamethasone intraoperatively (Murata-Ooiwa etal. 2017; Tammachote and Kanitnate 2020). Postoperatively, we use a
multimodal analgesic program to minimize the use of
opioids. Acetaminophen, celecoxib, and gabapentin are
given as scheduled medications and tramadol is the rst
breakthrough pain medication. Oxycodone immediate
release is the last resort breakthrough pain medication.
After discharge, we historically prescribed 90–120 opioid pills, however, reevaluated this quantity, given the
need to reduce overprescribing.
> If a patient fails to meet these criteria, pathways must
be in place to escalate care appropriately to an
overnight-
care suite or facility.
In our practice, a team meeting is held every week to
review cases and radiographs for the following week to
ensure that all members of the clinical team are on the
same page and aware of all the details pertaining to the
patients and surgeries for the upcoming week.
In a traditional hospital setting, there is a large
network of individuals participating in perioperative
patient care and education including social workers,
physicians, nurses, nursing aides, physical and occupational therapists, dieticians, and other medical
providers.
> When performing TJA in the outpatient setting the
responsibility of perioperative care is placed onto the
family and surgeon (Shah etal. 2019).
When comparing the time and encounters between
patients that underwent outpatient to inpatient surgeries, Shah etal. found that each patient undergoing out-
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J. A. Greenspoon et al.
patient surgery required an additional 48.4minutes of
staff time to prepare for surgery and care for in the rst
7days postoperatively (Shah etal. 2019).
> Surgeons starting to perform outpatient total joints
should anticipate the additional resources required to
care for patients and ensure that the team is adequately staffed to do so.
In our practice, a phone call is made from the attending
surgeon to the patient in the evening after surgery as well
as the following morning to check in with the patient and
address additional questions, concerns, or problems.
Physician extenders are utilized and readily available to
answer and address concerns that arise in the postoperative period. An extensive effort is made to encourage
patients to contact our ofce initially with any questions
or issues that arise in the immediate postoperative
period, as opposed to presenting to the emergency
department or seeking the advice of their primary care
provider. We have a very low threshold to bring patients
into the clinic in the postoperative period for further
evaluation.
24.3 Clinical Outcomes
department visits, readmission rates, or unplanned
clinic visits.
> The authors concluded that in the appropriate patient
population, outpatient TJA had no difference in out-
comes with regard to complications compared to the
traditional inpatient hospital setting (Darrith et al.
2019).
Patient satisfaction has been a focus in evaluating
healthcare delivery with the Centers for Medicare and
Medicaid services starting to tie nancial reimbursement to high-quality care. Kelly et al. investigated
patient satisfaction in the inpatient and outpatient TJA
population using specic questions from the Hospital
Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and a satisfaction scale of 0–10
(Kelly etal. 2018). Overall satisfaction scores were similarly high in the outpatient (9.7/10) and inpatient group
(9.5/10) (Kelly et al. 2018). However, outpatient TJA
patients were more satised with courtesy and respect
from nurses, assistance getting to bathroom or bedpan,
assistance with pain management, staff explanation of
medications received, and information concerning
symptoms or health problems upon discharge (Kelly
etal. 2018).
24
Several studies have been published recently pertaining
to cost, safety, and clinical outcomes, with a general
consensus that outpatient arthroplasty can be performed
safely and in a cost-effective manner in the appropriately
selected patient (Courtney et al. 2018; Darrith et al.
2019; Huang etal. 2017; Kelly etal. 2018; Lovald etal.
2014)
> Potential decreases in cost on a per-case basis result
from decreased stafng needs, decreased resource utilization, and increased efciency in the outpatient setting as compared to the traditional hospital setting
(Huang etal. 2017).
Savings have been reported up to $8500 or 30% per case
for a primary total knee arthroplasty (Huang etal. 2017;
Lovald etal. 2014).
A matched single-surgeon cohort analysis consisting
of 486 primary arthroplasties performed in either an
inpatient or outpatient setting was investigated looking
at complications between the two groups in the rst
90days postoperatively (Darrith etal. 2019); 243 consecutive patients who underwent outpatient total joint
replacements were matched to similar patients in the
inpatient setting with respect to gender, age, ASA score,
and BMI.Results demonstrated that there were no statistically signicant differences in rates of major complications, minor complications, reoperations, emergency
24.4 Conclusion
Outpatient TJA can successfully be performed if careful
attention is paid to patient selection and establishing a
care pathway focusing on pain management, patient
education, and evidence-based protocols for perioperative management. Performing surgery in the outpatient
setting has the potential to increase patient satisfaction
without compromising the quality of patient care and
patient safety.
Take-Home Messages
5 Outpatient total joint arthroplasty can be
safely performed in the properly selected
patient in both a freestanding ambulatory
surgery center or in a hospital setting.
5 Special attention must be given to patient
selection and education for outpatient procedures.
5 A multidisciplinary effort between surgeon,
clinical staff, patient, caregiver, physical
therapy, and anesthesia is required to
achieve optimal outcomes.
5 Outpatient arthroplasty has the potential to
increase patient and surgeon satisfaction.
Outpatient Total Knee Arthroplasty
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24
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