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Outpatient total and unicompartmental knee replacement possible, study finds
New developments in anesthesia and rehabilitation allow patients to go home on the day of surgery.
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Outpatient knee replacement has been made possible with the advent of newer anesthetics and rehabilitation protocols but some concerns – such as readmission and ER visits – still exist, according to a recently presented study.
“The length of stay with knee replacement, whether it is uni or totals, has clearly decreased in the last few decades,” Richard A. Berger, MD, said at the American Academy of Orthopaedic Surgeons annual meeting.
“In fact, 6 years ago we started doing outpatient total knee and unicompartmental knee arthroplasty … though these were on highly selective patients. The questions were: Can outpatient knee replacement be done safely in unselected patients? If so, what problems would occur?”
94% discharged on same day
Berger’s study assessed the feasibility and perioperative complications following outpatient total knee and unicompartmental knee arthroplasty (UKA).
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To accomplish the goal of outpatient total knee arthroplasty (TKA), a minimally invasive surgical technique, improved perioperative anesthesia and an expedited rehabilitation protocol were developed.
The study looked at 121 consecutive patients who had primary knee replacement completed by noon, with 10 patients refusing participation. The remaining 111 – 25 UKA and 86 TKA – followed a comprehensive perioperative clinical pathway, including education, regional anesthesia, preemptive oral analgesia, preemptive antiemetics and a rapid rehabilitation protocol.
Of the 111 patients, 104 (94%) were discharged on the day of the surgery. Four readmissions and one ER visit without readmission occurred within the first week following surgery. In the first month following surgery, four additional readmissions and one additional ER visit without readmission occurred. All readmissions were in the immediate perioperative period, according to the study, and in patients who had undergone primary TKA.
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Images: Berger RA |
Outpatient TKA possible
Berger said the lack of impact certain factors had on the results of the study was surprising.
“Ninety-four percent of the patients were able to go home the day of surgery,” he said. “Surprisingly, this was not related to age, weight, gender or BMI.”
Although there are unaccounted issues involving an immediate or delayed need for additional medical care, Berger said the results are impressive and may even improve with more stringent exclusion criteria.
Multimodal procedure
Berger’s study received praise from moderator Michael A. Kelly, MD, who had several questions regarding the practice.
“We are all seeing a bit of a push for this,” he said. “How much does the MIS component of this contribute to the ability to do what you’re asking them to do?”
Berger responded that minimally invasive surgery (MIS) is only one part of the protocol.
“I think the MIS an integral part, although it is not the only feature by any means,” he said. “It is multimodal, and it involves every department in your hospital from admitting all the way down to your discharge planner and everything in between.”
For more information:Reference:
- Richard A. Berger, MD, can be reached at One Westbrook Corporate Center, Suite 240, Westchester, Illinois 60154; 708-236-2600; e-mail: r.a.berger@sbcglobal.net. He receives royalties from Zimmer; is a consultant to Zimmer and TissueLink; and receives research or institutional support from Wright Medical, Zimmer, and Smith & Nephew.
- Berger RA, Sanders S, Thill ES, et al. Problems from allowing knee replacement to be discharged the day of surgery. Paper #283. Presented at the 2009 Annual Meeting of the American Academy of Orthopaedic Surgeons. February 25-28. Las Vegas.