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Future of THA, TKA likely to include discharge on the day of surgery
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In most Scandinavian orthopaedic clinics, the length of stay after total hip and total knee arthroplasty has been reduced significantly in the last decade. At my institution, Vejle Hospital, in Vejle, Denmark, the length of stay after these procedures has decreased from about 10 days in 2001 to an average of 2.3 days in 2014. This includes all types of primary and revision cases, acute neck fractures treated with total hip arthroplasty, and surgery in old and young patients. The only exceptions are revisions done for deep infection.
The main reason such a dramatic reduction in length of stay (LOS) was possible is the introduction of a rapid recovery program led by a multidisciplinary team. The focus for our team has been on what is needed to further reduce the LOS. Key considerations are drugs for multimodal pain management, detailed preoperative information provided to the patients and hospital staff, and early mobilization.
Same-day surgery
As an outgrowth of the success we have had with this new approach to total hip arthroplasty (THA) and total knee arthroplasty (TKA), the question has been raised as to what is needed to change the LOS so discharge is possible on the day of surgery for THA and TKA patients. During the past few years, younger patients have requested the opportunity to leave the clinic on the day of surgery. We planned those cases to be done first in the morning, to have the patient mobilized before lunchtime and then fully mobilized by the early evening, so the patient left the clinic about 6:00 p.m. However, to date, we have not devised a detailed set-up to handle many more such cases.
Other clinics in Europe now promote discharge on the day of surgery for THA and TKA. Therefore, we should study this area to document the safety of the strategy and define its best candidates, or who is not an ideal candidate for same-day total joint reconstruction and why. I am concerned that surgeons may strive to send patients home on the day of surgery to minimize costs within the department and have the room ready for a new patient next morning, but without the proper evidence. Therefore, before we are possibly pushed by hospitals to adopt day-surgery for THA and TKA, we should know who the real candidates are and the associated risks.
At-home care
We have already started examining these criteria at our institution by assessing several patients who may be potential candidates for same-day surgery, noting when they actually leave the clinic and, in particular, documenting why they were not discharged the day of surgery. Our first impression is that, although several patients seemed to be suitable candidates, the majority still cannot leave the hospital on the same day. Interestingly, this was mainly due to reasons other than pain — the obstacle we thought would present the biggest challenge. We found it was more risky to send patients home the day of surgery when they had no relatives to take care of them at home and when they were missing some information that should be on-hand when admitted for surgery.
THA and TKA day-surgery will eventually have a place in our clinics in the future, but we still need to learn who the real candidates are.
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- Per Kjaersgaard-Andersen, MD, is Chief Medical Editor of Orthopaedics Today Europe. He can be reached at Orthopaedics Today Europe, 6900 Grove Rd., Thorofare, NJ 08086, USA; email: orthopaedics@healio.com.
Disclosure: Kjaersgaard-Andersen reports no relevant financial disclosures.