---
title: 'Outpatient Joint Replacement in 2020'
type: 'lecture'
url: 'https://doc.social/lectures/outpatient-joint-replacement-in-2020'
published: '2020-12-06'
author: 'Cory Calendine, MD'
specialty: 'Orthopaedic Surgery'
topics: 'outpatient joint replacement, Outpatient, Hip Replacement, Pain, Knee Replacement'
transcript: 'yes'
---

# Outpatient Joint Replacement in 2020

## Summary

Honest assessment of why and how to safely utilize outpatient joint replacement focusing on the US experience. Detailed description of our multimodal pain pathway is included. (originally presented for the 65th Annual Meeting (virtual) of the Colombian Society of Orthopaedic Surgery and Traumatology, December 2020)

## Transcript

4,605 words · 27 min · 3 speakers · automatically transcribed (aws-transcribe) and not checked by a person; it may contain errors, particularly in names, drugs and dosages. The recording is the source.

[0:00] Speaker 1: Tell us your program of ambulatory Surgery. What are your results and what would you recommend to us in that field. Go ahead, doctor.
[0:10] Speaker 1: Thank you, uh, so much. And, uh, I, I don't know how many were able to join in the first session, but I have found this, uh, intellectual exchange, uh, excellent. The talks have been, uh, simply brilliant, and I'm, I'm, I'm truly honored and appreciate so much, uh, Doctor Bonilla, uh, inviting me and, and, and allowing me to participate in your program.
[0:32] Speaker 1: Uh, I, we are set to take 30 minutes to talk about Outpatient joint replacement. I would love and welcome this to be uh more of an exchange. Maybe I'll flip through some slides over the next, uh, 15 minutes or so, maybe 20. Then hopefully our panelists and our participants, we can open it up for a lively discussion.
[0:52] Speaker 1: You know, um, Outpatient joint replacement has really grown in the United States. We're gonna talk about a few reasons why. I wish so much we were together, uh, to facilitate this.
[1:03] Speaker 2: Doctor
[1:04] Speaker 2: Calline and the Bone and Joint Clinic in Tennessee here in Franklin. I've been, uh, I got a partial Knee Replacement 6 hours ago, and I'm walking.
[1:14] Speaker 2: I was walking when I got home, so it's like.
[1:17] Speaker 2: 2 hours of Surgery of a partial Knee Replacement. So, well done. These guys are great. You need a joint, go see Doctor C. That's the way to do
[1:28] Speaker 2: it.
[1:30] Speaker 1: So here in Tennessee, we do get to take care of a lot of musicians. This is one gentleman that we did a partial kneeon. He posts this on Social Media. You know how the world is today and he's doing uh quite well even hours uh after his procedure. So I am a paid consultant for Stryker. I'm an equity partner in an ASC. We'll talk about those terms, uh, and what they mean here in the US, the Ambulatory Surgery Center, and I sit on the editorial board for several orthopedic, uh, um, uh, journals here in the US.
[2:00] Speaker 1: Maybe further and pertinent to this topic is that I'm a US guy and I think that taints really how we Approach several of these problems, certainly Outpatient Surgery. Uh, I was born in South Carolina, raised in Naples, Florida, really schooled here in Tennessee where I still live. Uh, I, I went to UT Memphis and then ultimately Vanderbilt University for Orthopedics. But really my, my Joint replacement training came in Virginia under these two guys. You guys probably
[2:29] Speaker 1: I know these, uh, uh, individuals, Charlie and Jerry, Jerry Eng, and they have really, uh, shaped my philosophies about a lot of this. The reality is the length of stay, uh, varies greatly, uh, certainly by country if you look at some of the worldwide statistics, but even within the United States, it varies greatly, as does the surgical Approach. We had a great discussion last hour about some of the different approaches and, and advantages and disadvantages to both. And so.
[2:59] Speaker 1: I would tell you that there's a lot of variation. I don't want to imply that what we're about to reveal is normal here in the United States. In fact, if you look in the US, the average length of stay in 1987 was 3 weeks, which seems, uh, incredible now, the way we think about things. In 2002, again, our national statistics would say, would say it was about 4 days, and then there began some interest in trying to
[3:27] Speaker 1: Reduce the length of stay. So in 2013, you see on the screen 2.7 days. But we have these large databases of Health data and, and, and, and that's what this is, the, the Pearl diver database. And what they showed is 97% of Joint replacement is done connected to Inpatient stay. So, the, uh, most people are still staying in the hospital, but there has been this rapid growth of Outpatient, um, uh, or
[3:55] Speaker 1: At least the attempted Outpatient joint replacement. So there's been a 47% increase over just this three-year window, 2012 to 2015. Uh, the prediction is there'll be another 77% increase over the next 10 years, and by 2026, which, you know, I don't know how COVID is gonna change this, but by 2026, it's projected that over half of the joint replacements here in the US will be done as an Outpatient, um, uh, uh venture.
[4:25] Speaker 1: Now, the trend does not exist only in the United States. The trend, uh, is, is in many locations. This is a paper out of Denmark that tried to explore the feasibility of doing Outpatient Hip and Knee replacement. In their particular study, about 54% of them were considered eligible, um, uh, but.
[4:46] Speaker 1: Only 15% were discharged and so they looked at what are some of those causes for failed discharge and they found a, a, a female gender and Surgery late in the day, which kind of makes sense. They don't have time to get them comfortable and leave. This is an article from Chili. Uh, they, they, they looked and it had actually a pretty high success. 95% went, went home same day.
[5:08] Speaker 1: But a couple of dislocations, couple of, uh, one revision, one DVT. This is that same Denmark study. They looked back at that population and said, what are those elements, and I wanna talk a lot, uh, today about what are those elements in our program that have been successful. They found high-dose steroids and, and, and avoiding narcotics was really important to a same-day discharge, and I'll tell you exactly.
[5:31] Speaker 1: How we've been able to launch our program here. But it's a good question is what is the motivation? I've already referenced that COVID has changed many things in the United States. There are more people concerned about going into the hospital. Uh, our hospitals here at varying times in the Pandemic have been overwhelmed with, uh, with, with, with COVID patients, so people want to try to keep themselves safe.
[5:53] Speaker 1: Uh, plus there's just the overall burden. There's just not the availability of the hospital given those patients. But what about patient perception? I think what you'll see here is patients are driving some of this interest. This was a questionnaire, it's actually an academic center trying to evaluate do patients want to go home same day? What is their expectation? You see here that most of them.
[6:16] Speaker 1: Uh, expected a longer stay. Only 3% thought their length of stay after Joint replacement would be less than 24 hours. Uh, you know, 20% said greater than 3 days, but really most of them thought 1 to 2 days. And I think it's a, it's a lot about patient education. You'll hear me talk about that a little bit later too, um, with regard to what the
[6:38] Speaker 1: They expect to make sure we deliver what they expect. You know, we asked the question, are you comfortable? Are you comfortable going home the same day? And you can see most people, the largest column here, the, the tallest graph, if you will, about a third of the patients weren't sure one way or the Other. There were more that were uncomfortable than comfortable. So it really is an education.
[7:00] Speaker 1: Kind of thing. I, I, I wanna define the terms of service because these may or may not be different, uh, for you, uh, in Colombia. Uh, one, a hospital, this is probably straightforward. This is our normal place that we have done Joint replacement historically. I've already mentioned this term ambulatory Surgery center. What I'm trying to denote there is it's not attached to the hospital.
[7:22] Speaker 1: Uh, it can be specialty-specific. We talked about the ASC that I'm a part of. It's all Orthopedics and only Orthopedics. And, and, and, and it could, uh, have a 23 hour stay. So you can't really stay, uh, overnight or longer than 24 hours, but you can stay that first evening and go home the next morning.
[7:41] Speaker 1: Uh, and, and there's a different cost structure. You'll hear me, uh, say a little bit about money later. There is this concept of an HOPD, so a hospital-owned Outpatient department, and that functions somewhat like an ASC, but because it's attached to the hospital, often, uh, people are more likely to stay, um, uh, overnight.
[8:01] Speaker 1: Because it's an option, whereas ASC it's uh less of an option. Ultimately, when you ask patients about safety, what they say, uh, only what, what is that 11.3% feel that ambulatory Surgery centers are in fact safer despite some statistics which I'm about to show you which uh which show the opposite. There has been some concern.
[8:24] Speaker 1: That, uh, because these ASCs have a different cost structure and can be profitable, that, uh, people are kind of gaming the system and there have been some in our, our, uh, open publications here, uh, that, that showed maybe we're rushing too fast in Outpatient.
[8:40] Speaker 1: One comment that I should make repeatedly in this talk that it, it really is part of uh uh a whole system that must be employed to make sure that this is done safely. Let's talk a little bit about patient satisfaction when we look at inpatients versus outpatients. So this particular study, less than 200 patients looking at HCAP scores, which is kind of a, a patient reported outcome, kinda how it's a satisfaction survey, uh, family and friends test and then 8 specific questions.
[9:09] Speaker 1: These groups were essentially the same. The Outpatient groups, uh, the Outpatient group was a little bit younger, a little bit lighter, slightly healthier, um, but we asked them these questions, uh, things like, uh, um, did the nurses show you respect or how easy was, uh, was it to get in and out of the facility for your family, or we, we ask these kind of general satisfaction questions and really, the, the summary is there were, there were no major differences for overall.
[9:38] Speaker 1: satisfaction and those ones that leaned one way or the Other did favor Outpatient, specifically the staff explanation, the staff assistance, and clarity of discharge planning. So what you're starting to see here is the ASC has, is a more controlled environment cause it can be specialty-specific and therefore more directly catered to the patient. I think that's what we're seeing with its growth. And when you look at those small nuances, really none of them favored an Inpatient stay.
[10:07] Speaker 1: So there, there were, there were more patients that were dissatisfied with their discharge instructions in the hospital. But again, that's more of a process issue, isn't it? uh, than, than, than the actual facility itself. So patient satisfaction in Inpatient versus Outpatient, overall satisfaction was equal. Any differences favored Outpatient.
[10:28] Speaker 1: I think it would only be responsible to talk about the financial side of this. Uh, the, the, these are dated numbers now, of course, but, uh, the financial analysis from 2016, and this is obviously just in the US, um, if 30% of the hips went from Inpatient to Outpatient, it would save $300 million in charges and $87 million in reimbursements. So, so, so we're not really talking about small amounts of.
[10:56] Speaker 1: Money. A hospital overall and in summary is more expensive than AASC so there is some financial advantages to the system as a whole. If we want to try to deliver a safe, uh, affordable care over a large population, this may very well be an option. You know, Medicare here in the US, the, our government program, uh, for, for our elderly is the number one payer of Joint replacement.
[11:23] Speaker 1: And so the decisions they make with regard to Joint replacement obviously have a dramatic effect. Medicare initially said that all Hip and Knee replacement had to be done in the hospital, but slowly, and you can see this progression that I'm about to explain, they have allowed them to go in the ASC or Outpatient uh setting. So they removed total Knee from the inpatient-only list so they could be done in those HOPD facilities and then more recently, just in January of this year.
[11:51] Speaker 1: They allowed total knees and Medicare patients to go to the ambulatory Surgery centers, so true Outpatient facilities. They're following a similar path with total Hip. Again, I would love to have a conversation here in a few minutes as I wrap up my slides, talking about how this differs in Colombia or Other countries which you may be from, um, uh, uh, versus the US because who pays, insurance issues, uh, are relevant to this, uh, this discussion.
[12:20] Speaker 1: Now ASCs do have uh physician ownership. I, uh, disclosed to you that I'm an equity partner in our ASC which we opened in February of this year. In fact, 90% of those ambulatory Surgery centers have at least partial ownership by a physician.
[12:37] Speaker 1: Why is this relevant? Well, because there's financial incentive for the physician. Uh, let's be honest, uh, it's a, it's a Business for them as well, but also it's relevant because as owners, we have control of the details within the center. And so we're able to customize that experience for the patient. Uh, so I think it's a, it's, it's a two-edged sword. Now, physician.
[12:58] Speaker 1: distributorships still remain. That's where the physicians can actually own the implant companies and things like that. We do not have that in my market. It's actually under federal scrutiny. So even though there are areas for increased revenue, I think they have to be carefully evaluated to make sure there are, uh, there are no ethical concerns with regard to optimal patient care.
[13:20] Speaker 1: Our academy supports, uh, physician-owned Physical therapy and so there's some Other financial factors around doing your patients as an Outpatient and sending them to Outpatient Surgery faster that I think are part of the discussion. But, but the real question for me is why do patients, uh, stay in
[13:37] Speaker 1: In the hospital, right? Let's just step back a little bit and say why did they stay? Well, fear and anxiety, Pain, uh, the side effects of the medications we give, narcotics and anesthesia, also blood loss. So a lot of our, our plan with treating in the Outpatient world is about.
[13:54] Speaker 1: Trying to, to, to minimize, uh, these side effects. So there are post-operative medical risks and, and, and sometimes people stay in the hospital just because that's what my mom did or that's what my, my, my family member did or my friend. So there is a level of comfort with staying uh in the hospital, but what
[14:14] Speaker 1: About outcomes. This is the largest systematic review here in the US. It's 1000 patients, 95% went home same day. Uh, again, you can see multiple papers were referenced, uh, and this systematic review essentially said failure to discharge was for those reasons, those side effect reasons, uncontrolled Pain, nausea, and hypertension.
[14:35] Speaker 1: So, uh, readmission rate was low, reoperation rate was, was low, and, and a great question, uh, in, in, in, in this study was, would you choose it again? 80% said yes in one series, 96% in the Other. This is the largest, uh, single series. This was published in 2008. Uh, this is the Barron Group out of Ohio. Again, low readmission rates, low manipulation, low medical and surgical complications. I think we've
[15:01] Speaker 1: Established in our literature it can be done safely, but again, it takes an entire system to be able to execute that carefully. Um, this is Outpatient just total hips, 3-year study of 150 hips. Uh, you can see that, uh, uh, there was a careful preoperative select selection. It's relatively healthy people with no major medical problems and mandatory preoperative education. I can't overstress that enough. In this pacer, patient, it was Anterior approach.
[15:27] Speaker 1: With fluoro and cementless implants, uh, general was used 1313 times during this study, but most cases were spinal. We'll talk about how, how we do it here in my center. One was transferred to an Inpatient facility. Remember the ASC, not directly connected to the hospital, so that there was some excessive bleeding, so they transferred him to the hospital for a transfusion. There was one intraoperative calcar Fracture, um, two deep infections.
[15:53] Speaker 1: So a deep infection of 1.3%, which, you know, would, would, would be a little bit higher than my comfort level. Uh, we try to keep that uh below 1% and one superficial infection, one evaluation for dislocation. That was not my series results but a published uh a group out of, out of Memphis which I think does show, does show safety. Uh, here, here's another paper with uh 3000 total hips and what they were doing here is looking at that hospital.
[16:20] Speaker 1: Uh, versus ASC setting. Complication rates overall were about 4%. If you look at them, most of them were pretty minor. Uh, no differences, uh, in the ASC or HOPD. So how would you establish, I want to take, uh, just, uh, 5 to 10 minutes to talk about, uh, uh, my program, maybe 5 minutes and then we'll open it up for some questions. So these are the critical elements with regard to a, to a healthy program. One is Patient Selection.
[16:46] Speaker 1: Uh, another patient education. We're gonna go through these, uh, individually. Pain management is crucial, surgical technique, of course, and then transition to care issues. So when, when you're looking to start an Outpatient joint replacement program, where do you start? What patients do you select? You know, some people will reference the, the, the, the, the ASA, uh.
[17:07] Speaker 1: Criteria 12345. It's actually a pretty crude metric. Here's a more detailed explanation. Our anesthesiologist assigned this, uh, this, uh, classification. It's interesting when you look at the ASA classification and again, I'm curious if this is used in Colombia, but it really is based on
[17:28] Speaker 1: About 300 anesthesiologists that were just surveyed in 1978, so there wasn't great reliability between anesthesiologists, uh, despite the fact that we use it now in every case here in the US. The Charleston comorbidity index, uh, essentially a scoring system. We also use that and found that to be reasonably healthy, but now there are.
[17:49] Speaker 1: More and more tools used uh to try to assess them. This is a scoring system. This specific scoring system is now proprietary to DJO. It's essentially a, a scoring system based on uh medical history and well, you can see the subdivisions. It spits out a score if your score is.
[18:10] Speaker 1: Less than 60, you're considered a good candidate for a same-day discharge, uh, but if you do, if you have a good score less than 60 and have the proper patient education, you're even more likely for early discharge. Essentially, this study found ASA was weak, Charleston comorbidity index was not predicted.
[18:30] Speaker 1: And so we do need to keep searching for some orthopedic-specific um tools to use. Now, this, uh, I, I wanted to spend uh like I said, a couple of minutes talking about our center, exactly what our program details are, and this may be, uh, the, the, the, the area that you have some questions about later.
[18:50] Speaker 1: Uh, in our ASC, our Ambulatory Surgery Center, which I disclosed to you has been open since February, we do non-Mediccare patients, uh, uh, largely based on the Medicare Reimbursement portfolio, but also these patients are, are, are older and less healthy, so we're starting with non- Medicare patients, ASA 1 and 2. we do not use that orthopedic-specific tool as of yet.
[19:14] Speaker 1: Mentioned it was proprietary so it costs money. Um, so we use ASA 1 and 2. We do have a routine and careful preoperative medical evaluation. Uh, we make sure they have a normal EKG and some normal screening lab work and we review all outside consultant information. Patient education is paramount for us and we start that very early, clear expectations of going home.
[19:37] Speaker 1: Same day, consistent messaging across all your team. It begins with the physicians, but then it extends into our joint uh camp. We have everyone, uh, uh, meet in person. Uh, this is our 7th edition of our book because it's constantly being, uh, um, edited and, uh, and changed as our practice changes. We have a dedicated pathway navigator in our office which manages these people.
[20:01] Speaker 1: Uh, a lot of people wanna know how do you do the Pain control, right? Because we need adequate Pain control, but we also need to minimize side effects. Well, this is it. The morning of Surgery, we give him Tylenol IV, uh, Toradol, unless there's any contraindications and steroid.
[20:17] Speaker 1: Uh, 48 hours prior to the procedure, uh, we already have them on, uh, an anti-inflammatory, typically Celebrex, and we begin Lyrica in the evening. Uh, this is a nerve modification medi uh medication, and we think it probably helps with, uh, sleep in the early postoperative period. My guess is that's a big complaint for your patients, uh, uh, for the first.
[20:37] Speaker 1: Several weeks and sometimes a couple of months after Surgery. We no longer give preoperative narcotics. We used to give OxyContin, long-acting narcotic, uh, but we have found, uh, increased sedation and problems with that. So we actually try to minimize narcotics at every step. We do do an ultrasound-guided adductor canal. Our anesthesiologists do this using
[20:58] Speaker 1: Experel, I should mention in the US this is off-label. Experel is a, is a long-acting buppivacaine if you will. Um, I don't know if that's available where you are, uh, but it provides maybe 3 days of symptoms and has performed better for us than just buppivacaine. This is, uh, the anatomy of it all. Again, this is done by our, um,
[21:20] Speaker 1: uh, anesthesiologist, uh, prior to going to the operating room. Adductor canal versus femoral nerve block, we used to use femoral nerve blocks. The problem, of course, you're blocking the nerve higher and, uh, you're getting, uh, you're, you're gonna affect the quad. So when we try to, to work towards early mobility, we're having some problems with their quad recovery.
[21:40] Speaker 1: Essentially adotroca now has less effect on the quad and a lower fall risk with similar although perhaps slightly inferior, uh, Pain control. We, we, we have started now in the past 6 months doing a pre-procedural IPACC block infiltration between the popliteal artery.
[21:55] Speaker 1: Capsule of the Knee with repivacaine. This helps that posterior Knee Pain. That's a relatively uh low volume block, but we found it to be helpful for same-day discharge. Just as you would expect, the Pain control is better, particularly with regard to less posterior Knee Pain.
[22:11] Speaker 1: Pre-procedural regional blocks for a Hip. Currently we do none, but we had some pretty extensive experience with the fascia iliacus block. Some people still use this. You can see in the bottom drawing there, uh, the, the nerve splits and you're trying to get the lateral femoral cutaneous distribution and avoid the femoral nerve distribution, but we found that probably 10 to 20% of the time you affected the femoral nerve and again slowed rehab. So we no longer do.
[22:39] Speaker 1: Fascial iliac, uh, blocks for hips. Um, we only do regional blocks for knees. We use a single-shot spinal with short-acting spinal medications, either mepivacaine or chlorpra, uh, uh, chlorpra, uh, chlorprocane. Uh, you, you get about, you get slightly longer with mepivacaine, maybe 1 hour and a half, chlorprane, uh, uh, chloroprocane, uh, probably, uh, more like 45 minutes. Um, we do use adjuvants like Versed, uh, during the spinal placement.
[23:07] Speaker 1: Propofol intraoperatively and ketamine intraoperatively if needed. Again, you can see we're trying to avoid narcotics. We do do a perticular Injection and for us, it's just buppivacaine and Toradol. So there are some advantages, uh, uh, uh, to, to, to spinal. Um, the anesthesia guidelines now prefer, uh, uh, spinals for total knees, um, and a little stronger evidence for use of spinal and total hips. So anesthesia now.
[23:35] Speaker 1: In our country, at least, our largest governing body tends to recommend the spinals. You, you can do Ativa, and this is published in the literature in many, many areas which essentially is IV propofol. You avoid the inhalation agents and so you don't have that postoperative sedation. We've had some success with this in our center in cases that, uh, that, that can have a spinal or the spinal is ineffective. They still go home at the same, uh, measure. Post-op, we limit narcotics, Toradol, uh, we give them Robaxin in the recovery.
[24:03] Speaker 1: Room. We send everybody home with scheduled Tylenol, Celebrex, and Lyrica. Tramadol is their first line of defense. Probably 40% of our patients just take tramadol for their narcotic, but oxycodone, short-acting, uh, is, uh, is allowed for those that need something. Surgical technique, uh, we, I do use Robotics for unis and totals. Uh, we do a mixture of cementless and cemented Anterior approach which we discussed in the last hour is our routine Approach, but some post.
[24:31] Speaker 1: Your approaches are done. Again, we, we can have this Ongoing debate about anterior versus posterior Approach. I think the key is that you do, uh, what is, uh, what, what, what you're familiar with. Here in the US it's projected that, uh, 45% of, of hips will be done anterior by 2026, um, and, and so there's certainly great interest in that. I just, uh, add it for completeness. We, we put a, put a dry dressing on, uh, and a, and a, and a clear op site over.
[24:59] Speaker 1: We allow them to shower after they, uh, walk, uh, in the recovery room with our nurses. We don't have Physical therapy do it. Our nurses just mobilize them the first time. Our time from arrival to the PACU to discharge is about 40, 55 minutes. No precautions, home exercises for hips, formal PT, uh, for, for our total knees. The staff is important. You got to identify caretakers when you get home. We give them our cell phone number, but people rarely, uh, call.
[25:27] Speaker 1: They are going home the same day. We call them the next day and we make sure we're always available. People can do really well. This is an evolution for our program. It takes all of these key players, nurses, uh, obviously, the patient is at the top of the food chain, the surgeons, the quarterback, but really only a small, uh, participant here in the whole process. Uh, 80% of ours, uh, done at the ASR done at the ASC versus HOPD. They're healthy. We've had one to visit for dislocation.
[25:55] Speaker 1: Uh, and, and one OR return for, um,
[25:59] Speaker 1: Uh, for wound dehiscence. Aus, and I won't go through this, we simply don't have time. Aus has a position statement that essentially says, these are the crucial elements. You must have adequate oversight with data. You must be focused on improved quality and safety. You must.
[26:15] Speaker 1: To have Patient Selection, education, and social support. You must have expertise at all levels. This, uh, Outpatient joint replacement is not for all environments but has been a powerful tool for our practice. We should disclose any financial conflicts, particularly with regard to Ambulatory Surgery center.
[26:32] Speaker 1: In, in summary, uh, the, the, the official position is that, uh, some Hip and Knee replacements can be appropriately performed in the Outpatient setting if all of these factors are presented. I'll make sure that, uh, ACCCS, uh, guidelines, uh, for this are distributed, uh, to this great Congress. Ultimately, thank you so much for your time. Uh, I, I welcome any questions on Outpatient joint replacement. I'd love to hear the Colombian experience. Thank you.
[27:04] Speaker 3: And
[27:07] Speaker 3: Mocias uh