A comparison of functional outcomes following inpatient versus outpatient hip or knee arthroplasty

Abstract

Background The length of hospital stay after lower limb arthroplasty has rapidly decreased in the last decade, largely in part due to the rise of improved perioperative protocols, but also as a response to the increased economic demand associated with the rapid growth in hip and knee arthroplasty procedures. In line with this, the development of a new pathway after lower limb arthroplasty that allows for the surgery to be performed in an outpatient setting and permits for same-day discharge after the procedure is increasingly being offered. Although costs and complications between the inpatient and outpatient models have been compared, there appears to be little known about the effects on a patient’s physical function after undergoing hip or knee outpatient arthroplasty. Therefore, this systematic review aims to explore the available evidence for the effect on functional outcomes following inpatient versus outpatient hip or knee arthroplasty. Methods This systematic review adhered to the PRISMA guidelines and was prospectively registered (https://osf.io/8bfae/). An electronic search of three online databases (PubMed, CINAHL and EMBASE) was conducted to identify eligible studies. All studies investigating inpatient and outpatient comparator groups, for a population of patients undergoing hip or knee arthroplasty, that assessed one or more functional outcomes, were included. A methodological quality appraisal was undertaken for the final studies contained in this review. A narrative synthesis of results is described along with quantitative outcomes presented in tables and figures. Results A total of seven studies containing 1,876 participants were included in this review. Four studies assessed a THA population, two assessed TKA and one assessed both. Functional outcomes varied, with 20 different functional outcomes utilised, of which 18 were patient-reported tools. Results of functional outcomes offered mixed support for both inpatient and outpatient pathways. Conclusions The results of this review suggest that outpatient or inpatient pathway selection for hip or knee arthroplasty should not be based on the superiority of functional outcomes alone. However, given there is growing evidence in support of an outpatient pathway in select patients with respect to cost savings and without any increase in complications, it could be proposed that an equivalency of post-operative function between the two settings makes same-day discharge favourable. Publicly registered with Open Science Framework (https://osf.io/8bfae/).

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“…Another limitation is the lack of data on functional outcomes (e.g. quality of life), an understudied topic with mixed results [38]. A further limitation is that our administrative data does not allow us to differentiate inpatient stays on an "intention-to-treat" basis between patients who were originally planned for an outpatient arthroplasty (and were forced to stay overnight due to complications that prevented same day discharge) from patients that were originally planned for an inpatient stay.…”

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“…Osteoarthritis of the hip and knee is common in middle-aged and elderly people and is an important cause of physical disability, with clinical manifestations of joint pain, limitation of movement, and reduced quality of life [1,2] . The prevalence of osteoarthritis of the hip and knee has gradually increased with the global increase in life expectancy and obesity levels, and the number of patients in China has grown to 61.2 million [1,3] . Hip/knee arthroplasty is currently one of the most important means of treating hip and knee osteoarthritis, with the primary aim of relieving pain and improving joint function to a lesser extent [4] .…”