The Feasibility of Outpatient Revision Total Knee Arthroplasty in Selected Case Scenarios

Abstract

Background: As total knee arthroplasty (TKA) continues moving to the outpatient arena, the demand for revision surgery will subsequently increase which draws into question the feasibility for some revision scenarios as an outpatient. The purpose of this study is to report on the safety of outpatient revision knee arthroplasty. Methods: From June 2013 through December 2018, 102 patients (106 knees) underwent revision knee arthroplasty at a free-standing ambulatory surgery center. Mean patient age was 58.0 years, and 43% of patients were male. Procedures included the following: 45 cases of unicompartmental arthroplasty to TKA, 54 TKA revisions, and 52 cases involved a full exchange of components. Results: Ninety-three patients (88%) were discharged the same day without incident, none required transfer to acute facility, and 13 required overnight stay with 4 of these for convenience and 9 for medical reasons. There were no major complications within the first 48 hours postoperative. One patient required readmission for treatment of ileus 11 days postoperative. There were no other readmissions, no subsequent surgeries, and no deaths within 90 days. One or more major comorbidities were present in 66 patients. Conclusion: Outpatient revision knee arthroplasty was found to be safe in carefully selected patients and case scenarios. Presence of medical comorbidities was not associated with risk of complications. The paradigm changes of patient education, medical optimization, and a multimodal program to mitigate the risk of blood loss and reduce need for narcotics facilitates performing some revision arthroplasties safely in an outpatient setting.

Same-Day Discharge Following Aseptic Revision and Conversion Total Joint Arthroplasty: A Single-Institution Experience

“…With high SDD success rates, the current study and those by Law et al. [ 21 ] and Crawford et al. [ 22 ] help to inform best practices for safely transitioning rTJA from the inpatient to the outpatient setting, more specifically SDD.…”

“…Law et al. [ 21 ] and Crawford et al. [ 22 ] reported results of SDD aseptic rTKA and rTHA using identical patient-selection algorithms whereby patients with medical conditions that could not be optimized before surgery, organ-transplant patients, revisions requiring complex implants and long surgical durations, and cases where high blood loss was likely were ineligible for outpatient surgery.…”

“…In their hip study, [ 22 ] 21% of 47 cases were conversions, and 79% were revisions with procedures ranging from head exchange only to full component exchange. Sixty-two percent (66/106) of knee patients [ 21 ] and 32% (15/47) of hip patients [ 22 ] had 1 or more major comorbidity. Adjusting for 4 rTKA and 2 rTHA patients who delayed discharge for convenience, successful SDD rates were, respectively, 91.2% (93/102) and 97.8% (44/45), similar to the 97% success rate in our SDD case series.…”

“…Outpatient primary TJA has been adopted at a growing number of ambulatory surgical centers (ASCs) and hospital systems in the United States. Studies have demonstrated that with appropriate risk stratification and patient selection, and modern arthroplasty care pathways and perioperative protocols, outpatient primary TJA has outcomes equivalent or superior to inpatient primary TJA [ [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] ] More recently, early discharge following aseptic revision TJA has been investigated; however, only a few studies have been published to date, [ [21] , [22] , [23] , [24] ] with only 2 studies focused specifically on same-day discharge (SDD) [ 21 , 22 ]. As the trend toward outpatient primary and aseptic revision TJA accelerates, futher investigation is required to identify patient selection criteria and best perioperative practices to ensure patient safety.…”

Patients Who Undergo Early Aseptic Revision TKA Within 90 Days of Surgery Have a High Risk of Re-revision and Infection at 2 Years: A Large-database Study

“…Several groups have examined complications after revision TKA and found a higher incidence of general-health adverse events than for primary TKA, a lower complication rate at highervolume hospitals, and described the efficacy of various infection protocols [6,16,33,37,39,41,43]. However, these investigations either did not focus on aseptic revisions [16,39], did not isolate revisions occurring in the acute postoperative phase [6,33,37,43], or did not evaluate either [11,13,25,28,36,41].…”