Total Knee Arthroplasty in Freestanding Ambulatory Surgery Centers: 5-Year Retrospective Chart Review of 90-Day Postsurgical Outcomes and Health Care Resource Utilization

Abstract

Introduction:Migration of total knee arthroplasty (TKA) procedures from the inpatient setting to outpatient venues, especially freestanding ambulatory surgery centers (ASCs), requires the use of reliable patient selection algorithms and standardized perioperative pathways to facilitate favorable outcomes for patients.Methods:This retrospective chart review included consecutive TKA procedures performed over a 5-year period between January 2014 and January 2019 at 2 freestanding ASCs. The patient selection algorithm was developed on the basis of patient comorbidities to minimize the potential for adverse events. All procedures were performed by one of eight orthopedic surgeons who were identified a priori as adhering to similar multimodal pain management regimens, including the use of spinal anesthesia, general or monitored-care anesthesia, adductor canal blocks, pericapsular injection of liposomal bupivacaine, nonsteroidal anti-inflammatory drugs, gabapentin, tramadol, acetaminophen, and oxycodone on an as-needed basis. Outcomes, including surgical complications, healthcare resource utilization (HCRU), and patient satisfaction, were measured before discharge and at a 90-day follow-up visit.Results:Four hundred thirty-nine TKA procedures in 386 patients were identified for inclusion. Of these patients, 115 (29.8%) were performed in patients with the American Society of Anesthesiologists physical status IIIa. Mean (standard deviation) length of stay at the ASC was 500 (107) minutes, including 136 (47) minutes of surgery and 201 (78) minutes to ambulation. The overall rates of surgical complications and 90-day hospital admissions were low (1.4% and 0.7%, respectively), as was the need for additional HCRU, including additional surgical procedures related to index surgery, emergency department visits, and unplanned clinic visits or calls. At the 90-day follow-up visit, 96% of patients reported being pleased with their outcomes.Discussion:With careful patient selection, standardized perioperative pathways, and multimodal analgesia protocols, TKA procedures can be performed in the ASC setting with low complication rates, minimal postdischarge HCRU, and high rates of patient satisfaction.Level of evidence:III

Use of a Recovery Messaging Application in Outpatient Total Joint Replacement

“…According to the results of these studies, patients who undergo TJR in a same-day outpatient surgical setting and receive fast-track streamlined postoperative education or use an RMA have lower readmission rates (Bahadori et al, 2020; Berg et al, 2018; Campbell et al, 2019; Dehorney & Ashcraft, 2018; Gabor et al, 2020; Glans et al, 2020; Gruskay et al, 2019; Harris et al, 2021; Hussain et al, 2017; Lyman et al, 2020; Mascioli et al, 2021; Oosterholt et al, 2017; Stauber et al, 2020; Timmers et al, 2019; Zheng et al, 2019). Gabor et al (2020) reported low postoperative complication rates and only 2% of the sampled patients were readmitted to the hospital.…”

“…A systematic review has been conducted (Bahadori et al, 2020). The remaining nine articles were observational studies categorized as prospective comparative studies, before-and-after studies, retrospective studies, and case studies (Berg et al, 2018; Dehorney & Ashcraft, 2018; Gabor et al, 2020; Glans et al, 2020; Gruskay et al, 2019; Harris et al, 2021; Lyman et al, 2020; Mascioli et al, 2021; Oosterholt et al, 2017; Zheng et al, 2019).…”

CoenzymeQ10 and Ischemic Preconditioning Potentially Prevent Tourniquet-Induced Ischemia/Reperfusion in Knee Arthroplasty, but Combined Pretreatment Possibly Neutralizes Their Beneficial Effects

“…Clinically, postoperative morphine consumption at 24 and 48 h was significantly lower in the CoQ10 group when compared to the control and CoQ10 + IPC groups (Median [P25-P75] at 24 h; CoQ10 3.5 [ 1 , 2 , 3 , 4 , 5 , 6 ] vs. placebo 6 [ 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 ] vs. CoQ10 + IPC 9 [6–13.5] mg, p = 0.037) ( Figure 5 A). In accordance with the cumulative morphine dose, the NRS at 24 h was significantly lower in the CoQ10 group when compared to the placebo and the CoQ10 + IPC groups (Median [P25-P75]; CoQ10 2.5 [ 2 , 3 , 4 ] vs. placebo 5.5 [ 3 , 4 , 5 , 6 ] vs. CoQ10 + IPC 5.5 [ 3 , 4 , 5 , 6 ] mg, p = 0.013) ( Figure 5 B). These results indicated that CoQ10 provided preventive analgesia within the first 48 h after TKA.…”

“…Perioperative care of TKA becomes more challenging in patients with increasing age and multiple comorbidities [ 1 , 2 ]. Also, TKA has a trend toward an ambulatory setting [ 3 , 4 ]. Thus, besides a current anesthesia practice, alternative strategies to enhance function at the cellular levels are essential as an adjunct therapy to improve postoperative clinical outcomes.…”

Same-Day Outpatient Lower-Extremity Joint Replacement

“…In 2018 and 2020 respectively, TKA and THA were removed from the inpatient-only (IPO) list for Medicare reimbursement. This opened the door to Medicare reimbursement for TKA and THA in an ambulatory surgery center (ASC) through the addition of TKA and THA to the ASC covered-procedures list in 2020 and 2021, respectively 10-14 . Because of the transition of TJA to lower-cost settings, cost savings for insurers are expected to be substantial, and this trend will likely continue into the future 15-17 .…”