Outpatient Total Joint Replacement: How Has This Become Possible?

Thirty years ago, patients who underwent total hip and knee replacement would often spend 2 weeks in the hospital, with the first several days spent on bed rest. Ten years ago, a four-day hospital stay was standard of care and at least 50% of patients would then transfer from the hospital to an inpatient rehabilitation center. Slowly, over time, hospital duration of stay has shorted to three days, then two and finally one overnight for many patients, and the percentage of patients going from the hospital to a rehab center has similarly declined so that now only 10-20% of patients require this. What used to keep patients in the hospital was primarily management of postoperative pain.

The past several years have seen a host of advancements that have revolutionized the recovery from hip, knee and shoulder replacement through the development of rapid recovery programs. These advancements are outlined below:

1. Less invasive surgical techniques. Recognizing that surgery causes physiologic stress to the body, surgeons and engineers have improved implant designs and instruments to allow the placement of implants through smaller incisions with less muscle disruption. These results in less postoperative pain, fewer restrictions and earlier return of muscle and joint function.
2. Multi-modal pain management. Using combinations of medications that work synergistically provides much better pain relief that using a single medication. Combination protocols typically use several medications on a set schedule that provide a much more steady level of comfort than just relying on narcotics. This has allowed patients to drastically reduce the amount of narcotics necessary to recover. Many patients today are off all narcotics within a week of surgery.
3. Regional anesthesia. Nerve blocks around joints can substantially reduce postoperative pain, especially for total knees and total shoulders which tend to be more painful operations. These blocks use local anesthetic to numb sensory nerves around the joint so that patients have minimal pain input from the joint both during and after surgery.
4. Local anesthetic injections. In addition to nerve blocks, the use of local anesthesia injections around the operated joint provides major reduction in pain during the early postoperative period when pain is at its worst. It is now commonplace to see patients several hours after surgery with minimal pain.
5. Robust patient education. A well-educated patient, who knows what to expect, can much better cope with the postoperative period. Education around pain management, wound management and potential problems that can occur allows patients to trouble shoot on their own with great success and much less anxiety.
6. Patient optimization. It is well recognized that physical preparation for surgery, including strengthening exercises, health improvement and improved nutrition can make a difference in the early recovery. Making sure patients are in the best shape coming into surgery ensures a smoother recovery.
7. Improved postoperative communication. It is essential that patients have seamless access to their care providers in the early postoperative period. Frequent check-ins can prevent potential problems from escalating and make sure patients on a pathway of success.

With these 7 essential improvements, many patients are now able to undergo same-day total joint replacement and recover in the comfort of home the night of surgery. It is not uncommon for our patients at Atlantic Coast Surgical Suites to be walking out the door 2-3 hours after surgery. There is not ample data from published studies showing that same-day joint replacement in the ambulatory setting is both safe and successful with high levels of patient satisfaction. There is no place more comfortable and familiar than your own home and this is the optimal environment to recover quickly.