A multicenter team from one of Ohio’s best-known arthroplasty centers, reviewed outcomes, procedures and technique for 928 of their outpatient total knee arthroplasty (TKA) patients.
Their work, “Low complication rates in outpatient total knee arthroplasty,” was published in the May 18, 2019 edition of Knee Surgery, Sports Traumatology, Arthroscopy.
Co-author Keith Berend, M.D., an orthopedic surgeon at Joint Implant Surgeons, Inc. in New Albany, Ohio, described not only the genesis of his study but also how critical patient selection and meticulous attention to detail are necessary to optimize the outpatient TKA experience to OTW, “We began performing outpatient total joint arthroplasty in 2013 on patients who were very carefully selected. Medicare has no code for outpatient TKA so on average our patients have been younger.”
“Early on we determined that perioperative management is critical, as is pain control, fluid control, and properly-timed ambulation. You want to avoid blood loss, nausea, urinary retention (typically associated with narcotic overuse).”
“TKA in an outpatient setting is not an evolution of perioperative care as there are 35 individual things that must come together to reduce complications and side effects—as well as allow us to get the patient out of the facility safety. One major advance is that we have reduced the use of narcotics by synergistically stacking on Tramadol and performing fluid resuscitation.”
The procedures involved were “1143 outpatient TKAs with the Vanguard Complete Knee System. Patients were selected for outpatient surgery if they were medically optimized without a failing organ system and had sufficient support at home.”
“In 124 procedures, the patient stayed overnight for 23-h observation. Thirty-seven were for convenience reasons and 87 for medical observation. Heart disease and chronic obstructive pulmonary disease were associated with increased risk of overnight stay. Excluding manipulations, reoperation within 90 days occurred in eight knees. Patients with 2-year minimum follow-up had significant improvements in ROM [range of motion], Knee Society Clinical, Functional and Pain scores. Nine patients required revision. Manipulations were performed on 118 patients. The overall deep infection rate was 0.17%.”
Dr. Berend commented to OTW, “Our results indicate that not only must the patient must be medically optimized, but they require the appropriate insurance coverage for price and facility. Someone with a medical problem that cannot be optimized—such as organ failure—is not appropriate for the outpatient setting.”
“Our facility actually has a visitation program where surgeons, anesthesiologists, and other clinical staff visit us to see how everything works.”
“Our process has developed over the last six years; in many cases we have moved away from liposomal bupivacaine because it is not cost-effective. We can combine other things that produce some revenue for the center versus having to buy bupivacaine out of pocket. We have demonstrated that those are not synergistic, so a well-done block has the same effect as liposomal bupivacaine…but using these together has no synergistic benefit.”
“We are pleased to add to the growing literature indicating that outpatient TKA is safe for most patients.”
