Ebin - Pub Outpatient Hip and Knee Replacement Implementation and Essential Techniques 3031270363 9783031270369 1

Outpatient
Hip and Knee

Replacement
Implementation and Essential
Techniques
R. Michael Meneghini
Leonard T. Buller
Editors
123
Outpatient Hip and Knee Replacement
R. Michael Meneghini • Leonard T. Buller
Editors
Outpatient Hip and Knee

Replacement
Implementation and Essential Techniques
Editors
R. Michael Meneghini Leonard T. Buller
Department of Orthopedic Surgery, Indiana Department of Orthopedic Surgery
University School of Medicine Indiana University Health
Indiana Joint Replacement Institute Fishers, IN, USA
Indianapolis, IN, USA
ISBN 978-3-031-27036-9 ISBN 978-3-031-27037-6 (eBook)

https://doi.org/10.1007/978-3-031-27037-6
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
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Preface
We are in the midst of an outpatient revolution! Ten years ago, most orthopaedic
surgeons and healthcare providers would not have dreamed that the majority of total
hip and knee arthroplasty procedures would be performed in the outpatient setting
discharged to home within hours of their surgeries. Accelerated by the COVID-19
global pandemic which constrained hospital beds and resources, we are on a trajec-
tory to where the majority of patients undergoing primary total hip and knee arthro-
plasty are discharged to home the same day. However, due to the medical and
surgical complexity of these procedures and patients who they are performed on,
sophisticated programmes composed of high-functioning healthcare providers with
highly coordinated care pathways and protocols must be developed and maintained.
This book provides real-world and practical content from nationally and interna-
tionally recognized experts in outpatient hip and knee arthroplasty. They share their
insights on all the essential elements needed to develop a robust and successful
outpatient same-day-discharge hip and knee arthroplasty program. All the critical
issues are covered in the following text and include patient selection, perioperative
medical optimization and management, perioperative pain control and anaesthetic
techniques, common threats to patient discharge, patient connectivity and monitor-
ing outside the hospital as well as financial considerations. The reader will find all
the essential elements to develop and implement their own same day discharge out-
patient hip and knee program in either a hospital or ambulatory surgery centre
setting.
Indianapolis, IN, USA R. Michael Meneghini

Fishers, IN, USA Leonard T. Buller
v
Acknowledgements
To my amazing wife, Sarah. Sharing your life with an academic orthopaedic sur-
geon is challenging. Your immeasurable love, support, loyalty and selfless sacrifice
is awe-inspiring. I am blessed and eternally grateful. To my six wonderful children,
Ethan Angelo, Cecilia, Gianna, Luca, Mario and Milania. I am grateful for your love
and support and so proud of the compassionate, empathetic and uniquely talented
individuals you have all become. To my late mother, you are an inspiration in sur-
vival, love, passion, perseverance and true success in life. To my mentors, I am
eternally grateful for your inspiration, education and encouragement. I truly “stand
on the shoulders of giants”. To my colleagues on this incredible journey transform-
ing hip and knee arthroplasty to an outpatient procedure, in particular Dr. Pete
Caccavallo, Dr. Mark Nielson and Dr. David Conrad. I am honoured and humbled
by your partnership, collaboration and friendship and acknowledge this would not
have been possible without you. Finally, to my colleague, friend and co-editor, Dr.
Lenny Buller. Your expertise, dedication and partnership enabled this book to hap-
pen and I cannot thank you enough.
vii
Contents
1
Patient Selection for Same-day Discharge: Medical
and Surgical Risk Assessment�� 1
Peter Caccavallo and R. Michael Meneghini
2
Medical Optimization and Risk Mitigation for Readmission�� 9
Vignesh K. Alamanda and Bryan D. Springer
3
Surgical Appropriateness for Outpatient TJA in an ASC�� 17
Jesua Law, David A. Crawford, and Adolf V. Lombardi
4
Essential Components of Preoperative Education and Planning�� 25
Alexander Sah
5
Multimodal Pain Management Protocols for THA and TKA�� 37
Elizabeth B. Gausden, Mark W. Pagnano, and Matthew P. Abdel
6
Surgical Techniques and Protocols to Minimize Blood Loss
and Postoperative Pain�� 49
Nathanael Heckmann and Scott Sporer
7 Anesthesia for Outpatient TJA: Anesthetic Techniques
and Regional Blocks�� 59
Mark E. Nielson
8
Threats to Same Day Discharge: Prevention and Management�� 77
Charles P. Hannon, Parag D. Patel, and Craig J. Della Valle
9 there an Optimal Place for Outpatient TJA:
Is
Hospital, ASC, or “Other”?�� 85
William G. Hamilton, Roshan T. Melvani, and Agnes D. Cororaton
10
Navigating the Limitations and Obstacles of TJA
in a Free-Standing ASC �� 91
Nicholas B. Frisch and Richard A. Berger
ix
x Contents
11
Same-Day Discharge in the Hospital: Resources
and Program Elements�� 105
Gregory G. Polkowski and Michael D. Gabbard
12
Discharge the Day of Surgery: Strategies to Optimize
and Discharge Criteria�� 113
Joshua C. Rozell, Dimitri E. Delagrammaticas, and
Raymond H. Kim
13
Staying Connected with the Patient after Discharge:
Strategies and Resources �� 121
Tony S. Shen, Patawut Bovonratwet, and Michael P. Ast
14
Physical Therapy Following Same-Day Discharge
Total Joint Arthroplasty�� 127
Matthew J. Grosso and William Hozack
15
Strategies to Minimize Patient Anxiety, Emergency
Room Visits, and Readmissions Following Outpatient
Total Joint Arthroplasty�� 135
Charles De Cook
16
Making the Transition to Outpatient: Resources
and Pathway Changes�� 147
Paul K. Edwards, Jeffrey B. Stambough, Simon C. Mears,
and C. Lowry Barnes
17
Outcome Metrics: What to Measure Now and in the Future�� 157
Robert Pivec and Jess H. Lonner
18
How to Mitigate Risk for Surgeons, Institutions, and Patients�� 165
Leonard T. Buller and R. Michael Meneghini
19
Financial Considerations for Surgeons in the Outpatient
Setting: Costs and Ownership Models �� 177
Joe Zasa
20
Outpatient Hip and Knee Arthroplasty: Implications
for Hospitals, ASCs, and Payers �� 185
John R. Steele and Michael P. Bolognesi
Index�� 191
Chapter 1
Patient Selection for Same-day Discharge:
Medical and Surgical Risk Assessment
Peter Caccavallo and R. Michael Meneghini
Introduction
Total hip and knee arthroplasty (THA, TKA) performed in the outpatient setting has
become increasingly utilized due to multiple factors and there are multiple studies
that demonstrate efficacy for primaries [1, 2] and carefully selected revision cases
[3–6]. The factors driving utilization of outpatient hip and knee arthroplasty sur-
geons include investment in ambulatory surgery centers (ASCs); repercussions of
the COVID-19 pandemic such as constrained hospital resources and increased
patient demand; and Centers for Medicare and Medicaid Services (CMS) decisions
with the removal of these procedures from the inpatient-only list. Furthermore, case
volume projections for primary THA and TKA being performed in ASCs are pro-
jected to increase by 457% and 633%, respectively over the next decade [7].
Nevertheless, as more arthroplasties are performed in the outpatient setting, thor-
ough medical evaluation and proper patient selection and optimization will become
more critical for safe and effective rapid discharge. This chapter will highlight key
elements related to medical evaluation and patient selection and optimization for
outpatient total joint replacement.
P. Caccavallo
Perioperative Medicine, Indiana Joint Replacement Institute, Indianapolis, IN, USA
e-mail: [email protected]
R. M. Meneghini (*)
Department of Orthopaedic Surgery, Indiana University School of Medicine, Indiana Joint
Replacement Institute, Indianapolis, IN, USA
© The Author(s), under exclusive license to Springer Nature 1

Switzerland AG 2023
R. M. Meneghini, L. T. Buller (eds.), Outpatient Hip and Knee Replacement,
https://doi.org/10.1007/978-3-031-27037-6_1
2 P. Caccavallo and R. M. Meneghini
Medical Evaluation and Patient Selection
Many joint replacement surgeons limit their outpatient surgical practice to the
healthiest of patients. However, the vast majority of patients with end-stage arthritis
fail to fall into this category which greatly limits the number of patients eligible for
outpatient surgery. The key to outpatient surgical selection is to identify the patient
who will safely discharge on the same day and is at a low risk for readmission,
especially within the first 2 days. This is different than just identifying those who
have increased risk for a postoperative medical complication within 90 days of sur-
gery, which is the basis for most risk calculators. For example, a patient with stable
coronary artery disease who has reasonable exercise tolerance will be more likely to
discharge the same day after a total hip or knee arthroplasty. On the contrary, a
healthy patient with a history of poor postoperative pain tolerance would be a low
medical risk, but a high risk of failure for same-day discharge due to poor pain con-
trol. Further, an otherwise healthy patient with a history of postoperative urinary
retention would be problematic in terms of discharging the same day. Simply put,
increased medical complication risk does not necessarily equal the risk of outpatient
failure. There are many variables including psychological, social, and medical risks
that will allow one to effectively screen for appropriate outpatient candidates.
There are many medical risk assessment tools available (i.e., ASA, CCI, RAPT)
[8–10] but they were never intended to be used as an outpatient screening tool. The
most common classification system is the American Society of Anesthesiologists
(ASA) Physical Status Classification originally described in 1976 [8]. The ASA
score is based on a survey of 255 anesthesiologists used to determine the health
status of a patient based on a 1–5 scale. A score of 1 represents a “normal healthy
patient,” 5 indicates a patient that is about to die, and 4 is a patient with a medical
condition that is “a constant threat to life.” This leaves most patients with a score of
1, 2, or 3 for elective TJA. Separating patients into three categories is a poor screen-
ing tool for outpatient surgical selection as the score is not particularly discerning.
The authors of the original ASA publication even admit the classification system
“suffers from a lack of scientific precision” [8].
Furthermore, all patients should undergo a complete history and physical medi-
cal exam for identification of modifiable risk factors as well as appropriateness for
elective surgery from a cardiac standpoint using the most recent American College
of Cardiology and American Heart Association guidelines. Laboratory and cardiac
testing should be obtained for all patients based on current perioperative guidelines
including hemoglobin, creatinine, and HgA1c values. A physical exam is performed
with special attention to cardiac, pulmonary, and neurological baseline abnormali-
ties that delineate a clear physical baseline and avoidance of postoperative misun-
derstandings. In our outpatient program, patients are stratified using the Outpatient
Arthroplasty Risk Assessment (OARA) Score [11] which consists of nine catego-
ries including General, Hematological, Cardiac, Endocrine, Gastrointestinal,
Neurological/Psychological, Renal/Urology, Pulmonary, and Infectious disease.
The OARA Score has demonstrated near-perfect positive predictive values (PPV) of
1 Patient Selection for Same-day Discharge: Medical and Surgical Risk Assessment 3
91.5 and 98.8; and very low false positive rate values of 3.0 and 0.7 using cut-off
values of 59 and 79, respectively for determining which arthroplasty patients are
safe for early discharge in the outpatient setting [11, 12]. This score has also been
externally validated outside the original institution with a PPV of 86.1 for both
same-day and next-day discharge of THA patients in a rapid discharge program
[13]. The OARA Score, compared to other medical risk stratification tools, provides
a higher level of scientific precision as the score ranges from 0 to 100 on a continu-
ous scale compared to the ASA classification ranging from 1 to 5 on a categorical
scale. It is also important to note the OARA Score was not designed to be a measure
of physical status, medical complexity, or mortality. Key aspects of the OARA
Score are briefly summarized below:
General Medical
A patient’s general overall health and functional status are assessed. It is intuitive
that a patient with no home support and severe deconditioning is a poor outpatient
candidate. Obesity and morbid obesity, while not prohibitive to outpatient surgery,
tend to predict patients with poorer states of health and decreased medical compli-
ance. Screening for high narcotic and benzodiazepine tolerance or simply a history
of chronic pain control difficulties are barriers to physical and mental readiness for
same-day discharge. The General Medical category accounts for 180 possible points
contributing to the overall original OARA Score.
Hematological
Patients with anemia, especially significant or unevaluated anemia, can potentially

have a wide variety of known and unknown medical problems which can be exacer-
bated in the immediate postoperative period. With large expected blood loss, patients
with likely postoperative transfusion necessity should be avoided. Those with dif-
ficulty managing anticoagulation/antiplatelet medications will require more atten-
tion and sometimes increase the risk of outpatient failure. The Hematological
category accounts for 325 possible points contributing to the overall original
OARA Score.
Cardiac
While patients with stable coronary artery disease can make great outpatient candi-
dates, identifying those with tenuous conditions despite appropriate management
can be a challenge. With large fluid shifts, as well as intentional and unintentional
intraoperative hypotension, this may exclude patients with severe aortic stenosis or
a history of pulmonary edema. These patients frequently require longer periods of
postoperative monitoring as an inpatient. The Cardiac category accounts for 385
possible points contributing to the overall original OARA Score.
Endocrine
Uncontrolled diabetes is not only a marker for perioperative complications but also
noncompliance. Outpatient surgery requires increased responsibility on the side of
the patient. Those that show poor long-term compliance often will show poor short-
term compliance and an increased risk of readmission. Adrenal suppression can
make the aforementioned expected hypotension difficult to manage within the first
24 h. The Endocrine category accounts for 165 possible points contributing to the
overall original OARA Score.
Gastrointestinal
Patients with cirrhosis are high-risk patients in general. However, healthy patients
with a history of postoperative ileus and difficulty swallowing can be at high risk for
postoperative complications and readmissions. The Gastrointestinal category
accounts for 185 possible points contributing to the overall original OARA Score.
Neurological/Psychological
Patients with dementia are a challenge, even on the inpatient side. Postoperative
rehabilitation, expected pain, and detailed medicine directions can be quite intimi-
dating. It is often unpredictable who will tolerate anesthesia and postoperative
sedating medications or who will have prolonged postoperative delirium. Even
patients suffering from depression alone can find simple instructions challenging to
follow and are better treated as inpatients. The Neurological/Psychological category
Renal/Urology
Chronic renal disease is also very sensitive to fluid shifts and hypotension and fre-
quently will require specific fluid and medicinal adjustments beyond the day of
surgery. With a significant incidence of anesthetic-induced postoperative urinary
retention (POUR), patients with a history of POUR, or uncontrolled benign pros-

tatic hyperplasia (BPH) can be a challenge unless protocols are in place to manage
this common issue. The Renal/Urology category accounts for 220 possible points
contributing to the overall original OARA Score.
Pulmonary
Patient with tenuous asthma or chronic obstructive pulmonary disease (COPD) need
special consideration of its predicted stability postoperatively. Untreated sleep
apnea can be especially dangerous when postoperative pain and narcotic require-
ment are at their peak on postoperative day zero. The Pulmonary category accounts
for 250 possible points contributing to the overall original OARA Score.
Infectious Disease
The overall stress and physical demand for joint replacement is significant. Patients
with significant acute infections regardless of potential prosthetic joint infection
risk are a risk for same-day discharge failure. The Infectious Disease category
In addition to a medical risk stratification tool, program, or methodology such as
OARA, appropriate medical evaluation should include thorough medical history
and physical examination directed toward the psychological, social, and medical
issues that will predict the likelihood of outpatient safety and success. It is some-
times difficult to determine if a medical risk factor confers a higher likelihood of
delay in outpatient discharge. An appropriate medical evaluation that includes a
validated tool to identify risks for outpatient failure will open outpatient surgery to
a much larger population of patients that may have increased medical risks but
would still be appropriate for outpatient surgery. It not only provides patient assur-
ance and a guide for appropriate screening, but it provides an appropriate defense
for unforeseen and unavoidable complications that still rarely occur in all settings.
Perioperative Optimization
In addition to patient selection, perioperative patient optimization is also critical to

successful early discharge of outpatient arthroplasty patients. This involves multi-
disciplinary perioperative protocols developed in conjunction with anesthesia and a
dedicated internal medicine specialist [14]. Protocols prioritize intraoperative fluid
management and resuscitation, multimodal pain control, and overall consistent sur-
gical care (i.e., approach and operative time). Intraoperative fluid management
should emphasize euvolemia via protocols designed to allow/encourage patients to

drink clear liquids up to 2 h before surgery. We emphasize euvolemia rather than
hypovolemia or overhydration with excessive fluid loading, both of which can exac-
erbate postoperative urinary retention. Then, approximately 2 L of fluid is given
intraoperatively to maintain adequate tissue perfusion and oxygen delivery [15].
Pain control protocols should highlight multimodal medications given preopera-
tively and postoperatively [16]. Intraoperative pain control can be managed effec-
tively with nerve blocks and peri-articular injections, particularly for knees [17, 18].
Further, protocols should prioritize conserving intraoperative blood loss with the
use of tranexamic acid (TXA) [19, 20] and potentially advanced technology such as
abbreviated navigation of the femur which has shown to reduce blood loss during
joint replacement [21]. Postoperatively, an extended antibiotic prophylaxis protocol
has shown to reduce infection rates associated with primary and revision TJA [22–
24]. While some physicians have concerns about antibiotic resistance with this pro-
tocol, the rationale for extended antibiotic prophylaxis centers around extending the
“golden period” for maintaining low microbe levels and therefore preventing peri-
prosthetic joint infection in TJA [23, 25]. Further, the choice of wound dressing
should be considered as the use of closed incision negative pressure wound therapy
may be beneficial in reducing the incidence of incisional wound complications in
high-risk patients [26].
Barriers to Early Discharge in TJA
After successful patient selection and optimization, identifying the barriers to rapid
discharge for outpatient TJA patients are of utmost importance for continual proto-
col improvements. Recent studies suggest the main predictors for patients not dis-
charging same-day or next-day are postoperative urinary retention (POUR) [27];
hypotension, intractable pain, and nausea [28, 29]; general motor weakness [29];
and hypoxemia [3] among others. Further study is necessary to elucidate these pre-
dictors and other barriers to early discharge in TJA.
Conclusion
In summary, outpatient TJA is expected to increase exponentially over the next

decade which makes medical evaluation and patient selection paramount for its con-
tinued success. Several medical risk stratification tools exist but are limited by low
scientific precision and were designed to evaluate medical risk rather than surgical
risk to rapid discharge following TJA. The OARA Score was specifically designed
to screen for patients who are surgically appropriate for outpatient TJA and accounts
for comorbidities in nine medical categories. Furthermore, perioperative patient
optimization with multidisciplinary team protocols, proper intraoperative fluid

management, and multimodal pain control is also critical to a successful outpatient
TJA program.
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Chapter 2
Medical Optimization and Risk Mitigation
for Readmission
Vignesh K. Alamanda and Bryan D. Springer
Introduction
Primary total joint arthroplasty (TJA) represents one of the most commonly per-
formed surgeries in the United States. Rates of outpatient TJA have dramatically
increased [1] and while studies have shown that appropriately selected patients
undergoing outpatient TJA have similar outcomes to standard-stay inpatients, it is
crucial that these patients are optimized prior to their surgical intervention to ensure
safe and timely discharge [2, 3].
Modifiable Versus Non-modifiable Risk Factors
Risk factors can be differentiated between modifiable and non-modifiable. A modi-

fiable risk factor is one that can be changed, and such change can result in a different
outcome for that patient. A non-modifiable risk factor is one that cannot be changed
and, although important to recognize and counsel the patient on, is unfortunately
beyond the control of the surgeon and their patients. This chapter will focus on
identifying and acting on modifiable risk factors.
V. K. Alamanda
Hospital for Special Surgery, New York, NY, USA
B. D. Springer (*)
Hospital for Special Surgery, New York, NY, USA
OrthoCarolina Hip and Knee Center, Charlotte, NC, USA

Switzerland AG 2023
10 V. K. Alamanda and B. D. Springer
Patient Modifiable Risk Factors and Current Evidence
Diabetes
Diabetes and poor glycemic control have not only been associated with an increased
risk of surgical site infection but it is also implicated as a major contributor to PJI in
multiple studies. Analysis of these studies has shown a diagnosis of diabetes
increases the odds of PJI by more than double [4]. Hemoglobin A1c (Hgb A1c) has
been used as a marker of glycemic control in TJA candidates. A simple blood test,
Hgb A1c, provides insight into a patient’s glycemic control over the past 3 months
[5]. Patients with good glycemic control have a Hgb A1C level of less than 7.0%.
Other markers of glycemic control include perioperative glucose levels, which some
feel better predict PJI when compared to Hgb A1c alone [6]. Additionally, serum
fructosamine has been suggested as an adjunct measure of glycemic control over a
shorter duration of time when compared to Hgb A1c [7, 8].
Physiologically, the stress from surgery results in an increased production of
hormones that antagonize insulin and predispose patients to a relative hyperglyce-
mic state. Thus, in patients with already impaired glycemic control, it is crucial that
perioperative control be strictly enforced. Postoperative hyperglycemia, even in
patients without a diagnosis of diabetes, can increase the risk of developing a surgi-
cal site infection in a dose-related manner. Thus, it is the recommendation of the
authors that blood glucose levels be maintained between 110 and180 mg/dL (opti-
mal cutoff of around137 mg/dL) [9] in the perioperative period through frequent
blood sugar checks and initiation of diabetic management protocols postoperatively
following primary TJA [9]. We also recommend postponing surgery in patients with
uncontrolled diabetes and encouraging them to work with their primary care pro-
vider, a nutritionist, and/or an endocrinologist on better glycemic control.
Obesity
Obesity is when a person is too heavy for their height. Obesity is a global pandemic
thought to be caused by people consuming foods and drinks that are more energy-
dense (high in sugars and fats), and engaging in less physical activity. Body mass
index (BMI) is an index of weight-for-height used to classify obesity. It is defined
as a person’s weight in kilograms divided by the square of their height in meters (kg/
m2). In adults, overweight is defined as a BMI of 25 or more, whereas obesity is a
BMI of 30 or more.
Obesity has been correlated with higher rates of osteoarthritis and eventually
increased utilization of TJA [10]. Studies have shown that patient satisfaction and
functional improvement among the obese patient population is similar to the non-
obese group following TJA. However, obese patients are at a higher risk of postop-
erative complications [11]. Obesity predisposes patients to an increased surgical
2 Medical Optimization and Risk Mitigation for Readmission 11
dissection during exposure of the arthritic joint being replaced. This, in turn, can
lead to longer surgical times, which is associated with a higher risk of PJI [12]. The
poor vascularity of adipose tissue further compounds this problem, leading to poor
wound healing and a higher risk of persistent wound drainage. A consensus opinion
from the American Association of Hip and Knee Surgeons (AAHKS) evidence-
based committee emphasized considering delaying elective TJA in patients with a
BMI > 40 kg/m2, especially when associated with other comorbid conditions [10].
Additionally, some obese patients have metabolic syndrome, which is a cluster of
conditions arising from insulin resistance that impairs normal leukocyte function. It
is defined as having a BMI > 30 kg/m2 with central obesity, as well as two of the
following: hyperlipidemia, hyperglyceridemia, hypertension, or diabetes [13].
Zmistowski et al. demonstrated an increased risk of PJI (14.3% vs 0.8%) in those
with uncontrolled metabolic syndrome when compared to a healthy cohort [14].
Thus, patients with obesity should be screened for other characteristics that may
define metabolic syndrome and consideration should be made to counsel these
patients on the importance of modification of some or all of these risk factors.
Malnutrition
Malnutrition is often an unrecognized aspect of obesity, associated with the con-

sumption of high caloric but nutritionally poor diets. Malnutrition was found to be
present in 42.9% of obese patients in a prospective study evaluating the role of
malnutrition in TJA patients [15]. Laboratory tests can help to identify patients at
risk for malnutrition. These include a total lymphocyte count of less than 1500 cells/
mm3, a serum albumin of less than 3.5 g/dL, or a transferrin level of less than
200 mg/ dL. Patients with preoperative malnutrition should be encouraged to work
with a dietician to help improve their nutritional intake and help prepare them for
the catabolic demands required in the postsurgical period.
Smoking
Smoking, and its principal ingredient nicotine, has been associated with decreased
oxygen delivery to tissues secondary to microvascular constriction. Duchman et al.
reported an increased risk of wound complications with current more so than former
smokers in a large national database study [16]. The deleterious effects, in particular
PJI, seen with smoking have been confirmed by other studies [17].
Studies have shown smoking cessation programs may decrease complications
associated with the use of nicotine, even as late as 4 weeks preoperatively [18].
Thus, we recommend patients considering elective primary TJA have a minimum
period of 4 weeks of smoking cessation prior to their surgery. Smoking cessation
can be confirmed via easily available laboratory tests such as the serum cotinine
assay (normal value of <=10 ng/d).
Vitamin D
Vitamin D plays a crucial role in bone health. Vitamin D deficiency, as defined by a

serum 25-hydroxyvitamin D concentration ≤ 20 ng/mL, is prevalent in over 40% of
the United States population [19]. Interestingly, low levels of Vitamin D have been
associated with PJI. Animal models have also shown that the reversal of Vitamin D
deficiency can help decrease the development of PJI [20]. Thus, we recommend
patients with Vitamin D deficiency begin supplementation preoperatively.
Staphylococcus Aureus Screening
Implementation of an institution wide prescreening program using nasal swab rapid

polymerase chain reaction has allowed for the identification of patients who are
colonized with Staphylococcus aureus (S. aureus) and Methicillin Resistant
S. aureus (MRSA). Both universal decolonization and selected decolonization of
only colonized patients help with the elimination of the bacteria from a patient’s
nasal flora preoperatively. Nasal decolonization results in a significant reduction in
postoperative surgical site infections [21]. We Recommend patients undergoing
elective TJA undergo screening for S. aureus through nasal swabs and that surgeons
consider providing all patients, or just those that are colonized, with mupirocin
nasal ointment to be used twice daily in both nares and a bath with chlorhexidine
daily for 5 days prior to the scheduled surgery. Additionally, we recommend patients
screening positive for MRSA receive a single dose of vancomycin in addition to
standard perioperative antibiotics on the day of their surgery.
Inflammatory Arthropathies
Patients afflicted with inflammatory arthropathies such as rheumatoid arthritis and

systemic lupus erythematosus are at increased risk of postoperative PJI. Multiple
systematic reviews have validated the correlation between inflammatory arthropa-
thies and PJI, with Kong et al. demonstrating rheumatoid arthritis can increase the
odds of PJI by 1.6 times [22]. Many patients with inflammatory arthropathies pres-
ent to their surgeon on immunomodulators. These medications have the potential to
significantly impair wound healing and increase the risk of PJI. For example,
Momohara et al. demonstrated that patients on Tumor Necrosis Factor (TNF)-alpha
inhibitors are at significantly higher risk for surgical site infections [23]. Guidelines
jointly published by the American College of Rheumatology (ACR) and the

American Association of Hip and Knee Surgeon (AAHKS) used available evidence
to make recommendations on which medications should be continued and which
medications should be stopped in elective TJA [24]. In general, traditional Disease
Modifying Antirheumatic Medications (DMARDS) do not need to be withheld
prior to surgery. However, immunomodulating agents, such as TNF-alpha inhibi-
tors, place patients at increased risk for the development of a PJI and should be
withheld one dosing cycle prior to surgery.
Antibiotic Prophylaxis
Preoperative antibiotic prophylaxis is effective in reducing rates of surgical site

infections and has been incorporated in many surgical checklists [25]. Routine pro-
phylactic antibiotics should be dosed in accordance with the patient’s weight and
should include a first-generation cephalosporin such as cefazolin. Patients allergic
to beta-lactam antibiotics should receive vancomycin or clindamycin in a timely
fashion. Prophylactic antibiotics should be administered ideally as close to the time
of the incision as possible. First-generation cephalosporin and clindamycin should
be administered within 1 h and vancomycin should be administered within 2 h of
incision. We recommend that a single dose of vancomycin be considered in addition
to standard preoperative antibiotics for those who have been shown to be colonized
with MRSA or those who had a prior infection with MRSA.
Conclusion
The well-known saying, a stitch in time saves nine, is certainly applicable to improv-
ing outcomes and decreasing rates of complications among patients undergoing out-
patient TJA. While it will never be possible to completely eliminate all risks, it can
certainly help improve the odds.
References
1. Krause A, Sayeed Z, El-Othmani M, Pallekonda V, Mihalko W, Saleh KJ. Outpatient Total

knee arthroplasty: are we there yet? (part 1). Orthop Clin North Am. 2018;49(1):1–6.
2. Bert JM, Hooper J, Moen S. Outpatient Total joint arthroplasty. Curr Rev Musculoskelet Med.
2017;10(4):567–74.
3. Lovett-Carter D, Sayeed Z, Abaab L, Pallekonda V, Mihalko W, Saleh KJ. Impact of outpatient
Total joint replacement on postoperative outcomes. Orthop Clin North Am. 2018;49(1):35–44.
4. Marchant MH Jr, Viens NA, Cook C, Vail TP, Bolognesi MP. The impact of glycemic control
and diabetes mellitus on perioperative outcomes after total joint arthroplasty. J Bone Joint Surg
Am. 2009;91(7):1621–9.
5. Stryker LS, Abdel MP, Morrey ME, Morrow MM, Kor DJ, Morrey BF. Elevated postoperative
blood glucose and preoperative hemoglobin A1C are associated with increased wound com-
plications following total joint arthroplasty. J Bone Joint Surg Am. 2013;95(9):808–14. S1–2
6. Iorio R, Williams KM, Marcantonio AJ, Specht LM, Tilzey JF, Healy WL. Diabetes mel-
litus, hemoglobin A1C, and the incidence of total joint arthroplasty infection. J Arthroplast.
2012;27(5):726–9 e1.
7. Shohat N, Tarabichi M, Tischler EH, Jabbour S, Parvizi J. Serum Fructosamine: a simple
and inexpensive test for assessing preoperative glycemic control. J Bone Joint Surg Am.
2017;99(22):1900–8.
8. Kheir MM, Tan TL, Kheir M, Maltenfort MG, Chen AF. Postoperative blood glucose levels
predict infection after Total joint arthroplasty. J Bone Joint Surg Am. 2018;100(16):1423–31.
9. Gallagher JM, Erich RA, Gattermeyer R, Beam KK. Postoperative hyperglycemia can be
safely and effectively controlled in both diabetic and nondiabetic patients with use of a subcu-
taneous insulin protocol. JB JS Open Access. 2017;2(1):e0008.
10. Workgroup of the American Association of H, Knee Surgeons Evidence Based C. Obesity and
total joint arthroplasty: a literature based review. J Arthroplast. 2013;28(5):714–21.
11. Mason JB, Callaghan JJ, Hozack WJ, Krebs V, Mont MA, Parvizi J. Obesity in total joint
arthroplasty: an issue with gravity. J Arthroplast. 2014;29(10):1879.
12. Wang Q, Goswami K, Shohat N, Aalirezaie A, Manrique J, Parvizi J. Longer operative
time results in a higher rate of subsequent Periprosthetic joint infection in patients under-
going primary joint arthroplasty. J Arthroplast. 2019;34(5):947–53. https://doi.org/10.1016/j.
arth.2019.01.027. Epub 2019 Jan 18
13. Gage MJ, Schwarzkopf R, Abrouk M, Slover JD. Impact of metabolic syndrome on periopera-
tive complication rates after total joint arthroplasty surgery. J Arthroplast. 2014;29(9):1842–5.
14. Zmistowski B, Dizdarevic I, Jacovides CL, Radcliff KE, Mraovic B, Parvizi J. Patients with
uncontrolled components of metabolic syndrome have increased risk of complications follow-
ing total joint arthroplasty. J Arthroplast. 2013;28(6):904–7.
15. Huang R, Greenky M, Kerr GJ, Austin MS, Parvizi J. The effect of malnutrition on patients
undergoing elective joint arthroplasty. J Arthroplast. 2013;28(8 Suppl):21–4.
16. Duchman KR, Gao Y, Pugely AJ, Martin CT, Noiseux NO, Callaghan JJ. The effect of smok-
ing on short-term complications following Total hip and knee arthroplasty. J Bone Joint Surg
Am. 2015;97(13):1049–58.
17. Teng S, Yi C, Krettek C, Jagodzinski M. Smoking and risk of prosthesis-related complications
after total hip arthroplasty: a meta-analysis of cohort studies. PLoS One. 2015;10(4):e0125294.
18. Lindstrom D, Sadr Azodi O, Wladis A, Tonnesen H, Linder S, Nasell H, et al. Effects of a
perioperative smoking cessation intervention on postoperative complications: a randomized
trial. Ann Surg. 2008;248(5):739–45.
19. Forrest KY, Stuhldreher WL. Prevalence and correlates of vitamin D deficiency in US adults.
Nutr Res. 2011;31(1):48–54.
20. Hegde V, Dworsky EM, Stavrakis AI, Loftin AH, Zoller SD, Park HY, et al. Single-dose, pre-
operative vitamin-D supplementation decreases infection in a mouse model of periprosthetic
joint infection. J Bone Joint Surg Am. 2017;99(20):1737–44.
21. Kim DH, Spencer M, Davidson SM, Li L, Shaw JD, Gulczynski D, et al. Institutional pre-
screening for detection and eradication of methicillin-resistant Staphylococcus aureus in
patients undergoing elective orthopaedic surgery. J Bone Joint Surg Am. 2010;92(9):1820–6.
22. Kong L, Cao J, Zhang Y, Ding W, Shen Y. Risk factors for periprosthetic joint infection follow-
ing primary total hip or knee arthroplasty: a meta-analysis. Int Wound J. 2017;14(3):529–36.
23. Momohara S, Kawakami K, Iwamoto T, Yano K, Sakuma Y, Hiroshima R, et al. Prosthetic
joint infection after total hip or knee arthroplasty in rheumatoid arthritis patients treated
with nonbiologic and biologic disease-modifying antirheumatic drugs. Mod Rheumatol.

2011;21(5):469–75.
24. Goodman SM, Springer B, Guyatt G, Abdel MP, Dasa V, George M, et al. 2017 American
College of Rheumatology/American Association of hip and Knee Surgeons Guideline for the
perioperative Management of Antirheumatic Medication in patients with rheumatic diseases
undergoing elective Total hip or Total knee arthroplasty. J Arthroplast. 2017;32(9):2628–38.
25. Fernandez AH, Monge V, Garcinuno MA. Surgical antibiotic prophylaxis: effect in postopera-
tive infections. Eur J Epidemiol. 2001;17(4):369–74.
Chapter 3
Surgical Appropriateness for Outpatient
TJA in an ASC
Jesua Law, David A. Crawford, and Adolf V. Lombardi
Introduction
Outpatient Total Joint Arthroplasty (TJA) is the future [1]. Over the last decade
there have been multiple advancements in multimodal pain control [2, 3], blood
management [4], minimally invasive surgical techniques, and rapid recovery proto-
cols [5–7] that have revolutionized joint replacement surgery. These advancements
have changed the length of stay from weeks to days, and recently to only a few
hours at an outpatient setting [8, 9]. Higher patient satisfaction scores [10] and
fewer complications [11] have been documented in the outpatient setting as patients
are able to recover in an environment familiar to them, safe from pathogens [12],
and unnecessary lab draws [13]. With benefits to the patient, surgeon, and health-
care system, outpatient TJA has gained popularity worldwide [14]. The Centers for
Medicare and Medicaid Services (CMS) has seen the benefits of this and removed
primary total hip and knee arthroplasty from the inpatient-only list, as well as allow-
ing these procedures to be performed at an ASC.
Ambulatory Surgery Center Versus the Hospital
After acknowledging the benefits of outpatient TJA, the next decision is the surgical
venue for the operation. Surgeons have the option of performing surgery at a free-
standing hospital under an admitted “inpatient” status, a hospital-based “outpatient”
setting, or an ASC. While not all patients are candidates for a procedure at an ASC,
J. Law (*) · D. A. Crawford · A. V. Lombardi

JIS Orthopedics, New Albany, OH, USA
e-mail: [email protected]; [email protected];
[email protected]

Switzerland AG 2023
18 J. Law et al.
the ASC offers several advantages over the other two options. Ambulatory surgery
centers usually offer improved proficiency, as the mindset of most team members of
the ASC is to maximize productivity and efficiency [15]. Most staff members are
cross-trained and able to both provide patient care and assist in turnovers. The
enthusiasm to work efficiently is enhanced at an ASC as staff members realize they
are able to go home once the work is done and not “waiting for a shift to end.”
Ambulatory surgery centers usually offer a smaller, more personalized experience
for the surgeon and patient, and in physician-owned ASCs the healthcare provider
is able to directly impact the patient experience without layers or hospital bureau-
cracy impeding patient care.
It is important to emphasize that not all patients are candidates for outpatient
surgery and not all surgeries should be attempted at an ASC. Patient selection, and
case selection, is critically important for ASC cases to achieve the best possible
outcomes while minimizing complications.
Selection of Patients
Most patients will be appropriate candidates for outpatient TJA at an ASC; however,
some may have medical comorbidities that preclude this environment. Many authors
have discussed techniques for determining which patients are appropriate for outpa-
tient surgery [11]. One model uses an outpatient arthroplasty risk assessment
(OARA) scoring system [16] to help the surgeon evaluate comorbid conditions and
make the decision for outpatient surgery. The OARA scoring system is proprietary
and requires a licensing fee. A more simplified model [17] investigates whether the
patient has medical comorbid conditions that are not optimized prior to the time of
surgery. If chronic comorbid medical conditions are not optimized, then elective
surgery should be delayed until these conditions are optimized. In this simplified
model, the only contraindication for outpatient surgery is a failing organ system.
Patients with Chronic Obstructive Pulmonary Disease (specifically those requiring
oxygen), asthma, congestive heart failure, chronic kidney disease, or liver cirrhosis
[18] are at the highest risk for needing inpatient hospitalization and outpatient TJA
should be cautioned. Surgery in this group of patients should be performed along-
side a multidisciplinary medical team in a hospital setting for proper monitoring of
the patient. It should be emphasized that inpatient hospitalization is for monitoring
the medical comorbid conditions and not due to the arthroplasty itself. Once the
proper outpatient is selected, the surgeon must evaluate the limitations of the ASC
and consider the following set of conditions outlined below to determine if an ASC
is a proper venue.
3 Surgical Appropriateness for Outpatient TJA in an ASC 19
Selection of Cases
When considering the appropriateness of surgery at an ASC, it is critical that the

surgeon considers the complexity of the case, including the limited storage and
sterilization capacity. Since streamlined efficiency and steady workflow are the
main focus, most primary joint replacement cases can effortlessly be accomplished
at an ASC. However, complex revisions can easily overwhelm the sterile processing
capabilities when multiple instrument trays are needed. Oftentimes, these cases may
not even be candidates for outpatient joint replacement surgery, let alone surgery in
the ASC. Inpatient hospitalization should be considered in certain complex cases,
such as difficult femoral or acetabular reconstructions or grossly infected cases, due
to the greater propensity for blood loss [19] and the need for medical subspecialty
consultation. Polyethylene liner exchanges, partial knee to total knee replacement
revisions, and single component revisions are just a few of the “simpler” revisions
that can be safely performed in an outpatient ASC setting. However, a hospital-
based outpatient surgery center, or even inpatient hospitalization, should be consid-
ered as the complexity of the case increases.
Educating the Patient
Many patients will have preconceived notions of what to expect from their
TJA. Inpatient hospitalization and discharge to a short-term rehabilitation facility is
the perceived standard of care for some patients who may have had an arthroplasty
years ago or know a family member who underwent a joint replacement surgery.
Among these patients, outpatient surgery at an ASC is a foreign idea and same-day
discharge may seem rushed or intimidating. The surgeon and staff should educate
the patient regarding the benefits of recovering from surgery at home [20], and the
advancements in pain management protocols that allow their recovery to be accom-
plished comfortably. This explanation eases fears and improves satisfaction and
patient compliance [19–21]. A unified message must be delivered to the patient and
family so that the patient feels comfortable and supported by all members of the
team from the office staff to hospital/ASC employees.
Joint replacement classes, and even simple handouts, are some of the various
forms of education available to the patient. Regardless of the messaging, the pri-
mary source of educational materials should be written since patients often forget
up to 80% of the information presented during the visit [21] and further questions
often arise after the clinical encounter. Included in the patient educational materials
are expectations regarding wound care and hygiene after the surgical procedure,
exercises, and activity of daily living (ADL) goals for the first few days after sur-
gery, as well as a preoperative medical evaluation overview. Physical therapists are
available pre- and postoperatively to outline the stepwise approach to safely per-
forming ADLs, to teach patients how to use ambulatory aids, and perform more
20 J. Law et al.
complex activities such as going up and down stairs. Expectations for pain manage-
ment, blood clot prevention, presurgical home planning, and an outline of the risks
of surgery should all be included in these educational materials.
When questions arise that are not covered in the educational material, knowl-
edgeable office staff should be available to aid in answering questions. By viewing
the facility before surgery, patients are able to meet the staff and postoperative care
team. Wound and dressing instructions should be explained by knowledgeable nurs-
ing staff as well as what signs to look for if problems arise. To improve patient
comfort and decrease fear, setting clear expectations between the surgeon, patient,
and family [5–7] has been shown to be of prime importance.
Finally, patients should be educated on the fact that an ASC, despite having
improved outcomes and decreased complications, has limitations and if complica-
tions or difficult situations arise the patient may need to transfer to a free-standing
hospital.
Anesthesia and Pain Management
Many patients are fearful of outpatient TJA due to a perceived inability to manage
their pain once at home [22]. However, in outpatient TJA, uncontrolled pain is rarely
the cause of an overnight stay or emergency room visit within 48 h of surgery [11,
17]. One of the biggest advancements in the ability to perform joint replacement
surgery at an ASC is the advent of multimodal pain control and rapid recovery pro-
tocols [3, 23–25]. The minimization of pain, sedation, and nausea, while promoting
mobilization and a safe discharge, is the prime objective of these rapid recovery
protocols and will be discussed in subsequent chapters. Many multimodal pain regi-
mens have been described, but most involve a nonsteroidal anti-inflammatory
(NSAID), regional anesthesia, and a non-narcotic analgesic (acetaminophen) pre-
operatively along with minimal opioid usage.
The transition from general anesthesia alone to regional anesthesia has greatly
increased patient comfort and minimized the need for postoperative opioids. In both
partial and total knee arthroplasty patients, an adductor canal block and infiltration
of anesthetic into the posterior capsule are recommended. Femoral nerve blocks
should be avoided in the ASC setting due to quadriceps muscle weakness and
increased fall risk [26–28]. In hip replacement patients, spinal anesthesia in combi-
nation with sedation or light general anesthesia has been shown to decrease blood
loss, decrease short-term complications, lead to fewer “nonhome” discharges, and
improve patient satisfaction [29] when compared to general anesthesia alone [30].
Narcotics should be avoided in regional anesthesia blocks due to pruritus, nausea,
and sedation, which all can result in the patient staying more than 23 h for observa-
tion. Prior to closure, it is recommended that the patient receive an infiltration of
local anesthesia into the periarticular tissue, which has been shown to decrease post-
operative pain [31]. This combination of peripheral and general anesthesia has been
shown to decrease pain, increase early mobility, decrease the need for narcotics,
decrease the length of stay, and reduce readmissions [32, 33].
Postoperative Care and Follow Up
Postoperatively, the patient should have clear goals and expectations as outlined
above in the patient education section. It is important that the patient feels empow-
ered to perform their ADLs, but not abandoned. Oftentimes, a call from a staff
member shortly after surgery helps remind the patient of the predetermined goals
that were expressed and keeps the patient on track, answers questions, and helps
determine what is “normal and abnormal” with recovery. Physical therapy should
be started shortly after surgery to coach the patient in performing ADLs safely. The
goal of the therapist is to ensure a smooth transition to independence as well as keep
a trained eye on the patient to ensure issues do not arise. Therapists who see many
postsurgical patients can be a great resource for the patient, and the surgeon, by
alerting a member of the surgical team if concerns arise before issues escalate and
also keep the patient from feeling abandoned in the postoperative recovery period.
Follow-up visits vary from institution and clinical practice, but often require the
patient to come in for a wound check, postoperative radiograph, and range of motion
evaluation. If issues arise in this time period there may be a role to increase physical
therapy for a period of time and/or schedule a manipulation under anesthesia.
23-Hour Observation and Transfer Agreements
Surgery at an ASC has many benefits, as listed above, but also some limitations. In
a recent 2018 publication [17], 94% of total hip replacement patients were able to
discharge home as planned. Of the patients that required an overnight stay, half were
due to convenience and the most common medical reason for overnight observation
was urinary retention. Total knee patients had a higher overnight observation for
medical necessity at 7.6% [11]. Not every state allows for 23-h observation at the
ASC and the facility should have plans in place in case the patient necessitates a
longer than expected stay.
Patients who need further evaluation, blood transfusions, or have unforeseen
medical complications, while rare [11, 17], may require a short observational period
at an inpatient hospital setting. This is never convenient for the patient or family, but
having plans in place eases anxiety. In these situations, the ASC should have a trans-
fer agreement with a nearby hospital allowing patients direct access to a higher level
of medical care. It is important the patient receive discharge materials, prescrip-
tions, and any medical equipment needed postoperatively and the surgeon be in
communication with the admitting medical provider.
22 J. Law et al.
Conclusion
Outpatient joint replacement surgery at an ASC is safe, efficient, and has low com-
plication rates. In the properly selected patient, joint replacement surgery at an ASC
can have benefits to the surgeon and patient while being more cost-effective to the
healthcare system as a whole.
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monia in the United States. Am J Infect Control. 2018 Mar;46(3):322–7.
13. Greco NJ, Manocchio AG, Lombardi AV, et al. Should postoperative hemoglobin and potas-
sium levels be checked routinely following blood-conserving primary total joint arthroplasty?
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ful considerations must be made. Orthopedics Today. 2015;35(8):10–1.
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total knee arthroplasty: a systematic review of comparative- effectiveness research. Br J
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come after total knee arthroplasty? Clin Orthop Relat Res. 2009;467:2379–402.
31. Lombardi AV Jr, Berend KR, Mallory TH, Dodds KL, Adams JB. Soft tissue and intra-articular
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32. Beaupre LA, Johnston DB, Dieleman S, Tsui B. Impact of a preemptive multimodal analgesia
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33. Lovald ST, Ong KL, Lau EC, Joshi GP, Kurtz SM, Malkani AL. Readmission and complica-
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Chapter 4
Essential Components of Preoperative
Education and Planning
Alexander Sah
Introduction
In recent years, the practice of total joint arthroplasty (TJA) has experienced a dra-
matic change in environment, both figuratively and literally. In the reimbursement
arena, performing TJA in the traditional fee-for-service model has shifted to alterna-
tive payment models where surgeons are the leaders in directing the episode of care.
As a consequence of this change, surgeons must expand their skills beyond the
operating room and coordinate the entire continuum of care to optimize healthcare
value. Furthermore, the location of TJA is literally moving away from the traditional
hospital setting to freestanding ambulatory surgery centers (ASCs). These figurative
and literal changes require adaptations of standard perioperative programs to
advanced protocols in order to maximize outcomes and cost savings. Preoperative
education has been a mainstay of traditional TJA programs and is even more impor-
tant for success in these changing environments.
Influence of Bundled Payments on the Patient Experience
Bundled payment models aim to align surgeons and hospitals by placing them at
risk for financial penalty if predetermined outcome measures are not achieved.
Consequently, new opportunities have arisen where gainsharing relationships are
allowed for participants to share in program cost savings. Incentives now motivate
surgeon and hospitals to optimize outcomes while minimizing costs [1]. Shifting
care and costs away from unnecessary postsurgery treatment services to preopera-
tive education and preparation can achieve many of these goals.
A. Sah (*)
Institute for Joint Restoration, Washington Hospital, Fremont, CA, USA

Switzerland AG 2023
26 A. Sah
The content of preoperative education typically includes general information

related to presurgical processes, the surgical procedure, discharge disposition, post-
operative care, potential surgical and nonsurgical complications, answers to fre-
quently asked questions, postoperative pain management, and important staff
contacts. The adoption of alternative payment models, which include outcomes up
to several months after surgery, has led to changes in patient education needs. The
success of bundled payment models depends on avoiding adverse events, while
minimizing costs, and simultaneously optimizing patient outcomes. Preoperative
education can preemptively address many of the common causes for patient adverse
events and readmissions thereby making preoperative preparation efforts essential
to optimize the overall bundle.
Analyzing the components of the episode of care reveals that the major cost driv-
ers for hip and knee replacement are hospital length of stay (LOS), discharge to
post-acute care facilities, and hospital readmission [2, 3]. Literature has shown that
discharges to skilled nursing facilities lead to poorer overall outcomes, increased
costs, and higher complication rates [4–7]. In the bundled payment environment,
standard inpatient joint replacement discharges must be aimed at going home safely
to minimize costs and potential complications [8]. Preoperative education classes
have shown potential cost savings averaging over $4000 (27.2%) less than total
costs for those patients who did not participate in preoperative education classes
prior to elective hip or knee replacement [9, 10]. Recent literature has described
some of the steps necessary to successfully accomplish these objectives [11–13].
Most of these reports have concluded that preoperative education plays a critical
role to achieve these goals [14–18]. Cost savings resulting from proper education
can be significant, up to $12,000 per year for those patients who attended an educa-
tion program prior to surgery [19]. Simply put, preparation efforts prior to surgery
pays dividends for cost containment and better outcomes after elective hip and knee
replacement surgery.
Traditional Preoperative Joint Replacement Education
While hip and knee replacement are two of the most successful procedures in ortho-
pedics in terms of outcomes and satisfaction, results are improved with optimized
perioperative protocols [20]. Most attention is given to those protocols directly
affecting the surgical procedure or the immediate pre- or postoperative care pro-
vided to the patient. Elements of a successful comprehensive joint replacement pro-
gram are expansive enough to include all elements of the patient experience,
including preoperative education, joint class or camps, office support, and follow-
up staff and systems. Although these comprehensive clinical pathway programs are
multifaceted, the educational component is one of the most critical pieces for over-
all success.
Standard educational programs address patient preparation before surgery, the
surgical procedure, immediate recovery, avoidance of common complications, and
4 Essential Components of Preoperative Education and Planning 27
recovery after surgery. To most effectively communicate these issues to patients,

traditional preoperative education guidelines suggest simplifying medical terms,
using visual aids and models, organizing topics in chronological order, and having
presenters be staff who will later interact with the patient again [21]. Education
classes located on, or near, the joint replacement floor and at the hospital where
surgery will occur allows the opportunity for patient familiarity with the surgical
environment. Furthermore, patients and caregivers can become familiar with their
route to the hospital, meet staff, and visit the after-surgery areas to reduce anxiety
associated with their upcoming surgery.
Prior to surgery, patients learn to optimize their medical health in anticipation of
their surgery date. In addition to addressing their individual medical comorbidities
before surgery, maximizing overall conditioning and strength can aid in recovery
[22]. Furthermore, preparing the home environment for safety and simplifying
recovery is beneficial. This focus can greatly improve the chance that patients will
feel comfortable being discharged directly home, rather than to a nursing facility.
The preoperative class should also explain the surgical procedure in simple terms.
The use of videos, visual aids, and actual implant components can help patients
understand what is involved in their surgery, and the reasons for the expected recov-
ery. Pain management, swelling control, and ambulation goals are better understood
in the context of knowing the surgical procedure. By providing a road map of how
to address common symptoms after surgery, the patient is prepared and more confi-
dent in the respective treatments. This aspect of preoperative education is critical to
avoid emergency room visits and readmissions. Lastly, explanations of the longer
term recovery help manage expectations and patient satisfaction.
Thorough educational programs have been shown to benefit patients who attend
classes prior to surgery by having less anxiety, better postoperative pain control,
more realistic expectations of surgery, and a better understanding of their surgery.
Focusing the educational efforts earlier in the surgical experiences has been associ-
ated with improved outcomes [23–26]. The benefits of these programs include
decreased pre- and postoperative anxiety, decreased postoperative pain, better cop-
ing, decreased LOS, increased discharge to home, lower readmissions, and cost
savings [27]. Prior studies have shown that comprehensive patient education pro-
grams decrease discharge to post-acute care facilities and postoperative complica-
tions [28, 29]. Recent data showed that preoperative education as a single intervention
decreased LOS following total knee arthroplasty with no increase in complications
or readmissions within 90 days of discharge [9]. Furthermore, implementation of
patient education has positive impacts upon patient satisfaction, especially in man-
aging pain, which is a leading impediment to early discharge home [30].
28 A. Sah
The Effect of the Migration Towards Outpatient TJA
Successful outpatient joint replacement relies on building upon an already sound

foundation of preoperative education and patient preparation. It is important to
understand how the outpatient experience differs from the inpatient experience to
best modify existing preoperative education protocols. Outpatient joint replacement
differs from standard protocols in only one fundamental way—time [31]. It is not
defined by different surgical techniques or the use of specific implant types.
Outpatient joint replacement simply means having the ability to discharge a patient
within a specific time constraint. Once this is understood, the effects of time reduc-
tion on the patient experience can be better evaluated.
The most immediate impact of faster discharge is that there is less time to diag-
nose and treat potential adverse events related to medications, anesthesia, or surgi-
cal procedure. Patients and caregivers have less time to address postoperative
anxiety or review discharge instructions. Furthermore, recovery from surgery in the
outpatient setting is more likely to occur in isolation as opposed to in the inpatient
setting. More information must be covered in a shorter period of time for outpatient
surgery discharges. Lastly, and possibly most importantly, earlier discharge exposes
patients to earlier and more variable postoperative experiences at home. Emphasis
needs to be placed on how to manage earlier variability in pain, nausea, swelling,
and other symptoms because patients will be at home when some of these may
occur for the first time. Expectations for this 6–24 h window after discharge must be
clearly explained to the patient and caregiver. For these reasons, a key challenge to
the transition from the inpatient to outpatient setting is that the work that tradition-
ally happens after surgery must now occur on the “front-end.”
To meet the demands of providing consistent and safe outpatient joint replace-
ment discharges, preoperative education programs must be optimized, and in many
cases enhanced beyond standard procedures [32]. By understanding these differ-
ences and by being proactive, rather than reactive, the enhanced protocols can pro-
vide a safe and successful outpatient experience. In order to prepare for these
challenges in outpatient surgery, there are a minimum of four elements of the stan-
dard inpatient joint replacement protocols that should be augmented. These areas
include preoperative education, discharge instructions, staff availability, and cre-
ation of a safety net.
Setting the Foundation of Patient Expectations
The framework for patient expectations and education begins on the initial consulta-
tion. The goal of patient and caregiver education is to make patients feel confident
managing their own healthcare. Patients should understand that they must take an
active role in their success. Preoperative education is important to improve patient
expectations prior to surgery and provide them the understanding that they are the
primary factor in achieving a good outcome [33]. Preoperative education also pre-
pares patients psychologically for rehabilitation goals by providing them with clear
expectations of the recovery process [34]. Providing the patient with adequate infor-
mation can increase their sense of responsibility for a successful surgery, as well as
improve their ability to cope after surgery [35]. It is important that this philosophy
of self-empowerment permeates throughout all elements of patient preparation.
This understanding is particularly significant because individuals undergoing joint
replacement surgery have high expectations for their outcomes [36]. A strong cor-
relation has been reported between patient satisfaction and fulfillment of pain relief
and functional restoration [37, 38], Stated another way, up to 20% of all total knee
arthroplasty patients are not satisfied with their outcome, and the strongest predictor
of dissatisfaction is not having their expectations met [39]. Furthermore, there is a
disconnect between patients and surgeons, as patient expectations for pain relief and
functional outcome are higher than their surgeons’ expectations [40]. Improving the
alignment of patient and surgeon expectations before surgery may lead to improved
patient satisfaction after joint replacement. The initial consultation and subsequent
education programs are critical opportunities to establish this mutual
understanding.
Addressing Patient Anxiety Preemptively
As with any elective procedure, patients should be made aware of the potential risks
and benefits of surgery. Somewhat unique to TJA are the associated anxieties that
patients experience prior to surgery. Patient and caregiver concerns and questions
should be thoroughly addressed during the patient education phase. The anxiety of
the caregiver must be recognized, as it may also negatively affect the patient [41].
Preoperative education protocols should include written medication instructions,
including medications for pain management and venous thromboembolism prophy-
laxis. A recovery plan should be made, explicitly outlining patient expectations,
caregiver responsibilities, and physical therapy or nursing care if needed. Also,
patient expectations about pain levels, walking, driving, and returning to work need
to be managed and reasonable goals should be established. Some successful pro-
grams have included a 2-h presurgery meeting with the patient, a clinical care coor-
dinator, and a physical therapist to outline these expectations and address patient
concerns.
Pain after TJA correlates with heightened preoperative anxiety levels [42].
Preoperative education can decrease patient anxiety associated with an upcoming
surgical procedure [43, 44]. The literature supports that reducing preoperative
patient anxiety results in improved postoperative recovery, leading to higher levels
of patient satisfaction with their surgical experience, and reducing levels of self-
reported pain up to 1 year after surgery [45]. An observational study reported that
78% of participants believed that preoperative education was responsible for a
reduction in their anxiety prior to elective orthopedic surgery [46]. Several studies
30 A. Sah
have evaluated the most effective means to improve patient anxiety prior to surgery
and determined that providing information regarding the upcoming surgery and
subsequent hospitalization is most beneficial [29, 47, 48].
Understanding Patient Comprehension and Limitations
As education programs become more thorough and more complex, there is a risk
that patients will not absorb or retain the information. At some point, increasing the
amount of information taught to potentially anxious patients will instead cause
more confusion or stress than the benefits it may provide. In these education classes,
educators must be aware of the risk of the sheer volume of information conveyed in
shortening amounts of time thereby risking overloading the patient. Learners have
limitations in how much material they can comprehend, after which, they no longer
absorb the information. Worse, there is a risk of causing greater confusion, poten-
tially undermining previous preparation successes. It is also important to be aware
of the range of health literacy in the class of attendees. Preoperative education must
be taught at the lowest level of patient comprehension so that all participants can
benefit [49]. Health literacy remains vital in achieving a patients’ understanding of
their upcoming surgery and is considered the single best predictor of an individual’s
health status [50]. Providing education materials at the literacy level of the patient
population will improve their understanding of surgery, minimize anxiety, and
improve outcomes that are clinically significant [51]. Ensuring that the language is
understandable the first time it is read or heard will improve the quality of education
for orthopedic patients undergoing elective hip and knee replacement. Different
education techniques and media, as described below, may also increase material
absorption and minimize patient overload.
Family/Caregiver Preparedness
Social support is critical for recovery after arthroplasty procedures. In hospitals,

arthroplasty patients with strong social support had shorter LOS and were more
likely to be discharged home [52]. Commonly, social reasons may be a major factor
in why patients are unable to achieve a planned same-day discharge [53]. Previous
studies have clearly demonstrated a strong link between patient outcomes and a
patient’s social support system. The quality of a patient’s support system is associ-
ated with mortality, mental health, stress, and depression [54]. In addition, even
perceived social support can be an important factor after hip or knee replacement
[55]. Inadequate caregiver support impacts negatively the quality and rate of recov-
ery after a major operation, regardless of postoperative complications 56.
Some programs may have the patient choose a coach, who commits to attending
preoperative care meetings and staying with the patient for a defined period of time
following surgery [56]. A family member or caregiver should be present during the
preoperative education classes to better prepare for the upcoming surgery. The use
of a family member/caregiver, referred to as a “coach,” is a critical aspect of suc-
cessful outcomes after surgery [52, 57]. Some programs make patient and caregiver
attendance mandatory and reschedule surgery until the preoperative education class
is completed. Others have patients sign contracts that define the social network sup-
porting the patient and outlining the desired postoperative care algorithm in case of
complication or readmission. Some programs have a care coordinator do a home
visit to make sure that the patient will be able to recover adequately at home under
the supervision of a competent caregiver [57]. Regardless of the strategy selected,
patients with consistent social support have shorter hospital stays are more likely to
be discharged home, more likely to meet ambulation and transfer-out-of-bed tar-
gets, score hospital quality of care higher, and are more confident and ready to go
home on discharge [52]. The education class provides an opportunity to identify
recent changes in the patient’s social/family support system, an inability to obtain
needed durable medical equipment, failed arrangements for transportation to outpa-
tient physical therapy, unrealistic expectation of discharge to a rehabilitation hospi-
tal, and/or other issues that may hinder timely discharge. In this manner, the
preoperative class can act as a fail-safe check to make sure patients are appropri-
ately prepared for discharge directly home. Rarely, a patient has no social support.
In these circumstances, the problem can be identified in class and the need for a
coach can be stressed or discharge plans can be altered.
Evolution of Education Techniques
Traditional education classes combine written handouts with verbal lessons.

Learning by at least two different methods can often enhance learning by improving
retention and maximizing repetition. Repetition is an effective teaching tool, and
using different formats further ensures information retention while avoiding the
monotony of single format repetition. The use of animation, video, live demonstra-
tions, and interactive learning are especially helpful in the most successful pro-
grams. For example, videos have been shown an effective way to educate [58].
However, video education, like other multimedia techniques, is even more effective
when combined with live teaching from a healthcare provider. This may be because,
in general, learning via an interactive format is also more successful in accomplish-
ing education goals [59]. Having the education class available on the web for later
review can also be useful [60]. Interactive technologies such as virtual reality or
web-based learning modules in the comfort of their own home can also teach
patients in ways that were not previously possible. These advanced teaching tech-
niques are more engaging for patients and allow a different, and deeper, understand-
ing of the material.
Commonly with elective TJA, group teaching is applicable and has been shown
to be very effective. Advantages of group teaching include the benefit of hearing
32 A. Sah
answers to questions from the other participants, group support, and modeling of
behavior and skills by the group. The majority of patients responding to a survey
after attending a preoperative class preferred verbal education, stating that this was
clear and easy to understand [46]. Preoperative education classes for elective TJA
have been shown to promote a sense of social connectedness while also fostering
participants’ independence [43].
Interestingly, many outpatient programs do not offer live joint education camps.
Because these cases are shifted away from the hospital setting, a central location for
education is often lacking, as is the personnel to teach the classes. Hospitals may be
unwilling to provide the staff, space, and resources required to support a joint class
if the cases are going to be performed at a freestanding ASC. For this reason, vari-
ous technologies have become available to fill this void.
A gap between earlier outpatient discharge and first follow-up forms as a conse-
quence of rapid recovery total joint discharges. To fill this void, a significant amount
of resources may be required to answer additional phone calls or address questions.
Increased personnel to address these questions can be expensive and time-
consuming. As a consequence, web-based applications, wearable sensors, mobile
apps, virtual follow-ups, and remote care centers have become popular options to
assist in monitoring outpatient joint replacement patients. Increased use of technol-
ogy on the “back-end” of early patient discharges may help minimize complications
and readmissions. However, the additional preoperative education on the “front-
end” is likely to prepare patients to bridge the outpatient gap and reduce the need for
postoperative “touches.”
Conclusion
Preoperative education remains a mainstay in the success of total joint replacement

programs. The challenges to achieving success in both the bundled payment arena
and the transition to outpatient total joints can be addressed through modifications
to existing successful preoperative programs. More in-depth focus, with an empha-
sis on the early expectations for the first few hours at home after outpatient surgery,
can improve the probability of postoperative success. In both of the scenarios
described, optimizing patient outcomes while minimizing costs is an attainable goal
with enhanced preoperative education and preparation.
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Chapter 5
Multimodal Pain Management Protocols
for THA and TKA
Elizabeth B. Gausden, Mark W. Pagnano, and Matthew P. Abdel
Introduction
Improved perioperative pain control made possible through advances in multimodal

pain management may be the single most important factor that has facilitated out-
patient total joint arthroplasty (TJA). Inadequate pain control following total hip
arthroplasty (THA) or total knee arthroplasty (TKA) is associated with longer hos-
pital stays, readmissions, lower patient satisfaction, as well as decreased knee range
of motion for TKA patients [1]. Multimodal analgesia (MMA) has emerged as the
gold standard for patients following THAs and TKAs. This strategy enlists multiple
analgesics with varying mechanisms of action in order to produce a synergistic
effect of pain relief. In addition to lowering the amount of opioids required for simi-
lar levels of pain relief, multiple studies have demonstrated that the use of MMA is
associated with improved patient outcome and satisfaction, reduced hospital stays,
and lower resource utilization [2, 3]. Pain can be separated broadly into emanating
from both the neurogenic and inflammatory pathways, and the goal of MMA is to
block all possible pain pathways. Oral analgesia, regional anesthesia, peripheral
nerve blocks (PNBs), and parental analgesia are all components of
MMA. Furthermore, MMA can be categorized temporally, starting with preopera-
tive dosing of oral or parenteral analgesia, intraoperative use of regional anesthesia,
parenteral analgesia and periarticular infiltration of analgesia, and finally postopera-
tive analgesia in the post-anesthesia care unit, during floor care, and at home.
E. B. Gausden · M. W. Pagnano · M. P. Abdel (*)

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
e-mail: [email protected]; [email protected];
[email protected]

Switzerland AG 2023
38 E. B. Gausden et al.
Anti-Inflammatories and Acetaminophen
Prostaglandins are synthesized by local tissues during TJA, triggering an inflamma-

tory pain cascade. Preoperative administration of nonsteroidal anti-inflammatory
drugs (NSAIDs) theoretically reduces the early production of prostaglandins in tis-
sues during TJAs and reduces pain postoperatively. Multiple randomized clinical
trials (RCTs) have proven the efficacy of this technique of preoperative NSAID
administration to reduce postoperative opioid use, as well as pain, vomiting, sleep
disturbance, and improve knee range of motion in TKA patients [4, 5]. Theoretically,
preemptive analgesia prevents sensitization of pain receptors in the peripheral and
central nervous systems as once these sensors are triggered initially, a lower pain
threshold is required for triggering them in the postoperative period [6]. The poten-
tial downside of using NSAIDs prior to surgery is an increased risk of bleeding
intraoperatively and postoperatively, but this theoretical risk has not been borne out
in studies. Continuation of NSAIDs for 2 weeks following TJA is recommended as
they will continue to attenuate the production of prostaglandins, mediating the pain
experienced and do not require tapering for discontinuation.
Cyclooxygenase-2 (COX-2) inhibitors offer the benefit of selective inhibition of
COX-2 receptors that are increased in inflammation while sparing the constitutively
expressed COX-1 receptors regulate platelet function and line gastrointestinal
mucosa. As a result, the use of COX-2 inhibitors results in fewer adverse effects
compared to nonselective NSAIDs, such as diclofenac, ibuprofen, or naproxen,
including less GI complaints and platelet dysfunction. Buvanendran et al. [4] per-
formed an RCT to study the efficacy of perioperative rofecoxib, a COX-2 inhibitor,
versus placebo in patients undergoing TKA and found that the COX-2 inhibitor
reduced overall opioid consumption, pain, vomiting, sleep disturbance, and
improved knee range of motion.
Acetaminophen also reduces the production of prostaglandins, but via a poorly
understood mechanism independent of that of NSAIDs. Nevertheless, the combina-
tion of acetaminophen and NSAIDs reduces the amount of opioids consumed by
TJA patients compared to the administration of NSAIDs alone [7–9]. The use of
oral acetaminophen may be as effective as intravenous (IV) acetaminophen in terms
of improving analgesia in postoperative TJA patients [10]. Using a dose of 1000 mg
of acetaminophen compared to 650 mg has demonstrated superiority in pain relief
[11, 12], and that is incorporated into our institution’s MMA protocol (Table 5.1).
5 Multimodal Pain Management Protocols for THA and TKA 39
Table 5.1 Mayo multimodal opioid-sparing pain protocol [50]

Preoperative Details and Dosing
Acetaminophen 1000 mg PO followed by q6h IV dosing in the OR
Celecoxib 400 mg PO once
Caffeine 200 mg PO if the patient consumes >100 mg of caffeine
daily
Peripheral nerve blockade
Single shot Adductor Canal block/ 10 mL of 0.5% bupivacaine 1:200,000 epinephrine ± 50 μg
saphenous nerve block for TKA dexmedetomidine
Lumbar plexus block/psoas nerve Complex revision hips, surgeon preference
catheter
Femoral nerve catheter Revision knees, chronic pain, surgeon preference
Adductor canal catheter Chronic pain/opioid tolerance, surgeon preference
Intraoperative care
Single-shot spinal Intermediate-acting mepivacaine or low-dose bupivacaine
spinal without long-acting opioid
Sedation Propofol infusion titrated to effect
Periarticular injection (PAI) According to surgeon preference
Antiemetics Ondansetron 4 mg IV, dexamethasone 0.1 mg/kg up to
8 mg
Ketamine 10–40 mg IV divided doses through perioperative period
(10 mg IV/h recommended)
Post-anesthesia care unit (PACU)
Acetaminophen 1000 mg PO or IV once for pain
Oxycodone 5–10 mg PO q4 h PRN pain (5 mg for pain level 4–6;
10 mg for pain level > 6)
Hydromorphone 2–4 mg PO q4 h for pain in patients with allergies or
intolerance to oxycodone
Floor care
Acetaminophen 1000 mg PO q6 h
Ketorolac 15 mg IV q6 h for 4 doses (if GFR >50 mL/min)
Celecoxib 200 mg PO BID starting after 4 doses of ketorolac (only if
GFR >50 mL/min)
Dexamethasone 8 mg IV once on POD1 morning for patients <65 years
old; 4 mg IV once on POD1 morning for patients
66–80-years old
Tramadol 50–100 mg PO q4 h PRN pain (use 50 mg for pain rated 3;
use 100 mg for pain rated 4 or greater)
Oxycodone 5–10 mg PO q4 h PRN pain (5 for pain rated 4–6; 10 mg
for pain rated 7–10)
Fentanyl 25 μg IV q15 min PRN for pain 7–10 for 3 doses
Hydromorphone 0.2 mg IV q15 min PRN for pain 7–10 for 3 doses (for
those with intolerance to fentanyl)
Gabapentinoids
Pregabalin and gabapentin are gamma-aminobutyric acid (GABA) receptor inhibi-

tors that desensitize pain pathways in the central nervous system. Gabapentin spe-
cifically acts on presynaptic voltage-gated calcium channels that are upregulated in
nerve injury and decreases the hyperexcitability of secondary nociceptive neurons
in the dorsal horn of the spinal cord. Gabapentin was originally marketed in 1993 as
an antiepileptic, and since then has been used to treat neuropathic pain. While not
specifically approved by the Food and Drug Administration (FDA) for perioperative
pain control, there is evidence that the use of gabapentinoids in THA and TKA
patients may decrease opioid usage. Zhai et al. [13] completed a meta-analysis
examining the effect of gabapentin on acute postoperative pain in TKA patients.
Their study included 769 patients and concluded that gabapentin results in superior
pain relief compared to a placebo for pain control after TKA.
Similarly, a meta-analysis of studies using pregabalin in TKA concluded that
pregabalin reduced cumulative morphine consumption at 24 and 48 h postopera-
tively, and improved postoperative knee flexion at 48 h compared to patients treated
with placebo [14].
A concerning association between gabapentin use and respiratory depression, as
well as naloxone administration, has been identified recently [15, 16]. Similarly,
concomitant use of gabapentin in opioid users was associated with a 49% increased
risk of death from an opioid overdose in a case-control study of over 5000 patients
[17]. This association could be related to the additive effects of both drugs on sup-
pressing respiratory drive or increased absorption of gabapentin in the setting of
opioid use [17]. For these reasons, we have begun to discourage gabapentinoids as
part of MMA at our institution.
Steroids
The antiemetic and anti-inflammatory effects of steroids are well demonstrated in

the perioperative setting [18, 19]. In an RCT, Backes et al. [20] studied the effect of
10 mg of intravenous dexamethasone administered intraoperatively to patients
undergoing TJA and found that those treated with the steroid consumed less rescue
antiemetic and analgesic medications, and reported less pain and nausea. Those
treated with the IV steroid also had a significantly shorter length of stay and ambu-
lated further distances compared to the control group [20]. Potential risks associated
with perioperative steroid administration include poor glucose control, theoretically
increased infection risk, and gastrointestinal hemorrhage and need to be weighed
against the potential benefits in each TJA patient. We generally use dexamethasone
IV intraoperatively and administer an additional dose the morning after TJA for
patients under 80-years old (Table 5.1). Dexamethasone in intermediate doses or
higher, approximately 8–10 mg, can have a positive analgesic effect as well, and
pain is improved when steroids are administered in the first 48 h after surgery [21].
Opioids
Opioid receptors, found predominantly in the central nervous system, peripheral

nervous system, and gastrointestinal tract, mediate the physical and psychoactive
experience of pain. Previously, opioid administration in the perioperative setting
was done through patient-controlled analgesia (PCA) devices that allowed IV
administration of opioids in response to patients pushing a button. PCA usage is in
steady decline in the past decade as evidence has emerged illustrating the superior-
ity of multimodal approaches [22, 23].
A thorough evaluation of a patient’s use of opioids is fundamental to planning a
perioperative pain regimen. Sing et al. [24] found that patients using opioids preop-
eratively required more than 50 mean milligram of morphine equivalents over the
course of their hospital stay compared to patients who were non-opioid users preop-
eratively. Weaning patients from opioids preoperatively may be an effective strategy
to lower the incidence of perioperative complications, as Jain et al. [25] identified
lower complication rates in patients who had stopped using opioids within 3 months
of surgery. If weaning opioids is not possible, then selective use of PCAs for patients
with preoperative opioid dependence may be warranted. Further, if patients are opi-
oid dependent preoperatively, they may not be a candidate for same-day discharge
in the outpatient setting unless they are capable of weaning off the narcotics prior to
surgery, or there is a detailed plan to assist with their pain control at home
postoperatively.
Prescribing habits for postoperative opioids to be taken upon discharge home
have also changed as a result of greater awareness of the opioid epidemic. Huang
et al. [26] compared opioid usage postoperatively between THA and TKA patients
and identified higher consumption of pain pills in TKA patients (37 pills was the
median for THA patients and 67 pills for TKA patients), and TKA patients were five
times more likely to ask for a refill compared to THA patients. Hannon et al. [27]
revealed the median number of unused pills was 15 for patients who were given a
prescription for 30 tablets of 5 mg oxycodone immediate release (IR) compared to
73 unused pills for those patients given 90 tablets following TJA, with no difference
in pain scores or patient-reported outcome scores at 6 weeks postoperatively. From
our institution, Wyles et al. [23] demonstrated the efficacy of implementing institu-
tional guidelines (in this case a limit of 400 oral morphine equivalents which is
comparable to 50 tablets of 5 mg oxycodone) for reducing opioid prescription in
arthroplasty patients.
Neuraxial Anesthesia
Multiple studies have indicated the superiority of neuraxial anesthesia compared to

general endotracheal anesthesia (GETA) for patients undergoing THA or TKA [28,
29]. Advantages of neuraxial anesthesia for TJA patients include decreased risk of
surgical site infection, shorter surgical time, lower rates of deep vein thromboses
and pulmonary emboli, lower risk of pulmonary complications, less intraoperative
bleeding, lower transfusion rates, and lower length of hospital stay [28–31]. Despite
the documented benefits, the risks of neuraxial anesthesia include spinal hematoma,
epidural abscess, and nerve injury, and these risks must be weighed against the ben-
efits for every individual patient, especially those requiring chronic anticoagula-
tion [32].
Neuraxial anesthesia includes spinal and epidural anesthesia and the combina-
tion of the two techniques. Weinstein et al. [33] compared combined spinal epidural
(CSE) anesthesia, spinal anesthesia, and epidural anesthesia in patients undergoing
THA and TKA and concluded that a single-shot spinal technique resulted in reduced
odds for cardiac, pulmonary, gastrointestinal, and thromboembolic events. The
authors suggest that spinal anesthesia resulted in a more complete block during
surgery, resulting in less pain.
Unpublished data from a study recently completed at our institution, including
two of the coauthors of this chapter (MWP and MPA), compared spinal anesthesia
with an intermediate-acting local anesthetic, mepivacaine, to the more traditional
longer acting bupivacaine [34]. We found that spinal anesthesia using mepivacaine
allowed for a faster return of lower extremity function compared to bupivacaine
(185 min compared to 214 min, p = 0.01). Therefore, mepivacaine may be a better
agent for the outpatient setting and same-day discharge of THA and TKA patients.
Peripheral Nerve Blocks
Peripheral nerve blocks (PNB) following THA and TKA can provide longer acting
anesthesia for patients and act as a major contributor to limiting opioid usage as part
of MMA [35]. There are a variety of PNBs currently used as one modality of pain
control for THA and TKA, including posterior lumbar plexus nerve block (“psoas
block”), femoral nerve block (FNB), interspace between the popliteal artery and
posterior capsule of the knee (iPACK), sciatic nerve block (SCB), adductor canal
block (ACB), and fascia iliaca block. Like any modality, the benefit of PNBs must
be weighed against their potential risks, which include increased risk of falls and
delayed progress with ambulation secondary to motor blockade, peripheral nerve
injury, and prolonged dysesthesias. Ilfeld et al. [36] reported a 7% risk of a postop-
erative fall in patients who received a FNB or lumbar plexus block.
The ACB is more distal than a typical femoral nerve block, which allows for the
preservation of quadriceps function and facilitates early ambulation [37]. For this
reason, at our institution, we prefer a single-shot adductor canal block/saphenous
nerve block for most primary TKAs in order to achieve the benefit of the sensory
blockade and pain relief while maintaining motor function for same-day ambulation.
Continuous indwelling catheters left to provide sustained nerve blocks through-
out the postoperative period have also been studied in arthroplasty patients. Spangehl
et al. [38] compared three regimens in primary TKA patients: the first a continuous
femoral nerve catheter, the second a single-shot SCB, and the third a PAI cocktail of
ropivacaine, ketorolac, epinephrine, and morphine. There were no differences
between patients who had the single-shot SCB compared to those with the
indwelling femoral nerve catheter, but both of the block groups had more falls,
lower quadriceps function on postoperative day 1, and more peripheral nerve dyses-
thesias at 6 weeks postoperatively. Similarly, Elkassabany et al. [39] completed an
RCT comparing a single-shot ACB to a continuous ACB in TKA, finding no differ-
ence between groups in terms of opioid consumption, length of hospital stay, or
functional outcomes. Amundson et al. [40] compared TKA patients treated with
either a femoral nerve catheter plus sciatic nerve blocks, ropivacaine-based PAI, or
liposomal bupivacaine-based PAI in an RCT and found that the PAI groups were
comparable to the femoral nerve catheter with sciatic nerve block group in terms of
maximal pain scores on postoperative days 1 and 2. At our institution, indwelling
catheter nerve blocks are reserved for revisions or exceptional cases of patients with
preoperative chronic pain (Table 5.1).
In THA patients, various studies have concluded that the use of PNBs does not
result in superior pain control or lower opioid consumption. Nielsen et al. [41] stud-
ied obturator nerve blocks (ONBs) in a RCT of THA patients also undergoing spinal
anesthesia, finding equivalent opioid consumption and no difference in the level of
pain or nausea compared to a placebo. In an RCT from our institution, Johnson et al.
[42] compared continuous lumbar plexus block to periarticular injection (PAI) in
THA and found no substantial difference in terms of maximal pain or opioid con-
sumption postoperatively. Similarly, a recent meta-analysis including 2296 patients
demonstrated no difference between local infiltration analgesia and PNBs in terms
of analgesia or opioid consumption 24 h after THA. For this reason, our institutional
protocol for THA is a single-shot spinal anesthetic with PAI at the time of surgery
including ketorolac, morphine, bupivacaine, and a steroid. We selectively use lum-
bar plexus blocks for complex revision hips and according to specific surgeon pref-
erences (Table 5.1).
Periarticular Injections (Pais)
In the early 2000s, surgeons and anesthesiologists began using PAIs in THAs and
TKAS. These PAIs typically consist of various combinations of long and short-
acting local anesthetics, nonsteroidal anti-inflammatories, opioids, and adjuncts
such as epinephrine. There is an abundance of evidence demonstrating the efficacy
of PAIs in reducing postoperative pain levels, and opioid usage [38, 43]. The evi-
dence that PAI is as effective as certain PNBs for patients undergoing arthroplasty
is also growing [42, 44]. The optimal dosage and combination of local anesthetic
and adjuvants in the PAIs used in THAs and TKAs remains to be determined. Kelley
et al. [45] compared two PAI cocktails and found less postoperative pain when
ketorolac was included along with local anesthetic and epinephrine in the cocktail.
There is some evidence that administration of the PAI earlier in the surgical pro-
cedure (i.e., prior to incising tissues) may be superior to administration of PAI at the
late stages of arthroplasty [46]. This could be related to the preemptive block of pain
receptors resulting in the prevention of hypersensitization to pain in the postopera-
tive period, similar to the oral administration of anti-inflammatories prior to surgery.
The use of liposomal bupivacaine-based PAIs that allows for delayed delivery of
local anesthetic over time has also been proposed. Multiple studies have compared
liposomal bupivacaine to conventional bupivacaine when used in PAIs in arthro-
plasty, and most have found no difference in postoperative pain or opioid consump-
tion [40, 47–49]. Given the increased cost associated with liposomal bupivacaine,
we are no longer using this form in PAIs at our institution.
Conclusion
Contemporary multimodal pain management is an essential component of a suc-

cessful outpatient arthroplasty program and employs anesthetics and analgesics of
varying mechanisms of action and via various routes of administration periopera-
tively to prevent hypersensitization of pain receptors and to target multiple pain
pathways. The appropriate use of MMA in arthroplasty patients results in fewer
complications, lower opioid consumption, lower cost, and faster return to function.
While the ideal combination of anesthetic and analgesic techniques is likely to vary
based on individual surgeon and practice variables, it is clear that patients will ben-
efit from a deliberate, coordinated approach to pain management that includes the
preoperative, intraoperative, and postoperative periods. Failure to provide a thought-
ful MMA program undoubtedly increases the risk of failure to discharge and read-
missions when performing same-day discharge outpatient THA and TKA.
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Chapter 6
Surgical Techniques and Protocols
to Minimize Blood Loss and Postoperative
Pain
Nathanael Heckmann and Scott Sporer
Introduction
Modern outpatient total joint arthroplasty (TJA) is possible because of recent

advances in surgical techniques and perioperative protocols that have decreased
blood loss and minimized postoperative pain thereby facilitating more rapid recov-
ery. This has allowed selected patients to go home on the same day of surgery.
Historically, TJA was associated with a high rate of blood product transfusion, with
national rates ranging from 15–20% following total knee arthroplasty [1] and
24–28% following total hip arthroplasty [2]. Today, with less invasive surgical tech-
niques, hypotensive anesthesia, and the broad utilization of tranexamic acid, trans-
fusion rates have markedly decreased. Furthermore, modern advancements in
surgical techniques and postoperative pain protocols have allowed patients to mobi-
lize quicker and return home sooner. Here we describe blood management and sur-
gical techniques surgeons can utilize to safely facilitate outpatient TJA. Multimodal
pain protocols and anesthetic techniques including regional blocks are discussed in
separate chapters and will not be discussed extensively here.
N. Heckmann
Department of Orthopaedic Surgery, Keck Medical Center of USC, Los Angeles, CA, USA
S. Sporer (*)
Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA

Switzerland AG 2023
50 N. Heckmann and S. Sporer
Blood Management
Preoperative Optimization
Blood management starts with a thorough preoperative evaluation of the patient and
involves an assessment of the patient’s comorbidities, hemoglobin, and surgical
considerations based on the patient’s anatomy (i.e., presence of deformity, body
habitus, etc.). Prior to surgical intervention, patients should undergo a detailed med-
ical examination that includes a thorough assessment of nutritional status, comor-
bidity burden, body mass index, as well as other medical factors that may be
associated with anemia or increased intraoperative blood loss. Patients with a known
or presumptive history of blood dyscrasias, particularly coagulopathies, should be
assessed preoperatively by a hematologist for preoperative optimization and periop-
erative care.
Patients with low starting hemoglobin should be optimized to mitigate their risk
of requiring a postoperative blood transfusion. Medical treatment of preoperative
anemia should follow a systematic algorithm. First, if a singular underlying cause of
the patient’s anemia is identified (e.g., iron deficiency), this should be addressed and
corrected before elective TJA, if possible. If a patient is determined to have chronic
anemia from an irreversible medical condition (e.g., lupus, rheumatoid arthritis,
etc.), the surgeon should consider sending the patient to a hematologist or medical
specialist for further optimization and management.
In regard to perioperative blood management, several medical strategies exist to
optimize a patient preoperatively. Vitamin and mineral supplementation with iron,
folate, vitamin C, and vitamin B12 may help correct certain types of anemias, par-
ticularly if the anemia is caused by a specific vitamin or mineral deficiency. Vitamin
supplementation preoperatively may also provide the patient with ideal “building
blocks” to undergo postoperative hematopoiesis in a potentially more efficient way.
However, there is limited data about the clinical benefit of vitamin supplementation
in patients with normal preoperative hemoglobin [3–5]. A study by Cuenca et al.
assessed 156 consecutive patients who received ferrous sulfate (256 mg/day), vita-
min C (1000 mg/day), and folic acid (5 mg/day) for 30–45 days before undergoing
a primary total knee replacement [3]. The authors of this study noted a decrease in
transfusion rates in patients who received vitamin supplementation from 32% to
5.8%. However, the authors did not use tranexamic acid, used tourniquets that were
let down after skin closure, and used two deep drains in all patients, limiting the
generalizability of their findings. Currently, there are no high-quality data support-
ing the routine preoperative supplementation of all patients with vitamins and min-
erals. As such, preoperative supplementation should be done on a case-by-case
basis, particularly for patients with preoperative anemia and a known deficiency.
Erythropoietin supplementation may also be utilized for patients with preopera-
tive anemia prior to surgery. While routine use of preoperative erythropoietin sup-
plementation is not supported by the literature, its use for select cases where large
amounts of anticipated blood loss are expected and for patients with preoperative
6 Surgical Techniques and Protocols to Minimize Blood Loss and Postoperative Pain 51
anemia may be warranted. A study by Pierson et al. used erythropoietin in select

patients as part of a blood-conservation strategy in 500 consecutive patients under-
going primary total knee or total hip arthroplasty and reported a transfusion rate of
2.1% compared to 16.4% in a group that did not follow the author’s algorithm [6].
However, the authors of this study did not use tranexamic acid, limiting the applica-
bility of their findings to current clinical practice. Other authors have reported
decreased blood loss and lower transfusion rates associated with the preoperative
administration of erythropoietin in select patients [7, 8].
Lastly, preoperative autologous donation of blood products may be considered in
patients with preoperative anemia or if more than typical blood loss is expected at
the time of surgery. While this strategy was used frequently in the past with variable
efficacy, preoperative screening and optimization as well as the near-universal use
of tranexamic acid have led to a marked decrease in this practice [9]. As such, pre-
operative autologous donation of blood products should be used only for select
cases, particularly when large amounts of blood loss are expected, scenarios that are
almost always reserved for the inpatient surgical setting and thus not applicable to
outpatient surgery.
Intraoperative Blood Management Strategies
Intraoperative blood management strategies include tourniquet use during total

knee arthroplasty (TKA), electrocautery, less invasive surgical techniques, antifibri-
nolytic medication, and hemostatic agents. While the merits of tourniquet use dur-
ing primary TKA is currently a subject of debate, several studies have documented
improved visualization, increased operative efficiency, decreased operative time,
improved cement interdigitation, decreased blood loss, and decreased rates of post-
operative transfusion [10, 11]. However, some surgeons advocate against the use of
tourniquets during routine primary TKA, citing increased pain and swelling,
decreased quadriceps strength, and cellular damage related to transient ischemia. In
today’s climate of broad tranexamic use, the prior debates about the merits of tour-
niquet use as a means to decrease blood loss may be diminished and it remains the
surgeon’s choice based upon the level of surgical comfort.
The broad utilization of tranexamic acid had led to less blood loss and markedly
decreased rates of allogeneic blood transfusion following primary total hip and total
knee arthroplasty. In the past, high rates of transfusion in TJA mandated inpatient
observation. Recent guidelines from the American Academy of Hip and Knee
Surgeons, American Society of Regional Anesthesia and Pain Medicine, American
Academy of Orthopaedic Surgeons, The Hip Society, and The Knee Society now
recommend tranexamic acid administration for knee and hip arthroplasty as a means
of decreasing blood loss and reducing the risk of transfusion [12]. These guidelines
do not recommend a specific route of administration, citing insufficient data to rec-
ommend between intravenous, oral, topical, or a combination thereof. Rather, the
guidelines recommend that a dose of tranexamic acid be given, regardless of route,
prior to skin incision as an effective means to decrease blood transfusion rates.

Lastly, the guidelines cite a lack of sufficient data to support multiple doses of
tranexamic acid utilization. If there is one takeaway from this chapter, it is that all
patients should receive tranexamic acid in the perioperative period unless there is a
true contraindication to its administration.
Postoperative Pain
Tourniquet Use
In the discussion of postoperative surgical pain, one of the more commonly debated
topics is tourniquet use. As mentioned previously, tourniquet use during TKA
remains popular among surgeons due to improved visualization, reduced intraop-
erative blood loss, and improved cement mantle. However, the resultant ischemia
has been associated with increased postoperative pain [13–16]. As such, some sur-
geons advocate for tourniquet-less surgery, in which it is only used during cementa-
tion, as a means to decrease postoperative pain and promote more rapid functional
recovery. However, the evidence is conflicting as some studies failed to detect a
difference in postoperative pain levels among patients undergoing TKA with or
without tourniquet use [11, 17, 18]. A double-blinded randomized study by Goel
et al. assessed 200 patients undergoing elective TKA and randomized them to
undergo surgery with or without a tourniquet [11]. The authors of this study reported
greater blood loss and decreased surgical visualization in the group that did not
receive a tourniquet, and did find any difference between the two groups in regard
to pain, range of motion, or function.
While the topic of tourniquet use merits further investigation, some limited evi-
dence points to the notion that it may not necessarily be the use of tourniquets but
rather the manner in which they are used. One such possible concept is to use the
tourniquet for a shorter period of time, which was shown in a randomized trial to
reduce postoperative pain [19]. Considering most surgeons’ operative speed is not
easily modified, if shorter tourniquet time is desired, it is best to target its use to
maximize the benefit. Most techniques utilizing short tourniquet time focus on the
cementation portion to maximize the cement mantle and therefore the durability of
the reconstruction [16]. A recent meta-analysis of randomized controlled trials
found that cement-only tourniquet application resulted in greater blood loss, but
improved postoperative pain and earlier functional recovery [20]. The study was
limited by the general lack of high-quality trials investigating pain specifically.
More research is required on this topic, particularly in light of the increasing popu-
larity of uncemented TKAs, where improving the cement mantle is not a
consideration.
Tranexamic Acid
The utilization of tranexamic acid has rapidly increased in popularity in TJA as a

means to reduce blood loss and minimize the need for subsequent transfusion.
However, another benefit of this medication may be the ability to reduce early post-
operative pain by decreasing the size and duration of postoperative hemarthrosis.
By reducing the volume and duration of postoperative hemarthrosis, patients may
experience less pressure within the joint, allowing for decreased pain and improved
early range of motion. While the association between tranexamic acid use and
decreased pain is a relatively new concept that has been demonstrated in other
orthopedic specialties, particularly in anterior cruciate ligament reconstruction sur-
gery, this relationship has not been demonstrated in TJA.
Several well-powered randomized controlled trials have shown that tranexamic
acid given during anterior cruciate ligament reconstruction surgery significantly
reduces postoperative hemarthrosis and pain, along with the expected reduction in
blood loss [21–23]. However, limited data exists supporting a relationship between
tranexamic use and decreased postoperative pain in arthroplasty patients. Wang
et al. conducted a double-blinded prospective randomized controlled trial in patients
undergoing primary TKA [24]. All patients received pre-incision and 3-h postsurgi-
cal intravenous tranexamic acid,and were then randomized to receive oral tranexamic
acid or placebo for 14 days. The authors noted decreased ecchymosis and swelling
in the group that received prolonged oral tranexamic acid, but were unable to dem-
onstrate any differences in pain. However, the study was not powered to detect dif-
ferences in pain scores. A recent retrospective study by Grosso et al. found improved
pain levels during physical therapy in patients who received tranexamic acid during
TKA [25]. The authors of this study found that patients who received tranexamic
acid were able to ambulate approximately 20% more than patients who did not
receive this intervention. However, the retrospective nature of this study is subject
to confounding and bias, highlighting the need for further high-powered studies
before any definitive conclusion can be made between pain relief and tranexamic
acid utilization.
Incision Length and Surgical Technique
Surgical technique may play a crucial role in postoperative pain and recovery. One
technical aspect that was previously thought to influence pain is the length of the
skin incision, as more pain fibers are likely recruited by increasing incisional length,
suggesting smaller “minimally invasive” incisions may result in improved pain and
postoperative outcome. However, there is currently limited data to support this
notion [26]. A recent retrospective study by Nam et al. analyzed over 1800 patients
who underwent elective total hip arthroplasty and were unable to demonstrate a
relationship between incision length and postoperative pain [27]. A meta-analysis
by Xu et al. encompassing 14 studies and over 1100 THA patients found no differ-
ence in pain medication dosing postoperatively based on incision length [28].
While incision length alone may not provide any marked differences in postop-
erative pain, other aspects of so-called minimally invasive TJA may lead to decreased
postoperative pain and improved early functional recovery, such as decreased deep
dissection and less traumatic exposure technique. A study by Dorr et al. randomized
patients undergoing elective total hip arthroplasty to a minimally invasive 10 cm
incision group or a traditional long incision 20 cm group. At the end of the case, the
surgeon extended the incision length of the minimally invasive group to match the
incision length of the long incision group. The patients in the minimally invasive
group had improved early postoperative pain and shorter inpatient length of stay.
The authors of this study noted that the minimally invasive group underwent less
extensive splitting of the gluteus maximus and less extensive deep dissection, sug-
gesting that the benefits conferred by minimally invasive surgery may be related to
the extent of the deeper soft tissue manipulation rather than the length of the skin
incision. Another study by Majima et al. assessed 200 consecutive elective TKA
patients who were randomized to a minimally invasive patellar subluxation group or
a traditional extensile patellar eversion group [29]. The authors found that the mini-
mally invasive group had decreased postoperative pain and better postoperative
motion and improved postoperative strength. These studies suggest that factors
other than skin incision length have an effect on postoperative pain and recovery.
However, the data regarding minimally invasive surgery and postoperative pain
is mixed, largely due to limitations in the ability to accurately measure and stan-
dardize the extent of deeper soft tissue dissection, limitations in the sensitivity of
instruments available to measure pain, and the subjective nature of pain perception
by surgical patients. One small randomized trial found no difference in early post-
operative Knee Society Scores and Western Ontario and McMaster Universities
Osteoarthritis Index (WOMAC) scores between conventional and minimally inva-
sive TKA patients [30]. In contrast, a single-surgeon study found a minimally inva-
sive technique was associated with both improved range of motion and decreased
pain scores compared to a standard incision in patients undergoing elective total
knee arthroplasty [31]. This was corroborated in a smaller study, which found that
smaller incisions were associated with improved pain scores and decreased pain
medication usage, but were also associated with a higher incidence of varus
malalignment of the tibial component possibly due to reduced visualization [32].
More research is needed to assess what aspects of minimally invasive surgery lead
to less pain without compromising component position or implant longevity.
The surgical technique during TKA exposure may affect postoperative pain. A
small study comparing a minimally invasive midvastus approach to a standard
medial parapatellar incision found that the midvastus approach was associated with
reduced pain scores and decreased pain medication use [33]. This was confirmed in
a small randomized study, which found a similar, mini-subvastus approach resulted
in reduced pain and improved functional outcome scores compared to the standard
approach [34]. In contrast, a randomized double-blinded trial in patients undergoing
TKA found no difference in postoperative pain between a midvastus and standard
medial parapatellar approach [35]. However, this trial was performed in simultane-
ous bilateral TKA patients, with a different approach performed on each side limit-
ing the generalizability of these findings.
Conclusion
Advances in blood management and surgical technique for TJA have led to decreased
blood loss, lower rates of transfusion, decreased pain, and accelerated postoperative
recovery, facilitating same-day discharge. Further study is needed to elucidate the
technical aspects of minimally invasive surgery that lead to the most benefit in terms
of decreasing postoperative pain. Within the context of outpatient TJA, surgeons
should utilize tranexamic acid on all patients and choose a surgical technique they
are most comfortable with to reduce surgical times and hasten their patient’s
recovery.
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dard medial parapatellar approach: a prospective, randomized, double-blinded study in patients
undergoing bilateral total knee arthroplasty. J Arthroplast. 2010;25(6 Suppl):5–11. 11.e1
Chapter 7
Anesthesia for Outpatient TJA: Anesthetic
Techniques and Regional Blocks
Mark E. Nielson
Preoperatively
Patient Optimization
Following safe patient selection for outpatient TJA [1, 2], preoperative optimization
of patient physical status and comorbidities helps to insure a successful outpatient
surgery. At our institution, we achieve this goal by using a single internal medicine
physician who works only with TJA patients to prepare them for surgery and medi-
cally follow them after surgery. In addition, upcoming surgeries are discussed dur-
ing a routine coordinated care conference attended by all key members of the
multidisciplinary care team. The goal of the meeting is to share information across
disciplines, anticipate and answer questions, and proactively develop patient care
plans based on comorbidities and needs.
Institutions also have adopted Enhanced Recovery After Surgery (ERAS) proto-
cols to maximize optimal recovery following major surgery [3]. Important aspects
of ERAS protocols are preoperative nutrition, preoperative fluid status, multimodal
pain protocols, and early mobilization. The main objectives for fluid status and
nutrition remain the same for the reduction of postoperative insulin resistance [3].
Nutritional status should be addressed with increased protein intake if appropriate,
and fluid carbohydrate loading is appropriate for up to 2 h prior to surgery. This
helps to optimize fluid status and reduces the immediate risk from a catabolic state.
M. E. Nielson (*)
Indiana University Health Saxony Hospital, Fishers, IN, USA

Switzerland AG 2023
60 M. E. Nielson
Multimodal Pain Control
The nervous system is an intricate system of pain, pressure, and proprioceptive sen-
sors connected to signal transducing tissue. Signals are transmitted from the periph-
eral tissues to the brain via a pain pathway. Medications can act along many areas
of the signaling pathway. Multimodal analgesia permits a reduction of opioids and
therefore opioid-related side effects by targeting different pain receptors along the
pathway with different medications. Large doses of any one drug, especially those
with sedative effects, should be avoided in the outpatient setting. Some of the most
common medications used in multimodal pathways are summarized below along
with their mechanisms and sites of action.
Analgesics: Acetaminophen is an analgesic. Its exact mechanism of action is not
known. It is theorized however to inhibit prostaglandin synthesis as well as the acti-
vation of descending serotonergic pathways in the brain. Its effect is mainly central.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs work by inhibiting
the activity of cyclooxygenase enzymes. This in turn inhibits the synthesis of pros-
taglandins and thromboxanes from arachidonic acid. Their anti-inflammatory effect
is seen in the peripheral tissues but they also have central effects on the descending
pain control system.
Opioids: Opioids produce their pharmacologic actions by acting on receptors
located on neuronal cell membranes. Pain relief is thought to be due to the mu
receptor. They inhibit presynaptic neurotransmitter release. The site of action is
both central and peripheral (Fig. 7.1).
Gabanoids: Pregabalin and Gabapentin are the main gabanoids used in multi-
modal pain regimens. They exert their effects by inhibiting the alpha 2 delta subunit
of voltage-gated calcium channels. They have anti-hyperalgesic and anti-allodynic
effects. The site of action is both peripheral and central.
Antiemetics: Nausea and vomiting are mediated primarily by visceral stimula-
tion through dopamine and serotonin. The neurotransmitters histamine (H), acetyl-
choline, serotonin, and dopamine frequently are implicated in nausea and vomiting
and are the targets of most therapeutic modalities [5].
• Famotidine blocks H2 receptors. It has no direct antiemetic effect but reduces
acid secretion by up to 90%.
• Ondansetron is a serotonin antagonist with central activity.
• Promethazine is a weak dopamine receptor antagonist and H1 receptor blocker.
It has both central and peripheral effects.
• Dexamethasone’s antiemetic mechanism is not understood but it is theorized to
have direct central action at the solitary tract nucleus, interaction with the neu-
rotransmitter serotonin, and the receptor proteins tachykinin NK1 and NK2,
alpha-adrenaline. It has both central and peripheral effects. Of note, the anti-
emetic effect of dexamethasone is greater if given at the start, rather than the end,
of surgery. It has a half-life of over 50 h and thus some institutions avoid its use
because patients are in a state of postsurgical insulin resistance after surgery.
Some studies show an increased risk while others do not [6, 7].
7 Anesthesia for Outpatient TJA: Anesthetic Techniques and Regional Blocks 61
NSAIDs
opioids
–
– m
COX
PG COX AEA FAAH
AA metabolites
TX 2-AG
12-LOX
hepoxilins CB1
– –
presynaptic GABA release

–
output neurons
DESCENDING INHIBITION
Fig. 7.1 “Proposed model for the interaction of NSAIDs, opioids, and cannabinoids in the
descending pain control system to induce analgesia. Minus symbols indicate inhibition. Inhibition
of the cyclooxygenases (COX) by NSAIDs reduces the synthesis of prostaglandins (PG) and
thromboxanes (TX) and thus increases the availability of arachidonic acid (AA). Opioids also
increase the availability of AA by activating the phospholipase A2 via the μ-opioid receptor. Via the
12-lipoxygenases (12-LOX) AA is transformed into hepoxilins, which indirectly inhibit GABA
release. By inhibiting COX and FAAH the NSAIDs spare AEA and 2-AG, which bind to the CB1
receptor (The role of the CB2 receptor in this model has not been established.) and thus inhibit
GABA release. Removal of inhibition by GABA enhances the activity of output neurons that
inhibit pain” [4]. (Source: https://www.mdpi.com/1424-8247/3/5/1335. License: Creative
Commons Attribution License https://creativecommons.org/licenses/by-nc-sa/3.0/legalcode)
• Prochlorperazine’s mechanism of action is unknown but it is believed to block

dopamine in the brain.
• Essential oils: There are proprietary blends of essential oils that when inhaled
have been shown to have antiemetic effects. The exact mechanism of action is
unknown.
• Scopolamine is an anticholinergic. It acts as a competitive inhibitor at postgan-
glionic muscarinic receptor sites of the parasympathetic nervous system. It also
acts on smooth muscles that respond to acetylcholine but lack cholinergic
innervation.
• Anti-Anxiety: Benzodiazepines bind the alpha and gamma subunits of the gaba-a
receptor. This increases chloride ion channel opening and increases inhibitory
effects of gaba on neuronal excitability. Effects are mainly central. Midazolam
has been shown in one study to improve post-op nausea [8].
62 M. E. Nielson
Intraoperatively
Evidence-based guidelines for the best primary anesthetic have yet to be elucidated.
Several studies have shown that spinal anesthesia has fewer complications and side
effects than general anesthesia. However, current clinical trials are questioning
these results. The decision to use spinal anesthesia, general anesthesia, or a combi-
nation of both should be made on a program-by-program basis. The needs of each
program are influenced by both surgeon and anesthesia experience and prefer-
ence [9].
Spinal Anesthesia
Several studies have shown benefits from a spinal anesthetic. Decreased blood loss,
decreased nausea and vomiting, decreased length of stay, decreased incidence of
deep vein thrombosis, increased tissue oxygenation, and thus possible decreased
infection rates have all been demonstrated [10]. According to 2014 American
College of Cardiology/American Heart Association guidelines on cardiovascular
evaluation and management of patients undergoing non-cardiac surgery, there is no
difference in the incidence of myocardial infarction or death when spinal or general
anesthesia is used [11]. There are nonetheless multiple factors to consider if a spinal
anesthetic is chosen.
Timing: Metabolism and redistribution of anesthetics begin when a spinal is
placed limiting the amount of time a patient is rendered insensate from the local
anesthetic. If the duration is a concern, a combined spinal and epidural may be per-
formed. Hyperbaric bupivacaine 0.75% is the local anesthetic of choice for most
anesthesiologists for spinal anesthesia. However, more recently, different local
anesthetics have been chosen for their pharmacokinetic and pharmacodynamic pro-
files as briefly summarized below. The approximate duration of action based on the
dosage of each anesthetic is provided in Table 7.1.
Table 7.1 Approximate duration of local anesthetics based on dose

Local anesthetic Dose in milligrams Approximate duration in minutes
Bupivacaine 6 45–75
7.5 75–90
10 100–150
12 150–180
Mepivacaine 39 50–60
42 60–70
45 80–90
50 100–120
Lidocaine 50 100–120
Chloroprocaine 50 60
• Bupivacaine in an intermediate duration amide local anesthetic. It is most com-

monly seen in a hyperbaric formulation of 0.75% but some institutions use the
isobaric 0.5% formulation. It is the most commonly used spinal anesthetic par-
tially due to its low incidence of transient neurologic symptoms.
• Mepivacaine is a short duration amide local anesthetic. It is found in the isobaric
form both in 2% and 1.5% formulations. It is noteworthy that intrathecal use of
mepivacaine is off label. There has been a recent resurgence of its use as an intra-
thecal anesthetic with a low incidence of transient neurologic symptoms.
• Lidocaine is a short acting amide local anesthetic. Preservative-free lidocaine
can be readily found in 1% and 2% formulations. Some anesthesiologists avoid
lidocaine due to its history of a higher incidence of transient neurologic symp-
toms than bupivacaine and mepivacaine. However, it has been used recently as a
short acting local anesthetic with a low reported incidence of transient neuro-
logic symptoms [12].
• Chloroprocaine has FDA clearance as an ultra-short-acting local anesthetic for
intrathecal use. It is found in a 1% formulation and is an ester. The incidence of
transient neurologic symptoms with chloroprocaine is low.
Opioids in Spinal Anesthesia: The addition of an opioid to intrathecal local anes-
thetic can have a synergistic effect on analgesia duration. Hydrophilic opioids like
morphine have a biphasic effect on respiratory depression that can last up to 24 h.
Consequently, morphine is not indicated for outpatient procedures. Lipophilic opi-
oids like fentanyl do not have the same respiratory profile. Fentanyl, which also
extends the duration of local spinal anesthesia, has been shown to be safe. Some
studies report an increased incidence of urinary retention with the addition of any
opioid to the spinal anesthetic. However, fentanyl has been used extensively in the
outpatient setting for many years without significant consequences [13, 14]. The
typical dose of fentanyl is 15–25 μg in the local solution which may add an addi-
tional 15–30 min of time to local anesthesia duration.
Transient Neurologic Symptoms: The prevalence of transient neurologic symp-
toms (TNS) has driven the decision to use one local anesthetic over another.
Lidocaine has the highest listed incidence of TNS and bupivacaine the lowest. The
relevance of this in TJA is unclear.
Spinal Headache: A low cerebral spinal fluid (CSF) headache may develop after
spinal anesthesia. The mechanism is leaking CSF following a dural puncture. The
resulting decrease in CSF causes a gravity-related drag on the brain when standing
or sitting which improves while lying flat. The incidence of spinal headache is lower
in older patients and higher in younger patients. Consequently, CSF headache is
relatively rare in TJA because most patients are older. The incidence of spinal head-
ache is also influenced by the type of needle used. Incidence is higher with a cutting
needle and lower with a pencil point needle. It is recommended a pencil point nee-
dle be used.
Coagulation Status: Spinal anesthesia is contraindicated if a patient is in an anti-
coagulated state. The American Society of Regional Anesthesia (ASRA) has
64 M. E. Nielson
provided guidelines for anesthesia in these patients [15]. If a patient is not at an

acceptable risk per ASEA guidelines, spinal anesthesia should not be performed.
General Anesthesia
A common misconception is that general anesthesia is only performed with inhala-

tional anesthetics. General anesthesia is a level of sedation and is not defined solely
by the type of drug used. The American Society of Anesthesiologists defines general
anesthesia as a drug-induced loss of consciousness where patients are not arousable
to painful stimulation and often require assistance in maintaining an airway and
positive pressure ventilation may be required [16].
Pros of General Anesthesia: General anesthesia can be continuously given to a
patient and thus timing/duration of the anesthetic is not an issue. There also are no
contraindications related to coagulation status. The failure rate for administering
general anesthesia is virtually zero as a secured airway, either by a supraglottic air-
way or endotracheal tube, is all that is needed. General anesthesia can be adminis-
tered without a secure airway but is not recommended because the risk of aspiration
is increased. General anesthesia poses little to no concern regarding the patient’s
level of sedation and awareness during surgery, and patients quickly return to nor-
mal neurologic function.
Cons of General Anesthesia: General anesthetic blunts the response to surgical
stimuli, but it does not render a patient completely insensate. Physical responses to
surgery-related changes in heart rate and blood pressure can occur with the latter
contributing to blood loss. Treatment of iatrogenic hypertension in the post-
anesthetic care unit can present additional challenges and lingering antihypertensive
medications may result in hypotension. In addition, an unconscious patient may
move in response to surgical stimuli. Paralytics can be used, but they hinder the
immediate detection of nervous tissue damage. There is a greater incidence of nau-
sea and vomiting with general anesthesia, in particular general anesthesia utilizing
inhalational anesthetics.
Regional Anesthesia for the Hip
Regional anesthesia blocks peripheral nerves in a specific region of the body such
as the hip joint. The anteromedial joint capsule of the hip is innervated by the obtu-
rator nerve; the anterior joint capsule is innervated by the femoral nerve; and the
posteromedial capsule is innervated by the sciatic nerve and articular branches from
the sciatic nerve to the quadratus femoris muscle. Articular branches of the superior
gluteal nerve innervate the posterolateral joint capsule. The skin and superficial tis-
sues for surgical access are innervated by the lateral femoral cutaneous nerve [17].
Five common regional anesthesia nerve blocks for the hip are described below.
• Facia iliaca compartment blocks have shown good pain control after hip surgery
in multiple studies [18]. This block represents an anterior approach to lumbar
plexus blocks. A suprainguinal approach placing 30–40 mL of local anesthetic
just below the iliacus fascia reliably anesthetizes the femoral, lateral femoral
cutaneous, and obturator nerves. Some anesthesiologists have tried using low
concentrations of ropivacaine to avoid quadriceps weakness with variable results.
Whenever the femoral nerve is anesthetized, muscle weakness can be an issue.
• Quadratus lumborum blocks have been shown to provide pain control after total
hip arthroplasty while maintaining adequate muscle strength [19]. This block is
similar to the transversus abdominis plane block except local anesthetic is placed
posterolateral to the transversus abdominis muscle and just below the fascia of
the quadratus lumborum. Clinical trials are underway to help determine the use-
fulness of this block in the outpatient setting.
• Erector spinae blocks also have been shown to provide pain control after total hip
arthroplasty, with adequate strength maintained. Local anesthetic is placed below
the erector spinae muscles at the Lumbar 4 transverse process on the ipsilateral
side of the surgery. One study showed benefit in pain control as compared to a
standard intravenous pain medication regimen [20]. Further studies are needed to
determine the utility of this block.
• Lateral femoral cutaneous blocks have been shown to be effective for patients
with moderate to severe pain following total hip arthroplasty. It is primarily used
as a rescue block. The block is performed by ultrasound landmarks of the tensor
fascia lata and the sartorious muscle. The nerve can be visualized close to these
structures below the lateral edge of the inguinal ligament.
• Local infiltrative anesthesia (LIA) has been shown to improve pain scores when
compared to placebo. However, for hip replacement surgery, LIA is not better
than preoperative spinal anesthesia followed by multimodal analgesia with acet-
aminophen plus an NSAID/COX-2 inhibitor and either glucocorticoid or gaba-
pentinoid [21].
Regional Anesthesia for the Knee
Peripheral nerve blocks are commonly used in total knee arthroplasty. The anterior
knee capsule is innervated by the prepatellar plexus which consists of quadrants.
The superolateral quadrant is innervated by the nerve to the vastus lateralis, the
nerve to the vastus intermedius, superior lateral genicular nerves, and common fibu-
lar nerves. The inferolateral quadrant is innervated by inferior lateral genicular
nerves and recurrent fibular nerves. The superomedial quadrant is innervated by
nerves to the vastus lateralis, vastus medialis, vastus intermedius, and the superior
medial genicular nerves. The inferomedial quadrant is innervated by inferior medial
genicular nerves and the infrapatellar branch of the saphenous nerve [22]. The pos-
terior knee capsule is innervated by the obturator, tibial, and common fibular nerves.
Regional blocks commonly used for anterior knee pain include:
66 M. E. Nielson
• Femoral nerve blocks were traditionally the gold standard for pain control after
total knee arthroplasty. A high incidence of quadriceps weakness creating fall
risks and delayed rehabilitation after surgery have resulted in decreased use of
this block in the inpatient setting and virtually nonexistent use in the outpatient
setting.
• Adductor canal block has become the new gold standard in knee arthroplasty
because it provides equivalent pain control as femoral nerve block and is less
likely to reduce strength in the quadriceps muscle. The block is performed by
placing local anesthetic in the adductor canal below the sartorious muscle at the
mid to distal thigh. The vastoadductor fascia must be pierced by the needle or
local anesthetic may not reach the canal appropriately. The saphenous nerve,
nerve to the vastus medialis, and branches of the obturator nerve are reliably in
the canal. Proximal spread of local anesthetic may be seen in up to 58% of
patients. Whether the spread is clinically significant differs with each patient. At
our institution, clinically significant quadriceps weakness was observed in 9%
(92/1021) of patients (unpublished data). 20 mL appears to be the appropriate
dose to fill the canal [23]. Pointing the ultrasound transducer as well as the nee-
dle obliquely distal during injection theoretically places the local in a more distal
location.
Single shot adductor canal blocks require less equipment and follow-up and
do not require removal of equipment or post-procedural management.
Continuous adductor canal blocks may provide additional pain control
24–48 h after surgery but recent studies are contradictory [24]. A recently
published randomized control trial showed single shot and continuous adduc-
tor canal blocks to be virtually equivocal [25].
• Local Infiltrative Anesthesia includes periarticular injection which has been
shown to provide good pain control following knee arthroplasty when compared
to placebo [26]. Timing of the periarticular injection prior to arthrotomy rather
than following component implantation may also play a role in optimizing pain
control [27]. A recent study showed that periarticular injection provided better
pain relief than adductor canal block alone [28]. It is important to note however
that pain scores did not differ in the two groups on postoperative day 0.
Postoperative day 1 showed the difference. Local adjuncts to extend the duration
of analgesia were not used so neither the adductor canal block nor the periarticu-
lar injection would be expected to last more than 8–12 h given that the half-life
of bupivacaine is 2.7 h. Another study showed that the addition of an adductor
canal block improved pain and opioid consumption beyond that provided by
periarticular injection [29]. There are many different formulations with adjuncts
for periarticular injection. An example of a common formulation is Ropivacaine
200 mg, Ketorolac 30 mg, Clonidine 80 μg, and Epinephrine 0.5 mg in a total of
101.3 mL solution.
Regional blocks commonly used for posterior knee pain include:
• iPACK (Infiltration between Popliteal Artery and Capsule of the Knee) blocks
have emerged as effective means of providing pain control without significant
side effects. Local anesthetic is placed under ultrasound guidance between the
capsule of the knee and the popliteal artery. Articular branches of the tibial nerve
are anesthetized. Foot drop due to sciatic spread of local anesthetic can occur but
reported incidence is low.
• Spank (Sensory Posterior Articular Nerves of the Knee) blocks are similar to
iPACK blocks. Local anesthetic is injected at the medial epicondyle of the femur
under ultrasound guidance. The anesthetic then spreads along fascial planes to
the posterior capsule. Spread of anesthesia to the sciatic nerve is expected to have
a lower incidence than the iPACK block.
• Posterior capsule infiltration. LIA injections can be used for posterior infiltra-
tion. Care should be used to avoid sciatic innervation. One study calls into ques-
tion the benefit of posterior capsule infiltration and reports it is not necessary [30].
Anesthesia Adjuncts for Pain Control
• Ketamine Drip: Data on the efficacy and safety of ketamine in TJA are contradic-
tory, and concern about side effects including hallucination and over sedation
have limited its use. A recent study concluded that ketamine may not provide
much additional benefit for pain control in knee arthroplasty [31].
• Lidocaine Drip: Lidocaine has been utilized in ERAS protocols for open abdom-
inal procedures. There is a paucity of studies for TJA. Current clinical trials may
help determine its usefulness in the outpatient setting [46].
• Liposomal Bupivacaine: The efficacy of liposomal bupivacaine in TJA relative to
its substantially increased cost compared to generic anesthetics has been contro-
versial. A Cochrane Database Systematic Review of randomized, double-blind,
placebo- or active-controlled clinical trials of elective surgeries (including knee
arthroplasty) reported no superiority of surgical site infiltration with liposomal
bupivacaine compared to bupivacaine hydrochloride [32].
• Cryoanalgesia: Cryoanalgesia or cryoneurolysis delivers cold temperature to
selected nerves to block the transmission of pain signals to the brain. The ante-
rior and lateral femoral cutaneous nerves as well as the infrapatellar branch of the
saphenous nerve are targeted for knee pain. Research evidence is sparse but one
multicenter, randomized, double-blind study reported decreased pain in patients
with mild to moderate knee osteoarthritis compared to sham control treatment
for up to 150 days [33]. Up to a 45% reduction in opioid consumption over a
12 week postoperative period has been reported [34].
• Cooled Radiofrequency Treatment: Liquid-cooled thermal ablation of nerves has
been studied for postoperative total knee pain. The superolateral, superomedial,
and inferomedial genicular nerves are the target of this procedure. It has been
shown to have positive pain control results for patients who are not candidates
68 M. E. Nielson
for surgery or do not wish to have total knee surgery. It has not been shown to
decrease opioid consumption post-knee arthroplasty [35].
Fluid Management
Fluid management is an important aspect of anesthesia for TJA. Too little fluid can
possibly lead to acute kidney injury and too much fluid can contribute to postopera-
tive urinary retention [36]. Classically, fluid management was based on the estima-
tion of preoperative fluid deficits prior to anesthesia, maintenance requirements
during surgery, and fluid losses during surgery. The 4/2/1 rule was used in this set-
ting—4 mL/kg/h for the first 10 kg of body weight; 2 mL/kg/h for the next 10 kg of
weight; and 1 mL/kg/h of body weight over 20 kg. This formula was used both for
the amount of time the patient was NPO (nil per os) as well as for maintenance dur-
ing the case.
Modern fluid management techniques focus on goal-directed therapy. Fluid
interventions should be directed at a clinical variable that will optimize a patient’s
fluid status (e.g., stroke volume, respiratory variation). It is difficult to determine
stroke volume or respiratory variation during TJA without invasive monitoring.
However, blood pressure and possibly variation of pulse oximeter amplitude may
give clinical indications of the need for intraoperative fluid. If a spinal is performed,
a fluid bolus preoperatively is warranted. In general, more than two liters of crystal-
loid fluid (including the initial fluid bolus) is rarely needed if intraoperative blood
loss falls within the normal range [37]. ERAS society recommendations state “It is
recommended that intravenous fluids should be used judiciously and postoperative
intravenous fluids discouraged in favor of early oral intake.” [3].
Blood Loss
Tranexamic acid has been used extensively in TJA and has shown to decrease blood
loss. It is a synthetic lysine analog that reversibly binds to the lysine receptor sites
on plasminogen inhibiting the conversion of plasminogen to plasmin. Multiple stud-
ies have shown its safety profile. A clinical practice guide endorsed by both the
American Academy of Hip and Knee Surgeons and the American Society of
Regional Anesthesia and Pain Medicine is available [38].
Intraoperative Treatment of Nausea
Ondansetron and Dexamethasone are both effective for postoperative nausea.

Female gender post-puberty, nonsmoking status, history of postoperative nausea
and vomiting (PONV) or motion sickness, increasing duration of surgery, and use
of volatile anesthetics, nitrous oxide, large-dose neostigmine, or intraoperative or
postoperative opioids are well established PONV risk factors [39].
Postoperatively
Pain Management
Scheduled pain assessments should be performed prior to discharge. Typical scales

include numerical rating scales which use numbers such as 0 = no pain to
10 = extreme pain, visual analog scales where patients mark the place on a scale
corresponding to their pain level, and categorical scales where response options
such as none, mild, moderate, and severe are used to communicate pain. Pain con-
trol protocols should be developed. Some programs advocate utilizing as little opi-
oids as possible while others use opioids to help control moderate to severe pain.
Opioids should be used sparingly if possible, but their use is appropriate for uncon-
trolled pain.
Intractable postoperative pain (i.e., pain unrelieved by modest doses of opioid
medication) is rare. For hip arthroplasty patients with intractable pain, a rescue lat-
eral femoral cutaneous nerve block should be considered. For knee arthroplasty
patients with intractable anterior pain, an anterior femoral cutaneous nerve block
may help. For lateral pain, a vastus lateralis nerve block may help. For posterior
pain, a SPANK block can be used if no other posterior blocks have been performed.
Nausea and Vomiting
Pro re nata (PRN) orders for postoperative nausea typically include ondansetron and
possibly promethazine or prochlorperazine. There is evidence that essential oils also
are effective [40, 41].
70 M. E. Nielson
Urinary Retention
Acute postoperative urinary retention (POUR) is a significant barrier to outpatient

TJA as it can result in pathologic bladder distention and injury, urinary tract infec-
tion (with possible hematogenous periprosthetic infection), and catheterization-
related complications. The incidence of acute POUR following TJA has been
documented to range from 0 to 75%, varying based on the perioperative practices of
TJA programs; characteristics of study populations; and definitions, measurement,
and treatment methods for acute urinary retention [42]. High rates of POUR under-
score the need for defined criteria and an established treatment plan. Most success-
ful programs have an incidence below 5% [43]. Oliguria and acute kidney injury
also are significant concerns.
While it is understood that POUR is defined by residual urine in the bladder 4 h
after surgery, clinical criteria for the diagnosis of POUR (and commencement of
catheterization treatment) are more arbitrary and variable. Although there are no
TJA-specific guidelines, many surgeons use the adult urinary bladder capacity of
400–600 mL within 2–8 h of surgery as the threshold for intermittent catheterization
[44]. A randomized controlled trial examining catheterization thresholds following
fast-track TJA observed a significant reduction in postoperative catheterization from
32% when a 500 mL threshold was applied to 13% when an 800 mL threshold was
used with no attendant increase in urological complications [45]. Clinical criteria
and treatment protocols for POUR at our institution, resulting in a 3.9% incidence
of POUR in same-day discharge patients, [43] are provided in Appendix 1.
Sample Outpatient TJA Anesthesia Protocol
The Indiana University Health Saxony Hip and Knee Center has safely performed
479 outpatient hip and knee arthroplasty procedures between September 2014 and
November 2019. There have been no deaths. Data for cases performed by the end of
July 2018 indicate an all-cause 90-day readmission rate of 3.7% (6 patients).
Readmission reasons included atrial fibrillation, transient ischemic attack, superfi-
cial joint infection, deep joint infection, venous thromboembolism, and urinary tract
infection. Medical risk stratification for outpatient selection [1, 2] and the standard-
ized multimodal perioperative pain protocols provided in Appendix 2 have provided
the foundation for us to safely provide outpatient TJA.
ppendix 1: Indiana University Health Saxony hip and Knee

A
Center Call Orders for Postoperative Urinary Retention
Criterion for Oliguria Indication1
• Urine production less than 300 mL per 8 h shift

• Equates to 37.5 mL/h of urine production (300 mL/8 h)
Post-Anesthetic Care Unit documents time of last void prior to surgery.
Patients are asked to void in the 2–3 h postsurgical time frame. If unable, a blad-
der scan is performed.
• Scan >399: I/O catheterization is performed. Patient is then asked again to void
after an additional 2 h and the process recurs until the patient is able to void.
• Scan <400: Pt is asked to void after another hour. If still unable to void then I/O
catheterization is performed. Patients are then asked to void again after another
2 h and the process recurs until able to void. If the initial bladder scan shows less
than 37.5 mL/h urine production since arrival then a bolus of 500 mL IV crystal-
loid is given.
ppendix 2: Indiana University Health Saxony hip and Knee

A
Center Multimodal Perioperative Pain Protocol
for Outpatient Arthroplasty
Prior to Arrival for Surgery
• Patients are encouraged to drink clear carbohydrate fluids up to 2 h before the

scheduled arrival time. Scheduled Arrival time is emphasized rather than surgical
time to maintain 2 h of NPO in case surgeries are running ahead of schedule.
• 24 h before arrival time, begin 1000 mg acetaminophen TID
Preoperative Unit
Unless contraindicated patients are given:

• Ondansetron 4 mg IV push
• Gabapentin 300 mg po
• Oxycodone ER 20 mg po
1
Protocol pertains to patients without an indwelling catheter.
72 M. E. Nielson
• Famotidine 20 mg po
• Acetaminophen 1000 mg
• Celecoxib 400 mg po (if renally appropriate and not allergic)
• Hydroxizine 25 mg po
• Pantoprazole 40 mg
• Kefzol IV weight appropriate or appropriate substitute
Fluid bolus 1 L crystalloid as appropriate.
Primary hip and knee patients are not catheterized. They are asked to urinate
approximately 15 min prior to transfer to the operating room.
Intraoperatively
Primary Hips
• Spinal with Mepivacaine 1.5% approximately 37.5 mg but no more than 45 mg
and 25 μg Fentanyl
• General with LMA or ETT as appropriate and as little inhaled agent as
needed or TIVA
• Do not over-sedate patient with large doses of Midazolam in preparation for
spinal administration. Patients need to be able to participate in physical therapy
a few hours after surgery.
• If spinal appears to be wearing off before the procedure is completed (signs of
increased respirations, etc.), a small dose of fentanyl, morphine, or dilaudid is
given at the anesthesiologist’s discretion.
• 1 g IV tranexamic acid after anesthesia induction and 1 g IV at closing
• Unless contraindicated patients receive approximately 2 L IV crystalloid includ-
ing the preoperative bolus
• Ondansetron and/or Reglan or Compazine for nausea prophylaxis
Primary Knees
• Spinal with Mepivacaine 1.5% approximately 37.5 mg but no more than 45 mg
and 25 μg Fentanyl
• General with LMA or ETT as appropriate and as little inhaled agent as
needed or TIVA
• Do not over-sedate patient with large doses of Midazolam in preparation for
spinal administration. Patients need to be able to participate in physical therapy
a few hours after surgery.
• If the spinal appears to be wearing off before the procedure is completed (signs
of increased respirations, etc.), a small dose of fentanyl, morphine, or dilaudid is
given at the anesthesiologist’s discretion.
• 15–20 mL ropivacaine 0.5% with 4 mg of dexamethasone deposited in distal
adductor canal.
• Periarticular injection with ropivacaine 200 mg, clonidine 80 μg, epinephrine

0.5 mg in 100 mL.
• 1 g IV TXA after anesthesia induction and 1 g IV at closing
• Unless contraindicated patients receive approximately 2 L IV crystalloid includ-
ing the preoperative bolus
• Ondansetron and/or Reglan or Compazine for nausea prophylaxis
Post-Anesthetic Care Unit
• Cold therapy
• PRN pain medications based on patient pain rating:
–– Tramadol 50 mg Q4 prn
–– Oxycodone IR 5 Q4 prn
–– Oxycodone IR 10 Q4 prn
–– Dilaudid 0.5 mg IV Q2 prn
–– Kefzol IV or appropriate substitute (must be 8 h after preoperative dose)
–– Ondansetron 4 mg IV prn
–– Prochlorperazine 10 mg IV prn
–– Diphenhydramine 12.5 mg prn
• Physical therapy evaluation
• Occupational therapy evaluation for hip patients and all patients with BMI ≥ 35
Discharge Medications and Orders
• Acetaminophen 1000 mg TID
• Oxycodone ER 10 mg Q12 x 5 days
• Oxycodone IR 10 mg 1/2–1 tab q4H prn
• Cefadroxil 500 mg BID x 7 days
• Omeprazole 20 mg daily
• ASA 81 mg BID
• Celecoxib 200 mg BID
• Gabapentin 300 mg BID
• Docusate-Senna
• Miralax
• Cold therapy
• Elevation
In-home or outpatient physical therapy for knees only
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and narcotic consumption: a prospective randomized controlled trial. J Arthroplast.
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has no effect on postoperative pain outcomes: a prospective randomized sham-controlled trial
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article/124/6/1256/14502/Postoperative-Urinary-Catheterization-Thresholds.
Chapter 8
Threats to Same Day Discharge:
Prevention and Management
Charles P. Hannon, Parag D. Patel, and Craig J. Della Valle
Introduction
Historically, primary total joint arthroplasty (TJA) was associated with long inpa-
tient hospital stays, extended postoperative recoveries, and significant patient mor-
bidity. However, over the past 20 years, substantial advances have safely and
effectively shifted TJA from an inpatient-only procedure to an outpatient procedure
in properly selected patients [1–5].
The success of an outpatient TJA program is built upon appropriate patient selec-
tion, preoperative optimization, and patient education. In their review of 7747 TJAs
discharged the same day, Sher et al. identified younger patients, patients with fewer
comorbidities, and patients with lower body mass index as more likely to be safely
discharged home [6]. For a majority of these carefully selected patients, outpatient
TJA is very effective. Rates of severe adverse events after same day TJA have been
reported as low as 1.3% [6]. However, there are challenges that occur in the outpa-
tient setting that can delay discharge. Fraser et al., in their review of 106 patients
preselected for same day discharge, found that 85% successfully met same day
discharge criteria [7]. The most common medical reasons for not meeting discharge
criteria included dizziness or hypotension, failure to clear physical therapy, urinary
retention, and pain management. Patient preference was also a frequent reason for
delayed discharge. In these instances, patients cleared medical and physical therapy
C. P. Hannon · C. J. Della Valle (*)

Adult Reconstruction Division, Department of Orthopaedic Surgery, Rush University Medical
Center, Chicago, IL, USA
P. D. Patel
Department of Anesthesiology, Rush University Medical Center, Chicago, IL, USA
Rush Oakbrook Surgery Center, Oak Brook, IL, USA

Switzerland AG 2023
78 C. P. Hannon et al.
discharge criteria but preferred to stay overnight. Setting patient expectations

through preoperative education and providing reassurance throughout the periop-
erative period is critical to helping mitigate this change in patient preference.
However, medical complications still occur and threaten discharge. In this chapter,
we review the most common threats to discharge in outpatient TJA and provide
practical clinical advice on how to manage these complications.
Poor Pain Control
The key to addressing increased pain after TJA is prevention. Historically, opioids
were the cornerstone of pain control after TJA. However, increased attention to
opioids in light of today’s epidemic has highlighted their adverse effects including
sedation, respiratory depression, nausea, vomiting, urinary retention, and depen-
dence. As a result, multimodal analgesia has evolved to be the standard of care in
outpatient TJA [8].
As discussed in Chap. 5, the goal of multimodal analgesia is to give several anal-
gesic medications at different time points that target different pain pathways [9].
Several studies have demonstrated that multimodal analgesia is associated with
improved pain control, more rapid recovery, and shorter hospitalizations [10, 11].
Our multimodal regimen begins in the preoperative holding area with preemptive
administration of oral acetaminophen, celecoxib, and pregabalin. The goal of pre-
emptive medications is to blunt the peripheral and central nervous systems’ response
to tissue injury induced during surgery [12].
In the outpatient setting, we utilize a short acting spinal anesthetic for our hip
surgeries to allow for rapid return of motor and sensory function. For patients under-
going knee surgery, we have successfully used both short acting spinal and general
anesthesia, combined with an adductor canal block [13]. While neuraxial anesthetics
have generally been preferred historically, we have found that general anesthesia can
work very well for healthier patients as it minimizes the risks of many threats to
discharge including urinary retention and delayed return of motor function.
Intraoperatively, we use a periarticular injection that includes ropivacaine, epineph-
rine, ketorolac, and clonidine, which has been shown to further reduce pain and
opioid consumption following TJA [13]. Patients also receive 15 mg of intravenous
ketorolac and dexamethasone. Postoperatively, patients receive 1 g of acetamino-
phen every 8 h, 200 mg of celecoxib every 12 h, and 200 mg of gabapentin every 8 h.
Tramadol is also given to patients as a scheduled medication in the early postopera-
tive period, but it is later used as the first breakthrough pain medication. Oxycodone
immediate release is used as a “last resort” breakthrough pain medication.
For the vast majority of patients, we have found that the multimodal regimen above
is successful in adequately controlling pain postoperatively. However, some patients
may have postoperative pain that is more challenging to control. In these cases, it is
very helpful to work closely with the anesthesia and nursing staff to “troubleshoot”
the situation and determine the most appropriate course of action. In knee patients
8 Threats to Same Day Discharge: Prevention and Management 79
with pain that is refractory to our standard regimen, we have found that the most com-
mon cause is an adductor canal block that is ineffective. In this situation, we will
oftentimes consider having the anesthesia provider administer a femoral nerve block.
It is important to recognize that femoral nerve blocks, while typically quite effective,
are associated with quadriceps weakness and as such the patient is placed in a knee
immobilizer for 48 h postoperatively until quadriceps function returns [14, 15]. In
addition, we educate the patient and their family on the risk of falls and encourage the
use of an appropriate assistive device. For patients with pain that is challenging to
manage following hip surgery, we have had some success with an iliofascial block
administered by anesthesia; however, the results are not as predictable. Intravenous
opioid medications are used only as a last resort. In these situations, it is always
imperative to ensure that the neurovascular status of the extremity is intact and that
increased pain is not associated with phenomena such as a compartment syndrome.
Rarely, inpatient admission is required for pain that cannot be adequately controlled.
Urinary Retention
Postoperative urinary retention (POUR) following outpatient TJA is one of the most
common threats to early discharge. Rates of POUR have been identified as high as
3.9% for outpatient TJA patients [16]. In a review of 685 primary TJA discharged
the same day or day after surgery Ziemba-Davis et al. identified male gender, a his-
tory of urinary retention, the use of rocuronium, glycopyrrolate, neostigmine, fen-
tanyl spinal, and the absence of an indwelling urethral catheter as risk factors for
POUR. Interestingly, male patients who received anticholinergics and cholinester-
ase inhibitors intraoperatively had a 31% increased rate of POUR. Several other
studies have identified spinal anesthetics, as well as increased fluids (> 2 L) admin-
istered intraoperatively as risk factors for POUR [17, 18].
Given the high risk of POUR as a barrier to early discharge, it is prudent to
quickly screen patients for risk factors for POUR and either perform their proce-
dures as an inpatient or get a urological consult preoperatively. Patients who are
identified as high risk for POUR are typically scheduled earlier in the day. To reduce
the incidence of POUR, we encourage our anesthesiologists to avoid opioids, anti-
cholinergics, and cholinesterase inhibitors, especially in male patients with a history
of urinary retention. As stated above, for some patients a general anesthetic may be
preferred, as well, to lower the risk. In the PACU, we encourage patients to hydrate
with oral fluids. If patients are unable to void postoperatively, we encourage ambu-
lation. If after approximately 4 h the patient is still unable to void, we use a bladder
scanner to assess how much urine is in the bladder. If there is less than 400mL of
urine in the bladder, we continue to encourage hydration and ambulation. However,
if there is greater than 400mL we straight catheterize the patient. At this point, the
patient must be carefully educated that if they do not start to void normally, they
must either come back to the surgical facility for a repeat bladder scan, go see their
primary care physician or present to an emergency department; careful and frequent
follow-up with the patient by telephone is recommended. The other alternative is to

place a foley catheter and discharge the patient home and then have the patient see
their primary care physician or urologist for catheter removal and reassessment.
Hypotension and Tachycardia
Hypotension and tachycardia used to be common after TJA due to increased blood
loss in surgery. However, with the routine use of tranexamic acid, perioperative
blood loss has been dramatically reduced. Tranexamic acid acts as an anti-fibrinolytic
agent by competitively inhibiting the conversion of plasminogen to plasmin. The
American Association of Hip and Knee Surgeons clinical practice guideline recom-
mends tranexamic acid be given routinely in TJA because of the decreased blood
loss and transfusion rates when compared to placebo [19]. This has been widely
adopted and is now the standard of care in TJA, but the optimal dosing and route of
administration remain debated [20]. At our ambulatory surgery centers, we admin-
ister 1950 mg of tranexamic orally in the preoperative area prior to the procedure.
The risk of hypotension postoperatively is an additional reason we prefer to use
general anesthesia in the outpatient setting when otherwise safe for the patient. We
also encourage hydration preoperatively with clear liquids allowed for up to 4 h
prior to the procedure. Patients who are on angiotensin-converting enzyme (ACE)
inhibitors or angiotensin receptor blockers (ARB) for hypertension are instructed to
not take these medications the morning of surgery as these can exacerbate hypoten-
sion intraoperatively. Postoperatively, if a patient has persistent hypotension we
encourage oral fluid intake. If the patient is not able to tolerate oral liquids we work
closely with our anesthesia colleagues to address the hypotension. We typically first
administer a 500–1000 mL intravenous fluid bolus in the PACU to see how the
patient responds. We closely monitor the patient in the PACU. If there is a concern
for other medical causes of hypotension besides hypovolemia, we immediately con-
tact an internal medicine colleague to assist with management. In the outpatient
setting, these providers are not on site, but they are readily available by phone at our
academic tertiary care center to provide recommendations. If there is any concern,
we transfer the patient to an emergency department or can monitor the patient over-
night as all of our ambulatory surgical centers have 23 h observation capabilities.
Consideration should be made for this potential complication and a plan developed
depending on your outpatient center’s capacity.
Hypoxia
Hypoxia postoperatively is uncommon after outpatient TJA in properly selected

patients. At our institution, patients at increased risk for hypoxia (e.g., obstructive
sleep apnea, chronic obstructive pulmonary disease) are not offered outpatient
surgery to specifically prevent this postoperative complication or are scheduled

early in the day. Patients with obstructive sleep apnea (OSA) are 2–4 times more
likely to develop a medical complication after TJA compared to patients without
OSA [21]. Many patients with OSA are undiagnosed and thus we work closely with
our internal medicine colleagues to be sure that OSA is screened for during medical
clearance. Grau et al. found in their study of 7658 TJA that instituting a pulmonary
screening questionnaire and intervention protocol resulted in a 63-fold reduction in
pulmonary complications after TJA [14].
Another advantage of our multimodal analgesia protocol that limits opioids is
that it, too, helps prevent hypoxia postoperatively. However, if a patient presents
with hypoxia in the PACU we begin by administering oxygen via nasal cannula. The
patient’s oxygen saturation and heart rate are then continually monitored. As with
several of the other threats to discharge, we work closely with our anesthesia col-
leagues to address this situation. We have portable X-ray available at our ambula-
tory surgical centers and can get an anteroposterior chest radiograph if needed. We
encourage patients with hypoxia to utilize the incentive spirometer, as well. Often
this hypoxia is seen early in the PACU after surgery and is associated with sedation
from anesthesia or opioid use. If opioid-induced respiratory depression is suspected
we have naloxone available. The patient is then closely monitored after the proce-
dure and in most cases resolves. However, if the hypoxia persists we consult our
internal medicine colleagues. If there is any concern, we transfer the patient to an
emergency department or can monitor the patient overnight.
Nausea and Vomiting
Nausea and vomiting are common after any surgical procedure. As with several of
the threats to discharge discussed previously, prevention is key. We encourage
patients to hydrate up to 4 h prior to surgery with clear liquids. Throughout the
patient’s stay, we limit the use of opioids, which are associated with high rates of
nausea and vomiting. Intraoperatively, patients receive 10 mg of dexamethasone,
which decreases rates of nausea and vomiting after surgery. Tammachote et al.
found that patients who received 0.15 mg/kg of IV dexamethasone had better post-
operative pain relief and lower rates of nausea and vomiting compared to patients
who received a saline placebo.[15]. In addition, propofol, which is used for sedation
during neuraxial anesthesia, has a good antiemetic effect [22]. Propofol can also be
utilized as a component of general anesthesia to limit the use of anesthetic gasses
that increase the risk of postoperative nausea and vomiting.
If a patient has persistent nausea after surgery, we initially give IV ondansetron
4 mg every 4 h. We encourage hydration orally if the patient can tolerate oral intake.
If they cannot tolerate oral fluids we give intravenous fluids. If nausea persists after
ondansetron we give IV metoclopramide 10 mg. Typically, hydration and these
medications resolve nausea. Intramuscular ephedrine can also be used off-label to
treat nausea and vomiting and is reserved for refractory cases. While the mechanism
is not well understood, the sympathomimetic properties of ephedrine likely help

with lethargy, dizziness, and nausea. Patients who are concerned with nausea after
discharge are prescribed oral dissolving tablets of ondansetron 4 mg to take every
8 h as needed.
Unable to Safely Meet Physical Therapy Discharge Criteria
Proper patient selection and effective pain control are critical to ensuring that
patients are able to meet same day physical therapy discharge criteria. Maximizing
pain control as described above is important to ensure that patients are able to par-
ticipate in physical therapy. The use of general anesthesia or a short acting spinal as
well as an adductor canal block all minimize motor weakness that can inhibit par-
ticipation in physical therapy. We encourage the use of assistive devices during
physical therapy and have a physical therapist either on site or in an adjacent facility
to ensure that patients can safely ambulate prior to discharge. We attempt to sched-
ule patients preoperatively identified as potentially requiring additional therapy
prior to discharge as the first or second case so that they can have two therapy ses-
sions on the day of surgery. If a patient is still unable to meet discharge criteria, we
have the patient stay overnight in our observation unit and meet with physical ther-
apy in the morning.
Conclusion
Outpatient TJA is safe and effective for properly selected patients. While most
patients are able to safely discharge the same day after their TJA, complications can
occur after surgery that threatens to delay discharge. Dealing with these complica-
tions such as poor postoperative pain control and POUR can often be avoided with
proper selection and multimodal analgesia that limits opioids. However, when these
complications present after surgery, close care coordination with anesthesiology
and, if needed, internal medicine can help safely and effectively mitigate these
threats to discharge and allow patients to be discharged within 24 h. Patients with
complications require close follow-up after discharge and should be educated on the
importance of contacting their surgeon’s team if any concerns or issues arise.
References
1. Parcells BW, Giacobbe D, Macknet D, Smith A, Schottenfeld M, Harwood DA, et al. Total joint
arthroplasty in a stand-alone ambulatory surgical center: short-term outcomes. Orthopedics.
2016;39:223–8. https://doi.org/10.3928/01477447-20160419-06.
2. Goyal N, Chen AF, Padgett SE, Tan TL, Kheir MM, Hopper RH, et al. Otto Aufranc award: a
multicenter, randomized study of outpatient versus inpatient total hip arthroplasty. Clin Orthop
Relat Res. 2017;475:364–72. https://doi.org/10.1007/s11999-016-4915-z.
3. Berger RA, Sanders SA, Thill ES, Sporer SM, Valle C. Newer anesthesia and rehabilita-
tion protocols enable outpatient hip replacement in selected patients. Clin Orthop Relat Res.
2009;467:1424–30. https://doi.org/10.1007/s11999-009-0741-x.
4. Basques BA, Tetreault MW, Valle CJ. Same-day discharge compared with inpatient hospi-
talization following hip and knee arthroplasty. J Bone Jt Surg. 2017;99:1969–77. https://doi.
org/10.2106/jbjs.16.00739.
same-day outpatient joint arthroplasty: a systematic review. J Arthroplast. 2018;33:1265–74.
6. Sher A, Keswani A, Yao D, Anderson M, Koenig K, Moucha CS. Predictors of same-day dis-
charge in primary total joint arthroplasty patients and risk factors for post-discharge complica-
tions. J Arthroplast. 2017;32:S150–S156.e1. https://doi.org/10.1016/j.arth.2016.12.017.
7. Fraser JF, Danoff JR, Manrique J, Reynolds MJ, Hozack WJ. Identifying reasons for failed
same-day discharge following primary total hip arthroplasty. J Arthroplast. 2018;33:3624–8.
8. Hannon CP, Keating T, Lange JK, Ricciardi BF, Waddell BS, Valle CJ. Anesthesia and anal-
gesia practices in total joint arthroplasty: a survey of the AAHKS membership. J Arthroplast.
9. Kehlet H, Dahl JB. The value of “multimodal” or “balanced analgesia” in postoperative pain
treatment. Anesth Analg. 1993;77:1048. https://doi.org/10.1213/00000539-199311000-00030.
10. Sah AP, Liang K, Sclafani JA. Optimal multimodal analgesia treatment recommendations for
total joint arthroplasty. JBJS Rev. 2018;6:e7. https://doi.org/10.2106/jbjs.rvw.17.00137.
11. Golladay GJ, Balch KR, Dalury DF, Satpathy J, Jiranek WA. Oral multimodal analgesia for total
12. Kissin I. Preemptive analgesia: terminology and clinical relevance. Anesth Analg. 1994;79:809.
https://doi.org/10.1213/00000539-199410000-00037.
13. Ma H-H, Chou T-F, Tsai S-W, Chen C-F, Wu P-K, Chen W-M. The efficacy of intraoperative
periarticular injection in total hip arthroplasty: a systematic review and meta-analysis. Bmc
Musculoskelet Di. 2019;20:269. https://doi.org/10.1186/s12891-019-2628-7.
14. Grau L, Orozco FR, Duque AF, Post Z, Fink B, Ong AC. A simple protocol to stratify pulmo-
nary risk reduces complications after total joint arthroplasty. J Arthroplast. 2019;34:1233–9.
15. Tammachote N, Kanitnate S. Intravenous dexamethasone injection reduces pain from twelve
to twenty-one hours after total knee arthroplasty: a double-blind randomized placebo con-
trolled trial. J Arthroplast. 2019;35(2):394–400. https://doi.org/10.1016/j.arth.2019.09.002.
16. Ziemba-Davis M, Nielson M, Kraus K, Duncan N, Nayyar N, Meneghini MR. Identifiable risk
factors to minimize postoperative urinary retention in modern outpatient rapid recovery total
17. Lawrie CM, Ong AC, Hernandez VH, Rosas S, Post ZD, Orozco FR. Incidence and risk factors
for postoperative urinary retention in total hip arthroplasty performed under spinal anesthesia.
J Arthroplast. 2017;32:3748–51. https://doi.org/10.1016/j.arth.2017.07.009.
18. Scholten R, Kremers K, van de Groes S, Somford DM, Koëter S. Incidence and risk fac-
tors of postoperative urinary retention and bladder catheterization in patients undergoing fast-
track total joint arthroplasty: a prospective observational study on 371 patients. J Arthroplast.
19. Fillingham YA, Ramkumar DB, Jevsevar DS, Yates AJ, Bini SA, Clarke HD, et al. Tranexamic
acid use in Total joint arthroplasty: the clinical practice guidelines endorsed by the American
Association of hip and knee surgeons, American Society of Regional Anesthesia and Pain
Medicine, American Academy of Orthopaedic surgeons, hip society, and knee society. J
Arthroplast. 2018;33:3065–9. https://doi.org/10.1016/j.arth.2018.08.002.
20. Abdel MP, Berry DJ. AAHKS symposium current practice trends in primary hip and knee
arthroplasties among members of the American Association of hip and knee surgeons: an long-
term update. J Arthroplast. 2019;34:S24–7. https://doi.org/10.1016/j.arth.2019.02.006.
21. Vakharia RM, Cohen-Levy W, Vakharia AM, Donnally C, Law T, Roche MW. Sleep
apnea increases 90-day complications and cost following primary total joint arthroplasty. J
Arthroplast. 2018;34:959–964.e1. https://doi.org/10.1016/j.arth.2018.12.018.
22. Chang C-C, Wong C-S. Postoperative nausea and vomiting free for all: a solution from propo-
fol? Acta Anaesthesiol Taiwanica. 2017;54:106–7. https://doi.org/10.1016/j.aat.2016.12.002.
Chapter 9
Is there an Optimal Place for Outpatient
TJA: Hospital, ASC, or “Other”?
William G. Hamilton, Roshan T. Melvani, and Agnes D. Cororaton
In recent years the use of outpatient total joint arthroplasty (TJA) has increased with
advancements in perioperative protocols and refined anesthesia techniques.
Outpatient TJA can be performed either in a full-service hospital within the hospital
outpatient department (HOPD), or in a free-standing ambulatory surgery center
(ASC). HOPDs are under financial control and usually owned by the hospital, and
are often physically attached to the full-service hospital. Furthermore, any unit may
be considered an HOPD if it has financial or administrative contracts with a hospital
and is within 35 miles of the hospital [1]. ASCs are stand-alone facilities that oper-
ate with their own Medicare agreements and abide by the ASC Covered Procedures
List dictated by Center for Medicare and Medicaid Services (CMS). Total knee
arthroplasty (TKA) was removed from the inpatient-only (IPO) list in 2018, and as
of January 2020 was added to the ASC covered procedure list. Also in January
2020, total hip arthroplasty (THA) was removed from the IPO list, but will still not
be allowed to be performed in a free-standing ASC. Private insurers will usually
allow these procedures to be performed in either an ASC or HOPD.
Patient Mindset
Most surgeons agree that one of the most important factors leading to a successful
outpatient TJA is the patient’s intention, conviction, and willingness to go home on
the day of surgery. Currently, overnight stays are favored for patients or families that
strongly prefer the sense of security they get from staying overnight in a facility.
However, there is a growing acceptance and preference among patients to discharge
W. G. Hamilton (*) · R. T. Melvani · A. D. Cororaton

Anderson Orthopaedic Research Institute, Alexandria, VA, USA

Switzerland AG 2023
86 W. G. Hamilton et al.
home on the day of surgery. The acceptance of outpatient TJA is likely influenced
by the regional prevalence of same-day TJA.
It can be difficult to quantify this shifting mindset, and there is little published on
the subject. Meneghini et al. reported on a questionnaire that was used on 110 con-
secutive patients scheduled for TJA. Three patients expected same day discharge, 17
expected one-night stay at the hospital, and 54 expected two or more nights at the
hospital. Approximately half of the patients were aware of the outpatient TJA
option, with 55.3% of men and 31.7% of women reporting that they were comfort-
able with outpatient TJA (p = 0.03). The majority believed that faster recovery and
decreased likelihood of infection were advantages of outpatient TJA. Approximately
half of the patients in the study felt ambulatory surgery centers were as safe as hos-
pitals and believed that their individual home is the best place to recover from
TJA [2].
Husted et al. investigated 50 patients (30 TKA, 20 THA) who had surgery at an
ASC. Immediately after surgery, patients were then randomized to either recover in
the ASC or transfer to recover in a hospital arthroplasty ward. Twenty-four out of
twenty-five patients in the ASC group were discharged on the day of surgery (DOS)
compared with 20/25 discharged on the DOS from the hospital ward (p = 0.08). All
THA patients were discharged on the DOS and more TKA patients were discharged
from the ASC (15/16) compared to the hospital (9/14) (p = 0.04). The authors
offered several explanations that may have contributed to these differences. Those
randomized to the hospital group stayed with other inpatients from different spe-
cialties, potentially influencing their state of mind. Also, patients in the hospital
ward had regular beds which likely did not encourage easy mobilization, whereas
ASC patients had recovery beds that mimicked sitting and standing positions. They
also hypothesized that the staff influenced discharge, including a dedicated anesthe-
siologist who monitored and managed pain, nausea, and dizziness in the ASC com-
pared to the hospital ward where this was not the case [3].
Kelly et al. investigated patient satisfaction among 174 TJA patients. Outpatients
responded with more encouraging responses when asked about the staff’s explana-
tion of any prescription medications (outpatient = 91.4% vs. inpatient = 77.5%,
p = 0.026), the staff’s assistance with their pain management (98.3% vs. 88.0%,
p = 0.022), discharge instructions (98.3% vs. 90.1%, p = 0.05), and the courtesy and
respect from the nursing staff (100.0% vs. 92.2%, p = 0.022). Inpatients responded
with less satisfaction when asked how prepared they felt for discharge home (8.9%
vs. 0.0%, p = 0.014). The best responses in overall satisfaction with the facility
(87.1% vs. 93.4%, p = 0.204) and overall experience (89.2% vs. 95.2%, p = 0.177)
were similar between inpatients and outpatients, respectively. Inpatients in this
study were older, heavier, and had higher Charlson comorbidity scores [4].
9 Is there an Optimal Place for Outpatient TJA: Hospital, ASC, or “Other”? 87
Differences in Cost
Studies have suggested that Medicare and individual patients can save on payments
and out-of-pocket costs when procedures are performed in ASCs compared to
HOPDs. The cost to CMS is typically lower when procedures are performed at an
ASC, with one article reporting that the average ASC costs 53% of the amount paid
to HOPD [1]. This same article reported that knee arthroscopy was $1005 at an ASC
compared to $2098 at HOPD while knee arthroplasty was $5914 at an ASC com-
pared to $9349 at HOPD. Medicare saved $2.3 billion with procedures done at an
ASC in 2011 and is projected to save $57 billion in the next 10 years with proce-
dures done at ASCs. Patient out-of-pocket costs for orthopedic procedures amount
to approximately $251 at ASC compared to $524 for HOPD [1]. While out-of-
network issues with insurance companies potentially add another layer of complex-
ity to the cost that needs to be addressed in the future, data has shown that ASCs can
accommodate cost-effective procedures.
Physicians who have financial ownership in an ASC are allowed by law to refer
Medicare and Medicaid patients to their centers [5]. ASCs may be more responsive
to physician control and allow for financial incentives that pave the way for direct
accountability that may increase the quality of care.
Recommendations for Same Day Discharge
Effective same day discharge protocols require efficiency throughout the surgical
process. Patients must be educated in the office setting to insure comfort with the
concept of outpatient TJA. Ideally, centers should have efficient registration, patient
preparation, and timely discharge post-procedure to reduce prolonged patient wait-
ing times. Easily accessible locations with convenient parking improve patient sat-
isfaction. It is helpful when nursing staff are accustomed to an efficient routine that
helps prepare patients for surgery, including placing peripheral IVs, giving preop-
erative medications, and setting patient and family expectations. Anesthesia staff
should collaborate with surgical staff and use proven protocols in a timely fashion
to optimize outcomes. We favor the use of spinal anesthesia, but general anesthesia
can be safely employed. The operating room team’s preparation for setup and drap-
ing should be uniform, simple, and reproducible. Appropriate backup or revision
equipment should be available to handle intraoperative complications [6].
In the recovery room, narcotic medications should be used judiciously to avoid
over-medication that can lead to side effects of nausea and drowsiness. Anti-nausea
medications should be given prophylactically. Soon after admission to the post-
anesthesia care unit, patients can be transitioned from intravenous to oral fluids and
medications in preparation for discharge. Discharge instructions should be simple
and safe; providers should take the time to make sure that patients understand the
instructions clearly. To qualify for discharge, patients must ambulate and safely
88 W. G. Hamilton et al.
meet discharge criteria. Avoiding safety events leading to readmission is of para-

mount importance. Occasionally an overnight stay is required, so screening for
patients at higher risk for urinary retention, intractable pain or nausea, hypotension,
transportation issues, or social issues can help prevent transfer to an inpatient facil-
ity. Performing higher risk cases in a facility that has overnight capability may be
preferable.
Outcomes
While the literature comparing outcomes between these ASCs and HOPDs is pre-
liminary and limited, early data indicates that these two settings have comparable
patient outcomes. Careful patient selection is a factor in all of these reports leading
to substantial selection bias. However, a few recent studies have studied this topic.
One report performed a randomized study comparing 112 outpatient THAs dis-
charged with 108 inpatient primary THAs. The study showed no differences in
reoperations, hospital admissions without reoperation, emergency department visits
without reoperation, or acute office visits between groups. Inclusion criteria in this
study included age less than 75 years at the time of surgery, BMI < 40, opioid naïve,
and no requirement for ambulatory assistance. The visual analog scale pain was
comparable on the day of surgery (inpatient =2.5 vs. outpatient =3.3, p = 0.12), but
was higher for outpatients on the first day after surgery (2.8 vs. 3.7, p = 0.005).
Furthermore, there were no differences in the number of correspondences with the
surgeon’s office suggesting that outpatient THAs can be implemented without
requiring increased work postoperatively for the surgeon’s staff [7].
Sershon et al. evaluated 965 primary THAs who underwent same day discharge
from either an ASC (n = 335) or from a HOPD (n = 630). The study demonstrated
no increased complications regardless of the setting. Additionally, no differences
were found between groups for 90-day complication rates (ASC = 3.9% vs.
HOPD = 3.8%, p = 0.48), revision rates (0% vs. 0.3%, p = 0.30), all-cause reopera-
tion rates (0.3% vs. 0.8%, p = 0.35), emergency department visits (0.9% vs. 0.3%,
p = 0.23), or readmission rates (0.6% vs. 1.4%, p = 0.25) [8]. Another retrospective
study compared 288 outpatient unicompartmental knee arthroplasties (UKA) per-
formed in an ASC with 281 from HOPD. There was no difference in the overall
90-day complication rate (ASC = 4.2% vs. HOP = 6.4%, p = 0.26), day of surgery
admission (0 vs. 0.4%, p = 0.49), emergency department visits less than 24 h after
surgery (0.3% vs. 0.4%, p = 1.0), emergency department visits within 3 days of
surgery (1.0% vs. 1.4%, p = 0.72), and readmissions in the first 90 days (1.7% vs.
2.8%, p = 0.41) between groups [9].
9 Is there an Optimal Place for Outpatient TJA: Hospital, ASC, or “Other”? 89
Conclusion
Outpatient TJA is a growing trend and surgeons should be familiar with all of the
factors required for safely performing these procedures. While either the ASC or
HOPD can be utilized for outpatient TJA, ASCs provide efficiency, physician auton-
omy, and potential cost savings. HOPDs may still be ideal for surgeons who are
initiating the outpatient TJA process, as well as patients with risk factors that require
a safety net in the event of a complication.Conflict of InterestAuthor WGH has part
ownership of an ambulatory surgery center, receives research support from Biomet,
receives IP royalties and research support and is a paid consultant and presenter for
DePuy, A Johnson & Johnson Company, receives research support for Inova Health
Care Services, and receives IP royalties and is a paid consultant for Total Joint
Orthopaedics. Authors RM and ADC have nothing to disclose.
References
1. Tanaka, M. Ambulatory surgery centers versus hospital-based outpatient departments: what’s

the difference? AAOS Now 2019.
2. Meneghini RM, Ziemba-Davis M. Patient perceptions regarding outpatient hip and knee arthro-
plasties. J Arthroplast. 2017;32(9):2701–2705.e1. https://doi.org/10.1016/j.arth.2017.04.006.
3. Husted C, Gromov K, Hansen HK, Troelsen A, Kristensen BB, Husted H. Outpatient total
hip or knee arthroplasty in ambulatory surgery center versus arthroplasty ward: a randomized
controlled trial. Acta Orthop. 2019;4:1–9. https://doi.org/10.1080/17453674.2019.1686205.
4. Kelly MP, Calkins TE, Culvern C, Kogan M, Della Valle CJ. Inpatient versus outpatient hip and
knee arthroplasty: which has higher patient satisfaction? J Arthroplast. 2018;33(11):3402–6.
5. Iglehart JK. The emergence of physician-owned specialty hospitals. N Engl J Med.
2005;352(1):78–84.
6. Hamilton WG. Protocol development for outpatient Total joint arthroplasty. J Arthroplast.
2019;34(7S):S46–7. https://doi.org/10.1016/j.arth.2018.12.043.
7. Goyal N, Chen AF, Padgett SE, Tan TL, Kheir MM, Hopper RH Jr, Hamilton WG, Hozack
WJ. Otto Aufranc award: a multicenter, randomized study of outpatient versus inpatient
total hip arthroplasty. Clin Orthop Relat Res. 2017;475(2):364–72. https://doi.org/10.1007/
s11999-016-4915-z.
8. Sershon RA, McDonald JF 3rd, Ho H, Goyal N, Hamilton WG. Outpatient total hip arthro-
plasty performed at an ambulatory surgery center vs hospital outpatient setting: complications,
revisions, and readmissions. J Arthroplast. 2019;34(12):2861–5. https://doi.org/10.1016/j.
arth.2019.07.032.
9. Cody JP, Pfefferle KJ, Ammeen DJ, Fricka KB. Is outpatient unicompartmental knee
arthroplasty safe to perform at an ambulatory surgery center? A comparative study of early
post-operative complications. J Arthroplast. 2018;33(3):673–6. https://doi.org/10.1016/j.
arth.2017.10.007.
Chapter 10
Navigating the Limitations and Obstacles
of TJA in a Free-Standing ASC
Nicholas B. Frisch and Richard A. Berger
Patient Selection
Choosing the right patient is critical to success in a free-standing ASC. An entire

chapter of this book is devoted to selecting the right patient from a medical and
safety standpoint, but its importance cannot be overstated. When performing a joint
replacement in a hospital, those criteria are important, but if something is missed,
you have options. If a patient does not do well for any reason after surgery, they can
be admitted to observation units, to the floor for additional monitoring, or in some
cases a surgical intensive care unit.
It is imperative to understand the capabilities of the particular ASC in which
you operate. Each facility is different, both in terms of available accommodations,
capacity, and staffing. Some facilities have the option of 23 h observation, while
others do not. Some facilities may even be licensed for longer lengths of stay,
while others may require transfer to a facility that can accommodate a higher level
of care. Furthermore, there are typically dedicated rooms required for the patient
that may need to meet certain requirements and also accommodate family or
friends staying with them (Fig. 10.1). For those facilities that do have extended
stay options, there will be an additional requirement for anesthesia provider cover-
age and on-call coverage. Additional coverage options can be logistically chal-
lenging and limited in capacity depending on the facility. Understanding how
many overnight rooms are available to the patient and their family may impact
N. B. Frisch (*)
Department of Orthopaedic Surgery, Ascension Providence Rochester Hospital,
Rochester, MI, USA
R. A. Berger
Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA

Switzerland AG 2023
92 N. B. Frisch and R. A. Berger
Fig. 10.1 Dedicated room

for overnight stay and up
to 23 h observation
which cases are boarded on which days and how many cases surgeons are com-
fortable doing on those days. There are different regulations around how long a
patient can stay in an ASC. A protocol should be in place to ensure that there is a
process for managing patient discharge prior to the 24 h time limit. To that point,
surgeons need to know the options for transferring and what arrangements the
ASC has in circumstances where this may become necessary. Specifically, whether
they have a contract with an ambulance or transportation company to facilitate the
transfer? Are you as a surgeon credentialed at the facility where your patient may
be transferred? If not, do you have a colleague who can manage your patient upon
transfer?
Choosing the right patient also encompasses surgical options. Instead of allow-
ing their administrator, or the patient, to decide if a case goes to the ASC, surgeons
should assess the patient’s medical status, their need for special equipment, and the
complexity of the case before offering the ASC as an option. Whether it is a unicom-
partmental knee arthroplasty that requires conversion to a total knee arthroplasty
(TKA), a TKA that requires additional constraint, or a complex total hip arthro-
plasty that requires less frequently utilized implant options or specialized stems, the
surgeon should assess whether each case is suitable for the ASC.
10 Navigating the Limitations and Obstacles of TJA in a Free-Standing ASC 93
Space—A Different Frontier in an ASC
Part of the efficiency and cost-effectiveness of an ASC is the appropriate utilization

of space. Each square foot of space has a value. The surgeon’s experience in an ASC
can usually be broken down into a relatively straightforward process. As a surgeon,
think about what your steps are from the time you pull into the parking lot to the
time you drive home. Most likely it resembles something like this:
Change See Perform See Change

Enter Talk to Exit
in locker patient surgery patient in in locker
ASC family ASC
room in pre-op in OR recovery room
As such, the perception of space may be limited to those specific experiences and
encounters. But from a facility design standpoint, space is significantly more sophis-
ticated. While layout will inevitably vary between facilities, there are other critical
functions that dictate a surgeon’s ability to perform joint replacement at the ASC.
From a 10,000-foot view, it is first important to realize that space extends beyond
the scope of the physical building. Parking ratios are calculated to ensure appropri-
ate parking for patients, staff, and physicians. Depending on the location there may
be other tenants in the building, or the ASC is part of a larger facility such as a mall
or medical office building (MOB). Depending on the size of the ASC and the case
mix (i.e., joints, spine, sports, etc.), the throughput may affect these ratios and will
be calculated accordingly. The size of the waiting room is another example. How
many chairs are needed for family members (what is the average number of people
that accompany each patient)? To calculate these numbers requires predictive mod-
eling for the number of patients in the preoperative area, the operating room, and the
recovery room at one given time. During that time, family and friends will require
adequate space to wait. Efficiently scheduling and managing that process will
ensure that there is ample space and comfort without overcrowding, but not exces-
sive space that could be repurposed to add more value to the center.
A common theme in ASCs is the cross-utilization of space. This is most com-
monly seen in the preoperative and recovery areas. Depending on the daily volume
and case mix, earlier in the day the recovery area can be used similarly to the preop-
erative area to prepare patients for surgery. As the day progresses, the preoperative
area can be transitioned to a recovery area. In contrast, most hospitals have separate
dedicated preoperative and postoperative space that may or may not be in proximity
to one another (Figs. 10.2 and 10.3). The ability to cross-utilize space is often
planned during facility design so that the two areas are in close proximity to one
another. This also affords the ability to cross-utilize staff so that nurses and staff can
work together, using the same protocols in both the preoperative and recovery pro-
cess. While staffing ratios will inevitably vary between facilities, this is a common
practice and can have a positive impact on staff overhead.
When talking about the physical space of the ASC from an operating standpoint,
there are several important considerations. Understanding the requirements
a b
Fig. 10.2 Ambulatory surgery center (a) preoperative area and (b) recovery area. Although the
images are not large enough to show the true layout, the preoperative and recovery areas are
directly adjacent to one another for the purpose of cross-utilization as needed
a b
Fig. 10.3 Hospital (a) preoperative area and (b) recovery area. Note that the recovery picture
represents only one pod of several at a larger hospital facility
necessary to perform certain procedures such as TJA will determine the necessary
infrastructure and facility design. Focusing specifically on joint replacement, there
are four main categories that must be considered: (1) Instruments, (2) Implants, (3)
Disposable Goods, and (4) Sterile Processing. Storage of disposable goods requires
careful inventory management. Given space limitations the overall quantity of
goods stored is often far less than in hospitals. Leadership will closely monitor
inventory and manage restocking and delivery in real time to accommodate the
cases on the schedule, but ensure no overcrowding of storage space (Figs. 10.4
and 10.5).
The close management of inventory requires surgeons to be prepared not just for
the procedure, but request any specialized equipment necessary in the event of an
issue. For example, a patient may have unrecognized ligament laxity or there may
be an intraoperative injury to the medial collateral ligament (MCL), which while
rare has been reported to occur in 0.5–3% of TKA [1–4]. Either case would require
additional implant requirements to address appropriately. There are many options,
a b
Fig. 10.4 Ambulatory surgery center storage (a) Sterile storage (b) Disposable storage
Fig. 10.5 Hospital

storage. While space
dedicated to instrument
and equipment storage will
vary significantly between
hospitals, this represents an
example of three separate
rooms utilized for storage
in one hospital system
the best of which can be debated, but may be as follows: (1) primary repair with
hinged knee brace [1], (2) primary repair with internal augmentation [2], (3) conver-
sion to more constrained implants [4–7], and (4) a combination of each option. Any
of these options requires more than just routine implants, instrumentation, and sup-
plies. It may sound strange for those of us working in the hospital environment, but
even heavier braided suture may not be routinely stocked unless you have requested
it. Depending on your preference, you would need to have certain types of suture,
perhaps certain suture anchors, hinged knee braces (which may or may not be read-
ily stocked), and of course more constrained implant options. The latter poses an
even larger challenge given limitations in space and sterile processing as well as
advanced vendor negotiations. This example typifies the need for a thorough preop-
erative plan, so that ultimately you choose the right patients and can therefore rely
less on rare special equipment needs.
Instruments
Most surgeons are used to walking into the OR and having the instruments ready.
They may or may not know how many trays are even required to do their cases, but
for the majority of total joint replacements, that number is not insignificant. In a
large hospital, there is typically ample storage for such equipment. In an ASC, that
is not necessarily the case. The way that different facilities manage instruments and
implants varies based on space and general operating procedures. Some facilities
will have instruments they purchased or are on consignment. Others will require
vendors to bring instruments in or coordinate with affiliated hospital systems to
stock appropriate instruments as needed. Limited space often means making
arrangements for some devices and vendor trays “just in time.” Hospitals often have
storage racks allocated for loaner instruments, whereas most ASCs do not have
space for this. Instead, ASCs default to just-in-time delivery arrangements often
24 h prior to surgery for specific implants. Again, these deliveries are scheduled and
the contents pre-determined to meet the needs of the case. Patient selection and
preparation dictate this process and if the work has not been done on the front end,
the options will be limited if additional equipment is ultimately required as men-
tioned above.
The way that surgeons and staff utilize instruments will also vary. For example,
when the surgeon has completed a portion of the case and certain instruments are no
longer needed, they are handed off for processing. This routinely happens through-
out the case in an ASC, and not just at the end. Other strategies can be employed to
improve instrument efficiency such as the development of a “mini-bar” for when
instruments are missing or dropped or contaminated. With this strategy, entire trays
are not opened for a single instrument, rather single instruments are packed indi-
vidually. Having individual instruments peel-packed and available in a set location
(“mini-bar”) allows for redundancy when needed without significant cost and logis-
tics of full sets.
Managing instrument utilization efficiently can also be approached proactively
by critically assessing the instrumentation trays being used. Most surgeons use the
same instruments for their cases. Yet, in most hospitals those instruments come
from a variety of different instrument sets. It would not be uncommon in a hospital
to open an osteotome set that contains 12 different straight and curved osteotomes
even though you may only use a 1/2 inch curved osteotome for your case. Similarly,
most hospitals have an “ortho basic” set with a mix of dozens of instruments that are
commonly used in any orthopedic procedure. At our hospital, we have looked at this
extensively and began creating dedicated hip and knee instrument sets. This process
brought the number of instrument trays down from 9 full trays down to 1 small tray
for total hips and 1 small tray for partial and total knees (Fig. 10.6a, b). In addition,
working with your vendors to decrease the number of instruments needed to be
more efficient can substantially reduce the implant-specific instrumentation needed
(Fig. 10.6c, d). This equates to not just fewer trays, but faster turnover, improved
efficiency intraoperatively, easier cross-training of staff, less space requirements,
faster sterile processing, and instrument replacement. All of this decreases time and
a b
c d
Fig. 10.6 Instrumentation for (a) total hip arthroplasty and (b) total knee arthroplasty. Complete
operating room instrumentation including implant instrumentation for (c) total hip arthroplasty
and (d) total knee arthroplasty
cost associated with each case. Cichos et al. recently reported on the value of opti-
mizing surgical instrumentation and demonstrated that after implementing lean
principles they were able to reduce instrumentation by 55% for a total annual cost
savings of $270,976 [8].
Sterile Processing
Due to more consolidated and few overall sets, there must be an efficient process for
turning over instruments. Some of these have been mentioned above, but a more
comprehensive understanding of sterile processing and instrument management can
clearly demonstrate the challenges ASCs face. Leadership must have a defined and
well-communicated plan as to how to execute instrument turnover, including when
sets will be needed again and for which patient/OR. The decontamination depart-
ment is much more consolidated in an ASC compared to a hospital (Figs. 10.7 and
10.8). First, there are no cart washers in most ASCs, meaning carts require manual
cleaning before reuse. Dirty instruments go on the same countertop for cleaning as
the instruments that were “barely used” creating tighter working conditions for the
staff on the sterilization side of the process. This is in contrast to most hospital ster-
ilization departments that have separate areas for contaminated versus clean but
used instruments. Planning and facility design are critical to the success of these
processes at the ASC. With limited counter space, sink, and general cleaning space,
instruments must move into the washers and through the pass-thru window quickly
Fig. 10.7 Ambulatory

surgery center sterile
processing. These images
represent the sterile
processing space for a
four-room ambulatory
facility
a b
Fig. 10.8 Hospital sterile processing. There are several stages to sterile processing in hospitals
and a significant amount of space and equipment is dedicated to processing. (a) Instrument cart
cleaner. (b) Soak and sonic sinks. (c) Instrument washers on conveyer belt. (d) Steris sterilizers
to make space for incoming dirty instruments entering decontamination. It is also

imperative that certain trays are identified and prioritized if they are needed again
on the same day.
If you ask most surgeons about sterile processing, it is likely they have never
even seen the facility or equipment at their hospital. Figures 10.7 and 10.8 demon-
strate the clear contrast between ASC and hospital decontamination and steriliza-
tion areas. While it is possible in some larger hospitals to perform high-volume joint
replacement, depending on the size of the ASC it is fascinating to think that in that
small space they can process similar volumes of total joint instrumentation as the
larger hospital facilities in less time. The sterilization area demonstrated in Fig. 10.7
is from an ASC that between 0700 and 1700 can accommodate two surgeons per-
forming 10 total joints. That is 20 total joints per day which typifies the efficiency
despite lack of space.
An ASC is an Island
At an ASC, you have what you have. Preparation is critical. What are your bail-out
options? Do you have redundant trays/instruments? Diligent coordination with the
vendors and developing an understanding of what the options are for different
instruments and implants will be necessary. The ASC management needs clear
arrangements with the vendors for ensuring options are available and pricing is pre-
negotiated. For example, if you are in a situation where there is an intraoperative
fracture or soft tissue compromise, you may want to have cerclage cables, basic
plates, and screws or perhaps more constrained implants available. If you are per-
forming a partial knee replacement you will want to have a total knee available.
Another consideration is imaging. Does your facility have digital radiographs
or fluoroscopy available? For total joints, is that equipment adequate? A facility
may have a mini C-arm for hand or foot and ankle cases, but do they have a full-
size C-arm or portable radiographs with a sufficient plate to get intraoperative
imaging when needed? Other less commonly used items that should be considered
are different suture options and perhaps anchors if needed. Appreciating you may
not have access to your office or hospital PACS system from the ASC OR requires
either printing images in advance or bringing a device that can access those
images. Operating rooms, in general, may not vary greatly in size between ASCs
and hospitals, but the equipment and capabilities in the ORs can be different
(Fig. 10.9). Knowing what you need is one thing but knowing what you may need
and making sure it is available requires planning and coordination with your man-
agement team.
a b
Fig. 10.9 (a) Ambulatory surgery center operating room and (b) Hospital Operating Room
Durable medical equipment (DME) represents another topic. Although less com-
monly used in joint replacement, every facility has different policies when it comes
to stocking DME. Smaller facilities may actually bring braces in for specific proce-
dures while others stock a variety of common DME products. There are multiple
different DME vendors and working with your management team to ensure you
have products that are sufficient to cover your needs is important. In some cases, if
you have DME available in your office, a reasonable solution is to provide it prior
to surgery and have the patient bring it with them. Alternatively, you can provide
your prescriptions for DME in advance and they can be procured independently and
brought in. The last thing you want is for the surgery to go well and the patient is
unable to leave when they are cleared because a walker is not available.
Medications are often determined by the ASC drug formulary. This formulary is
typically decided and voted on at the medical executive committee and/or board
meetings. Having a formal process often keeps the formulary consolidated to a list
of options that all surgeons will use. This is different from hospitals that have a
breadth of options and the capacity to cater to each individual surgeon. That may
limit options as far as antibiotics, local anesthetics, or additional custom protocols
surgeons prefer. As a general rule, if it is not on the formulary, unless you ask for it,
it will not be there.
Everything Moves Faster
Your surgical technique may be the same, but everything else moves faster in an
ASC. Even though staffing levels are typically less than at most hospitals, the staff
is uniquely selected based on expertise and efficiency to accommodate the appropri-
ate volume required. The surgeon has less variability in staff and the staff knows
what to expect when showing up for those surgery days. In most circumstances,
ASC staff have specialized training in the procedures being performed and if sur-
geons operate regularly at the ASC, they have those preferences down to a tee. Staff
call-ins are more difficult to manage logistically but are much less common in a
well-run ASC and contingency plans are quickly mobilized when necessary. In gen-
eral, because the ASC is a smaller environment the culture of the organization
evokes a strong sense of responsibility and ownership at the staff level. In the event
of call-ins, it is often the ASC leadership that will fill in the gaps due to lean staffing
models and those leaders are cross-trained to do so efficiently.
In many cases, surgeons will bring their own staff, whether it be a physician
assistant (PA) or nurse practitioner (NP), a private scrub tech or first assistant (FA),
or even a registered nurse (RN). For those who do not bring additional staff, the
ASC will provide appropriate staffing. In either scenario, there is a culture of effi-
ciency and productivity. Understanding this culture is drastically different than a
typical hospital staffing structure. Expectations of ASC staff are much higher. First
assistants and/or PAs in ASCs are expected not only to assist in positioning and in
surgery, but the entire staff, regardless of their position, helps with setup and
cleanup. The same thing applies to the nurses and the techs. Again, the staffing
ratios are less in the ASC environment and there are often no environmental services
departments to clean the operating rooms between cases. Even though the number
of staff is fewer, turnover remains much faster as clinical staff rise to the occasion
and work harder to facilitate smooth transitions between the cases.
For many surgeons entering an ASC for the first time, this can be an adjustment.
It is not uncommon in many hospitals to have an hour or more turnover time between
cases. Most ASCs have turnovers closer to 10–15 min. When considering that time,
surgeons often have to adapt and make changes to their workflow in order to main-
tain the schedule. There are no shift changes like we see at the hospital and many
ASCs provide lunch for the staff and surgeons so that the downtime can be as pro-
ductive as possible and efficiencies maximized.
Anesthesia
Perhaps one of the most important advances in joint replacement surgery is a com-
prehensive understanding of managing pain. There is an entire chapter in this book
dedicated to anesthesia, but in an ASC the importance of efficient anesthesia proto-
cols cannot be understated. To accommodate a fast recovery, short-acting local
anesthetic agents and minimal narcotic use are preferred. However, they place con-
straints on the surgeon, requiring a more coordinated approach for prepping, drap-
ing, and performing the surgery. Thus, the surgeon has to carefully choose the cases
that can be performed in the ASC due to time limitations from the short-acting
anesthesia.
Our preference has been a single-shot spinal for outpatient anesthesia using a
short-acting agent such as lidocaine or low-dose hyperbaric bupiviaine [9]. Working
with the anesthesiologist at your ASC to adjust dosing based on your surgical tech-
niques, timing and protocols is critical and may take time. Unlike the hospital envi-
ronment where patients with prolonged blocks can easily be admitted and monitored,
in an ASC the impact is longer recovery room time which is detrimental to the entire
ASC process. Longer recovery time results in a longer wait time for families,
decreasing waiting room capacity, increased staff required for that patient, decreas-
ing availability for other patients or cross-utilization in other areas, and overall
increased marginal cost of the case. As in many aspects of the ASC, a failure or
delay in one area affects the entire process adversely.
Concurrent with the shift toward neuraxial anesthesia has been an expansion of
multimodal pain pathways. Medications are determined by the ASC drug formulary,
so if you use specific agents or multimodal pathways, or have certain preferences
for nerve blocks, you will need to ensure the facility approves and stocks those for
your cases in advance.
Physical Therapy
Typically, most ASCs do not have physical therapy on site. There remains some
debate on whether or not having a physical therapist in the recovery room provides
tangible patient benefit. That said, surgeons have different preferences for postop-
erative therapy and options are available. Many ASCs actually provide the nursing
staff training on postoperative recovery protocols and the staff is cross-trained to fill
that need. These requirements may vary based on individual discharge criteria, but
a protocol is recommended to ensure quality, safety, and reproducible processes in
the center.
In some cases, it is possible to bring therapists from your own office. Certain
facilities contract with outside companies to provide therapy services directly at the
ASC. There can be some advantages to contracted arrangements from an economic
standpoint. Having an outside therapy company on site alleviates the burden on
your staff, which therefore decreases staffing needs and can effectively increase
throughput. These arrangements may or may not require direct compensation from
the ASC but more often than not the therapy company provides those services inde-
pendently and manages any additional billing directly. Alternatively, some therapy
companies will provide these services without cost, in hopes that they will develop
a relationship with the patient to provide home or outpatient therapy in the postop-
erative period.
For example, following surgery at the ASC, the therapy company does an initial
visit to the patient in the recovery room by a licensed therapist. The patient is treated
with manual passive range of motion education and evaluation. They provide a
basic introduction to bed exercises (i.e., quad sets, heel slides, straight leg raise,
etc.). The patient will be educated on using an assist device, fitted for that device
and ambulate a certain distance (i.e., 200–300 feet). Safety and stability while using
stairs will be reviewed. Of note, your facility may or may not have stairs available
and if you are just starting a joint replacement program either the facility or the
therapy group will have to procure appropriate stairs. Once this is complete, the
patient is discharged home.
References
1. Bohl DD, Wetters NG, Del Gaizo DJ, Jacobs JJ, Rosenberg AG, Della Valle CJ. Repair of
intraoperative injury to the medial collateral ligament during primary Total knee arthroplasty.
J Bone Joint Surg Am. 2016;98(1):35–9.
2. Shahi A, Tan TL, Tarabichi S, Maher A, Della Valle C, Saleh UH. Primary repair of iatro-
genic medial collateral ligament injury during TKA: a modified technique. J Arthroplast.
2015;30(5):854–7.
3. Leopold SS, McStay C, Klafeta K, Jacobs JJ, Berger RA, Rosenberg AG. Primary repair of
intraoperative disruption of the medical collateral ligament during total knee arthroplasty. J
Bone Joint Surg Am. 2001;83-a(1):86–91.
4. Lee GC, Lotke PA. Management of intraoperative medial collateral ligament injury during
TKA. Clin Orthop Relat Res. 2011;469(1):64–8.
5. Hartford JM, Goodman SB, Schurman DJ, Knoblick G. Complex primary and revision total
knee arthroplasty using the condylar constrained prosthesis: an average 5-year follow-up. J
Arthroplast. 1998;13(4):380–7.
6. Callaghan JJ, O'Rourke MR, Liu SS. The role of implant constraint in revision total knee
arthroplasty: not too little, not too much. J Arthroplast. 2005;20(4 Suppl 2):41–3.
7. Rosenberg AG, Verner JJ, Galante JO. Clinical results of total knee revision using the total
condylar III prosthesis. Clin Orthop Relat Res. 1991;273:83–90.
8. Cichos KH, Hyde ZB, Mabry SE, Ghanem ES, Brabston EW, Hayes LW, et al. Optimization of
orthopedic surgical instrument trays: lean principles to reduce fixed operating room expenses.
J Arthroplast. 2019;34(12):2834–40.
9. Frisch NB, Darrith B, Hansen DC, Wells A, Sanders S, Berger RA. Single-dose lidocaine spi-
nal anesthesia in hip and knee arthroplasty. Arthroplast today. 2018;4(2):236–9.
Chapter 11
Same-Day Discharge in the Hospital:
Resources and Program Elements
Gregory G. Polkowski and Michael D. Gabbard
Introduction
Modern advancements in total joint arthroplasty (TJA) techniques promoting rapid

recovery, including immediate weight bearing, multimodal pain regimens, spinal
anesthesia, and blood management strategies have culminated in the rise of outpa-
tient TJA [1–6]. The initial transition to same-day TJA occurred in the ambulatory
surgery center (ASC) setting. In this environment, the surgeon maintained complete
control of the patient experience, and it allowed the process to be refined, demon-
strated adequate safety, and led to the establishment of patient selection criteria that
makes same-day TJA feasible. Surgeons view this as an opportunity to improve
efficiency and minimize potential complications of prolonged time spent in the hos-
pital, which in turn results in improved patient satisfaction with their joint replace-
ment experience [7]. While there may be fewer obstacles to the implementation of
outpatient TJA in an ASC, there are numerous compelling reasons to consider it in
a hospital setting.
Reasons to Consider Outpatient TJA in Hospital Setting
Compared to ASCs, many large hospitals are characterized by having cumbersome

and frequently archaic processes that are difficult to control and change. The bureau-
cratic quagmire creates frustration for both surgeons and patients. However, per-
forming outpatient TJA in a large hospital setting can still be attractive for several
G. G. Polkowski (*) · M. D. Gabbard

Department of Orthopaedic Surgery, Vanderbilt University Medical Center,
Nashville, TN, USA

Switzerland AG 2023
106 G. G. Polkowski and M. D. Gabbard
reasons. The most compelling reason is to provide a better overall patient experi-
ence and improve patient satisfaction. In general, the time a patient spends in the
hospital is not enjoyable. The transition from admission to surgery to recovery, and,
finally, discharge is fragmented and inefficient.
Large hospitals have conflicting interests including high volumes of patients,
hourly employees, numerous trainees in multiple fields, and lack of incentives for
timely completion of tasks. These issues can lead to significant compromises in
efficiency. Patients often experience large delays at multiple levels including in the
post-anesthesia care unit (PACU) and waiting on inpatient bed assignments. These
delays can often result in missed physical therapy on the day of surgery, delayed
meeting with case managers, and ultimately result in significantly increased time
before readiness for discharge. This can be a source of frustration to patients and
their families, resulting in dissatisfaction with their experience. A well-designed
outpatient TJA program would offer the opportunity to mitigate this.
The following example, while not always typical, demonstrates the challenges of
delivering care at our 1000+ bed tertiary-referral academic medical center. A patient
may wait over an hour in a crowded waiting room, and spend another 1–2 h in the
holding room while a new nurse struggles to achieve intravenous access. They are
interviewed by a medical student, anesthesia resident, and eventually anesthesia
attending on three separate occasions. The surgical case cart could not be found dur-
ing the room turnover, delaying the start time another 30 min. Once in the operating
room, the anesthesia trainee struggles to administer spinal anesthesia, and eventu-
ally the operation is performed. The hospital is relatively full, and there is a “PACU
delay” of another 20 min while the patient begins their recovery in the operating
room. Because of the hospital capacity issues, instead of going to the orthopedic
floor 60–90 min after they come out of surgery, the patient spends 4–5 h in the
recovery room. They wait another hour for the designated patient transportation
personnel to take them to their room, and by the time they arrive, they have missed
the dinner food service, and the physical therapy team has gone home for the day.
They are awakened every couple of hours at night for nursing assessments, vital
signs, and phlebotomy. Before the sun comes up, they are visited by a medical stu-
dent, an orthopaedic resident, and eventually the attending surgeon. Even if they are
doing well, there is another delay before they have their first inpatient physical
therapy session and finally start to walk. Because of hospital policy, the case manag-
ers and discharge planners, who are obligated to process every patient, eventually
see the patient and perform their assessment, even though the patient does not
require home health services, and already has an outpatient physical therapy
appointment arranged for the day after their discharge. Once deemed appropriate
for discharge to home, the nursing discharge process can take another 1–2 h, depend-
ing upon patient load, and transportation via wheelchair to their car may require
another 45 min. Not all of these delays occur for every patient, but the level of frus-
tration that is felt as they do add up can be maddening. To optimize patient satisfac-
tion, then, it stands to reason that minimizing the number of steps the patient is
required to experience, in the large hospital setting, will reduce the number of delays
and improve overall satisfaction.
11 Same-Day Discharge in the Hospital: Resources and Program Elements 107
Patient safety is another reason to consider outpatient TJA, even in the hospital
setting. In 2014, the CDC reported that medical errors were the third leading cause
of death, behind heart disease and cancer [8]. Each step in the patient-care pathway
during a hospitalization, regardless of the need for hospitalization, creates an oppor-
tunity for error. The longer the time and the more steps the patient is exposed to, the
greater the chance of a medical error occurring. Even though a tremendous amount
of effort has been put forth to reduce hospital error, the simplest way to avoid it is
not to spend time in the hospital.
Another appealing reason to consider outpatient TJA in the hospital setting is to
maintain your individual value as a surgeon to the hospital system. Formerly, total
hip (THA) and knee arthroplasty (TKA) were considered inpatient-only procedures,
which provided inherent value to the total joint replacement surgeon performing
these procedures in the hospital setting. However, as TKA and THA are removed
from the Centers for Medicare and Medicaid Services Inpatient-Only list, it has
resulted in an overall paradigm change. In the absence of the hospital diagnosis-
related group (DRG) associated with inpatient admission designation, the value cre-
ated by reducing the length of stay from 1 to2 days to zero days by proactively
launching an outpatient surgery program aligns the incentives of the hospital admin-
istrators (length of stay) with the surgeon and patients (patient experience), creating
value. With coordinated efforts between surgeons and hospital administration, an
outpatient TJA program can result in mutual success.
Implementation of Outpatient TJA in Hospital Setting
Implementation of an outpatient TJA in a hospital setting requires considerable

planning, which begins with the evaluation of potential barriers to success. This can
be accomplished by first mapping the process from arrival at the hospital through
discharge. It is important to identify each segment of the patient-care pathway, the
key players involved in each step, and what the limitations are to progress to the
subsequent step. Common obstacles identified can include an excess number of
people involved in the process, shift worker mentality of individuals, and an overall
large number of steps required to meet discharge criteria. It is important to critically
evaluate each individual item and determine whether it is optimal to relocate it in the
process, enhance its effectiveness, or eliminate it completely. Oftentimes the most
effective choices are aimed at simplifying the process. Relocating steps that can be
performed prior to surgery and eliminating all unnecessary steps on the date of sur-
gery will maximize efficiency and the likelihood of a successful outpatient TJA. For
example, one path to same-day discharge may involve the patient moving from the
PACU to the orthopedic floor to undergo physical therapy, and then eventual dis-
charge. A more efficient process, though, is to make the transition from the hospital
room discharge model to a PACU discharge model, in which the patient is immedi-
ately assessed in the recovery room. This involves removal of numerous patient
transport steps, delays in PT, involvement of case manager/social worker, and delays
in discharge medications and orders. This ultimately results in a substantially more

efficient process.
Another aspect of implementing a successful outpatient TJA program in the hos-
pital setting requires organizing a multidisciplinary team and achieving buy-in
towards the common goal of outpatient TJA. Delivering the same consistent mes-
sage to each person at every step of the patient-care path is essential, and more dif-
ficult in the hospital setting compared with the ASC. Our experience has shown that
this process is best achieved when this is a surgeon-led effort. In order to transform
a multidisciplinary group of individuals, with previously misaligned priorities, into
a cooperative effort requires significant engagement. Overcoming the potential
energy to get the proverbial ball rolling can be a challenge. One helpful process is
to create a “program” or “trial” at the hospital and give it a name, so it is recogniz-
able. When beginning this process at our institution, we named it H.E.R.O., (High
Efficiency Reconstructive Orthopaedics), which allowed those involved in the care
of HERO patients to feel like they were part of a patient-care process that was dif-
ferent than the typical hospital experience.
The importance of the “Team” in the success of an outpatient TJA program in the
hospital setting cannot be overstated. Being part of a special process can generate
excitement among team members. It is also important to emphasize teamwork and
accentuate the importance of each individual’s role in achieving success. After-
hours activities or sponsored lunches can be tools used to enhance group bonding
and reinforce the importance of their roles. Large groups need a big push to make
changes, but if individuals feel they are a part of something larger than themselves
it can be a significant motivating factor. Following the implementation of a pro-
gram, continue to elicit feedback from all members of the team and consider changes
based on this feedback. There will be many opportunities for continued improvement.
Other considerations for an outpatient TJA program in the hospital setting
include patient selection criteria. There are various methods and recommendations
for this, but ultimately the selection of appropriate patients that can be successful in
your program will lead to the best results. It is important to not try to make outpa-
tient TJA fit for those who are uncomfortable with the idea or who have medical
comorbidities requiring full hospitalization for management and monitoring.
Despite the increasing frequency of outpatient TJA, a recent study by Meneghini
et al. reported only 54.5% of patients were aware that outpatient TJA was even an
option and 54% expected to spend two or more nights in the hospital [9]. This dem-
onstrates that among patients who will be candidates for outpatient TJA, preopera-
tive education surrounding expectations is extremely important to alleviate anxiety
and prepare patients and their caregivers. In general, it is preferable to schedule
potential outpatient cases earlier in the day to allow ample time to reach necessary
discharge criteria. Coordinating with physical therapists and making them aware of
potential outpatient candidates in advance will allow for prioritization and the earli-
est feasible PT for these patients. It is important to keep in mind that even when
outpatient joint replacement is the primary plan, it is not always successful for vari-
ous reasons. However, an attractive benefit of an outpatient TJA program in a
hospital setting versus an ASC is that when a patient fails discharge, it is typically a
seamless transition back to the traditional inpatient model.
xperiences with Outpatient TJA in Hospital Setting

E
in the Literature
The majority of peer-reviewed literature on outpatient TJA involves patients who

receive their care in the ASC setting, and the data on outpatient surgery in the hos-
pital setting is fairly limited. There are a few reports of implementation of outpatient
TJA in hospital settings in the literature. First, Gogineni et al. report on the transi-
tion to outpatient hip and knee arthroplasty at a large, academic hospital [10]. All of
their TJA procedures were performed as per their standard protocols with the only
difference for the outpatient group being that they received PT in the PACU and
were discharged home the same day if criteria were met. Seventy-nine percent
(83/105) of patients were successfully discharged home the same day. Predictors of
same-day discharge included TKA, shorter duration of surgery, and longer first
ambulation distance in PACU. Average time in PACU prior to ambulation was
186 min and average overall PACU stay prior to discharge was 351 min. The most
common causes for failed same-day discharge were orthostatic hypotension, patient
decision, urinary retention, and nausea. There were only two emergency department
visits within 48 h of surgery, one for syncope and one for traumatic wound dehis-
cence. This study demonstrates the successful implementation of outpatient TJA in
a large, multispecialty, tertiary care hospital.
A prospective study at a public, university-affiliated hospital in Chile reported on
their experience with a novel outpatient THA program [11]. In a carefully selected
group of patients, 68/72 (94.4%) were successfully discharged home the same day.
Patients spent an average of 5 h in the recovery room prior to discharge. Three
patients required overnight stays in the recovery room (two for nausea, one for
transportation issues), and only one required transition to inpatient status due to
prolonged anesthesia effects. There were no emergency department visits during the
first week after surgery. All patients reported they were satisfied with their outpa-
tient track choice and would recommend it to others. This study provides another
example of implementation of outpatient joint replacement in a hospital setting with
a high rate of success and patient satisfaction and few complications.
Schultz et al. report on the implementation of an accelerated recovery and outpa-
tient TJA program at a County hospital [12]. They describe their experience in cre-
ating a multidisciplinary team aimed at maximizing efficiency in TJA. They
compared 108 TJA patients after implementation of their protocol to the 108 imme-
diately prior. They report a decrease in length of stay (3.4 days to 1.6), decrease in
overall complication rate (21% to 7%), increase in discharge to home (72% to 92%),
and decreased overall mean total cost of TJA by approximately 25%. Despite iden-
tifying a lack of strong social support systems as a unique challenge, they
demonstrated success with an accelerated recovery program even in a large, county

hospital.
Conclusion
Outpatient TJA continues to gain momentum and will be performed with increasing
frequency in the future. While implementing an outpatient TJA program in a large
hospital setting has some distinct challenges in comparison to an ASC, there remains
good reason to consider it. Outpatient TJA provides an opportunity to improve
patient experience and offers value to the hospital system. The most pertinent crite-
ria for successful implementation remain proper patient selection and education.
Efforts in preparation, coordination, and education prior to the day of surgery allow
outpatient TJA to be feasible. For the in-hospital experience, cutting down the size
of the process and developing an engaged, multidisciplinary team is critical to the
process. Continually eliciting feedback from these team members and making
applicable changes will ensure reproducible success. Lastly, there will be patients
who fail to meet discharge criteria for various reasons, and an attractive benefit of
an outpatient TJA program in a hospital setting is the option of a seamless transition
back to the traditional inpatient model when deemed necessary.
References
ahead and stay ahead. J Arthroplast. 2015;30(4):518–20.
2. Hozack WJ, Matsen-Ko L. Rapid recovery after hip and knee arthroplasty: a process and a
destination. J Arthroplast. 2015;30(4):517.
3. Berend KR, Lombardi AV, Mallory TH. Rapid recovery protocol for peri-operative care of
total hip and total knee arthroplasty patients. Surg Technol Int. 2004;13:239.
4. Russo MW, Parks NL, Hamilton WG. Perioperative pain management and anesthesia: a critical
component to rapid recovery Total joint arthroplasty. Orthop Clin North Am. 2017;48(4):401–5.
5. Galbraith AS, McGloughlin E, Cashman J. Enhanced recovery protocols in total joint arthro-
plasty: a review of the literature and their implementation. Ir J Med Sci. 2018;187(1):97–109.
same-day outpatient joint arthroplasty: a systematic review. J Arthroplast. 2018;33(4):1265–74.
7. Hamilton DF, Lane JV, Gaston P, Patton JT, Macdonald D, Simpson AH, Howie CR. What
determines patient satisfaction with surgery? A prospective cohort study of 4709 patients fol-
lowing total joint replacement. BMJ Open. 2013;3(4):e002525.
8. Makary MA, Daniel M. Medical error—the third leading cause of death in the
US. BMJ. 2016;3:353.
9. Meneghini RM, Ziemba-Davis M. Patient perceptions regarding outpatient hip and knee
arthroplasties. J Arthroplast. 2017;32(9):2701–5.
10. Gogineni HC, Gray CF, Prieto HA, Deen JT, Boezaart AP, Parvataneni HK. Transition to
outpatient total hip and knee arthroplasty: experience at an academic tertiary care center.
11. Paredes O, Ñuñez R, Klaber I. Successful initial experience with a novel outpatient total hip
arthroplasty program in a public health system in Chile. Int Orthop. 2018;42(8):1783–7.
12. Schultz BJ, Segovia N, Castillo TN. Successful implementation of an accelerated recovery and
outpatient total joint arthroplasty program at a county hospital. J Am Acad Orthop Surg Glob
Res Rev. 2019;3(9):e110.
Chapter 12
Discharge the Day of Surgery: Strategies
to Optimize and Discharge Criteria
Joshua C. Rozell, Dimitri E. Delagrammaticas, and Raymond H. Kim
Preoperative Visit
Expectations should be discussed with the patient during the first visit when surgery
is scheduled. This involves clearly identifying appropriate candidates based on
medical, technical, and social factors, setting a tone of expectation for outpatient
recovery, and delivering a consistent and coordinated message from the surgeon,
mid-level providers, scheduler, and operating room facility. The decision to enroll a
patient in a same-day discharge program should be shared. The patient should
understand that recovery at home is very different from recovery in a hospital set-
ting. There are certain advantages to in-home recoveries, such as recovery in famil-
iar surroundings, better sleep quality, less noise, less exposure to potential infections,
and having a support system of family and friends [1, 2]. The preoperative visit also
involves a thorough discussion of medications including their purpose and intended
schedule of use, scheduling and explaining the role and frequency of outpatient
physical therapy, and setting up postoperative visits. As some patients may have
difficulty retaining all of the details of the presurgical conversation, including key
caregivers and family members in the visit as well as giving patients a written total
joint replacement recovery guide to take home and read is helpful to reinforce the
key aspects of the preoperative visit. Moreover, since the patient goes home on the
same day, the work typically performed by a social worker in the hospital setting
J. C. Rozell
NYU Langone Health, New York, NY, USA
D. E. Delagrammaticas
Central Coast Orthopedic Group, San Luis Obispo, CA, USA
R. H. Kim (*)
The Steadman Clinic, Vail, CO, USA

Switzerland AG 2023
114 J. C. Rozell et al.
falls on the surgical team, much of which should be coordinated well before the
surgical date. Coordinating each step of the postoperative disposition before the
surgical date ensures that the recovery proceeds seamlessly without any delays or
miscommunication in receiving the appropriate care. Many practices offer a preop-
erative joint replacement class [3]. These group sessions are often led by a nurse or
nurse practitioner who reviews the surgical process from start to finish with the
patients. This also serves as a forum for patients to ask questions and voice any
concerns. Having multiple avenues to deliver the preoperative message ensures that
patients can, depending on learning styles, take advantage of classes, lectures, vid-
eos, pictures, and information packets to be knowledgeable and well-equipped to
succeed with the same-day discharge on the day of surgery [4].
Patient Selection
Not all patients are appropriate candidates for same-day discharge. An important
aspect of performing an early discharge or outpatient arthroplasty is appropriately
selecting patients to avoid putting them at undue risk either in the ambulatory set-
ting or at home. To this end, evaluation for inclusion involves an assessment of a
patient’s medical comorbidities, social and living situation, psychological prepared-
ness, and motivation. It is important to have a consistent tool by which patients can
predictably be chosen for discharge on the same day or within 23 h. The Outpatient
Arthroplasty Risk Assessment (OARA) score is one such tool validated to identify
patients who may or may not be candidates for same-day discharge [5, 6]. The
OARA score assigns a point value to questions pertaining to medical conditions in
specific body systems and a summation score that can be interpreted to identify
patients appropriate for outpatient surgery. Working with a consistent perioperative
internal medicine practitioner who understands the key program characteristics,
such as recovery protocols, anesthetic techniques, surgeon experience, optimized
care pathways, and is involved in a routine multidisciplinary care conference is a
critical aspect of identifying and optimizing patients for outpatient arthroplasty.
Understandably, the availability of a perioperative internal medicine specialist dedi-
cated solely to TJA patients may not be available in many practice settings; how-
ever, the concept should serve as a model for consistent and outpatient-focused
preoperative medical evaluations [5].
Anesthesia and Pain Management
On the day of surgery the entire patient experience should be as streamlined as pos-
sible. Over the last several years, anesthesia pain protocols have made significant
advancements, allowing surgery to be performed under a short-acting spinal anes-
thetic with a multimodal pain approach, utilizing minimal to no opioids. The
12 Discharge the Day of Surgery: Strategies to Optimize and Discharge Criteria 115
approach to pain management should involve taking a patient’s pain history, preop-
erative narcotic exposure, and an evaluation of their overall response to pain.
Involvement, coordination, and buy-in between both the surgeon and anesthesiolo-
gist in developing a rapid recovery total joint protocol are imperative to maintain
consistency, efficiency, and safety [7]. Patient, as well as facility-related factors,
may affect the exact details of the protocol, but in general avoiding inhaled anesthet-
ics in favor of regional anesthesia and intravenous sedation is preferable to mini-
mize nausea, dizziness, and excessive sedation. These side effects of general
anesthesia may contribute to potential failed progression through the postoperative
discharge criteria. Furthermore, avoiding longer than necessary spinal, as well as
utilizing local or regional local anesthetic infiltration that avoids motor blockade
can mitigate the risk of urinary retention and delayed mobilization [8].
Below is an example anesthesia regimen for the surgical episode, beginning in
the holding area and finishing in the recovery area. In general, most protocols will
involve a preoperative pain medication cocktail consisting of non-narcotic medica-
tions to supplement the postoperative pain regimen. For knee replacement, regional
anesthetic infiltration in the form of an adductor canal block can provide partial
blockage of pain in the knee and avoid motor involvement. Data regarding the use
of adductor canal blocks for total knee arthroplasty is mixed, with some studies
advocating for blocks while others report sufficient analgesia with periarticular
injection alone [9–11]. Adductor canal blocks typically fail to completely anesthe-
tize the lateral and posterior aspect of the knee, so supplemental local infiltration
may be required [12]. To improve the efficiency of the operative day, the spinal and/
or block should ideally be performed outside of the operating room, either in the
holding area or an induction room.
Preoperatively:
• Acetaminophen 1000 mg PO.
• Pregabalin 150 mg PO; Dose can be decreased to 75 mg for elderly patients.
• Celecoxib 400 mg PO; Dose can be decreased to 200 mg for elderly patients.
• For TKA Only: Adductor Canal Nerve Block: Ropivacaine 0.2%, 20 mL.
• Midazolam 2 mg IV for sedation during the block/spinal.
Spinal (Titrated to surgeon speed or case complexity) placed preoperatively
before patient arrives in the operating room:
• Mepivacaine 1.5% Isobaric 45 mg (3 mL). Should last 2–3 h.
• Mepivacaine 1.5% Isobaric 60 mg (4 mL) for slower surgeons or revisions.
• Bupivacaine 0.75% Hyperbaric 12–15 mg for very slow surgeons. This will
delay the discharge of patients from PACU due to prolong motor blockade.
Intraoperatively
• Propofol Infusion: Dose from 50–100 μg/kg/min.
• Decadron 0.15 mg/kg with a maximum dose of 15 mg.
• Ketamine 0.5 mg/kg up to 50 mg; Decrease dose for elderly patients.
• Ketorolac 30 mg IV; May need to hold in patients with renal insufficiency.
• Ondansetron 4 mg IV.
Recovery Room
• Fentanyl 25 μg IV to maximum dose of 100 μg available as needed until the
patient can safely tolerate oral medication.
• Oxycodone 5–10 mg PO available as needed.
Surgical Technique and Coordination in the Operating Room
The most consistent aspect of the same-day discharge program is the surgeon’s
technique. A surgeon’s experience and comfort level performing the procedure defi-
nitely plays a role in operative time, soft tissue manipulation and trauma, and the
ability to send people home on the same day. The surgery itself need not be rushed;
even more critical is the communication and efficiency of the operative team.
Surgical team members including physician assistants, nurses, and scrub techs need
to be well-versed and facile in assisting the surgeon with the procedure, knowing the
steps of the procedure, and how to facilitate efficient operating room turnover and
set-up. The time between closure and incision of the subsequent case is where much
of the time saving can be appreciated. The coordination of patient transfer, room
turnover, and subsequent case set-up should run like a well-coordinated pit stop,
where every member of the operating room team has a specific and consistent set of
tasks. Tasks should be completed in parallel rather than in series: time should not be
wasted waiting for one step to be completed before starting the next. As soon as the
patient exits the operating room, the prior case instruments should already be
removed from the room and the room cleaning and turnover started. As soon as
instruments are verified as being available and in the room, the next patient should
be entering the room to begin positioning and draping while the instruments are
organized. The back table and mayo stands should be set up the same way each time
so instruments are not missed and are easily located during the case. A sufficient
number of instrument sets should be available to avoid sterile processing delays
between cases. If feasible, a separate cart with all instruments individually peel-
packed can be maintained as a backup to mitigate the inevitable processing issues or
accidentally dropped instruments [13]. If the surgeon is using two operating rooms,
each one should be an exact replica of the other to minimize delays or miscommu-
nication and facilitate standardization. Timesaving on the order of minutes should
be valued, where changes that create as little as a 5–10 min savings between each
case can facilitate performing an additional case without added time to the day.
Excellent surgical technique should not be compromised for the sake of time, and
surgical time should not be the metric of operative time, but rather the time between
drapes down to drapes up.
Postoperative Care and Physical Therapy
Preoperative counseling about the expectations for pain, as well as the intended use
for each treatment, can empower patients to take control of their pain management
after surgery, which will be required immediately as part of a same-day discharge.
Explaining that pain and soreness during the first few days after surgery will be at
their peak can normalize the experience and avoid psychologically induced escala-
tion in pain leading to pain crisis and potential readmission or emergency room
visits. Identifying, involving, and educating family and caregivers before surgery is
important, as they become the primary nursing care for patients once they
return home.
Once the patient arrives in the recovery area, acclimation after surgery should be
seamless and quick. Perioperative nurses should be well-trained in specifically car-
ing for same-day surgery patients and rapid recovery protocols including fluid
hydration, pain control, and monitoring. The head of the bed should be raised to
>50° immediately upon arrival. This helps reorient patients to their surroundings.
Oxygen should be discontinued when saturation levels are above 92% on room air.
Liquids should be started immediately to facilitate hydration and the diet should be
advanced as tolerated. In the same way, oral pain medications should be started as
soon as the patient is able to tolerate them. All of these measures attempt to encour-
age the patient that he or she is back to normalcy and not confined to the hospital
bed with tubes and intravenous lines. Further, prolonged convalescence in bed
should be avoided and the patient should be dressed in their clothing as soon as pos-
sible and transferred to a chair.
Physical therapy should be made aware of same-day surgery patients prior to the
day of surgery so they can prioritize seeing them as soon as medically able. Patients
who enter the operating room before noon may be more likely to go home on the
same day compared with patients who have surgery after noon due to delay in mobi-
lization and availability of time for therapy. Physical therapy should consult with
the patient within 1–2 h after surgery if the anesthesia team uses an appropriately
timed spinal. Timing of the spinal administration with the surgery is critical in mak-
ing sure patients have return of motor function shortly after surgery and can partici-
pate in therapy without delay.
Physical therapy should focus on getting the patient to ambulate shortly after
surgery. Again, this will simulate the home environment and encourage the patient
that this is the normal postoperative protocol, rather than staying in bed. The goals
for home discharge are below:
1. Walk 50–80 feet on level ground with minimal assistance.
2. Walk up and down stairs.
3. Perform bathroom transfers independently.
4. Go from a supine position in bed to standing.
5. Perform activities of daily living such as dressing oneself.
6. Understand how to perform exercises at home with and without assistance.
Medical Discharge Criteria
In addition to meeting the physical therapy goals noted above, the patient must meet
the below medical criteria in order to be safely discharged home on the same day
and avoid readmission:
1. Tolerate an oral diet.
2. No significant nausea or vomiting.
3. Void after surgery.
4. Pain well-controlled.
5. Vital signs stable.
6. Patient is seen and cleared by the operating surgeon.
Post-Discharge Follow-Up
Patients want to feel a constant connection with their surgeon and care team, espe-
cially if they are discharged home on the same day [14]. Patients often need to feel
reassured that their pain level and swelling are within normal limits and their symp-
toms are all to be expected after surgery. Therefore, it is imperative to follow-up
with the patient by phone within a week after surgery but preferably on postopera-
tive day 1 to see how they are feeling. By reaching out early and establishing that
the surgical team is available for the patient and able to normalize their experience,
patients are more likely to feel at ease and report greater satisfaction with their
recovery and care. As a result, patients may be less likely to go to the emergency
room for issues that can be resolved over the phone with their surgeon or team [15].
Conclusion
As surgical technique and efficiency continue to improve and an emphasis shifts

toward value-based healthcare, more and more arthroplasty surgeons will look to
perform outpatient surgery. The ability to set up a comprehensive same-day surgery
program involves the contributions and motivation of multiple parties, including the
surgeon, anesthesia, surgical facility, and most importantly the patient. Surgeon
leadership is paramount to success in aligning the goals of the hospital or surgery
center with the surgeon. With clear leadership, standardized anesthesia, physical
therapy, and recovery protocols can be put in place. Most importantly, recruiting
appropriately screened and optimized patients for same-day surgery will result in
the greatest chance of success. Consistent and deliberate counseling and care coor-
dination prior to and throughout the surgical episode empower patients to take con-
trol of their recovery and ensures no detail is unclear or miscommunicated.
Following these patients closely after surgery improves patient care,
communication, and likely contributes to lower readmissions and greater satisfac-

tion with the surgical process.
References
1. Fleischman AN, Austin MS, Purtill JJ, Parvizi J, Hozack WJ. Patients living alone can be
safely discharged directly home after total joint arthroplasty: a prospective cohort study. J
Bone Joint Surg Am. 2018;100(2):99–106.
2. Goyal N, Chen AF, Padgett SE, Tan TL, Kheir MM, Hopper RH, Hamilton WG, Hozack
WJ. Otto Aufranc award: a multicenter, randomized study of outpatient versus inpatient total
hip arthroplasty. Clin Orthop Relat Res. 2017;475(2):364–72.
3. Yoon RS, Nellans KW, Geller JA, Kim AD, Jacobs MR, Macaulay W. Patient education before
hip or knee arthroplasty lowers length of stay. J Arthroplast. 2010;25(4):547–51.
4. Giraudet-Le Quintrec JS, Coste J, Vastel L, Pacault V, Jeanne L, Lamas JP, Kerboull L,
Fougeray M, Conseiller C, Kahan A, Courpied JP. Positive effect of patient education for hip
surgery: a randomized trial. Clin Orthop Relat Res. 2003;414:112–20.
5. Meneghini RM, Ziemba-Davis M, Ishmael MK, Kuzma AL, Caccavallo P. Safe selection of
outpatient joint arthroplasty patients with medical risk stratification: the “outpatient arthro-
plasty risk assessment score”. J Arthroplast. 2017;32(8):2325–31.
update on the outpatient arthroplasty risk assessment score. J Arthroplast. 2019;34(7S):S40–3.
7. Gogineni HC, Gray CF, Prieto HA, Deen JT, Boezaart AP, Parvataneni HK. Transition to
outpatient total hip and knee arthroplasty: experience at an academic tertiary care center.
Arthroplasty Today. 2019;5(1):100–5.
8. Turnbull ZA, Sastow D, Giambrone GP, Tedore T. Anesthesia for the patient undergoing total
knee replacement: current status and future prospects. Local Reg Anesth. 2017;10:1–7.
9. Grosso MJ, Murtaugh T, Lakra A, Brown AR, Maniker RB, Cooper HJ, Macaulay W, Shah RP,
Geller JA. Adductor canal block compared with periarticular bupivacaine injection for total
knee arthroplasty: a prospective randomized trial. J Bone Joint Surg Am. 2018;100(13):1141–6.
10. Sardana V, Burzynski JM, Scuderi GR. Adductor canal block or local infiltrate analgesia for
pain control after total knee arthroplasty? A systematic review and meta-analysis of random-
ized controlled trials. J Arthroplast. 2019;34(1):183–9.
11. Kulkarni MM, Dadheech AN, Wakankar HM, Ganjewar NV, Hedgire SS, Pandit
HG. Randomized prospective comparative study of adductor canal block vs periarticular
infiltration on early functional outcome after unilateral total knee arthroplasty. J Arthroplast.
2019;34(10):2360–4.
12. Eccles CJ, Swiergosz AM, Smith AF, Bhimani SJ, Smith LS, Malkani AL. Decreased opioid
consumption and length of stay using an ipack and adductor canal nerve block following total
knee arthroplasty. J Knee Surg. 2019;34:705.
13. Goldberg TD, Maltry JA, Ahuja M, Inzana JA. Logistical and economic advantages of sterile-
packed, single-use instruments for total knee arthroplasty. J Arthroplast. 2019;34(9):1876–83.
14. Shah RP, Karas V, Berger RA. Rapid discharge and outpatient total joint arthroplasty introduce
a burden of care to the surgeon. J Arthroplast. 2019;34(7):1307–11.
15. Sharareh B, Schwarzkopf R. Effectiveness of telemedical applications in postoperative follow-
up after total joint arthroplasty. J Arthroplast. 2014;29(5):918–22.
Chapter 13
Staying Connected with the Patient after
Discharge: Strategies and Resources
Tony S. Shen, Patawut Bovonratwet, and Michael P. Ast
Introduction
The demand for total joint arthroplasty (TJA) is projected to increase significantly
in the coming decades [1]. As a result, the development of new strategies to maxi-
mize cost-effectiveness and to streamline the delivery of care is being increasingly
explored. Outpatient arthroplasty has been shown to reduce the overall cost of sur-
gery, largely by avoiding hospital admission [2]. A number of investigations into the
safety of outpatient arthroplasty have been performed to date [3–7]. While comor-
bidities such as age greater than 80, smoking, bleeding disorders, and high ASA
class were associated with an increased risk of complications, most studies con-
clude that outpatient arthroplasty is safe and cost-effective in carefully selected
patients without clear risk factors for complication or readmission [8, 9].
In the outpatient setting, without the typical resources of the hospital in place,
many elements of postoperative care rely on communication between the patient
and the care team. A robust system of communication postoperatively plays a cru-
cial role in minimizing unnecessary anxiety, reducing emergency room visits and
readmissions, increasing patient satisfaction, and ultimately ensuring patient safety.
A traditional hospital stay of several days allowed for several opportunities for
patients to ask questions, have their anxiety alleviated, and have expectations set
regarding normal occurrences after joint replacement surgery. The transition to out-
patient surgery represents an important challenge and a potential opportunity for
innovation. This chapter discusses strategies and resources for staying connected
with outpatient TJA patients postoperatively.
T. S. Shen · P. Bovonratwet · M. P. Ast (*)

Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery,
New York, NY, USA
e-mail: [email protected]; [email protected]; [email protected]

Switzerland AG 2023
122 T. S. Shen et al.
Options for Staying Connected
A traditional in-person follow-up visit is expensive and time-intensive for both the
patient and surgeon and may not be the most cost-effective manner of communica-
tion postoperatively [10]. Marsh et al. showed that for the patient’s first TJA follow-
up visit in a traditional clinic setting, the cost to the healthcare payer perspective
was approximately $71 while the cost to the societal perspective was $162 [11].
Due to advances in communications technology, other avenues of cost-effective
patient follow-up are now being developed, including web-based assessments and
HIPAA-compliant text messaging platforms. In the same study, Marsh et al. showed
that for the patient’s first TJA follow-up visit via a web-based assessment, the cost
to the healthcare payer perspective was only $45 while the cost to the societal per-
spective was only $98 [11]. This difference in cost is an important consideration
when designing an outpatient arthroplasty pathway with potentially more frequent
postoperative communication.
Role of Telemedicine and Electronic-Based Follow-Up
Telemedicine originally referred to the use of information and communications

technology to provide health services to people who are at a distance from their
healthcare provider. However, due to the potential for substantial cost savings to the
healthcare system, these methods have also been adapted to substitute for traditional
in-person clinic follow-up visits [11]. Recent investigations of these technologically
based follow-up strategies have demonstrated usefulness in monitoring recovery,
reducing unplanned follow-up visits, and reducing costs.
Several types of nonconventional follow-up strategies utilizing communications
technology have been reported in the literature. Hällfors et al. implemented a con-
sultation telephone service for patients who underwent TJA and found that 87% of
all issues were able to be resolved with a telephone conversation alone; the remain-
ing 13% required further care in the emergency department [12]. In the context of
outpatient arthroplasty, their results display an opportunity to optimize the strategy
to safely address postoperative issues that may arise. While this area of study is rela-
tively novel, there is an increasing body of literature reporting on the use of tele-
medicine and technologically based follow-up strategies.
Wood et al. described an electronic web-based assessment, where each patient
was given a website address and a unique username/password to gain access to the
web page and enter their data [13]. The web page could be accessed from any com-
puter with an Internet connection. The web page contained the same questionnaires
used in their outpatient clinic, with the exception of outcome scores that require
physician input. Patient feedback at the conclusion of their study revealed that 95%
of patients found the web assessment more convenient than a traditional clinic
visit [13].
13 Staying Connected with the Patient after Discharge: Strategies and Resources 123
In another study by Sharareh et al., the authors utilized computer-based video

conferencing software as their mode of follow-up with patients after TJA [14]. The
live video sessions in their study were scheduled for 1 week, 3 weeks, 4 weeks,
6 weeks, and 9 weeks following surgery. All sessions consisted of a 30-min window.
Outcome scores such as postoperative Hip Disability and Osteoarthritis Outcome
Score (HOOS) and Knee Injury and Osteoarthritis Outcome Score (KOOS) were
recorded for all patients undergoing total hip arthroplasty and total knee arthro-
plasty, respectively during these sessions [14]. After implementation of the live
video program, the authors demonstrated a statistically significant reduction in
unplanned clinic visits and calls. Additionally, the authors noted higher postopera-
tive satisfaction in patients who underwent telemedicine follow-up compared to
those who received traditional follow-up [14]. Similarly, positive results using video
conferencing programs have also been reported in other non-arthroplasty settings
[15, 16].
In addition to telephone or electronic communication, mobile-based patient
engagement through smartphone applications (apps) has been explored with prom-
ising preliminary results [17]. Several of these exist in the orthopedic space, some
of which were designed by their users and others that are commercially available
through third-party vendors. Studies have been published with both of these types
of mobile patient engagement platforms. Bitsaki et al. developed a mobile applica-
tion that patients who underwent TJA can download on their smartphones. The
mobile application in their study allows patients to fill in information about symp-
toms in the replaced joint and complete certain questionnaires (such as The Western
Ontario and McMaster Universities Osteoarthritis Index). A cost analysis of their
mobile-based system was notable for a total cost reduction of 13,578€ per
patient [17].
Mobile-based patient engagement platforms not only facilitate patient communi-
cation and reduce costs but also have been shown to reduce unplanned hospital
readmissions and postoperative complications. Rosner et al. demonstrated a reduc-
tion in potentially avoidable 90-day costs, 90-day hospital admissions, and compli-
cations after implementing a new class of automated digital patient engagement
platforms, where patients received guidance and remote monitoring perioperatively.
The investigators reviewed claims data for 186 patients enrolled in a digitally based
follow-up program that was available online as well as on mobile devices. This
group was compared to 372 patients who had traditional follow-up. They noted a
mean savings of $656 per patient as well as a 54.4% relative reduction in postopera-
tive complications [18]. Zhang et al. reviewed 1434 patients who were registered in
an online follow-up platform. These patients were able to send images of their sur-
gical wound for evaluation remotely. The investigators found that of the 430 patients
who sent an image, 423 patients had normal-appearing wounds. The remaining
patients were seen at a scheduled follow-up appointment [19].
In addition to patient monitoring, telemedicine and technologically based strate-
gies may be used to augment postoperative rehabilitation. As a proof of concept,
Russell et al. randomized patients who underwent primary total knee arthroplasty to
6 weeks of either conventional physical therapy or a simulated telerehabilitation
program. The telerehabilitation group underwent their physical therapy session

under the real-time guidance of a physical therapist through an Internet connection
using only household equipment. These patients still traveled to the rehabilitation
center and underwent their session in a standardized simulated living room with the
physical therapist in another room. The investigators showed that outcomes achieved
using telerehabilitation at 6 weeks following total knee arthroplasty were compa-
rable with those after conventional rehabilitation. Patients in the telerehabilitation
group also reported a high level of satisfaction [20]. Based on these results, Moffet
et al. designed a trial in which total knee arthroplasty patients were randomized to
true in-home telerehabilitation or traditional rehabilitation. They demonstrated that
patient-reported outcomes (Western Ontario and McMaster Universities
Osteoarthritis Index and Knee Injury and Osteoarthritis Outcome Score) in the in-
home telerehabilitation group were non-inferior to those who underwent traditional
rehabilitation [21].
Numerous additional studies have examined the utility of telerehabilitation in
terms of clinical and economic effectiveness [22–24]. Other studies have investi-
gated the validity of measurements made remotely in a telerehabilitation setting and
found that the range of motion was highly reliable [25, 26]. In general, telerehabili-
tation has been shown to be noninferior to traditional in-person physical therapy for
postoperative rehabilitation after TJA.
It is important to note however that just as the patient selection is critical for the
safety of outpatient arthroplasty, not all patients are appropriate candidates for
telerehabilitation. Klements et al. noted that approximately one-third of patients in
their population benefited from traditional in-person therapy in addition to telereha-
bilitation [27, 28]. Further, Plate et al. reviewed the utilization pattern of their insti-
tutional electronic patient portal after TJA and found that patients who had risk
factors for readmission such as discharge to an assisted living facility, Medicare/
Medicaid insurance, and increased comorbidities were also less likely to use their
electronic patient portal. Further, patients who did use the portal were found to have
an increased readmission rate if the response rate to their messages was less than
75% [29].
Conclusion
As the landscape of TJA shifts towards the outpatient model, innovation in post-
discharge patient communication may lead to improved patient satisfaction and
cost-effectiveness. Technology-based patient communication platforms provide an
opportunity to enhance postoperative care, as an increasing proportion of patients
are likely to communicate using an online platform [30]. Already, orthopedic cen-
ters from around the world have reported promising results with remote patient
monitoring and patient engagement platforms. When designing an outpatient arthro-
plasty pathway, the utilization of a technology-based patient engagement platform
should be strongly considered to potentially decrease complications and
13 Staying Connected with the Patient after Discharge: Strategies and Resources 125
readmissions and improve patient outcomes. Surgeons and team members can also
choose to use these platforms to supplement postoperative physical therapy when
appropriate.
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tient vs inpatient total knee arthroplasty: an ACS-NSQIP. Analysis. 2017;32:1773. https://doi.
org/10.1016/j.arth.2017.01.043.
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tive complications of outpatient knee arthroplasty. Clin Orthop Relat Res. 2009;467:1443–9.
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Chapter 14
Physical Therapy Following Same-Day
Discharge Total Joint Arthroplasty
Matthew J. Grosso and William Hozack
Introduction
Along with other fields within total joint arthroplasty (TJA), physical therapy (PT)
utilization has evolved significantly over the last decade. The tradition with regard
to postoperative rehabilitation has been to administer formal guided PT to all
patients undergoing TJA [1]. While the goals of therapy—to optimize return of
function and allow for safe return to activities—have not changed over time, these
goals were achieved primarily with inpatient PT, using strict discharge require-
ments, and often requiring a multiple-day hospital stay. In addition, a post-inpatient
rehabilitation facility was promoted as an essential aspect of recovery following
TJA [1].
With the advent of rapid recovery protocols, these paradigms have changed sig-
nificantly, ultimately facilitating same-day discharge [2, 3]. Evidence-based medi-
cine combined with an understanding of responsible resource management have
greatly redefined the role of PT. For the modern same-day discharge TJA patient, a
unique set of protocols are now in place that allow for safe and effective home dis-
charge. Although the goals of safe and effective return to function are still similar,
the timeline has shifted significantly, along with the methods to achieve these goals
in same-day arthroplasty.
M. J. Grosso (*) · W. Hozack

The Rothman Orthopaedic Institute & Thomas Jefferson University Hospital,
Philadelphia, PA, USA

Switzerland AG 2023
128 M. J. Grosso and W. Hozack
Critical Factors for Successful Same-Day PT and Discharge
Same-day discharge is reliant on three critical factors that allow for postoperative
mobilization with physical therapy: multimodal pain management, elimination of
postoperative activity precautions, and reduced reliance on formal PT programs.
Same-day PT is critically dependent on an appropriate multimodal pain manage-
ment protocol. At our institution, we follow a set protocol involving preoperative
pain medications, minimization of opioid medications, peri-incisional injections,
and regional nerve blocks. Preoperatively, patients receive oral acetaminophen
(975 mg), pregabalin (75 mg), and celecoxib (400 mg) within 2 h of the surgical
procedure. More recently, celecoxib is increasingly replaced with intravenous
ketorolac (15 mg) given prior to incision. Postoperatively, standing doses of oral
acetaminophen (650 mg) every 6 h, pregabalin (75 mg) every 12 h, and ketorolac
(30 mg) every 6 h are administered to reduce reliance on breakthrough opioid medi-
cations [4]. Intraoperatively, peri-articular injections can be utilized in hip patients,
but are more important for knee patients. A number of cocktails have been described,
although ~60 mL of 0.5% bupivacaine has had success equivalent to more expen-
sive cocktails, and currently is our standard of care [5]. In total knee arthroplasty
patients, adductor canal blocks have demonstrated effectiveness in reducing pain
and postoperative opioid consumption [6].
Elimination of postoperative precautions, particularly for total hip arthroplasty
(THA), facilitates same-day PT and discharge. In a randomized controlled trial,
Peak et al. demonstrated that utilization of functional restrictions following total hip
arthroplasty does not reduce the prevalence of early postoperative dislocations [7].
This study examined dislocation rates utilizing an anterolateral approach, but simi-
lar reports have supported eliminating precautions for both the anterior and poste-
rior approach as well [8, 9]. We believe that patients without precautions are less
hesitant and more likely to mobilize both postoperatively, and post-discharge,
allowing for more rapid recovery.
Finally, a critical factor necessary for successful same-day discharge is a
reduced reliance on formal PT programs. The improved pain management regi-
mens and reduced concerns about instability have created a situation in which out-
patient TJA is a safe reality. In a prospective randomized trial, Goyal et al.
randomized total hip arthroplasty (THA) patients to an outpatient (<12 h) versus
inpatient (overnight, >12 h) stay. They demonstrated that outpatient care, including
outpatient PT, led to similar outcomes, with no increase in complication rate [10].
In addition to same-day discharge, we discourage the utilization of inpatient reha-
bilitation. A number of studies have demonstrated no benefit, or even worse out-
comes, with the utilization of post-discharge rehabilitation facilities [2, 11, 12]. We
also emphasize outpatient PT over home PT. Outpatient PT requires mobilization
out of the house, which has inherent value. A number of studies have demonstrated
more rapid gains for patients who underwent outpatient PT compared to home PT
following TKA [13, 14].
14 Physical Therapy Following Same-Day Discharge Total Joint Arthroplasty 129
Role of Prehabilitation
Preoperative physical therapy sessions in preparation for surgery, or prehabilitation,

have been considered for TJA patients. Evidence suggests that better preoperative
health status (e.g., greater physical function and strength) is a predictor of good
postoperative outcomes following TJA [15, 16]. Therefore, prehabilitation was
introduced in an attempt to improve preoperative functional status, with the goal of
improved postoperative outcomes. However, the current evidence is conflicting
regarding the benefit of prehabilitation prior to TJA [17–20]. In a meta-analysis of
35 studies and 2956 patients, Moyer et al. reported that prehabilitation may result in
small to moderate improvements in function and length of stay for both total hip and
total knee patients, although the significant variety in preoperative exercises across
studies made comparisons difficult [20]. At our institution, prehabilitation is not the
standard of care and is reserved for a very small percentage of patients on a surgeon
discretion basis. Patients receiving this prehabilitation program are rarely, if ever,
being considered for same-day discharge. Further studies may be warranted to
investigate the role of prehabilitation in improving rates of same-day discharge.
Day of Surgery Physical Therapy Protocols
Our institution follows a specific protocol for safe same-day discharge, for which
physical therapy plays a critical role. Following surgery, PT is initiated within
1–6 h, with mean times closer to 1.5–3 h [10]. Since our patients have spinal anes-
thesia, initiation of PT can be delayed pending restoration of motor and sensory
function. Modifications of the dosage and type of spinal anesthetic have facilitated
this early mobilization. An appropriate multimodal pain management protocol, as
discussed above, and close coordination with the anesthesia team are critical for
early mobilization. Mobilization is achieved with the help of an assistive device,
which can be crutches, walker, or a cane, depending on the patient, and physical
therapist assessment. This device is usually the same device that the patient takes
home. Once mobilized, there are a specific set of PT goals. In addition to medical
and psychological factors, there are specific PT criteria that must be met prior to
discharge, which include the ability to stand from a supine position in the bed, walk
80 feet, and go up and down stairs (Table 14.1). We find that these goals are
Table 14.1 Physical therapy Criteria

discharge criteria for total
1. Walk 80 feet on level ground
joint arthroplasty
2. Walk up and down stairs (if stairs at home)
3. Demonstrate understanding of home exercises
4. Perform bathroom transfers
5. Stand from supine position in bed
6. Be able to dress self and perform basic activities of
daily living
achievable for the majority of patients. In a prospective cohort study from our insti-
tution, 26% of patients failed to achieve same-day discharge, but only a small por-
tion of these patients (18% of failed-discharge patients, 5% of total cohort) failed
because of inability to clear PT. [21]
These protocols are identical for total hip, total knee, and unicondylar knee
replacement. For the total knee and unicondylar protocols, we also ensure patients
understand the appropriate range-of-motion exercises, and inappropriate resting
positions (such as a pillow under the leg).
Post-Discharge Physical Therapy Protocols
Traditionally, strict postoperative outpatient therapy has been administered to

patients undergoing TJA. However, these paradigms have shifted, and there are sev-
eral studies supporting no formal therapy for total hip arthroplasty, unicondylar
knee arthroplasty, and select patients in total knee arthroplasty (TKA).
There is now strong evidence that suggests that formal PT is not required for the
majority of patients who undergo THA. Austin et al. in a randomized controlled
clinical trial, demonstrated that formal outpatient PT is not required following THA
[22]. They report unsupervised home exercise is both safe and efficacious for a
majority of patients. There are several alternatives to formal outpatient PT. Web-
based, self-directed programs are gaining popularity and have shown efficacy in this
population [23]. Group physiotherapy sessions are another alternative, which dem-
onstrate efficiency and cost-effectiveness [24]. However, it is the authors’ prefer-
ence to avoid any formalized protocol, and, instead, to emphasize to the patient to
perform their normal daily activities, and that each of those activities requires
movement of the hip. This is discussed with the patients as a customized PT pro-
gram based on activities of daily living.
The issue of formal PT is more complex following TKA, because of a greater
concern for early range of motion postoperatively. Failure to achieve degrees of
flexion and extension can lead to limitations in daily activities and poor outcomes
[25, 26]. Laubenthal et al. demonstrated that 67° of flexion is needed for the swing
phase of gait, 83° for climbing stairs, 90° for descending stairs, and 93° for standing
up from a chair [25]. Therefore, we have been more hesitant in eliminating formal
PT in our total knee arthroplasty patients. However, Fleischman et al. demonstrated
that unsupervised home exercise is not inferior to outpatient PT after TKA [27].
They demonstrated a similar range of motion and patient-reported outcomes through
6 months postoperatively. To ensure success, patient selection can be critical. Wang
and colleagues showed that an early postoperative visit (approximately 2 weeks)
may be helpful to identify patients who are not progressing appropriately and can
benefit from formal PT. [28] Web-based protocols may also help decrease the num-
ber of patients who require formal therapy sessions [29].
While range of motion is still a concern following unicondylar knee arthroplasty

(UKA), it is less of an issue compared to TKA [30]. Similar to THA, evidence sug-
gests that the majority of UKA patients do well with self-directed exercises follow-
ing UKA. In a randomized clinical trial comparing formal outpatient PT to
unsupervised home exercises, Fillingham et al. demonstrated no differences in
ROM or patient reported outcomes at 6 weeks from surgery [31]. However, of the
25 patients randomized to the unsupervised therapy, three (12%), crossed over to
the formal outpatient PT group due to limited progress. This suggests that a subset
of UKA patients may not be suitable for unsupervised therapy, and further work is
needed to identify the at-risk cohort.
For those patients requiring post-discharge PT, as stated in the critical factors
section, our preference is for post-discharge outpatient PT over home PT. We see
significant value in the act of mobilizing to the outpatient PT center, which requires
mobility, transfers, and knee ROM at multiple time points (in and out of car, stair-
cases, walking across the street, etc.). Indeed, a number of studies have demon-
strated more rapid gains for patients who underwent outpatient PT compared to
home PT following TKA [13, 14].
Conclusions
Postoperative physical therapy has evolved with rapid recovery protocols to allow
safe and effective same-day discharge following primary TJA. Immediate postop-
erative therapy (POD0) should focus on early mobilization and meeting discharge
goals in a safe and effective manner. Post-discharge formal physical therapy is not
required for most patients who undergo outpatient joint replacement surgery.
Defining the appropriate patients suitable for unsupervised home exercise programs
is critical, particularly for total knee arthroplasty patients.
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20. Moyer R, Ikert K, Long K, Marsh J. The value of preoperative exercise and education for
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21. Fraser JF, Danoff JR, Manrique J, Reynolds MJ, Hozack WJ. Identifying reasons for failed
same-day discharge following primary total hip arthroplasty. J Arthroplast. 2018;33:3624–8.
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23. Klement MR, Rondon AJ, McEntee RM, Kheir M, Austin MS. Web-based, self-directed phys-
ical therapy after total hip arthroplasty is safe and effective for most, but not all, patients. J
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ticipants after joint replacement surgery as 1-to-1 physiotherapy: a sequential cohort study.
Arch Phys Med Rehabil. 2009;90:1727–33. https://doi.org/10.1016/j.apmr.2009.04.019.
25. Laubenthal KN, Smidt GL, Kettelkamp DB. A quantitative analysis of knee motion during
activities of daily living. Phys Ther. 1972;52:34–43. https://doi.org/10.1093/ptj/52.1.34.
26. Huddleston J, Alaiti A, Goldvasser D, Scarborough D, Freiberg A, Rubash H, et al. Ambulatory
measurement of knee motion and physical activity: preliminary evaluation of a smart activity
monitor. J Neuroeng Rehabil. 2006;3:21. https://doi.org/10.1186/1743-0003-3-21.
27. Fleischman AN, Crizer MP, Tarabichi M, Smith S, Rothman RH, Lonner JH, et al. 2018 John
N. Insall award: recovery of knee flexion with unsupervised home exercise is not inferior to out-
patient physical therapy after TKA: a randomized trial. Clin Orthop Relat Res. 2019;477:60–9.
https://doi.org/10.1097/CORR.0000000000000561.
28. Wang WL, Rondon AJ, Tan TL, Wilsman J, Purtill JJ. Self-directed home exercises vs outpa-
tient physical therapy after total knee arthroplasty: value and outcomes following a protocol
change. J Arthroplast. 2019;34:2388–91. https://doi.org/10.1016/j.arth.2019.05.020.
29. Russell TG, Buttrum P, Wootton R, Jull GA. Internet-based outpatient telerehabilitation for
patients following total knee arthroplasty: a randomized controlled trial. J Bone Joint Surg Am.
2011;93:113–20. https://doi.org/10.2106/JBJS.I.01375.
30. Kleeblad LJ, van der List JP, Zuiderbaan HA, Pearle AD. Larger range of motion and increased
return to activity, but higher revision rates following unicompartmental versus total knee
arthroplasty in patients under 65: a systematic review. Knee Surg Sports Traumatol Arthrosc.
2018;26:1811–22. https://doi.org/10.1007/s00167-017-4817-y.
31. Fillingham YA, Darrith B, Lonner JH, Culvern C, Crizer M, Della Valle CJ. Formal physical
therapy may not be necessary after unicompartmental knee arthroplasty: a randomized clinical
trial. J Arthroplast. 2018;33:S93–S99.e3. https://doi.org/10.1016/j.arth.2018.02.049.
Chapter 15
Strategies to Minimize Patient Anxiety,
Emergency Room Visits, and Readmissions
Following Outpatient Total Joint
Arthroplasty
Charles De Cook
Introduction
Already the highest expenditure in the CMS budget, total joint arthroplasty (TJA)
utilization is projected to rise exponentially over the coming decades, especially
across younger patient demographics [1]. At the same time, the rise in value-based
payment models has brought tremendous emphasis on healthcare cost containment.
The convergence of these trends makes the successful reduction in the length of
hospital (LOS) stay after TJA both crucial and feasible. Indeed, over the last
30 years, the average LOS after TJA, particularly after total knee arthroplasty (TKA)
and total hip arthroplasty (THA), has gone from a few weeks to a few days, and now
to a same-day procedure in the ambulatory surgery setting. But 30/90-day readmis-
sions of Medicare beneficiaries after TJA surgery have been reported to be as high
as 15% [2, 3]. Reducing LOS is only meaningful when we concurrently reduce (or
eliminate) avoidable emergency room (ER) visits and hospital readmissions
postsurgery.
The patient’s state of mind going into surgery is an often under-appreciated fac-
tor in postsurgical outcomes [4]. Minimizing patient anxiety prior to surgery leads
to better outcomes, including a reduction in avoidable ER visits and readmissions
(Fig. 15.1). Thus, anxiety reduction methods through effective patient engagement
and education are key component of a successful preoperative patient preparation
strategy.
C. De Cook (*)
Total Joint Specialists, Atlanta, GA, USA

Switzerland AG 2023
136 C. De Cook
Fig. 15.1 When preoperative preparation goes up, anxiety, ER visits, and hospital readmissions
during recovery go down
Anxiety and Patient Outcomes
It is common for people to experience anxiety when anticipating surgery. A signifi-

cant part of patient anxiety comes from not knowing what to expect during or after
the operation. Patients typically harbor unknowns about anesthesia, separation from
family, postoperative pain, loss of independence, and changes in body image [5].
When will they be able to walk again? When will they be able to drive? Will they be
able to go to the washroom by themselves? When can they resume normal activi-
ties? When will they return to work?
Placebo-controlled studies have taught us how strong the placebo effect can be,
especially for a surgical procedure, [6] demonstrating that what patients believe
preoperatively about their surgery directly impacts what they believe postopera-
tively about their outcome. Unfortunately, minimizing patient anxiety is not a com-
mon priority of current preoperative preparation. Patients are frequently left in the
dark and can feel abandoned, particularly when it comes to the day of surgery [7].
Add to that the long wait times usually associated with TJA surgery, and patients
may spend weeks or months trapped in a negative anxiety loop, predisposing them
to poor outcomes before their surgery even begins.
15 Strategies to Minimize Patient Anxiety, Emergency Room Visits, and… 137
Reducing Patient Anxiety
Alleviating preoperative anxiety is, of course, a mental game. Patient anxiety is best
addressed prospectively, with formal protocols for the entire care team around
active listening and dispelling patient “unknowns” through effective engagement
and education (Fig. 15.2). Patients do better when they are encouraged from the
beginning to play an active role in their own preoperative preparation and feel less
anxious when they have a sense of when they will be able to get back to their normal
activities after surgery.
One strategy that has been shown to be successful toward reducing patient anxi-
ety is to demonstrate empathy [8]. When patients feel that they have been listened
to, they feel understood and validated. This means that we must not only provide
patients with educational content but should encourage patients to express their
emotions and share any questions they have, preferably in person. Done properly,
this approach can transform the typically stressful process of obtaining appropriate
Fig. 15.2 Systematically engaging and educating patients as part of preoperative preparation
changes their “unknowns” to “knowns” and minimizes anxiety
138 C. De Cook
clearances into a more copacetic experience. Multiple experiments [9] have shown
that a deliberately supportive patient-practitioner relationship is key to creating
belief in a successful outcome.
The first office visit is the best time to understand each patient’s goals for their
TJA surgery and to set their expectations on positive outcomes. This can help the
patient maintain the perspective that it is their choice to have this surgery and ensure
that the whole care team understands what the patient is aiming to achieve. Ask
enabling questions during this visit, such as “Who is going to take care of you after
surgery?” This serves not only the practical purpose of ensuring there is an adequate
postsurgery plan in place but also engages the patient early on in visualizing a suc-
cessful postoperative arrangement in which their needs are being met. Another way
of doing this is to introduce patients before surgery to some of the physical therapy
exercises they will be given during their postoperative recovery, so they gain a sense
of what these motions look and feel like before surgical pain and dysfunction set in.
When a patient’s needs, goals, and modifiable risk factors are identified up front, the
whole care team can work together to ensure that the patient’s preoperative prepara-
tion is aligned accordingly.
The fear of being unconscious has been shown to be a significant cause of anxi-
ety for patients on the day of surgery [10]. It is common for patients to experience
“anesthetic catastrophizing,” which is the fear of being rendered unconscious and
not waking up, of dying while under the anesthetic, of having a mask put over their
face, and of having to put their trust in strangers. A recent survey showed that 20%
of patients were worried about brain damage from anesthesia, waking up during
surgery, and having memory loss, while roughly half that amount (9%) were con-
cerned about postoperative pain [11]. With concerns about anesthesia being so
widespread, it is important to reduce anxiety by dispelling misconceptions associ-
ated with regional or general anesthesia.
Reducing Caregiver Anxiety
Like the patient, the caregiver will also be faced with unknowns regarding what they
will need to do, how long they will need to do it, and when they, too, will be able to
return to their normal activities. Also, as with the patient, caregiver anxiety around
these unknowns is heightened when the TJA is performed at an ASC, with their role
of caring for the patient at home set to begin the same day as the surgery.
Similar to reducing patient anxiety, caregiver anxiety is best addressed by turn-
ing unknowns into knowns at the outset through effective presurgery education and
engagement. The sooner the caregiver understands their role, the better. The care-
giver, who is generally a family member, friend, neighbor, or coworker, should be
encouraged to attend all meetings and classes with the patient, as well as attending
a class designed especially for caregivers of patients after TJA surgery [12].
Caregivers should be made to feel like the critical stakeholder they are throughout
all relevant aspects of preoperative risk assessment and preparation. They should
also be encouraged to embrace the social-emotional aspect of their role such as

partnering with the patient to set expectations before surgery around positive post-
surgery outcomes.
Reducing Surgeon Anxiety
ASCs are safe economical settings for TJA surgeries [13]. However, performing
TJAs at ASCs is more logistically complex relative to performing TJAs in the hos-
pital setting. Traditional hospital settings offer a wealth of space, equipment, and
support staff, backed by a long history of established procedures for addressing any
complication that may arise during or after surgery. In contrast, ASCs are designed
for efficiency, such that surgeons who come sufficiently prepared in advance have
everything they need, and nothing extra [14]. This makes meticulous preoperative
patient selection and preparation more than “nice-to-have”; it is essential.
Postoperative adverse events such as heart attacks, sleep apnea, anemia, or respira-
tory arrest are less of a concern when the patient is staying the night in the hospital
and can be managed and monitored by healthcare professionals. Hence, surgeons
who are relatively new to performing TJAs at ASCs may experience some height-
ened preoperative anxiety of their own.
Surgeons can minimize their own anxiety by making sure to have rigorous patient
selection and medical optimization processes in place and by creating the right team
culture. When implementing complex and life-dependent yet mundane processes,
Atul Gawande advocates using a checklist [15]. One critical component of a suc-
cessful presurgery preparation process is making sure everyone knows who is in
charge of patient optimization. Further, surgeon anxiety will be minimized when it
is allowed to be normalized within a deliberate care team culture. Surgeons should
be expected to bring their “A” game every day, but at the same time feel comfortable
letting their team know when a particular patient or procedure may be cause for
extra concern, paving the way for their team to then give that particular patient or
procedure the extra attention that is needed.
ER Visits and Hospital Readmissions
People spend more time in the hospital today than at any other time in history [16].
And, the number of patients who bounce back to the hospital shortly after being
discharged can be significant. Combined 30-day readmission rates for THA and
TKA procedures are around 4.4% [17]. A meta-analysis of readmission rates pub-
lished between 1982 and 2013 found that for THA, rates are 5.6% at 30 days and
7.7% at 90 days, while for TKA, rates are 3.3% at 30 days and 9.7% at 90 days [18].
It might be expected that performing TJAs in the ASC setting carries an inher-
ently higher risk of ER visits and readmissions during recovery. This is a
140 C. De Cook
misconception. Between 2004 and 2008, when joint replacements happened exclu-
sively in the hospital setting with a typical LOS of 3–5 days [19], there was actually
a dramatic increase in readmission rates of Medicare patients within 90 days of
THA (primary or revision), from 7.4% to 11.9% [20]. Ninety day readmission rates
following TKA over the same time period were even higher, at 15.6% [2]. This puts
a strain on the healthcare system, making the elimination of preventable ER visits
and hospital readmissions a priority for policymakers. In addition to the financial
burden, avoidable hospital visits expose patients to undue risks of nosocomial and
iatrogenic infections. Perhaps most importantly, ER visits and hospital readmis-
sions carry an incalculable emotional toll on patients and their loved ones.
Reducing ER Visits
The reality is that patients who undergo TJA surgery at an ASC are less likely to
experience catastrophic complications, including a cardiac event and pulmonary
embolism (PE), than those who have the procedure performed in a traditional hos-
pital setting [21]. This is a testament to the power of proper preoperative preparation
and patient selection, whereby we select low-risk patients and engage in effective
patient education and medical optimization prior to surgery. Minimization of unnec-
essary ER visits during recovery is a hallmark of success in the outpatient arena.
The more prepared patients and caregivers are before surgery, the easier it is for
patients to gain solid footing on the road to a smooth recovery after surgery because
they understand what to expect.
The most common reasons for postoperative ER visits are pain, swelling, and/or
medication side effects [22, 23]. Common causes of ER visits among older patients
are fluid and electrolyte disorders. Evidence is mounting that teaching patients how
to detect early signs of these issues and proactively address them before they esca-
late results in less futile use of the ER. Arming patients and caregivers in advance
with appropriate “if … then” statements prior to surgery will minimize the likeli-
hood of these things leading to ER visits. “If you experience swelling, then you
should …,” or “If your wound becomes red, then you should … ”.
Reducing Readmissions
Another assumption that might seem reasonable is the notion that the more time
TJA patients get to spend recovering in the hospital after surgery, the better their
outcomes. In fact, longer lengths of postsurgery hospital stays for TJA patients,
particularly stays over 3 days, have been shown to correlate with a higher likelihood
of postoperative complications and readmissions [24].
When it comes to readmission following TJA surgery, the rates are lower than
that of the general Medicare population but still significant. The most common
reason for postoperative TJA readmissions is surgical site infection. These readmis-
sions can happen at unpredictable times [25] and they pose a financial burden to
hospitals under the bundled healthcare payment model [26].
In a study of 5732 patients undergoing either THA or TKA between 2013 and
2018, it was revealed that the major risk factors associated with readmissions are
age, body mass index (BMI), smoking, narcotic use, length of stay, discharge to
skilled nursing facility and multiple comorbidities, such as psychiatric diagnoses
and occurrence of cardiac dysrhythmias [27]. These risk factors were similar for
both 30-day and 90-day readmissions. Clearly, the key to predicting, and potentially
avoiding, readmission after surgery lies in performing comprehensive risk assess-
ments prior to surgery. This enables us to preemptively identify risk factors that can
be modified prior to surgery, such as working with patients to lower their BMI, stop
smoking, stop using narcotics and get treatment for psychiatric disorders.
If a patient is shown to be at high risk of complications due to modifiable factors,
it is important to delay TJA surgery long enough to optimize that patient. Improving
one or more of these risk factors will directly impact the likelihood of hospital read-
mission after surgery. Multiple studies have shown that with appropriate patient
selection, arthroplasty patients can be discharged safely on the same day as surgery
[21]. One way to take advantage of modifiable risk factors and extended preopera-
tive patient care is to make use of preoperative optimization programs. Such pro-
grams have been shown to reduce complications, such as readmission, after
TJA [28].
Another common misconception is the perceived benefit of sending patients to
skilled nursing facilities, rather than sending them home. In fact, it has been shown
that complications and readmission rates are higher if you send patients to a skilled
nursing facility versus sending them home [29]. As long as your care team works
closely with the patient and their at-home caregiver, providing adequate education
and decreasing modifiable risk factors ahead of surgery, sending TJA patients home
the same day is the best option.
Patients who are candidates for TJA in the ASC setting must be assessed upfront
for the level of social support from family and friends that will be available to them
after surgery. One patient will have a spouse and older children at home to help with
postoperative care, while another patient might live alone. One patient will have
good mental health, while another might struggle with addiction and depression.
Studies of TJAs performed in the hospital setting have shown that the greater the
social support that patients receive from family and friends postsurgery, the lower
the patient’s length of stay. Conversely, the higher a patient’s psychological distress
and the less social support they have, the longer their length of stay is likely to be.
However, even with higher psychological distress, higher social support will still
result in a shorter length of stay [30].
142 C. De Cook
seful Tools for Reducing Anxiety, ER Visits,

U
and Readmissions
Apps for Patients and Caregivers
Traditionally, patients and caregivers have been instructed to page the provider on-
call should urgent concerns arise. These traditional interactions between patients
and healthcare providers tend to be information-heavy, but short in terms of time
[31]. They can also produce varied success. Fortunately, today there are medical
apps that are designed with patient-centered care in mind. This technology helps a
healthcare team connect with and monitor patients who are comfortable communi-
cating via apps on their smartphones or mobile technologies [32].
With the right assistive apps, patients can, in theory, engage in an integrated care
pathway that follows them through all stages of their TJA experience, from the ini-
tial referral through surgery and recovery. These apps can provide patients with
targeted educational materials and customized care plans, potentially saving patients
from getting misinformed by following the wrong sources online. Ideally, these
apps can also collect patient-reported outcomes on symptoms, medication side
effects, and even levels of postsurgical anxiety or distress and link these patient
inputs to provider alerts. This model offers an efficient way to preemptively address
patient concerns and provide comprehensive care coordination, while the patient is
still at home and before the issues escalate into avoidable ER visits.
Assessment Tools for Surgeons
Simply knowing the risk factors is not enough. Once the data is gathered, it must be
iteratively modified and reassessed to achieve target patient optimization. This is a
complex process. Fortunately, there are preoperative evidence-based assessment
tools that can be used to help determine not only the risk factors involved with a
patient’s TJA surgery but how those risk factors might affect the outcome and post-
operative recovery.
The first tool is the Readmission Risk Assessment Tool (RRAT) [33]. This is a
tool that should be applied to all clinical, referral, preoperative, and surgical infor-
mation regarding the patient. The RRAT allows a patient’s healthcare team to ana-
lyze their data and develop a risk stratification that identifies the number and severity
of modifiable risks the patient has. Once the RRAT score has been calculated, the
patient can be identified as high-risk or low-risk for readmission.
Another assessment tool that is useful for a TJA patient’s healthcare team is the
Outpatient Arthroplasty Risk Assessment (OARA). This assessment tool is a vali-
dated multidisciplinary algorithm for risk stratification and patient assessment that
was designed specifically for the identification of patients for both same-day and
next-day discharge after TJA surgery [34]. The assessment is geared toward the
safety of the patient, with scores between 0 and 79 identifying patients who are
good candidates for day surgery. Patients are scored on the basis of nine health cat-
egories, which include general health, hematology, cardiology, endocrine, gastroin-
testinal, renal, pulmonary, psychiatric/neurological, and infectious disease [35].
Conclusion
By 2030, the overall number of total knee arthroplasties (TKA) and total hip arthro-
plasties (THA) are expected to reach 3.48 million and 572,000 respectively [36, 37].
When it comes to TJA in the outpatient setting, preparation is the key to success and
for reducing postoperative ER visits and readmissions. Patients often experience
heightened anxiety prior to surgery, and if a patient is at high risk for complications,
this can increase the anxiety of everyone involved, including the patient, the care-
giver, the surgeon, and the healthcare team. It is absolutely critical that, as surgeons,
we understand a patient’s individual risk factors, both modifiable and those that are
not. Of particular importance are the modifiable risk factors, which include obesity,
poor nutrition, poorly controlled diabetes, smoking, venous thromboembolic dis-
ease, cardiovascular disease, and psychological and neurocognitive problems,
behavioral problems, Staphylococcus aureus colonization, physical deconditioning
and the risk of falling. These risk factors have been proven to negatively affect post-
operative outcomes and increase the risk of readmission [38].
It is critically important to consider comorbidities prior to surgical intervention,
as this has been shown to reduce postsurgical complications and improve outcomes.
When this is coupled with the medical optimization of high-risk TJA candidates, it
also improves patient engagement, which, in turn, reduces anxiety. An example of
this is Perioperative Orthopedic Surgical Home (POSH), which is an optimization
pathway that targets eight modifiable comorbidities that were targeted by the RRAT
and are identified by surgeon-led screening [39]. These include infection risks;
smoking; obesity/malnutrition; cardiovascular disease; deep venous thrombosis;
neurocognitive, psychological, or substance-related problems; physical decon-
ditioning; diabetes.
As technology continues to improve and patient-centered care is fully embraced,
patients will feel increasingly listened to, understood, and validated. This will result
in a better understanding of the TJA surgical procedure and the postoperative out-
come. The key is to initiate this patient education early in the preoperative stages of
the care pathway, so the patient has time to learn and digest information, have their
questions and concerns addressed, and form relationships with their healthcare
team. When this happens consistently and thoroughly, patient preoperative anxiety
will be significantly reduced, which will in turn reduce the likelihood of postopera-
tive ER visits and readmissions (Fig. 15.3).
144 C. De Cook
Fig. 15.3 Total joint arthroplasty patient experience at an ambulatory surgery center versus the
hospital setting
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30. Zeppieri KE, Butera KA, Iams D, Parvataneni HK, George SZ. The role of social support
and psychological distress in predicting discharge: a pilot study for hip and knee arthroplasty
patients. J Arthroplast. 2019;34(11):2555–60.
146 C. De Cook
31. van Kasteren Y, Freyne J, Hussain MS. Total knee replacement and the effect of technology
on cocreation for improved outcomes and delivery: qualitative multi-stakeholder study. J Med
Internet Res. 2018;20(3):e95.
32. Semple JL, Armstrong KA. Mobile applications for postoperative monitoring after discharge.
CMAJ. 2017;189(1):E22–4.
33. Boraiah S, Joo L, Inneh IA, Rathod P, Meftah M, Band P, et al. Management of modifiable risk
factors prior to primary hip and knee arthroplasty: a readmission risk assessment tool. J Bone
Joint Surg Am. 2015;97(23):1921–8.
update on the outpatient arthroplasty risk assessment score. J Arthroplast. 2019;34(7S):S40–3.
35. International Congress for Joint Reconstruction. Selecting patients for outpa-
tient surgery: a novel scoring system. February 25, 2019. https://icjr.net/articles/
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36. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee
arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780–5.
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pedic surgical home: optimizing total joint arthroplasty candidates and preventing readmis-
sion. J Arthroplast. 2019;34(7S):S91–6.
Chapter 16
Making the Transition to Outpatient:
Resources and Pathway Changes
Paul K. Edwards, Jeffrey B. Stambough, Simon C. Mears,

and C. Lowry Barnes
Introduction
Making the transition to outpatient (OP) total hip and knee replacement can have
many challenges. Recently, surgeons have sought to identify the critical steps to
accomplish this transition [1–7]. Our total joint arthroplasty (TJA) clinical pathway
(CP) is a structured, multidisciplinary plan of care, with detailed steps that are stan-
dardized to elective total hip and knee replacement patients. This chapter identifies
some of the key elements in a successful CP that we recommend initiating prior to
an OP TJA program.
Patient Selection
Appropriate patient selection combined with proper preoperative optimization is

vital to the success of an OP TJA program. Recent reports have shown that utilizing
strict OP exclusion criteria results in similar risks of adverse events and readmis-
sions between OP and inpatient (IP) TJA. Excluding patients with a history of dia-
betes mellitus, myocardial infarction, stroke, congestive heart failure, deep venous
thromboembolism, pulmonary embolism, cardiac arrhythmia, respiratory failure,
chronic pain requiring regular opioid medications, active cardiopulmonary disease,
history of sleep apnea, active anticoagulation therapy, and morbid obesity from OP
selection yields similar outcomes to inpatient TJA [8–10].
P. K. Edwards (*) · J. B. Stambough · S. C. Mears · C. L. Barnes

Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
e-mail: [email protected]; [email protected]; [email protected]

Switzerland AG 2023
148 P. K. Edwards et al.
An increased risk in perioperative TJA complications has been reported in

patients age >75 years, uncontrolled diabetes, chronic obstructive pulmonary dis-
ease, high BMI (>35 kg/m2), chronic opioid use, functional neurological impair-
ments, dependent functional status, low preoperative cognitive capacity, congestive
heart failure, liver cirrhosis, and chronic kidney disease [11–13]. Other institutions
have implemented thresholds for outpatient TJA for candid consideration including
BMI < 35 kg/m2, ASA classification <3, strong social support system with an avail-
able “coach” for the first 2 postoperative weeks, <75 years of age, and able to par-
ticipate in an outpatient program [13, 14]. The partners in our total joint practice
have agreed upon a few strict exclusion criteria for OP TJA (Table 16.1).
Table 16.1 Exclusion criteria for outpatient TJA

Medical Factors Psychosocial Factors
CHF Age > 70 years
CVA Live alone
CKD History of falls
ESRD Excessive alcohol/drug abuse
COPD Smoking history
Hepatitis Chronic opioid use
HIV/AIDS History of depression/anxiety
Sleep apnea Assistance for ADLs
BMI >40 kg/m2 Lack of transportation
Atrial fibrillation Chronic pressure ulcers
Vascular disease Hospitalization <6 months ago
Chornic steroid use Admission to SNF <6 months ago
History of post-op ileus Noncompliance with home meds
Solid organ transplant No “coach” or caretaker
CAD with prior cardiac stents
Chronic anemia (Hgb <10 g/dL)
Thrombocytopenai (platelets <75 k)
ASA = > 4 assessed by anesthesia
History of malignant hyperthermia
Malnutrition
*Total lymphocytes <1500 cells/mm
*Albumin <3.5 g/dL
Transferrin level < 200 mg/dL
16 Making the Transition to Outpatient: Resources and Pathway Changes 149
Preoperative Optimization/Clearance Pathways
Utilization of two distinct medical clearance pathways are beneficial. One pathway
is reserved for patients that are healthier and can be considered potentially appropri-
ate for OP TJA, while the second pathway includes patients with more extensive
medical issues (e.g., uncontrolled hypertension, pulmonary issues, congestive heart
failure, prior cardiac stents, coagulopathies, prior DVT/PE, anticoagulation agents
beyond ASA, chronic anemia, end-stage renal disease, etc.) [2]. Patients are initially
screened by the surgeon or mid-level provider at the surgical office visit. Relatively
healthy patients along with those meeting OP TJA criteria are referred to one of our
three fellowship-trained Sports Medicine Primary Care Physician (PCP) partners to
undergo a thorough medical evaluation. We have learned that a single location for
medical optimization/clearance provides many benefits and minimizes preoperative
clearance variability. While this streamlined process not only provides a single
depot for history, physical exams, and consultant medical clearances (e.g.,
Cardiology, Hematology, etc.), it also affords consistent and judicious use of preop-
erative medical laboratory studies that aligns with our overarching goal of providing
a safe, cost-conscious approach for joint replacement. The patients who do not meet
OP criteria are referred to our Internal Medicine (IM) colleagues for further evalua-
tion/optimization dependent on their comorbidities. Patients referred to the IM
pathway are not candidates for OP TJA.
Education
Preoperative hip and knee replacement education classes are paramount to success-
ful short stay joint replacement. These sessions have demonstrated utility in decreas-
ing pre- and postoperative anxiety, postoperative pain, improving coping skills,
leading to shorter length of stay (LOS), improving home discharge, lowering read-
missions, and imparting cost savings to the episode of care [1, 6, 7, 15–28].
Specifically, implementation of a CP with a mandatory preoperative educational
program has demonstrated shorter hospital LOS, decreased readmissions, and
improved home discharge [1, 2, 5–7]. Recent data revealed preoperative education
as the single intervention associated with decreasing LOS following total knee
arthroplasty without increasing complications or readmissions within 90 days of
discharge [28].
One key feature to improve learning and retention is the use of general informa-
tion tailored to the specific procedure in an interactive format using the “spaced
retention method” [29–31]. A previous review article outlines this method as effec-
tive in educating adult patients regarding their elective hip or knee replacement
surgery. This technique has been shown to increase memory retention by up to
200% [32–34]. Our CP accomplishes this teaching by aligning the surgeon, sur-
geon’s mid-level provider, surgeon’s office RN, PCP Sports Medicine Clearance
team, and the preoperative education instructors to teach consistent, correct detailed
information in repetition at varying spaced intervals.
In addition to proper preoperative education, it is vital that the education material
is written at a level the patient can comprehend. Since only 12% of US adults have
proficient health literacy, patient education material should be written at a sixth
grade or lower reading level and include pictures and illustrations [35, 36]. It is
important to note the patient education material provided by the American Academy
of Orthopaedic Surgeons (AAOS) has a readability score above the eighth grade
level and therefore may need to be modified or tailored to some of your patient
population [37–41]. Presenters should be the treating staff and classes should be
taught on or near the joint replacement hospital floor [20]. Other guidelines for the
preoperative education material suggest avoiding medical jargon, structuring the
program to be chronological, and using visual images and models for demonstra-
tion [20].
Perhaps an even more critical element to successful OP TJA is the identification
of a strong support system [42]. We require our OP TJA candidates to have a family
member or close friend, designated as a “coach,” commit to being available as a
caretaker for at least 2 weeks after surgery and to assist the patient on the day of
discharge. It is important to educate the patient and their “coach” to pay special
attention to warning signs that could indicate a medical complication that can occur
in the first 24 h after a procedure, such as oversedation, urinary retention, nausea,
vomiting, dehydration, and hypotension. Therefore, we require mandatory patient
attendance and highly encourage “coach” attendance for the educational joint acad-
emy class prior to elective hip or knee arthroplasty. Our patients also sign a “non-
binding” contract in which they identify their “coach” as well as three individuals
available to assist with personal needs and transportation after hospital discharge
(Figs. 16.1 and 16.2). If a patient fails to attend class, we delay surgery until the
class can be completed. For complete transparency and partner accountability, our
practice emails a monthly report that details the percentage of each surgeon’s
patients and coaches who attend the education class prior to joint replacement.
UAMS HIPKNEE ACADEMY AGREEMENT
Welcome to the UAMS HipKnee Academy. Our goal is to give you the information you need to have the best
experience you can with your replacement surgery. We aim to send you home with family or friends the day
after surgery. We do not plan to send you to inpatient rehab, skilled nursing home, or home health unless
medically needed.
What we do:
• Keep pain under control
• Use long acting numbing shots
• Help you to walk the day of surgery
• Help you to get home and to move around as quickly as possible
• Start physical therapy the day after knee patients leave the hospital
• Help patients stay out of rehabs where they could get infections
What is not usally needed:

• IV narcotic drugs
• Urinary catheters
• IV lines
• Long hospital stays
• Continuous passive motion machines (CPMs) because they have not been shown to help patients
• Physical therapy for hip patients
We need to make sure you understand our program and have the support of family and friends you need to
recover. Please bring this signed form with you to the HipKnee Academy class at UAMS.
I agree to attend HipKnee Academy at UAMS. This class will help me to understand what to expect with my
surgery, when I go home, and therapy. I do not have to attend if I have been to HipKnee Academy in the last
year.
I agree to bring my coach with me to HipKnee Academy. This coach is someone who will be with me at home
for the first five to seven days after surgery.
I agree to see a doctor at UAMS before my surgery.
I agree to use the phone numbers that will be given to me if I need medical help. I will be given a daytime
phone number to call during clinic hours, and a separate phone number for nights or weekends to reach a
doctor or physician assistant (PA). I will call these numbers instead of going to my primary care clinic or the
emergency room first. I will call those numbers if I have trouble with pain, swelling, redness, or am worried
about infection.
Figs. 16.1 and 16.2 Total joint arthroplasty patient contract

By signing this form, I agree to the above and understand that I must plan to follow all discharge instructions
from my surgeon. If I do not do all that I have agreed to, my surgery may be rescheduled or cancelled.
Patient Signature Date
My coach will be .
The following people will be able to help with my personal needs and driving after I leave the hospital:
Thank you for choosing UAMS for your joint replacement suregery. We look forward to giving you the best care
before, during, and after your surgery. See you in HipKnee Academy!
Sincerely,
UAMS Hip and Knee Replacement team
Simon C. Mears, M.D., Ph.D.

Paul K. Edwards, M.D.
C. Lowry Barnes, M.D.
Jeffrey B. Stambough, M.D.
Figs. 16.1 and 16.2 (continued)
Anesthesia
Modern neuraxial spinal anesthesia (SA) has been the preferred anesthetic modality
for rapid recovery in elective TJA. Several studies from high-volume joint replace-
ment centers have reported SA is associated with less blood loss, lower transfusions
rates, shorter LOS, lower rates of intensive care unit (ICU) utilization, lower rates
of cardiopulmonary complications, lower deep vein thrombosis risks, and improved
30-day morbidity and mortality [43–47]. Although SA remains the accepted stan-
dard for OP TJA, recent reports show that excellent outcomes can be achieved when
modern general anesthetic (GA) techniques are utilized. We recently reported
equivocal complications and outcomes using contemporary GA techniques in a
series of 1527 consecutive primary TJAs (644 total hip and 883 total knee arthro-
plasties) performed over a 3-year span at a single institution. In our cohort, 96.3%
of patients were discharged in less than 24 h after elective TJA with a 2.4% 90-day
readmission rate and a 1.3% reoperation rate [48]. Our contemporary GA tech-
niques are detailed in this recent publication [48].
Same-Day Discharge Criteria
Once a patient has been determined as a potential candidate for OP TJA surgery, it is
important to adequately inform the patient and family of the risks and potential ben-
efits of same-day discharge. The patient, their “coach,” and their support team should
understand the same-day discharge criteria and agree to participate in this pathway.
If surgery is performed in a free-standing Ambulatory Surgery Center, there needs to
be previously established protocols with efficient pathways in place to allow for IP
hospital admission in the circumstance when same-day discharge criteria are not met.
Recently, AAHKS proposed evidence-based guidelines be followed for safe
same-day discharge to home after TJA (http://www.aahks.org/position-statements/
outpatient-joint-replacement/). Prior to discharge, all patients should undergo a
comprehensive physical therapy evaluation. Patients should be able to ambulate
with assistance to and from the bathroom, ascend and descend at least two steps,
and walk independently on ground level using an assistive device. Patients should
demonstrate they can tolerate oral fluids, have pain controlled with oral medica-
tions, void without difficulty, and remain hemodynamically stable (Table 16.2).
Systematic processes at all centers participating in OP TJA must be in place to allow
for such changes in care plans if an IP admission is necessary. The conditions listed
in Table 16.3 need to be assessed carefully and if they place the patient at increased
risk for complications or adverse events, then IP admission should occur (Table 16.3).
Table 16.2 Same-day TJA Social support network in place

discharge criteria
Voids without difficulty
Tolerates oral fluids without difficulty
Adequate pain control with oral medications
Remains hemodynamically stable during mobilization
Physical therapy requirement
*Safely ambulate
*Independently transfer
*Ascend/descend steps
Table 16.3 Appropriate TJA inpatient admission criteria

Requires assistance of PT to safely ambulate
Home environment not conducive to safe recovery
Requires monitoring of electrolytes or hematologic parameters
Requires monitoring of medical condition (diabetes, hypertension, etc.)
Unable to understand postoperative instructions (precautions, medication adherence, or safety)
Any other condition or status that is likely to require a level of support, intervention, or
monitoring not readily available outside of the hospital inpatient setting
Existence of any one of the following factors:
*Inadequate pain control on oral pain medication
*Unable to tolerate oral intake
*Unable to void freely
*Hemodynamically unstable
Staying Connected
Communication after home discharge is critical to safe and successful outcomes. In

an effort to avoid unnecessary Emergency Department (ED) visits, office visits, and
hospital readmissions all patients are instructed to call a “hotline” number for any
questions or concerns. We also counsel all patients to call the “hotline” prior to mak-
ing any unplanned visit to the ED. Patient calls during daytime hours are received
by our office nursing staff and addressed with the respective team. After-hours and
weekend questions are addressed via the “hotline” number that is answered by a
rotating schedule of one of the surgeons or mid-level providers. A recent study has
shown that managing an all access number is actually not as burdensome as one
may imagine. Our data showed on average one phone call was received per day,
with an average duration of 3.9 min per call [49].
In addition to the patient “hotline” number, we contract with a third-party group
to assist in proactive patient phone calls at specific pre- and postoperative intervals.
The purpose of these calls is to identify and solve any issues or patient concerns
prior to an unnecessary ED visit, readmission, or office visit. These “touches” allow
for real-time clinical decision-making and for an adjustment in the frequency of
“touches” depending on the severity of the particular issues. In concert with our
clinical pathway, we have previously demonstrated excellent outcomes with very
low complication and readmission rates through the different phases of care.
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Chapter 17
Outcome Metrics: What to Measure Now
and in the Future
Robert Pivec and Jess H. Lonner
Introduction
Recognition that total joint arthroplasty (TJA) represents the highest single expen-
diture for the Centers for Medicare and Medicaid Services (CMS) has been a cata-
lyst for the implementation of alternative treatment and cost containment initiatives
for total hip and knee replacement, irrespective of payer [1]. Interest in outpatient
TJA has paralleled changes at the Federal level, particularly with a shift towards
Alternative Payment Models (APMs), such as the mandatory Comprehensive Care
for Joint Replacement (CJR) model started in 2016 or the voluntary Bundled
Payments for Care Improvement (BPCI) Advanced model [2]. Furthermore, there is
a growing use of ambulatory surgery centers (ASCs) for outpatient TJA in appropri-
ately indicated patients [3, 4]. These broad shifts in both the method of healthcare
delivery (outpatient TJA) and the method of reimbursement (APMs) make it incum-
bent on the surgeon to know which clinical and nonclinical data is collected and
tracked. Outcome metrics can be extremely helpful for informing decisions regard-
ing patient selection, protocol development, surgical techniques, site of care, and
appropriateness of outpatient TJA. Equally, if not more important, outcomes assess-
ment is critical to ensure that the shift to outpatient TJA does not increase readmis-
sions or complications and that indirect costs are not increased as a result.
R. Pivec · J. H. Lonner (*)

Rothman Orthopaedic Institute, Philadelphia, PA, USA
Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson
University, Philadelphia, PA, USA
e-mail: [email protected]; [email protected]

Switzerland AG 2023
158 R. Pivec and J. H. Lonner
ssessing Success: Patient-Report Outcomes

A
and Satisfaction Scores
Patient-reported outcome measures (PROMs) are the foundation of assessing clini-

cal outcomes following TJA. Although there are numerous PROMs to choose from,
the authors routinely obtain Lower Extremity Function (LEF), Knee Injury and
Osteoarthritis Outcome Score (KOOS)/Hip Disability and Osteoarthritis Outcome
Score (HOOS), 12-Item Short Form Mental and Physical Component Survey (SF-12
MCS and PCS), and New Knee Society Scores both at the initial visit and at subse-
quent follow-up visits. These outcome metrics represent both disease-specific and
general health scores and have historically been utilized primarily for research pur-
poses. More recently, some of these have been used by payers to quantify the quality
of care and determine value-based payments. It is anticipated that value-based care
payment initiatives will increasingly rely on PROMs to influence compensation for
care. Collection of PROMs enables the surgeon and care team to monitor their own
TJA patient outcomes longitudinally. Common validated outcome measures such as
KOOS, HOOS, Oxford Knee Scores, and New Knee Society Scoring systems are
useful surgery-specific tools for knee and hip arthroplasty [5, 6].
The utility of disease-specific PROMs such as Western Ontario and McMaster
University Osteoarthritis Index (WOMAC), Oxford Hip Score, and Knee Society
Clinical Rating Score (KSCRS) was demonstrated by Halawi et al. to have a higher
correlation with patient satisfaction than general health scores (e.g., SF-12), activity
(e.g., UCLA Activity Score), or perceptions of normalcy [5]. More specifically, the
authors observed that of disease-specific PROMs, the pain domain was most closely
correlated with patient satisfaction [4].
Patient satisfaction is increasingly recognized as an important measure of out-
come after TJA, which was often ignored in classic PROMs. Patient satisfaction
with ASC care is collected through a CMS program termed Consumer Assessment
of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey
(OAS CAHPS), which mirrors the inpatient side of hospital satisfaction reporting
(HCAHPS). However, unlike its inpatient cousin, OAS CAHPS is a voluntary pro-
gram started by CMS in 2016. As of 2022, it remains a voluntary initiative per
CMS. Although ASCs at this time are not monetarily penalized for low satisfaction
scores (unlike inpatient procedures which are monitored via HCAHPS), this type of
revenue-penalty model, which has been termed Value-Based Purchasing (VBP) by
CMS, was mandated to be implemented for ASCs as well by the Affordable Care
Act (ACA).
Pain management has been well-documented to impact satisfaction scores;
therefore, surgeons should collect metrics that include patient satisfaction, particu-
larly since it is tied to HCAHPS (and likely OAS CAHPS in the future) and hospital
reimbursement via the VBP program. Prior studies have demonstrated that low
HCAHPS scores were primarily correlated with poor pain control, which led to
increased emphasis on pain management. Thus, the measurement of patient satis-
faction, as it relates to pain management, will become increasingly important in the
17 Outcome Metrics: What to Measure Now and in the Future 159
future as VBP programs transition from the inpatient side to ASCs. In a recent study
assessing the correlation between pain and low patient satisfaction scores, Jung
et al. demonstrated that patient satisfaction was actually better correlated with a
shorter length-of-stay (LOS) than pain [7]. Data is now emerging showing that the
inherently shorter LOSs with ASCs are translating into higher patient satisfaction
compared to inpatient TJA. A recent study by Kelly et al. demonstrated that com-
pared to inpatient surgery, outpatient TJA patients were more satisfied—particularly
with regards to pain management, nurse responsiveness, and thoroughness of dis-
charge planning—and preferred the outpatient procedures [8].
While we do not expect any clinically meaningful changes in longer term joint-
specific outcomes measures when TJA surgeries are transitioned to the outpatient
setting, cost of care and patient satisfaction may be improved. Additionally, atten-
tion to outcomes metrics should assist the surgeon and institution in informing
patient selection and perioperative protocols, mitigating risk, controlling costs, and
improving outcomes in outpatient TJA. The onus is on us to ensure that the shift to
outpatient care does not increase readmissions, complications, or indirect costs, and
it is our responsibility to carefully track these particular outcomes with regards to
outpatient TJA.
Assessing Safety: Complications
It is recommended that surgeons routinely track their complications and need for
hospital readmissions, ensuring that they are not occurring with greater frequency
in the outpatient compared to the inpatient settings. Healy et al. and Iorio et al. have
published comprehensive standardized lists of complications of both TKA and THA
that may serve as useful resources (Table 17.1) [9–11].
Complications are recorded, tracked, and publicly reported by CMS. For the
inpatient setting, there are currently eight complications with mandated reporting
and public disclosure (Table 17.2). The complications are then compared to other
hospitals in the local region to identify statistical outliers (defined as outside of the
95% confidence interval bounds for the region) and publicly reported on a per-
hospital basis using a color-coded scheme (Table 17.3).
Similar reporting models apply to ASCs, where reimbursement is tied to compli-
ance with CMS reporting requirements, including provisions for public reporting,
via the Ambulatory Surgical Center Quality Reporting Program (ASCQR). If ASCs
do not comply with reporting requirements, they may incur a 2% reduction to any
future ASC Medicare payment update thereby decreasing revenues. Although not
TJA-specific, some of these complications do pertain to hip and knee replacement
including wrong site surgery, patient falls, and transfers to acute care hospitals
(Table 17.4). Certainly, the latter two risks are of great concern in the outpatient
setting and may be mitigated with careful patient selection and meticulous periop-
erative management.
Table 17.1 Complications for knee and hip arthroplasty as defined by the Knee Society [9] and
Hip Society [11]
Complications for total knee arthroplasty Complications for total hip arthroplasty
1. Bleeding 1. Bleeding
2. Wound complication 2. Wound complication
3. Thromboembolic disease 3. Thromboembolic disease
4. Neural deficit 4. Neural deficit
5. Vascular injury 5. Vascular injury
6. Medial collateral ligament injury 6. Dislocation/instability
7. Instability 7. Periprosthetic fracture
8. Malalignment 8. Abductor muscle disruption
9. Stiffness 9. Deep periprosthetic joint infection
10. Deep periprosthetic joint infection 10. Heterotopic ossification
11. Periprosthetic fracture 11. Bearing surface wear
12. Extensor mechanism disruption 12. Osteolysis
13. Patellofemoral dislocation 13. Implant loosening
14. Tibiofemoral dislocation 14. Cup-liner dissociation
15. Bearing surface wear 15. Implant fracture
16. Osteolysis 16. Reoperation
17. Implant loosening 17. Revision
18. Implant fracture or tibial insert dissociation 18. Readmission
19. Reoperation 19. Death
20. Revision
21. Readmission
22. Death
Table 17.2 Complications tracked and reported by CMS
Complication Reporting period

Acute myocardial infarction (AMI) 7 days of admission
Pneumonia 7 days of admission
Sepsis/septic shock 7 days of admission
Surgical site bleeding 30 days of admission
Pulmonary embolism 30 days of admission
Death 30 days of admission
Mechanical complications 90 days of admission
Periprosthetic joint infection/wound infection 90 days of admission
Assessing Failure: Readmissions
Readmissions or transfers following outpatient TJA, if performed in the outpatient

hospital setting, or transfers/admission to the hospital from the ASC setting, are
both tracked and publicly reported by CMS. Again, these occurrences, regardless of
payer, should be closely followed by surgeons in order to maintain a high level of
patient care and ideally should be reviewed on a month-by-month basis to ensure
that patient selection and perioperative protocols are acceptable [12].
Table 17.3 CMS reporting criteria for complications

The
number of
Better than the national No different than the Worse than the national cases is too
Category rate national rate rate small
Criterion The entire 95% interval The 95% interval The entire 95% interval Fewer than
estimate surrounding estimate surrounding estimate surrounding 25 cases
the hospital’s rate is the hospital’s rate the hospital’s rate is
lower than the national includes the national higher than the national
rate rate rate
Table 17.4 Ambulatory surgery center reporting mandates pertaining to TJA

Reporting Code Complication
ASC-1 Patient burn
ASC-2 Patient fall
ASC-3 Wrong site, wrong side, wrong patient, wrong procedure,
wrong implant
ASC-4 All-cause hospital transfer/admission
ASC-13 Normothermia
CMS tracks six procedures (including hip and knee replacement) and levies a
penalty if the readmission rate is above a certain threshold, except for exempt insti-
tutions (such as VA, rural hospitals, Children’s hospitals, among others) [13]. If TJA
is performed in a hospital outpatient setting, the institution may be liable for read-
missions for a maximum penalty of 3% Medicare revenue per year under the
Hospital Readmissions Reduction Program (HRRP). [13, 14] A recent study by
Springer et al. demonstrated a higher readmission rate for outpatient TJA (11.7%)
compared to inpatient TJA (6.6%). Many of these readmissions were either due to
poor pain control at home or wound complications. Interestingly, despite higher
readmission rates, patients who underwent outpatient TJA were significantly more
satisfied than inpatients [15].
On the ambulatory side, CMS tracks the number of patients that require transfer/
admission to a hospital from an ASC (Table 17.4). Another proposed rule in 2019
has evaluated the possibility of adding a further tracked metric for Emergency
Department (ED) visits and admissions within 7 days of various ASC procedures,
including TJA. However, at this time the proposed rule is limited to General Surgery
procedures only, for tracked diagnoses such as bleeding or DVT/PE. Currently, no
financial penalties have been levied (CMS currently only requires compliance with
reporting outcomes via the ASCQR program). However, it is possible that revenue
may be withheld with future CMS rule changes if ASC transfer and/or admission
rates are above a certain threshold, similar to the HRRP. While CMS has formalized
some of these policies, and though CMS-insured patients are not the common
demographic for outpatient TJA, private payers often follow the lead of CMS and
may eventually impose similar penalties for admissions.
While there is some incentive for surgeon practices with bundled payment
arrangements with private insurances and CMS to transition TJA to an outpatient
setting in ASCs, complications and hospital admissions or transfers can have a large
financial impact given the practices’ assumed risk for costs for the entire episode of
care. Surgeons will need to keep a close eye on both their readmission rates, but also
their transfer and post-discharge ED visits particularly if performing outpatient TJA
in an ASC. Better screening of patients preoperatively to optimize patients and
appropriately select patients for the outpatient setting, optimized perioperative man-
agement protocols, as well as perioperative navigation and access to the care team,
may help decrease complications, unnecessary ED visits, and readmission rates [16].
Assessing Costs: Healthcare Costs in the CJR Era
Across a broad spectrum of procedures, Medicare estimated savings of almost $7

billion between 2007 through 2011 and up to $12 billion between 2012 through
2017 by shifting outpatient surgical procedures from hospitals to ASCs for patients
considered low-risk [17]. While the typical targeted demographic for outpatient TJA
is not necessarily the Medicare-aged population, but rather the younger patient
cohort, the general message is the same. Payers may stand to save a great deal of
money if carefully selected TJA cases are transitioned to the ASC. In APM and
bundled care arrangements, hospitals and physicians may be held accountable for
costs for an entire 90-day episode of care and are required to pay a penalty if spend-
ing following TJA exceeds what is termed the quality-adjusted spending benchmark
[18, 19]. Although the CJR model was designed in an era of inpatient TJA, in the
future surgeons need to be prepared for ongoing CMS rule changes, and shifting
models of reimbursement by private payers, to align reimbursement models between
inpatient and outpatient procedures. [20]
Surgeons also need to be aware of the difference in reimbursement for TJA in the
inpatient versus ambulatory setting, which can range anywhere from 18 to 28% less
if performed in an outpatient setting. One further layer of added complexity is dif-
ferentiating between the hospital outpatient department (HOPD) and an ASC which
also have further reimbursement differentials, with similar procedures performed in
an ASC reimbursed at rates ~20% lower than if done in a HOPD [18, 19]. In many
non-Medicare bundled care arrangements, total costs per episode of care after total
and partial joint arthroplasty may also prove a beneficial cost impact from transi-
tioning to outpatient cases, as long as complications and indirect costs are mitigated
during the episode of care.
The ability to accurately measure costs will be paramount for efficient operation
in the ambulatory setting. A recent study by Palsis et al. evaluated two different
methods of accounting for TJA: traditional accounting and what is termed time-
driven activity-based costing (TDABC) [20]. The authors noted that while fixed
costs such as implant costs or surgeon’s fees were accurately accounted for with
traditional accounting, indirect costs and space/equipment costs were substantially
overestimated with traditional account methods. The authors concluded that for
total knee arthroplasty traditional accounting produced a negative margin of 36%,
when CMS payments were used as a revenue source, and a positive margin of 22%
when TDABC methods were used. Thus, it is critical that surgeons, particularly
those with ownership or gain-sharing arrangements with ASCs ensure they have a
robust accounting capability that accurately manages the costs of care.
Conclusion
Outcomes metrics is a term that represents a vast array of potential data that can be
collected and analyzed for patients undergoing TJA. Although there is some over-
lap, outcomes metrics that are of primary interest to the surgeon to help inform and
guide improvements in perioperative surgical care may not align with the metrics
that are preferred by regulatory agencies such as CMS or commercial insurance
providers. Surgeons may find it informative, effective, and efficient to adopt sys-
tems to effectively track useful outcomes measures while remaining in compliance
with regulatory bodies for patient data reporting. In the case of outpatient knee and
hip arthroplasty, the key outcomes measures to assess are costs of care, patient sat-
isfaction, and the risks of complications, Emergency Department visits, and hospital
transfers/admissions. While functional outcomes measures will likely not show
obvious differences when surgery is performed on an outpatient or inpatient basis,
our responsibility is to confirm that we can deliver outpatient TJA safely and cost-
effectively in the outpatient setting, and that patients are equally, if not more satis-
fied compared to those receiving inpatient TJA. These are important outcomes
measures for us to track longitudinally and frequently, as we work to refine indica-
tions for outpatient surgery, inform patient selection criteria, influence perioperative
protocols for patient care and access to the care team, and expand the numbers of
knee and hip replacements performed in ASCs.
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Chapter 18
How to Mitigate Risk for Surgeons,
Institutions, and Patients
Leonard T. Buller and R. Michael Meneghini
Introduction
Total joint arthroplasty (TJA) is an excellent treatment for disabling joint disease
[1]. Since its original description, the primary goals of TJA have remained constant:
to perform a durable reconstruction that reduces pain, restores function, and
improves the quality of life [2]. Until recently, multiple days of inpatient care fol-
lowing TJA was the expectation. Lately, there has been a transition from a “sick-
patient” to a “well-patient” model, whereby patients are optimized prior to surgery
and no longer require prolonged in-hospital care. Simultaneously, refinements in
surgical technique, multimodal pain management, blood conservation, and physical
therapy have resulted in quicker recovery and a transition to outpatient TJA [3].
Interest in outpatient TJA has also been driven by financial considerations, like sur-
geon ownership of ambulatory surgery centers (ASCs) [4]. The pressure to transi-
tion to outpatient TJA was further escalated in the United States with the Outpatient
Prospective Payment System 2018 rule, which removed TKA from the inpatient-
only list, causing hospitals and payers to treat all Medicare TKA patients as outpa-
tients [5]. All of these factors provided a groundwork for developing rapid recovery
protocols to accommodate early discharge after TJA. However, the safety of outpa-
tient TJA remains a concern. This chapter describes how to minimize risk to patients,
surgeons, and institutions through appropriate preoperative evaluation, optimiza-
tion, and multidisciplinary care coordination.
L. T. Buller (*) · R. M. Meneghini

Department of Orthopaedic Surgery, Indiana University School of Medicine,
Indianapolis, IN, USA

Switzerland AG 2023
166 L. T. Buller and R. M. Meneghini
Reducing Patient Risk
Reducing risk in outpatient TJA begins well before the patient enters the operating
room; commencing with appropriate surgical indications, as even the best surgery
on the wrong patient will yield more harm than benefit. Risk stratification and pre-
operative optimization, as described in the first two chapters, is mandatory for all
patients undergoing elective TJA. The preoperative evaluation should include medi-
cal, dental, and where appropriate cardiac clearances, medication reconciliations,
and a venous thromboembolism prophylaxis plan [6]. The medical team is respon-
sible for identifying and correcting any modifiable risk factors. Multiple new medi-
cal diagnoses are made during prescreening and up to 2.5% of patients are considered
to have unacceptably high surgical risk for elective TJA [7]. Furthermore, only a
minority of patients lack comorbidities (13% of total knee arthroplasties (TKAs)
and 17% of total hip arthroplasties (THAs)), emphasizing the importance of pre-
screening [8].
After preoperative optimization, selecting those patients appropriate for outpa-
tient TJA has traditionally been limited to nonspecific surrogates such as the
American Society of Anesthesiologists Physical Status (ASA-PS) classification or
the Charlson Comorbidity Index (CCI), which were not specifically designed for
this purpose. Surgeons often combine these indices with the knowledge that certain
medical comorbidities are associated with longer hospital stays [9], and select
patients without these conditions for an outpatient pathway [10]. However, this
selection strategy is not evidence-based and has been shown in multiple studies to
result in poor reliability in identifying those patients capable of outpatient TJA [11,
12], underscoring the importance of accurate risk stratification for safe patient
selection. This is particularly important when considering most outpatient TJA stud-
ies are performed within the safety net of outpatient hospital departments, where
patients who do not meet discharge criteria can be converted to an inpatient hospi-
talization. As the expansion of outpatient TJA in ASCs continues, risk reduction
through appropriate patient selection will become critical.
The Outpatient Arthroplasty Risk Assessment (OARA) score was specifically
designed to identify patients medically appropriate for same- and next-day dis-
charge after TJA. Appreciating the vulnerabilities of outpatient TJA patients, the
OARA score was specifically designed to err in the direction of patient safety and
multiple studies have evaluated its validity [13, 14]. Using a preoperative cutoff of
79 points, the OARA score approaches the desired 100% positive predictive value
(PPV), 100% specificity, and 0% False Positive Rate (FPR). The high PPV, or prob-
ability that patients with lower scores were discharged home the same day, and
specificity, or proportion of patients with higher scores who did not go home the
same day; combined with the low FPR, or proportion of patients with higher scores
who went home the same day, indicates that the OARA score effectively identifies
patients who can safely undergo outpatient TJA. Additionally, the low Negative
Predictive Value, or probability that patients with a higher score were not discharged
the same day, low sensitivity, or proportion of patients with a lower score who were
18 How to Mitigate Risk for Surgeons, Institutions, and Patients 167
discharged the same day, and high False Negative Rate, or proportion of patients
with a lower score who did not go home the same day, reflects the design of the
score to err in the direction of patient safety. Accurate risk stratification, using
evidence-based selection criteria, is a critical step in reducing patient risk in outpa-
tient TJA.
A patient’s fear and anxiety of the unknown and pain is a primary barrier to out-
patient TJA [15, 16]. However, there are multiple benefits from recovering in the
home environment including elimination of nosocomial risks and institutional dis-
turbances, as well as access to preferred foods and leisure objects. Expectation set-
ting through a unified, team-based approach is crucial in alleviating patient fears
and explaining the benefits of outpatient TJA. Preoperative patient education begins
in the office at the initial visit with written and electronic patient educational materi-
als. Standardized patient education positively impacts patient satisfaction, particu-
larly with regard to pain management, which is a leading barrier to early discharge
[17]. Additionally, preoperative education improves postoperative outcomes, lowers
costs, and reduces lengths of stay [18]. Expectations for recovery should be com-
municated to patients in all educational materials and by all staff involved in patient
care. The expectations should include a discussion of the disease process and entire
phase of care, the location of recovery and/or therapy, pain expectations, ambulation
expectations, driving expectations, and return to work expectations. More informa-
tion is covered in a shorter period of time and an emphasis should be placed on how
to manage variability in pain, nausea, swelling, and other symptoms that the patients
may experience for the first time at home. Appropriate optimization, risk stratifica-
tion, and preoperative education are all strategies that reduce patient risk. However,
surgeon and institution variables are also responsible for reducing patient risk in
outpatient TJA.
Reducing Surgeon Risk
Appropriate surgical indication for TJA is the first way to reduce surgeon risk.
Surgeons should assure the patient’s specific disease pattern makes them likely to
benefit from outpatient TJA. This includes utilizing tools that predict patients at risk
of a poor outcome [19], as well as tools that identify patients at risk for failure of
early discharge [20]. While outpatient TJA results in less rounding, lower inpatient
burden, and fewer healthcare provider “touches,” the overall patient care commit-
ment is not less [21], including an increase in the number of phone calls [22]. The
shift in perioperative care burden from the hospital to caregivers [23] and the surgi-
cal team mandates enhancement of outpatient staff accessibility [24]. Multiple strat-
egies exist to increase staff availability including hiring more staff, extending clinic
hours, scheduling preemptive telephone calls, or utilizing technologies to monitor
patient recovery [25, 26]. A safety net is required to assure patient well-being, mini-
mize complications, and reduce readmissions. When patients are discharged home
earlier, they are more isolated and oftentimes geographically distanced from their
surgeon. Regardless of discharge disposition and timing, postsurgical patients still

have the same risks of complications after surgery. Therefore, a successful outpa-
tient TJA must include a safety net to minimize the risk of feeling or experiencing
abandonment.
Surgeon risk can also be reduced by understanding how a predictable set of com-
plications routinely delays patient discharge in an outpatient pathway: blood pres-
sure (hypotension or hypertension), over-sedation, postoperative urinary retention
(POUR), postoperative nausea and/or vomiting, pain and social support issues [27].
To reduce surgeon risk, each of these should be considered in detail before outpa-
tient TJA. Additionally, establishing a way to track and monitor outcomes is critical
to assess the strengths and weaknesses of individual protocols. These protocols can
then be modified based on this data, further reducing surgeon risk. Important proto-
cols to develop during the establishment of an outpatient TJA pathway include pain
management (multimodal drugs and narcotic minimization), anesthesia, blood and
fluid management, and surgical technique. Though previously discussed in other
chapters, we will briefly address each of these and their role in reducing surgeon risk.
Multimodal pain management, through an established pathway, in combination
with technically excellent surgery and anesthesia that reduces side effects and com-
plications is crucial to expediting recovery. The goals are to minimize pain, seda-
tion, hypoventilation, urinary retention, and nausea while encouraging early
mobilization. A multimodal approach that starts before surgery and includes proto-
cols after the patient is discharged home has been demonstrated by many high-
volume centers to result in successful rapid recovery after TJA [28–33].
The choice of anesthesia varies by surgeon and anesthesiologist preference, but
the two teams should cooperate with the mutual understanding of the goal of early
mobilization. Anesthesia should provide adequate sedation and pain control intra-
operatively, as well as maintain a level of postoperative pain control while minimiz-
ing confusion, sedation, and nausea. Neuraxial anesthesia decreases postoperative
narcotic use, decreases cardiopulmonary morbidity, decreases the risk of thrombo-
embolic events, decreases blood loss, and optimizes muscle relaxation, which eases
surgical exposure [34–36]. When done correctly, a short-acting spinal with a half-
life of 2 h provides an early motor return, allowing for participation in physical
therapy shortly after completion of the procedure. Regional anesthesia is also help-
ful in postoperative pain management, decreasing the need for narcotics, allowing
earlier ambulation, and reducing the rate of readmissions and hospital length of stay
[37–40]. Soft tissue, peri- and intra-articular injections have also been demon-
strated, in multiple administration forms, to reduce postoperative pain, decrease the
need for oral narcotics, and improve range of motion [41–43].
Attention to blood and fluid management is critical, as blood loss remains a con-
cern for the safety of outpatient TJA; particularly in ASCs, where blood transfusions
are often unavailable. Development of an effective blood management strategy
begins with identifying patients who may be at risk for requiring postoperative
transfusion [44, 45] and incorporating modern transfusion protocols that include
both the hemoglobin level as well as patient symptoms. The widespread use of
tranexamic acid has dramatically reduced perioperative blood loss and transfusions
[46, 47], without increasing thromboembolic complications [48], and should be

given to all eligible patients [49–51].
Perioperative hydration is also crucial to reduce the number of postoperative
complications that prevent outpatient TJA, including POUR. The American Society
of Anesthesiologists guidelines should be utilized, which encourages patients who
meet the appropriate criteria to drink clear liquids up to 2 h before surgery [52].
Intraoperative IV hydration ensures intravascular volumes are sufficient to mini-
mize orthostatic hypotension, tachycardia, and low urine output. Rapid recovery
protocols should aim for approximately two liters of intraoperative IV crystalloids,
with an additional 1 L postoperatively. Despite a low relative incidence, the use of
rocuronium, glycopyrrolate, neostigmine, and fentanyl spinals are associated with
POUR and their use in the perioperative period should be minimized [53].
Finally, the influence of surgical approach on the ability to undergo outpatient
TJA should be considered in as much as the surgeon should be comfortable with the
chosen approach and must be diligent to minimize intraoperative complications.
When effectively executed, surgical approach does not appear to have a significant
influence on overall postoperative pain, length of stay, or ability to mobilize [54].
The focus should be on maximizing efficiency and streamlining the procedure,
removing extraneous steps or delays and minimizing complications. Surgeons and
teams should be aware that introducing new techniques is associated with a learning
curve, which may result in increased blood loss, complications, and time [55].
Operating room efficiency is the key and surgeons should surround themselves with
staff who make the procedure run as smoothly as possible. Everyone involved
should know their steps to limit errors and reduce risk.
Reducing Institution Risk
After appropriate patient selection and optimization, a multidisciplinary approach

to outpatient TJA is critical to assure the procedure is performed safely and with a
low risk of complications. The first step in reducing institutional risk is convincing
institution administration that their support of an outpatient TJA pathway will be
directly beneficial by improving bed availability and reducing exposure to expenses
[56]. Hospital and ASC insurance contracting is crucial to assure the insurance pre-
approval process identifies facility-fee reimbursement issues and non-covered
patient costs. Some insurers consider TJA performed at an ASC “out of network.”
Therefore, it is critical to obtain credentialing for outpatient TJA and do a thorough
pro forma based on the payer mix, meet with the payers, and negotiate rates for each
procedure. With regards to Medicare patients, many hospitals are charged early dis-
charge penalties for outpatient TJA and identifying these situations ahead of time
can minimize the financial burden on the patient and should be a part of the institu-
tional screening program for outpatient TJA.
A multidisciplinary approach to outpatient TJA dramatically reduces lengths of
stay and readmission rates, while enabling earlier ambulation [29]. We recommend
creating a routine coordinated care conference attended by key members of the

multidisciplinary team to discuss upcoming surgeries. The goal of this meeting is to
share information across disciplines, anticipate and answer questions, and proac-
tively develop patient care plans. The team members should include the surgeon,
anesthesiologist, hospitalist [57], nursing staff [58], physical therapy, and pharmacy.
To further reduce institution risk, as a part of preoperative optimization, specific
protocols should be established by the multidisciplinary team to address common
medical conditions. For example, smokers should be counseled regarding preopera-
tive cessation to optimize wound healing and reduce anesthesia-related risks. Obese
patients should be educated on the increased risks associated with obesity and
weight loss recommendations should be established. Similarly, patients with poorly
managed diabetes mellitus, a known risk factor for higher postoperative complica-
tions [59], should have their procedure delayed until strict glycemic control is
attained. Individualized risk stratification for deep vein thromboembolism should
also be included [6], and plans for prophylaxis should be made preemptively to
avoid delays, confusion, and the risk of readmissions in the postoperative period.
Appropriately selecting patients eligible for outpatient TJA will reduce institu-
tional risk. Unlike ASA-PS and the CCI scores, the OARA score is not a measure of
physical status, medical complexity, or mortality but still accounts for comorbid
conditions relevant to TJA. This is helpful because some patients who are poor can-
didates for early discharge may have low ASA-PS and CCI scores. For instance, a
patient with a history of poor pain control due to fibromyalgia, who is otherwise
healthy, would have an ASA-PS score of 1, and a low CCI but a high OARA score,
making them unacceptable for early discharge. In contrast, a patient with multiple
but stable medical problems may have higher ASA-PS and CCI scores, but a lower
OARA score. Thus, the OARA score helps reduce the institutional risk of inpatient
conversions or readmissions through appropriate stratification.
As opposed to being with similar patients in the inpatient setting, recovery within
an outpatient protocol is more likely to occur in isolation. Consequently, the impor-
tance of a “Joint class” or “Joint camp,” in which a group of patients attends a meet-
ing to hear the full details of the procedure, expands patient education beyond
didactic materials. This allows patients to socialize and work together through ques-
tions and answers. Joint classes have been demonstrated to decrease lengths of stay
by nearly 50% and increase the likelihood of timely discharge by 62% [60].
Standardized reading material in these classes is useful as a reference to answer
patient questions, but the institution must assure staffing is available to answer spe-
cific questions not covered in the handouts.
A final area for risk reduction at the institution level is in the immediate postop-
erative setting. The goals of immediate postoperative management in outpatient
TJA are minimization of pain and early mobilization. During the acute phase, expe-
rienced anesthesia and nursing staff transfer the patient from the operating room to
the post-anesthesia care unit to stabilize them medically and manage pain and nau-
sea. During the step-down phase, patients are transferred to a private recovery area
where they begin rehabilitation and are educated on proper wound care and how to
assess for signs of complications. The institution should assure staff familiar with
rapid recovery protocols are available to facilitate this process, which decreases
patient anxiety and fear [28, 61]. Finally, a member of the team should be respon-
sible for reaching out to the patient within 24–48 h postoperatively to assess their
progress and answer questions.
At the institution level, anticipatory management is advisable to establish and
adhere to vetted protocols, as opposed to reacting after a complication or readmis-
sion occurs. The importance of data collection to track volume, outcomes, and
patient progress cannot be overstated and will assure necessary staff and service line
resources are available. While careful patient selection is critical to minimize risk,
so is facility and staff selection to maximize operating room efficiency and safety.
This includes training staff on patient setup and room layout to facilitate efficient
surgery and faster turnover, as well as standardization of instrument trays to reduce
setup time and decrease the cost of sterilizing unused instruments. Establishing
institutional protocols will decrease risk by improving reproducibility, decreasing
operating room times, decreasing time to onboard staff, improving staff confidence,
and increasing a surgeon’s confidence in their staff.
Conclusion
With increasing pressure to improve efficiency and reduce cost, improvements in

our understanding of postoperative recovery have allowed for an evidence-based
shift towards outpatient TJA. Rapid recovery TJA has been successfully performed
in multiple patient populations, with low rates of complications and readmissions
[62, 63], even in elderly patients [64–69]. In its current state, appropriately per-
formed outpatient TJA is a safe [70–73], cost-efficient [4, 74, 75], and patient-
friendly strategy [76]. It is projected that greater than half of all primary TJAs will
be performed in an outpatient setting by 2026 [77]. Most patients recover in a pre-
dictable fashion following surgery [30, 64, 78–81] and standardizing care will
increase efficiency and the reproducibility of outcomes. Safe and successful outpa-
tient TJA relies on a number of important factors including patient selection, multi-
disciplinary care coordination, standardized perioperative protocols, and
postoperative management. As the proportion of outpatient TJAs increases, it is
crucial to create evidence-based safeguards to minimize patient, surgeon, and insti-
tution risk.
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Chapter 19
Financial Considerations for Surgeons
in the Outpatient Setting: Costs
and Ownership Models
Joe Zasa
Introduction
In conjunction with the clinical and patient care aspects of an arthroplasty program,
the economic reality of performing total joint arthroplasty (TJA) in an ambulatory
surgery center (ASC) must also be addressed. Medicare and commercial payers see
the cost benefits and the positive outcomes associated with performing total joints
in ASCs. Accordingly, many surgery centers have successfully renegotiated com-
mercial payer contracts and “carved out” the applicable arthroplasty CPT codes.
However, it must be emphasized that negotiating payer contracts is only one, albeit
a critical, factor when developing and growing an outpatient TJA program. There
are a myriad factors inherent in establishing a successful arthroplasty program; thus,
it is not as simplistic as adding yet another service line to the ASC, such as ophthal-
mology or endoscopy. The obvious differentiator is that high-cost implants are uti-
lized; however, there are other factors that must be considered in order to develop a
comprehensive and successful program.
In 2016, the Ambulatory Surgery Center Association (ASCA) published
Developing and Managing Surgery Centers, the first book on ASC development and
management. In that text, a methodically planned approach to developing ASCs is
emphasized with a foundational business plan utilized as the “blueprint” for the
project. To summarize, comprehensive planning prior to the development of an ASC
begets a sound financial structure through realistic and accurate projections. This
links together with the development of solid operational systems, selection of staff,
administration, and anesthesia best suited for the project, and lays the groundwork
for surgeon participation and sound organizational leadership committed to the best
J. Zasa (*)
ASD Management, Dallas, TX, USA

Switzerland AG 2023
178 J. Zasa
interests of the ASC. Essentially, the culture of the ASC that is so critical to its long-
term success begins during the planning phase.
Developing an outpatient TJA program is simply a microcosm of ASC develop-
ment so, for illustrative purposes, the following highlights our process for develop-
ing an arthroplasty program and emphasizes key aspects that we believe are integral
to program success.
Develop a Business Plan
A business plan is not just a proforma or financial projection; rather, it is a thorough

vetting of all aspects of the arthroplasty program. Developing the business plan acts
as a reference point to establish the foundation for the program.
The business plan consists of:
1. Executive Summary—this is a summary of the program and includes volume and
financial assumptions, an explanation and support for the financial projections,
the timing of the project, the surgeons involved and their level of commitment,
necessary approvals, competition, projected capital expenditures, third party
payer issues, expected vendor pricing particularly for implants, work and patient
flow, and the overall benefits of the program.
2. Financial Projections—included should be:
(a) Sources and Uses of funds showing the start-up costs for the program and
how it is being funded.
(b) Income Statement using three scenarios (low, probable, and aggressive).
Two income statements should be prepared. The first is explicitly for the
arthroplasty program and details revenues and direct expenses specific to the
arthroplasty program. The second is an income statement for the existing
ASC showing its performance before and after the joint program is
implemented.
3. Supporting Schedules:
(a) Existing outpatient arthroplasty volume,
(b) Projected surgeon volume at the ASC (low, probable, and aggressive),
(c) Revenue and payer mix assumptions,
(d) Staffing assumptions,
(e) Vendor implant pricing from the selected implant vendor.
(f)Equipment requirements (tied back to the sources and uses of funds see
above) with supporting vendor bids.
(g) Projected construction costs from the selected contractor, if applicable, (tied
back to the sources and uses of funds see above).
19 Financial Considerations for Surgeons in the Outpatient Setting: Costs… 179
pecific Steps Required to Develop a Comprehensive Business

S
Plan for TJA
As described above, a comprehensive plan must be developed. The following is the

process we follow:
Creating and Meeting with the Implementation Team
The initial step is to identify the implementers to assist with the project. These team
members with different skill sets are identified as you consider the key concepts and
goals that are envisioned. A team of surgeons, anesthesiologists, nursing personnel,
administrative, and business personnel is recommended. Discussing the program,
its goals, and vision with a diverse group has the added benefit of establishing a
“deeper dive” into the project and raises questions or issues that may have been
previously overlooked. Core concepts should include patient flow, workflow, staff-
ing requirements, preoperative and postoperative procedures, whether overnight
(23 h) stay is required or envisioned, discharge protocols, equipment and construc-
tion requirements, and vendors.
Sources and Uses of Funds
What capital expenditures or start-up expenses are required? This includes new
equipment and instrumentation, construction costs, and miscellaneous fees such as
legal and regulatory fees.
Second, how will the capital expenditures be funded? The amount of debt or
equity should be vetted. If using debt, it can be financed through equipment vendors
or through local banking arrangements typically. Our experience is that vendor
financing is typically slightly more expensive but does not require personal guaran-
tees. However, construction costs must be funded by a lending institution or by
using working capital reserves of the current ASC. Notwithstanding, bids should be
obtained for construction costs and equipment to obtain best pricing. In sum, com-
petition is good and shopping for equipment vendors and contractors is important.
The selected bids should be scheduled in the business plan and tied back to the
projections.
As a brief segue, OR room size and 23 h stay are key topics. Typically, joint
surgeons are accustomed to larger operating rooms (ORs). With the standard ASC
OR in the 400–450 square foot range, the typical hospital OR is in the 600–700
square foot range. While TJA can be safely performed in the standard ASC OR, the
equipment and nature of the case make for tight quarters. This is not an issue for a
start-up surgery center that can design larger ORs, but it is a key issue for existing
180 J. Zasa
centers looking to start a TJA program. Note the cost to retrofit ORs can be very
expensive, so this is something that the surgeons must discuss and agree upon before
significant expenditures are made. Similarly, 23-h stay must be planned from an
operations standpoint (days the service is provided, dietary, and personnel) as well
as from a design standpoint. Every ASC is different, but there are enhanced privacy
issues when starting up a 23 h program and it will likely impact the recovery room
and number of bays due to the common desire to have walls and doors in the 23 h
designated area. In summary, understanding these costs are imperative in planning
your program.
Initial Proforma
After understanding the start-up costs, the next step is to construct an initial projec-
tion of the economic impact of the program. Patient volume is critical so query the
interested surgeons regarding how many outpatient joints they performed in the
preceding 12 months and then estimate future growth. This must be a conservative
estimate. We then run three scenarios using 60%, 70%, and 80% of projected vol-
ume to make conservative estimates regarding annual patient volume.
Determining expected revenue is simply a function of assessing the cases pro-
jected and assigning reimbursement from your third-party payer contracts. For
Medicare, estimate based on the published rates that are being circulated for com-
ments. If your contracts do not have reimbursement for these codes, we do not
include them in this initial proforma. Once the payer mix is determined, use a
weighted average of reimbursement to determine expected revenue per case.
Next, assess cost per case. You can ask for surgeon preference cards from the
hospital to assess non-implant costs fairly easily. We measure supply costs and
drugs and add a factor for variable expenses such as laundry, linen, transcription,
and coding. For the implants, obtain vendor pricing from your device
representatives.
As an example, see an initial proforma:
Note the term “gross margin” because the capital expenditures are not included
in this and additional staffing is not included. Typically, the equipment is depreci-
ated over 5 years, and the construction cost is depreciated depending on factors
outside the scope of this chapter. Thus, for illustrative purposes, we will use the
actual cash flow based on a debt model.
Refinement of the Projections
The initial projections provide a base for the economic impact of the project, but are
simply an initial exercise to determine feasibility. The real key is the refinement
phase. If the business plan is the meat, the “secret sauce” is this phase when devel-
oping a joint program.
There are two distinct areas of focus:
1. Implant Pricing
2. Third-Party Payer Reimbursement
The surgery center business is essentially a fixed-cost business with only one true
material variable cost: medical supplies and drugs. Staffing is really more of a
hybrid because the relatively small size of an ASC begets a core group of staff
required whether the center does 200 cases per month or 300 cases per month. Thus,
the incremental volume does not necessarily beget additional staffing. Thus, there is
real economics of scale as additional volume is added as long as there is the capacity
to perform the cases. For this reason, in our example above, we do not have addi-
tional staffing to accommodate the joint program and do not count staffing cost in
the gross margin analysis. Each center is different and staffing is very much volume-
based, so be aware of the core concept of fixed and variable costs, but staff accord-
ing to your circumstances.
Compare and contrast staffing to the largest cost impacting the joint program:
implant cost. The absolute best way to refine this cost is to create a RFP (request for
proposal) and ask the implant vendors for their best pricing contingent upon the
surgery center and surgeons using their implant on an almost exclusive basis (e.g.,
90%). If the surgeons can work together and standardize implant costs, it will have
a material impact on the cost of care, and hence the profitability of the program. In
summary, standardize implants among the surgeons, obtain proposals from the
implant vendors for best pricing tied to volume guarantees and drive your implant
cost in the right direction.
182 J. Zasa
As Medicare publishes its rates for TJA, third-party payers will gravitate to pric-
ing similar to what CMS promulgates. However, this is an area where gains can be
made that will be a win/win for the payers, patients, and your ASC. Note in the
initial proforma (see above) we do not include volume from payers who do not pay
for joint procedures in our estimates. Similarly, we do not include volume from pay-
ers who reimburse for these procedures at rates that are below the cost of the proce-
dure. There is a real opportunity to contract with these payers and augment the
proforma through additional volume by securing these contracts at favorable rates.
Once you highlight that they are paying local hospitals at least two times (and typi-
cally more) than the rate you will accept for the same procedure, and stress the sav-
ings by moving this volume to your ASC, you create an opportunity for your ASC
to lower the cost of care for the patient and the payer and drive volume to your ASC.
Notwithstanding, negotiating with third-party payers is more of an art than a sci-
ence but it should be noted that information is key. Specifically, knowing your cost
to perform the case is essential, as well as having an idea of what they are paying at
your current site of service by obtaining Explanation of Benefits (EOBs) from
patients or obtaining this data from databases. It must be emphasized that you have
leverage if these cases are being performed at the hospital because, on average,
hospitals are paid approximately two times what an ASC receives from Medicare
and the third-party payers tend to follow this methodology. By showing the payer
that these costly cases can be moved to a safer setting at a lower price, they are more
inclined to carve out these procedures in your current contract. Additionally, by
knowing your actual cost and refining the cost through vendor standardization, you
have the ability to negotiate favorable rates and not undercut yourself. Remember,
the first offer they make is rarely the one you will take, so shoot for 20–30% below
the hospital rate and use the information to augment your contracting process.
Technology and Evolution
As a final note, as you develop a successful program be sure to highlight this prog-
ress within your community. We submit that it is important to market your arthro-
plasty program through social media to refine and optimize your presence on search
engines and on review sites, such as Yelp. One strategy is to regularly promote
patient outcomes, patient and family experiences, and cost effectiveness on your
website, Facebook page, Instagram page, and in the media. A marketing expert can
assist. Lastly, embrace technology. One specific example is using smartphone apps
to monitor and manage pain control. These are still in their infancy but will be a key
component in the delivery of care.
Conclusion
In summary, build a team of implementers to assist with your project, develop a

sound and thoroughly vetted business plan that will lay the groundwork for a suc-
cessful program, refine your program through implant standardization, and refined
payer contracting by knowing your costs and highlighting the advantages for payers
to carve out these procedures at your ASC. Finally, market and highlight the advan-
tages of your program, patient outcomes, and savings. We are at the forefront of
huge growth in TJA at ASCs. With proper and methodical planning and execution,
you give your ASC the ability to be a leader in your market by developing it as a
program of excellence.
Chapter 20
Outpatient Hip and Knee Arthroplasty:
Implications for Hospitals, ASCs,
and Payers
John R. Steele and Michael P. Bolognesi
Introduction
Hospitals, surgeons, and payers have recognized the potential benefits that outpa-
tient total hip and total knee arthroplasty may provide for some patients. Although
peer-reviewed literature on outpatient arthroplasty is evolving, multiple studies
have demonstrated that outpatient total joint arthroplasty (TJA) can be safe and
cost-effective compared to hospital-performed TJA in appropriately selected
patients [1–6]. With this promising data and in the face of mounting cost pressures,
insurers have begun covering TKA and THA performed in outpatient settings. As a
result, the number of outpatient TJA surgeries has increased tremendously in recent
years, with greater than one-half of primary TJA surgeries predicted to take place in
the outpatient setting by 2026 [7]. The transition of large numbers of TJA surgeries
to the outpatient setting will have a profound impact on hospitals, ASCs, and payers,
the topic of this chapter.
In general, ASCs and payers stand to gain financially, while hospitals are likely to
incur financial losses. As their market share of TJA increases, ASCs will perform
more surgeries and make more money. However, TJA patients will present new chal-
lenges for them that they will have to adapt to in order to provide safe and appropriate
care. Payers also stand to gain financially as they reimburse less to hospitals, sur-
geons, and ASCs for TJA episodes of care. Hospitals are likely to incur financial
losses as they are reimbursed less for TJA episodes of care. In addition, inpatient TJA
patient cohorts are likely to become sicker and costlier on average as healthier patients
undergo TJA in the outpatient setting. A summary of the likely effects of growing
numbers of outpatient arthroplasty on these stakeholders is summarized in Table 20.1.
J. R. Steele (*) · M. P. Bolognesi

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
e-mail: [email protected]; [email protected]

Switzerland AG 2023
186 J. R. Steele and M. P. Bolognesi
Table 20.1 Summary of likely effects of outpatient arthroplasty on hospitals, ASCs, and payers
Hospitals – Likely to incur financial losses
– Inpatient TJA patient cohort likely to become sicker and costlier
– Less likely to gainshare in bundled payment models
Ambulatory – TJA market share likely to increase, resulting in financial gains
surgery centers – ASCs must adapt to meet the unique challenges presented by TJA patients,
including the need for increased recovery space and time, physical
therapists, implant and instrument space, and sterilization equipment
Payers – Likely to make financial gains as they reimburse surgeons and hospitals
less for TJA episodes of care
– Unintended, potentially deleterious consequences on bundled payment
models
Implications for Hospitals
Although outpatient TJA can provide improved outcomes and cost savings in appro-
priately selected patients [1–6], a large proportion of TJA patients require inpatient
care based on factors such as age, medical comorbidities, and socioeconomic situa-
tion. As growing numbers of younger, healthier patients undergo outpatient TJA, the
risk profile of patients undergoing inpatient TJA will worsen, stressing hospitals. In
addition, there is growing concern that physician and hospital/facility reimburse-
ments for inpatient TJA will decrease as payers adjust to the lower costs of outpa-
tient TJA [8].
CMS already reimburses differently for inpatient and outpatient surgeries, even
if both are performed in the hospital. As part of the Federal Balanced Budget Act of
1997, CMS created a Medicare “outpatient prospective payment system” (OPPS)
for all hospital outpatient services as an alternative to the inpatient payment system
(IPPS), which reimburses hospitals for all inpatient surgery. Although these two
payment systems function similarly, the facility payment for outpatient surgery is
significantly lower than the hospital reimbursement for a similar inpatient proce-
dure, due to the lower utilization of resources as well as decreased staffing and time
consumption associated with outpatient care [8]. In 2018, the 50th percentile hospi-
tal reimbursement for uncomplicated TKA was approximately $11,760 under IPPS
and approximately $10,123 under OPPS [9]. Similarly, prior research has shown
that the average reimbursement after outpatient THA is $1155 less than inpatient
THA [10]. To make matters worse, many healthcare providers and hospitals are
concerned that CMS may reduce hospital reimbursements for inpatient TJA surger-
ies to the level of OPPS in the future.
Decreased reimbursement to hospitals for inpatient TJA would have two signifi-
cant effects on hospitals. First, patients who require inpatient admission have more
medical comorbidities and utilize more resources during their hospital stay, increas-
ing the cost to the hospital associated with their admission. If reimbursement for
inpatient TJA continues to decrease, hospitals may experience financial losses for
their inpatient TJA patients [11]. This in turn may force hospitals to evaluate their
20 Outpatient Hip and Knee Arthroplasty: Implications for Hospitals, ASCs, and Payers 187
ability to provide inpatient TJA, which would limit access to care for those patients
who are not outpatient candidates.
Second, the transition of healthy patients undergoing TJA to the outpatient set-
ting will have unintended and potentially deleterious consequences on alternative
payment models including the Bundled Payments for Care Improvement (BPCI)
and Comprehensive Care for Joint Replacement (CCJR) initiatives. In these pay-
ment models, participant hospitals and surgeons are financially accountable for the
quality and cost of an episode of care which ranges from 30 to 90 days. Hospitals
receive a single payment for the entire episode of care for a patient undergoing TJA,
and are able to gainshare when the cost of admission is lower than the payment, but
lose money when the cost is larger than their reimbursement. A key component of
this system is that all TKA or THA patients are included so that the savings associ-
ated with healthier patients can offset the costs associated with higher resource uti-
lization for sicker patients. If healthy TJA patients are “cherry picked” for outpatient
surgery and are no longer in the alternative payment model pool, this shifts the risk
profile of patients in the pool in a direction that may be costly and unsustainable for
hospitals [8]. For example, one analysis of CMS data for TKA patients found that
up to 40% of TKA patients leave within 24 h and could be removed from the BPCI
program if they transition to outpatient, which would result in substantially less sav-
ings to hospitals of an average of $1100 per patient [12].
Implications for ASCs
As previously stated, greater than one-half of primary TJA surgeries are predicted to
take place in the outpatient setting by 2026 [7]. Although some of these surgeries
will occur in hospital outpatient departments (HOPDs), a large proportion will
likely be performed in ASCs. As such, ASCs stand to make huge financial gains as
their market share of TJAs increases. However, appropriate selection of patients that
are able to undergo TJA at an ASC is essential, and ASCs will have to adapt and
provide new services in order to adequately treat TJA patients’ unique needs.
Multiple studies have demonstrated improved outcomes and cost savings associ-
ated with TJA performed in ASCs versus inpatient facilities or HOPDs [1–7].
However, this is predicated on appropriate patient selection, as ASCs do not offer a
number of services that are important for complex patients. Whereas hospitals pro-
vide an environment where acute postoperative complications can be diagnosed and
intervened upon by appropriate medical personnel, ASCs often do not. Therefore,
patients with severe or multiple comorbidities are not appropriate for TJA at an
ASC, and ASCs must pay special attention to indicating appropriate patients for
care at their facilities. Furthermore, ASCs do not have the ability to discharge
patients to acute rehabilitation facilities or skilled nursing facilities, so only patients
that are unlikely to need these services are appropriately indicated to undergo TJA
at an ASC.
Lastly, ASCs require emergency medical services and hospital transfer policies
in place for when rare but severe complications such as vascular injury or malignant
hypothermia, among others, occur [7].
There are other unique challenges to performing TJA in the ASC setting that
must be considered prior to starting an outpatient TJA program at an ASC. TJA
patients often take several hours to recover and must walk and practice stairs with
physical therapy in order to meet discharge criteria. ASCs must therefore have phys-
ical therapy, or discharge readiness, services available and have the physical space
for recovery as well as gait and stair training to occur. Next, TJA surgery requires
more trays and instruments than the majority of traditional outpatient surgeries.
ASCs often have less space available to house these instruments and less steriliza-
tion equipment available to sterilize instruments. This must be evaluated, and good
communication between surgeons, ASCs and vendors is paramount to ensuring that
appropriate equipment is available [7]. Lastly, it must be noted that the majority of
ASCs are physician-owned, which may present the potential for financial conflicts
of interest. In their 2018 statement on outpatient joint replacement, AAHKS recom-
mended that “any financial conflicts related to outpatient discharge, such as owner-
ship in an ambulatory surgery center, physician-owned distributorship or outpatient
services, be transparently disclosed to the patient [13].”
Implications for Payers
Along with ASCs, payers stand to gain financially from the growth of outpatient
TJA. On average, CMS reimburses hospitals less for outpatient TJA than they do for
inpatient TJA. In 2018 this difference was approximately $1637 for uncomplicated
TKA [9]. Thus, as the percentage of TJA surgeries performed as outpatient increases,
CMS will save significant amounts of money. In addition, many surgeons and hos-
pitals believe that CMS will decrease the reimbursement for inpatient TJA to the
level of outpatient TJA, further decreasing the amount of money CMS will spend on
TJA. As private payers often follow reimbursement proposed by CMS, they too will
likely decrease payment to surgeons and hospitals for TJA episodes of care.
Therefore, private payers will also make financial gains through decreased reim-
bursement for TJA.
One unintended consequence of outpatient TJA that may negatively affect CMS
involves the bundled payment models which they have been implementing. As pre-
viously discussed, bundled payment models including BPCI and CCJR shift finan-
cial risk to hospitals and surgeons by paying them a fixed amount for the entire
episode of care surrounding TJA. These models have been successful in terms of
quality improvement and cost savings for CMS [12]. However, these models rely on
having healthy patients included in the population so that the money hospitals make
on these patients offsets the losses that they incur on older, sicker patients. If the
younger, healthier patients are transitioned to the outpatient setting, hospitals may
20 Outpatient Hip and Knee Arthroplasty: Implications for Hospitals, ASCs, and Payers 189
be at risk of losing money on performing TJA in the inpatient setting. This may in
turn result in decreased hospital participation in bundled payment models and thus
less cost savings overall for CMS in future payment programs [12].
Conclusion
Hospitals, surgeons, and payers have recognized the potential benefits that outpa-
tient total hip and total knee arthroplasty can provide for appropriately selected, but
not all, patients. The transition of more TJA from the inpatient to the outpatient set-
ting will have significant effects on hospitals, ASCs, and payers. In general, ASCs
stand to make financial gains as their market share of TJA increases, but TJA patients
will present new challenges for them that they will have to adapt to. Payers also
stand to gain financially as they reimburse less for TJA episodes of care. Hospitals
are likely to incur financial losses as they are reimbursed less for TJA. In addition,
they are likely to lose healthy patients to the outpatient setting, causing their inpa-
tient TJA patient cohort to become sicker and costlier on average. This, in turn, will
likely have unintended consequences on bundled payment models that may subse-
quently affect all of these stakeholders.
References
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2. Berger RA, Kusuma SK, Sanders SA, Thill ES, Sporer SM. The feasibility and perioperative
complications of outpatient knee arthroplasty. Clin Orthop Relat Res. 2009;467(6):1443.
3. Huang A, Ryu JJ, Dervin G. Cost savings of outpatient versus standard inpatient total knee
arthroplasty. Can J Surg. 2017;60(1):57.
4. Lovald ST, Ong KL, Malkani AL, Lau EC, Schmier JK, Kurtz SM, Manley MT. Complications,
mortality, and costs for outpatient and short-stay total knee arthroplasty patients in comparison
to standard-stay patients. J Arthroplast. 2014;29(3):510.
Arthroplasty Today. 2018;4(4):484.
6. Aynardi M, Post Z, Ong A, Orozco F, Sukin DC. Outpatient surgery as a means of cost reduc-
tion in total hip arthroplasty: a case-control study. HSS J. 2014;10(3):252.
7. DeCook CA. Outpatient joint arthroplasty: transitioning to the ambulatory surgery center. J
Arthroplast. 2019;34(7s):S48.
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Index
A Anti-anxiety, 61
Acetaminophen, 38 Antibiotic prophylaxis, 13
Adductor canal block, 66 Antiemetics, 60
Ambulatory Surgery Center Association ASC Covered Procedures List, 85
(ASCA), 177
Ambulatory Surgery Center Operating
Room, 100 B
Ambulatory Surgery Center Sterile Benzodiazepines, 61
Processing, 98 Blood management, 17
Ambulatory Surgery Center Storage, 95 intraoperative blood management
Ambulatory surgery centers (ASCs), 25, 94, strategies, 51, 52
153, 165, 177 preoperative optimization, 50, 51
Ambulatory Surgical Center Quality Reporting strategies, 105
Program (ASCQR), 159 Blood transfusions, 21
American Academy of Orthopaedic Surgeons Body mass index (BMI), 10
(AAOS), 51, 150 Bundled payment model, 25, 26
American Association of Hip and Knee Bupivacaine, 63
Surgeon (AAHKS), 13, 51
American College of Cardiology/American
Heart Association guidelines, 62 C
American College of Rheumatology Caregiver anxiety, 138
(ACR), 13 Centers for Medicare and Medicaid Services
American Society of Anesthesiologists, 64 (CMS), 1, 17, 85, 157
American Society of Anesthesiologists Charlson Comorbidity Index (CCI),
Physical Status (ASA-PS) 166
classification, 166 Chloroprocaine, 63
American Society of Regional Anesthesia, CMS Reporting Criteria, 161
51 Coagulation status, 63
Analgesics, 60 Comprehensive Care for Joint Replacement
Anesthesia, 102, 152 (CJR) model, 157
Angiotensin-converting enzyme (ACE) Cooled Radiofrequency Treatment,
inhibitors, 80 67
Angiotensin receptor blockers (ARB), COVID-19 pandemic, 1
80 Cryoanalgesia, 67
© The Editor(s) (if applicable) and The Author(s), under exclusive license to 191
Springer Nature Switzerland AG 2023
https://doi.org/10.1007/978-3-031-27037-6
192 Index
D Hospital operating room, 100

Dexamethasone, 69 Hospital readmissions reduction program
Dexamethasone’s antiemetic mechanism, 60 (HRRP), 161
Diagnosis-related group (DRG), 107 Hospital sterile processing, 99
Discharge criteria Hospital storage, 95
anesthesia and pain management, Hypotension, 80
114, 115 Hypoxia, 80, 81
patient selection, 114
post-discharge follow up, 118
postoperative care and physical therapy, I
117, 118 Indiana University Health Saxony Hip and
preoperative visit, 113, 114 Knee Center, 70
surgical technique and coordination, in Infiltration between Popliteal Artery and
operating room, 116 Capsule of the Knee (iPACK), 67
Disease Modifying Antirheumatic Medications Initial proforma, 180–181
(DMARDS), 13 Interoperative period
Durable medical equipment (DME), 101 anesthesia adjuncts for pain control, 67
blood loss, 68
fluid management, 68
E general anesthesia, 64
Emergency room (ER), 135 intraoperative treatment of nausea, 69
Enhanced Recovery After Surgery (ERAS) regional anesthesia, for hip, 64
protocols, 59 regional anesthesia, for knee, 65
Erythropoietin supplementation, 50 spinal anesthesia, 62–64
Essential oils, 61 Intravenous opioid medications, 79
Evidence-based medicine, 127
Excellent surgical technique, 116
Executive summary, 178 J
Joint replacement classes, 19
F
Facia iliaca compartment blocks, 65 K
False negative rate, 167 Ketamine drip, 67
False positive rate (FPR), 166 Knee and hip arthroplasty, 160
Famotidine blocks H2 receptors, 60 Knee Injury and Osteoarthritis Outcome Score
Femoral nerve blocks, 66 (KOOS), 123
Financial projections, 178 Knee Society Clinical Rating Score
Fluid management, 68 (KSCRS), 158
G L
Gabanoids, 60 Lateral femoral cutaneous blocks, 65
General anesthetic (GA) techniques, Lidocaine, 63
20, 64, 152 Lidocaine drip, 67
Gross margin, 181 Liposomal bupivacaine, 67
Group physiotherapy sessions, 130 Local infiltrative anesthesia (LIA), 65, 66
H M
High efficiency reconstructive Malnutrition, 11
orthopaedics, 108 Mayo Multimodal Opioid-Sparing Pain
Hip Disability and Osteoarthritis Outcome Protocol, 39
Score (HOOS), 123 Medical risk stratification, 70
Index 193
Mepivacaine, 63 implications for hospitals, 186, 187

Methicillin resistant S. aureus (MRSA), 12 implications for prayer, 188, 189
Midvastus approach, 54 in hospital setting, 109, 110
Minimally invasive surgical techniques, 17, 54 options for staying connected, 122
Mobile-based patient engagement patient mindset, 85, 86
platforms, 123 patient selection, 147
Mobilization, 129 post-discharge physical therapy protocols,
Modern fluid management techniques, 68 130, 131
Modifiable risk factors prehabilitation, role of, 129
antibiotic prophylaxis, 13 preoperative optimization/clearing
diabetes, 10 pathways, 149
inflammatory arthropathies, 12, 13 reducing institution risk, 169–171
malnutrition, 11 reducing patient risk in, 166, 167
vs. non-modifiable risk factors, 9 reducing surgeon risk, 167–169
obesity, 10 refinement of projections, 181, 182
smoking, 11, 12 safe same-day discharge, 129
Staphylococcus aureus screening, 12 same day discharge criteria, 87, 88, 153
vitamin D, 12 staying connected, 154
Multimodal analgesia, 60 technology and evolution, 182
Multimodal pain control, 17 telemedicine and electronic based
Multimodal pain management, 128, 168 follow-up, 122–124
Multimodal pain regimens, 105 Oxford Hip Score, 158
Oxycodone, 78
N
Neuraxial anesthesia, 42 P
Non-narcotic analgesic (acetaminophen), 20 Pain management, 158
Nonsteroidal anti-inflammatory drugs Pain medicine, 51
(NSAIDS), 20, 60 Patient anxiety, 29, 30
Patient preference, 77
Patient safety, 107
O Patient satisfaction, 158
Obesity, 10 Patient-reported outcome measures (PROMs),
Obstructive sleep apnea (OSA), 81 158, 159
Ondansetron, 60, 69 Perioperative hydration, 169
Opioids, 60 Perioperative period
Outcome assessment multimodal pain control, 60, 61
complications, 159 patient optimization, 59
healthcare costs in, 162 Peripheral nerve blocks (PNB), 42, 65
patient-reported outcome measures, Physical therapy, 103, 117
158, 159 Physical therapy discharge criteria, 129
readmissions, 160, 162 Placebo-controlled studies, 136
Outpatient arthroplasty, 121 Polyethylene liner exchanges, 19
Outpatient arthroplasty risk assessment Post-anesthesia care unit (PACU), 106
(OARA) score, 18, 114, 142, 166 Post-discharge formal physical therapy,
Outpatient total joint arthroplasty (TJA) 131
anesthesia, 152 Posterior capsule infiltration, 67
business plan, 178 Postoperative Knee Society Scores, 54
comprehensive business plan, 179–181 Postoperative pain
cost differences, 87 incision length and surgical
education, 149 technique, 53, 54
hospital setting, 107, 108 tourniquet use, 52
implications for ASC, 187, 188 tranexamic acid, 53
194 Index
Postoperative period periarticular injection, 43

nausea and vomiting, 69 peripheral nerve blocks, 42
pain management, 69 Total joint arthroplasty (TJA)
urinary retention, 70 ambulatory surgery center vs hospital, 17
Preoperative anemia, 50 anesthesia and pain management, 20, 21
Preoperative education, 29 antiemetic and anti-inflammatory effects of
Pro re nata (PRN) orders, 69 steroids, 40
Promethazine, 60 anxiety and patient outcomes, 136
Propofol, 81 assessment tools for surgeons, 142
barriers to early discharge in, 6
caregiver anxiety, 138
Q case selection, 19
Quadratus lumborum blocks, 65 education techniques, 31, 32
ER visits and hospital readmissions,
139, 140
R ER visits reducing, 140
Randomized controlled trial, 128 family/caregiver preparedness, 30, 31
Randomized total hip arthroplasty (THA), 128 in free-standing ASC, 100, 101
Readmissions, 70, 160, 162 and hospital decontamination and
Regional anesthesia, 20 sterilization areas, 99
for hip, 64 anesthesia, 102
for knee, 65 patient selection, 91, 92
Regional blocks, 66 perception of space, 93–97
Revolutionized joint replacement surgery, 17 physical therapy, 103
Routine prophylactic antibiotics, 13 sterile processing, 98, 100
hospital setting, 107
23-h observation and transfer
S agreements, 21
Same-day discharge, 128 hypotension and tachycardia, 80
Same-day PT, 128 hypoxia, 80, 81
Scopolamine, 61 medical evaluation and patient
Sensory posterior articular nerves of the selection, 2, 3
knee, 67 cardiac, 3
Serum fructosamine, 10 endocrine, 4
Single shot adductor canal blocks, 66 gastrointestinal, 4
Smoking, 11, 12 general medical, 3
Smoking cessation programs, 11 hematological, 3
Spaced retention method, 150 infectious disease, 5
Spinal anesthesia, 105 neurological/psychological, 4
Spinal headache, 63 perioperative patient optimization, 5, 6
Staphylococcus aureus colonization, 143 pulmonary, 5
Supporting schedules, 178 renal/urology, 4
Surgeon anxiety, 139 nausea and vomiting, 81, 82
outpatient joint replacement, 28
pain control, 78, 79
T patient anxiety, 29, 30, 137
Tachycardia, 80 patient comprehension and limitations, 30
Telerehabilitation, 124 patient education, 19, 20, 77
TKA exposure, 54 patient expectations, 28, 29
Total hip arthroplasty (THA), 85, 97 patient selection, 18, 77
gabapentinoids, 40 physical therapy discharge criteria, 82
neuraxial anesthesia, 41, 42 postoperative care and follow up, 21
opioid receptors, 41 preoperative education, 78
Index 195
preoperative optimization, 77 U
reducing readmissions, 140, 141 Unicompartmental knee arthroplasty, 92
surgeon anxiety, 139 Urinary retention, 79, 80
traditional preoperative joint replacement
education, 26, 27
urinary retention, 79, 80 V
Total knee arthroplasty (TKA), 51, 85, 97 VBP programs transition, 159
anti-inflammatory and acetaminophen, 38 Vitamin and mineral supplementation, 50
gabapentinoids, 40 Vitamin D deficiency, 12
neuraxial anesthesia, 41, 42
opioid receptors, 41
periarticular injection, 43 W
peripheral nerve blocks, 42 Web-based protocols, 130
Tranexamic acid, 51, 53, 68 Western Ontario and McMaster University
Transient neurologic symptoms, 63 Osteoarthritis Index
Tumor necrosis factor (TNF)-alpha (WOMAC), 54, 158
inhibitors, 12 Wound complications, 11

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Outpatient

Hip and Knee

Outpatient Hip and Knee

ISBN 978-3-031-27036-9 ISBN 978-3-031-27037-6 (eBook)

Indianapolis, IN, USA R. Michael Meneghini

Peter Caccavallo and R. Michael Meneghini

© The Author(s), under exclusive license to Springer Nature 1

Medical Evaluation and Patient Selection

Patients with anemia, especially significant or unevaluated anemia, can potentially

retention (POUR), patients with a history of POUR, or uncontrolled benign pros-

In addition to patient selection, perioperative patient optimization is also critical to

should emphasize euvolemia via protocols designed to allow/encourage patients to

Barriers to Early Discharge in TJA

In summary, outpatient TJA is expected to increase exponentially over the next

optimization with multidisciplinary team protocols, proper intraoperative fluid

Vignesh K. Alamanda and Bryan D. Springer

Modifiable Versus Non-modifiable Risk Factors

Risk factors can be differentiated between modifiable and non-modifiable. A modi-

© The Author(s), under exclusive license to Springer Nature 9

Patient Modifiable Risk Factors and Current Evidence

Malnutrition is often an unrecognized aspect of obesity, associated with the con-

Vitamin D plays a crucial role in bone health. Vitamin D deficiency, as defined by a

Staphylococcus Aureus Screening

Implementation of an institution wide prescreening program using nasal swab rapid

Patients afflicted with inflammatory arthropathies such as rheumatoid arthritis and

jointly published by the American College of Rheumatology (ACR) and the

Preoperative antibiotic prophylaxis is effective in reducing rates of surgical site

1. Krause A, Sayeed Z, El-Othmani M, Pallekonda V, Mihalko W, Saleh KJ. Outpatient Total

with nonbiologic and biologic disease-modifying antirheumatic drugs. Mod Rheumatol.

Jesua Law, David A. Crawford, and Adolf V. Lombardi

Ambulatory Surgery Center Versus the Hospital

J. Law (*) · D. A. Crawford · A. V. Lombardi

© The Author(s), under exclusive license to Springer Nature 17

When considering the appropriateness of surgery at an ASC, it is critical that the

Educating the Patient

Anesthesia and Pain Management

Postoperative Care and Follow Up

23-Hour Observation and Transfer Agreements

Influence of Bundled Payments on the Patient Experience

© The Author(s), under exclusive license to Springer Nature 25

The content of preoperative education typically includes general information

Traditional Preoperative Joint Replacement Education

recovery after surgery. To most effectively communicate these issues to patients,

The Effect of the Migration Towards Outpatient TJA

Successful outpatient joint replacement relies on building upon an already sound

Setting the Foundation of Patient Expectations

Addressing Patient Anxiety Preemptively

Understanding Patient Comprehension and Limitations

Social support is critical for recovery after arthroplasty procedures. In hospitals,

Evolution of Education Techniques

Traditional education classes combine written handouts with verbal lessons.

Preoperative education remains a mainstay in the success of total joint replacement

a successful program. J Bone Joint Surg Am. 2019;101(21):1948–54. https://doi.org/10.2106/

arthroplasty: a cohort study. J Am Acad Orthop Surg. 2020;28(4):e145–50. https://doi.

Elizabeth B. Gausden, Mark W. Pagnano, and Matthew P. Abdel

Improved perioperative pain control made possible through advances in multimodal

E. B. Gausden · M. W. Pagnano · M. P. Abdel (*)

© The Author(s), under exclusive license to Springer Nature 37

Anti-Inflammatories and Acetaminophen

Indianapolis, IN, USA R. Michael Meneghini

Medical Evaluation and Patient Selection

Barriers to Early Discharge in TJA

Modifiable Versus Non-modifiable Risk Factors

Patient Modifiable Risk Factors and Current Evidence

Staphylococcus Aureus Screening

Ambulatory Surgery Center Versus the Hospital

Educating the Patient

Anesthesia and Pain Management

Postoperative Care and Follow Up

23-Hour Observation and Transfer Agreements

Influence of Bundled Payments on the Patient Experience

Traditional Preoperative Joint Replacement Education

The Effect of the Migration Towards Outpatient TJA

Setting the Foundation of Patient Expectations

Addressing Patient Anxiety Preemptively

Understanding Patient Comprehension and Limitations

Evolution of Education Techniques

Anti-Inflammatories and Acetaminophen

Peripheral Nerve Blocks

Periarticular Injections (Pais)

Intraoperative Blood Management Strategies

Incision Length and Surgical Technique

Multimodal Pain Control

Regional Anesthesia for the Hip

Regional Anesthesia for the Knee

Anesthesia Adjuncts for Pain Control

Intraoperative Treatment of Nausea

Nausea and Vomiting

Sample Outpatient TJA Anesthesia Protocol

ppendix 1: Indiana University Health Saxony hip and Knee

Criterion for Oliguria Indication1

ppendix 2: Indiana University Health Saxony hip and Knee

Prior to Arrival for Surgery

Poor Pain Control

Hypotension and Tachycardia

Nausea and Vomiting

Unable to Safely Meet Physical Therapy Discharge Criteria

Recommendations for Same Day Discharge

Space—A Different Frontier in an ASC