There has been a paradigm shift in the approach to taking care of patients who require joint replacements. This change has developed due to the advent of new anesthetics, rehabilitation protocols, newer surgical techniques requiring smaller incisions, and education of the public. It has been well demonstrated that the complication rate in patients having joint replacements in an outpatient facility is far lower than that in a general hospital. The incidence of infection, one of the most serious complications of a joint replacement, is far lower. The environment is far more patient friendly. The cost is significantly less. The physicians and the patients are much happier.
For the past ten years at the four of the surgical centers operated by Surgery One in San Diego County, hundreds of outpatient joint replacements have been performed. These include total shoulders, total knees, total hips, unicompartment knees, partial shoulder replacements and total ankles. The results have been quite striking. In the past, the thought of undergoing a joint replacement conjured up a notion of an extremely painful procedure that lasted many hours that required up to one week of hospitalization and many more months of postoperative rehabilitation.
As technology has changed, so has the mindset of the treating physician and the public. The joint replacement surgeons have now embraced the notion of joint replacement being performed in an outpatient facility, and the results have been quite striking. The patients have the option of staying overnight in a 23-hour facility and then are generally discharged home and/or to a skilled nursing facility. Of the hundreds of cases performed at the four facilities, I am aware of only three admissions to a hospital. Two of the three were as a result of the patients becoming confused with the analgesic medication on the second postoperative day.
Generally, the protocol is for the patient to be seen at the facility for a preoperative consultation. The anesthesiologist interviews the patient, and then arrangements are made for the patient either to be transferred home and/or to a skilled nursing facility following the surgical procedure. In the case of total knee replacements or unicompartment knees, CPM units, home physical therapy, visiting nurses and injections of anticoagulant medications are arranged.
The age, the weight or the gender of the patient did not appear to be a factor. Naturally, one is not performing these procedures on patients with significant underlying medical co-morbidities. From an antidotal standpoint, I have replaced the knee of a 384-pound male who had a previous total knee replacement performed at a hospital five years previously on the contralateral side. He went home the following morning and has done extremely well. He requested the surgery to be performed on an outpatient basis, as he did not have insurance, and he was not prepared to pay the exorbitant hospital fees and wanted a global fee for the procedure. His global fee including the implant was less than $20,000.00.
The second patient who weighed 360 pounds requested a hip replacement and presented to my office on December 28 informing me that his insurance would be running out on the 31st of December. His surgery was performed on the 29th of December. He was transferred to a skilled nursing facility the day following surgery and thus far has been doing extremely well with no evidence of any postoperative complications. With the advent of global fees and bundling, joint replacements will be performed far more frequently in an outpatient setting. It is an environment that has much lower risks and much lower postoperative complications than inpatient hospitals. It is far more cost effective, and the response of the patients has been extremely favorable. If one reviews the orthopedic literature, it is now becoming standard of care in the community, and the number of cases being performed in an outpatient setting will continue to increase.
Norman Kane, M.D., F.R.C.S. (C)
