In the December 6, 2017 issue of The Journal, Arshi et al. report on a detailed analysis of a large administrative database, looking specifically at one-year complications associated with outpatient versus standard inpatient knee replacement. This type of analysis is crucial because of the rapidly growing interest in outpatient joint replacement among patients, payers, and the orthopaedic community.
The data convince me that these outpatient procedures should proceed, but with a little more caution. Although the absolute complication rates in both surgical settings were very low, after adjusting for age, sex, and comorbidities, the authors found a higher relative risk of several surgical and medical complications among outpatients—including component failure, infection, knee stiffness requiring manipulation under anesthesia, and deep vein thrombosis.
One important element that is lacking in this analysis is adjustment for surgeon/hospital volume. We know from important work by Katz and others that patients managed at centers and by surgeons with greater volumes of total knee replacement have lower risks of perioperative adverse events.
These results from Arshi et al. are definitely not a call to stop the expansion of outpatient joint replacement protocols. Instead, I think this study should prompt every joint-replacement center to analyze its risk-adjusted inpatient and outpatient outcomes—and to ensure, as these authors emphasize, that outpatients receive the same level of attention to rehabilitation, antibiotic administration, and thromboprophylaxis as inpatients.
Enhancing outpatient knee-replacement protocols will serve local communities well, and the nationwide orthopaedic community will receive further confirmation that outpatient joint replacement is a move in the right direction.
Marc Swiontkowski, MD
In the April 19, 2017 issue of The Journal, Cancienne et al. compare complication and readmission rates for patients undergoing ambulatory shoulder arthroplasty with those among patients admitted as hospital inpatients postoperatively. Because the analysis was based on data from a large national insurer, we can be quite sure of appropriate coding and accurate data capture.
Similar to our recent report regarding outpatient hand and elbow surgery, in no instance were complications present at a significantly higher rate in the patients who underwent ambulatory shoulder arthroplasty, and the rate of hospital readmission after discharge was not significantly different at 30 or 90 days between the two cohorts.
This definitely is a tip of the hat to orthopaedic surgeons, nurses, and anesthesiologists, who are making sound decisions regarding which patients are appropriate for outpatient arthroplasty. Cancienne et al. found that obesity and morbid obesity were significant demographic risk factors for readmission among the ambulatory cohort, and they also identified the following comorbidities as readmission risk factors in that group:
- Peripheral vascular disease
- Congestive heart failure
- Chronic lung disease
- Chronic anemia
These results offer further documentation regarding the shift away from hospital-based care after orthopaedic surgery. Those of us who perform surgery in dedicated orthopaedic centers as well as general hospital operating rooms understand the concepts of efficiency, focus, maintenance of team skills, and limiting waste. Those objectives in large part drive the move to outpatient surgery. But patients, who almost always prefer to be at home and sleep in their own beds (or recliners in the case of shoulder replacement), may be an even more powerful driver of ambulatory care in the future.
Major advances in postoperative pain management are great enablers in this regard, and I believe the trend will continue. I envision a day when the only patients admitted to hospitals after orthopaedic surgery are those with unstable medical issues who potentially may need ICU care postoperatively.
Marc Swiontkowski, MD
In the April 5, 2017 issue of The Journal, Noureldin et al. analyzed more than 14,000 procedures from the NSQIP database to determine the rate of unplanned 30-day readmission after outpatient surgical procedures of the hand and elbow. The 1.2% rate seems well within the range of acceptability, particularly because the more than 450 institutions contributing to this database probably serve populations who don’t have the best overall health and comorbidity profiles.
Missing causes for about one-third of the readmissions illustrate one issue with data accuracy in these large administrative datasets. While the authors acknowledged a “lack of granularity” as the greatest limitation in analyzing large databases, they added that the readmissions with no listed cause “were likely unrelated to the principal procedure.”
It was not surprising that infection was the most common cause for readmission. However, it would have been nice to know the rate of confirmed infection via positive cultures, as I suspect many of these patients were readmitted for erythema, swelling, warmth, and discomfort associated with postoperative hematoma rather than infection.
Regardless of the need for higher-quality data on complications following outpatient orthopaedic surgical procedures, this analysis gives us more confidence that the move toward outpatient surgical care in our specialty is warranted. I think most patients would rather sleep in their own home as long as preoperative comorbidities and ASA levels are considered and adequate postoperative pain control can be achieved in an outpatient setting. The trend toward outpatient orthopaedic treatment is likely to continue as we gather higher-quality data and better understand the risk-benefit profile.
Marc Swiontkowski, MD