Indications and Advantages of Outpatient Total Joint Replacement

by Gautham Gondi, MD

Indications and Advantages of Outpatient Total Joint Replacement

Total joint replacements performed in an outpatient facility, not in a hospital, are becoming more common. Depending on several factors, you may be eligible to have your total hip, total knee or total shoulder replacement done as an outpatient. OrthoVirginia physicians perform outpatient total joint replacements across the state.

What is outpatient total joint replacement?

Outpatient total joint replacement is a regular joint replacement surgery that happens in a surgery center instead of a hospital and the patient goes home the same day.

Before the COVID-19 pandemic started, experts estimated there would be 1.2 million total joint replacements in the United States in 2020. Of those, about 10% would be outpatient procedures. However, outpatient procedures are growing and are expected to be 25% of total joint replacements in 2022 and 50% in 2026.

What are the advantages of outpatient total joint replacement?

Safety

  • Surgery centers do not have inpatients who may have infectious diseases like hospitals do, so there is less chance of diseases spreading between patients.
  • Surgery centers have dedicated anesthesiologists who are used to working in an outpatient environment and use a combination of techniques to allow for pain relief and the ability to go home the same day.
  • Not all patients qualify for outpatient procedures, and the ones who do are healthier.
  • Taking tranexamic acid (TXA) before surgery reduces your bleeding and complications from that bleeding.

Cost

  • Surgery at a surgery center can cost half as much as surgery at a hospital, saving the patient and the insurance company money.
  • Unfortunately, Medicare and Medicaid do not allow surgeries at outpatient surgery centers.

Hope for a quick recovery

  • Since patients are recovering in their own homes, including immediately moving around and sleeping in comfortable surroundings, they may be more motivated and recover faster than if they were in an uncomfortable hospital bed.
  • Studies show a slightly quicker short-term recovery for patients who have outpatient total joint procedures over patients who have inpatient total joint procedures. The long-term success rate (over years) is the same for both types of surgery.

Who is eligible for outpatient total joint replacement?

Patients who are eligible for an inpatient total joint replacement and who do not have Medicare or Medicaid may be eligible for an outpatient total joint replacement.

Additional criteria are not having heart or lung issues, such as a recent heart attack or COPD. Patients with chronic kidney disease are evaluated on a case-by-case basis.

If you meet those criteria, talk with your doctor to see if you’re eligible.

How should I prepare for my outpatient total joint replacement?

Preparation is key to a successful outpatient total joint replacement.

  1. Take the tranexamic acid you were prescribed to reduce the amount of bleeding during your procedure.
  2. Set up one-level living with all of your durable medical equipment supplies. Make sure that you have access to everything you need on one level of your house, such as meals, ice, and a place to sleep. Many patients find recliners more comfortable than beds for sleeping in the weeks directly after their replacement. Have equipment like walkers and canes ready to go.
  3. If possible, use a Polar Care ice machine. Insurance doesn’t pay for it, but patients find them extremely helpful and may continue to use them for weeks after surgery to reduce swelling and pain. Water and ice are placed into a machine and circulated through a pad that is placed around the joint that was replaced.
  4. Schedule your physical therapy ahead of time. While you may have a stationary bike at home or easy access to a swimming pool, both of which you can take advantage of, you still need formal physical therapy. You may qualify for telemedicine physical therapy or may come into our safe facilities.
  5. Have your medications available. You will be prescribed pain medications, anticoagulants, and possibly anti-nausea medications.
  6. Arrange food and transportation. You won’t be able to prepare meals or drive yourself anywhere at first, so have family or friends to stay with you to help out.

Frequently asked questions about outpatient total joint replacement

When does the surgeon decide I get to go home?

You must meet certain criteria before you go home:

  • Get up
  • Go to the restroom
  • Not have active nausea and vomiting

The surgery center staff will work with you to make sure you meet all the criteria before you go.

When do I start physical therapy?

You start physical therapy exercises the day of surgery, and usually have your first outpatient physical therapy appointment the business day after surgery. You’ll be walking the day of surgery and doing physical therapy exercises specific to which joint you had replaced.

How do I care for my wound? When can I shower?

You will receive wound care instructions from your surgery team. Usually total joint replacements are closed with deep stitches, which stay in, and then with a glue called Dermabond on top. Sometimes staples are used instead of glue. Overtop there is a waterproof bandage called Aquacel, which stays in place for 5-7 days. The day after your surgery, the other bandages come off and you can shower. After the Aquacel comes off, if you have Dermabond glue you can continue to shower. If you have staples, you may need another type of bandage on top during showers. Overall, there isn’t a great deal of wound care needed.

If I have a total knee replacement or total hip replacement, will I need to use a walker? How long will I need help to walk?

You will need a walker right after surgery. If you can control the leg that had the surgery and you’re not groggy or dizzy, then usually you can start using a cane in about a week.

When you use a cane, hold the cane in the hand opposite the leg you had surgery on. If you had surgery in your right leg, hold the cane in your left hand to provide more stability.

Once you can get out of a chair and out of a bed safely, you can stop using the cane.

What happens if I’m still in a lot of pain when I go home?

The staff will make sure that you’re not in a lot of pain when you’re discharged from the surgery center. If the pain meds wear off, that’s when multimodal pain management kicks in. Multimodal pain management means using several different ways to control pain instead of relying on one type of pain medication. If you’re already on one narcotic, for example, you wouldn’t be given an additional narcotic. Instead, you may take an anti-inflammatory drug. Other drugs you may take are possibly nerve medications or muscle relaxers and you would be encouraged to put a Polar Care machine or ice packs on the joint.

You will have instructions for all the medications and when to take them and numbers to call if you have a question.

Am I at greater risk of death? Am I at greater risk for a blood clot?

No, having an outpatient total joint replacement does not put you at a greater risk of death or a blood clot. Studies using tens of thousands of patients from across multiple surgery centers show that outpatient total joint replacements have a lower rate of death and a lower rate of major complications like blood clots than do inpatient total joint procedures.

Is there a difference in training for surgeons who do outpatient and inpatient total joint replacements?

No, there is no difference in training. The same surgeons perform both inpatient and outpatient procedures.

Is there a difference in the types of anesthesia used for outpatient and inpatient total joint replacements?

It depends on the surgery center, but often slightly different types of anesthesia are used. In surgery centers, patients need to be able to go home the same day so anesthesiologists are more likely to use general anesthesia. In hospitals, patients are staying overnight so anesthesiologists are more likely to use a spinal block. Spinal blocks have a much higher incidence of urinary retention, which is not an issue when at a hospital but which may be a problem when having an outpatient procedure.

Is COVID-19 making anything different?

Yes, we are taking multiple precautions due to COVID-19.

  • Requiring all patients to take a COVID-19 test before their surgery date and rescheduling to a later date the surgery of anyone who tests positive.
  • Screening all patients, visitors, employees, and visitors for symptoms of coronavirus or other respiratory illnesses, including screening for fever.
  • Practicing social distancing as much as possible.
  • Limiting the number of guests per surgery patient to one.
  • Requiring masks for everyone within our facility.
  • Extra cleaning.