Tempering Expectations for Outpatient Total Knee Arthroplasty for Patients Over 70

Published:January 10, 2022DOI:https://doi.org/10.1016/j.arth.2022.01.004



      Total knee arthroplasty (TKA) is now considered an outpatient procedure, yet advanced age impacts patients’ ability to achieve outpatient discharge. Therefore, the purpose of this study was to determine the rate of successful outpatient discharge for TKA patients above 70 years of age and identify potential barriers to success.


      This retrospective review included 352 unilateral TKA patients. The rapid discharge protocol was followed for all patients with the intention of discharge within a 24-hour period. Successful outpatient discharge was classified as ≤24 hour stay and failure was any stay exceeding a 24 hour period in the hospital. Univariate logistic regressions were performed to determine the influence of independent variables on discharge status for all patients and only patients over 70 years old.


      Overall, 46 patients (13%) failed to achieve outpatient discharge, with 35 (76%) patients being ≥70 years old. For patients ≥70, age was not a predictive variable for failure to achieve outpatient discharge (p=0.484). However, being female [Odds Ratio (OR): 3.273, 95% Confidence Interval (CI): 1.286-8.325; p=0.013] and the use of an assistive walking device [OR: 3.031, CI: 1.387-6.625; p=0.005] remained independent contributors to prolonged hospital stay.


      With patients ≥70 years old more likely to require >24 hour stays, age should be an evaluated metric for justifying higher levels of reimbursement. Although TKA is now considered an outpatient procedure, greater consideration should be given to patients ≥70 years old for higher levels of reimbursement as outpatient discharge is less likely to be successful.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Arthroplasty
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Yates A.J.
        • Kerr J.M.
        • Froimson M.I.
        • Della Valle C.J.
        • Huddleston J.I.
        The Unintended Impact of the Removal of Total Knee Arthroplasty From the Center for Medicare and Medicaid Services Inpatient-Only List.
        J Arthroplasty. 2018; 33: 3602-3606https://doi.org/10.1016/j.arth.2018.09.043
      1. Nakasone CK, Combs D, Buchner B and Andrews S. Day of surgery discharge success after implementation of a rapid discharge protocol following unilateral unicompartmental knee arthroplasty. Knee, 2020. https://doi.org/10.1016/j.knee.2020.03.003

        • Berger R.A.
        • Kusuma S.K.
        • Sanders S.A.
        • Thill E.S.
        • Sporer S.M.
        The feasibility and perioperative complications of outpatient knee arthroplasty.
        Clin Orthop Relat Res. 2009; 467: 1443-1449https://doi.org/10.1007/s11999-009-0736-7
        • Berger R.A.
        • Sanders S.
        • Gerlinger T.
        • Della Valle C.
        • Jacobs J.J.
        • Rosenberg A.G.
        Outpatient total knee arthroplasty with a minimally invasive technique.
        J Arthroplasty. 2005; 20: 33-38https://doi.org/10.1016/j.arth.2005.05.021
        • Klingenstein G.G.
        • Schoifet S.D.
        • Jain R.K.
        • Reid J.J.
        • Porat M.D.
        • Otegbeye M.K.
        Rapid Discharge to Home After Total Knee Arthroplasty Is Safe in Eligible Medicare Patients.
        J Arthroplasty. 2017; 32: 3308-3313https://doi.org/10.1016/j.arth.2017.06.034
        • Edwards P.K.
        • Kee J.R.
        • Mears S.C.
        • Barnes C.L.
        Is Rapid Recovery Hip and Knee Replacement Possible and Safe in the Octogenarian Patient?.
        J Arthroplasty. 2018; 33: 316-319https://doi.org/10.1016/j.arth.2017.09.060
        • Van Horne A.
        • Van Horne J.
        Patient-optimizing enhanced recovery pathways for total knee and hip arthroplasty in Medicare patients: implication for transition to ambulatory surgery centers.
        Arthroplast Today. 2019; 5: 497-502https://doi.org/10.1016/j.artd.2019.08.008
        • Pitter F.T.
        • Jorgensen C.C.
        • Lindberg-Larsen M.
        • Kehlet H.
        • Lundbeck Foundation Center for Fast-track H.
        • Knee Replacement Collaborative G.
        Postoperative Morbidity and Discharge Destinations After Fast-Track Hip and Knee Arthroplasty in Patients Older Than 85 Years.
        Anesth Analg. 2016; 122: 1807-1815https://doi.org/10.1213/ANE.0000000000001190
        • Roger C.
        • Debuyzer E.
        • Dehl M.
        • Bulaid Y.
        • Lamrani A.
        • Havet E.
        • Mertl P.
        Factors associated with hospital stay length, discharge destination, and 30-day readmission rate after primary hip or knee arthroplasty: Retrospective Cohort Study.
        Orthop Traumatol Surg Res. 2019; 105: 949-955https://doi.org/10.1016/j.otsr.2019.04.012
        • Courtney P.M.
        • Froimson M.I.
        • Meneghini R.M.
        • Lee G.C.
        • Della Valle C.J.
        Can Total Knee Arthroplasty Be Performed Safely as an Outpatient in the Medicare Population?.
        J Arthroplasty. 2018; 33: S28-S31https://doi.org/10.1016/j.arth.2018.01.003
        • El Bitar Y.F.
        • Illingworth K.D.
        • Scaife S.L.
        • Horberg J.V.
        • Saleh K.J.
        Hospital Length of Stay following Primary Total Knee Arthroplasty: Data from the Nationwide Inpatient Sample Database.
        J Arthroplasty. 2015; 30: 1710-1715https://doi.org/10.1016/j.arth.2015.05.003
        • Husted H.
        • Holm G.
        • Jacobsen S.
        Predictors of length of stay and patient satisfaction after hip and knee replacement surgery: fast-track experience in 712 patients.
        Acta Orthop. 2008; 79: 168-173https://doi.org/10.1080/17453670710014941
        • Jorgensen C.C.
        • Kehlet H.
        • Lundbeck Foundation Centre for Fast-track H.
        • Knee Replacement Collaborative G.
        Role of patient characteristics for fast-track hip and knee arthroplasty.
        Br J Anaesth. 2013; 110: 972-980https://doi.org/10.1093/bja/aes505
        • Inneh I.A.
        The Combined Influence of Sociodemographic, Preoperative Comorbid and Intraoperative Factors on Longer Length of Stay After Elective Primary Total Knee Arthroplasty.
        J Arthroplasty. 2015; 30: 1883-1886https://doi.org/10.1016/j.arth.2015.05.032
        • Mathijssen N.M.
        • Verburg H.
        • van Leeuwen C.C.
        • Molenaar T.L.
        • Hannink G.
        Factors influencing length of hospital stay after primary total knee arthroplasty in a fast-track setting.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 2692-2696https://doi.org/10.1007/s00167-015-3932-x
        • Zeng F.
        • Waldo D.
        Total knee arthroplasty post acute care costs by discharge status.
        Value Health. 2016; 19: A13-A14https://doi.org/10.1016/j.jval.2016.03.273
        • Halawi M.J.
        • Stone A.D.
        • Gronbeck C.
        • Savoy L.
        • Cote M.P.
        Medicare coverage is an independent predictor of prolonged hospitalization after primary total joint arthroplasty.
        Arthroplast Today. 2019; 5: 489-492https://doi.org/10.1016/j.artd.2019.07.001
        • Zmistowski B.
        • Restrepo C.
        • Hess J.
        • Adibi D.
        • Cangoz S.
        • Parvizi J.
        Unplanned readmission after total joint arthroplasty: rates, reasons, and risk factors.
        J Bone Joint Surg Am. 2013; 95: 1869-1876https://doi.org/10.2106/JBJS.L.00679
        • Kain Z.N.
        • Vakharia S.
        • Garson L.
        • Engwall S.
        • Schwarzkopf R.
        • Gupta R.
        • Cannesson M.
        The perioperative surgical home as a future perioperative practice model.
        Anesth Analg. 2014; 118: 1126-1130https://doi.org/10.1213/ANE.0000000000000190
        • Matsumoto M.
        • Saito S.
        • Andrews S.
        • Mathews K.
        • Morikawa L.
        • Nakasone C.
        Barriers to achieving same day discharge following unilateral unicompartmental knee arthroplasty.
        Knee. 2020; 27: 1365-1369https://doi.org/10.1016/j.knee.2020.07.002
        • Courtney P.M.
        • Rozell J.C.
        • Melnic C.M.
        • Lee G.C.
        Who Should Not Undergo Short Stay Hip and Knee Arthroplasty? Risk Factors Associated With Major Medical Complications Following Primary Total Joint Arthroplasty.
        J Arthroplasty. 2015; 30: 1-4https://doi.org/10.1016/j.arth.2015.01.056
        • Vincent K.R.
        • Vincent H.K.
        • Lee L.W.
        • Alfano A.P.
        Outcomes in total knee arthroplasty patients after inpatient rehabilitation: influence of age and gender.
        Am J Phys Med Rehabil. 2006; 85: 482-489https://doi.org/10.1097/01.phm.0000219151.18749.50
        • Bovonratwet P.
        • Fu M.C.
        • Tyagi V.
        • Gu A.
        • Sculco P.K.
        • Grauer J.N.
        Is Discharge Within a Day of Total Knee Arthroplasty Safe in the Octogenarian Population?.
        J Arthroplasty. 2019; 34: 235-241https://doi.org/10.1016/j.arth.2018.10.005
        • Schwarzkopf R.
        • Ho J.
        • Quinn J.R.
        • Snir N.
        • Mukamel D.
        Factors Influencing Discharge Destination After Total Knee Arthroplasty: A Database Analysis.
        Geriatr Orthop Surg Rehabil. 2016; 7: 95-99https://doi.org/10.1177/2151458516645635
        • Gwam C.U.
        • Mohamed N.S.
        • Davila Castrodad I.M.
        • George N.E.
        • Remily E.A.
        • Wilkie W.A.
        • Barg V.
        • Gbadamosi W.A.
        • Delanois R.E.
        Factors associated with non-home discharge after total knee arthroplasty: Potential for cost savings?.
        Knee. 2020; 27: 1176-1181https://doi.org/10.1016/j.knee.2020.05.012
        • Keswani A.
        • Tasi M.C.
        • Fields A.
        • Lovy A.J.
        • Moucha C.S.
        • Bozic K.J.
        Discharge Destination After Total Joint Arthroplasty: An Analysis of Postdischarge Outcomes, Placement Risk Factors, and Recent Trends.
        J Arthroplasty. 2016; 31: 1155-1162https://doi.org/10.1016/j.arth.2015.11.044