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Reasons and Risk Factors for Failed Same-Day Discharge After Primary Total Knee Arthroplasty

Published:November 01, 2022DOI:https://doi.org/10.1016/j.arth.2022.10.044

      Abstract

      Background

      As ambulatory total knee arthroplasty (TKA) becomes increasingly common, unplanned admission after surgery presents a challenge for the health care system. Studies evaluating the reasons and risk factors for this occurrence are limited. We sought to evaluate the reasons for unplanned admission after surgery and identify risk factors associated with this occurrence.

      Methods

      Patients registered in an institutional ambulatory joint arthroplasty program who underwent a TKA from 2017-2020 were retrospectively reviewed. The criteria for enrollment include candidates for unilateral TKA between the ages of 18 and 70 years, with a body mass index (BMI) of less than 35, and appropriate social and material support at home. Patients who had certain comorbidities including coronary artery disease, valvular heart disease, and opioid dependence were not eligible. A total of 274 patients who underwent TKA with planned same-day discharge (SDD) were identified in the medical record and reviewed. In this cohort, 140 patients (51.1%) were discharged on the day of surgery and 134 patients (48.9%) required a minimum 1-night admission. Demographics, comorbidities, and perioperative data were collected. Factors associated with failed SDD were identified using multivariate logistic regression.

      Results

      The most common reasons for failed SDD were failure to meet ambulation goals (25%) and logistical issues related to a late-day case (19%). Risk factors for failed SDD include general anesthesia (odds ratio (OR) 12.60, P = .047), procedure start time after 11:00 am (OR 5.16, P < .001), highest postoperative pain score >8 (visual analogue scale, OR 5.78, P = .001). Willingness to accept a higher pain threshold before discharge (visual analogue scale 4 to 10) was associated with successful SDD (OR 3.0, P < .001). Age and American Society of Anesthesiologists (ASA) classification were not associated with failed SDD.

      Conclusions

      The most common reasons for failed SDD were related to logistical issues and postoperative mobilization. Risk factors for failed SDD involve case timing and pain control. Modifiable perioperative factors may play an important role in successful SDD after TKA.

      Keywords

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      References

        • 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: 780-785
        • Maradit Kremers H.
        • Larson D.R.
        • Crowson C.S.
        • Kremers W.K.
        • Washington R.E.
        • Steiner C.A.
        • et al.
        Prevalence of total hip and knee replacement in the United States.
        J Bone Joint Surg Am. 2015; 97: 1386-1397
        • Singh J.A.
        • Yu S.
        • Chen L.
        • Cleveland J.D.
        Rates of total joint replacement in the United States: future projections to 2020–2040 using the national inpatient sample.
        J Rheumatol. 2019; 46: 1134-1140
        • Hoffmann J.D.
        • Kusnezov N.A.
        • Dunn J.C.
        • Zarkadis N.J.
        • Goodman G.P.
        • Berger R.A.
        The shift to same-day outpatient joint arthroplasty: a systematic review.
        J Arthroplasty. 2018; 33: 1265-1274
        • Bumpass D.B.
        • Nunley R.M.
        Assessing the value of a total joint replacement.
        Curr Rev Musculoskelet Med. 2012; 5: 274-282
        • Aynardi M.
        • Post Z.
        • Ong A.
        • Orozco F.
        • Sukin D.C.
        Outpatient surgery as a means of cost reduction in total hip arthroplasty: a case-control study.
        HSS J. 2014; 10: 252-255
        • Gibon E.
        • Parvataneni H.K.
        • Prieto H.A.
        • Photos L.L.
        • Stone W.Z.
        • Gray C.F.
        Outpatient total knee arthroplasty: is it economically feasible in the hospital setting?.
        Arthroplast Today. 2020; 6: 231-235
        • DeMik D.E.
        • Carender C.N.
        • An Q.
        • Callaghan J.J.
        • Brown T.S.
        • Bedard N.A.
        Has removal from the inpatient-only list increased complications after outpatient total knee arthroplasty?.
        J Arthroplasty. 2021; 36: 2297-2301.e1
        • Crawford A.M.
        • Chen A.F.
        • Sabeti A.
        • Jay J.F.
        • Shah V.M.
        Team Approach: same-day discharge of patients undergoing total joint arthroplasty.
        JBJS Rev. 2020; 8: e0176
        • Chambers M.
        • Huddleston J.I.
        • Halawi M.J.
        Total knee arthroplasty in ambulatory surgery centers: the new reality!.
        Arthroplast Today. 2020; 6: 146-148
        • Mundi R.
        • Axelrod D.E.
        • Najafabadi B.T.
        • Chamas B.
        • Chaudhry H.
        • Bhandari M.
        Early discharge after total hip and knee arthroplasty-an observational cohort study evaluating safety in 330,000 patients.
        J Arthroplasty. 2020; 35: 3482-3487.e3
        • Basques B.A.
        • Tetreault M.W.
        • Della Valle C.J.
        Same-day discharge compared with inpatient hospitalization following hip and knee arthroplasty.
        J Bone Joint Surg Am. 2017; 99: 1969-1977
        • Reddy N.C.
        • Prentice H.A.
        • Paxton E.W.
        • Hinman A.D.
        • Lin A.G.
        • Navarro R.A.
        Association between same-day discharge total joint arthroplasty and risk of 90-day adverse events in patients with ASA classification of ≥3.
        J Bone Joint Surg Am. 2021; 103: 2032-2044
        • Mascioli A.A.
        • Shaw M.L.
        • Boykin S.
        • Mahadevan P.
        • Wilder J.H.
        • Bell J.W.
        • et al.
        Total knee arthroplasty in freestanding ambulatory surgery centers: 5-year retrospective chart review of 90-day postsurgical outcomes and health care resource utilization.
        J Am Acad Orthop Surg. 2021; 29: e1184
        • Bovonratwet P.
        • Ondeck N.T.
        • Nelson S.J.
        • Cui J.J.
        • Webb M.L.
        • Grauer J.N.
        Comparison of outpatient vs inpatient total knee arthroplasty: an ACS-NSQIP analysis.
        J Arthroplasty. 2017; 32: 1773-1778
        • Lovald S.T.
        • Ong K.L.
        • Malkani A.L.
        • Lau E.C.
        • Schmier J.K.
        • Kurtz S.M.
        • et al.
        Complications, mortality, and costs for outpatient and short-stay total knee arthroplasty patients in comparison to standard-stay patients.
        J Arthroplasty. 2014; 29: 510-515
        • Huang A.
        • Ryu J.J.
        • Dervin G.
        Cost savings of outpatient versus standard inpatient total knee arthroplasty.
        Can J Surg. 2017; 60: 57-62
        • Hoeffel D.P.
        • Daly P.J.
        • Kelly B.J.
        • Giveans M.R.
        Outcomes of the first 1,000 total hip and total knee arthroplasties at a same-day surgery center using a rapid-recovery protocol.
        J Am Acad Orthop Surg Glob Res Rev. 2019; 3: e022
        • Desai N.
        • El-Boghdadly K.
        • Albrecht E.
        Peripheral nerve blockade and novel analgesic modalities for ambulatory anesthesia.
        Curr Opin Anaesthesiol. 2020; 33: 760-767
        • Berger R.A.
        • Sanders S.A.
        • Thill E.S.
        • Sporer S.M.
        • Della Valle C.
        Newer anesthesia and rehabilitation protocols enable outpatient hip replacement in selected patients.
        Clin Orthop Relat Res. 2009; 467: 1424-1430
        • Hartog YMd
        • Mathijssen N.M.C.
        • Vehmeijer S.B.W.
        Total hip arthroplasty in an outpatient setting in 27 selected patients.
        Acta Orthop. 2015; 86: 667-670
        • Keulen M.H.F.
        • Asselberghs S.
        • Boonen B.
        • Hendrickx R.P.M.
        • van Haaren E.H.
        • Schotanus M.G.M.
        Predictors of (Un)successful same-day discharge in selected patients following outpatient hip and knee arthroplasty.
        J Arthroplasty. 2020; 35: 1986-1992
        • Kort N.P.
        • Bemelmans Y.F.L.
        • van der Kuy P.H.M.
        • Jansen J.
        • Schotanus M.G.M.
        Patient selection criteria for outpatient joint arthroplasty.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 2668-2675
        • Sibia U.S.
        • King P.J.
        • MacDonald J.H.
        Who is not a candidate for a 1-day hospital-based total knee arthroplasty?.
        J Arthroplasty. 2017; 32: 16-19
        • Sher A.
        • Keswani A.
        • Yao D.H.
        • Anderson M.
        • Koenig K.
        • Moucha C.S.
        Predictors of same-day discharge in primary total joint arthroplasty patients and risk factors for post-discharge complications.
        J Arthroplasty. 2017; 32: S150-S156.e1
        • Meneghini R.M.
        • Ziemba-Davis M.
        • Ishmael M.K.
        • Kuzma A.L.
        • Caccavallo P.
        Safe selection of outpatient joint arthroplasty patients with medical risk stratification: the "outpatient Arthroplasty risk assessment score".
        J Arthroplasty. 2017; 32: 2325-2331
        • Nowak L.L.
        • Schemitsch E.H.
        Same-day and delayed hospital discharge are associated with worse outcomes following total knee arthroplasty.
        Bone Joint J. 2019; 101-B: 70-76
        • Liu J.
        • Elkassabany N.
        • Poeran J.
        • Gonzalez Della Valle A.
        • Kim D.H.
        • Maalouf D.
        • et al.
        Association between same day discharge total knee and total hip arthroplasty and risks of cardiac/pulmonary complications and readmission: a population-based observational study.
        BMJ Open. 2019; 9: e031260
        • Johnson D.J.
        • Castle J.P.
        • Hartwell M.J.
        • D'Heurle A.M.
        • Manning D.W.
        Risk factors for greater than 24-hour length of stay after primary total knee arthroplasty.
        J Arthroplasty. 2020; 35: 633-637
        • Gruskay J.
        • Richardson S.
        • Schairer W.
        • Kahlenberg C.
        • Steinhaus M.
        • Rauck R.
        • et al.
        Incidence and safety profile of outpatient unicompartmental knee arthroplasty.
        Knee. 2019; 26: 708-713
        • Lovald S.
        • Ong K.
        • Lau E.
        • Joshi G.
        • Kurtz S.
        • Malkani A.
        Patient selection in outpatient and short-stay total knee arthroplasty.
        J Surg Orthop Adv. 2014; 23: 2-8