key: cord-0999518-soooniqv authors: Buller, Leonard T.; Hubbard, Trey; Ziemba-Davis, Mary; Deckard, Evan R.; Meneghini, R. Michael title: Safety of Same and Next Day Discharge Following Revision Hip and Knee Arthroplasty Using Modern Perioperative Protocols date: 2020-07-30 journal: J Arthroplasty DOI: 10.1016/j.arth.2020.07.062 sha: 5840ebdf814467d914b84af7aade7b16132016c6 doc_id: 999518 cord_uid: soooniqv INTRODUCTION: Advances in perioperative care have enabled early discharge and outpatient primary total joint arthroplasty (TJA). However, the safety of early discharge after revision TJA (rTJA) remains unknown and the COVID-19 pandemic will force decreased hospitalization. This study compared 90-day outcomes in patients undergoing aseptic rTJA discharged the same or next day (early) to those discharged two or three days postoperatively (later). METHODS: 530 aseptic rTJAs performed at a single tertiary referral center (12/5/2011-12/30/2019) were identified. Early and later discharge patients were matched as closely as possible on procedure type, sex, ASA-PS classification, age, and BMI. All patients were optimized using modern perioperative protocols. The rate of 90-day ED visits and hospital admissions was compared between groups. RESULTS: 183 early discharge rTJAs (54 hips, 129 knees) in 178 patients were matched to 183 later discharge rTJAs (71 hips, 112 knees) in 165 patients. 62% of the sample was female, with an overall average age and BMI of 63±9.9 (range: 18-92) years and 32±6.9 (range: 18-58) kg/m(2). There was no statistical difference in 90-day ED visit rates between early (6/178, 3.4%) and later (11/165, 6.7%) discharge patients (p=0.214). 90-day hospital admission rates for early (7/178, 3.9%) and later (4/165, 2.4%) did not differ (p=0.545) CONCLUSIONS: Using modern perioperative protocols and with appropriate patient selection, early discharge following aseptic rTJA does not increase 90-day readmissions or ED visits. As hospital inpatient capacity remains limited due to COVID-19, select rTJA patients may discharge home the same or next day to preserve hospital beds and resources for more critical medically related illness. Total joint arthroplasty (TJA) is one of the most successful of orthopaedic procedures [1] . 48 Historically, multiple days of inpatient care was the expectation following primary TJA. 49 However, innovations in perioperative care, including surgical technique, pain management, 50 blood conservation and physical therapy, have enabled rapid recovery and early discharge [2] [3] [4] . 51 Evidence demonstrates early discharge primary TJA (<24 hour stay) to be safe [5] [6] [7] [8] [9] [10] [11] [12] and cost 52 saving [13, 14] , without increasing readmission rates [15] [16] [17] . 53 Despite the clinical success of primary TJA, complications requiring revision remain a 54 costly societal burden [18] . As the demand for TJA increases [19] , so will the number of 55 revisions [20] . The most common etiologies leading to revision total hip arthroplasty (rTHA) 56 include: instability, aseptic loosening and infection [21] . The most common etiologies leading to 57 revision total knee arthroplasty (rTKA) include: infection, aseptic loosening and instability 58 [22, 23] . Revision TJA traditionally results in longer inpatient lengths of stay (LOS) than primary 59 TJAs. For example, in a 2009 study the average LOS following the most basic rTHA (head-liner 60 exchange) was reported as five days and the average LOS for all types of rTHA procedures was 61 over six days [21] . Similarly, the average LOS for an aseptic rTKA was reported to be over four 62 days and increased to over five days when infection cases were included [22, 23] . 63 As surgeons, patients, and institutions become more comfortable with rapid recovery 64 Patient Care Protocols: As part of our standardized perioperative care program, all patients 92 underwent preoperative risk assessment and medical clearance within four weeks of surgery by a 93 medical specialist whose practice focuses exclusively on hip and knee arthroplasty patients. Each 94 patient's upcoming surgery was discussed at a coordinated care conference attended by members 95 of the multidisciplinary team the week prior to their scheduled surgery. During this meeting, 96 information is shared across disciplines and patient care plans are proactively developed, which 97 are shared with everyone who provides direct care or services to the patient. Preoperatively, 98 patients and family members received comprehensive clinic-based education and attended a 99 hospital-based joint replacement class. Postoperatively, all patients were encouraged to ambulate 100 by the afternoon on the day of surgery when possible and attempts were made to standardize 101 rehabilitation protocols. Postoperative care was assumed by the operative surgeon, the internal 102 medicine specialist, clinic staff, and a multidisciplinary inpatient care team. Postoperative pain 103 control for the first 24 hours was by an anesthesia pain service. The same modern perioperative 104 pain control, clinical, and rehabilitation protocols were used for all patients. 105 Perioperative and Postoperative Pain Control and Anesthesia Protocols: A multimodal 106 preoperative pain protocol was used in all cases. Unless allergic or contraindicated, patients were 107 given acetaminophen (1000 mg PO) 24 hours before surgery and oxycodone (10 to 20 mg PO), 108 celecoxib (200 mg PO), and pregabalin (75 mg PO) immediately before surgery. (200 mg PO bid), oxycodone (5-10 mg hourly prn for mild pain and 10-20 mg hourly prn for 125 moderate pain), or hydromorphone (0.5 mg IV q20 minutes prn for severe pain). IV tranexamic 126 acid (1 g prior to incision followed by 1 g two hours later) was standardly used. 127 Thromboprophylaxis was with enteric coated aspirin 81 mg twice daily for six weeks along with 128 23 hours of sequential compression devices during hospitalization. Those patients at higher risk 129 for thromboembolism were treated with additional chemoprophylaxis. This research did not receive any specific grant from funding agencies in the public, commercial, 147 or not-for-profit sectors. 148 Demographic and case characteristics for the two study groups are shown in Table 150 2. rTHA was performed in 30% of early discharge and 39% of later discharge patients 151 for hip and knee procedures in Table 3 . ALTR was the most common reason for rTHA in 159 early discharge patients whereas loosening was more common in later discharge patients later discharge patients (p=0.152). Components revised in early discharge and later 162 discharge cases are shown in Table 4 (Table 5 ). Causes ranged from allergic rash to a pain pump to acute 177 hematogenous infection in the study joint requiring I&D with component retention. Table 178 5 also shows that four early discharge patient (4/178, 2.2%) and one later discharge patient 179 (1/165, 0.06%) were directly admitted to the hospital within 90 days of rTJA (p=0.373). 180 Improvement Program database who underwent aseptic rTKA and were discharged zero to two 216 days after the procedure and compared to those discharged three to four days postoperatively 217 [37]. The authors found no difference in the 30-day complication rate between the two groups. 218 In contrast to the study by Gu et al, a major strength of the present study is the lack of selection 219 bias inherent in a large database study. Specifically, all patients included in our study were 220 exposed to the same modern perioperative protocols. Additionally, a large database study lacks 221 the appropriate granularity to adjust for institutional protocols or other medical reasons that may 222 delay discharge following rTKA. Our study utilized matching on multiple potential 223 in part because none of the infection cases performed during the study period were discharged 273 early, within POD zero or one. Therefore, this study is not generalizable to the PJI patient Safety of Early Discharge Revision Total Joint Arthroplasty 13 population. We chose not to include these patients as controls as they are oftentimes more 275 medically complex, have defined logistical issues related to orchestrating long-term intravenous 276 antibiotics mandating an extended hospital stay, and have higher unplanned readmission rates 277 [44, 45] , which would have introduced significant bias. Future studies should seek to determine 278 whether a reduction in LOS among patients with PJI has a detrimental effect on outcomes 279 including readmission rates, complication rates and infection eradication rates. Moreover, it 280 should be noted that this study only evaluated readmission and ED visit rates and did not 281 evaluate other outcomes related to patient outcomes following rTJA, like patient reported 282 outcome measures or long-term success of the implants. Finally, the results of this study are 283 generalizable, in as much as one is able to adopt the multidisciplinary approach described in the 284 present study. One part of the multidisciplinary approach is attendance at the joint 285 replacement class, which is strongly suggested for all revision patients. We did not record 286 the relative number of participants in each group and this may also represent a source of 287 confounding and future studies should determine whether this affects discharge timing and 288 safety in aseptic rTJA. This study demonstrates the feasibility and safety of short stay rTJA, but 289 also emphasizes the fact that even with a multidisciplinary approach and rapid recovery 290 protocols, not all revision patients will be safe to undergo early discharge. 291 In conclusion, this study demonstrates the relative safety of early discharge of aseptic 292 rTJA patients without an increase in readmission or ED visits within the first 90-days after 293 surgery. As lengths of stay following rTJA continue to decrease, it is crucial to create evidence-294 based safeguards to assure focus remains on patient safety to keep the perioperative complication 295 rates as low as possible. Implementation of a multidisciplinary approach to patient care is essential to predicting patient needs in the perioperative period and improves the safety and 297 feasibility of early discharge patients undergoing aseptic rTJA. 298 299 Outpatient total joint arthroplasty with discharge to home at a freestanding ambulatory Outcomes of the First 1,000 Total Hip and 343 Total Knee Arthroplasties at a Same-day Surgery Center Using a Rapid-recovery Protocol Arthroplasty Has Minimal Short-Term Complications With the Use of Institutional Effects of the Length of Stay on the 349 Cost of Total Knee and Total Hip Arthroplasty from 2002 to 2013 Outpatient Surgery as a Means of Cost 352 Reduction in Total Hip Arthroplasty: A Case-Control Study Hospital Discharge 355 within 2 Days Following Total Hip or Knee Arthroplasty Does Not Increase Major-356 Complication and Readmission Rates Rapid Recovery 359 Protocols for Primary Total Hip Arthroplasty Can Safely Reduce Length of Stay Without 360 Increasing Readmissions Do shorter lengths 362 of stay increase readmissions after total joint replacements? Projections of primary and revision hip and 368 knee arthroplasty in the United States from 2005 to 2030 The epidemiology of revision total knee 371 and hip arthroplasty in England and Wales: A comparative analysis with projections for 372 the United States. a study using the national joint registry dataset The Epidemiology of Revision Total Hip Arthroplasty in the United States The epidemiology of revision 378 total knee arthroplasty in the United States Why Are Total Knee 381 Arthroplasties Failing Today-Has Anything Changed After 10 Years? Choosing Rapid recovery protocol for peri-operative care 389 of total hip and total knee arthroplasty patients The feasibility and 391 perioperative complications of outpatient knee arthroplasty Same-Day Discharge Compared with Inpatient Hospitalization Following Hip and Knee Arthroplasty Older patients have the most 397 to gain from orthopaedic enhanced recovery programmes Safety and Effectiveness of Total Hip Arthroplasty as an Outpatient Procedure: A 401 Matched-Cohort Analysis Minimally Invasive Outpatient Total Hip Arthroplasty Rapid Recovery Programs in Arthroplasty Inpatient Versus Outpatient Complications After Total Joint Arthroplasty A population-416 based nested case-control study of the costs of hip and knee replacement surgery Effect of Early Discharge 419 on Postoperative Comorbidity and Complications for Patients Undergoing Revision Total Knee Arthroplasty Hospital Discharge Within 1 Day After Total Joint Arthroplasty From a Veterans Affairs 423 Hospital Does Not Increase Complication and Readmission Rates An Analysis of a National Database Outpatient Total Hip Arthroplasty Safe? Low Rates of Adverse Events 435 Following Ambulatory Outpatient Total Hip Arthroplasty at a Free-Standing Surgery Discharge After Total Hip Arthroplasty in the Medicare Population What are the rates and causes of hospital readmission 441 after total knee arthroplasty? Knee Causes and frequency of unplanned hospital 444 readmission after total hip arthroplasty Is Rapid Recovery Hip and Knee 447 Replacement Possible and Safe in the Octogenarian Patient? Fall with knee dislocation and extensor mesh rupture (study joint) Figure 1 . Flowchart of index (LOS 0 to 1) and comparison (LOS 2 to3) cases.