Outpatient Knee replacement

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OutPatient TKR Program

Partial and total knee replacement is the surgical treatment for knee arthritis, where the damaged knee is removed and replaced with an artificial knee implant. Traditionally performed as an inpatient procedure, partial and total knee replacement surgeries are now being conducted on an outpatient
basis, allowing patients to go home the same day of the surgery (or the next day). Not every patient is a candidate for outpatient joint replacement. The decision to undergo outpatient joint replacement should be made with your surgeon and family. For those patients who are candidates for outpatient surgery it can provide a streamlined experience and allows you to recover in the comfort of your own home

Patient Selection

Appropriate patient selection is key to successful outpatient TJA.
Multiple indices have been proposed to estimate patient”s medical risk stratification before undergoing outpatient TJA like the Outpatient Arthroplasty Risk Assessment (OARA) score,ASA grading,Charlson Comorbidity Index.OARA is the most sensitive and specific. Non-medical factors that are likely associated with improved rates of safe discharge after outpatient TJA include strong social/family support, home living situation , preoperative mobility status and the patient’s motivation for same day discharge. Further research is needed to identify the ideal prediction tool that will incorporate medical co- morbidities, patient-specific factors, and social influences to best identify which patients can undergo safe outpatient TJA.

Intraoperative Factors

Spinal anesthesia and regional blocks Improvements in anesthesia care range from the type of anesthetics used, adjunctive analgesia optimization, and medication advances. The most common reasons for delayed discharge after TJA were pain, postoperative nausea and vomiting (PONV) and hypotension.
The majority of outpatient TJA cases utilize neuraxial anesthesia and regional blocks to limit PONV and improve pain control. In the immediate postoperative period, spinal anesthesia and adductor canal block had significantly decreased rates of nausea, blood loss and DVT/PE compared to general anesthesia, and was also associated with shorter length of stay in TKA.
Multimodal pain control Multimodal pain control is a method of decreasing surgical pain at numerous points along the pain pathway from the site of injury to the brain. Multimodal pain control utilizes a wide range of pre-operative medications including non-steroidal anti-inflammatory drugs (NSAID), narcotics, gabapentiniods, dexamethasone and acetaminophen.24 In addition, spinal anesthesia and regional blocks are key components to multi-modal pain control.

Preoperative Management Education

Once a patient is deemed medically appropriate for outpatient arthroplasty, the most important step is patient education. A preoperative education class can establish patient expectations for the day of surgery and immediately postoperatively, ensuring that the patient’s safety will be maintained, allowing for questions to be answered and decrease anxiety related to the process

The addition of a preoperative physical therapy session can help the transition back to home by giving instruction for performing basic mobility tasks after TJA

Intraoperative Factors

Spinal anesthesia and regional blocks Improvements in anesthesia care range from the type of anesthetics used, adjunctive analgesia optimization, and medication advances. The most common reasons for delayed discharge after TJA were pain, postoperative nausea and vomiting (PONV) and hypotension.
The majority of outpatient TJA cases utilize neuraxial anesthesia and regional blocks to limit PONV and improve pain control. In the immediate postoperative period, spinal anesthesia and adductor canal block had significantly decreased rates of nausea, blood loss and DVT/PE compared to general anesthesia, and was also associated with shorter length of stay in TKA.
Multimodal pain control Multimodal pain control is a method of decreasing surgical pain at numerous points along the pain pathway from the site of injury to the brain. Multimodal pain control utilizes a wide range of pre-operative medications including non-steroidal anti-inflammatory drugs (NSAID), narcotics, gabapentiniods, dexamethasone and acetaminophen.24 In addition, spinal anesthesia and regional blocks are key components to multi-modal pain control.

Surgical Factors

Surgical techniques have evolved to limit blood loss, decrease soft tissue disruption, improve cosmetic appearance, and assist in faster patient recovery.

Postoperative Mobilization Rapid Recovery Protocols

A key component of postoperative care in outpatient TJA is early ambulation in the recovery unit. Tasks included sit to stand, ambulating up to 100 feet, transferring to bathroom and navigating a flight of stairs. An added benefit to early mobilization is a decrease in thromboembolic events. Coupled with preoperative education, this approach is crucial to a successful outpatient practice.

Creating a safety net for patients that are discharged home.

Implementation of standardized home physical therapy and home nursing, in addition to follow-up phone calls or mobile phone total joint applications with the ability of the patient to discuss issues directly with their care team following discharge ensures patient confidence and acceptability.

Outcome Complications

As the prevalence of outpatient TJA has increased, more studies have been performed to evaluate complications rates, rates of readmission, rates of reoperation, patient satisfaction, and health system costs in comparison to inpatient TJA

One notable adverse event identified is an increased incidence of post-discharge blood transfusion when compared to the inpatient group however this can be optimized pre operatively.

In addition to providing a safe surgical process, maintaining or improving levels of patient satisfaction is important in establishing a successful outpatient TJA program.

When performed in the carefully selected and appropriately prepared patient, outpatient TJA can substantially reduce health care costs and hospital burdens.

Outpatient total joint arthroplasty is safe for carefully selected patient populations.

Conclusion

Outpatient TJA has the potential to improve patient outcomes, improve patient satisfaction, and reduce health care costs. Until now, outpatient TJA has been performed in select patient populations. Further research on complications, readmission rates, and patient satisfaction will be paramount as outpatient TJA increases to ensure patient safety and positive outcomes. Initial results are promising, delivering a safe and effective outpatient TJA experience while reducing healthcare costs.

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DR.DEEPAK THAKUR

A Conscientious, Reliable and Hardworking Medical Professional, Pays Attention to Details, Crusader of Clinical Governance, With Excellent Interpersonal and Time Management Skills

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