Joint Replacement Journal Club September 2015: Same Day Surgery?

We discuss recently published article: "Who should not undergo short stay hip and knee arthroplasty..." Gwo-Chin Lee et al. in Journal of Arthroplasty September 2015 (see full article)

The first patient to undergo a total knee replacement stayed in the hospital for 6 months.  Over the years however, the average length of stay has continued to decrease (1).   We are even getting away from thinking that any hospitalization is essential for joint replacement surgery.  One study found no significant difference in rates of infection, blood clots or death in patients that were "short stay" (< 3 days) or "standard stay" (Medicare recommended 3-4 days).

While hospital stay times continue to shorten, the question remains: How long, if at all, does a patient need to be hospitalized after a joint replacement?  

This is a challenging question, in part because theres no "right" answer.  We know that a lot depends on the patient.  Medicine is becoming more and more personalized, and the "one-size fits all" model is thankfully going away.  And the way that doctors are able to personalize medicine is by studying everyone to look for emerging trends.  

These trends highlight the patient factors that are important in guiding treatment.  For example, patients have different eye colors but that doesnt affect their outcomes, and therefore, its not useful in deciding how long a patient should stay in the hospital.  In contrast, patients have different levels of glucose control (diabetes being pathologically bad control) and this does affect outcomes, and therefore it should be used in deciding how long a patient stays in the hospital.  There are so many factors that influence hospitalization, and many of them arent even medical.  For example, persons family support system is important to consider because we all need help when recovering from major surgery. 

It is therefore critical to continue to look for objective criteria (patient factors) that help doctors determine whether a patient is a good candidate for "Same-Day" or "Short-Stay" joint replacement surgery.  The aforementioned study (2) that saw no difference in the overall rate of postoperative complications, did however find a higher risk of rehospitalization in older patients, less healthy patients (higher charlson socre), and patients with a history of heart failure.   This recent study by Gwo-Chin Lee's team at UPenn continued to look for patient risk factors that would make them poor candidates for shorter hospital stay after joint replacement surgery. 

Looking at 1,012 patients undergoing primary total hip or knee replacement, they identified 70 patients with postoperative complications (6.9%).  Interestingly, 84% occurred after 24 hours, suggesting that keeping patients in observation for one day would likely not help in identifying or treating the issue.  They found results similar to the other study: a history of congestive heart failure, or coronary artery disease increased the risk of complications.  Additionally, lung disease (COPD), and liver failure (cirrhosis), and older age were patient risk factors.  A similar study (3) looking at timing of postoperative complications at Jefferson Hospital (just down the street from UPenn) also found that cardiopulmonary complications were the most common, and that 90% occurred within 4 days of surgery.

This study is valuable in identifying important risk factors that should help a surgeon decide how long a patient needs to be hospitalized following surgery.  While many patients clearly recover well at home after a joint replacement, other patients, specifically those with serious underlying medical conditions, are probably best monitored in a hospital setting for a few days.


1. Memtsoudis SG et al. Trends in demographics, comorbidity profiles, in-hospital complications and mortality associated with primary knee arthroplasty 3,830,420 hospital discharges in the US between 1990-2004. J Arthro 2009; 24(4): 518. see article. length of stay is declining from 8 days to 4 days average.  complications are decreasing even though patient comorbidites are increasing. discharge to care facilities are increasing.

2. Lovald ST et al. Complications, mortality, and costs for outpatient and short-stay total knee arthroplasty patients in comparison to standard-stay patients. J Arthro 2014; 29(3): 510. see article. no difference in outcomes. 

3. Parvizi J et al. Total joint arthroplasty: when do fatal or near-fatal complications occur? JBJS 2007; 89(1): 27. see article. 90% occur within 4 days of index surgery.