Advances in modern medicine have made procedures that were historically considered a big deal, much easier on the patients. The first patients to receive a total hip replacement required months of hospitalization to recover. However, the surgical techniques have evolved to make incisions smaller. Techniques in post-operative pain control have advanced beyond zonking patients out with high doses of narcotics (morphine is in the same chemical family as heroin). Now patients getting a total knee replacement receive nerve blocks (injections of lidocaine, think numbing a tooth before a dentist fills a cavity) that remove pain from around the knee for many hours, and combinations of medications prevent painful inflammation while preventing the pain signal from reaching the brain. Additionally, surgery is shorter and less traumatic so there is less blood loss. Medications now prevent the need to transfuse patients as commonly as before.
All of this means that a total knee replacement has become easier on the patient. But how easy? And does this mean patients dont need to stay in the hospital after surgery? Or if they do, can they leave after only one or two days without risking medical deterioration and re-admission to the hospital.
The answer is: it depends. It depends on the surgeon...how confident they are with their pain control protocol, blood loss protocol, and technical ability. It also depends on the patient. Is the patient healthy? Do they have a good support system at home?
Past studies have shown that Total knee replacements and partial knee replacements (aka unicondylar knee arthroplasty) can safely be discharged home the day of surgery as long as they meet certain discharge criteria indicating medical safety. In that study, nausea was a big cause of delayed discharge, however < 5% required readmission to the hospital and <1% were seen in the emergency room. This suggests that same day surgery is possible.
What about early discharge from the hospital (< 2 night stay). A recent study wanted to see if patients that did get discharged home early after total knee replacement found no difference between patients that left the hospital early and those that stayed for the standard 3 nights after a knee replacement. They found that the risk of needing to go to the Emergency Room depended on the overall health of the patient before surgery (measured via Charleston Comorbidity Index) and was not related to the length of hospital stay.
Overall the research on this subject shows that if a patient fits the mold for someone that is healthy and able to go home early after surgery, there is a low overall risk that they will need to be readmitted to the hospital or be seen in the emergency room. This risk is overall not related to hospitalization and therefore, there is hope that going forward fewer patients will need to spend unnecessary time in the hospital, and get to recover in the comfort of their own home!
1. R.A. Berger, S.K. Kusuma, S.A. Sanders, et al. The feasibility and perioperative complications of outpatient knee arthroplasty Clin Orthop Relat Res, 467 (6) (2009), p. 1443. full article. one of first papers to suggest same day surgery for TKA.
2. R.A. Berger, S. Sanders, T. Gerlinger, et al. Outpatient total knee arthroplasty with a minimally invasive technique J Arthroplasty, 20 (3) (2005), p. 33. similar to the above, looking at 135 consecutvie patients. Average age of 68, only 3 readmissions within periop period but none related to early discharge (ie gi bleed 8 days out, superficial wound infection, etc). full article.
3.Selective early hospital discharge does not increase readmission but unnecessary return to the emergency department is excessive across groups after primary total knee arthroplasty. Rossman SR et al. J Arthroplasty. (2016). full article
4. V. Aram, D. Petruccelli, M. Winemaker, et al.Total joint arthroplasty readmission rates and reasons for 30-day hospital readmission. J Arthroplasty, 29 (3) (2014), p. 465. full article.
5. E.A. Daily, A. Cizik, J. Kasten, et al. Risk factors for readmission of orthopaedic surgical patients J Bone Joint Surg Am, 95 (11) (2013), p. 1012. full article.
6. J.S. Vorhies, Y. Wang, J.H. Herndon, et al. Decreased length of stay after TKA is not associated with increased readmission rates in a national Medicare sample Clin Orthop Relat Res, 470 (1) (2012), p. 166.
7. B. Zmistowski, C. Restrepo, J. Hess, et al. Unplanned Readmission after total joint arthroplasty: rates, reasons, and risk factors J Bone Joint Surg Am, 95-A (2013), p. 1869. full article.