Goyal N, Chen AF, Padgett SE, Tan TL, Kheir MM, Hopper RH Jr, Hamilton WG, Hozack WJ. Otto Aufranc Award: a multicenter, randomized study of outpatient versus inpatient total hip arthroplasty. Clin Orthop Relat Res. 2016 Jun 10. [Epub ahead of print].
In patients having total hip arthroplasty, does planned discharge on the same day versus the next day lead to different outcomes in terms of postoperative pain, complications, and health-care provider visits?
Randomized (allocation concealed)*, unblinded, controlled trial with 4 weeks of follow-up and intention-to-treat analysis. ClinicalTrials.gov NCT02230657.
2 high-volume, adult reconstruction centers in the United States.
220 patients <75 years of age (mean age, 60 years; 53% men) with a body mass index of <40 kg/m2 who underwent primary unilateral total hip arthroplasty through a direct anterior approach. The exclusion criteria included chronic opioid use, need for a walker or wheelchair, lack of assistance at home, or history of cardiopulmonary disease with need for acute inpatient monitoring. 100% of patients completed follow-up.
Planned same-day discharge ≤12 hours after surgery (outpatient group, n = 112) or planned next-day discharge after an overnight hospital stay (inpatient group, n = 108). All patients had to meet the same criteria before discharge.
Main outcome measures:
Outcomes were postoperative pain as assessed with a visual analog scale (VAS) (0 = no pain and 10 = worst pain), perioperative complications, visits to a health-care provider (physician’s office, emergency department, or hospital readmission), and surgery office contacts.
In the outpatient group, 76% of patients had same-day discharge, 23% had next-day discharge, and 1% stayed in hospital for 2 nights. In the inpatient group, 75% had next-day discharge, 17% had same-day discharge, and 8% stayed in hospital for >1 night. 1 day after discharge, the outpatient group had more pain than the inpatient group (Table I); the groups did not differ in terms of pain on the day of surgery or 4 weeks after surgery (Table I), reoperations (1.79% vs. 0.93%, p = 1.0), hospital readmissions (0.89% vs. 3.70%, p = 0.21), emergency department visits (0% vs. 1.85%, p = 0.24), acute office visits (1.79% vs. 0%, p = 0.50), or contacts with the surgery office (mean number of contacts at 4 weeks, 2.4 vs. 2.4, p = 0.94).
In patients having primary total hip arthroplasty through an anterior approach in a high-volume setting, same-day versus next-day discharge was associated with increased pain on the day after surgery but not on the day of surgery or 4 weeks after surgery.
*Information provided by author.
Source of funding:
No external funding.
For correspondence: Dr. N. Goyal, Anderson Orthopaedic Research Institute & Inova Center for Joint Replacement at Mount Vernon Hospital, 2501 Parkers Lane, Suite 200, Alexandria, VA 22306. E-mail address: firstname.lastname@example.org.
Goyal and colleagues performed a well-constructed, randomized trial of outpatient total hip arthroplasty. The key finding was that outpatient total joint replacement was done successfully in 2 high-volume centers. The only negative finding was that patients who were discharged on the day of surgery had more pain on postoperative day 1 than those who stayed in the hospital overnight. The optimal patient population, care setting, and aggregate work (not just telephone traffic) needed for a successful outpatient total joint program were not defined.
Other important findings should be noted. First, the study sites were high-volume centers, where outpatient surgery and next-day discharge were common. These centers had achieved a highly refined optimal length of stay before initiation of the study. The aggregate investment of time and talent needed to initiate and maintain the program was not evaluated in the study. Second, the selection criteria for the trial excluded many potential patients because of weight, narcotic use, availability of home care, and ambulatory status, ultimately resulting in a patient cohort that was 7 years younger than the average patient undergoing total hip arthroplasty in the United States1. Third, about one quarter of patients in the same-day discharge group stayed in the hospital, and a smaller percentage in the next-day discharge group went home on the day of surgery. This finding suggests that overnight capabilities must be available. Finally, Goyal and colleagues found a previously unreported predominance of women in the inpatient group who stayed longer than 1 night. This finding should be explored. In summary, this trial suggested that outpatient total hip surgery can be done successfully, but it did not show that this is the best option for all patients in all settings.
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