The current status of daycase hip and knee arthroplasty within the English National Health Service: a retrospective analysis of hospital episode statistics data

An overnight sensation: the effect of an acute introduction of a short-stay pathway on a previously compromised arthroplasty service

Aims

In this study, we report the impact of implementing a new short-stay hip and knee arthroplasty pathway in an NHS hospital. This was enacted due to existing concerns around long length of stay (LOS) and reduced elective operating capacity each winter due to bed pressures. The overnight introduction of this pathway was aimed to reduce LOS, alleviate bed pressures, minimize readmission rates, and generate financial savings, all combining to facilitate full elective activity during the winter.

Methods

We conducted a prospective study at a regional tertiary arthroplasty centre. The new pathway was introduced across the service overnight. It included rigorous preoperative optimization, specific anaesthetic protocols, and uniform changes in surgical practice to allow a focus on early mobilization and discharge on the day of surgery where possible. Data collection spanned 17 months, encompassing the initial six months post-implementation of the short-stay pathway. LOS data were collected for the full period and data were compared pre- and post-implementation of the new pathway. Patient satisfaction and 30-day readmission data were also collected.

Results

There was a significant decrease in median LOS from four days pre-implementation to one day post-implementation. Patient satisfaction was high and the 30-day readmission rate was unchanged (5.95%, n = 43), with no readmissions directly related to decreased inpatient stay. Financial analyses revealed substantial cost savings due to reduced LOS and the elimination of routine postoperative blood tests. Elective activity over winter was significantly higher (203 more arthroplasties, 79% increase) than in the same time period in the previous year.

Conclusion

An acute introduction of a carefully planned and coordinated short-stay hip and knee pathway is safe, cost-effective, and popular with patients, but also contributes to increased efficiency in the delivery of elective healthcare in the context of increasing demand and financial constraints in the NHS.

Clinical and cost-effectiveness of earlier discharge from acute hospital after total joint arthroplasty

BACKGROUND

Reducing length of stay has been proposed as a key component of policies that aim to meet demand and minimize costs associated with total joint arthroplasty. However, few studies explore shifting of healthcare utilization when length of stay is shortened.

METHODS

This retrospective cohort study examined patients undergoing primary, total hip and knee arthroplasty for osteoarthritis to simulate a policy-level institutional reduction in acute hospital stay by 1 day. Costs, quality of life, and rates of complications, readmission and discharge to inpatient rehabilitation were compared in patients with a three- and four-day length of acute stay. Balance was achieved using overlap-propensity weighting.

RESULTS

In total, 2023 patients were included. Earlier discharge from acute hospital was not associated with a change in odds of 90-day complications (OR: 0.85 [95% CI, 0.58 to 1.27]; P = 0.447), readmissions (OR: 1.11 [95% CI, 0.67 to 1.82]; P = 0.691), and emergency department presentations (OR: 1.07 [95% CI, 0.66 to 1.73]; P = 0.774). Earlier discharge from acute hospital was associated with an increase in odds of discharge to inpatient rehabilitation (OR: 2.16 [95% CI, 1.45 to 3.20]; P < 0.001). No significant differences in costs and quality adjusted life years were observed at one-year. Cost savings during index admission were shifted onto increased costs associated with inpatient rehabilitation.

CONCLUSION

Earlier discharge was not associated with changes in 90-day complications, readmission, or ED presentations. However, an increase in utilization of inpatient rehabilitation was observed, offsetting early cost savings. Patients who were discharged from acute care on day three had no difference in costs compared to those discharged on day four.

Unicompartmental knee arthroplasty: an exemplar of surgical and engineering collaboration

Cite this article: Bone Jt Open  2024;5(12):1120–1122.

Using orthopaedic health care resources efficiently: A cost analysis of day surgery for unicompartmental knee replacement

BACKGROUND

Day surgery for unicompartmental knee replacement (UKR) could potentially reduce hospital costs. We aimed to measure the impact of introducing a day surgery UKR pathway on mean length of stay (LOS) and costs for the UK NHS, compared to an accelerated inpatient pathway. Secondly, the study aimed to compare the magnitude of costs using three costing approaches: top-down costing; simple micro-costing; and real-world costing.

METHODS

We conducted an observational, before-and-after study of 2,111 UKR patients at one NHS hospital: 1,094 patients followed the day surgery pathway between September 2017 and February 2020; and 1,017 patients followed the accelerated inpatient pathway between September 2013 and February 2016. Top-down costs were estimated using Average NHS Costs. Simple micro-costing used the cost per bed-day. Real-world costs for this centre were estimated by costing actual changes in staffing levels.

RESULTS

532 (48.5%) patients in the day surgery pathway were discharged on the day of surgery compared with 36 (3.5%) patients in the accelerated inpatient pathway. The day surgery pathway reduced the mean LOS by 2.2 (95% CI: 1.81, 2.53) nights and was associated with an 18% decrease in Average NHS Costs (p < 0.001). Mean savings were £1,429 per patient with the Average NHS Costs approach, £905 per patient with the micro-costing approach, and £577 per patient with the "real-world" costing approach. Overall, moving NHS UKR surgeries to a day surgery pathway could save the NHS £8,659,740 per year.

CONCLUSION

Day surgery for UKR could produce substantial cost savings for hospitals and the NHS.

Implementation of outpatient hip and knee arthroplasty in a multicenter public healthcare setting

BACKGROUND AND PURPOSE

Length of hospital stay after hip and knee arthroplasty is about 1 day in Denmark with few patients discharged on the day of surgery. Hence, a protocol for multicenter implementation of discharge on day of surgery has been instituted. We aimed to describe the implementation of outpatient hip and knee arthroplasty in a multicenter public healthcare setting.

METHODS

We performed a prospective multicenter study from 7 public hospitals across Denmark. Patients were screened using well-defined in- and exclusion criteria and were discharged on day of surgery when fulfilling functional discharge criteria. The study period was from September 2022 to February 2023 with variable start of implementation. Data from the same centers in a 6-month period before the COVID pandemic from July 2019 to December 2019 was used for baseline control.

RESULTS

Of 2,756 primary hip and knee arthroplasties, 37% (95% confidence interval [CI] 35-39) were eligible (range 21-50% in centers) and 52% (range 24-62%) of these were discharged on day of surgery. 21% (CI 20-23) of all patients (eligible and non-eligible) were discharged on day of surgery with a range of 10-31% within centers. This was an additional 15% (CI 13-17, P < 0.001) compared with patients discharged in the control period (6% in 2019).

CONCLUSION

We found it possible to perform outpatient hip and knee replacement in 21% of patients in a public healthcare setting, probably to be increased with further center experience.

Half of all hip and knee arthroplasty patients may be potential day-case candidates: a nationwide register study of 166,730 procedures

BACKGROUND AND PURPOSE

The overall potential pool of day-case candidates on a national level in hip and knee arthroplasty is unknown. We aimed to estimate the proportion of hip and knee arthroplasty patients eligible for day-case surgery based on contemporary widely used criteria and determine whether there has been a change in the proportion of eligible patients over time and, secondarily, to investigate the proportion of eligible patients discharged on the day of surgery.

METHODS

Based on data from the Danish National Patient Register, we identified all patients undergoing primary unilateral hip or knee arthroplasty from January 2010 to March 2020. Using a modification of day-case eligibility criteria proposed by a national multicenter collaboration, we sorted patients into either day-case eligible or ineligible. A day-case procedure was defined as discharge on the day of surgery.

RESULTS

We included patients comprising a total of 166,730 primary total hip (THA), total knee (TKA), and unicompartmental knee arthroplasty (UKA). 48% (95% confidence interval [CI] 48-49) were eligible for day-case surgery, with a decline from 50% (CI 49-51) in 2010 to 46% (CI 46-47) eligible in 2019. More UKA patients were day-case eligible (55%, CI 54-56) than THA (47%, CI 47-48) and TKA patients (49%, CI 48-49). A maximum of 8.0% (CI 7.4-8.5) of eligible patients were discharged on the day of surgery in 2019.

CONCLUSION

48% of the Danish hip and knee arthroplasty patients were potential day-case candidates, with a small decline in eligibility from 50% in 2010 to 46% in 2019. Day of surgery discharge among day-case eligible patients peaked at 8% in 2019. Thus, the potential for more day-case surgery seems large.

Quick Transition to One Day Length of Stay after Hip and Knee Arthroplasty Using a Digital Follow-Up Tool during COVID-19: A Retrospective Comparative Study

The COVID-19 pandemic highlighted the need for efficient use of hospital infrastructure. The hypothesis was that a rapid shift to outpatient surgery after hip or knee arthroplasty could be implemented without compromising quality of care. The aim of this study was to assess the safety, pain management and patient-reported outcomes before and after the implementation of an accelerated discharge program using a digital follow-up tool. A retrospective cohort design was used to compare 97 patients who received primary total hip or knee arthroplasty during the pandemic (early discharge) to comparable 194 pre-pandemic patients (normal discharge). Both cohorts had the same inclusion criteria and were closely monitored using the digital follow-up tool. The accelerated discharge program reduced length of stay from a median of 3 days (before the pandemic) to a median of 1 day (during the pandemic) (p < 0.001). The complication rate of 2% was the same for both groups (p > 0.05). Patient-reported outcomes for matched samples of hip (n = 100) and knee (n = 82) arthroplasty patients were similar before, at 6 weeks and 3 months after surgery for both groups (p > 0.05). There were no differences in pain and medication consumption for the first 6 weeks (p > 0.05). This study demonstrates that reducing length of stay from three to one night after total knee or hip arthroplasty, with the help of a digital follow-up tool, results in a stable rate of complications, readmission, and comparable clinical outcomes, while reducing the socio-economic burden on the health system.

Regional anaesthesia for ambulatory surgery

Regional anaesthesia (RA) has an important and ever-expanding role in ambulatory surgery. Specific practices vary depending on the preferences and resources of the anaesthesia team and hospital setting. It is used for various purposes, including as primary anaesthetic technique for surgery but also as postoperative analgesic modality. The limited duration of action of currently available local anaesthetics limits their application in postoperative pain control and enhanced recovery. The search for the holy grail of regional anaesthetics continues. Current evidence suggests that a peripheral nerve block performed with long-acting local anaesthetics in combination with intravenous or perineural dexamethasone gives the longest and most optimal sensory block. In this review, we outline some possible blocks for ambulatory surgery and additives to perform RA. Moreover, we give an update on local anaesthesia drugs and adjuvants, paediatric RA in ambulatory care and discuss the impact of RA by COVID-19.

Low readmission and reattendance rate in day-case total knee arthroplasties

Aims

The rate of day-case total knee arthroplasty (TKA) in the UK is currently approximately 0.5%. Reducing length of stay allows orthopaedic providers to improve efficiency, increase operative throughput, and tackle the rising demand for joint arthroplasty surgery and the COVID-19-related backlog. Here, we report safe delivery of day-case TKA in an NHS trust via inpatient wards with no additional resources.

Methods

Day-case TKAs, defined as patients discharged on the same calendar day as surgery, were retrospectively reviewed with a minimum follow-up of six months. Analysis of hospital and primary care records was performed to determine readmission and reattendance rates. Telephone interviews were conducted to determine patient satisfaction.

Results

Since 2016, 301/7350 TKAs (4.1%) in 290 patients at our institution were discharged on the day of surgery. Mean follow-up was 31.4 months (6.2 to 70.0). In all, 28 patients (9.3%) attended the emergency department or other acute care settings within 90 days of surgery, most often with wound concerns or leg swelling; six patients (2.0%) were readmitted. No patients underwent a subsequent revision procedure, and there were no periprosthetic infections. Two patients (0.7%) underwent secondary patella resurfacing, and one patient underwent arthroscopic arthrolysis after previous manipulation under anaesthetic (MUA). Three patients (1.0%) underwent MUA alone. Primary care consultation records, available for 206 patients, showed 16 patients (7.8%) contacted their general practitioner within two weeks postoperatively; two (1.0%) were referred to secondary care. Overall, 115/121 patients (95%) telephoned stated they would have day-case TKA again.

Conclusion

Day-case TKA can be safely delivered in the NHS with no additional resources. We found low incidence of contact with primary and secondary care in the postoperative period, and high patient satisfaction.

Complications after lateral unicompartmental knee arthroplasty in a fast-track setting: a prospective cohort study of 170 procedures

BACKGROUND AND PURPOSE

In existing studies on fasttrack unicompartmental knee arthroplasty (UKA), the majority of surgeries are medial. There are substantial differences between lateral and medial UKA, which is why outcomes cannot automatically be compared. To gain information on the feasibility and safety of fast-track protocols in lateral UKAs, we investigated length of stay (LOS) and early complications after lateral UKA, performed using a fast-track protocol in well-established fast-track centers.

PATIENTS AND METHODS

We retrospectively evaluated prospectively collected data on patients undergoing lateral UKA in a fast-track setup from 2010 to 2018 at 7 Danish fast-track centers. Data on patient characteristics, LOS, complications, reoperations, and revisions was analyzed using descriptive statistics. Safety and feasibility were defined as complication and reoperation rates within 90 days comparable to non-fast track lateral UKA or fast-track medial UKA.

RESULTS

We included 170 of patients with a mean age of 66 (SD 12) years. Median LOS was 1 day (interquartile range 1-1), which was unchanged from 2012-2018. 18% were discharged on the day of surgery. Within 90 days, 7 patients experienced medical complications and 5 patients experienced surgical complications. 3 patients underwent reoperation, 2 were soft tissue revisions and the third was removal of an exostosis due to catching of the patella. 1 patient was revised due to a bearing dislocation.

CONCLUSION

Our findings suggest that lateral UKA in a fast-track setting is feasible and safe.

Are postoperative blood tests always required after lower limb arthroplasty?

Aims

It is common practice for patients to have postoperative blood tests after total joint replacement (TJR). However, there have been significant improvements in perioperative care with arthroplasty surgery, and a drive to reduce the length of stay (LOS) and move towards day-case TJR. We should reconsider whether this intervention is necessary for all patients.

Methods

This retrospective study included all patients who underwent a primary unilateral TJR at a single tertiary arthroplasty centre during a one-year period. Electronic medical records of 1,402 patients were reviewed for patient demographics, LOS, and American Society of Anesthesiologists (ASA) grade. Blood tests were examined to investigate the incidence of postoperative anaemia, electrolyte abnormalities, and incidence of acute kidney injury (AKI).

Results

For total knee arthroplasties, preoperative (R = -0.22) and postoperative haemoglobin (R = 0.2) levels were both negatively correlated with LOS (p < 0.001). For all patients who had undergone a TJR, 19 patients (0.014%) required a blood transfusion postoperatively due to symptomatic anaemia. Risk factors identified were age, preoperative anaemia, and long-term aspirin use. Significant abnormal sodium levels were found in123 patients (8.7%). However, only 36 patients (2.6%) required intervening treatment. Risk factors identified were age, preoperative abnormal sodium level, and long-term use of non-steroidal anti-inflammatory drugs, angiotensin receptor blockers, and corticosteroids. Similarly, abnormal potassium levels were evident in 53 patients (3.8%), and only 18 patients (1.3%) required intervening treatment. Risk factors identified were preoperative abnormal potassium level, and long-term use of angiotensin-converting enzyme inhibitors and diuretics. The incidence of AKI was 4.4% (61 patients). Risk factors identified were age, increased ASA grade, preoperative abnormal sodium, and creatinine level.

Conclusion

Routine blood tests after primary TJR is unnecessary for most patients. Blood tests should only be performed on those with identifiable risk factors such as preoperative anaemia and electrolyte abnormalities, haematological conditions, long-term aspirin use, and electrolyte-altering medications.

Study protocol for discharge on day of surgery after hip and knee arthroplasty from the Center for Fast-track Hip and Knee Replacement

BACKGROUND AND PURPOSE

Limited data exists on the implementation process and safety of discharge on the day of surgery after primary hip and knee arthroplasty in a multicenter setting. We report our study protocol on the investigation of the feasibility, safety, and socioeconomic aspects following discharge on day of surgery after hip and knee arthroplasty across 8 fast-track centers.

PATIENTS AND METHODS

This is a study protocol for a prospective cohort study on discharge on day of surgery from the Center for Fast-track Hip and Knee Replacement. The collaboration includes 8 centers covering 40% of the primary hip and knee arthroplasty procedures undertaken in Denmark. All patients scheduled for surgery are screened for eligibility using well-defined inclusion and exclusion criteria. Eligible patients fulfilling discharge criteria will be discharged on day of surgery. We expect to screen 9,000 patients annually. Duration and outcome: Patients will be enrolled over a 3-year period from September 2022 and reporting of results will run continuously until December 2025. We shall report the proportion of eligible patients and patients discharged on day of surgery as well as limiting factors. Readmissions and complications within 30 days are recorded with real-time follow-up by research staff. Furthermore, patient-reported information on willingness to repeat discharge on day of surgery, contacts with the healthcare system, complications, and workability is registered 30 days postoperatively. EQ-5D, Oxford Knee Score, and Oxford Hip Score are completed preoperatively and after 3 months and 1 year. Finally, outcome data will be used in the development of a prediction model for successful discharge on the day of surgery.

AUGMENTED REALITY NAVIGATION FRAMEWORK FOR TOTAL HIP ARTHROPLASTY SURGERY

In a total hip arthroplasty surgery, correctly implanting the artificial acetabulum and the femoral head is essential for a successful treatment. An augmented reality (AR) navigation framework is proposed in this paper to provide accurate surgical guidance in a total hip arthroplasty procedure. The AR framework consists of three parts: (1) preoperative surgical planning to generate virtual information for AR; (2) computer vision-based tracking for the real-time localization of both acetabular cup positioner and bony landmarks during surgery; (3) registration of a virtual object onto a real-world operative field to properly overlay the preoperative surgical planning data onto a three-dimensional (3D)-printed pelvis model. The cost-effective framework is designed with our clinical partner based on real surgical conditions. The bony landmarks are automatically detected and used for the registration between virtual and real objects. The AR performance is evaluated with a pelvis model, and it presents mean errors of 2.2[Formula: see text]mm and 0.8∘ in position and orientation, respectively, between real and virtual spaces. These small errors are within the tolerance of positive surgical outcomes.