Abstract
Background
The COVID-19 pandemic has had a lasting impact on patients seeking total hip and knee arthroplasty (THA, TKA) including more patients undergoing same day discharge (SDD) following total joint arthroplasty (TJA). The purpose of this study was to assess whether expansion of SDD TJA during the COVID-19 pandemic resulted in more early complications following TJA. We anticipated that as many institutions quickly launched SDD TJA programs there may be an increase in 30-day complications.
Methods
We retrospectively queried the ACS-NSQIP database for all patients undergoing primary elective TJA from January 1, 2018, to December 31, 2020. Participants who underwent THA or TKA between January 1, 2018 and March 1, 2020 were grouped into pre-COVID and between March 1, 2020 and December 31, 2020 were grouped into post-COVID categories. Patients with length of stay greater than 0 were excluded. Primary outcome was any complication at 30 days. Secondary outcomes included readmission and re-operation 30 days.
Results
A total of 14,438 patients underwent TKA, with 9,580 occurring pre-COVID and 4,858 post-COVID. There was no difference in rates of total complication between the pre-COVID (3.55%) and post-COVID (3.99%) groups (p=0.197). Rates of readmissions for were similar for the pre-COVID (1.75%) and post-COVID (1.98%) groups (p=0.381). There was no statistically significant difference in respiratory complications between the pre-COVID (0.41%) and post-COVID group (0.23%, p=0.03). A total of 12,265 patients underwent THA, with 7,680 occurring pre-COVID and 4,585 post-COVID. There was no difference in rates of total complication between the pre-COVID (3.25%) and post-COVID (3.49%) groups (p=0.52). Rates of readmissions for were similar for the pre-COVID (1.77%) and post-COVID (1.68%) groups (p=0.381). There was no statistically significant difference in respiratory complications between the pre-COVID (0.16%) and post-COVID group (0.07%, p=0.26). Combined data to include THA and TKA patients did not find a statistical difference in the rate of complications or readmission but did note a decrease in the rate of combined respiratory complications in the post-COVID group (0.15% vs. 0.30%, p=0.028).
Conclusion
Rapid expansion of SDD TJA during the COVID-19 pandemic did not increase overall complication, readmission, or re-operation rates.
Level of Evidence: IV
Keywords: covid, total joint arthroplasty, NSQIP, total knee arthroplasty, total hip
Introduction
With an aging population, the American Academy of Orthopedic Surgeons has estimated an increase of up to 180% in hip and knee arthroplasty in the next 10 years.1 The SARS-CoV-2 (COVID-19) pandemic has had a lasting impact on patients seeking total hip and knee arthroplasty (THA, TKA). In mid-March of 2020, the American College of Surgeons (ACS) and the Centers for Medicare and Medicaid Services (CMS) proposed postponing or cancelling all “elective” or “non-essential” procedures.2 As a result, many patients scheduled to undergo THA and TKA procedures had their surgeries postponed. It has been estimated approximately 30,000 primary total joint arthroplasty (TJA) procedures and 3,000 revision TJA procedures were cancelled per week.3 One of the primary reasons for delaying non-essential procedures was to limit hospital occupancy in the event beds were necessary to care for patients with COVID-19-related symptoms. In 2018, CMS removed TKA from the inpatient-only list, followed by THA in 2020, allowing these procedures to be completed as a same day discharge (SDD), defined as length of stay (LOS) 0 days. As the COVID-19 pandemic continued, many hospitals allowed same day discharge procedures to be performed which allowed patients improved access to care without increasing hospital census. This change led to a rapid and unprecedented expansion in SDD programs by arthroplasty surgeons at many institutions.4 Prior to this, SDD occurred in approximately 2.9% of patients undergoing primary TKA and 2.2% of patients undergoing primary THA.5
While inpatient length of stay continues to decrease there is still persistent concern that complications such as uncontrolled pain, post-operative medical, and wound complications would go unnoticed in patients undergoing SDD.6,7 SDD following TJA has previously reported to be safe, effective, and cost saving.8-10 Studies have shown equivalent or even improved outcomes with SDD TJA.11 Patients also benefit from recovering in a familiar environment without increased exposure to nosocomial organisms, including COVID-19.12 However, many of these procedures are performed at highly specialized centers that have refined perioperative care pathways including patient selection, education, pain management regimens, and close post-operative telephone follow-up.10,13-15 It is unknown whether similar results can be expected with the rapid expansion in TJA with SDD driven by the COVID-19 pandemic. Therefore, the purpose of this study was to assess whether expansion of SDD TJA during the COVID-19 pandemic resulted in more early complications following TJA. We anticipate that as many institutions quickly launched SDD TJA programs there may be an increase in 30-day complications. We hypothesize that the indications for outpatient TJA may also have been expanded allowing patients with more comorbidities to undergo outpatient TJA when they previously would have been denied the option.
Methods
We retrospectively queried the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database for all patients undergoing primary elective TJA from January 1, 2018, to December 31, 2020. The ACS-NSQIP database is a nationally validated, risk-adjusted, outcomes based program that collects data from over 700 hospitals. ACS-NSQIP collects over 300 variables per patient including principal diagnosis, demographics, comorbidities, and surgical outcomes. Routine auditing provides assurance of high-quality data with a disagreement rate of less than 1.8%.16 Further details of ACS-NSQIP are available elsewhere.16,17 This study was deemed exempt by the University of Iowa IRB. No external funding was used in this study.
Patients were identified based on Current Procedural Terminology (CPT) codes 27447 and 27130. Only patients who underwent primary, elective TJA were included. ACS-NSQIP provides the length of stay (LOS) of each patient which they define as the LOS from admission to discharge with 0 being considered same day discharge. Patients with length of stay greater than 0, revision arthroplasty, arthroplasty for fracture or neoplasm, patients with unrelated concurrent CPT codes, and patients under 18 years of age were excluded.
Primary outcome was any complication at 30 days including, deep surgical site infection, wound disruption, pneumonia, unplanned intubation, pulmonary embolism, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke/CVA, cardiac arrest requiring CPR, myocardial infarction, transfusions, DVT requiring therapy, sepsis, septic shock, and death. Secondary outcomes included readmission and re-operation 30 days. All outcomes were assessed using standard definitions as defined by NSQIP.16
The ACS and CMS guidelines were set in place in March of 2020 which we used as our definition as the start of the COVID-19 pandemic impact on United States healthcare. Since, ACS-NSQIP does not report which month surgeries were performed in we classified all procedures taking place after the start of the second quarter to be within the COVID-19 era.
Participants who underwent THA or TKA between January 1, 2018 and March 1, 2020 were grouped into pre-COVID and between March 1, 2020 and December 31, 2020 were grouped into post-COVID categories. Characteristics were compared between pre- and post-COVID groups by surgical procedure and with all procedures combined. Continuous variables were described using mean ± standard deviation and compared between groups using independent t-tests. Frequencies (percentages) were used to describe categorical variables and between-group differences were evaluated using chi-square or exact tests. The frequency of postoperative complications and readmissions were evaluated using chi-square tests for all procedures combined and separately for THA and TKA procedures. Outcomes included any complication, respiratory complication and readmission. Analyses were completed using R Statistical Software (v4.1.2; R Core Team 2021) and Microsoft Excel (2021).
Results
A total of 14,438 patients underwent TKA, with 9,580 occurring pre-COVID and 4,858 post-COVID. There was no statistically significant difference between groups when assessing age, sex, BMI, history of smoking or diabetes. The pre-COVID group had more patients with history of severe COPD, (1.84% vs 1.38% p=0.034). The post-COVID group had significantly less patients with ASA score of 2 (62.9 vs 59.1, p<0.001) and significantly more patients with an ASA score of 3 (34.8 vs 38.1, p<0.001). More patients in the post-COVID group had procedures completed under general anesthesia (25.0% vs 28.3%), MAC/IV sedation (9.7% vs 17.4%), and regional anesthesia (0.63% vs 1.44%) as compared to pre-COVID group in which more spinal anesthesia was utilized (63.8% vs 52.0%, p<0.001 for all). (Table 1)
Table 1.
Total Knee Arthroplasty
| Characteristic | Pre- COVID | Post- COVID | Relative Difference | p-Value |
|---|---|---|---|---|
| N | 9580 | 4858 | ||
| Avg Age | 66.12 | 64.98 | -1.73% | 0.9263 |
| - Std Dev | 8.73 | 8.74 | ||
| % Female | 54.6% | 52.9% | -3.00% | 0.0621 |
| Race | ||||
| % Asian | 5.50% | 3.77% | -31.52% | 0.0000 |
| % Black | 6.57% | 8.13% | 23.84% | 0.0008 |
| % White | 80.1% | 75.8% | -5.34% | 0.0000 |
| % Hispanic | 10.87% | 9.45% | -13.05% | 0.0071 |
| Avg BMI | 31.35 | 31.99 | 2.05% | 0.9365 |
| - Std Dev | 5.49 | 5.89 | ||
| % Diabetic | 15.0% | 15.0% | -0.16% | 0.9688 |
| % Smoker | 5.51% | 5.91% | 7.19% | 0.3347 |
| % Dyspnea | 2.08% | 2.47% | 18.91% | 0.1398 |
| % Dependent due to health | 0.21% | 0.10% | -50.70% | 0.1061 |
| % With severe COPD history | 1.84% | 1.38% | -24.93% | 0.0343 |
| % Ascites | 0.00% | 0.02% | - | 0.3173 |
| % CHF | 0.04% | 0.14% | 245.10% | 0.0791 |
| % Hypertension | 55.3% | 56.8% | 2.87% | 0.0699 |
| % Acute renal failure | 0.00% | 0.02% | - | 0.3173 |
| % On dialysis | 0.11% | 0.08% | -28.29% | 0.5457 |
| % Steroid use | 2.37% | 2.70% | 13.80% | 0.2420 |
| % Weight loss | 0.17% | 0.06% | -63.02% | 0.0551 |
| % Bleeding disorders | 1.33% | 1.63% | 22.67% | 0.1638 |
| ASA Classification | ||||
| % No Disturb | 1.85% | 2.18% | 18.10% | 0.1823 |
| % Mild Disturb | 62.9% | 59.1% | -6.05% | 0.0000 |
| % Severe Disturb | 34.8% | 38.1% | 9.62% | 0.0001 |
| % Life Threat | 0.44% | 0.62% | 40.86% | 0.1719 |
| Principal anesthesia technique | ||||
| % Epidural | 0.68% | 0.66% | -2.92% | 0.8901 |
| % General | 25.0% | 28.3% | 13.47% | 0.0000 |
| % MAC / IV Sedation | 9.7% | 17.4% | 78.96% | 0.0000 |
| % Regional | 0.63% | 1.44% | 130.07% | 0.0000 |
| % Spinal | 63.8% | 52.0% | -18.62% | 0.0000 |
| Avg. Total Operation Time | 81.95 | 85.92 | 4.84% | 0.9141 |
| - Std Dev | 25.55 | 26.49 |
For TKA, there was no difference in rates of total complication between the pre-COVID (3.55%) and post-COVID (3.99%) groups (p=0.197). Rates of readmissions for were similar for the pre-COVID (1.75%) and post-COVID (1.98%) groups (p=0.381). There was no statistically significant difference in respiratory complications between the pre-COVID (0.41%) and post-COVID group (0.23%, p=0.03). (Table 2)
Table 2.
Total Knee Arthroplasty
| Any complication? | Pre- COVID | Post-COVID | ||
|---|---|---|---|---|
| No | 9240 | 4664 | ||
| Yes | 340 | 194 | ChiSq | 1.6643 |
| Rate | 3.55% | 3.99% | p-Value | 0.197 |
| Readmission? | Pre- COVID | Post-COVID | ||
| No | 9412 | 4762 | ||
| Yes | 168 | 96 | ChiSq | 0.76912 |
| Rate | 1.75% | 1.98% | p-Value | 0.3805 |
| Respiratory complication? | Pre- COVID | Post-COVID | ||
| No | 9541 | 4847 | ||
| Yes | 39 | 11 | ChiSq | 2.5477 |
| Rate | 0.41% | 0.23% | p-Value | 0.1105 |
A total of 12,265 patients underwent THA, with 7,680 occurring pre-COVID and 4,585 post-COVID. There was no statistically significant difference between groups when assessing age, sex, BMI, history of smoking or diabetes. The post-COVID group had more patients with history of severe COPD, (1.92% vs 1.30% p=0.034), patients with hypertension (45.9 vs. 42.3, p<0.01), and patients on dialysis (0.24% vs 0.07%, p=0.025). The post-COVID group has significantly more ASA 3 (30.0% vs. 26.5%, p<0.01) and ASA 4 (0.74% vs. 0.43%, p=0.03). (Table 3)
Table 3.
Total Hip Arthroplasty
| Characteristic | Pre- COVID | Post- COVID | Relative Difference | p-Value |
|---|---|---|---|---|
| N | 7680 | 4585 | ||
| Avg Age | 62.88 | 62.51 | -0.59% | 0.9801 |
| - Std Dev | 10.46 | 10.54 | ||
| % Female | 48.6% | 46.9% | -3.57% | 0.0624 |
| Race | ||||
| % Asian | 3.59% | 3.18% | -11.39% | 0.2219 |
| % Black | 5.92% | 7.59% | 28.11% | 0.0005 |
| % White | 76.3% | 73.1% | -4.19% | 0.0001 |
| % Hispanic | 4.64% | 4.71% | 1.63% | 0.8480 |
| Avg BMI | 29.15 | 29.56 | 1.39% | 0.9579 |
| - Std Dev | 5.25 | 5.57 | ||
| % Diabetic | 7.5% | 8.2% | 8.67% | 0.1956 |
| % Smoker | 8.24% | 9.23% | 11.93% | 0.0636 |
| % Dyspnea | 1.61% | 1.85% | 14.82% | 0.3301 |
| % Dependent due to health | 0.44% | 0.17% | -60.59% | 0.0060 |
| % With severe COPD history | 1.30% | 1.92% | 47.40% | 0.0102 |
| % Ascites | 0.00% | 0.00% | - | - |
| % CHF | 0.03% | 0.11% | 318.76% | 0.1111 |
| % Hypertension | 42.3% | 45.9% | 8.48% | 0.0001 |
| % Acute renal failure | 0.04% | 0.04% | 11.67% | 0.9050 |
| % On dialysis | 0.07% | 0.24% | 268.51% | 0.0248 |
| % Steroid use | 1.94% | 2.42% | 24.78% | 0.0817 |
| % Weight loss | 0.16% | 0.26% | 67.50% | 0.2301 |
| % Bleeding disorders | 0.68% | 0.83% | 22.41% | 0.3530 |
| ASA Classification | ||||
| % No Disturb | 5.95% | 4.93% | -17.16% | 0.0146 |
| % Mild Disturb | 67.2% | 64.3% | -4.23% | 0.0014 |
| % Severe Disturb | 26.5% | 30.0% | 13.43% | 0.0000 |
| % Life Threat | 0.43% | 0.74% | 72.58% | 0.0339 |
| Principal anesthesia technique | ||||
| % Epidural | 0.36% | 0.65% | 79.47% | 0.0351 |
| % General | 24.6% | 28.0% | 13.97% | 0.0000 |
| % MAC / IV Sedation | 10.6% | 18.7% | 77.21% | 0.0000 |
| % Regional | 0.44% | 1.81% | 308.90% | 0.0000 |
| % Spinal | 64.0% | 50.8% | -20.71% | 0.0000 |
| Avg. Total Operation Time | 81.29 | 85.16728 | 4.77% | 0.9191 |
| - Std Dev | 25.87 | 28.06 |
For THA, there was no difference in rates of total complication between the pre-COVID (3.25%) and post-COVID (3.49%) groups (p=0.52). Rates of readmissions for were similar for the pre-COVID (1.77%) and post-COVID (1.68%) groups (p=0.381). There was no statistically significant difference in respiratory complications between the pre-COVID (0.16%) and post-COVID group (0.07%, p=0.26). (Table 4)
Table 4.
Total Hip Arthroplasty
| Any complication? | Pre- COVID | Post-COVID | ||
|---|---|---|---|---|
| No | 7430 | 4425 | ||
| Yes | 250 | 160 | ChiSq | 0.41847 |
| Rate | 3.26% | 3.49% | p-Value | 0.5177 |
| Readmission? | Pre- COVID | Post-COVID | ||
| No | 7544 | 4509 | ||
| Yes | 136 | 76 | ChiSq | 0.15525 |
| Rate | 1.77% | 1.66% | p-Value | 0.6936 |
| Respiratory complication? | Pre- COVID | Post-COVID | ||
| No | 7668 | 4582 | ||
| Yes | 12 | 3 | ChiSq | 1.2664 |
| Rate | 0.16% | 0.07% | p-Value | 0.2604 |
Combined data including THA and TKA patients did not find a statistical difference in the rate of complications pre-COVID (3.42%) compared to post-COVID (3.75%, p=0.17). There was also no statistically significant difference in readmission rates (1.76% pre-COVID vs. 1.82% post-COVID, p=0.76.) There was a decrease in the rate of combined respiratory complications in the post-COVID group (0.15% vs. 0.30%, p=0.028. However, there was no significant difference when evaluating respiratory complications individually. (Tables 5, 6) (Figure 1)
Table 5.
Total Knee Arthroplasty + Total Hip Arthroplasty
| Characteristic | Pre- COVID | Post- COVID | Relative Difference | p-Value |
|---|---|---|---|---|
| N | 17260 | 9443 | ||
| Avg Age | 64.68 | 63.78 | -1.39% | 0.9477 |
| - Std Dev | 9.67 | 9.73 | ||
| % Female | 51.9% | 50.0% | -3.71% | 0.0026 |
| Race | ||||
| % Asian | 4.65% | 3.48% | -25.11% | 0.0000 |
| % Black | 6.28% | 7.87% | 25.28% | 0.0000 |
| % White | 78.4% | 74.5% | -4.98% | 0.0000 |
| % Hispanic | 8.09% | 7.15% | -11.68% | 0.0050 |
| Avg BMI | 30.37 | 30.81 | 1.44% | 0.9567 |
| - Std Dev | 5.49 | 5.86 | ||
| % Diabetic | 11.7% | 11.7% | 0.01% | 0.9972 |
| % Smoker | 6.73% | 7.52% | 11.78% | 0.0169 |
| % Dyspnea | 1.87% | 2.17% | 16.01% | 0.0998 |
| % Dependent due to health | 0.31% | 0.14% | -56.00% | 0.0022 |
| % With severe COPD history | 1.60% | 1.64% | 2.65% | 0.7936 |
| % Ascites | 0.00% | 0.01% | - | 0.3173 |
| % CHF | 0.03% | 0.13% | 265.56% | 0.0189 |
| % Hypertension | 49.5% | 51.5% | 4.11% | 0.0015 |
| % Acute renal failure | 0.02% | 0.03% | 82.78% | 0.4913 |
| % On dialysis | 0.09% | 0.16% | 71.36% | 0.1600 |
| % Steroid use | 2.18% | 2.56% | 17.64% | 0.0510 |
| % Weight loss | 0.16% | 0.16% | -2.08% | 0.9474 |
| % Bleeding disorders | 1.04% | 1.24% | 19.47% | 0.1419 |
| ASA Classification | ||||
| % No Disturb | 3.67% | 3.52% | -4.29% | 0.5076 |
| % Mild Disturb | 64.8% | 61.6% | -4.88% | 0.0000 |
| % Severe Disturb | 31.1% | 34.2% | 10.00% | 0.0000 |
| % Life Threat | 0.43% | 0.68% | 55.97% | 0.0132 |
| Principal anesthesia technique | ||||
| % Epidural | 0.54% | 0.66% | 21.85% | 0.2393 |
| % General | 24.8% | 28.2% | 13.65% | 0.0000 |
| % MAC / IV Sedation | 10.1% | 18.0% | 78.69% | 0.0000 |
| % Regional | 0.54% | 1.62% | 197.51% | 0.0000 |
| % Spinal | 63.9% | 51.4% | -19.63% | 0.0000 |
| Avg. Total Operation Time | 81.66 | 85.56 | 4.78% | 0.9171 |
| - Std Dev | 25.69 | 27.27 |
Table 6.
Total Knee Arthroplasty + Total Hip Arthroplasty
| Any complication? | Pre- COVID | Post-COVID | ||
|---|---|---|---|---|
| No | 16670 | 9089 | ||
| Yes | 590 | 354 | ChiSq | 1.8593 |
| Rate | 3.42% | 3.75% | p-Value | 0.1727 |
| Readmission? | Pre- COVID | Post-COVID | ||
| No | 16956 | 9271 | ||
| Yes | 304 | 172 | ChiSq | 0.094142 |
| Rate | 1.76% | 1.82% | p-Value | 0.759 |
| Respiratory complication? | Pre- COVID | Post-COVID | ||
| No | 17209 | 9429 | ||
| Yes | 51 | 14 | ChiSq | 4.8587 |
| Rate | 0.30% | 0.15% | p-Value | 0.02751 |
Figure 1.
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Discussion
The COVID-19 pandemic led to unprecedented changes to the healthcare system and had a profound effect on hip and knee arthroplasty. The guidelines recommended by the ACS and CMS lead to restrictions on which procedures could be completed during the beginning of the pandemic era. As a results, many institutions quickly developed programs for same-day discharge. The goal of this study was to evaluate if rapid expansion of same day discharge TJA during the COVID-19 pandemic increased early complications.
Prior literature has evaluated the effects of anesthesia and surgery on the immune system and describe a transient immunosuppression following procedures.18-20 Quinlan et al. performed a large data base study evaluating patient susceptibility to viral illness following TJA. They concluded that there was no increased incidence of influenza in patients who recently underwent TJA.21 Our study revealed that there was no increase in respiratory complications during the post-COVID era when evaluating TKA and THA separately. There was a decrease in respiratory complications when combining THA and TKA data.
Courtney et al. completed a NSQIP database study evaluating the 30-day complication rate, readmission rate, and reoperation rates for patients undergoing SDD TJA. They found that outpatient TJA alone was not a risk factor for readmission or reoperation and was a negative risk factor for complications. They did report that patients over 70 years of age, those with malnutrition, cardiac history, smoking history, or diabetes mellitus are at higher risk for readmission and complications following TJA.22 Our study found no difference in readmission, reoperation, or overall complication rates between the pre-COVID and post-COVID groups.
The limitations to this study are similar to other large database studies. First, we are unable to define an exact timepoint at which institutions prohibited or reduced the number of TJA performed and likewise we are unable to define a timepoint when SDD TJA was allowed as it was variable throughout the country. While we are not able to define an exact timeline the ACS and CMS made their recommendations concurrently and thus, we assume the majority of institutions followed these guidelines at approximately the same time. Second, we cannot separate institutions that have had established SDD programs from those that started SDD programs during the pandemic. Theoretically, institutions that began SDD during the pandemic could have an increased rate of readmission, reoperation or 30-day and 90-day complication which could be outweighed by practices with established SDD programs. Since this is a large database study, any miscoding or misbilling could lead to potential sources of error that could affect the quality of the study.
Conclusion
While there has been increased interest in same day discharge following total joint arthroplasty for several years, the COVID-19 pandemic caused institutions to rapidly integrate SDD TJA programs. The goal of this study was to evaluate early complications of SDD TJA in the pre-COVID and post-COVID era. We did not find any increase in the readmission, reoperation, and overall complication rates between groups. There was a decrease in respiratory complications when combining TKA and THA data which could reflect an increased diligence in pre-operative respiratory optimization.
References
- 1.Sloan M, Premkumar A, Sheth NP. Projected volume of primary total joint arthroplasty in the US, 2014 to 2030. JBJS. 2018; 100(17):1455–1460. doi: 10.2106/JBJS.17.01617. [DOI] [PubMed] [Google Scholar]
- 2.Sarac NJ, Sarac BA, Schoenbrunner AR, et al. A Review of State Guidelines for Elective Orthopaedic Procedures During the COVID-19 Outbreak. J Bone Joint Surg Am. 2020;102(11):942–945. doi: 10.2106/JBJS.20.00510. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Bedard NA, Elkins JM, Brown TS. Effect of COVID-19 on Hip and Knee Arthroplasty Surgical Volume in the United States. J Arthroplasty. 2020;35(7S):S45–S48. doi: 10.1016/j.arth.2020.04.060. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Mitchell BA, Cleary LM, Samuel LT, et al. An Increase in Same-day Discharge After Total Joint Arthroplasty During the COVID-19 Pandemic Does Not Influence Patient Outcomes: A Retrospective Cohort Analysis. Arthroplast Today. 2023;20:101115. doi: 10.1016/j.artd.2023.101115. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Debbi EM, Mosich GM, Bendich I, Kapadia M, Ast MP, Westrich GH. Same-Day Discharge Total Hip and Knee Arthroplasty: Trends, Complications, and Readmission Rates. J Arthroplasty. 2022;37(3):444–448. doi: 10.1016/j.arth.2021.11.023. e441. [DOI] [PubMed] [Google Scholar]
- 6.Mabrey JD, Toohey JS, Armstrong DA, Lavery L, Wammack LA. Clinical pathway management of total knee arthroplasty. Clinical Orthopaedics and Related Research®. 1997;345:125–133. [PubMed] [Google Scholar]
- 7.Adelani MA, Barrack RL. Patient perceptions of the safety of outpatient total knee arthroplasty. The Journal of Arthroplasty. 2019;34(3):462–464. doi: 10.1016/j.arth.2018.11.030. [DOI] [PubMed] [Google Scholar]
- 8.Tingle C, Berger R, Bolognesi M, Della Valle C, Lombardi Jr A, Scuderi G. Same-day outpatient TJR gains popularity, but careful considerations must be made. Orthopedics Today. 2015;35(8):10–11. [Google Scholar]
- 9.Berger RA, Kusuma SK, Sanders SA, Thill ES, Sporer SM. The feasibility and perioperative complications of outpatient knee arthroplasty. Clinical Orthopaedics and Related Research®. 2009;467:1443–1449. doi: 10.1007/s11999-009-0736-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Crawford DC, Li CS, Sprague S, Bhandari M. Clinical and cost implications of inpatient versus outpatient orthopedic surgeries: a systematic review of the published literature. Orthopedic reviews. 2015;7(4) doi: 10.4081/or.2015.6177. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Kort NP, Bemelmans YF, Schotanus MG. Outpatient surgery for unicompartmental knee arthroplasty is effective and safe. Knee Surgery, Sports Traumatology, Arthroscopy. 2017;25:2659–2667. doi: 10.1007/s00167-015-3680-y. [DOI] [PubMed] [Google Scholar]
- 12.Giuliano KK, Baker D, Quinn B. The epidemiology of nonventilator hospital-acquired pneumonia in the United States. American journal of infection control. 2018;46(3):322–327. doi: 10.1016/j.ajic.2017.09.005. [DOI] [PubMed] [Google Scholar]
- 13.Berend K, Lombardi A, Berend M, Adams J, Morris M. The outpatient total hip arthroplasty: a paradigm change. The Bone & Joint Journal. 2018;100(1_Supple_A):31–35. doi: 10.1302/0301-620X.100B1.BJJ-2017-0514.R1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Meneghini RM, Ziemba-Davis M, Ishmael MK, Kuzma AL, Caccavallo P. Safe selection of outpatient joint arthroplasty patients with medical risk stratification: the “outpatient arthroplasty risk assessment score”. The Journal of Arthroplasty. 2017;32(8):2325–2331. doi: 10.1016/j.arth.2017.03.004. [DOI] [PubMed] [Google Scholar]
- 15.Kandarian B, Indelli PF, Sinha S, et al. Implementation of the IPACK (Infiltration between the Popliteal Artery and Capsule of the Knee) block into a multimodal analgesic pathway for total knee replacement. Korean journal of anesthesiology. 2019;72(3):238–244. doi: 10.4097/kja.d.18.00346. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Program ACoSNSQI. User guide for the 2011 participant use data file. In: American College of Surgeons Chicago; 2012. [Google Scholar]
- 17.Khuri SF. The NSQIP: a new frontier in surgery. Surgery. 2005;138(5):837–843. doi: 10.1016/j.surg.2005.08.016. [DOI] [PubMed] [Google Scholar]
- 18.Plein LM, Rittner HL. Opioids and the immune system - friend or foe. Br J Pharmacol. 2018;175(14):2717–2725. doi: 10.1111/bph.13750. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Procopio MA, Rassias AJ, DeLeo JA, Pahl J, Hildebrandt L, Yeager MP. The in vivo effects of general and epidural anesthesia on human immune function. Anesth Analg. 2001;93(2):460–465. doi: 10.1097/00000539-200108000-00044. 464th contents page. [DOI] [PubMed] [Google Scholar]
- 20.Salo M. Effects of anaesthesia and surgery on the immune response. Acta Anaesthesiol Scand. 1992;36(3):201–220. doi: 10.1111/j.1399-6576.1992.tb03452.x. [DOI] [PubMed] [Google Scholar]
- 21.Quinlan ND, Werner BC, Novicoff WM, Browne JA. Are Patients More Susceptible to Viral Illness Immediately Following Hip and Knee Arthroplasty? An Analysis of Influenza Diagnoses Using Multiple Administrative Databases. J Arthroplasty. 2021;36(4):1251–1256. doi: 10.1016/j.arth.2020.10.045. e1255. [DOI] [PubMed] [Google Scholar]
- 22.Courtney PM, Boniello AJ, Berger RA. Complications Following Outpatient Total Joint Arthroplasty: An Analysis of a National Database. J Arthroplasty. 2017;32(5):1426–1430. doi: 10.1016/j.arth.2016.11.055. [DOI] [PubMed] [Google Scholar]