What Happens After They Go Home? Early Patient Challenges After Same-Day Discharge Total Hip Arthroplasty

Abstract

Background

Same-day discharge (SDD) total hip arthroplasty (THA) offers benefits in cost, recovery time, and patient satisfaction. While SDD THA has demonstrated comparable safety and outcomes to inpatient procedures, there is limited literature on the patient experience during the first 24 hours postdischarge. This study explores patients' self-reported challenges in the immediate postoperative period following SDD.

Methods

A survey was administered to a consecutive sample of 616 THA patients at a single high-volume institution between September 11, 2024, and June 10, 2025. The survey asked patients to identify the most significant challenge or concern encountered within the first 24 hours after discharge. Open-ended responses were categorized by 2 independent reviewers. Where appropriate and when subcategories were clearly identifiable, further breakdown of responses was performed. Any discrepancies were resolved by a third independent reviewer.

Results

Analysis of 589 valid responses revealed 6 broad categories of challenges. The most reported challenges were pain (29.7%) and mobility (27.5%). A significant subcategory of mobility issues specifically referenced getting in or out of bed (9.2% of all responses). Other concerns included varying medical symptoms (13.6%), logistical challenges (8.3%) including medication management, sleep issues (6.3%), and mental/emotional challenges (3.2%). No challenges were reported by 11.4% of patients.

Conclusions

This study identifies the most common challenges faced by SDD THA patients, with pain and mobility concerns being the most frequently reported issues. These findings highlight the importance of tailored preoperative education and postoperative support to address early recovery difficulties and improve patient outcomes in outpatient THA settings.

Introduction

The transition from inpatient to outpatient total joint arthroplasty has accelerated in recent years due to advancements in multidisciplinary care coordination, discharge planning, and standardized perioperative care protocols [[1], [2], [3], [4]]. Total hip arthroplasty (THA), which was traditionally managed in the inpatient setting, is now increasingly performed on an outpatient basis, with same-day discharge (SDD) generally understood to be a safe and feasible option for appropriately selected patients [[5], [6], [7], [8], [9]]. This shift is supported by mounting evidence suggesting that, when performed under optimized protocols, outpatient total joint arthroplasty can achieve similar complication and readmission rates as inpatient procedures while offering potential benefits such as cost savings, faster recovery, and improved patient satisfaction [[10], [11], [12], [13], [14]].

Despite the growing adoption of outpatient THA, most investigations to date have evaluated safety, outcomes, and feasibility primarily from the perspective of the surgical team or healthcare system looking at metrics such as postoperative complication, readmission, and reoperation. The first 24 hours following THA with SDD are a critical period in the patient experience, as the responsibility for recovery rapidly transitions from the hospital to the patient and their support system. With appropriate patient selection and perioperative optimization, readmissions and complications within the first 24 hours are rare, supporting the safety of SDD protocols [11,15]. However, far fewer studies have focused on the patient experience during the critical first 24 hours after discharge. The immediate postoperative period presents unique physical, emotional, and logistical challenges, especially for SDD patients who must navigate pain control, mobility, medication management, and wound care without extended hospital support.

The purpose of this study was to systematically evaluate and categorize the self-reported challenges and concerns encountered by SDD THA patients during the first 24 hours after surgery. By analyzing these responses and stratifying them across demographic subgroups, we aim to identify the most common and impactful postoperative challenges faced by this population and inform future efforts to improve patient-centered care in the outpatient arthroplasty setting. Specifically, this paper seeks to (1) quantify the types and frequencies of challenges reported and (2) determine whether patient characteristics such as age, gender, or marital status are associated with differences in reported challenges.

Material and methods

An Institutional Review Board determined that this study met the criteria for exemption prior to the start of the investigation. This study aimed to identify the most significant challenges experienced by patients who underwent THA with SDD during the first 24 hours postoperatively. A single open-ended survey question was used to assess patient-reported challenges:

“What was the single most significant challenge or concern you experienced during the first 24 hours after you were discharged following your recent joint replacement surgery? (Please enter your response in the box below).”

The survey was administered to all SDD THA patients treated at a single high-volume institution between September 2024 and June 2025 (616 patients). The survey was distributed via email and/or text message 2 days postoperatively. The questionnaire remained active for 7 days following the initial notification, expiring on postoperative day 9. Responses were received between postoperative days 2 and 8, with the majority of patients (84%) completing the survey on postoperative day 2. A total of 596 patients responded. The sole exclusion criterion for the final analysis was failure to achieve discharge on the day of surgery. Accordingly, 7 patients who could not be discharged from the hospital outpatient unit on the day of surgery were excluded, resulting in a final analytic cohort of 589 patients. Demographic data, including age, sex, and marital status, were collected for analysis.

The outpatient THA discharge protocol used in this study was designed to support safe SDD through comprehensive perioperative planning and patient education. Eligibility for the outpatient pathway was determined based on medical stability, functional status, and the availability of home support. All patients underwent preoperative education that included medication planning, assistive device preparation, recovery expectations, and the avoidance of extreme hip ranges of motion during the early postoperative period. Education was given through online teaching/education modules as well as booklets given in the clinic. A designated caregiver or “coach” was required to be present at home following surgery. On the day of surgery, patients were admitted on schedule and received multimodal pain control, including spinal anesthesia with short-acting agents when possible alongside periarticular injections. The anterior surgical approach was used in the large majority of cases (94%). Discharge criteria included adequate pain control with oral medication, ambulation with assistance, tolerating oral intake, stable vital signs, and the ability to void spontaneously. Patients were discharged with detailed instructions and access to online educational tools and direct communication pathways to the care team. The protocol avoided routine use of Foley catheters, drains, and intravenous narcotics to reduce recovery barriers and improve safety [1].

Two independent reviewers analyzed the open-ended responses and identified appropriate categories of response. Any discrepancies in categorization were resolved by a third independent reviewer. To assess inter-rater reliability, Cohen's kappa coefficient was calculated. The resulting kappa of 0.96 indicated almost perfect agreement between the 2 reviewers. If a respondent listed multiple challenges without explicitly identifying one as the most significant or foundational issue, the challenge listed first was counted. If a response clearly indicated a dominant issue that led to other difficulties (eg, “pain was terrible, and it made it hard to walk”), that primary issue was classified. The "no challenges" response reflected only explicit patient statements to that effect; no blank or nonresponses were included in this category or in the analysis. The frequency of responses was calculated for each challenge category. We identified 6 principal challenges or concerns. The final categories used for classification were (1) pain, (2) mobility, (3) sleep, (4) medical complications (nausea, vomiting, constipation, urinary frequency, etc.), (5) logistical concerns (medication management, transportation, communication, etc.), and (6) mental/emotional concerns. Demographic variables including age, gender, and marital status were analyzed using Kruskal–Wallis or Chi-square tests for categorical comparisons. A P value of <.05 was considered statistically significant.

Results

Patient ages ranged from 15 to 95 years, with a mean age of 67.0 years. Of the 589 patients, 346 (58.7%) were women and 342 (58.1%) were married. Marital status was unreported for 122 patients (20.7%) and recorded as unknown for an additional 11 patients (1.9%), resulting in unavailable marital-status data for 133 patients (22.6% of the cohort). Physical pain (175 cases; 29.7%) and mobility limitations (162; 27.5%) were the most commonly reported challenges. Within the mobility category, subcategories of moving in/out of bed (54 patients/9.17% of all cases), bathroom mobility (12 patients/2.04%), and stiffness (12 patients/2.04% of all cases) were also identified. The third highest category was medical symptoms, which included nausea, vomiting, constipation, urinary frequency, urinary retention, syncope, hypotension, fatigue/drowsiness, headaches, pruritus, rashes, and numbness. Patients who listed swelling as their biggest issue were also included in the medical category. Swelling alone represented 11 cases (1.87%). Logistical issues were the fourth highest category. This included patient concerns with medication management, communication with the medical team, and lifestyle adjustments. The other major categories were sleep disturbances (6.28%) and emotional concerns (3.23%) such as fear, anxiety, or worries about potential challenges. Sixty-seven patients (11.38%) reported no challenges (Table 1).

Table 1.

Number of patients reporting a challenge by category.

Challenge classification	Subcategory	Number of patients
Pain		175 (29.7%)
Mobility		162 (27.5%)
	Getting in or out of bed	54 (9.2%)
	Stiffness	12 (2.0%)
	Accessing the bathroom	12 (2.0%)
Medical		80 (13.6%)
	Swelling	11 (1.87%)
Logistical		49 (8.3%)
Sleep		37 (6.3%)
Mental/emotional		19 (3.2%)
No challenges		67 (11.38%)

Data are presented as n (%).

No significant differences in age were observed across challenge categories (Kruskal–Wallis, P > .05) (Table 2). No significant differences were observed across challenge categories when comparing gender or marital status (Chi-square, P > .05) (Table 3 and Table 4).

Table 2.

Challenge categorization by age at surgery.

Challenge	Patients	Age
Pain	175	66.43 ± 10.197 [15, 95]
Mobility/stiffness	162	66.93 ± 9.104 [43, 86]
Medical	80	66.14 ± 11.162 [36, 94]
Logistical	49	67.63 ± 11.013 [18, 87]
Emotional/mental	19	67.79 ± 10.025 [52, 83]
Sleep	37	67.19 ± 9.067 [44, 85]
None	67	68.69 ± 7.180 [53, 84]
Total	589	66.97 ± 9.725 [15, 95]

Data are presented as mean ± standard deviation [range].

Table 3.

Challenge categorization by gender.

Challenge	Women	Men
Pain	106 (31%)	69 (28%)
Mobility/stiffness	93 (27%)	69 (28%)
Medical	50 (14%)	30 (12%)
Logistical	30 (9%)	19 (8%)
Emotional/mental	13 (4%)	6 (2%)
Sleep	20 (6%)	17 (7%)
None	34 (10%)	33 (14%)

Data are presented as n (%).

P = .705, Chi-square.

Table 4.

Challenge categorization by marital status.

Challenge	Married/partnered	Previously married	Never married	Unknown/unreported
Pain	94 (27%)	19 (30%)	21 (44%)	41 (31%)
Mobility/stiffness	101 (29%)	19 (30%)	7 (15%)	35 (26%)
Medical	52 (15%)	5 (8%)	7 (15%)	16 (12%)
Logistical	24 (7%)	9 (14%)	4 (8%)	12 (9%)
Emotional/mental	8 (2%)	3 (5%)	1 (2%)	7 (5%)
Sleep	24 (7%)	4 (6%)	3 (6%)	6 (5%)
None	41 (12%)	5 (8%)	5 (10%)	16 (12%)
Total	344	64	48	133

Data are presented as n (%).

P = .440, Chi-square.

Discussion

This study represents a novel contribution to the literature by directly surveying patients who underwent SDD after THA, capturing their perceptions of the most significant challenges during the first postoperative day. The most frequently cited concerns included pain, mobility limitations, sleep disturbances, medical symptoms, and logistical issues such as medication management and lifestyle adjustments. These findings reinforce the importance of adequately preparing patients not just clinically, but also functionally and emotionally, for the demands of same-day recovery.

Effective pain control after THA, while minimizing narcotic use, is a critical but challenging aspect of postoperative care. Surgeons must provide adequate analgesia to enable early mobilization and functional recovery, yet excessive reliance on opioids increases the risk of dizziness, nausea, vomiting, constipation, and even postoperative delirium, all of which can compromise safety and delay rehabilitation. This is especially concerning in older adults, where opioid-related cognitive changes can precipitate falls or impair confidence with early ambulation. Achieving this balance requires a thoughtful, multimodal pain-management strategy that incorporates regional anesthesia, nonopioid medications, and careful titration of narcotics, allowing patients to stay comfortable enough to participate in therapy without exposing them to unnecessary medication-related side effects.

Our findings are consistent with prior literature that underscores the importance of pain and logistics in the early postoperative period. Liu et al. [16] explored patient experiences with subacute pain management after TKA or THA and found that patients' ability to manage pain was influenced not only by medication access but also by preoperative expectations, health system support, and psychosocial factors such as motivation and family support. Similarly, Adelani and Barrack et al. [17] and Meneghini et al. [18] have showed that many patients undergoing joint arthroplasty were either unaware of outpatient options or uncertain about their comfort with SDD, emphasizing a widespread knowledge gap and need for targeted education. The qualitative study by Scott et al. [19] also identified significant stakeholder concerns, particularly around patient safety, communication, and managing expectations in the early outpatient recovery phase.

Prior qualitative studies suggest patients often feel unprepared for self-management postdischarge, particularly in areas such as pain control, sleep, and navigating their home environment with limited mobility [[20], [21], [22]]. While many outpatient pathways are designed with safety and cost-efficiency in mind, they may underappreciate the psychosocial and functional demands placed on patients during the transition home. For decades, our institution has provided a robust preoperative education program that includes early postoperative care information highlighted by videos, booklets, and preoperative visits. Despite considerable educational efforts from our team, the results demonstrate nearly 10% of patients still reported avoidable logistical challenges following their outpatient experience. The high frequency of concerns related to pain and mobility further underscores the importance of robust preoperative education, anticipatory pain guidance, and accessible postoperative support. Preoperative patient education should explicitly address realistic expectations for pain in the first 24 hours, including anticipated discomfort as regional anesthesia wears off. Specific guidance on positioning, assistive device use, and safe bed transfers should also be provided. Educational materials (eg, videos, written guides) should highlight the "getting in and out of bed" task, which was the most commonly cited mobility subchallenge (9.2% of all responses).

Importantly, this study also emphasizes the value of open-ended survey tools in understanding patient perspectives. Unlike multiple-choice or scaled assessments, free-text responses allow patients to identify what they perceive as most impactful, sometimes revealing concerns that clinicians may not anticipate. Our analysis demonstrates that even in a well-structured outpatient THA program, patients face a broad range of early recovery difficulties that merit continued attention.

This study is subject to several limitations. First, it was conducted at a single institution with a specific outpatient pathway, which may limit generalizability to settings with different surgical teams, protocols, or discharge resources. Second, although the response rate was robust, nonresponse bias remains a possibility; patients who experienced either extreme satisfaction or significant difficulty may have been more likely to respond. The analysis of marital status was additionally limited by the relatively high proportion of unavailable data, as marital status was unreported or unknown for 133 patients (22.6% of the cohort). This reduced the effective sample size available for subgroup comparisons and may have limited the statistical power to detect an association between marital status and the type of postoperative challenge reported. Moreover, if marital status data were not missing at random, the observed association may have been subject to bias. Therefore, the absence of a statistically significant association should be interpreted cautiously and should not be considered evidence that marital status or social support has no influence on the immediate postoperative experience. Third, because survey responses could be submitted over several postoperative days, some participants may have been susceptible to recall bias or temporal reinterpretation of symptoms experienced during the first 24 hours after surgery. However, the potential influence of this limitation was likely modest, as 84% of respondents completed the survey on postoperative day 2, in close temporal proximity to the period being assessed. Fourth, while our open-ended approach offers rich qualitative data, it inherently relies on subjective interpretation and may miss issues unmentioned by patients. Finally, this study does not link reported challenges to clinical outcomes such as readmissions or complications, which could provide additional context for future investigations.

Finally, the reported challenges were not linked to subsequent clinical utilization or recovery outcomes, including unscheduled postoperative telephone calls, emergency department visits, readmissions, delayed progression in physical therapy, or requests for additional pain-medication prescriptions. Consequently, the clinical significance of the individual challenge categories could not be determined. Future studies should prospectively evaluate whether specific challenges reported during the first 24 hours after discharge are associated with outcomes such as increased postoperative support needs, unplanned clinical contact, delayed functional recovery, or additional analgesic requirements. Such analyses may help identify patients who would benefit from targeted education, earlier postoperative follow-up, or enhanced support following SDD.

Conclusions

As SDD THA becomes increasingly routine, understanding patients' early recovery experience is essential for optimizing care. This study identifies the most commonly reported challenges during the first 24 hours after discharge, with pain and mobility emerging as key areas of concern. No statistically significant associations were detected between the type of challenge reported and patient age, sex, or marital status; however, the marital-status analysis was limited by the proportion of patients with unavailable data. These findings can inform targeted preoperative education, discharge planning, and follow-up protocols to better support patients and improve the safety and satisfaction of outpatient joint arthroplasty.

CRediT authorship contribution statement

Christopher M. Jaicks: Writing – review & editing, Writing – original draft, Visualization, Methodology, Investigation, Formal analysis. Jacqueline R. Ray: Writing – review & editing, Writing – original draft, Visualization, Methodology, Formal analysis. Jad Ismail: Formal analysis, Methodology, Visualization, Writing – original draft, Writing – review & editing. Tobenna N. Nwankwo: Writing – review & editing, Writing – original draft, Formal analysis, Conceptualization. Henry Ho: Writing – review & editing, Investigation, Formal analysis, Data curation. Robert A. Sershon: Writing – review & editing, Writing – original draft, Supervision, Investigation, Conceptualization.

Conflicts of interest

Robert A. Sershon receives royalties from Zimmer; is a paid employee for a company or supplier 2ndMD and Zimmer; and receives research support from a company or supplier as a Principal Investigator from Zimmer. All other authors declare no potential conflicts of interest.

For full disclosure statements refer to https://doi.org/10.1016/j.artd.2026.102167.