Home Alone Joint Surgery Patients Do Better?

“Patients Living Alone Can Be Safely Discharged Directly Home After Total Joint Arthroplasty: A Prospective Cohort Study,” is published in the January 17, 2018 edition of The Journal of Bone and Joint Surgery.

Co-author Andrew Fleischman, M.D., with the Rothman Institute in Philadelphia, commented to OTW, “There has been a growing interest in value-based care across orthopedics. While certain costly interventions have withstood based on their assumption of efficacy, it is up to us to identify which services actually improve outcomes and are cost effective.”

The authors wrote, “In this prospective observational study, 910 consecutive patients underwent primary, unilateral total hip arthroplasty or total knee arthroplasty at a single institution from November 2015 to June 2016. Patients who underwent simultaneous, bilateral, or revision total joint arthroplasty were excluded…”

“A nurse navigator was assigned to each patient to provide preoperative education and discharge planning, as well as postoperative surveillance to identify unplanned clinical events and complications.”

“All patients undergoing total hip arthroplasty received an uncemented acetabular component and uncemented proximally porous-coated femoral stem through either a modified Harding approach (238 patients) or a modified Smith-Petersen approach (279 patients).”

“All patients undergoing total knee arthroplasty received a cemented posterior-stabilized or cruciate-retaining total knee replacement through a medial parapatellar approach. Patients received standardized multimodal pain management and antibiotics and continued daily inpatient physiotherapy and occupational therapy until discharge.”

“Patients with support at home relinquished assistive walking devices more quickly, although the median was 3 to 4 weeks for both the total hip arthroplasty group and the total knee arthroplasty group despite home living status.”

“A higher proportion of patients living alone had no expectation of walking independently and planned to continue using a cane or walker indefinitely compared with the control group.”

“Conversely, patients living alone tended to drive sooner than their counterparts, although the median was also 3 to 4 weeks for both the total hip arthroplasty group and the total knee arthroplasty group.”

“A higher proportion of patients living alone were not drivers at 12.2% compared with 3.3% for the control group.”

“Finally, there was no difference in return to work; the median time back to work was 3 to 4 weeks after total hip arthroplasty and 7 to 8 weeks after total knee arthroplasty for both groups. Also, there was no difference in the proportion of retirees at 47.0% for patients living alone compared with 43.4% for the control group.”

Dr. Fleischman told OTW, “The take home message is that patients who live by themselves can have a great experience and outcome when recovering from elective total joint surgery at home on their own.”

“Surgeons should help guide patients and use their judgment to come up with a postoperative plan that by themselves and their patients are comfortable and confident in. Managing expectations is key, and patients should be coached to have optimistic expectations. We no longer operate under the ‘sick’ model.”