Done Cautiously, Early Discharge After Revision TJA Works Well

Should patients be discharged early after revision total joint arthroplasty (TJA)? That remains an unanswered question, say researchers who compared 90-day outcomes in patients undergoing aseptic revision TJA discharged the same or next day to those discharged two or three days after surgery.

Their research, “Safety of Same and Next Day Discharge Following Revision Hip and Knee Arthroplasty Using Modern Perioperative Protocols,” was published in the July 29, 2020 edition of The Journal of Arthroplasty.

Co-author Leonard Buller, M.D., assistant professor at the Indiana University School of Medicine, explained to the genesis of the study to OTW, “For a number of years, our group has worked to develop and publish on standardized perioperative care protocols using a multidisciplinary team to enable rapid recovery following primary total joint arthroplasty (TJA). When successfully implemented, rapid recovery TJA is a safe, cost-efficient, and patient-friendly approach that results in improved patient functional outcomes and no increase in hospital readmission or complication rates.”

“As our patients and the institution became more accustomed to rapid recovery primary TJA, a natural evolution was the implementation of these perioperative protocols to our revision patient population. With the COVID-19 pandemic bringing to light our limited healthcare resources nationally and highlighting our need to preserve inpatient hospital equipment and beds for patients who are stricken with severe medical illness, we sought to objectively study our rapid recovery revision patient population to determine its safety.”

The researchers examined 530 aseptic revision TJAs, with the groups matched as closely as possible on several variables. All patients were optimized using the latest perioperative protocols, which included a preoperative risk assessment and medical clearance by a hip and knee arthroplasty specialist. Also preoperatively, each surgery was addressed at a care conference attended by members of the multidisciplinary team. Additionally, patients and family members received comprehensive clinic-based education and attended a hospital-based joint replacement class.

“Despite the increased surgical complexity associated with revision TJA and the associated physical stress on patients,” said Dr. Buller to OTW, “modern perioperative protocols and appropriate patient selection allowed early discharge (within one day after surgery) after aseptic revision TJA without an increase in 90-day readmissions or emergency department visits compared to a group of patients discharged later.”

“In the setting of the COVID-19 pandemic with the potential for hospital inpatient capacity to remain limited, this research emphasizes that select revision TJA patients may discharge home the same or next day without an increased risk of early complications, readmissions or emergency department visits. This should preserve hospital beds and resources for more critical medically related illness and not risk exposing our high risk revision population to potential nosocomial complications.”

The word of the day? Meticulous

“Early discharge following revision TJA is not for everyone. A surgeon seeking to translate an early discharge primary TJA program to a revision TJA program should do so cautiously and with a well-coordinated, multi-disciplinary team-based approach. The results of this study should not be interpreted to mean every aseptic revision TJA should be discharged early. Instead, patients should be discharged when they are medically and socially safe for discharge, but through successful optimization and team based postoperative care, appropriately selected patients may be discharged early without an increase in complications.”