• Fast-track
• Hip arthroplasty
• Knee arthroplasty
• Outpatient surgery
• Postoperative pain
• Postoperative pain management

• Arthroplasty
• Inpatient
• Outpatient

• Humans
• Cost-Benefit Analysis
• Arthroplasty, Replacement, Hip/economics
• Arthroplasty, Replacement, Hip/adverse effects
• Patient Readmission/statistics & numerical data
• Patient Readmission/economics
• Arthroplasty, Replacement, Knee/economics
• Arthroplasty, Replacement, Knee/adverse effects
• Ambulatory Surgical Procedures/economics
• Ambulatory Surgical Procedures/adverse effects
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Postoperative Complications/economics
• Inpatients/statistics & numerical data
• Treatment Outcome
• Outpatients

• Humans
• Arthroplasty, Replacement, Knee
• Female
• Male
• Patient Discharge
• Aged
• Middle Aged
• Ambulatory Surgical Procedures
• Retrospective Studies
• Patient Reported Outcome Measures

• Ambulatoria
• Arthroplasty
• Artoplastia
• Cadera
• Hip
• No income
• Outpatient
• Prótesis total cadera
• Sin ingreso
• Total hip prosthesis

• Knee joint replacement
• Prototype
• System
• TKR
• Telerehabilitation
• Total knee replacement
• Usability

• Humans
• Arthroplasty, Replacement, Knee/rehabilitation
• Exercise Therapy/methods
• Telerehabilitation
• Iran
• Home Care Services
• Male
• Female
• Patient Education as Topic/methods
• Treatment Outcome
• Osteoarthritis, Knee/surgery
• Osteoarthritis, Knee/rehabilitation
• Knee Joint/surgery
• Knee Joint/physiopathology

• Humans
• Arthroplasty, Replacement, Knee/methods
• Arthroplasty, Replacement, Knee/adverse effects
• Postoperative Nausea and Vomiting/prevention & control
• Postoperative Nausea and Vomiting/epidemiology
• Length of Stay/statistics & numerical data
• Pain, Postoperative/drug therapy
• Adrenal Cortex Hormones/administration & dosage
• Adrenal Cortex Hormones/therapeutic use
• Perioperative Care/methods

• Humans
• Ambulatory Surgical Procedures
• Arthroplasty, Replacement, Hip/methods
• Arthroplasty, Replacement, Knee/methods
• Lower Extremity
• Patient Discharge
• Registries

• NSQIP
• age
• complications
• database
• reoperation
• total knee arthroplasty

• Humans
• Arthroplasty, Replacement, Knee
• Outpatients
• Arthroplasty, Replacement, Hip/adverse effects
• Postoperative Complications

• Day surgery
• ERAS
• Outcome
• Total knee arthroplasty

• Humans
• Arthroplasty, Replacement, Knee/adverse effects
• Ambulatory Surgical Procedures
• Quality of Life
• Standard of Care
• Recovery of Function
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Length of Stay
• Retrospective Studies

• ambulatory surgery
• complications
• hospital
• outcomes. cost-effectiveness
• outpatient
• safety
• same-day discharge
• short stay
• shoulder arthroplasty

• adult surgery
• public health
• quality in health care
• rehabilitation medicine

• Humans
• Forecasting
• Prognosis

• Humans
• Patient Discharge
• Prospective Studies
• Length of Stay
• Arthroplasty, Replacement, Knee/methods
• Arthroplasty, Replacement, Hip/adverse effects
• Arthroplasty, Replacement, Hip/methods
• Multicenter Studies as Topic

• Outpatient
• Skilled nursing facility
• Total hip arthroplasty

• Knee arthroplasty
• Outpatient surgery
• Readmission
• Unicompartmental knee arthroplasty

• Arthroplasty
• Enhanced recovery after surgery
• Fast-track
• Hip
• Knee
• Outpatient
• Replacement

• Clinical pathway
• Hip arthroplasty
• Knee arthroplasty
• Outpatient joint arthroplasty

• Enhanced recovery
• Enhanced recovery after surgery
• Liver
• Liver transplantation
• Recovery

Pressure to reduce healthcare costs, limited hospital availability along with improvements in surgical technique and perioperative care motivated many centers to focus on outpatient pathway implementation. However, in many short-stay protocols, the focus has shifted away from aiming to reduce complications and improved rehabilitation, to using length of stay as the main factor of success. To improve patient outcomes and maintain safety, the best way to implement a successful outpatient program would be to combine it with the principles of enhanced recovery after surgery (ERAS), and to improve patient recovery to a level where the patient is able to leave the hospital sooner. This article delivers a case for modernizing total hip arthroplasty perioperative pathways by implementing ERAS-outpatient protocols.

• arthroplasty
• complication
• enhanced recovery after surgery
• fast-track
• hip
• knee
• outpatient
• patient outcome

• Complication
• inpatient
• outpatient
• readmission
• total hip arthroplasty

Fast-track hip and knee arthroplasty (HA and KA) has been increasingly common over the last decade. In the same time period, there was a strong trend toward less restrictive mobilization. However, few reports have been published on combining these novel programs while measuring the postoperative results by patient-reported outcome measures (PROMs). Descriptions of fast-track surgery programs and their results are warranted.

The aim of this retrospective cohort study was to examine if it is possible to achieve excellent PROM results for hip and knee arthroplasty patients in a fast-track pathway without postoperative restrictions. During 2014–2017, the stepwise introduction of a PROM program was implemented at Stavanger University Hospital for all scheduled HA and KA patients, with preoperative assessments and postoperative follow-ups at the outpatient clinic. Standardized information with a focus on early mobilization and no postoperative restrictions was also initiated for the same patients. The generic EuroQol questionnaire (EQ-5D) and either the Hip or Knee disability/injury and Osteoarthritis Outcome Score (HOOS or KOOS) were used.

PROM response rates varied from 80 to 99%. The median (interquartile range) change from preoperative to one-year postoperative results were as follows for HA and KA patients, respectively: pain, 55 (43–68) and 47 (31–61); other symptoms, 50 (40–65) and 36 (19–50); function in daily living, 54 (41–65) and 44 (31–55); function in sports and recreation, 56 (38–75) and 40 (15–64); joint-related quality of life, 69 (50–81) and 56 (38–75). The length of stay (LOS) was reduced by 1.9 days (mean), corresponding to a 40% reduction for HA patients and a 37% reduction for KA patients.

We found excellent PROM results after fast-track HA and KA with no postoperative restrictions. We believe that a fast-track program focusing on mobilization without any postoperative restrictions is superior for most patients, but further comparative studies are warranted.

The online version contains supplementary material available at 10.1186/s12891-022-05276-y.

• Arthroplasty
• Fast-track
• Hip
• Knee
• No postoperative restrictions
• Patient reported outcome measures

• Ambulatory Surgical Procedures/adverse effects
• Humans
• Medical Errors/prevention & control
• Orthopedic Procedures/adverse effects
• Orthopedics
• Outpatients
• Patient Safety

Over the past decades, clinical pathways (CPs) for hip and knee arthroplasty have been strongly and continuously evolved based on scientific evidence and innovation.

The present systematic review, including meta-analysis, aimed to compare the safety and efficacy of enhanced recovery pathways (ERP) with regular pathways for patients with hip and/or knee arthroplasty.

A literature search in healthcare databases (Embase, PubMed, Cochrane Library, CINAHL, and Web of Science) was conducted from inception up to June 2018. Relevant randomized controlled trials as well as observational studies comparing ERP, based on novel evidence, with regular or standard pathways, prescribing care as usual for hip and/or knee arthroplasty, were included. The effect of both CPs was assessed for (serious) adverse events [(S)AEs], readmission rate, length of hospital stay (LoS), clinician-derived clinical outcomes, patient reported outcome measures (PROMs), and financial benefits. If possible, a meta-analysis was performed. In case of considerable heterogeneity among studies, a qualitative analysis was performed.

Forty studies were eligible for data extraction, 34 in meta-analysis and 40 in qualitative analysis. The total sample size consisted of more than 2 million patients undergoing hip or knee arthroplasty, with a mean age of 66 years and with 60% of females. The methodological quality of the included studies ranged from average to good. The ERP had lower (S)AEs [relative risk (RR): 0.9, 95% confidence interval (CI): 0.8-1] and readmission rates (RR: 0.8, 95%CI: 0.7-1), and reduced LoS [median days 6.5 (0.3-9.5)], and showed similar or improved outcomes for functional recovery and PROMs compared to regular pathways. The analyses for readmission presented a statistically significant difference in the enhanced recovery pathway in favor of knee arthroplasties (P = 0.01). ERP were reported to be cost effective, and the cost reduction varied largely between studies (€109 and $20573). The overall outcomes of all studies reported using Grading of Recommendation, Assessment, Development and Evaluation, presented moderate or high quality of evidence.

This study showed that implementation of ERP resulted in improved clinical and patient related outcomes compared to regular pathways in hip and knee arthroplasty, with a potential reduction of costs.

• Hip arthroplasty
• Knee arthroplasty
• Joint arthroplasty
• Clinical pathway
• Enhanced recovery pathway
• Systematic review
• Meta-analysis

The aim of this study is to assess whether administration of gabapentin and methylprednisolone as “pre-emptive analgesia” in a group of patients above 65 years of age would be effective in complex pain management therapy following total knee arthroplasty (TKA). One hundred seventy patients above 65 years were qualified for the study, with exclusion of 10 patients due to clinical circumstances. One hundred sixty patients were randomly double-blinded into two groups: the study group (80 patients) and the control group (80 patients). The study group received as “pre-emptive” analgesia a single dose of 300 mg oral (PO) gabapentin and 125 mg intravenous (IV) methylprednisolone, while the control received a placebo. All patients received opioid and non-opioid analgesic agents perioperatively calculated for 1 kg of total body weight. We measured (1) pain intensity level at rest (numerical rating scale, NRS), (2) life parameters, (3) levels of inflammatory markers (leukocytosis, C reactive protein CRP), and (4) all complications. Following administration of gabapentin and methylprednisolone as “pre-emptive” analgesia, the NRS score at rest was calculated at 6, 12 (p < 0.000001), 18 (p < 0.00004) and 24 (p = 0.005569) h postoperatively. Methylprednisolone with gabapentin significantly decreased the dose of parenteral opioid preparations (p = 0.000006). The duration time of analgesia was significantly longer in study group (p < 0.000001), with CRP values lower on all postoperative days (1, 2 days—p < 0.00001, 3 days—p = 0.00538), and leukocytosis on day 2 (p < 0.0086) and 3 (p < 0.00042). No infectious complications were observed in the first postoperative days; in the control group, one patient manifested transient ischemic attack (TIA). The use of gabapentin and methylprednisolone as a single dose decreased the level of postoperative pain on the day of surgery, the dose of opioid analgesic preparations, and the level of inflammatory parameters without infectious processes.

Patient selection for outpatient total joint arthroplasty (TJA) is important for optimizing patient outcomes. This study develops machine learning models that may aid in patient selection for outpatient TJA based on medical comorbidities and demographic factors.

This study queried elective total knee arthroplasty (TKA) and total hip arthroplasty (THA) cases during 2010-2018 in the American College of Surgeons National Surgical Quality Improvement Program. Artificial neural network models predicted same-day discharge and length of stay (LOS) fewer than 2 days (short LOS). Multiple linear and logistic regression analyses were used to identify variables significantly associated with predicted outcomes.

A total of 284,731 TKA cases and 153,053 THA cases met inclusion criteria. For TKA, prediction of short LOS had an area under the receiver operating characteristic curve (AUC) of 0.767 and accuracy of 84.1%; prediction of same-day discharge had an AUC of 0.802 and accuracy of 89.2%. For THA, prediction of short LOS had an AUC of 0.757 and accuracy of 70.6%; prediction of same-day discharge had an AUC of 0.814 and accuracy of 78.8%.

This study developed machine learning models for aiding patient selection for outpatient TJA, through accurately predicting short LOS or outpatient vs inpatient cases. As outpatient TJA expands, it will be important to optimize preoperative patient selection and effectively screen surgical candidates from a broader patient population. Incorporating models such as these into electronic medical records could aid in decision-making and resource planning in real time.

• ACS-NSQIP
• Artificial intelligence
• Length of stay
• Machine learning
• Total hip arthroplasty
• Total knee arthroplasty

• Arthroplasty, replacement, hip
• Arthroplasty, replacement, knee
• Enhanced recovery after surgery
• Fast-track
• Mixed methods research
• Outpatient
• Patient experience
• Patient outcome assessment

• Arthroplasty, Replacement, Hip
• Arthroplasty, Replacement, Knee/adverse effects
• Enhanced Recovery After Surgery
• Humans
• Inpatients
• Length of Stay
• Outpatients

• Day case
• Hip and knee arthroplasty
• Lengths of stay
• Shortening

• catastrophic events
• emergency department visit
• outpatient
• readmission
• same-day discharge
• total hip arthroplasty

• Analgesics, Opioid/therapeutic use
• Arthroplasty, Replacement, Hip/adverse effects
• Humans
• Pain Measurement
• Pain, Postoperative/diagnosis
• Pilot Projects

• KL2 TR002367 NCATS NIH HHS

One of the most important steps before implementing short stay total hip arthroplasty (THA) is establishing patient criteria. Most existing criteria are mainly based on medical condition, but as physical functioning is associated with outcome after THA, we aim to evaluate the added value of a measure of physical functioning to predict short-stay THA.

We used retrospective data of 1559 patients who underwent an anterior THA procedure. Logistic regression analyses were performed to study the predictive value of preoperative variables among which preoperative physical functioning by use of the Timed Up and Go test (TUG) for short stay THA (< 36 h). The receiver operating characteristic (ROC) curve and Youden Index were used to define a cutoff point for TUG associated with short stay THA.

TUG was significantly associated with LOS (OR 0.84, 95%CI 0.82–0.87) as analyzed by univariate regression analysis. In multivariate regression, a model with the TUG had a better performance with an AUC of 0.77 (95%CI 0.74–0.79) and a R² of 0.27 compared to the basic model (AUC 0.75, 95%CI 0.73–0.77, R² 0.24). Patients with a preoperative TUG less than 9.7 s had an OR of 4.01 (95%CI 3.19–5.05) of being discharged within 36 h.

Performance based physical functioning, measured by the TUG, is associated with short stay THA. This knowledge will help in the decision-making process for the planning and expectations in short stay THA protocols with the advantage that the TUG is a simple and fast instrument to be carried out.

• Physical functioning
• Risk stratification
• Total hip arthroplasty

• Arthroplasty
• Day case
• Day surgery
• Enhanced recovery
• Fast track
• Outpatient
• Same day

Purpose: We aimed to study the influence of fast-track care programs in total hip and total knee replacements (THR and TKR) at Swedish hospitals on the risk of revision and mortality within 2 years after the operation. Methods: Data were collected from the Swedish Hip and Knee Arthroplasty Registers (SHAR and SKAR), including 67,913 THR and 59,268 TKR operations from 2011 to 2015 on patients with osteoarthritis. Operations from 2011 to 2015 Revision and mortality in the fast-track group were compared with non-fast-track using Kaplan–Meier survival analysis and Cox regression analysis with adjustments. Results: The hazard ratio (HR) for revision within 2 years after THR with fast-track was 1.19 (CI: 1.03–1.39), indicating increased risk, whereas no increased risk was found in TKR (HR 0.91; CI: 0.79–1.06). The risk of death within 2 years was estimated with a HR of 0.85 (CI: 0.74–0.97) for TKR and 0.96 (CI: 0.85–1.09) for THR in fast-track hospitals compared to non-fast-track. Conclusions: Fast-track programs at Swedish hospitals were associated with an increased risk of revision in THR but not in TKR, while we found the mortality to be lower (TKR) or similar (THR) as compared to non-fast track.

• fast-track
• mortality
• risk of revision
• total hip replacement
• total knee replacement

• 90-day outcomes
• ankle fractures
• complications
• costs
• inpatient
• outpatient

• Daycase surgery
• Enhanced recovery after surgery
• Hip arthroplasty
• Knee arthroplasty

• Arthroplasty, Replacement, Hip
• Arthroplasty, Replacement, Knee
• Humans
• Lower Extremity/surgery
• Outpatients
• Postoperative Period

The English National Health Service (NHS), and all health services around the world, will continue to face economic and capacity challenges. Quality improvement (QI) interventions, such as Enhanced Recovery after Surgery (ERAS), that are proven to improve patient care and deliver operational benefits are therefore needed. However, widespread implementation remains a challenge. Implementation of ERAS within the NHS over the last 10 years is reviewed, with a focus on total hip arthroplasty (THA) and total knee arthroplasty (TKA). Difficulties with implementation are highlighted, and a recommendation for the future is presented. This perspective is novel in the ERAS literature, and centres around increasing the understanding of perioperative care teams on the need for utilising a recognised QI method (e.g., plan–do–study–act cycles, Lean, and Six Sigma) to implement ERAS protocols (which are a QI intervention) successfully. The importance of differentiating between a QI method and a QI intervention has value across all other ERAS surgical procedures.

• enhanced recovery after surgery
• orthopaedics
• quality improvement
• surgery

• Allied Health Personnel
• Enhanced Recovery After Surgery
• Humans
• Length of Stay
• Quality Improvement
• Recovery of Function
• State Medicine

• arthroplasty
• enhanced recovery
• fast-track surgery
• hip replacement
• knee replacement
• outpatient

The aim of the study was to assess whether administration of a single dose of methylprednisolone in the group patients above 65 years of age will be effective in complex analgesic management after total hip arthroplasty (THA).

Seventy-seven patients above 65 years old were double-blind randomized into two: the study and controls groups. Pre-operatively, the study group received as a single dose of 125 mg intravenous methylprednisolone, while the others saline solution as placebo. Peri-operatively, all the patients were administered opioid and nonopioid analgesic agents. We measured the levels of inflammatory markers (leukocytosis, C-reactive protein—CRP), pain intensity level (visual analog scale—VAS; numerical rating scale—NRS), the life parameters, and noted complications.

Following administration of methylprednisolone were significantly lower levels of CRP on all the four post-operative days; leukocytosis on the second day; the VAS/NRS score at rest after six, 12, and 18 hours post-operatively, diminished the dose of parenteral opioid preparations (oxycodone hydrochloride), the duration of analgesia by peripheral nerve block was significantly higher as compared with the placebo group (p < 0.000001). No infectious complications were noted; there was one patient who developed post-operative delirium.

A single dose of methylprednisolone significantly reduces the level of post-operative pain at rest on the day of THA in the group patients above 65 years of age, decreases the dose of opioid analgesic agents, and significantly decreases the level of inflammatory markers, without infectious processes.

• Infection rate
• Methylprednisolone
• Opioid dose
• Pain intensity
• Total hip joint replacement

• patient education as topic
• postoperative period
• qualitative research
• total hip replacement
• total knee replacement

• Aged
• Ambulatory Surgical Procedures/trends
• Arthroplasty, Replacement/trends
• Female
• Follow-Up Studies
• Humans
• Male
• Middle Aged
• Patient Discharge/trends
• Patient Safety
• Postoperative Complications/epidemiology
• Retrospective Studies
• Treatment Outcome
• United States