SAME DAY TKA VS THE CLASSIC: ARE YOU CRAZY? MY PATIENTS ARE WELL CARED FOR

1. SAME DAY TKA VS THE CLASSIC: ARE YOU CRAZY?MY PATIENTS ARE WELL CARED FOR Douglas A. Dennis, M.D. Adjunct Professor, Department of Bioengineering Denver University Adjunct Professor, Dept. of Biomedical Engineering University of Tennessee Assistant Clinical Professor, Dept. of Orthopedics University of Colorado School of Medicine

2. DISCLOSURE • Consultant : Depuy Synthes / Corin • Royalties: • Depuy / Wolters Kluwer • Laboratory Research Support • Depuy Synthes • Porter Adventist Hospital • Ownership Interest: Joint Vue

3. ADOLPH • You’ve Been Doing Too Much Outpatient Surgery !!

4. THIS I KNOW !! • Many Small Studies Demonstrate Outpatient TKA Can Be Done Safely In A Selected Group Of Patients • I Still Have A Lot Of Questions • JUST BECAUSE IT CAN BE DONE, IS IT THE BEST TREATMENT METHOD FOR OUR PATIENTS ??

5. OUTPATIENT TKA • If 500 Outpatient TKA Patients Are Performed Safely & One Patient Dies Or Has A Major Complication & If The Patient Were Hospitalized & Emergency Treatment Was Administered More Promptly, Lessening The Magnitude Of The Complication, IS IT WORTH IT ??

6. OUTPATIENT TKA • Many ASCs Are Not On A Hospital Campus • Is There An Intensivist On Site ? • How Long Will It Take ?? • Ambulance To Arrive • Patient Transport To An Acute Care Hospital

7. OUTPATIENT TKA • Numerous Reports Show Similar Complication & Readmission Rates Between Outpatient & Inpatient Cohorts • Cohorts Are Rarely Matched • Outpatient Subjects Typically Younger, Healthier, & More Psychologically Prepared

8. OUTPATIENT TKA • IF STUDIES WERE DONE OF MATCHED COHORTS (AGE, MORBIDITIES, ETC.) DONE INPATIENT VS OUTPATIENT, WOULD COMPLICATIONS & READMISSIONS RATES STILL BE THE SAME??

9. OUTPATIENT TKA • A Lot Of Outpatient Knee Arthroplasty Data Involves UKA • Will Similar Results Be Obtained With Outpatient TKA • Especially In Medicare Aged Patients ??

10. OUTPATIENT TKA • When Comparing Variables Of Similar Incidence, Large Cohort Size Is Required To Detect Small Differences

11. OUTPATIENT TKA Are The Ideal Candidates For Outpatient Surgery Clearly Identified In Studies Involving Thousands Of Patients ??

12. TKA MORTALITY • Power Analysis • Stat Change: • 0.2% To 0.4% • 9,425 Subjects Required • Are Multiple Studies With Large #s Of Patients Available?

13. OUTPATIENT TKA • Not All Outpatient Data Similar • 177,818 Joint Arthroplasties • 1,236 Outpatient • NSQIP Database • Matched Vs Inpatient Cohort • Adverse Events Similar • ↑ Return To OR In Outpatient Cohort Basques, Dela Valle, et al, JBJS 2018

14. OUTPATIENT TKA • Another Large Database Analysis • Pearl Diver Analysis (Humana Subset) • 4,291 Outpatient Vs 128,951 Inpatient • Data Adjusted For Age, Gender, & CCI • ↑ Incidence In Outpatient Cohort • Revision TKA / I & D / DVT • Closed Manipulation / Acute Renal Failure Arshi, et al, JBJS 2017

15. OUTPATIENT TKA • Some Outpatient TKA Protocols “Send The Hospital Home With The Patient” • Visiting RN, HHA, PT • Are They Really Saving $$$ Or Just Cost Shifting ??

16. Early Discharge Not Associated With ↑ Readmission But Excessive Postoperative ER Visits Encountered • Cost Savings Vs Shifting ??

17. OUTPATIENT TKA • Many Outpatient Surgical Centers Are Physician Owned • Surgeons Potentially Economically Incentivized To Take Patients To Outpatient Surgical Centers

18. OUTPATIENT TKA • Will Some Surgeon Owner Make A Poor Decision Regarding Patient Selection Due To Secondary Economic Benefit And Adverse Patient Events Occur ??

19. OUTPATIENT TKA • Anesthesiologist Fears • Falls: Lingering Anesthesia Effects • Postop Bleeding (Anticoagulants) • Urinary Retention → Readmission • Epidural Hematoma • Cardiac Arrhythmia • Respiratory Depression • Pain Control After Block Cessation

20. OUTPATIENT TKA: OTHER RISKS • Postop Respiratory Depression • Obstructive Sleep Apnea • Incidence Reported To Be As High As 23.4% In ♀ / 49% In ♂ • Many OSA Undiagnosed !! • Risk Of Respiratory Complications In OSA Subjects Consuming Opiods For Postop Pain Control Is Substantial • Risks: Hypoxia / Pneumonia / Death

21. OUTPATIENT TKA: OTHER RISKS • Postop Urinary Retention • If Undiagnosed & Not Treated In A Timely Fashion, Urinary Retention Can Result In Permanent Bladder Damage, Hydronephrosis, Chronic UTI’s, Etc.

22. SUMMARY • Can Be Done Safely In Selected Patients • Larger Studies Required To Define Proper Patient Selection & Safety • FEARS: • Major Complications @ ASCs Located Distant From A Major Hospital • Surgeon Ownership → Poor Patient Selection • Increased Resources Required Not Available To All Surgeons • Not Yet Ready For Widespread Use !!

23. THANK YOU