Outpatient versus Inpatient Hip Replacement

By William P Barrett, MD

In an award-winning paper at the 2016 Hip Society meeting, authors Goyal, MD, et al. Presented their prospective randomized study comparing 2 groups of patients undergoing hip replacement surgery. Inclusion criteria in this study included healthy patients under the age of 75 who were not morbidly obese, had no significant medical problems, and were ambulating without a cane or crutch prior to surgery. Patients with multiple medical comorbidities, use of preoperative narcotic painkillers, and need for ambulatory aids were excluded. All patients underwent an direct anterior approach total hip replacement under spinal anesthetic.

Several advancements in the care for patients undergoing hip replacement including preoperative education and therapy, perioperative protocols including early immobilization, multimodal pain management, and coordination of pre and postoperative care have made it possible to dramatically shorten the length of stay for hip replacement. At our institution, it is routine that patients go home the day after their surgical procedure and they are up ambulating, weightbearing as tolerated, on the day of their surgery. The authors of this study enrolled patients in 1 of 2 groups, (1) an outpatient group where the patient would leave the hospital within 12 hours of the surgical procedure and (2) an inpatient group where the patient would leave the hospital following day. Because randomization, both groups were very similar with regard to their preoperative status. At followup, it turns out that 76% of the patients in the outpatient group were able to go home the day of surgery and 75% of the inpatient group went home as planned. The reasons for the outpatient patient staying overnight included dizziness or low blood pressure, pain, nausea, difficulty walking, and urinary retention. At followup, there was no difference at 4 weeks with regard to pain and function or complications or re-admissions. It was noted that the outpatient group had a higher pain level on the day following surgery than the inpatient group did.

This study demonstrates that shortened lengths of stay after hip replacement has become the norm. In otherwise healthy individuals without medical comorbidities or significant obesity, discharge home the day of surgery can be realized.  Of note, 25% of patients were not able to be discharged that day and therefore required the ability to spend the night. As we move to shorter and shorter lengths of stay, the opportunity go home the day of surgery and/or spend the night will be essential.

We are developing plans to build an outpatient surgery center for joint replacement and spinal procedures here at Valley Medical Center and look forward to working with our colleagues from the hospital to develop coordinated care for these patients.