Orthopedics

Feature Article 

Safety and Efficacy of Same-Day Hip Resurfacing

Lidia Ani, MD; Afshin A. Anoushiravani, MD; James E. Feng, MD; Michael Collins, BSc; Ran Schwarzkopf, MD, MSc; James Slover, MD, MSc; William Macaulay, MD; Scott Marwin, MD

Abstract

Same-day discharge (SDD) surgery in total hip arthroplasty (THA) has been shown to have similar outcomes to non-SDD THA in select patient populations. Hip resurfacing arthroplasty (HRA) is an alternative to THA for young, active patients, making them ideal candidates for SDD. This study compared the safety and efficacy of non-SDD HRA and SDD HRA for specific postoperative outcomes. An electronic data warehouse query was performed for procedures labeled “hip resurfacing.” Data collected included demographics, surgical factors, and quality metrics. Statistical analyses were evaluated using a graphing and statistics software program. Categorical variables were analyzed with chi-square tests and continuous variables with Student's t tests, with P<.05 deemed significant. Sixty-three of 274 total HRAs were enrolled in this SDD HRA protocol. No significant difference was observed between SDD HRA and non-SDD HRA baseline characteristics. On postoperative day 0, 98.41% of SDD HRA recipients were discharged successfully. The SDD HRA recipients had shorter stays, with 1.59% requiring a hospital stay of 2 days or more compared with 56.87% of non-SDD HRA recipients (P<.0001). The non-SDD HRA recipients were found to have shorter surgical times than SDD HRA recipients (104.74 vs 125.51 minutes, P=.01). Rates of infection, periprosthetic fractures, emergency department visits, and hospital readmissions were equivalent (P=.99). Same-day discharge HRA is a safe and effective procedure with similar outcomes to non-SDD HRA regarding infections, fractures, emergency department visits, and readmissions. The major benefit of SDD is a shorter hospital stay that may lead to decreased cost while preserving and enhancing quality of care and patient satisfaction. [Orthopedics. 2020;43(6):e595–e600.]

Abstract

Same-day discharge (SDD) surgery in total hip arthroplasty (THA) has been shown to have similar outcomes to non-SDD THA in select patient populations. Hip resurfacing arthroplasty (HRA) is an alternative to THA for young, active patients, making them ideal candidates for SDD. This study compared the safety and efficacy of non-SDD HRA and SDD HRA for specific postoperative outcomes. An electronic data warehouse query was performed for procedures labeled “hip resurfacing.” Data collected included demographics, surgical factors, and quality metrics. Statistical analyses were evaluated using a graphing and statistics software program. Categorical variables were analyzed with chi-square tests and continuous variables with Student's t tests, with P<.05 deemed significant. Sixty-three of 274 total HRAs were enrolled in this SDD HRA protocol. No significant difference was observed between SDD HRA and non-SDD HRA baseline characteristics. On postoperative day 0, 98.41% of SDD HRA recipients were discharged successfully. The SDD HRA recipients had shorter stays, with 1.59% requiring a hospital stay of 2 days or more compared with 56.87% of non-SDD HRA recipients (P<.0001). The non-SDD HRA recipients were found to have shorter surgical times than SDD HRA recipients (104.74 vs 125.51 minutes, P=.01). Rates of infection, periprosthetic fractures, emergency department visits, and hospital readmissions were equivalent (P=.99). Same-day discharge HRA is a safe and effective procedure with similar outcomes to non-SDD HRA regarding infections, fractures, emergency department visits, and readmissions. The major benefit of SDD is a shorter hospital stay that may lead to decreased cost while preserving and enhancing quality of care and patient satisfaction. [Orthopedics. 2020;43(6):e595–e600.]

Hip resurfacing arthroplasty (HRA) is a surgical procedure that has retained popularity as an alternative to total hip arthroplasty (THA), particularly among active, young adult men. By preserving the femoral neck and offset, and through the provision of the largest prosthetic femoral head possible, HRA lowers the risk for postoperative dislocation, preserves a more natural gait pattern, and is more permissive for highly active lifestyles.1–3 Furthermore, when appropriately indicated, HRA has demonstrated equivalent outcomes when compared with THA controls.1,4–6

In a similar manner, same-day discharge (SDD) THA recipients compared with non-SDD THA recipients have been reported to have noninferior clinical outcomes, superior patient satisfaction scores, and enhanced value-based care metrics (eg, cost-effectiveness and hospital length of stay [LOS]).7–10 However, no study to date has comparatively assessed the differences in outcomes between HRA candidates undergoing SDD HRA and non-SDD HRA protocols. Given the apparent advantages and comparable patient cohorts, HRA candidates have been proposed to be ideal for SDD. Therefore, the purpose of this study was to compare SDD HRA and non-SDD HRA outcomes at a tertiary care center.

Materials and Methods

Study Design

Institutional review board approval was obtained prior to the initiation of this retrospective observational cohort study. Inclusion criteria for this study consisted of all patients who underwent unilateral HRA between January 2012 and March 2018 at a single, urban, tertiary academic care center. A query was performed of the electronic data warehouse of the authors' institution, Caboodle (version 15; Epic, Verona, Wisconsin). Demographics characteristics (patient age, sex, body mass index [BMI], race, marital status, smoking status, insurance type, and American Society of Anesthesiologists score) and perioperative variables (anesthesia type, laterality, LOS, surgical duration, and discharge disposition) were obtained directly from the authors' electronic data warehouse. Complications and quality outcomes were obtained by a combination of manual chart review and through their institution's database, which included 1-year HRA-related readmission, peri-prosthetic fractures, 90-day infection, and 60-day emergency department visits.

Patients were subsequently divided into SDD HRA enrolled candidates vs non-SDD HRA candidates. Patients who enrolled into the SDD protocol but were discharged beyond postoperative day 0 were categorized as program failures. Patients in the non-SDD HRA cohort had either undergone surgery prior to the implementation of the SDD pathway or opted out of the program.

SDD Perioperative Management

All patients in this study underwent HRA performed by 1 of 5 orthopedic surgeons at the authors' institution. Each patient receiving SDD HRA was risk stratified and medically optimized prior to surgery. To qualify for SDD HRA, patients had to meet all the following criteria: no history of coronary artery disease or arrhythmias, no history of deep venous thrombosis or pulmonary embolism, not currently receiving chronic anticoagulation or antithrombotic agents, no history of moderate or severe sleep apnea, hemoglobin of 12 g/dL or greater, and a BMI of 40 kg/m2 or less. Patients were only included in the SDD group if they were discharged before midnight on the day of surgery.

Physicians discussed the risks, benefits, and alternatives to HRA with all patients. In addition, each patient had an individual 2-hour session with a clinical care coordinator and a physical and occupational therapist prior to his or her surgery. During this encounter, the patient was educated on the expected recovery course, pain management modalities, physical therapy exercises, postoperative expectations, and discharge planning. Inclusion in the SDD group required the presence of a designated family member or acquaintance who could transport the patient home and assist with activities of daily living in the immediate postoperative period. A maximum travel time of 1.5 hours from the institution to the patient's residence was also required for inclusion. Patients were free to withdraw from the program at any time prior to surgery.

All HRAs were performed using the Birmingham Hip Resurfacing System (Smith & Nephew, Memphis, Tennessee). Spinal anesthesia was attempted in all surgical candidates, with general anesthesia reserved only for patients with technically challenging spinal access. Additional anesthetic medications administered during the surgery included intravenous fentanyl, propofol, midazolam, and dexamethasone. All patients received standardized antibiotics for 24 hours initiated within 1 hour prior to the surgical start time. The SDD patients received 1 dose of intravenous cefazolin perioperatively. If they were present in-house at the time for administration of the second dose, they would receive it then; if not, they were discharged with 2 oral doses of cephalexin to take every 8 hours.

A uniform perioperative multimodal pain regimen was established, which reduced the need for narcotics. Patients were administered several nonnarcotic medications, including oral acetaminophen and celecoxib, pre- and postoperatively. An intra-articular injection of 30 mL of 0.25% bupivacaine and liposomal bupivacaine was administered prior to closure. Oral and intravenous opioid administration was strongly discouraged unless all nonnarcotic alternatives were deemed ineffective. Patient- controlled analgesia was reserved for severe refractory cases.

Postoperatively, all patients received thromboprophylaxis agents consisting of 81 or 325 mg of aspirin orally twice daily for 4 weeks and mechanical compression devices for 2 weeks. Active smokers and patients in the non-SDD HRA group with a history of a thrombotic event or a hyper-coagulable state were prescribed 40 mg of enoxaparin sodium subcutaneously daily for 4 weeks instead of aspirin and mechanical compression devices, as per the authors' institutional protocol. Of note, no patients with a history of thrombotic event or hypercoagulable state were included in the SDD group.

After the patients had been deemed safe for discharge, all SDD patients were discharged home with either home health care services or self-care. On postoperative day 1, patients received a call from the clinical care coordinator to ensure that they were recovering appropriately. In addition, physical therapists and visiting nurses followed-up intermittently with each HRA recipient at the patient's residence to assist with wound care and rehabilitation for 2 weeks. All other details of postoperative management were surgeon-specific and identical to their standard of care practices for inpatient HRA.

Statistical Analysis

All data were collected and transformed using Excel for Mac 2011 version 14.6.2 (Microsoft Corp, Redmond, Washington). Statistical analysis was performed using Prism 7 software (GraphPad, La Jolla, California). Baseline and demographic characteristics were summarized by standard descriptive summaries (eg, means and SD for continuous variables). An analysis was performed comparing baseline patient characteristics and outcomes between SDD and non-SDD HRA recipients. Categorical baseline characteristics and outcomes were analyzed using a chi-square test with Fisher's P reported between the 2 groups. A Student's t test was used to compare group means between the 2 groups. In all instances, P<.05 was deemed significant.

Results

Baseline Demographics

In total, 274 consecutive HRAs were performed on 260 patients at the authors' institution during a 6-year period. Of the 274 HRAs, 63 were enrolled into the SDD program at the authors' institution and the remaining 211 underwent non-SDD HRA. Analysis of demographic variables among the SDD HRA and non-SDD HRA cohorts demonstrated no statistically significant difference in mean age (50.98 vs 51.24 years; P=.83), sex (male, 98.41% vs 98.58; P>.99), mean BMI (30.16 vs 30.69 kg/m2; P=.37), median American Society of Anesthesiologists score (2 vs 2; P=.94), smoking status (never smokers, 77.78% vs 67.77%; P=.30), and marital status (married/with partner, 80.95% vs 75.83%; P=.50; Table 1).

Baseline and Demographic Characteristics

Table 1:

Baseline and Demographic Characteristics

Postoperative Outcomes

The non-SDD HRA cohort was found to have a significantly shorter mean surgical duration than the SDD HRA cohort (104.74 vs 125.51 minutes; P=.01). No significant difference was found in anesthesia type (P=.71), laterality of procedure (P=.08), or discharge disposition (P=.24) between the non-SDD HRA and SDD HRA cohorts (Table 2). The majority (98.41%) of patients in the SDD HRA cohort were successfully discharged on postoperative day 0. One patient in the SDD HRA cohort failed to be discharged on postoperative day 0 due to postoperative hypotension and vasovagal syncope. The patient was a 41-year-old white man with a BMI of 35 kg/m2 and an American Society of Anesthesiologists score of 2 whose surgical history included gastric sleeve surgery and nasal surgery. His hospital length of stay was 2 days. Among SDD HRA recipients, 1.59% (1 patient) had LOS of 2 days or more compared with 56.87% of non-SDD HRA recipients (P<.0001).

Surgical and Inpatient Factors

Table 2:

Surgical and Inpatient Factors

Quality Metrics

In the non-SDD HRA cohort, 1 patient was readmitted 5 weeks after HRA for a periprosthetic fracture requiring conversion to a THA; 3 patients were readmitted within 90 days for surgical site infections requiring irrigation and debridement; and 1 patient was readmitted with chronic hip pain 1 year following HRA and underwent debridement with soft tissue repair (Table 3). One non-SDD HRA patient visited the emergency department 6 weeks following surgery due to radicular neck pain and was treated with ketorolac and diazepam; the patient did not require admission.

Quality Outcomes

Table 3:

Quality Outcomes

In the SDD cohort, 1 patient was read-mitted within 90 days of the procedure for surgical site infection requiring irrigation and debridement (Table 3). No periprosthetic fractures, dislocations, or HRA-related emergency department visits were documented in the SDD cohort. Total all-cause 90-day readmission rate was 1.90% in the non-SDD HRA cohort vs 1.59% in the SDD HRA cohort (P=.99).

Discussion

Background

A push has been made in recent decades for health care providers and hospitals to improve efficiency of services. This includes optimizing quality metrics, such as LOS and readmissions. With the emphasis on decreasing LOS comes the concern that these efforts could lead to a decrease in patient outcomes and a potentially increase use of the health care system, causing an overall decrease in efficiency. However, SDD total joint arthroplasty has been shown to have clinical outcomes comparable to traditional inpatient procedures regarding metrics such as readmission rates, infection, and other perioperative complications.7–11 Hip resurfacing arthroplasty is an alternative to total joint arthroplasty in well-informed and selected patients, but prior to this study the outcomes of SDD HRA compared with inpatient HRA had not yet been directly evaluated.12

Candidate Selection

Patients who would typically be considered good candidates for HRA are active men younger than 65 years who have osteoarthritis but otherwise have normal femoral and acetabular anatomy and who wish to resume an active lifestyle.13–16 Female patients of childbearing age are not encouraged to undergo HRA due to the unknown effects of increased metal ion levels on fetuses; however, female sex itself has not been consistently shown to be associated with HRA failure, as measured by the need for revision surgery.16–19

In the current study, there was no significant difference in the age, sex, or American Society of Anesthesiologists score distributions between SDD HRA and non-SDD HRA patients, demonstrating similar health statuses between the 2 cohorts. This suggests that patients who are suitable for HRA should also be considered for SDD HRA. Of note, general anesthesia, which 15.87% of the patients in the SDD HRA cohort underwent, is not a contraindication to SDD, as seen in a study of patients undergoing ambulatory surgery under general anesthesia that found that even with anesthesia durations of more than 2 hours patients were still able to be discharged home within 8 hours of surgery.20

Same-Day Discharge Surgery Failures

The SDD HRA program had a high rate of program completion, with only 1 (1.59%) of 63 patients failing to discharge by postoperative day 0. This was a result of postoperative hypotension and 2 episodes of syncope that were likely vasovagal in origin. There were no previously noted medical conditions that would have potentially disqualified the patient from enrolling in the SDD program. However, this patient had undergone bariatric surgery a few years prior to this HRA admission.

Given that 98.41% of the patients who enrolled in the SDD HRA program did successfully complete the program, this failure is most likely due to patient-specific causes and does not appear to represent a systematic flaw in the selection protocol. Furthermore, excessive pain was never a cause for SDD failure and is consistent with literature that demonstrates that HRA patients have less pain than similar THA patients during the first 24 hours.21

In summary, the authors found that SDD HRA is a safe and effective alternative to traditional in-patient HRA, with noninferior outcomes and the advantage of decreased LOS. This is similar to the success of SDD in the standard THA population. Therefore, despite its differences, the study demonstrates that HRA is also an appropriate procedure for SDD in the correct patients. The authors attribute the success of their SDD program to rigid patient selection and the strong emphasis on patient education prior to the procedure. As stated previously, each patient enrolled in the SDD HRA program of the authors' institution met with a clinical care coordinator prior to his or her procedure and received extensive instruction on what to expect during and after the surgery.

Other studies have similarly found that setting clear expectations and increasing patient education efforts preoperatively can help decrease hospital LOS.22,23 This enhances patient-centered decision making and allows for increased efficiency, as evidenced by improvement in value-based care metrics such as LOS. The education component was likely a large factor in the success of the SDD HRA program, but the principle of increasing the focus on patient education prior to procedures can and should be used in other settings to decrease the need for readmissions and other unnecessary uses of the health care system.

Limitations

This study was not without limitations. As a retrospective study, it was susceptible to interpretation biases and errors in data collection and has limited ability to control for confounding variables. The study timeline was another limitation, as SDD only became available at the authors' institution in 2015, by which time 43 patients in this study (20.4% of the total non-SDD HRA cohort) had undergone non-SDD HRA. The remaining 168 (79.6%) underwent non-SDD HRA during the same time period as the 63 SDD HRA patients. However, given that patient demographic profiles are similar between the SDD and non-SDD cohorts, this is likely to have had only a minimal effect on the study results. If anything, it may have improved the quality and patient outcomes of the non-SDD group because patients who were fit for SDD but were unable to enroll because it was not yet available at the authors' institution were instead included in the non-SDD HRA group.

One factor the authors did not evaluate in this study was the degree of blood loss in SDD vs non-SDD patients, as measured objectively by postoperative hemoglobin levels compared with preoperative levels. This was mostly due to the fact that the authors do not routinely check postoperative hemoglobin levels at their institution for primary hip and knee arthroplasty cases.

The authors were also unable to explain the significantly shorter mean surgical time in the non-SDD HRA cohort compared with the SDD HRA cohort because the surgeons performing the procedures and their contributions in both cohorts did not change, nor did the surgical protocols, techniques, or implants used throughout the study period.

Finally, given the low complication and readmission rates, this study may be underpowered to truly assess a statistical difference between these two cohorts. However, considering the rare incidence of these occurrences, this is not likely to be clinically significant. Despite these limitations, this study suggests that SDD HRA can be consistently performed in a safe and effective manner to enhance the value and reliability of care delivery.

Conclusion

Same-day discharge HRA is a safe and effective procedure, with outcomes similar to conventional inpatient HRA regarding postoperative complications, emergency department visits, and hospital readmissions. Given the similar demographics of SDD HRA and non-SDD HRA patients in this study, the authors suggest that SDD HRA can be broadened to include an increasing number of HRA patients. The HRA candidates enrolled into SDD integrated care pathways may benefit from significantly shorter LOS and improved care delivery. In addition, HRA candidates partaking in SDD programs may receive patient-centric education sessions further enhancing their recovery.

References

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Baseline and Demographic Characteristics

CharacteristicSDD HRA (n=63)Non-SDD HRA (n=211)PAll HRA (n=274)
Age, mean±SD, y50.98±8.2951.24±7.58.8351.18±7.74
Sex, No. (%)>.99
  Female1 (1.59)3 (1.42)4 (1.46)
  Male62 (98.41)208 (98.58)270 (98.54)
BMI, mean±SD, kg/m230.16±4.0130.69±4.58.3730.57±4.45
ASA score, No. (%).94
  19 (14.29)32 (15.17)41 (14.96)
  245 (71.43)146 (69.19)191 (69.71)
  39 (14.29)32 (15.17)41 (14.96)
  Unknown01 (0.48)1 (0.36)
  Median222
Smoking, No. (%).30
  Current4 (6.35)22 (10.43)26 (9.49)
  Former10 (15.87)46 (21.80)56 (20.44)
  Never49 (77.78)143 (67.77)192 (70.07)
Marital status, No. (%).50
  Married/partner51 (80.95)160 (75.83)211 (77.01)
  Single/divorced/widowed12 (19.05)51 (24.17)63 (22.99)
Race, No. (%).59
  Black4 (6.35)11 (5.21)15 (5.47)
  Asian2 (3.17)3 (1.42)5 (1.82)
  White52 (82.54)170 (80.57)222 (81.02)
  Other5 (7.94)27 (12.80)32 (11.68)
Insurance type, No. (%).37
  Medicare1 (1.59)8 (3.79)9 (3.28)
  Medicaid1 (1.59)5 (2.37)6 (2.19)
  Commercial59 (93.65)180 (85.31)239 (87.23)
  Workers' compensation2 (3.17)18 (8.53)20 (7.30)

Surgical and Inpatient Factors

FactorSDD HRA (n=63)Non-SDD HRA (n=211)PAll HRA (n=274)
Laterality, No. (%).08
  Left26 (41.27%)115 (54.50%)141 (51.46%)
  Right37 (58.73%)96 (45.50%)133 (48.54%)
Anesthesia type, No..71
  Spinal53 (84.13%)172 (81.52%)225 (82.12%)
  General10 (15.87%)39 (18.48%)49 (17.88%)
Surgical duration, mean±SD, min125.51±63.10104.74±26.58.01109.51±39.04
Length of hospital stay, d, No.<.0001
  062 (98.41%)062 (22.63%)
  1091 (43.13%)91 (33.21%)
  21 (1.59%)95 (45.02%)96 (35.04%)
  >2025 (11.85%)25 (9.12%)
Discharge disposition, No..24
  Home with self-care7 (11.11%)14 (6.64%)21 (7.66%)
  Home with health care services56 (88.89%)197 (93.36%)253 (92.34%)

Quality Outcomes

Outcome, No.SDD HRA (n=63)Non-SDD HRA (n=211)PAll HRA (n=274)
All-cause readmission (90 days)1 (1.59%)4 (1.90%).995 (1.82%)
Infection (90 days)1 (1.59%)3 (1.42%).994 (1.46%)
Periprosthetic fracture (all-time)01 (0.47%).991 (0.36%)
ED visit (60 days)01 (0.47%).991 (0.36%)
Related readmission (1 year)1 (1.59%)5 (2.37%).996 (2.84%)
Authors

The authors are from the Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Ran Schwarzkopf, MD, MSc, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 E 17th St, New York, NY 10003 ( ran.schwarzkopf@nyumc.org).

Received: April 06, 2019
Accepted: September 09, 2019
Posted Online: August 20, 2020

10.3928/01477447-20200812-07

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