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20 Executive Briefing: Executive Briefing: Outpatient Total Joint Arthroplasty more prevalent due to the complications associated with indwell- ing femoral nerve blocks. Short acting spinal blocks allow for rapid rehabilitation and decrease the risk of postoperative nausea and vomiting. Appropriately performed general anesthetics, either inha- lation with isoflurane or sevoflurane using a laryngeal mask airway can be performed as an alternative to a short acting spinal block. Postoperative recovery includes the use of oral hyrdrocodone and intravenous fentanyl for breakthrough discomfort. Injection of the capsular structures by the surgeon includes one of various report- ed mixed anesthetic "cocktails" or the utilization of a bupivicaine li- posome injectable suspension. Utilizing a postperative narcotic oral medicine mixture technique, pericapsular injection techniques and an adductor nerve block for TKA allows for the patient to be ambu- latory within a few hours after surgery without significant ambula- tory pain. Cold therapy has been shown to be beneficial in the early postoperative period and the majority of surgeons recommend its use for at least 48 to 72 hours postoperatively. Surgical procedure: It is critical to try to avoid significant blood loss and bleeding at the time of surgical intervention. Some out- patient total joint surgeons avoid using a tourniquet completely during a TKA but have the tourniquet in place in case any un- toward bleeding during the procedure ensues. Ideally a shorter incision for TKA and a relatively smaller incision should be utilized if the posterior approach is employed for a THA or the anterior ap- proach is utilized for a THA. If the surgeon uses a tourniquet for a TKA, it is important to release the tourniquet prior to closure and coagulate all major bleeders prior to soft tissue injection of either bupvicaine liposomal injection or one of the anesthetic "cocktails." Postoperative recovery: The postoperative recovery phase is critical and must be set up ahead of time to allow for rapid rehabili- tation subsequent to TJA. Ideally, home physical therapy should be instituted on day one or two. If "in home" PT cannot be set up, then OP PT should be instituted within 48 hours after the surgery. PT should consist of ROM exercises, quadriceps strengthening, hamstring strengthening and weight bearing as tolerated with an external aid consisting of a walker, crutches or cane(s). If the therapist is not trained in drain removal, or a home healthcare nurse is not seeing the patient daily, then the patient should re- turn to see the surgeon within 48 hours after the surgery. In some practices, the home care nurse sees the patient on postoperative days one, two and three. If "in-home" PT is available, progression to activities of daily living can begin on day three. The patient should return to see the surgeon in one week after the surgery to perform wound check. Assuming that the postoperative course is unremarkable, in-home or outpatient physical therapy must be continued three times per week for a minimum of three weeks or until the patient has reached a minimum of 90 degrees of knee flexion, is able to walk independently with crutches or a cane, and is independent in their home setting without a caregiver present. Most surgeons continue high dose aspirin for a minimum of four weeks postoperatively, monitor the use of warafarin or prescribe enoxaparin for two to four weeks post-op. Cost effective care considerations: Implant cost considerations are critical determinants for SDSD. "Stable technology implants" (STIs) differ from generic implants when considering their usage in the SDSD setting. STIs by definition have a minimum of 10 years of survivorship data whereas generic implants are simply "copies" of existing implants without long term survivorship data. STIs have been used throughout the United States and Europe and registry data in many cases reports survivorship data as high as 98 percent at 15 years. Usage of these implants in a "repless system" with an intraoperative "error checking" platform and "surgical nurse training module" can result in dramatic savings for both the surgeon's ASC and/or the hospital supply chain when utilized. Implant companies are developing methods to employ these models in the United States and Europe. SDSD with or without an overnight stay in the postoperative recovery room area in an ASC versus an overnight stay room adjacent to the ASC facility results in significant savings to the insurer. Some groups are utilizing hotels with RN monitoring or short or long term care centers for postoperative care. Summary and further considerations: SDSD after total joint TJA has significant advantages. Many patients are averse to stay- ing overnight in a hospital. It allows for surgery to be performed at ASCs that might not otherwise allow for an overnight stay. Pain control and the treatment of nausea must be aggressive in order to prevent delay in discharge, postoperative admissions or emer- gency room visits. Utilizing peripheral blocks and soft tissue anes- thetic injections surrounding the hip and knee joint have dramati- cally reduced pain symptoms. There is a significant decrease in cost utilizing this approach especially if STIs with an intraoperative error checking system are utilized. It is important to make certain that the patient's health insurance covers home PT and a home healthcare nurse. Appropriate patient selection and education is essential. The patient must understand that they are going to have to be responsible to perform their therapy at home with assistance or in an outpatient setting. They will need a caregiver with them at home for the first 48 to 72 hours. Ideally a home care nurse should be utilized as well as a home physical therapist for the first two to four days after surgery. Subsequently, OP PT should be performed. At least four weeks of anticoagulation with full dose ASA should be utilized in healthy patients without a history of predisposing factors that would require more aggressive anticoagulation treatment. n References Gondusky J et al. Day of Surgery Discharge after Unicompartmental Knee Arthroplasty: An Effective Perioperative Pathway. Jrn'l Arthroplasty 2014; (29): 516-519. Lovald S et al. Complications, Mortality and Costs for Outpatient and Short-Stay Total Knee Arthroplasty Patients in Comparison to Standard- Stay Patients. Jrn'l Arthroplasty 2014; (29):510-515. Kolisek F et al. Comparison of outpatient versus inpatient total knee ar- throplasty. Clin Orthop Relat Res.2009; 467 (6):1438-1445. Levin B et al. Blood Management Strategies for Total Knee Arthroplasty. Jrn'l Am Acad Orthop. 2014; Vol 22 (6): 361-371. Syncera, powered by Smith & Nephew, offers hospitals and other healthcare provid- ers a pioneering delivery model for clinically proven primary total hip and knee prod- ucts using cutting-edge technologies that streamline the orthopedic service offering and provide attractive economics. For more information visit www.syncera.com.