Archive Orthopedic Surgery 2018

On Point

The Changing Landscape of Orthopedics

P. Maxwell Courtney

P. Maxwell Courtney, MD


ONE OVERNIGHT Researchers say next-day, rather than same-day, discharge for some Medicare patients who undergo joint replacement represents the "sweet spot" for minimal complications.

Alate-afternoon hip revision is a cruel way to end a busy surgeon's day, but it struck me after I finished that case that revision surgery is symbolic of orthopedics today. Let's put aside for a moment that revision arthroplasty is a technically challenging surgery to perform. Many surgeons are not compensated appropriately for their time and work, often taking a stressful 4 hours to revise a well-fixed hip replacement when they could perform 5 primary replacements in the same time. Instead, let's focus on what the increase in joint revisions says about the state of our specialty.

  • Revision burden. First, it tells us that patients are outliving their original joint implants, which for most patients last 10 to 20 years. We can expect a steady stream of revisions — and not just because more people are undergoing joint replacements at a younger age and living longer, more active lives. Studies show that patients have about a 10% chance of having a revision of their hip or knee replacement after 10 years. With newer plastic inserts, most of the revisions I'm performing now are no longer for wear and tear, but for periprosthetic fractures and joint infections.
  • Not everyone's a candidate for same-day discharge. Now that Medicare is on board with outpatient total knee arthroplasty (TKA) reimbursement, it's important to remember that we shouldn't rush every patient out the door in 4 hours. Yes, we're performing more and more joint replacements in ambulatory surgical centers, but not every patient is a candidate for same-day discharge. For a subset of healthy Medicare patients with a complication rate similar to an inpatient stay, next-day (23-hour) discharge may be the "sweet spot" that minimizes complications, according to a study in The Journal of Arthroplasty that I co-authored (

Our study compared the complication rates among outpatient (same-day discharge), short-stay (discharge within 1 day) and inpatient TKA in the hopes of identifying the ideal candidates for an outpatient or short-stay procedure. We concluded that older patients with medical comorbidities should at least spend the night.

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