I'd been thinking about transitioning my total hips from inpatient to outpatient, but hadn't yet taken the leap when the bass fisherman walked into my clinic. He was quite blunt in telling me that he wasn't crazy about doctors and he certainly didn't want to spend a night in the hospital when he had his hip replaced. He was young and healthy, so I thought, "Why not?"

That decision, made back in 2013, was based on more than just the fact that I was confronted by an impatient patient. It was based on the positive results I'd been obtaining for years in inpatient ORs using an anterior approach.

I learned total hip replacement during my residency, using a posterior approach that kept patients in the hospital for at least 3 days. On the day after surgery, we removed the drain placed during the procedure. We changed the dressing the next day. On the third post-op day we referred the patient to an inpatient rehabilitation facility for 10 days to 2 weeks. These days, I reserve the posterior approach for those rare occasions when I need access to the back of the hip for technical reasons, such as removing previously placed implants from the posterior hip socket or acetabulum, or augmenting a deficient posterior wall of the acetabulum.

When I initially tried the anterior approach, I still kept patients in the hospital for 3 days, but I started noticing that they were more mobile soon after surgery, so I kept them hospitalized for only 2 days. Then I realized that some patients were ready to go home the day of surgery, which made me think: "Why am I doing this in the hospital? I have access to outpatient centers that have 23-hour observation and the capability to keep patients overnight."

Anterior is superior

That's when I began selectively choosing patients for surgery in the outpatient facilities, with the intention of keeping them overnight. That bass fisherman was the first member of this group, which eventually included 10 patients. Based on the positive results, I began a routine protocol in which I use the anterior approach and discharge the patient the day of surgery. Here's why the transition has proven to be beneficial.

• It's efficient. Surgery takes about 40 minutes to complete. It's done under spinal anesthesia, so patients don't have to be intubated. The anesthesia typically wears off in an hour or 2, and the patient can start to walk. Once patients regain motor and sensory function, a trained physical therapist mobilizes them, with the goal of walking 100 feet. Additional discharge criteria are pain control with oral medications, tolerating a normal diet without nausea, mobilization without orthostatic hypotension, stable vital signs/asymptomatic acute blood loss anemia and a successful episode of controlled voiding.
• At-home recovery is best. Rather than being discharged to another medical facility (rehab center), patients go home to sleep in their own beds and recuperate in safe, familiar surroundings. They can bear weight immediately and are mobile. They're usually able to walk to the bathroom or walk to the kitchen to make a sandwich. That makes the recovery phase easier on their caregivers.

Psychologically, patients do better when recovering at home instead of at a hotel or recovery facility. At home, they're in control of their surroundings, which is a great morale booster. They manage their activities and their medications. I give patients my cell phone number so that they can contact me immediately if they have problems or questions.

After 2 days at home, patients start on an outpatient physical therapy regimen. They drive to the physical therapy site, go in and complete their therapy, and then get back in the car and go home. That process is more beneficial for patients than having a therapist come to their house because the physical action of getting to and from therapy shows them what they're capable of doing. Before surgery, each patient goes through an intensive "pre-hab" protocol that teaches them how to get in and out of a car, climb stairs and so on, so they know what to expect. Using those skills soon after surgery promotes a sense of accomplishment.

Physical therapy usually lasts for about 10 visits, and I see patients in the clinic at 2 weeks and 6 weeks after surgery, at which time most patients are recovering nicely and able to do almost anything they want.

• Complications are rare. Our complication rate is less than 1%, which is comparable to or less than what's seen in inpatient settings. The 2 biggest post-op issues are pain control and blood management. It's important to do a good job of pain management: If you control patients' pain, they can move about and are ready for same-day discharge.

We manage pain with a multi-modal approach that includes medications provided before and after surgery, as well as a local injection of bupivacaine. Medications generally include a non-steroidal anti-inflammatory drug (NSAID), acetaminophen, an anti-anxiety medication and oxycodone. We give dexamethasone intraoperatively to help control pain and prevent nausea. We usually discontinue opioids by the first follow-up visit at 2 weeks post-op.

Some studies suggest that the anterior approach might result in more blood loss than the posterior approach, but I think that's dependent on the experience of the surgeon. I've done more than 500 hip replacements with the anterior approach in the outpatient setting, and have had to transfer only 1 patient to the hospital on the day after surgery because of symptomatic blood loss and anemia.

We do a couple of things to minimize the risk that patients will have asymptomatic anemia post-operatively. First, if patients are anemic pre-operatively, we determine why they are and consider ways to correct it, such as by giving them iron supplements. They might also have an occult GI bleed that needs to be treated. Second, we give oral tranexamic acid, a medicine that helps with clotting, to all patients before surgery. Spinal anesthesia also lets us maintain a lower blood pressure, which results in less bleeding. We also use hemostatic devices to help minimize blood loss.

No looking back

In our 5-year experience with anterior-approach total hip replacement, we've had low complication rates, high patient satisfaction and significant cost savings. If your surgeons and your facility are properly prepared and your patients carefully selected, outpatient total hips are a win for everyone involved. OSM