Should We Expand Outpatient Total Joint Selection Criteria? Re-exploring Hard Stop Criteria.

Abstract

The increasing adoption of same-day discharge (SDD) for total hip (THA) and total knee arthroplasty (TKA) at ambulatory surgical centers (ASCs) has excluded patients who have "hard stop" (HS) medical comorbidities. However, it is believed these criteria better predict 90-day complications than predict SDD failure. Therefore, the purpose of this study was to examine 24-hour and 90 day complications in patients who have and do not have HS comorbidities undergoing THA and TKA. A retrospective review from January 21, 2021, to September 18, 2024, was performed on all patients who underwent THA or TKA at an academic ASC after intentional preoperative screening and medical optimization per institutional protocols. Demographic information, International Classification of Diseases-10 codes, preoperative lab values and 24-hour, and 90-day complications were recorded. A total of 2,368 patients met inclusion criteria, of which 437 (18.5%) had ≥ 1 HS criteria. Patients were stratified into two groups: those meeting ≥ 1 HS criteria and those who did not. Odds ratios (ORs) for 24-hour and 90-day complications. In total, 15 patients (0.6%) experienced at least one 24-hour complication that resulted in direct hospital admission from the ASC or readmission within 24 hours. There were 12 (5.3%) patients who had at least one complication between one and 90 days. Patients who had HS comorbidities showed no significant difference in 24-hour complication rates (OR: 0.7, 95% confidence interval: 0.2 to 2.6) but had significantly higher odds of 90-day complications (OR: 1.7, 95% confidence interval: 1.1 to 2.6) than those who did not. Robust pre- and perioperative protocols enabled safe SDD for high-risk patients traditionally excluded by HS criteria. Our study demonstrates that HS criteria better predict 90-day complications than SDD failure. Further research is needed to develop tools to reliably identify patients at risk of 24-hour complications because, ultimately, this is paramount for evaluating ASC candidacy.