Same-calendar-day discharge after hip and knee arthroplasty

Hot topic snapshot

Over the last decade there has been increasing institutional and societal pressure for cost savings and efficiency in both total knee arthroplasty (TKA) and total hip arthroplasty (THA). In the USA, the Centers for Medicare and Medicaid Services (CMS) removed TKA from the Inpatient-Only (IPO) List in 2018 and THA in 2020. Combined with cost containment, advancements in medical technology, arthroplasty techniques, and anesthesia and pain protocols, surgeons—particularly in the US—increasingly offer same-calendar-day discharge (SCDD) arthroplasty to select patients. A generalized reduction in length of stay has, however, been observed across multiple geographic regions, though regional differences remain.

Multiple studies have demonstrated the feasibility, safety, and efficacy of TKA and THA in the outpatient setting [1]. The benefits of same-day hip or knee arthroplasty include a lower risk of hospital-acquired infection, quicker return to normal activities, and a more comfortable recovery at home; good candidates include those patients who are motivated, in good general health, and who have a good support team at home. These efforts have led to the rise of ambulatory arthroplasty allowing carefully selected patients to be safely discharged on the day of surgery. Not only is SCDD THA or TKA safe, and affording similar outcomes to inpatient THA or TKA, it also potentially provides significant cost savings. The impetus of reducing healthcare costs has been an additional catalyst for this “paradigm shift” towards ambulatory arthroplasty.

In this article, we discuss the evolving trend toward same-calendar-day discharge with a pioneer in this field, Young-Min Kwon, and take a closer look at how this can be applied in other regions with Seung-Jae Lim.

In the field

Over the past 30 years, the average length of stay for, specifically, THA has decreased dramatically from 2 weeks to a couple of days. This has been achieved through a combination of innovations in patient education and perioperative care pathways, surgical and anesthetic techniques, blood conservation, multimodal pain management, and accelerated recovery pathways. When questioning how we can perform SCDD after THA or TKA, it is crucial to understand that the outpatient program has to contain essential elements, as described in the American Association of Hip and Knee Surgeons (AAHKS) and American Academy of Orthopaedic Surgeons (AAOS) joint position statement (for further reading, see the AAHKS Position Statement on Outpatient Joint Replacement in 2024 [1] and Karam et al [2]). When considering patients, such an outpatient program must involve good patient selection, patient education and expectation management, and good social support. From the side of the healthcare center, evidence-based pathways and protocols for anesthesia and pain management [2], blood conservation, wound management, mobilization, and venous thromboembolism prophylaxis should be in place. The clinical and surgical team’s expertise and experience is crucial, as Kwon states, “Having everyone in the team being on the same page helps to achieve the optimal outcome”. The health facility environment needs to be conducive to optimizing surgical outcomes, and finally postdischarge communication needs to be considered and followed through.

References

1. American Association of Hip and Knee Surgeons. Position Statement on Outpatient Joint Replacement. Published 2018; updated 2024. Available at: AAHKS-Outpatient-Position-Statement-2024.pdf. Accessed April 10, 2026.
2. Karam JA, Schwenk ES, Parvizi J. An Update on Multimodal Pain Management After Total Joint Arthroplasty. J Bone Joint Surg Am. 2021;103(17):1652–1662.
3. Scully RD, Kappa JE, Melvin JS. "Outpatient"-Same-calendar-day Discharge Hip and Knee Arthroplasty. J Am Acad Orthop Surg. 2020;28(20):e900–e909.
4. Sheridan GA, Howard LC, Neufeld ME, et al. Factors Associated With Length of Stay for Hip and Knee Arthroplasty: A 20-Year Single-Province Population-Based Analysis of Longitudinal Temporal Trends. Arthroplasty Today. 2023;24:101274.
5. French JMR, Deere K, Sayers A, et al. Trends in hip and knee replacement length of stay and patient demographics in England: a population-based study of 1,455,842 primary procedures. BMC Medicine. 2025;23(1):561.
6. Richardson MK, Wier J, Liu KC, et al. Same-Day Total Joint Arthroplasty in the United States From 2016 to 2020: The Impact of the Medicare Inpatient Only List and the COVID-19 Pandemic. J Arthroplasty. 2024;39(4):858–863.e852.
7. Gleicher Y, Peacock S, Peer M, et al. Transitioning to outpatient arthroplasty during COVID-19: time to pivot. Cmaj. 2021;193(13):E455.
8. Klemt C, Cohen-Levy WB, Pattavina MH, et al. The Same Day Discharges following Primary Total Knee Arthroplasty: A Single Surgeon, Propensity Score-Matched Cohort Analysis. J Knee Surg. 2023;36(13):1380–1385.
9. Skopec L, Berenson RA, Simon B, et al. Variation in processes of care for total hip arthroplasty across high-income countries. Health Aff Sch. 2024;2(4):qxae043.
10. Kuwakado S, Kawaguchi K, Sakugawa A, et al. Factors Affecting the Length of Convalescent Hospital Stay Following Total Hip and Knee Arthroplasty. Prog Rehabil Med. 2021;6:20210033.
11. Tokunaga J, Imanaka Y. Influence of length of stay on patient satisfaction with hospital care in Japan. Int J Qual Health Care. 2002;14(6):493–502.
12. Fan Y, Xu Q, Jin G, et al. The cost of total hip arthroplasty: compare the hospitalization costs of national centralized procurement and national volume-based procurement. Front Public Health. 2024;12:1383308.