On a recent morning in Fremont, Calif., a group of orthopedic surgeons stood crowded around operating rooms inside Washington Outpatient Surgery Center, scribbling notes as patients moved through hip and knee replacements with striking speed.
Some had traveled from across the U.S. Others had flown in internationally.
What they came to study was not simply robotic surgery. It was a broader question rapidly reshaping orthopedics: How far can joint replacement safely move outside the hospital?
For Alexander Sah, MD, an orthopedic surgeon at Fremont, Calif.-based Sah Orthopaedic Associates and medical director of the outpatient joint replacement program at Washington Outpatient Surgery, the answer increasingly depends on building an entire outpatient system around precision, efficiency and repeatability, not just the surgery itself.
Inside Washington Outpatient Surgery, Dr. Sah and his team are performing increasingly complex robotic joint replacements in an ASC setting while redesigning workflows around same-day recovery.
“They see how all these technologies really reach their peak potential in the ASC setting,” Dr. Sah said. “Everything is built around efficiency, reliability and reproducibility.”
Dr. Sah specializes in hip and knee replacement surgery and has become nationally known for outpatient anterior hip replacement and ASC-based arthroplasty workflows. He also serves as chief medical officer for Think Surgical.
As outpatient joint replacement rapidly expands nationwide, programs like his are increasingly becoming a testing ground for how technology, staffing and operational redesign may reshape orthopedic surgery over the next decade.
Why outpatient orthopedics is accelerating
For years, hip and knee replacement surgeries were largely confined to hospitals, where patients often remained for several days after surgery. That model has shifted dramatically.
Advances in minimally invasive techniques, anesthesia protocols, pain management and perioperative care have steadily pushed joint replacement into outpatient settings.
Dr. Sah said anterior hip replacement, in particular, has helped accelerate that transition.
“Anterior hip replacement has really become the predominant way total hip replacements are done in the United States now,” he said. But according to Dr. Sah, the biggest operational challenge is no longer simply performing the surgery itself.
The challenge is building a system capable of delivering consistently reliable outcomes at scale.
“It’s all about throughput,” he said. “It’s all about having a very reliable and reproducible end product delivered to your recovery room.” That requires far more than surgical skill alone.
The technologies reshaping ASC workflows
Inside Dr. Sah’s program, technologies are layered across nearly every phase of care. Some focus on surgical precision. Others target operational efficiency. Others attempt to improve patient flow throughout the facility itself.
One platform uses AI to analyze intraoperative imaging during anterior hip replacement surgery, allowing surgeons to compare reconstructed anatomy against the patient’s native biomechanics in real time.
“Did you restore their leg length? Did you restore their offset? Did you restore the biomechanics to match the other side?” Dr. Sah said. “This AI technology allows objective evaluation almost instantaneously.”
The center has also adopted handheld robotic technology for knee replacement procedures, an approach Dr. Sah believes may fit outpatient environments more naturally than larger robotic systems traditionally designed around hospitals.
Unlike some larger robotic platforms that require multiple large carts and dedicated operating room space, he said newer handheld systems, such as Think Surgical’s Tmini miniature robotic system, allow surgeons to move more efficiently between operating rooms inside smaller ASC environments.
“Space is a commodity in the ASC,” Dr. Sah said. “You don’t have room for all these huge robots.”
He believes one reason outpatient robotic adoption has remained slower than expected nationally is that many systems were originally designed around hospital workflows rather than ambulatory settings. “There are a lot of hurdles,” he said. “Size of the robot, cost of the robot, how it disrupts your workflow and the fact that many are tied to a single implant platform.”
The operational side of the ASC has also become increasingly data-driven. Patients wear tracking bands that allow teams to monitor movement through preoperative holding, anesthesia, surgery and recovery areas in real time, helping identify bottlenecks and turnover inefficiencies.
“This gives you a great look at what’s happening to the patient experience and where there’s opportunity to be faster or better,” Dr. Sah said.
Even sterilization systems have been redesigned around faster turnover and reduced waste.
“All these little things add up,” he said.
Why team culture matters as much as technology
Despite the attention surrounding robotics and AI, Dr. Sah said the most important part of building a successful outpatient arthroplasty program has been team buy-in.
That includes nurses, surgical technicians, therapists, anesthesiologists and recovery staff, all of whom must understand both the operational goals and the patient expectations surrounding same-day discharge.
For many staff members, he said, the transformation becomes obvious once they begin seeing patients leave the ASC only hours after surgery, often walking independently or with minimal assistance.
“We’re used to joints being in the hospital for two or three days,” Dr. Sah said. “Now, you’re seeing patients leave in a few hours and spend the night in their own home with their own family.”
That shift, he believes, has fundamentally changed how outpatient orthopedic teams think about recovery.
The financial balancing act facing ASCs
The rapid expansion of outpatient orthopedics has also introduced new financial pressures. Robotics, AI platforms and advanced sterilization systems represent major capital investments for ASCs already operating within tight margins.
Dr. Sah said one of the biggest challenges is determining which technologies genuinely improve outcomes, and which simply add cost.
“There are so many places where you could spend, spend, spend,” he said. “The question is: What benefit is it actually giving you?”
Dr. Sah said some of the clearest validation came when the ASC independently chose to purchase technologies after seeing how they affected workflows and efficiency. In multiple cases, he said, administrators acquired systems without him directly requesting them.
“I think that shows they saw the true benefit of these technologies,” he said.
Still, Dr. Sah believes outpatient orthopedic programs must remain disciplined about avoiding technology adoption for its own sake. “In the ASC, the bottom line is everything,” he said.
What the next phase of outpatient orthopedics may look like
As more surgeons visit programs like Washington Outpatient Surgery to study workflows and technology adoption, Dr. Sah believes outpatient joint replacement will continue expanding rapidly nationwide.
“Industry partners all see this as the next phase,” he said. But he believes the future of outpatient orthopedics may look different depending on geography, physician alignment models and health system structures.
Some markets may favor surgeon-owned ASCs. Others may rely on hospital partnerships or joint ventures with large ASC operators.
“There are many different business models,” Dr. Sah said. “A lot of what visitors are trying to figure out is what works best in their own geography and practice situation.”
What many of the visiting surgeons seemed to recognize, Dr. Sah said, is that outpatient orthopedics is no longer simply about moving cases out of hospitals. Increasingly, it is about redesigning the entire surgical experience around efficiency, recovery and scale.
For many orthopedic leaders, that future is no longer theoretical. It is already operating inside ASCs today.
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