Is outpatient TJR the new frontier for orthopedics? 4 surgeons discuss


Four total joint replacement surgeons weigh in on the trajectory of total joint procedures in the outpatient setting.

Ask TJR surgeons is a weekly series of questions posed to orthopedic surgeons around the country about clinical, business and policy issues affecting orthopedic care. We invite all orthopedic surgeon and specialist responses.


Next week's question: Is independent practice still a viable option for TJR surgeons or would you recommend young surgeons seek hospital employment?

Please send responses to Anuja Vaidya at by Thursday, July 6, at 5 p.m. CST.


Question: In what ways will outpatient TJR evolve in the next five to 10 years?


G. Daxton Steele, MD. Total Joint Replacement Surgeon at Andrews Institute for Orthopaedics & Sports Medicine (Gulf Breeze, Fla.): I'd say we're still in the learning phase in regards to outpatient total joints. There are some physicians that will continue to push the envelope, and some physicians will sit back and wait to see what develops. Over the next five to 10 years we should learn a lot more about who are the optimal patients that we can perform total joint surgeries on in an outpatient setting and those for whom it's not quite as safe or optimal to do so.


Michael J. Chmell, MD. Orthopedic Surgeon at OrthoIllinois (Rockford): Depending on our government, and what happens with Medicare, I would foresee up to 50 percent of TJR done on an outpatient basis 10 years from now. I expect the rapid evolution in anesthetic and pain management techniques that is occurring now to continue, resulting in even better outcomes and more outpatient TJRs in the future.


Matthew S. Austin, MD. Adult Reconstruction Division Chief and Adult Reconstruction Fellowship Director at Rothman Institute (Philadelphia): The practice of evidence-based medicine has shortened TJR patient average length of stay to well under two days and patients are going home safely, without the hassle or additional cost of unnecessary post-acute care.


Cost curves have been driven down as a result but are flattening, or will flatten, in the near term. There is a finite amount to what can be saved until further clinical advancement is realized and regulations change. Outpatient joints are being touted as the next frontier for savings, but few surgeons are comfortable performing them in surgery centers, favoring instead the outpatient hospital setting as the test environment, and really only for the healthiest patients. Moreover, only 15 states have 23-hour stay rules in the outpatient setting which makes regulation a roadblock to potential advancement. Even CMS is unsure of a wholesale removal of TJR from its inpatient-only procedure list, and is considering only the removal of TKA after additional study.


Value-based care has been validated by its coordination of the interests of patient, provider and payer, and further by its ability to realize improved quality of care at lower costs. Continued advancement, however, needs deliberate execution to continue forward without steps backwards.


Jeffrey C. Davis, MD. Orthopedic Surgeon at Andrews Sports Medicine & Orthopaedic Center (Birmingham, Ala.): I anticipate continued growth in certain markets and improved protocols to insure safety and success. The model of joint replacement continues to go away from "sick model" to "well model" and the outpatient TJR trend will certainly accelerate this change. Continued improvements in multi-modal pain management and rehabilitation both before and after the procedure would be expected. Some modification of approaches and event implants is likely to occur during this time frame.


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