Causes and risk factors for same-day discharge failure after total hip and knee arthroplasty: a meta-analysis

Abstract

In recent decades, the trend toward early same-day discharge (SDD) after surgery has dramatically increased. Efforts to develop adequate risk stratification tools to guide decision-making regarding SDD versus prolonged hospitalization after total hip arthroplasty (THA) remain largely incomplete. The purpose of this report is to identify the most frequent causes and risk factors associated with SDD failure in patients undergoing THA and total knee arthroplasty (TKA). A systematic search following PRISMA guidelines of four bibliographic databases was conducted for comparative studies between patients who were successfully discharged on the same day and those who failed. Outcomes of interests were causes and risk factors associated with same-day discharge failure. Odds ratios (OR) were calculated for dichotomous variables, whereas mean differences (MD) were calculated for continuous variables. Meta-analysis was performed using RevMan software. Random effects were used if there was evidence of heterogeneity. Eight studies with 3492 patients were included. The most common cause of SDD failure was orthostatic hypotension, followed by inadequate physical condition, nausea/vomiting, pain, and urinary retention. Female sex was a risk factor for failure (OR 0.77, 95% CI 0.63-0.93), especially in the THA subgroup. ASA score IV (OR 0.33, 95% CI 0.14-0.76) and III (OR 0.72, 95% CI 0.52-0.99) were risk factors, as were having > 2 allergies and smoking patients. General anesthesia increased failure risk (OR 0.58, 95% CI 0.42-0.80), while spinal anesthesia was protective (OR 1.62, 95% CI 1.17-2.24). The direct anterior and posterior approaches showed no significant differences. In conclusion, orthostatic hypotension was the primary cause of SDD failure. Risk factors identified for SDD failure in orthopedic surgery include female sex, ASA III and IV classifications, a higher number of allergies, smoking patients and the use of general anesthesia. These factors can be addressed to enhance SDD outcomes.

Keywords: Failed discharge; Hip arthroplasty; Joint arthroplasty; Knee arthroplasty; Outpatient; Same-day discharge.

Figure 1

PRISMA flowchart depicting the study selection process for meta-analysis.

Figure 2

Forest plots showing the effect of age on same-day discharge failure risk. Mean age (A) and age over 65 years (B) were not associated with discharge failure. No differences were observed in patients under 50 years (C).

Figure 3

Forest plots of additional risk factors. Having more than 2 allergies was a risk factor for failure (A), while previous joint arthroplasty was associated with success (C). Earlier surgery time showed a protective effect (D). Smoking did not significantly impact outcomes (B).

Figure 4

Forest plots showing general anesthesia as a risk factor (a), and spinal anesthesia as protective against discharge failure (b). The type of approach did not show significant differences neither direct anterior (c) nor posterior (d) approach.