Same-Day Total Hip and Knee Arthroplasty: The Anesthesiologist’s Expanding Role in Ambulatory ERAS

Introduction: The Evolution of Outpatient Joint Replacement

The movement of elective primary THA and TKA toward same-day discharge reflects broad advances in surgical care, multimodal analgesia, blood conservation, patient education, perioperative medicine, and organized ERAS pathways. It is not the result of any single technical intervention. [1,3]

A 2025 systematic review and meta-analysis of prospective studies found no statistically significant difference in pooled readmission or overall complication rates between outpatient and inpatient joint arthroplasty. However, these findings warrant cautious interpretation. Outpatient cohorts represent highly selected populations, and the included studies were notably heterogeneous. [2] Accordingly, the term “outpatient” should not be interpreted as inherently lower risk. Contemporary programs instead seek to identify patients whose medical condition, surgical circumstances, functional capacity, and social environment permit safe recovery at home after predefined discharge criteria have been met. [1]

Medicare policy has also progressively increased flexibility regarding the surgical site of service. THA and TKA were removed from the inpatient-only framework prior to 2026. For the 2026 calendar year, the Centers for Medicare & Medicaid Services continued the broader removal of procedures from the inpatient-only list and expanded the ambulatory surgical center covered-procedure framework, all while emphasizing physician judgment regarding clinical appropriateness. [14]

It is vital to remember that payment eligibility and clinical suitability are separate questions. Medicare policy can permit outpatient payment for a procedure without establishing that an individual patient is medically or functionally appropriate for same-day discharge. [14]

The Expanding Role of the Anesthesiologist in Ambulatory ERAS

Discussions of anesthesia for joint replacement have traditionally emphasized the choice between neuraxial and general anesthesia. [4,5] While that decision remains highly relevant in ambulatory ERAS, it represents only one component of comprehensive perioperative care. An uncomplicated intraoperative anesthetic does not, by itself, establish readiness for discharge several hours later. [1,3]

Successful discharge also depends on adequate pain control, recovery of lower-extremity function, acceptable hemodynamics, control of nausea and vomiting, the ability to transfer and ambulate safely, and a reliable plan for post-discharge support. [1,3,11] The anesthesiologist thus influences the entire early recovery course. This influence begins with preoperative assessment and anesthetic planning, and extends through analgesia, PONV prevention, hemodynamic management, recovery from anesthesia, and preparation for mobilization. [1,3]

Patient Selection as the First Perioperative Intervention

A safe same-day pathway begins by identifying patients who are reasonable candidates for it. [1] The American Association of Hip and Knee Surgeons (AAHKS) emphasizes a multidisciplinary assessment incorporating medical comorbidities, anticipated postoperative monitoring needs, surgical complexity, social support, and physical barriers in the home environment. [1]

The goal is not to exclude every patient with chronic disease. Clinicians must instead distinguish stable, appropriately managed conditions from circumstances in which a few hours of postoperative observation may not provide an adequate safety margin. [1,15]

A 2024 systematic review incorporating 11 studies and 157,045 patients identified associations between failed same-day discharge and factors including older age, hypertension, diabetes, cardiovascular disease, chronic obstructive pulmonary disease, obesity, higher postoperative pain, higher ASA classification, and later procedure start times. [13] However, many individual predictors appeared in only one or two component studies, substantially limiting the certainty and generalizability of individual risk estimates. [13] Furthermore, observed demographic associations, including sex and race, should not be converted into biological exclusion criteria. These relationships may simply reflect clinical, social, access-related, or other unmeasured factors. [13]

Structured medical risk tools can effectively supplement this clinical assessment. [15] In a 2025 multicenter study spanning 40 locations and identifying 12,809 primary arthroplasties, patients with Outpatient Arthroplasty Risk Assessment (OARA) scores below 60 or 80 were at least 2.6 times more likely to achieve same-day discharge. Higher scores were associated with more complications and readmissions. [15] While this study provides multicenter support for OARA as a risk-stratification adjunct, it remains Level III observational evidence. A numerical score should inform, rather than replace, individualized clinical assessment. [15]

Table 1. Practical Preoperative Assessment

Domain	Clinical question	Relevance to same-day discharge
Medical stability	Are important cardiopulmonary, renal, metabolic, or other conditions sufficiently stable for rapid postoperative transition? [1,13]	Anticipated need for prolonged monitoring may favor observation or inpatient care. [1]
Analgesic risk	Is the patient opioid tolerant or particularly vulnerable to sedating analgesic adjuncts? [16,17]	Pain, sedation, and opioid adverse effects may interfere with recovery and mobility. [13,16,17]
PONV risk	Does the patient have clinical risk factors for PONV or post-discharge nausea and vomiting? [11]	Prevention can directly influence hydration, medication tolerance, mobility, and discharge. [11]
Function and support	Is safe ambulation expected, and is reliable assistance available after discharge? [1]	Same-day recovery extends well into the home environment. [1]
Surgical and logistical factors	Is this a routine primary procedure, and is sufficient time available for postoperative recovery and functional assessment? [1,13]	Greater complexity and late operating-room timing can reduce the likelihood of same-day discharge. [1,13]

Spinal Versus General Anesthesia: An Unresolved Debate

Spinal anesthesia is frequently incorporated into rapid-recovery arthroplasty programs, but contemporary outpatient evidence does not establish it as mandatory for successful same-day discharge. [1,4,5]

A 2024 retrospective matched-cohort study compared 105 general anesthesia cases with 105 spinal anesthesia cases at a single freestanding ambulatory surgery center. All spinal anesthesia patients and 103 of the 105 general anesthesia patients were discharged on the day of surgery, a difference that was not statistically significant. [4] Recovery time depended partly on the specific spinal anesthetic used. Mean time before facility discharge was 206 minutes with mepivacaine spinal anesthesia, 227 minutes with general anesthesia, and 291 minutes with bupivacaine spinal anesthesia. [4] In the same cohort, patients receiving general anesthesia had higher early postoperative pain scores and more nausea than those receiving either spinal regimen.

These outcomes describe one specific retrospective pathway and do not establish that general anesthesia universally produces worse pain or PONV than spinal anesthesia. [4] The study perfectly illustrates why a simple “spinal versus general” comparison can be misleading. The specific neuraxial drug, duration of motor block, general anesthesia technique, opioid exposure, antiemetic strategy, and surrounding ERAS pathway all heavily influence recovery. [4]

The remaining uncertainty is substantial enough to warrant prospective study. The GASPS trial, published as a multicenter randomized trial protocol in 2026, was designed specifically because no completed randomized controlled trial had compared general with spinal anesthesia for outpatient primary THA and TKA using same-day discharge as the targeted pathway outcome. [5] Its primary outcome is successful discharge on the day of surgery without readmission within 48 hours. Secondary and exploratory assessments include discharge readiness, quality of recovery, safety, pain, PONV, opioid consumption, mobilization, and patient-reported outcomes. [5] Until these randomized results are available, anesthetic selection should remain individualized rather than doctrinal. [4,5]

Functional Recovery as the Primary Endpoint

Ambulatory arthroplasty changes the practical definition of a successful anesthetic. Intraoperative stability continues to be essential, but success also depends heavily on recovery during the first several postoperative hours. [1,3]

Residual lower-extremity weakness can interfere directly with transfers and ambulation. Excessive sedation can delay participation in functional assessment. Uncontrolled pain can prevent weight bearing and movement. PONV can impair oral intake and mobility, ultimately contributing to an unsuccessful discharge. [1,6,11,13,16,17] The relevant endpoint is therefore an integrated recovery profile rather than a single anesthesia-related metric. [1,3]

Regional Analgesia for Total Knee Arthroplasty: Balancing Pain Relief and Motor Function

TKA presents an important clinical tradeoff between achieving analgesia and preserving motor function. [6] Multisociety guidance supports peripheral nerve blockade as an analgesic strategy but distinguishes among techniques according to their analgesic benefit and motor effects. A femoral nerve block can significantly impair quadriceps function, whereas adductor canal techniques generally better preserve motor function while still contributing to analgesia. [6]

For a patient expected to stand and ambulate within hours, that distinction has direct functional relevance. Motor-sparing approaches are therefore highly attractive when peripheral nerve blocks are incorporated into a same-day discharge pathway. [1,6] However, no regional technique should be considered in isolation from periarticular infiltration, systemic multimodal analgesia, surgical technique, local expertise, and specific discharge requirements. [6]

Regional Analgesia for Total Hip Arthroplasty: Weighing the Incremental Benefits

The regional anesthesia decision after THA is less uniform. [7] Multisociety guidance identifies potential analgesic or opioid-sparing benefits from selected regional approaches, while simultaneously recognizing differences in evidence strength, technical complexity, motor effects, and comparisons with periarticular or local infiltration strategies. [7]

Outpatient status alone is not an indication to add a particular hip block. The relevant clinical question is whether the incremental analgesic benefit is likely to justify the procedural burden and potential adverse effects within that specific recovery pathway. [7]

Multimodal Analgesia as a Comprehensive Recovery Strategy

Pain control is essential after THA and TKA, but the objective of an ambulatory pathway is not maximal analgesia at any physiologic cost. [1,3] The goal is to provide sufficient comfort to permit movement while limiting nausea, excessive sedation, respiratory depression, motor impairment, and other treatment-related barriers to recovery. [1,11,16,17]

Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are evidence-supported components of multimodal analgesia in primary total joint arthroplasty when clinically appropriate. [9,10] The ERAS Society recommends routine NSAID use in patients without contraindications and specifically cautions against inappropriate use in patients with pre-existing kidney disease. [3] Perioperative corticosteroids can also reduce postoperative pain, opioid requirements, nausea, and vomiting, thereby addressing several recovery barriers simultaneously. Their use still requires careful patient-specific assessment. [8]

Opioids remain effective rescue analgesics, but ERAS pathways emphasize minimizing opioid exposure. Drowsiness, respiratory depression, nausea, vomiting, urinary retention, and other opioid-related effects can severely interfere with early recovery. [3,16]

The Nuanced Role of Gabapentinoids in Multimodal Regimens

Gabapentin and pregabalin should not be treated as interchangeable simply because they belong to the same drug class. [17] AAHKS multisociety guidance concluded that perioperative gabapentinoids did not reduce postoperative pain overall, although pregabalin specifically reduced opioid consumption. After discharge, pregabalin demonstrated reductions in postoperative pain and opioid consumption in the evidence reviewed for the guideline, whereas gabapentin did not. [17]

Furthermore, gabapentinoids may increase sedation and respiratory-depression risks, particularly when combined with opioids or other central nervous system depressants. [17] For a same-day pathway, these tradeoffs support selective, patient-specific use rather than the automatic inclusion of a gabapentinoid in every multimodal regimen. [17] The operative principle is multimodal optimization rather than maximal medication use. [3,9,10,16,17]

Postoperative Nausea and Vomiting Prevention as a Discharge Intervention

PONV has particular relevance in ambulatory arthroplasty because nausea or vomiting can impair hydration, oral medication tolerance, mobilization, and readiness to travel home. [1,11] The Fifth Consensus Guidelines for PONV, published in 2025, update previous guidance and continue an algorithmic approach incorporating risk assessment, baseline-risk mitigation, prophylaxis, and rescue therapy. [11]

Within enhanced-recovery pathways, multimodal PONV prevention is a major component of recovery planning. Risk-reduction strategies include opioid-sparing analgesia, adequate hydration, regional anesthesia when appropriate, and anesthetic techniques that decrease baseline PONV risk. [11] The guideline supports combination prophylaxis rather than waiting for symptoms to develop, with prophylactic intensity increasing as risk rises. [11] This approach is especially relevant to ambulatory surgery because post-discharge nausea and vomiting may develop after the patient has already left the monitored environment. [11]

The 2024 outpatient arthroplasty cohort provides one example of why PONV prevention must be integrated with anesthetic selection. Nausea occurred more frequently in the general anesthesia group than in either spinal group in that particular study. [4] That observation should inform risk mitigation, but it should not be generalized into a universal claim that general anesthesia necessarily produces more PONV in every contemporary pathway. [4,11]

Managing Hemodynamics, Hydration, and Blood Conservation

Blood conservation is an established component of enhanced-recovery arthroplasty care. [1,3] Multisociety clinical guidance supports tranexamic acid (TXA) as an effective blood-conservation strategy in total joint arthroplasty when clinically appropriate. [12] AAHKS also identifies minimizing blood loss and preventing dehydration as vital contributors to rapid recovery. [1]

For the anesthesiologist, the practical objective is to maintain adequate perfusion and hemodynamic stability compatible with early standing and ambulation, rather than pursuing a single intraoperative blood-pressure or fluid target for every patient. [1,3] Postoperative symptoms during mobilization remain clinically important even when the intraoperative course was apparently uncomplicated. [1,3]

Integrating the Recovery Area into the ERAS Pathway

A high-functioning outpatient arthroplasty program limits unnecessary delays between surgery and meaningful functional assessment without jeopardizing safety. [1,3] This requires tight coordination among anesthesia, nursing, surgery, physical therapy, and discharge personnel, rather than isolated sequential care. [1]

A 2026 quality-improvement study of primary THA illustrates this systems approach. Iterative changes within an established ERAS-based same-day program improved discharge efficiency and decreased complications that interfered with same-day discharge, all without a detected increase in overall postoperative complications. [18] Because this was a nonrandomized quality-improvement project conducted within a specific institutional pathway, the findings do not establish universal superiority of its individual anesthetic components. [18] The broader takeaway is that reliable same-day discharge is ultimately a product of coordinated process design. [1,18]

Defining Clinical and Functional Discharge Readiness

Same-day discharge should depend on clinical and functional readiness rather than elapsed clock time alone. [1,3] AAHKS emphasizes the assessment of safe transfers, protected ambulation, stair training when applicable, adequate recovery, and post-discharge communication. [1]

Table 2. Practical Discharge Domains

Domain	Desired state
Hemodynamics	Sufficient stability for standing and ambulation without clinically important symptoms. [1,3]
Motor recovery	Adequate lower-extremity function for safe transfer and walking. [1,6]
Pain	Controlled sufficiently to permit movement using the planned outpatient regimen. [1,9,10,16]
Nausea and vomiting	Controlled sufficiently for hydration, medications, mobility, and travel home. [11]
Function	Transfer and ambulation capability demonstrated; stairs assessed when relevant to the patient’s home environment. [1]
Home plan	Appropriate assistance, medications, instructions, communication pathway, and access to postoperative clinical support. [1]

A patient who does not satisfy these criteria should not be discharged merely to preserve an institutional same-day discharge target. [1] Conversion from intended same-day discharge to extended observation or inpatient care can represent the correct application of a safety pathway rather than a failure of the pathway itself. [1]

Understanding the Mechanisms Behind Failed Same-Day Discharge

Failed same-day discharge is inherently multifactorial. [13] Systematic-review evidence identifies associations with both patient-related and modifiable perioperative factors, including medical comorbidity, greater postoperative pain, later procedure timing, and other characteristics. [13] Several common barriers are directly or indirectly influenced by anesthesia management, including uncontrolled pain, nausea, sedation, residual motor blockade, hemodynamic intolerance, and delayed mobility. [1,6,11,13,16,17]

Quality-improvement analysis is most informative when unsuccessful same-day discharge is classified by mechanism. A persistent motor blockade represents a very different systems problem from inadequate social support, late surgery, uncontrolled pain, or medical decompensation. [1,13,18]

Standardizing Decision Points Without Rigid Protocols

Standardization improves reliability, but excessive protocol rigidity can conflict with individualized care. [1,3] THA and TKA patients differ widely in comorbidity burden, baseline function, opioid exposure, pain sensitivity, PONV risk, home support, and contraindications to particular anesthetic or analgesic techniques. [1,13,16,17]

A more defensible approach is to standardize decision points while allowing the specific intervention selected at each point to vary. [1,3] For example, every patient can undergo a PONV risk assessment without receiving an identical antiemetic regimen. [11] An opioid-sparing pathway can be standardized without administering an NSAID to a patient with a clear contraindication. [3,10] Rapid restoration of lower-extremity function can remain a universal goal without mandating spinal or general anesthesia for every single patient. [4,5]

Navigating Special Populations and Higher-Risk Patients

The expansion of outpatient arthroplasty does not make conventional medical risk irrelevant. [1,13,15] Greater comorbidity burden is consistently associated with a lower probability of successful same-day discharge during observational research. [13,15] These associations do not establish a universal list of prohibited diagnoses. Rather, they support coordinating the planned setting and duration of postoperative monitoring to the patient’s anticipated physiologic and functional recovery requirements. [1,15]

Advanced age alone likewise should not function as an automatic exclusion criterion. Its significance depends entirely on accompanying comorbidity, functional reserve, mobility, home environment, and support needs. [1,13] Patients receiving chronic opioids or other sedating medications require additional attention, as achieving adequate postoperative analgesia without excessive central nervous system effects may be considerably more difficult. [16,17]

A Practical Anesthesia Framework for Planned Same-Day Discharge

A contemporary ambulatory arthroplasty strategy can be organized around five core objectives rather than around one preferred anesthetic.

1. Determine Whether Same-Day Discharge Is Clinically and Socially Reasonable: Consider medical stability, surgical complexity, anticipated monitoring requirements, functional status, and home support. Structured risk tools can supplement, but should never replace, clinical judgment. [1,13,15]
2. Choose Anesthesia for Recovery Characteristics as Well as Intraoperative Conditions: Both spinal and contemporary general anesthesia can support successful outpatient THA and TKA. Definitive randomized evidence establishing the superiority of either approach for same-day discharge remains pending. [4,5]
3. Build Analgesia Around Function: Use evidence-supported multimodal therapy and procedure-specific regional or local techniques while limiting avoidable motor weakness, excessive sedation, and opioid-related adverse effects. [6-10,16,17]
4. Prevent Predictable Barriers to Discharge: PONV prophylaxis, blood conservation, appropriate hydration and hemodynamic management, and avoidance of excessive residual anesthetic effects should be considered components of the discharge pathway instead of isolated intraoperative decisions. [1,11,12]
5. Preserve a Safe Exit From the Outpatient Pathway: Patients who fail predefined functional or clinical criteria should receive additional observation or inpatient care when necessary, rather than being discharged solely to meet an outpatient performance target. [1]

Clinical Implications for Perioperative Care

Same-day arthroplasty broadens the anesthesiologist’s responsibility from simple intraoperative anesthetic delivery toward the management of an integrated perioperative recovery system. [1,3] The central question is not just which anesthetic should be used. It is which combination of patient selection, anesthetic technique, analgesia, PONV prevention, physiologic management, and recovery processes offers a particular patient the best probability of safe functional recovery on the day of surgery. [1,3]

This complexity also explains why observational comparisons of spinal and general anesthesia can be so difficult to generalize. Outcomes depend not only on the broad category of anesthesia but also on exactly how that anesthetic is delivered and on the surrounding ERAS pathway. [4,5]

Acknowledging the Limitations of Current Evidence

Outpatient arthroplasty research remains susceptible to selection bias because patients selected for same-day discharge are often healthier or treated in experienced, highly organized programs. [1,2] Results from selected outpatient cohorts therefore cannot be extrapolated automatically to patients who would not meet outpatient eligibility criteria. [1,2]

Many studies evaluating predictors of failed same-day discharge are observational, and several candidate predictors have been inconsistently replicated. [13] Evidence strength also differs significantly among regional techniques and analgesic interventions. [6,7] Most importantly, as of the August 7, 2026 evidence cutoff, a completed randomized trial specifically comparing general with spinal anesthesia within a contemporary outpatient THA and TKA pathway targeting same-day discharge had not yet been identified. [5] The ongoing GASPS trial is explicitly designed to address this evidence gap. [5]

Future Directions and Unanswered Questions in Outpatient Arthroplasty

Moving forward, the medical community needs more robust data to guide our most difficult clinical decisions regarding outpatient joint replacement. Future studies must assess the entire recovery profile rather than limiting comparisons to operating-room or postanesthesia care unit duration. [4,5]

Relevant outcomes need to include successful same-day discharge, time to discharge readiness, pain scores, PONV incidence, opioid exposure, motor recovery, mobilization milestones, unplanned observation, early readmission, quality of recovery, patient experience, and economic outcomes. [4,5] Crucially, studies should also distinguish between specific implementations of spinal and general anesthesia instead of treating each broad category as a homogeneous intervention. [4,5]

Finally, additional external validation of selection tools and prospective study of patients with greater medical complexity will become increasingly important if outpatient eligibility criteria continue to broaden across healthcare systems. [2,15]

Conclusion: Redefining the Anesthesiologist’s Role in Joint Replacement

Same-day THA and TKA are best understood as multidisciplinary perioperative pathways rather than conventional arthroplasties with an unusually short length of stay. [1,3] Current evidence strongly supports careful patient selection, coordinated ERAS infrastructure, multimodal analgesia, procedure-specific regional strategies, PONV prevention, blood conservation, early functional assessment, and reliable post-discharge support. [1,3,6-12]

Evidence available through August 7, 2026, does not establish one anesthetic technique as universally superior for same-day THA and TKA. A multicenter randomized trial is currently addressing the unresolved general-versus-spinal comparison. [4,5]

The anesthesiologist’s expanding role therefore lies not merely in choosing between neuraxial or general anesthesia. It includes helping to create a comprehensive recovery trajectory in which analgesia, consciousness, motor function, hemodynamics, nausea control, and mobility converge early enough for safe discharge, while preserving a clear and safe pathway to additional care when they do not. [1,3,11]

References

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