Daycase Hip and Knee Arthroplasty in Møre and Romsdal Trial

The increasing demand for hip and knee arthroplasty has created a need for more efficient perioperative pathways without compromising patient safety, recovery, or satisfaction. Advances in surgical technique, anaesthesia, multimodal analgesia, early mobilization, and structured follow-up have made discharge on the day of surgery feasible for selected patients. However, the proportion of patients who can complete a day-case pathway in routine clinical practice, and the reasons why intended same-day discharge is not achieved, may vary between hospitals and patient populations.

The DART Study will evaluate the implementation of a standardized day-case arthroplasty pathway across three hospitals within Møre og Romsdal Hospital Trust: Sjukehuset Nordmøre og Romsdal at Hjelset, Ålesund Hospital, and Volda Hospital. The study will include patients scheduled for primary total hip arthroplasty, total knee arthroplasty, or unicompartmental knee arthroplasty. The study is investigator-initiated and embedded in ordinary clinical care.

All patients scheduled for one of the eligible procedures during the recruitment period will be screened prospectively. Screening will document whether the patient fulfils the predefined criteria for participation in the day-case pathway.

The predefined eligibility assessment will include relevant medical, functional, cognitive, and logistical factors. Factors expected to preclude participation in the day-case pathway include severe systemic disease, advanced frailty, impaired cognition or inability to comply with instructions, body mass index above 40 kg/m², age above 80 years, and travel circumstances that make rapid access to an acute hospital difficult. Final eligibility will be determined by the treating clinical team according to the study criteria and an individual clinical assessment.

Patients included in the day-case pathway will receive standardized preoperative information and preparation. The perioperative pathway is designed to support early recovery and includes evidence-based anaesthesia, multimodal opioid-sparing analgesia, early oral intake, and mobilization shortly after surgery. Regional analgesic techniques will be adapted to the type of procedure. Patients undergoing knee arthroplasty will receive a genicular nerve block and femoral triangle block as part of the pain-management pathway. Patients undergoing total hip arthroplasty will receive a pericapsular nerve group block. The use and effect of the regional block will be documented. After a pericapsular nerve group block, the ability to perform active knee extension while sitting will be assessed as an indicator of quadriceps motor function.

After surgery, patients will be transferred to a dedicated postoperative day unit. Readiness for discharge will be assessed using standardized clinical criteria. These will include stable vital signs, satisfactory control of pain and nausea, ability to eat and drink, satisfactory urinary function when clinically required, safe mobilization with an appropriate walking aid, and the presence of adequate support after discharge. Patients must also understand the medication plan, postoperative instructions, warning symptoms, and whom to contact if problems occur.

Discharge on the day of surgery will be attempted only when the discharge criteria are fulfilled and both the patient and the responsible clinical team consider discharge appropriate. Patients who do not fulfil the criteria, develop a clinical problem, or do not feel ready to leave hospital will remain admitted according to usual clinical practice. The reason for an overnight stay or prolonged admission will be documented. Potential reasons may include pain, nausea or vomiting, dizziness, delayed mobilization, urinary retention, wound-related concerns, medical instability, logistical factors, or patient preference.

The study will record the time of discharge and classify patients according to whether they were discharged on the day of surgery or stayed in hospital overnight or longer. Same-day discharge will be defined as discharge to the patient's usual place of residence on the calendar day of surgery without an overnight hospital stay.

Baseline data will include age, sex, body mass index, American Society of Anesthesiologists physical status classification, Clinical Frailty Scale score, diagnosis, operated side, type of arthroplasty, and pain intensity. Relevant perioperative and surgical information will also be collected, including the regional analgesic technique, postoperative motor function where applicable, pain during rest and mobilization, and time of discharge.

Patient-reported outcome measures will be collected electronically at predefined time points. Before surgery, patients will complete joint-specific outcome measures according to the operated joint. Knee patients will complete the Knee injury and Osteoarthritis Outcome Score, and hip patients will complete the Hip disability and Osteoarthritis Outcome Score. Patients will also complete the Forgotten Joint Score, EuroQol 5-Dimension questionnaire, and numerical rating scales for pain.

Early postoperative recovery will be assessed using the Norwegian version of the 15-item Quality of Recovery questionnaire. This questionnaire will be administered on the day of surgery, on postoperative day 1, on postoperative day 3 and 7. Pain intensity at rest and during activity or mobilization will be recorded using numerical rating scales. Patients will keep a pain diary during the first postoperative week. Use of rescue opioid medication, including the number of immediate-release oxycodone tablets taken after discharge, will be recorded.

Patients will be contacted by telephone on the first postoperative day. The telephone consultation will assess general recovery, pain, medication use, possible complications, and the need for additional medical advice or assessment. Further follow-up will be conducted at approximately 7 days, 30 days, and 3 months after surgery.

Postoperative complications will be recorded prospectively and graded according to the Clavien-Dindo classification. Events of particular interest include venous thromboembolism, pulmonary embolism, myocardial infarction, stroke, surgical-site or periprosthetic infection, urinary retention, urinary tract infection, pneumonia, wound complications, and other medical or surgical events requiring treatment. For each complication, the study team will assess whether the event may be related to the day-case pathway.

Unplanned contacts with healthcare services will be documented, including telephone consultations, visits to a general practitioner, out-of-hours medical services, emergency department visits, and hospital admissions. Hospital readmissions within 30 days will be classified as all-cause readmissions and, where possible, as related or unrelated to same-day discharge. Reoperations and mortality will also be recorded.

At 3 months, recovery will be assessed using pain scores, quality-of-recovery assessment, joint-specific patient-reported outcomes, Forgotten Joint Score, and EuroQol 5-Dimension. These data will provide information on whether early discharge is associated with satisfactory short-term recovery and patient-reported health status.

The main analyses will be descriptive and will reflect implementation of the pathway in routine practice. The proportion of screened patients who fulfil the day-case eligibility criteria will be reported, together with the proportion of eligible patients who achieve same-day discharge. Reasons for exclusion from the pathway and reasons for unsuccessful same-day discharge will be summarized.

Patient characteristics, perioperative factors, early recovery, complications, healthcare contacts, readmissions, and patient-reported outcomes will be described for the study population. Outcomes may also be compared between patients discharged on the day of surgery and patients who remain in hospital overnight or longer. Exploratory analyses may be used to identify patient-related, procedural, logistical, or perioperative factors associated with successful same-day discharge.

Because discharge is determined by clinical readiness and not by random allocation, comparisons between discharge groups will be interpreted as observational associations. Statistical analyses may therefore include adjustment for relevant baseline differences, such as age, sex, body mass index, comorbidity, frailty, procedure type, and hospital.

The study is expected to include approximately 2-300 patients, with representation from both hip and knee arthroplasty pathways. Recruitment will continue for approximately 12 months if the planned number of participants is reached and may be extended to a maximum of approximately 18 months if necessary.

The DART Study will provide detailed information on patient selection, pathway completion, early recovery, safety events, and healthcare use after implementation of day-case hip and knee arthroplasty in a regional hospital system. The results are intended to support further refinement of patient-selection criteria, perioperative care, discharge procedures, and follow-up arrangements for day-case arthroplasty.

Inclusion criteria

• Patients 18-80 years old scheduled for primary TKA, UKA or THA

Exclusion criteria

• Patient not motivated for daycase surgery, lack of adult caregiver staying with the patient for the first 24 hours post-discharge, ASA class 3 (if not approved by anesthesiologist) and 4, travel distance to acute hospital no more than 1 hour (ferry-free), dementia or other reasons for lacking compliance (e.g. substance abuse, severe psychiatric disorder etc.) BMI >40 kg/m2, patients with anticipated high level of pain due to previous experience, comorbidity (i.e. chronic pain syndrome, fibromyalgia), patients treated with opoid analgesics on a regular basis prior to surgery.