In my corner of the world, the days of routine inpatient ACL reconstruction surgery are long gone. In fact, those days never even existed for me. Since I started my solo practice nine years ago, I have performed as many as 50 outpatient ACL reconstructions a year. I have admitted just one young patient because he could not void right away.

From every vantage point, outpatient ACL reconstruction makes sense. The procedure has low morbidity. Unlike a major general surgical case, there are no fluid shifts and there is no excessive bleeding. Technological advances now allow us to perform quicker procedures with less post-op morbidity. Modern pain management has greatly improved pain control. And outpatient ACL reconstruction is drastically cheaper - with estimated savings ranging up to nearly 60 percent depending on the setting and circumstance.^1,2,3,4

Technological Advances
A primary technological advance has been the development and refinement of arthroscopic and endoscopic surgery, which allows us to perform the whole procedure - including harvesting of the bone-patellar-bone autograft, creation of the tibial and femoral tunnels, and graft fixation -through a single working incision. Like many ACL surgeons, I no longer even consider a lateral vastus incision for creating the femoral tunnel or affixing the femoral plug.

Several more recent advances have also made outpatient ACL reconstruction not only possible but preferable for me and my patients. They include:

- Precision jigs. These help reduce operative time. I use a system that uses the PCL as an anatomic landmark for locating and creating the tibial tunnel. It has eliminated much of the time-consuming 'seek and find' aspects of the procedure.

High-flow pumps. Like many arthroscopic surgeons, I now use a high-flow irrigation pump. This provides consistent distention of the joint capsule and hemostasis, allowing me to visualize the joint structures without a tourniquet in most cases. This approach eliminates the postop hemarthrosis and pain associated with tourniquet use, greatly improving recovery. In the less common cases in which visualization is suboptimal, I inflate the tourniquet, and rarely, I aspirate fluid from the site and create the femoral tunnel with the knee dry. I also 'footprint' the femoral hole to a depth of 10 mm to verify that there is a back wall and ensure proper, posterior femoral graft placement.

Modern Pain Management
Perhaps the most critical element of successful outpatient ACL reconstruction is good pain management. I believe there are three important elements of effective pain management. They include:

- Patient education. Before surgery, my team makes every effort to help patients anticipate the level and course of postoperative pain. When we manage their expectations, patients are much better equipped to manage their own pain.
- Local prophylactic analgesia. Before surgery, I use a liberal amount of local analgesia in an effort to pre-empt the neural blockade and thereby minimize the surgically-induced nociceptive sensitization that amplifies and prolongs postoperative pain. Although the true clinical benefit of pre-emptive analgesia is still unclear, my clinical experience suggests that it helps.
We strongly encourage regional anesthesia plus a femoral nerve block, which provides the pre-emptive neural blockade. We recommend the femoral nerve block because it provides 10- to 12-hour pain relief. When patients decline regional anesthesia and opt for general anesthesia, I inject the knee preoperatively with 20 cc lidocaine 1% and epinephrine, 20 cc marcaine 0.25%, and 5 cc morphine.
- Uninterrupted analgesia. To sustain the neural blockade, I make a strong effort to maintain an uninterrupted flow of analgesics. We encourage all patients who received general anesthesia to accept a femoral nerve block while still on the table or in the recovery room. Immediately after surgery, nearly all patients - whether they received general or regional anesthesia - also receive an intra-articular injection of 20 cc marcaine 0.25% along with another 5 cc of morphine, plus 30 mg IM ketorolac. The only exception is those patients who've had general anesthesia, accepted the post-op femoral nerve block, and have low body weight or other characteristics that may contraindicate the postop dose of marcaine; the anesthesiologist may skip the postop marcaine dose in these cases. I then place all patients into an ice machine. All patients leave for home with a continuous-flow ice machine and a prescription for Percoset or Oxycontin (the controlled release form of the same drug combination) that they received before surgery. Both options have advantages. Percoset has a quicker onset of action for fast pain relief. Oxycontin offers twice a day dosing, and it can be titrated up if the patient needs added pain relief. It also seems to aid sleep. Physical therapy begins on day 2, and all patients participate in a structured rehab protocol.

Follow-up
Some critics say that the outpatient approach is inefficient in the long run because patients require strict follow-up in the early postoperative period, which takes a lot of extra time, effort, and money. Some argue that a visiting nurse is needed to ensure patient safety and comfort.

There is no question that, simply by virtue of performing ACL reconstruction on an outpatient basis, surgeons take on the added responsibility of a rigid early follow-up schedule. Indeed, the reality that my patients go right home motivates me to be very diligent with follow-up, but I don't view this as a disadvantage. I have settled into a system that works well for my patients, my staff, and me and adds little extra burden to my practice. I send all patients home with a brace and an icing regimen and instruct them to move about. We call all patients the night of surgery to ensure they are taking their medications and to change the drug regimen if breakthrough pain occurs. We also make sure they are using ice and experiencing a normal post-op course (e.g., the patient is afebrile, up and moving, does not have excessive swelling, etc.). We call them again the next day with the same goals in mind. We then see all patients on post-op day two or three for an in-office assessment and again at 10 days for removal of stitches. With this schedule, I need only conduct one extra visit (at day three), and I have a high level of confidence that we will become aware of any complications should they occur. To date, I have encountered only one case of deep vein thrombosis at eight weeks post-op.

I have also found that a visiting nurse is not only unnecessary for my patient population but may be counterproductive. We used to employ a male nurse to visit our patients after surgery. But we found that this made no difference in their comfort or satisfaction level.

It All Adds Up.
Overall, I have found that the benefits of outpatient ACL reconstruction far outweigh any potential disadvantages. A colleague and I performed an economic study and found that the average cost difference between ambulatory ACL reconstruction and inpatient ACL reconstruction with a one-night stay was $4,700, for a 56 percent savings.¹ This cost differential resulted primarily from charge differences between the main operating room and the ambulatory surgery suite and would probably have been even greater if we performed the outpatient procedures in an ASC.

1. Aronowitz ER, Kleinbart FA. Outpatient ACL reconstruction using intraoperative local analgesia and oral postoperative pain medication. Orthopedics. 1998;21(7):781-4.
2. Malek MM, DeLuca JV, Kunkle KL. Knable KR. Outpatient ACL surgery: A review of safety, practicality, and economy. Instr Course Lect. 1996;45:281-6.
3. Novak PJ, Bach BR Jr, Bush-Joseph CA, Badrinath S. Cost containment: A charge comparison of anterior cruciate ligament reconstruction. Arthroscopy. 1996;12:160
4. Kao JT, Giangarra CE, Singer G, Martin S. A comparison of outpatient and inpatient anterior cruciate ligament reconstruction surgery. Arthroscopy. 1995;11(2):151-6.

NO - Patients Need to Stay Overnight

Donald B. Goodfellow, MD
Assistant Professor of Orthopedic Surgery,
Case Western Reserve University
Head, Division of Sports Medicine,
University Hospitals of Cleveland
Cleveland, Ohio

Ninety percent of the approximately 180 ACL reconstructions I perform each year are inpatient procedures. I define "inpatient procedure" as an overnight stay, and the great majority of my patients do go home in 23 hours. Although my patients and I are afforded this "luxury" largely because, here in Cleveland, we can still bill and receive reimbursement for services rendered, this is not the primary reason my patients stay overnight. Years of clinical experience have taught me that there is a strong rationale for an overnight stay.

An overnight stay offers two primary benefits: Anxiety relief for the patient and the ability to oversee and manage the patient in the early postoperative period. I cannot overstate the importance of postoperative oversight, in part because I would be loathe to perform my particular surgical technique if I knew my patients were going right home as a matter of course.

Anxiety Relief
My patient population is primarily young. Many are of high-school age. The ACL reconstruction is often their first surgical procedure, and many are really anxious because they don't have any idea what to expect. I have found that patient education, while important, cannot prepare these young patients for the surgical experience. Most patients - not to mention their parents - are eager to accept my offer of an overnight stay, and this often goes a long way toward relieving the entire family's anxiety.

Postoperative Oversight
When I perform my single-incision, endoscopic ACL reconstruction technique, usually using a bone-patellar-bone autograft with Endobutton fixation, I apply a tourniquet in approximately 90 percent of cases. Although critics of this approach focus on the potential for tourniquets to cause post-op hemarthrosis and associated pain, these disadvantages almost always take a back seat to the benefit of tourniquet use. Often, a tourniquet is the only way to achieve the visualization needed to ensure proper, posterior femoral graft placement. I perform quite a few repeat ACL reconstructions, and the most common reason for graft failure that I see is excessively anterior placement of the femoral graft. I believe that some of the ??'over-the-top?? ? femoral jigs confer a false sense of posterior positioning, and if the surgeon cannot see over the top of the condyle, the result can be a too-anterior femoral placement. This causes the graft to be excessively taut, limiting flexion or causing a loss of extension. By keeping my patients overnight, I can use a tourniquet to achieve my surgical goals, and I can place a knee drain knowing that the healthcare team will be able to manage it properly and remove it the next day.

The overnight stay also gives the healthcare team the time they need to monitor the patient for anesthesia-related complications, motivate the patient to get up and about, teach crutch-walking techniques, and manage breakthrough pain.

Typically, we use general or epidural anesthesia, depending on patient preference. We always encourage a marcaine femoral nerve block for pain relief that lasts up to 12 hours; patients who refuse the nerve block receive an intra-articular injection of 30 cc marcaine 0.75% with 2 to 4 mg of morphine, plus local infiltration of analgesics at the incisional and graft sites. Before the block wears off or at bedtime, we administer Oxycontin. When breakthrough pain occurs, we prescribe PCA, or the nurse will administer IV morphine or Demerol. If pain continues, we add Vicodin or Darvocet. We send the patient home with a prescription for Oxycontin, which the patient usually takes for a maximum of 7 to 10 days.

All in the Family
As economic pressures increase here in the Cleveland area, the time may come when I am forced to reconsider this position. I question the true benefit of the outpatient approach, however. I believe my patients will require a visiting nurse or other qualified health professional to evaluate for urinary retention, pain, and swelling. I also serve patients who live as far as 60 miles from the hospital, and we will need to ensure that these patients have their drains pulled on the first postoperative day and somehow return for a medical evaluation on the second or the third postoperative day.

Unfortunately, the outpatient scenario could also compromise what I currently feel is a rewarding and interdependent relationship with my patients. My young patients, their families, and I all participate in the surgery and in patient care, and I believe this contributes to overall patient satisfaction. I also worry that the pressures to perform outpatient surgery could become so great that they could compromise the quality of surgery. I am sure we all hope this will never happen.

NO - Pain Control is the Primary Reason I Perform Inpatient ACL Reconstruction

Susan N Pick, MD
Orthopedic Surgeon and Part Owner,
Specialty Surgery Center
Crossville, Tenn.

Even though I have a stake in an ambulatory surgery center, I perform all my ACL reconstructions on an inpatient basis. All my ACL patients stay at least one night, and about half spend two nights in the hospital. The primary reason is pain control. ACL reconstruction is by far one of the most painful procedures I perform, and in my opinion, surgery is only half of the battle when it comes to ensuring success. I believe that an active and immediate rehabilitation program represents the other half of the battle, and this is only possible when the patient is able to get right on top of the pain - and stay on top.

I perform an endoscopic, single-incision technique using a bone-patellar tendon-bone graft fixed with interference screws. Before surgery, my patients all receive a continuous marcaine epidural, which we remove on post-op day 1. I also implant a catheter at the graft donor site and infuse marcaine via a pump for approximately 60 hours after surgery. This helps greatly with postoperative pain.

I begin CPM in the recovery room, and I get the patient up and moving with therapy the very next morning. When the epidural is finished, I immediately switch the patient to oral Percoset, IV Demerol, or morphine depending on the level of pain.

Patients who cannot crutch-walk stay an extra night so we can manage breakthrough pain and set them on the road to rehabilitation before they go home. All patients leave the hospital with a 25-pill Percoset prescription. I will then prescribe hydrocodone if pain relief is still needed after a week, with subsequent and rapid downward titration. We continue physical therapy on an outpatient basis two to three times a week for 6 to 12 weeks, depending on the patient's progress.

Here in this small Tennessee town, my ACL patients are not elite athletes; they are more likely to be "weekend warriors" or high-school students. While I could send them home with a PCA system, I am uncomfortable with this option. Home pumps are not foolproof, and it can be difficult to set the pump so patients don't get too much medication yet get enough relief so they can rehabilitate. For this reason, I will continue to check my ACL patients into the hospital.