June 2025 Edition — COA BulletinClinical Insights

Sebastian Rodriguez-Elizalde, MD, MSc, FRCSC
Humber Hip and Knee Fellowship Program Director, University of Toronto
Humber Hospital

As part of the COA’s ongoing commitment to innovation in surgical care, this national webinar explored the expanding role of same day discharge in orthopaedics, with a focus on patient safety, system efficiency, and clinical outcomes. Presented in partnership with Healthcare Excellence Canada, Choosing Wisely Canada, and the Canadian Association of Physical Medicine and Rehabilitation, the session brought together experts from across the continuum of care to discuss the evolving landscape of same day orthopaedic surgery in Canada.

Moderated by Dr. Pascal-André Vendittoli (Université de Montréal), the panel featured orthopaedic surgeons, rehabilitation specialists, and advanced practice clinicians, each offering insights into their institutional models and patient-centered protocols. Presenters included Dr. Brent Lanting (Western University), Dr. Sebastian Rodriguez-Elizalde (Humber River Health), Dr. Meiqi Guo (Toronto Rehabilitation Institute), and Danielle Jepson (Toronto Rehabilitation Institute).

Topics addressed included:

• The clinical and operational case for same day total joint arthroplasty (TJA)
• Patient safety protocols and multidisciplinary coordination
• Real-world implementation strategies and institutional data
• Lessons from the Humber River model
• Considerations for rehabilitation, patient selection, and post-operative follow-up

This summary outlines the core presentation delivered by Dr. Rodriguez-Elizalde, highlighting outcomes and efficiencies achieved through the development of a same day discharge pathway for hip and knee arthroplasty patients at Humber River Hospital.

Enhancing Efficiency and Safety in Same-Day Discharge for Total Joint Arthroplasty: A Canadian Experience

The landscape of total joint arthroplasty (TJA) in Canada is undergoing a rapid evolution, with a growing shift toward same day discharge (SDD) models. This trend has been accelerated by multiple system pressures, including pandemic-related shutdowns and ramp-ups, financial constraints, and healthcare resources shortages. The impetus for more efficient surgical pathways has also seen acceleration by the Ontario Government’s desire to introduce Integrated Health System for Care (IHSC) in joint replacement programs.

According to Canadian Institute for Health Information (CIHI) data, the proportion of same day hip and knee arthroplasties has risen significantly over the 2021–2024 period. From an almost non-existence, same day surgery as a proportion of total joint replacement surgery has risen to about 20% nationwide. This shift is not only feasible but increasingly essential for the sustainability of our healthcare systems.

Pre-Operative Optimization

The foundation of successful SDD protocols lies in patient engagement and education. Pre-operative teaching sessions—including Hip and Knee classes—must deliver consistent messaging across the care continuum. Crucially, families and caregivers must be prepared and aligned with discharge expectations.

Anesthesia plays a pivotal role in facilitating early discharge. The adoption of multi-modal, pre-emptive analgesia—anchored in low-dose spinal anesthesia—has eliminated the need for general anesthesia (GA) and narcotics in most cases. Tailored spinal dosing and the use of ultrasound-guided regional blocks (particularly adductor canal blocks instead of femoral nerve blocks) provide effective analgesia while preserving motor function.

Efficiency is further enhanced when anesthesia services are moved out of the operating room (OR). Performing spinals and regional blocks in a designated block room, supported by anesthesia assistants and “float” anesthetists, facilitates parallel processing and maximizes the OR for strictly surgical time, enhancing throughput.

Intra-Operative Considerations

Historically, post-operative admission was often necessitated because of blood loss. Up to 50% of patients needed transfusionIn prior to the implementation of modern peri-operative care. In modern times, Tranexamic acid (TXA) administration—intravenously before surgery, intra-articularly at closure, and orally post-operatively—has significantly reduced blood loss, and the overall transfusion rate is less than 1%.

Surgeon-led pain control strategies further augment anesthesia efforts. Intra-articular analgesic cocktails, prepared by pharmacy and delivered in precise volumes to specific anatomical zones, have proven effective. Minimally invasive surgical techniques, emphasizing reduced soft tissue trauma, also contribute to improved post-operative comfort.

Post-Operative Efficiencies and Paradigm Shift

Perhaps the greatest barrier to SDD is post-operative recovery infrastructure, particularly in the traditional paradigm that routes all patients through the Post-Anesthesia Care Unit (PACU). At Humber River Hospital, the surgical day care (SDC) pathway which bypasses PACU completely, has redefined this process.

Patients undergoing spinal anesthesia with minimal regression and no motor block can safely bypass PACU, reducing delays and resource use. Most adequately prepared patients do not need the enhanced monitoring of a PACU setting.

Comparative data between PACU and SDC pathways reveal significant efficiencies: SDC patients require fewer nurse handovers, fewer porter transports and benefit from faster mobilization, enabling timely physiotherapy and discharge.

Statistically, 72% of patients at Humber bypass PACU, with 88.4% of all TJA patients discharged on the same day. Of those who do require PACU recovery, nearly half are ultimately admitted.

Safety and Outcomes

Three years of Humber institutional data comparing same day total hip arthroplasty (SD-THA) with admitted THA show no differences in key outcome measures—including readmissions, 30-day mortality, emergency department visits, or infection rates. Notably, these results were achieved without stringent patient selection criteria, reinforcing the generalizability of this model across diverse patient populations.

Conclusion

Same day discharge for TJA is both safe and effective when implemented through a structured, multidisciplinary approach. Efficiency gains stem from well-coordinated teamwork among surgeons, anesthesiologists, nurses, and physiotherapists. By shifting the care paradigm and optimizing each phase of the surgical journey, institutions can increase surgical throughput, improve patient satisfaction, and alleviate systemic burdens.

As healthcare systems across Canada continue to evolve, the Humber model offers a reproducible and scalable blueprint for delivering high-quality, efficient arthroplasty care in the modern era.

James L. Howard, MD, FRCSC
Western University
Moderator, Current Concepts in Total Joint Replacement Symposium
COA Annual Meeting 2024

As part of last year’s Annual Meeting scientific program, the symposium Current Concepts in Total Joint Replacement brought together leading experts in the field to explore innovations, challenges, and emerging evidence in arthroplasty. Held on Thursday, June 13, 2024, in Halifax, Nova Scotia, the symposium featured four distinguished speakers who addressed a spectrum of contemporary topics including alignment strategies, robotic technologies, patient-specific surgical targets, and the integration of patient-reported outcomes into clinical practice.

Dr. Steven J.M. MacDonald (Western University, President, Hip Society) – Understanding Alignment in 2024

Dr. Steve J.M. MacDonald opened the session with a review of evolving concepts in joint alignment. He highlighted how the field has shifted from a traditional mechanical alignment philosophy toward more personalized approaches, such as kinematic and functional alignment, that may better reflect individual patient anatomy and biomechanics. Drawing on recent clinical data and imaging analysis, Dr. MacDonald discussed the implications of these strategies on implant survivorship and patient outcomes. He emphasized the need for balanced decision-making between technological precision and the nuanced art of clinical judgment. His presentation set the stage for deeper conversations around how evolving alignment strategies may affect future outcomes and patient-specific needs.

Professor Fares Haddad (University College London Hospital , Editor in Chief, Bone & Joint Journal)– Robotic Surgery: From Innovation to Evidence Base

Following Dr. MacDonald, Prof. Fares Haddad presented a critical examination of robotic-assisted surgery in joint replacement, tracing its trajectory from conceptual innovation to evidence-based practice. Prof. Haddad reviewed the growing body of literature supporting robotic systems for both hip and knee arthroplasty, highlighting benefits such as improved implant positioning, enhanced intraoperative planning, and reduced soft tissue disruption. However, he underscored the current limitations including cost, learning curve, and the need for high-quality comparative studies with long-term outcome data. Prof. Haddad advocated for a pragmatic and data-driven approach to adoption, urging the orthopaedic community to rigorously assess whether technological improvements are translating into meaningful clinical benefit.

Dr. Michael Dunbar (Dalhousie University, Past President, Canadian Arthroplasty Society) – Enabling Technology Towards a Patient Specific Target in Arthroplasty

Dr. Michael Dunbar continued the discussion by exploring how enabling technologies—such as navigation, robotics, and preoperative imaging—can support the move toward individualized surgical targets in arthroplasty. He emphasized the importance of preoperative planning that accounts for each patient’s unique anatomy, functional goals, and alignment preferences. Dr. Dunbar argued that the future of arthroplasty lies in leveraging technology not just for accuracy, but for personalization—achieving a “best fit” for each patient rather than a one-size-fits-all approach.

Dr. Kevin Bozic (Dell Medical School, University of Texas at Austin, Past President, American Academy of Orthopaedic Surgeons)– Incorporation of Patient Reported Outcomes into Routine Clinical Practice

Rounding out the session, Dr. Kevin Bozic addressed the growing importance of patient-reported outcome measures (PROMs) in joint replacement surgery. He made a compelling case for incorporating PROMs into routine clinical workflows to better assess the effectiveness of care from the patient’s perspective. Dr. Bozic outlined practical strategies for implementation, including digital data collection, standardized metrics, and integration with electronic health records. He also discussed how PROMs can inform shared decision-making, drive quality improvement initiatives, and support value-based care models. His talk highlighted the need for a more holistic understanding of surgical success, one that includes not only radiographic and functional outcomes but also patient satisfaction and quality of life.

Conclusion

The Current Concepts in Total Joint Replacement symposium underscored the rapid evolution of arthroplasty practice as it intersects with technological innovation, evidence-based medicine, and patient-centered care. Together, the four presentations offered a multifaceted view of how alignment strategies, surgical tools, and outcome measurements are being redefined to meet the demands of modern health care. From theoretical foundations to real-world implementation, the symposium left attendees with a clearer understanding of where joint replacement is headed—and what it will take to get there.

Anthony Adili, P.Eng, MD, FRCSC
Associate Professor / Vice Chair of Surgery, McMaster University
John A. Bauer Chair in Surgery
Chief Innovation Officer, St. Joseph’s Healthcare
Chair, Annual Scientific Meeting
November 1-2, 2024
Ontario Orthopaedic Association

At the Ontario Orthopaedic Association (OOA) Annual Scientific Meeting on November 1, 2024, , a symposium highlighted Ontario’s evolving surgical delivery models, emphasizing the province’s adoption of ambulatory surgical centres (ASCs) as a progressive strategy to expand surgical capacity, shorten wait times, and improve patient outcomes. Three orthopaedic surgeons—Dr. Paul E. Beaulé as Chief of Staff at The Ottawa Hospital, Dr. Abdel‐Rahman Lawendy as Chief of Surgery at London Health Sciences, and Dr. Anthony Adili as Chief of Innovation at St. Joseph’s Healthcare Hamilton – shared their successes and insights about ASCs in Ontario and identified critical factors for implementing efficient outpatient surgery systems. Their presentations focused on key determinants of optimized care that centered on patient selection, streamlined workflows, safety metrics, cost-effectiveness, and integration into health care systems.  This article synthesizes their perspectives to inform strategic advancements in surgical care.

Patient Selection and Optimization

Strict inclusion criteria are fundamental to safety in ASCs. Successful implementation of an ASC requires a clear focus on low-risk patients with manageable comorbidities who can safely undergo same-day surgery. At London’s Nazem Kadri Surgical Centre (NKSC), for example, patients with factors like difficult airways or recent serious cardiac events are excluded to avoid high-risk cases. Candidates are typically those undergoing “low complexity” procedures (e.g. routine orthopaedic or hernia repairs) where patients can be discharged home the same day. Ensuring that patients have preoperative education, medical optimization and adequate home support is critical. This careful patient selection process maximizes safety and allows ASCs to maintain excellent outcomes while expanding access.

Workflow and Operational Models

Ambulatory centres implement innovative workflow models to achieve remarkable efficiency. A hallmark is running dedicated OR teams and streamlined schedules. The Academic Orthopaedic Surgical Associates of Ottawa (AOAO) piloted an Integrated Ambulatory Orthopaedic Centre that staggered cases across multiple ORs – one surgeon can supervise two to three simultaneous rooms – enabling extraordinarily high throughput (in one trial, a single surgeon completed up to ten joint replacements in a day). At the London NKSC, two operating rooms and lean processes allow about 15 surgeries per day, roughly 2,000 surgeries per year in its initial setup. Turnover times are minimized by having focused teams for cleaning and preparation.  Dr. Adili noted that over nine million surgeries annually are performed in private ASCs in the United States, which offer faster case turnover (~21-minute turnovers in top centres), reduced complication rates, and significantly lower costs (roughly 60% of hospital-based surgery costs).  All three surgeons stressed standardization of protocols (anesthesiology, nursing, instrumentation) to reduce variability. London’s centre uses a “lean management” approach to eliminate waste and idle time, resulting in patients spending on average 1.5 hours less at the facility compared to hospital norms. Nursing and anesthesia staff are often self-selected volunteers in these centres, creating a highly motivated team culture. The net effect is higher OR utilization (aiming for >85% usage) and the ability to triple surgical volume when capacity is expanded (London’s NKSC is planning to expand the current facility to six ORs with an expected capacity of ~6,000 cases/year). These operational innovations demonstrate how ASCs can significantly boost productivity while maintaining quality.

Clinical Safety and Outcomes

Patient safety and surgical outcomes in the ambulatory setting have been excellent, reinforcing that efficiency does not come at the expense of quality. In Ottawa’s early experience with an Integrated Ambulatory Care Centre (IACC) for joint replacements, outcomes were comparable to inpatient surgery. The initial cohort had no surgical site infections and no unexpected hospital admissions post-surgery.  This underscores the safety of proper patient selection (internal data). A matched comparison of ambulatory vs. hospital joint replacement patients showed no increase in complications or readmissions for the ASC group.  This aligns with broader research that outpatient hip and knee arthroplasties have similar or lower risks of 90-day readmission, ED visits, and one-year complications compared to inpatients. Dr. Lawendy reported that standard hospital safety protocols are met at the NKSC (e.g. infection control and anesthesia standards), and all cases are day-surgeries by design. Robust postoperative follow-up is also part of the model –surgeons personally call each patient the day after surgery to monitor recovery and address concerns. Patient-reported outcomes and satisfaction scores have been outstanding. The London centre consistently records very high patient satisfaction with the experience, reflecting not only good clinical outcomes but also the positive patient experience. Together, these results show that with proper safeguards, ASCs can deliver equal or better outcomes as traditional inpatient surgery settings.

Cost-Efficiency and Funding Models

A major advantage of the ASC model is its cost-effectiveness. By focusing on high-volume, low-complexity cases, these centres significantly lower the cost per case through economies of scale and process efficiencies.  The streamlined model at NKSC performs surgeries faster and at a lower cost than at the main hospital.  All three surgeons noted that these centres achieve efficiencies like shorter length of stay (freeing up recovery beds), optimized staffing, and avoidance of hospital overhead expenses. Importantly, the funding models for Ontario’s ASCs have remained publicly funded.  Dr. Adili noted that some private surgical facilities in Ontario operate with ~80% of their cases being government-funded rather than private pay – a hybrid model that leverages private-sector capacity while preserving universal access. Overall, these approaches show how ASCs can be cost-efficient and scalable within a public health care framework, delivering more surgeries within the same budget envelope by redistributing resources more effectively.

System Integration and Strategic Leadership

Integrating ambulatory surgical centres into the broader health system requires strategic vision and h4 leadership. A recurring message was that ASCs should complement, not compete with, hospitals.  Dr. Beaulé’s concept of Integrated Ambulatory Centres envisages free-standing facilities working in tandem with hospital sites.  An ambulatory orthopaedic centre can handle all eligible day surgeries, thereby freeing hospital ORs and inpatient beds for more complex cases.  London’s NKSC is physically located near the main hospital, reinforcing its role as an extension of the hospital surgical program rather than a standalone clinic. Care pathways are coordinated so that if a patient at the ASC needs unexpected inpatient care, seamless transfer is possible. From a system perspective, Ontario’s Ministry of Health views these centres as key to reducing the surgical backlog and maintaining the province’s leading wait time performance.

Surgeon-led initiatives, supported by hospital administrators and government policy, are transforming surgical care delivery.  Dr. Lawendy, Chief of surgery at The London Health Sciences, spearheaded the NKSC project and his dual role as medical director of the centre allowed him to bridge hospital priorities with innovative practices, paving the way for broader adoption.  Dr. Beaulé, Chief of Staff at the Ottawa Hospital, and colleagues formed the Surgical Associates of Ottawa (AOAO) to champion the ambulatory model in their region, aligning surgeons under a common vision to improve access (with support from the Ontario Medical Association’s call for integrated centres).  Dr. Beaule stresses that modern healthcare demands delivery models that emphasize patient-centered value—defined as outcomes achieved per dollar spent—over volume or access alone.  Dr. Adili, as Chief of Innovation at St. Joseph’s Healthcare Hamilton, and former Chief of Surgery at St. Joseph’s Healthcare, has been a vocal proponent of sharing best practices across institutions and exploring partnerships to expand ambulatory surgery capacity. All three stress the importance of data transparency and continuous improvement.  By tracking outcomes and efficiency metrics, they can demonstrate success to funders and quickly address challenges. The expansion of NKSC as a fully publicly funded ASC and plans for new centres are the direct result of this strategic vision and teamwork . Executives are encouraged to continue fostering such leadership and cross-sector partnerships to ensure ASCs integrate smoothly into the health system’s future.

Conclusion

Across the themes of patient selection, operations, outcomes, cost, and integration, these Ontario experiences illustrate a powerful innovation in surgical care. Ambulatory surgical centres, when properly implemented, can significantly increase surgical throughput and convenience for patients without compromising safety or quality . They do so in a cost-effective manner that aligns with public healthcare goals.  Key to this success is adhering to strict patient eligibility, using optimized workflows and dedicated teams, tracking performance, and embedding the centres within the larger health system. With continued strategic leadership, Ontario’s expansion of ASCs is poised to improve surgical access and outcomes on a provincial scale, offering a blueprint for modernizing surgical care delivery in a sustainable, patient-centered way.

Mansur Halai
Research Chair; Canadian Orthopaedic Foot and Ankle Society
St Michael’s Hospital, University of Toronto

The Canadian Orthopaedic Foot and Ankle Society (COFAS) genuinely has a global presence in the advancement of foot and ankle research. This is a testament to its original founding members, from East to West, who have collectively conducted landmark trials resulting in the publication of practice guiding papers. These publications have made COFAS an internationally recognized organization on the topic of among other things, ankle arthritis, ankle replacement and ankle and hindfoot arthrodesis[i],[ii].

I became COFAS research chair in 2023 and my “Scopus Primus” was to develop a randomised study involving the collective COFAS group. At the time, we felt that other centres across the world including my colleagues in the United Kingdom were conducting important Randomized trials including studies such as the TARVA study a methodologically robust trial looking at ankle replacement vs fusion. We felt that it would be important to understand the research direction COFAS as a group wished to pursue.

To this end, at the beginning of 2024, we conducted two surveys of COFAS members, and held an in-person brainstorming Think-Tank. Further, our new President (Dr Warren Latham) led excellent monthly meetings with the COFAS Executive members, where there was always an update on research matters. Given the massive success of our friends in the Canadian Orthopaedic Trauma Society (COTS) COFAS executive felt that not only can we learn from COTS, but we wanted to collaborate with them in projects that aligned with both our interests. An example of this was bringing on COFAS surgeons to the PILON Study, spearheaded by Professor Schemitsch in London. This collaboration will be both an invaluable learning opportunity for us to design randomised studies of our own in the future and strengthen ties between our two Canadian subspecialties.

We are striving to muster up enthusiasm across the country, guided by the experienced academic researchers like Professors Daniels, Younger and Glazebrook, (Picture 1). In addition, extra in-person meetings have taken place throughout the year as COFAS has hosted several meetings across the country: Toronto April 2024, Whistler January 2025 and Ottawa April 2025 (Picture 2). This was after a highlight meeting at our very own COA’s subspecialty day in Halifax, where we had international speakers and a record number of attendees. We hosted our first ever COFAS Travelling fellows across the Eastern cities of Toronto, Ottawa and Halifax. These Fellows were from Holland and Chile, that ignited our multiple academic sessions and journal clubs that took place with their international perspective.

Whilst we wished to continue the sterling work on arthritis done previously, two new areas were clearly on the membership’s hitlist to tackle. The current management of the diabetic Charcot foot, particularly with a minimally invasive slant was chosen as a hot topic to investigate. Another domain which has developed is the creation of Canada’s first minimally invasive forefoot database. Whilst still in its infancy in Toronto and Halifax, this will hopefully compliment the hugely successful ankle arthritis national database for decades to come. Accordingly, over the past year multiple meetings have taken place with much progress. Industry have been keen to support our venture too, which is needed to provide community surgeons with assistance they require in data collection. This is slow, humbling, yet fruitful exercise. Time will tell how sweet the fruits will be, but the process will provide a blueprint for many more projects to come.

[i] Daniels TR, Younger AS, Penner M, Wing K, Dryden PJ, Wong H, Glazebrook M. Intermediate-term results of total ankle replacement and ankle arthrodesis: a COFAS multicenter study. J Bone Joint Surg Am. 2014 Jan 15;96(2):135-42. doi: 10.2106/JBJS.L.01597. PMID: 24430413.

[ii] Glazebrook M, Balasubramaniam U, Walls A, Younger ASE, Penner M, Wing K, Dryden PJ, Daniels TR. Outcomes of Total Ankle Replacement Versus Ankle Arthrodesis for the Treatment of End-Stage Ankle Arthritis: A Concise Follow-up, at a Minimum of 10 Years, of a Previous Report. J Bone Joint Surg Am. 2025 Mar 19;107(6):552-557. doi: 10.2106/JBJS.24.00361. Epub 2024 Dec 23. PMID: 39715299.