Orthopaedics & Traumatology: Surgery & Research 103 (2017) S83–S90

Available online at

ScienceDirect
www.sciencedirect.com

Review article

Developments in ambulatory surgery in orthopedics in France in 2016

C. Hulet a,∗ , G. Rochcongar a , C. Court b
a
Département de chirurgie orthopédique et traumatologique, niveau 11, Inserm U1075 COMETE « mobilité : attention, orientation & chronobiologie »,
université de Caen Basse-Normandie, CHU de Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France
b
Orthopédie TRaumatologie, hôpital Kremlin-Bicêtre, hôpitaux universitaires Paris Sud, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France

a r t i c l e i n f o a b s t r a c t

Article history: Under the new categorization introduced by the Health Authorities, ambulatory surgery (AS) in France
Received 24 March 2016 now accounts for 50% of procedures, taking all surgical specialties together. The replacement of full
Accepted 4 November 2016 hospital admission by AS is now well established and recognized. Health-care centers have learned, in
coordination with the medico-surgical and paramedical teams, how to set up AS units and the corre-
Keywords: sponding clinical pathways. There is no single model handed down from above. The authorities have
Ambulatory surgery encouraged these developments, partly by regulations but also by means of financial incentives. Patient
Organization
eligibility and psychosocial criteria are crucial determining factors for the success of the AS strategy. The
Surgical act
Anesthesia
surgeons involved are strongly committed. Feedback from many orthopedic subspecialties (shoulder,
Patient eligibility foot, knee, spine, hand, large joints, emergency and pediatric surgery) testify to the rise of AS, which now
accounts for 41% of all orthopedic procedures. Questions remain, however, concerning the role of the GP
in the continuity of care, the role of innovation and teaching, the creation of new jobs, and the attrac-
tiveness of AS for surgeons. More than ever, it is the patient who is “ambulatory”, within an organized
structure in which surgical technique and pain management are well controlled. Not all patients can be
eligible, but the AS concept is becoming standard, and overnight stay will become a matter for medical
and surgical prescription.
© 2016 Elsevier Masson SAS. All rights reserved.

1. What is the general situation in ambulatory surgery in
France?
Ambulatory surgery (AS) was introduced in France in 1970 in
a law governing hospitals, but without any corresponding decrees
instituting actual practice. The foundational decrees came in 1992
(decrees 92-1101 and 92-1102, later completed by another decree
in 2015). The AS concept then developed as a replacement for
surgery under full conventional hospital admission. The definition
of AS given in articles L. 6121-1 and L. 622-1, D. 6124-301 to 305 of
the French Public Health Code is: “Structures practicing anesthesia
or ambulatory surgery and providing services on a day-basis equal
to or less than 12 hours without overnight stay, for patients whose
health status corresponds to these forms of treatment”. AS is devel-
oping and is now an essential modality of care. It is an alternative
to full hospital admission, aiming to enable the patient to be dis-
charged home on the day of surgery itself. It represents a source
of progress, in which the patient is the center of the health-care
process. It is no longer necessary to be kept in overnight to be well
∗ Corresponding author.
E-mail address: hulet-c@chu-caen.fr (C. Hulet).
treated [1,2]. In an instructional lecture, Raimbeau [2] described AS
as not a technique so much as an organization concept, founded on
a “tripod” comprising a structure, a patient and a procedure. What
is ambulatory is not the procedure, but the patient.
The structure has to implement organizational rules enabling
treatment at the end of the appropriate clinical pathway, ensuring
quality and safety. The development of AS is the fruit of reflec-
tion and exchanges between the General Administration of Health
Provision (DGOS: Direction général de l’offre de soins) and the Profes-
sional National Council (CNP: Conseil national professionnel) of the
French Society of Orthopedic Surgery and Traumatology (SoFCOT),
with their sometimes specific points of view; it should enable the
“ambulatory turning” sought by the authorities to be made.
This modality of treatment got off the ground more slowly than
in other countries, but had greatly developed in France in recent
years.
France was long in the rear of the pack for ambulatory pro-
cedures: 12th out of 14 in Europe, with a 30% AS rate in 1997,
compared to 94% for the US according to the IAAS (International
Association for Ambulatory Surgery) survey [3]. According to the
most recent IAAS survey, in 2009, France was still backward, with
a 35% AS rate, well behind northern Europe (Denmark, 74%; Swe-
den, 69%; Netherlands, 53%; UK, 52%). South European countries,

http://dx.doi.org/10.1016/j.otsr.2016.11.005
1877-0568/© 2016 Elsevier Masson SAS. All rights reserved.
S84 C. Hulet et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) S83–S90

Fig. 1. National AS progression in surgery as a whole

From: ATIH [5]. Fig. 2. Comparative progression of the former and new definitions of the field of
application of AS during the period 2009–2014 [6]. Old (green line) and new defini-
tion.
such as Italy, Spain and Portugal, are even further behind. However,
these figures are already old, and need to be taken with caution as
definitions of AS vary from country to country (12-hour admission
in France, but < 24 hour “day surgery” in the US), as do health sys-
tems (health-care organization and coverage), health policies and
financial incentives.
The overall AS rate in France among surgical procedures as a
whole was 32.3% in 2007, according to the DGOS [4]. In 2014, it
was 44.9% (Fig. 1), with a target of 50% for 2015 [5,6]. Detailed
study of the figures shows wide differences between regions (Île-
de-France region, 47.8%; Limousin, 40.7%), and between private and
public centers in a given region (53.7% versus 33.5% respectively
in 2014) (Table 1). France seems sluggish in developing AS, look-
ing at the present rate of nearly 50% for 2016 [7] as a percentage
of procedures overall. However, this needs setting against the fact
that, in terms of absolute numbers of procedures, France comes sec-
ond after the UK in Europe (with 3 million in 2014). Moreover, the
Fig. 3. AS rate 2010–2014 and target progression for the period 2016 to 2020 [5].
authorities are supporting the movement, with a declared national
priority and the catch-word “ambulatory turning”, as, above all, are
health professionals, who are the actual agents and are developing 50.2% on the new (Fig. 2). In 2015, the target was 52.5%, and 66.2%
new treatments and extending AS to heavier procedures (anterior for 2020 in the “strong” scenario advocated in the report by the Gen-
cruciate ligament repair, and shoulder stabilization). eral Social Affairs Inspectorate (IGAS: Inspection générale des affaires
In September 2015, in order to be in line with other European sociales) and General Finance Inspectorate (IGF: Inspection générale
strategies, the way the national AS rate is calculated was changed. des finances) [7]. It is noteworthy that this update was based on an
Four K base-groups of diagnosis-related groups (DRGs) (03K02, annual progression of 2.9%, which remains to be achieved. It is an
5K14, 11K07, 12K06) and 3 Z base-groups (09Z02, 14Z08, 23Z03) ambitious target (Fig. 3); these rates are defined by the authorities.
were added to the C base-group procedures in the new definition
[5,6]. Thus, the AS rate for 2014 was 45.1% on the old definition and
2. How is AS organized, with what impact on the clinical
pathway?
Table 1
Variation in AS rates according to administrative region [5,6].
The development of AS is founded on 3 actions that have been
Administrative regions, January 1, 2016 AS rate AS rate implemented:
[17] Former New definitions
definitions (%) 2014 (%)
• organizing AS to ensure quality and safety of care;
Île-de-France 47.8 52.4
• increasing the number of procedures;
Centre-Val de Loire 43.6 48.8
Bourgogne-Franche-Comté 42.3 47.0 • providing financial incentives to overcome certain barriers [4].
Normandie 44.2 48.6
Nord-Pas-de-Calais-Picardie 45.4 51.0
Alsace-Champagne-Ardenne-Lorraine 43.2 47.4
It must be said that implementation has largely concerned 2
Pays de la Loire 46.3 51.4 of the 3: organizing AS to ensure quality and safety of care and
Bretagne 45.1 48.9 extending the eligibility of procedures for AS.
Aquitaine-Limousin-Poitou-Charentes 44.3 49.5
Languedoc-Roussillon-Midi-Pyrénées 43.1 48.5
Auvergne-Rhône-Alpes 43.7 49.0 2.1. Structures
Provence-Alpes-Côte d’Azur 47.0 52.6
Corse 48.9 54.0
Starting up AS practice requires authorization from the Regional
Guadeloupe 46.7 51.5
Martinique 39.6 49.8
Health Agency (ARS: Agence régionale de santé). This may be pro-
Guyane 25.4 33.7 vided to a health-care center, one or several physicians, or an entity.
La Réunion 46.0 52.5 There is no prerequisite organizational model, but in real life 4 types
Total France 44.9 50.0 of organization are possible:
 C. Hulet et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) S83–S90
• integrated structure, with an AS unit but surgery room shared
with full admission. This is the most frequent case, and allows AS
procedures to be carried out first, enabling greater flexibility;
• dedicated structure, with AS unit and a specific AS surgery room
alongside traditional surgery rooms;
• satellite structure, with AS unit and AS surgery room integrated;
• independent structure, totally separate from and independent of
any traditional structure.
2.2. Staff
Each AS unit or structure should comprise at least 1 anesthesi-
ologist, 1 health manager, and a number of paramedics according
to patient volume; regarding nurses, the initial ratio was 1 per 5
patients [8,9]. AS units are distinct from traditional structures, and
the relation with the surgery rooms (specific or not) is at the cen-
ter’s discretion: there is a general framework, but the details of
each center’s organization are left up to the medical, paramedical
and care-management team on the ground. It is up to the individual
to adapt to the chosen model.
2.3. Recent developments and guidelines
Improving AS organization in terms of concepts common to all
AS activity is the task of the authorities (DGOS, HAS [Health Author-
ity], and ANAP [National Performance Support Agency: Agence
nationale d’appui à la performance]). Thus, the health insurance sys-
tem (sécurité sociale) code [8] has been changed on 5 points for
AS:
• opening times for AS units can be extended, while patient stay
remains limited to 12 hours maximum; opening time, as distinct
from stay, can thus exceed 12 hours. The intention is to increase
turnover, but this remains to be assessed;
• staff may be shared between full admission and AS units;
• the ratio of 1 nurse to 5 patients in the structure has been
abandoned, while keeping the principle of a permanent skele-
ton medical and nursing staff. Thus, the size and composition of
the care team is adapted according to the patients’ health needs
and the type and volume of activity. AS is based on a specific
organization, and AS structures have their own premises and
equipment;
• staff involved in AS are to have suitable training;
• those ensuring continuity of care are to be identified precisely,
with their contact details, included in the discharge file given to
the patient, to improve health-care quality and safety.
To these ends, the HAS and ANAP have published numerous
guidelines for the work to be done in the 1200 medico-surgical
centers in France. These are addressed to health-care profession-
als, health-care center directors and managers and to the regulatory
authorities, and concern the following parameters: core knowl-
edge, organizational guidelines, assessment criteria for patient
management in AS, and AS act pricing in France and abroad [10–17].
All these documents can be downloaded from the HAS and ANAP
websites.
Thus, organizational definitions and certain aspects of quality
and safety have been determined. All aspects of AS unit organi-
zation are fully understood, exchanged and shared by all those
concerned within each establishment.
2.4. Clinical pathway and “ambulatory passport”
Then come the organizational steps of AS patient management:
a clinical pathway and “ambulatory passport” specific to the par-
ticular health-care center and common to all health professionals.
S85
AS patient management comprises a rigorous clinical and orga-
nizational process common to all health-care professionals: a
formalized pathway of pre- and postoperative steps, and sup-
port processes (human, material and logistic resources). There
are a number of challenges: coordination between the various
professionals, anticipating management from up- to downstream,
satisfying the patient and guaranteeing the quality and safety of
care. For this, certain steps are fundamental and should be shared
by all those involved.
2.4.1. The steps along the clinical pathway comprise
2.4.1.1. Surgery consultation. Surgery consultation with indication
for surgery: patient selection on medical and ambulatory crite-
ria, information, assessment of treatment options and risk/benefit
ratio, discharge prescription and analgesia, planned postoperative
follow-up [18].
2.4.1.2. Anesthesiology consultation. Anesthesiology consultation
ruling out contraindications, with patient selection and eligibility.
Following these two consultations, eligibility for ambulatory
management can be established on case-by-case assessment of the
risk/benefit ratio and level of structure maturity: care team expe-
rience, available resources and organization.
Eligibility is first assessed by the surgeon, anesthesiologist and
referring physician: patient’s understanding of what is being pro-
posed, aptitude to comply with medical prescriptions, and social
(hygiene) conditions. The following 3 points are indispensable:
availability of immediate postoperative accompaniment, residence
at less than 1 hour from a suitable care structure, and functioning
telephone.
The second step concerns the surgeon: absence of major hem-
orrhagic or respiratory risk, and normal expected postoperative
course for so-called “simple” procedures.
The third step concerns the anesthesiologist and patient age:
neonates and infants aged less than 3 years require specific anes-
thesiological competencies, quite different from those for patients
with ASA grades I, II and III “stabilized”.
2.4.1.3. Preoperative period (D–1). Coordination between the vari-
ous actors, reminder of essential information for event-free surgery.
2.4.1.4. Operative period (D0). Day of procedure, with all quality
and safety criteria for the procedure itself and for recovery room
stay.
2.4.1.5. Discharge period. Same-day discharge and aptitude to
leave the center validated by a physician. The phone-call on D1 after
return home is mandatory. Continuity of care has been ensured
by planning when the AS process was first set up: transmission to
patient of medical documents for the GP, procedure for contacting
the AS unit (or telephone emergency service) in case of difficulty
and contact details for a health-care structure near to the patient’s
place of residence.
2.4.1.6. Follow-up assessment. Follow-up assessment, as in con-
ventional surgery, to ensure follow-up (with no necessarily
predetermined schedule).
These stages involve coordinating all actors and the whole
paramedical, executive and managerial team. The patient is neces-
sarily much more actively involved than in the past, and is an actor
in the care pathway. Understanding and validation of patient infor-
mation thus become especially important, and should be ensured
as of the initial surgery consultation.
S86 C. Hulet et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) S83–S90
2.4.2. Ambulatory passport
The care team provides an ambulatory passport to the patient,
ensuring a certain significant degree of information and a link
between patient and professionals (contact details, appointments,
reports, etc.). This requires real coordination and proper under-
standing of the patient’s pathway on the part of the surgical,
medical, anesthesiological and administrative teams and commu-
nity caregivers up- and downstream of treatment, to ensure control
of risk, quality of treatment and professional satisfaction.
3. What are the financial and non-financial incentives for
the development of AS in orthopedics/traumatology?
Following the concept of “target acts” in 2009, thinking now
no longer focuses on act but on diagnosis-related groups (DRG).
Hospital stays coded as “J” (“séjour en J”) are defined for all DRGs,
with the aim of pricing convergence: same price as for a level 1 stay,
regardless of the mean hospital stay or major diagnostic category
for orthopedic surgery, if the patient is eligible for the surgery.
In parallel, the DGOS launched a constructive “chat” with sci-
entific societies. The SoFCOT CNP and its specific components
analyzed all the acts inventoried by the national insurance scheme
(CCAM). DRGs were classified according to feasibility in AS (Table 2).
Thresholds, or indeed lists, were, however, avoided: classifying acts
was to be up to the scientific societies. After detailed collaborative
study, each DRG was assigned a range of potential progression
toward AS over coming years (Table 2). This idea of a “range” was
applied to all DRGs in orthopedic surgery, with low and high esti-
mates for each procedure. No quantitative thresholds or any sort
were applied, validated or accepted. A list of eligible acts was not
deemed desirable.
The authorities implemented various measures during the same
period: requirement for prior approval, and certain financial incen-
tives.
The requirement for prior approval was instituted by the
National Health Insurance Scheme (CNAM), to increase the num-
ber of procedures performed using AS. It was first implemented in
the 2008 Budget, with 5 procedures for the whole field of surgery;
there are now more than 55 surgical acts. The SoFCOT CNP was a
constructive dialog partner; but, in view of the one-sided manda-
tory aspect of the measures decided upon by the CNAM, no further
acts were agreed in 2015, and these coercive measures are no longer
acceptable to our Society.
Financial incentives for institutions were set up in parallel: a
single ambulatory surgery price for certain frequent procedures;
Table 2
Examples of upper and lower thresholds of AS evolution for DRGs.
DRG Title
8C13 Local resection
08C27 Spine
08C37 Foot & ankle
08C40 Arthroscopy, other locations
Table 3
Contributions of various specialties to national AS rate of 40.8%.
Field Admissions (thousands)
D11-OPH 953.74
D10-ORL, Stomat 918.46
D01-Digestivea 3151.35
D15-Uro-Neph 1088.50
D02-Orth-Traum 1665.04
From: ATIH (http://www.scansante.fr/applications/indicateurs-analyse-activite/submit?snatnav=&mbout=dummy&periode=2012A2014 V11F&secteur=TOT2SECT&groupe=code
reg&modalite=25&agregat=DA).
a
D01 includes digestive surgery and all endoscopies.
and, in 2014, a pricing restriction was removed, when the Technical
Agency for Hospital Admission Information (ATIH: Agence technique
de l’information sur hospitalisation) and the DGOS got rid of the lower
limit of hospital stay for all surgical procedures for all level 1 and
2 DRGs in full hospital admission. These steps have been effective
stimuli for the development of AS [19].
More recently, thanks to support from the ATIH, it has been pos-
sible to calculate the percentage of AS in orthopedic surgery. This
is a frequent form of functional surgery, amounting to 7% of sur-
gical procedures as a whole in France, comprising 56 DRGs and a
potential 1360 surgical acts. Using the ATIH’s concept of “specialty
field”, the contribution of each specialty to the overall national pro-
gression can be determined (Table 3). The rate of AS in orthopedic
surgery (field D02 [erthopedic surgery]) was 41% in 2014 (29% DG
public hospital, 50% OQN [private hospital]) (Table 4, Fig. 4), with
regional differences. Spinal surgery is not included.
These developments come under the “ambulatory turning”
advocated by the Health Authority. The General Social Affairs
Inspectorate published a report on perspectives in AS in France [7],
to which there was a great deal of reaction as it presented cur-
rent data but very much in terms of centers and much less of the
surgeons performing the procedures. Six important points emerge:
• the SoFCOT CNP cannot go along with a pricing policy in which
rates per DRG are presented as minima to be achieved under
threat of sanctions;
• the SoFCOT CNP rejected the concept of minimum rate or thresh-
old. In its reply to the IGAS report, it stressed that the issue of
responsibility in AS has not been settled, and is more important
than questions of rates and thresholds. In presenting its report,
the commission attributed postoperative care to the community
physician or anesthesiologist, whereas postoperative course is in
fact part and parcel of the surgical procedure in its globality and
must be the responsibility of the surgeon. The safety and quality
of care in AS require greater involvement of the surgeon in the
postoperative phase;
• ambulatory management, as the report states, requires organiza-
tional investment under the surgeon’s responsibility; this takes
time, both up- and downstream of the actual procedure, but is
not presently taken into account, whereas it should be a factor in
pricing;
• the role of technical innovation is poorly defined;
% AS Lower threshold (%) Upper threshold (%)
17% 17 30
0.24% 1 10
23% 40 65
5% 25 40
% overall activity AS Mean stay (days)
2014–2015
4% 77–80% 0.5
4% 61–62% 1.2
13% 53–54% 2.6
5% 40–41% 3.1
7% 38–39% 3.7
 C. Hulet et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) S83–S90 S87

Table 4
Progression of 5 orthopedic surgery DRGs 2013–2015.

DRG Year No of procedures % AS National mean stay (days) Range

08C/24 2013 88,777 0% 8.58 0%

TKA (total knee
arthroplasty)
2014 96,168 < 0.01% 8.08
2015 84,959 < 0.1% 7.45
08C34/ 2013 41,937 3% 3.22 5–15%
ACL repair
2014 43,792 12% 2.6
2015 38,556 23.50% 1.95
08C37 2013 105,569 28% 2.02 35–60%
Foot & ankle surgery
2014 110,090 34% 1.7
2015 96,969 44% 1.32
08C48 2013 99,967 0 8.13 0%
THA (total hip
arthroplasty)
2014 103,425 < 0.01% 7.53
2015 89,267 < 0.5% 6.85
08C58 2013 62,275 14.50% 2.07 13–20%
Shoulder arthroscopy
2014 64,562 22% 1.75
2015 57,139 28% 1.48

From: ATIH scan santé.

• it is not possible to recommend surgical procedures according
to kind of hospital admission. Adopting AS is bound to affect
implantable medical device management;
• the role and functioning of hospital patient hotels remain to be
defined.
The trend is just as strong in pediatric orthopedic surgery, where
AS amounts to nearly 50%. Eligibility and operating rules are differ-
ent in this field.
It is interesting to focus on 5 DRGs (Table 4), some representing
current practice and others important perspectives for innovation.

4.1. Foot surgery

4. What feedback is there from the various sectors?
There are no laws or regulations defining the feasibility of a
procedure.
In hand surgery, the proportion of AS has grown strongly, and
now stands at more than 80%. To be provocative, one might ask
what role remains for full admission in hand surgery: a few complex
procedures and some emergencies? Emergency AS is feasible as
such: it is an organizational question of capacity flow, to include
emergency operations without disordering the overall schedule.
The potential for emergency surgery is vast and remains to be
explored: non-operative treatment, and simple hand or wrist frac-
ture. The only limitation is major risk of ischemia or infection.
Foot surgery (08C37; foot procedure, age > 17 years; Table 4)
amounts to more than 96,000 procedures per year, more than 63%
of which involving hallux valgus. This pathology is the subject of
extensive literature from the French Association for Foot Surgery
(AFCP) [20]. The rate of AS has grown strongly in the last 2 years,
by 16%, to reach 44%; 20% of admissions are for 1 day, representing
a potential 65% rate of AS in coming years.
Mouton et al. [21] assessed results in 619 cases of forefoot AS.
Analgesia systematically comprised ketoprofen LP 100 or pred-
nisolone 20 mg, both step-2 analgesics, and vitamin C (1 g/day for
45 days). Results were very encouraging; only 6.85% of patients
needed to consult their community physician or the emergency

Fig. 4. AS rate in specialty D2 ([5], orthopedic surgery).

S88 C. Hulet et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) S83–S90
department; it is on these patients that efforts should be focused.
This was confirmed by Chaudier et al. [22], who demonstrated that
foot surgery is painful, but not more for ambulatory than classical
admission.
Multimodal anesthesia [23] is an important aspect of treatment,
associating peroneal block and truncal ankle block. Metatarsal
block is an interesting alternative to sciatic block, as shown in a
comparative study of 50 cases [24]. Perimetatarsal injection is bet-
ter suited to AS, allowing rapid transfer to the recovery room and
early rising 1 hour later.
In a study by the AFCP, Colombier et al. [20] analyzed failure
of AS in 492 foot procedures: 76.5% forefoot and 23.5% midfoot.
Overall satisfaction was high. Two points emerged:
• conversion to conventional admission was 2.3%: 17.5% for social
reasons, 45.1% for medical reasons (nausea and vomiting), 28.4%
for surgical reasons (pain or bleeding), and 9% for organizational
reasons;
• readmission in the days following surgery was 0.9% (i.e., very
low).
Limitations are mainly psychosocial and environmental: under-
standing the information, adherence to prescription, hygiene
conditions, availability and reliability of the accompanier, and dis-
tance between residence and care structure. All should be analyzed;
they account for almost 20% of conversion [25]. They should in
theory be anticipated, as integral to selection and eligibility.
4.2. Anterior cruciate ligament (ACL) repair
Anterior cruciate ligament (ACL) repair (DRG 8C34) is now a
frequent procedure (> 40,000 per year) and mean hospital stay has
greatly changed nationally. It is the procedure for which the AS
rate has increased the most, from 3% to 23.5% in 2 years (Table 4).
Progress in arthroscopy favors minimally invasive surgery. More-
over, potential growth in AS is strong, with 20% 1-day stays,
potentially manageable on AS.
An important study by Servien and Cucurullo [26] for the French
Arthroscopy Society (SFA) reported routine implementation with
no complications. Baverel and Dejour [27] demonstrated AS ACL
repair to be feasible, independently of choice of graft. Postoperative
course was relatively pain-free, with a low rate of adverse events
[28,29]; satisfaction was high (88%).
It is essential to adapt anesthesia; most teams have aban-
doned peroneal block [26] in favor of peri-articular and harvesting
site injection. Tranexamic acid [30], used in arthroplasty, has also
been used, and reduces the severity of postoperative hemarthro-
sis. Karaaslan [30] also reported significant impact on results, with
improved range of motion. Readmission after arthroscopic knee
surgery is low, at 0.92% for Westerman et al. [31].
4.3. Shoulder surgery
Shoulder surgery (DRG 8C58) is equally promising. AS rates rose
from 14% to 25.8% for shoulder arthroscopy, and the potential for
transfer is 25%. Arthroscopic rotator cuff repair and bone block are
now feasible [32]: in 17 procedures performed, there were no early
readmissions. Here again, pain may be a limiting factor, and the
development of local catheters is advantageous. Westerman et al.
[31] reported that pain was a cause of readmission within 30 days in
7% of cases. Pain intensity does not differ between arthroscopic and
open surgery. Patient education and information are determining
factors.
4.4. For frequent but heavier surgery
For frequent but heavier surgery, such as hip or knee replace-
ment, data are sparse apart from anecdotal publications in the
media, with less than 0.5% and 0.1% AS rates, respectively. The
potential, on the other hand, is great. The clinical-surgical pathway
has been developed by teamwork between surgeons, anaesthetists
and paramedical teams, notably including physiotherapists. This
particular form of organization requires totally different therapeu-
tic commitment and education: the patient becomes actor, and
preoperative education by a dedicated physiotherapy and/or nurs-
ing team is indispensable. This should also include the concept
of rapid post-surgical recovery, with all the organizational factors
that requires. This form of treatment is not possible without the
contribution of anesthesiologists, who have shown that 80% of post-
operative bleeding occurs within 24 hours, and that postoperative
assessment involves biological parameters such as hemoglobin and
troponin assay [33–35]. Biological assessment is more reasonable
than purely clinical assessment, which is subjective.
Jouffroy et al. [36,37] twice reported results, taking account of
blood loss and biological parameters:
• in the first period, total hip replacement was performed as AS
with a very precise methodology, but 40% failure;
• in the second period, the methodology was revised in light of the
difficulties encountered in the first period: hip replacement was
performed with overnight admission, biological assessment and
collection and measurement of blood loss; this extended eligibil-
ity, increased quality and safety, and reduced failure to 6%.
4.5. Knee
In the knee, Thienpont et al. [38] listed factors affecting rapid
recovery: eligibility (anemia, history of deep venous thrombosis,
muscle force, and psychosocial factors), perioperative risk (anes-
thesia, postoperative pain, postoperative bleeding and transfusion),
psychosocial factors and cognitive disorder, orthostatic disorder,
and comorbidity. In knee replacement, Kort et al. [39,40] reported
favorable results with unicompartmental implants in 17 patients,
with control of pain and no readmissions. In total knee replace-
ment, Villeminot et al. [41] reported more than 180 cases managed
using AS (61% of the author’s total) without extra complications
or early postoperative and post-discharge readmissions, although
with 6 conversions to full admission and 4 early readmissions.
4.6. Discal hernia
Other procedures, such as for discal hernia, are still in the inno-
vation phase in AS, but will be developed [42]. Two recent studies
by Chin et al. [43,44] showed patient selection to be a determining
factor: objective and subjective clinical results were reported, with
100% posterior lumbar fusion without immediate complications.
It is very important to develop a methodology to treat and man-
age heavy pathologies with optimal type of hospital admission. The
extension of AS to heavier procedures has reduced mean hospital
stay for knee or hip replacement by 1 day in 2 years. This, associated
with the development of rapid recovery, will change our structures,
with frequent treatment on a 5-day week basis in these cases. How-
ever, not all knee and hip replacements are going to be ambulatory.
It will be interesting to analyze patient satisfaction: do all wish to
have ambulatory implantation? We have no way of answering this
question.
 C. Hulet et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) S83–S90
5. What does the future hold, and what is in suspense?
AS has greatly progressed in orthopedics since the 4 procedures
originally concerned. The overall rate is interesting, but the rates
per specialty field (orthopedic surgery) are more representative and
better indices (D2 = 41%). The “tripod” of structure, patient and pro-
cedure has become fundamental. More than ever, it is the patient
who is ambulatory, and this requires perfectly controlled, techni-
cally optimized surgery with an excellent collaboration between
surgeon and anesthetist. Overnight stay becomes a matter of med-
ical prescription. The institutional and organizational definitions
around AS are well established; things are progressing, and archi-
tectural developments enable yet further progress.
Nevertheless, the other two “feet” are involved in all the steps
along the clinical pathway and notably concern all the actors
involved.
AS structures are going to improve, working on quality and orga-
nization. Setting up specific guidelines and steps top be adhered
to during ambulatory surgery, the IPAQSS health-care quality and
safety enhancement indices should iron out certain flaws and
improve organization, which is central to the process. Innovative
practices will develop, with new jobs and e-health tools for remote
follow-up. The other two factors requiring vigilance are the patient
and the surgeon.
Upstream of surgery, psychosocial criteria and eligibility need
working on [45]. Illiteracy and hearing impairment rates are high
(13% and 6%, respectively). The patient’s environment is fundamen-
tal to the care pathway: social isolation is definitely an element
to be taken into account in considering AS. It may be socially
necessary to propose overnight stay in order for the patient to
be accompanied: e.g., in single-parent families or for students in
residence away from the family home. In parallel, the anesthe-
sia consultation needs to plan for management of postoperative
pain and nausea/vomiting. Correctly understood patient informa-
tion is essential from the outset. New information tools need
developing.
In the actual surgical procedure, pain management is essen-
tial to the patient’s reassurance and benefit. Beaussier et al. [23]
present all the new methods. AS patients need not only optimal
analgesia but also as few as possible of the side effects asso-
ciated with analgesics, and especially opioids, and locoregional
analgesia techniques. “Multimodal” analgesia here comes into its
own, associating various molecules and/or techniques through-
out surgery. Non-morphine-based analgesics should be preferred;
locoregional analgesia should be developed, with peri-articular
anesthetics. The organization of postoperative pain management
is just as important, and may sometimes be seen as an obstacle
to AS; optimal management is a key to successful AS in whatever
orthopedic procedure. Poorly controlled pain is one of the most fre-
quent complaints after AS; it is a source of discomfort, unscheduled
readmission, delayed functional recovery and thus patient dissat-
isfaction. The strategy adopted should take account of the surgery
performed, the patient and his or her social environment, and the
organizational context of treatment. Patients can be discharged
with a functional neural block that provides effective pain control.
Patient preparation and information play a decisive role in pain
control at home. Nursing follow-up may be justified in some cases
of more complex analgesia.
Downstream of surgery, the patient needs e-health follow-up,
and the role of the GP needs to be determined: he or she should be
informed of treatment, but should she also be the first port of call
in case of difficulty? This is a complex and delicate issue.
The surgeon holds responsibility for the procedure. The qual-
ity and safety of treatment depends on implementing means of
assessment: rates of conversion to conventional admission and of
readmission after discharge from the AS unit.
S89
The organizational measures that ensure quality are often the
responsibility of the surgeon, and this needs to be made attrac-
tive, with added value: perhaps removing regulatory limitations
on the period before seeing the patient again after surgery, a fixed
follow-up payment, or increased AS prices. Telephone follow-up,
e-health applications and new kinds of job will emerge, all com-
bining to enable ambulatory management of heavier pathologies
(and e-health).
There is room for improvement in terms of national health insur-
ance cover for AS by the national health insurance system for the
self-employed and by some of the private top-up insurance compa-
nies (which make up the shortfall between the national insurance
cover and the price to the patient).
Practice also needs adapting to specific patient populations, tak-
ing account of existing up- and downstream services and, finally,
encouraging acceptance of AS without imposing it. Risk manage-
ment is developing, and should in coming years allow stock to be
taken of the situation.
Structures can now legitimately be said to be adapted and well
defined. Two feet of the tripod remain: the patient and the pro-
cedure. The idea of the “eligible pair” (surgeon and anaesthetist)
needs developing, to extend our present limits: a 60-year-old ASA 1
patient may be eligible for ambulatory hip replacement, whereas a
hand surgery patient with a poor social situation may need conven-
tional admission. If the patient requires surveillance in intensive
care, overnight stay will be necessary and should be medically pre-
scribed [45].
It is the patient who is ambulatory, but it is the surgeon who
alone is responsible for the surgery. The IGAS-IGF report has very
little to say about surgeons, in contrast to hospital managers.
Encouragement for and recognition of the surgeon’s involvement
by the authorities is fundamental, yet apparently not a priority.
6. Conclusion
The objective is to enable and organize a progressive transi-
tion to AS by preparing the ground for our colleagues and helping
them solve everyday problems. To improve our practice, it is nec-
essary, based on the scientific literature, to develop the following:
assessment of failure and the causes of failure, improvement in
pain management, and lifting psychosocial limitations so as to
strengthen our patients’ compliance and eligibility.
Taken together, these developments and the procedures, devel-
oped in teams on the ground, contribute to improving clinical
practice in all fields of surgery, illustrating the driving force pro-
vided by reflection on ambulatory strategy.
Several questions remain burning issues:
• what do our insurance companies have to say about “risk man-
agement” within AS units, with all the medicolegal aspects?
• what role for the GP in the follow-up of patients discharged
home?
• how will the development of AS affect the utility and pertinence
of surgery? As procedures become banal and apparently simple,
being ambulatory, will they mushroom?
• is AS liable to become a marketing tool for centers, physicians and
insurers?
AS accounts for 41% of procedures in orthopaedics, and will con-
tinue to grow, with considerable potential. Not all procedures will
be eligible, but a significant dynamic has been released, defining a
new economic model in which the gold standard will no longer be
full hospital admission but ambulatory surgery.
S90 C. Hulet et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) S83–S90
Disclosure of interest
The authors declare that they have no competing interest.
References
[1] Vons C. L’ambulatoire va être la norme de prise en charge pour une grande
partie des patients opérés en chirurgie digestive et viscérale. [Day case surgery
is going to be considered as the gold standard care of most digestive surgery
patients]. e-memoires Acad Natl Chir 2010;10:027–31.
[2] Raimbeau G. Développement et limites de la chirurgie ambulatoire. In:
Conférence d’enseignement SOFCOT. Expansion scientifique française. Paris:
Elsevier Masson SAS; 2009. p. 256–66 http://www.iaas-med.com/index.php/
InternationalAssociationforAmbulatorySurgery.
[3] IAAS. Ambulatory (day) surgery. Suggested international terminology and defi-
nitions. London: International Association for Ambulatory Surgery (IAAS); 2003
[Policy brief: day surgery: making it happen. London: IAAS;2007].
[4] Hulet C, Pineau V, Burdin G, Delforge S, Klebaner I, Rochcongar G. État des
lieux de la chirurgie ambulatoire pour l’orthopédie traumatologie en 2012. e-
memoires Acad Natl Chir 2012;11:036–9.
[5] GDR guide de état des lieux 2014 sur activité de la chirurgie ambula-
toire nouveau périmètre. http://www.scansante.fr/applications/action-gdr-
chirurgie-ambulatoire.
[6] Instruction No DGO S/R3/2015/296 du 28 septembre 2015 relative aux objec-
tifs et orientations stratégiques du programme national de développement
de la chirurgie ambulatoire pour la période 2015–2020. AFSH1522968J. cir-
culaire.legifrance.gouv.fr.
[7] Rapport IGAS IGF, Perspectives du développement de la chirurgie ambulatoire
en France (MAP) : http://www.igas.gouv.fr/spip.php?article431.
[8] Arrêté du 28 février 2012 fixant pour l’année 2012 les éléments tarifaires men-
tionnés aux I et IV de l’article L. 162-22-10 du Code de la sécurité sociale et
aux IV et V de l’article 33 modifié de la loi de financement de la sécurité sociale
pour 2004. JO 29 février 2012.
[9] Déci sion no 2013.0028/DC/SEAP du 27 mars 2013 du collège de la HAS adoptant
le document intitulé « Recommandations organisationnelles et outils sur la
chirurgie ambulatoire ». Décision no 2013.0029/DC/SEAP du 27 mars 2013 du
collège de la HAS adoptant le guide méthodologique « sécurité des patients en
chirurgie ambulatoire ».
[10] Haute Autorité de santé, Agence nationale d’appui à la performance. Ensemble
pour le développement de la chirurgie ambulatoire. Socle de connaissances.
Saint-Denis La Plaine ; Paris: HAS ; ANAP; 2012 http://www.hassante.fr/portail/
upload/docs/application/pdf/2012-04/rapport-socle de connaissances.pdf.
[11] Haute Autorité de santé, Agence nationale d’appui à la performance. Ensemble
pour le développement de la chirurgie ambulatoire. Recommandations
organisationnelles de la chirurgie ambulatoire : outils et guide. Saint-Denis La
Plaine ; Paris: HAS ; ANAP; 2013 http://www.hassante.fr/portail/upload/docs/
application/pdf/2012-04/rapport-socle de connaissances.pdfhttp://www.
hassante.fr/portail/upload/docs/application/pdf/2013 06/recommandations
vd.pdf.
[12] Haute Autorité de santé, Agence nationale d’appui à la performance. Ensemble
pour le développement de la chirurgie ambulatoire. Éléments d’appréciation
en vue de la prise en charge d’un patient en chirurgie ambulatoire. Saint-Denis
La Plaine ; Paris: HAS ; ANAP; 2013 http://www.hassante.fr/portail/upload/
docs/application/pdf/201407/rapport chir ambu axe2 vf.pdfhttp://www.
hassante.fr/portail/upload/docs/application/pdf/2012-04/rapport-socle de
connaissances.pdf.
[13] Haute Autorité de santé, Agence nationale d’appui à la performance. Ensemble
pour le développement de la chirurgie ambulatoire. Tarification de la chirurgie
ambulatoire en France et à l’étranger : état des lieux et perspectives. Saint-Denis
La Plaine ; Paris: HAS ; ANAP; 2013.
[14] HAS. Chirurgie ambulatoire en orthopédie; 2014 http://www.has-sante.fr/
portail/jcms/c 1773302/fr/chirurgie-ambulatoire-en-orthopedie.
[15] HAS. Éléments d’appréciation en vue de la prise en charge d’un patient
en chirurgie ambulatoire; 2014 http://www.has-sante.fr/portail/jcms/
c 1346147/fr/elements-dappreciation-en-vue-de-la-prise-en-charge-dun-
patient-en-chirurgie-ambulatoire.
[16] HAS-ANAP. http://www.has-sante.fr/portail/jcms/c 1337911/dimension-
organisationnelle-de-la-chirurgie-ambulatoire-modeles-et-outils-note-de-
cadrage.
[17] Déroulement de l’expérimentation des indicateurs de processus et de
résultat; 2016 http://www.has-sante.fr/portail/jcms/c 2022569/fr/ipaqss-
2016-experimentation-des-indicateurs-de-processus-et-de-resultats-en-
chirurgie-ambulatoire.
[18] SFAR. Recommandations formalisées d’experts. Prise en charge anesthésique
des patients en hospitalisation ambulatoire; 2009 http://www.sfar.org/
article/207/prise-en-charge-anesthesique-des-patients-en-hospitalisation-
ambulatoire-rfe-2009.
[19] Arrêté du 25 février 2014 fixant pour l’année 2014 les éléments tarifaires men-
tionnés aux I et IV de l’article L. 162-22-10 du Code de la sécurité sociale. NOR :
AFSH1404920A.
[20] Chirurgie du pied et de la cheville en mode ambulatoire.Colombier J-A, Toullec
E, editors. Mises au point de l’AFCP. Elsevier Masson; 2015 [152 pp., ISBN :
9782294741623, EISBN : 978229474728].
[21] Mouton A, Le Strat V, Medevielle D, Kerroumi Y, Graff W, French Associa-
tion of Foot Surgery (AFCP). Patient’s satisfaction after outpatient forefoot
surgery: study of 619 cases. Orthop Traumatol Surg Res 2015;101:S217–20,
http://dx.doi.org/10.1016/j.otsr.2015.06.004 [Epub 2015 Aug 13].
[22] Chaudier P, Bourdin M, Gauthier J, Fessy MH, Besse JL. Similar levels of pain are
reported in forefoot surgery after management as a day case and admission for
48 hours: a continuous prospective study of 317 patients. Bone Joint J 2015;97-
B:1645–50, http://dx.doi.org/10.1302/0301-620X.97B12.35608.
[23] Beaussier M, Sciard D, Sautet A. New modalities of pain treatment after out-
patient orthopaedic surgery. Orthop Traumatol Surg Res 2016;102:S121–4,
http://dx.doi.org/10.1016/j.otsr.2015.05.011 [Epub 2016 Jan 20].
[24] Adam F, Pelle-Lancien E, Bauer T, Solignac N, Sessler DI, Chauvin M.
Anesthesia and postoperative analgesia after percutaneous hallux valgus
repair in ambulatory patients. Ann Fr Anesth Reanim 2012;31:e265–8,
http://dx.doi.org/10.1016/j.annfar.2012.07.022 [Epub 2012 Oct 3].
[25] Massa H, Hubert S, Carles M, Raucules A. Anesthésie du patient en ambulatoire.
EMC Anesthésie-Réanimation. Paris: Elsevier Masson SAS; 2010 [36-635-A-10].
[26] Cucurulo T, Servien E. Chirurgie du ligament croisé antérieur en ambulatoire.
In: SFA Congrès de Grenoble. 2015.
[27] Baverel L, Demey G, Odri GA, Leroy P, Saffarini M, Dejour D. Do outcomes of
outpatient ACL reconstruction vary with graft type? Orthop Traumatol Surg Res
2015;101:803–6, http://dx.doi.org/10.1016/j.otsr. 2015.08.012 [Epub 2015 Oct
20].
[28] Lefevre N, Klouche S, de Pamphilis O, Devaux C, Herman S, Bohu Y. Postopera-
tive discomfort after outpatient anterior cruciate ligament reconstruction: a
prospective comparative study. Orthop Traumatol Surg Res 2015;101:163–6,
http://dx.doi.org/10.1016/j.otsr.2014.07.036 [Epub 2015 Feb 7].
[29] Lefevre N, Bohu Y, de Pamphilis O, Klouche S, Devaux C, Herman S.
Outpatient surgery feasibility in anterior cruciate ligament reconstruc-
tion: a prospective comparative assessment. Orthop Traumatol Surg Res
2014;100:521–6, http://dx.doi.org/10.1016/j.otsr.2014.03.024 [Epub 2014 Jul
28. PMID: 25082774].
[30] Karaaslan F, Karaoğlu S, Yurdakul E. Reducing intra-articular hemarthrosis after
arthroscopic anterior cruciate ligament reconstruction by the administration
of intravenous tranexamic acid: a prospective, randomized controlled trial. Am
J Sports Med 2015;43:2720–6, http://dx.doi.org/10.1177/0363546515599629.
[31] Westermann RW, Pugely AJ, Ries Z, Amendola A, Martin CT, Gao Y, et al.
Causes and predictors of 30-day readmission after shoulder and knee
arthroscopy: an analysis of 15,167 cases. Arthroscopy 2015;31:1035e1–40e1,
http://dx.doi.org/10.1016/j.arthro.2015.03.029.
[32] Bohu Y, Klouche S, Gerometta A, Herman S, Lefevre N. Outpatient Latarjet
surgery for gleno-humeral instability: prospective comparative assessment of
feasibility and safety. Orthop Traumatol Surg Res 2016;102:336–71.
[33] Lefrancois V, Dufour-Trivini M, Goursaud S, Pegoix M, Lemasson E, Daccache
G, et al. Caractérisation du dommage myocardique en chirurgie orthopédique
programmée de la hanche et du genou. Ann Fr Anesth Reanim 2013;32S:
188–9.
[34] Lefrancois V, Pegoix M, Goursaud S, Dufour-Trivini M, Delaunay J, Boissel M,
et al. Saignement postopératoire dans les suites d’une arthroplastie primaire
de hanche et de genou. Intérêt d’une évaluation standardisée des pertes. Ann
Fr Anesth Reanim 2013;32S:A371–2.
[35] Lefrancois V, Pegoix M, Daccache G, Fellahi J-L, Hanouz J-L. Evaluation of post-
operative bleeding and acute myocardial injury after major orthopedic surgery.
Eur J Anaesthesiol 2014;31:93.
[36] Jouffroy P, Dromzee E, Lancrin F. Prothèse totale de hanche en ambulatoire.
Description du protocole et résultats précoces. Rev Chir Orthop Traumatol
2014;100:S288.
[37] Jouffroy P, Dromzee E, Lancrin F. PTH en hospitalisation d’une nuit. Description
du protocole et résultats précoces. Rev Chir Orthop Traumatol 2015;101:S196.
[38] Thienpont E, Lavand’homme P, Kehlet H. The constraints on day-case total
knee arthroplasty: the fastest fast track. Bone Joint J 2015;97-B:40–4,
http://dx.doi.org/10.1302/0301-620X.97B10.36610.
[39] Kort NP, Bemelmans YF, Schotanus MG. Outpatient surgery for unicompart-
mental knee arthroplasty is effective and safe. Knee Surg Sports Traumatol
Arthrosc 2015, http://dx.doi.org/10.1007/s00167-015-3680-y.
[40] Kort NP, Bemelmans YF, van der Kuy PH, Jansen J, Schotanus MG. Patient
selection criteria for outpatient joint arthroplasty. Knee Surg Sports Traumatol
Arthrosc 2016, http://dx.doi.org/10.1007/s00167-016-4140-z.
[41] Villeminot J. Total knee prosthesis surgery. In: European Congress of Ambula-
tory Surgery (AFCA IAAS). 2016.
[42] Asselineau Molina V, Court C, Vincent C, Gagey O. Hernies discales lom-
baires – quelle organisation pour passer de la chirurgie classique à la chirurgie
ambulatoire et premiers résultats. Passer de l’hospitalisation classique à la
chirurgie ambulatoire. Rev Chir Orthop Traumatol 2015;101:S205.
[43] Chin KR, Pencle FJ, Coombs AV, Brown MD, Conklin KJ, O’Neill AM, et al.
Lateral lumbar interbody fusion in ambulatory surgery centers: patient selec-
tion and outcome measures compared with an inhospital cohort. Spine
2016;41:686–92, http://dx.doi.org/10.1097/BRS.0000000000001285.
[44] Chin KR, Coombs AV, Seale JA. Feasibility and patient-reported outcomes after
outpatient single-level instrumented posterior lumbar interbody fusion in a
surgery center: preliminary results in 16 patients. Spine 2015;40:E36–42,
http://dx.doi.org/10.1097/BRS.0000000000000604.
[45] Raimbeau G. Nuitée sur ordonnance ! Rev Tech Hosp 2016;756:9–11.