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      Why still in hospital after fast-track hip and knee arthroplasty?

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          Abstract

          Background and purpose

          Length of stay (LOS) following total hip and knee arthroplasty (THA and TKA) has been reduced to about 3 days in fast-track setups with functional discharge criteria. Earlier studies have identified patient characteristics predicting LOS, but little is known about specific reasons for being hospitalized following fast-track THA and TKA.

          Patients and methods

          To determine clinical and logistical factors that keep patients in hospital for the first postoperative 24–72 hours, we performed a cohort study of consecutive, unselected patients undergoing unilateral primary THA (n = 98) or TKA (n = 109). Median length of stay was 2 days. Patients were operated with spinal anesthesia and received multimodal analgesia with paracetamol, a COX-2 inhibitor, and gabapentin—with opioid only on request. Fulfillment of functional discharge criteria was assessed twice daily and specified reasons for not allowing discharge were registered.

          Results

          Pain, dizziness, and general weakness were the main clinical reasons for being hospitalized at 24 and 48 hours postoperatively while nausea, vomiting, confusion, and sedation delayed discharge to a minimal extent. Waiting for blood transfusion (when needed), for start of physiotherapy, and for postoperative radiographic examination delayed discharge in one fifth of the patients.

          Interpretation

          Future efforts to enhance recovery and reduce length of stay after THA and TKA should focus on analgesia, prevention of orthostatism, and rapid recovery of muscle function.

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          Evidence-based surgical care and the evolution of fast-track surgery.

          Henrik Kehlet, Douglas Wilmore (2008)
          Optimization of postoperative outcome requires the application of evidence-based principles of care carefully integrated into a multimodal rehabilitation program. To assess, synthesize, and discuss implementation of "fast-track" recovery programs. Medline MBASE (January 1966-May 2007) and the Cochrane library (January 1966-May 2007) were searched using the following keywords: fast-track, enhanced recovery, accelerated rehabilitation, and multimodal and perioperative care. In addition, the synthesis on the many specific interventions and organizational and implementation issues were based on data published within the past 5 years from major anesthesiological and surgical journals, using systematic reviews where appropriate instead of multiple references of original work. Based on an increasing amount of multinational, multicenter cohort studies, randomized studies, and meta-analyses, the concept of the "fast-track methodology" has uniformly provided a major enhancement in recovery leading to decreased hospital stay and with an apparent reduction in medical morbidity but unaltered "surgery-specific" morbidity in a variety of procedures. However, despite being based on a combination of evidence-based unimodal principles of care, recent surveys have demonstrated slow adaptation and implementation of the fast-track methodology. Multimodal evidence-based care within the fast-track methodology significantly enhances postoperative recovery and reduces morbidity, and should therefore be more widely adopted. Further improvement is expected by future integration of minimal invasive surgery, pharmacological stress-reduction, and effective multimodal, nonopioid analgesia.
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            Predictors of length of stay and patient satisfaction after hip and knee replacement surgery: fast-track experience in 712 patients.

            Gitte Holm, Steffen Jacobsen, Henrik Husted (2008)
            Very few studies have focused on patient characteristics that influence length of stay (LOS) in fast-track total hip (THR) and knee arthroplasty (TKR). The aim of this prospective study was to identify patient characteristics associated with LOS and patient satisfaction after total hip and knee replacement surgery. Between September 2003 and December 2005, 712 consecutive, unselected patients (440 women) with a mean age of 69 (31-91) years were admitted for hip and knee replacement surgery at our specialized fast-track joint replacement unit. Epidemiological, physical, and perioperative parameters were registered and correlated to LOS and patient satisfaction. 92% of the patients were discharged directly to their homes within 5 days, and 41% were discharged within 3 days. Age, sex, marital status, co-morbidity, preoperative use of walking aids, pre- and postoperative hemoglobin levels, the need for blood transfusion, ASA score, and time between surgery and mobilization, were all found to influence postoperative outcome in general, and LOS and patient satisfaction in particular. We identified several patient characteristics that influence postoperative outcome, LOS, and patient satisfaction in our series of consecutive fast-track joint replacement patients, enabling further attention to be paid to certain aspects of surgery and rehabilitation.
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              Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: a case study of 325 patients.

              Dennis Kerr, Lawrence Kohan (2008)
              We have developed a multimodal technique for the control of pain following knee and hip surgery, called "local infiltration analgesia" (LIA). It is based on systematic infiltration of a mixture of ropiva-caine, ketorolac, and adrenaline into the tissues around the surgical field to achieve satisfactory pain control with little physiological disturbance. The technique allows virtually immediate mobilization and earlier discharge from hospital. In this open, nonrandomized case series, we used LIA to manage postoperative pain in all 325 patients presenting to our service from Jan 1, 2005 to Dec 31,2006 for elective hip resurfacing (HRA), primary total hip replacement (THR), or primary total knee replacement arthroplasty (TKR). We recorded pain scores, mobilization times, and morphine usage for the entire group. Pain control was generally satisfactory (numerical rating scale pain score range 0-3). No morphine was required for postoperative pain control in two-thirds of the patients. Most patients were able to walk with assistance between 5 and 6 h after surgery and independent mobility was achieved 13-22 h after surgery. Orthostatic hypotension, nausea, and vomiting were occasionally associated with standing for the first time, but other side effects were unremarkable. 230 (71%) of the 325 patients were discharged directly home after a single overnight stay in hospital. Local infiltration analgesia is simple, practical, safe, and effective for pain management after knee and hip surgery.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Acta Orthop
                Journal ID (publisher-id): ORT
                Title: Acta Orthopaedica
                Publisher: Informa Healthcare
                ISSN (Print): 1745-3674
                ISSN (Electronic): 1745-3682
                Publication date (Print): December 2011
                Publication date (Electronic): 25 November 2011
                Volume: 82
                Issue: 6
                Pages: 679-684
                Affiliations
                1simpleDepartment of Orthopaedic Surgery
                2simpleDepartment of Anaesthesiology , Hvidovre University Hospital
                3Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen University
                4The Lundbeck Centre for Fast-track Hip and Knee Arthroplasty, Copenhagen, Denmark
                Author notes
                Article
                Publisher ID: ORT_A_636682_O
                DOI: 10.3109/17453674.2011.636682
                PMC ID: 3247885
                PubMed ID: 22066560
                SO-VID: b1b4571c-2026-4ab3-8a90-c841656c8dfa
                Copyright © Copyright: © Nordic Orthopaedic Federation
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the source is credited.

                History
                Date received : 24 May 2011
                Date accepted : 02 August 2011
                Categories
                Subject: Article

                ScienceOpen disciplines: Orthopedics
                Data availability:
                ScienceOpen disciplines: Orthopedics

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