[Challenges of fast-track arthroplasty in Germany]

Stepwise implementation of an enhanced recovery pathway for elective total hip arthroplasty in a Swiss hospital: a cohort study

BACKGROUND

Enhanced recovery programs after total hip arthroplasty have been shown to reduce hospital length of stay without compromising results, but yet there is a lack of data for the Swiss population. Therefore, this retrospective cohort study evaluated whether similar positive effects on clinical outcomes are present in the context of the Swiss healthcare system.

METHODS

Patients who underwent elective primary total hip arthroplasty were analysed. The baseline group comprised 50 patients treated consecutively by one surgeon in 2013 according to the clinical practice guidelines. Another surgeon implemented a new standardised treatment protocol in April 2014. In January 2018, this protocol was followed by an enhanced recovery program that integrated all care providers at the hospital. The data of the baseline group (series 0) and four series of 50 patients each, two treated with the standardised treatment protocol (series 1-2) and two treated with the enhanced recovery program (series 3-4), were analysed. All patients had follow-ups at 6 weeks and 3 months after surgery. The primary outcomes were length of stay and discharge destination; the secondary outcomes were admission on the day of surgery (instead of one day prior), the use of urinary catheters, the administration of opioids, the difference between pre- and postoperative haemoglobin, blood transfusions, and adverse events within 3 months of surgery.

RESULTS

The median length of stay was 10 days in the baseline group and only 5 days after the implementation of the standardised protocol and enhanced recovery program in series 4 (p <0.001). The percentage of patients discharged directly home was higher in series 4 than in the baseline group (84% vs. 66%, p = 0.085). Patients admitted to the hospital on the day of surgery increased from 2% in series 0 to 98% in series 4 (p <0.001). The use of urinary catheters was significantly higher in the baseline group (100% of patients) than in series 3 and 4 (0%) (p <0.001), and the number of patients who did not require opioids was significantly higher in series 4 than in series 0 (36% vs. 10%, p = 0.007). The median blood loss (500 ml vs. 300 ml, p <0.001), median difference in pre- and postoperative haemoglobin (29 g/dl vs. 25 g/dl, p = 0.145), and number of blood transfusions (5 vs. 2 p = 0.99) were higher in the baseline group than in series 4. The number of adverse events did not differ significantly between groups (p = 0.699).

CONCLUSIONS

Almost all parameters examined in this study showed improvement, whereas the rate of adverse events was not affected and remained low. The presented data can be used as a benchmark, but details of these findings need to be confirmed in larger cohorts.

Postoperative Inpatient Rehabilitation Does Not Increase Knee Function after Primary Total Knee Arthroplasty

Inpatient rehabilitation (IR) is a common postoperative protocol after total knee replacement (TKA). Because IR is expensive and should therefore be justified, this study determined the difference in knee function one year after TKA in patients treated with IR or outpatient rehabilitation, fast-track rehabilitation (FTR) in particular, which also entails a reduced hospital length of stay. A total of 205 patients were included in this multi-center prospective cohort study. Of the patients, 104 had primary TKA at a German university hospital and received IR, while 101 had primary TKA at a Canadian university hospital and received FTR. Patients receiving IR or FTR were matched by pre-operative demographics and knee function. Oxford Knee Score (OKS), Western Ontario and McMaster Universities Arthritis Index (WOMAC), and EuroQol visual analogue scale (EQ-VAS) determined knee function one year after surgery. Patients receiving IR had a 2.8-point lower improvement in OKS (p = 0.001), a 6.7-point lower improvement in WOMAC (p = 0.063), and a 12.3-point higher improvement in EQ-VAS (p = 0.281) than patients receiving FTR. IR does not provide long-term benefits to patient recovery after primary uncomplicated TKA under the current rehabilitation regime.

[Discharge readiness versus discharge-Results of the PROMISE study]

Hintergrund

Für Deutschland werden im Rahmen optimierter Behandlungsprozesse rund um die Implantation einer Knie- oder Hüftendoprothese stationäre Aufenthaltszeiten angegeben, die die international publizierten Zeiten deutlich übertreffen. Die vorliegende Analyse von Daten der PROMISE-Studie beschäftigt sich in diesem Zusammenhang mit dem Verhältnis von Entlassbarkeit und Entlassung.

Methode

In drei Krankenhäusern unterschiedlicher Versorgungsstufen wurde ein gemeinsam entwickelter, optimierter Versorgungsstandard etabliert und für eine weitgehend unselektionierte Patientenkohorte umgesetzt. Unter anderem wurden Daten zum Erreichen der Entlasskriterien (EK) und der tatsächlichen Entlassung erhoben. Univariate Vergleiche wurden durch Chi-Quadrat-Tests oder Mann-Whitney-U-Tests durchgeführt.

Ergebnisse

Insgesamt konnten 1782 Patienten eingeschlossen werden, von denen 85,3 % nach im Mittel (MW) 2,4 Tagen (Median 2) postoperativ alle zuvor definierten EK erreicht haben. Die Entlassung für diese Gruppe erfolgte nach 5,4 (MW) Tagen (Median 5). Die restlichen Probanden (14,7 %) hatten bei Entlassung nach 6,5 (MW) Tagen (Median 6) mindestens ein EK nicht erreicht. Für verschiedene Subgruppen konnten signifikante Unterschiede festgestellt werden.

Fazit

Die sogenannten EK werden als relative Kriterien eingesetzt. Das Erreichen führt im Allgemeinen nicht zu einer zeitnahen Entlassung der Patienten aus dem Krankenhaus. Wäre dies der Fall, wären auch in Deutschland international übliche Aufenthaltszeiten Realität. Was die Entlassung tatsächlich bestimmt, bleibt offen. Eine Vielzahl von medizinischen, organisatorischen, strukturellen und finanziellen Einflussfaktoren könnten bedeutend sein.

[Rehabilitation following total knee replacement]

BACKGROUND

Total knee replacement requires follow-up treatment. This can take place on an outpatient basis as part of health insurance coverage, but also as outpatient or inpatient rehabilitation.

KIND OF REHABILITATION

Outpatient rehabilitation provides comparable results to inpatient rehabilitation, but only for those patients who are suitable for outpatient rehabilitation. Inpatient rehabilitation should be indicated depending on general health status, general physical fitness, housing situation, accessibility of rehabilitation facilities and possibilities of social support in the home environment, as well as age and comorbidities. Physiotherapeutic procedures should focus on exercise therapy. Passive reactive measures complement the therapy. For patients of working age, the activity profile should be considered as part of the rehabilitation process. Patient education, with information on prosthesis-appropriate behavior, represents an important component in follow-up treatment.

PROSPECT

Demographic change requires increasing consideration of orthogeriatric aspects. Fast-track programs will not make follow-up treatment superfluous, but with accelerated processes they represent a new challenge for sectoral cooperation.

[Intraoperative assessment of pelvic tilt and cup position in total hip arthroplasty: the relevance of navigation and robotics]

The optimal 3D positioning of the prosthesis components is of great importance for the stability and function of a total hip endoprosthesis. Pelvic tilt has a particular influence on the position of the implant. In order to use intraoperatively the knowledge on pelvic kinematics gained through preoperative imaging procedures and movement analyses, "image-based" and "image-free" robotic and navigation procedures are available. With the "image-based" procedures, a 3D CT scan serves as the surgeon's basis for operative planning. The "image-free" procedures are based on the principles of stereotaxy. In the future, information about static and dynamic pelvic tilt will be conntected with navigation and robotic systems for total hip arthroplasty. Along with intraoperative data a patientindividual optimized implant position can be achieved.