Reducing incision length or intensifying rehabilitation: what makes the difference to length of stay in total hip replacement in a UK setting?

Improvement of early functional outcomes in hospitalized geriatric patients after hip surgery

Computer supported clinical practice has great potential to improve process performance and care outcomes. However, further research is needed to evaluate the efficiency of Health Information Technology (HIT) across the various clinical settings. This study focuses on the status of the patient as determined by various potential predicting factors for functional recovery during hospitalization after hip surgery. We assess the relations among patient's characteristics, (co)morbidities, surgical procedures, hospital courses and modified Salvati-Wilson's (SW) score on discharge. The aim is to improve decision making in clinical practice at General hospital "Djordje Joanovic" in Zrenjanin, Serbia, by applying the variation of the Johnson's algorithm for data reduction. The data are related to hospitalized geriatric patients after hip surgery. The second aim is to define the methodology for decision making based on data related to hospitalized geriatric patients after hip surgery in local environments. The SW score as a measure of results of early functional recovery, was affected by age, surgical procedure, the lowest postoperative value of red blood cells during hospitalization, haemoglobin level on discharge, length of hospitalization and length of rehabilitation. It is possible to improve decision making in clinical practice at General hospital "Djordje Joanovic" in Zrenjanin, Serbia, by applying the variation of the Johnson's algorithm for data reduction. The applied method is useful for any local environment for similar geriatric population, in effort to improve their own clinical practice.

Early commencement of physical therapy in the acute phase following elective lower limb arthroplasty produces favorable outcomes: a systematic review and meta-analysis examining allied health service models

BACKGROUND

Temporal and dose-response relationships between allied health (AH) and recovery in the acute phase following lower limb (LL) arthroplasty are unclear. This systematic review investigates whether early commencement, additional therapy and/or weekend AH affects length of stay (LOS) and patient outcomes in the acute phase following LL arthroplasty.

METHODS

Electronic databases were searched in February 2015. Studies were included if they evaluated any of the following aspects of AH for adults following LL arthroplasty in the acute phase: Early compared to later therapy commencement; Additional therapy; or a 6- or 7-day service compared to a lesser service.

RESULTS

Twenty-four studies met the inclusion criteria, of which 19 investigated effects of physical therapy (PT) alone. Earlier PT reduced LOS (WMD = -1.23 days; 95% CI, -2.16 to -0.30) and resulted in higher probability of discharge directly home (relative risk = 1.45; 95% CI, 1.26-1.67). Addition of weekend PT reduced LOS (WMD = -1.04 days; 95% CI, -1.66 to -0.41) and improved function (SMD = 0.37; 95% CI, 0.02-0.73). Increasing PT from once to twice daily did not affect LOS (WMD = -0.35 days; 95% CI, -0.96-0.26) or function (SMD = 0.31; 95% CI, -0.06-0.71).

DISCUSSION

Early PT commencement and a weekend service may produce favorable outcomes following LL arthroplasty when baseline LOS is 4 days or more. Redistributing PT resources to commence as early as day of surgery regardless of weekday may accelerate postoperative recovery. Current, high quality research is needed to confirm these findings.

Effect of day of the week of primary total hip arthroplasty on length of stay at a university-based teaching medical center

Length of hospital stay (LHS) after primary total hip arthroplasty (THA) constitutes a critical outcome measure, as prolonged LHS implies increased resource expenditure. Investigations have highlighted factors that affect LHS after THA. These factors include advanced age, medical comorbidities, obesity, intraoperative time, anesthesia technique, surgical site infection, and incision length. We retrospectively analyzed the effect of day of the week of primary THA on LHS. We reviewed the surgery and patient factors of 273 consecutive patients who underwent THA at our institution, a tertiary-care teaching hospital. There was a 15% increase in LHS for patients who underwent THA on Thursday versus Monday when controlling for other covariates that can affect LHS. Other statistically significant variables associated with increased LHS included American Society of Anesthesiologists grade, transfusion requirements, and postoperative complications. The day of the week of THA may be an independent variable affecting LHS. Institutions with reduced weekend resources may want to perform THA earlier in the week to try to reduce LHS.

Blood management may have an impact on length of stay after total hip arthroplasty

BACKGROUND

The steady rise in demand for total hip arthroplasty constitutes a significant and increasing burden on health care resources. The biggest contributors to the total cost of hip replacement procedures other than the price of the implant are hospital stay and postoperative rehabilitation. Blood management is one of the most adjustable factors that can impact length of stay and cost-efficiency while improving patient safety.

QUESTIONS/PURPOSES

The primary purpose of this retrospective study was to assess the potential impact of blood management interventions on length of hospital stay after primary unilateral total hip arthroplasty. This was achieved by first identifying which patient and surgical factors are associated with an increased risk of prolonged hospital stay. Subsequently, the significant factors were controlled for through a multivariate regression analysis to quantify the association between blood transfusions and increased hospital stay.

METHODS

Retrospectively, the study included 2,104 primary total hip replacements. Eight hundred eighty-eight procedures were performed on males and 1,216 on females, with a mean age of 64 years at the time of the surgery (range 18-94 years) and BMI of 28.6 kg/m(2) (range 12-51.5 kg/m(2)). The correlation between each factor and length of stay was analyzed separately using univariate regression analysis. Those variables with p ≤ 0.05 in the univariate model were selected for inclusion in the multivariate logistic regressions. Multiple linear regression was used to analyze the effect of each significant factor and derive odds ratios with adjustment for the other variables.

RESULTS

Multivariate Poisson regression revealed that increased length of stay was significantly correlated to patient age (p = 0.05), the use of coumadin (p = 0.02) or lovenox/heparin (p = 0.007) as opposed to aspirin for anticoagulation, and allogeneic blood transfusion (p < 0.0001). The data shows that allogeneic blood transfusion is associated with a longer hospital stay regardless of absolute drop in hemoglobin level postoperatively or at discharge or the number of units transfused (OR = 1.18, 95% CI = 1.09 to 1.28, p < 0.001).

CONCLUSION

Transfusion of allogeneic blood is independently associated with increased hospital stay after total hip arthroplasty. Blood management modalities that can significantly reduce transfusion risk could impact length of stay as well as the total cost of hip replacement procedures.

Effect of weekend physiotherapy provision on physiotherapy and hospital length of stay after total knee and total hip replacement

Objective The aim of the present study was to investigate a change in physiotherapy provision from a 5- to 7-days-a-week service on both physiotherapy and hospital length of stay (LOS) after total knee (TKR) and total hip (THR) replacement. Methods A retrospective analysis of a clinical database was conducted for patients who received either a TKR or THR between July 2010 and June 2012 in one regional hospital. Results There was a significant decrease in physiotherapy LOS from 5.0 days (interquartile range (IQR) 5.0–6.0 days) for a 5-day physiotherapy service, to 5.0 days (IQR 4.0–5.0 days) for 7-day physiotherapy service (U = 1443.5, z = –4.62, P = 0.001). However, hospital LOS was not reduced (P = 0.110). For TKR, physiotherapy LOS decreased significantly by 1 day with a 7-day physiotherapy service (U = 518.0, z = –4.20, P = 0.001). However, hospital LOS was again no different (P = 0.309). For THR there was no difference in physiotherapy LOS (P = 0.060) or hospital LOS (P = 0.303) between the 5- and 7-day physiotherapy services. Where physiotherapy LOS was less than hospital LOS, delayed discharge was due primarily to non-medical issues (72%) associated with hospital organisational aspects. Conclusions Increasing the provision of physiotherapy service after TKR provides an increase in physiotherapy sessions and has the potential to reduce hospital LOS. To be effective this must align with other administrative aspects of hospital discharge. What is known about the topic? Previous studies have investigated the effect of increasing physiotherapy services following total hip replacement (THR) and total knee replacement (TKR) surgery, with varying reports of decreased or unaffected hospital length of stay (LOS). What does this paper add? This study investigates both hospital and physiotherapy LOS individually for THR and TKR patients following an increase from a 5- to 7-day physiotherapy service. Where physiotherapy LOS decreased and hospital LOS did not, delays in hospital discharge were investigated. What are the implications for practitioners? Additional physiotherapy services decrease physiotherapy LOS for TKR patients, but administrative aspects of hospital discharge must improve to reduce hospital LOS.

Is limited incision better than standard total hip arthroplasty? A meta-analysis

BACKGROUND

The literature comparing limited incision and standard incision THAs is confusing regarding whether limited incision THA improves short-term recovery without compromising long-term durability and survival. Further, previously published meta-analyses cannot conclude that limited incision THA is better. With new data, we seek to discover if the answers now exist.

PURPOSE

We used meta-analysis to compare surgical and hospitalization data, clinical outcomes, and complication rates, and thus (1) confirm whether limited incision THA is at least comparable to standard incision THA; and (2) determine whether limited incision THA is an improvement over standard incision THA.

METHODS

The PubMed database was searched using the terms "minimally", "invasive", and "total hip". Inclusion was limited to studies directly comparing limited incision with standard incision THA and reporting effect sizes.

RESULTS

We identified 418 articles. Of these 11 provided background information and 30 provided data (3548 THAs) for the systematic review. Limited incision THA was better than standard incision THA in four measures: length of hospitalization (6 versus 7 days), VAS pain at discharge (2 versus 4), blood loss (421 mL versus 494 mL), and the Harris hip score at 3 months postoperation (90 versus 84). There were no outcomes for which standard incision was better. There was no major difference in the rate of complications.

CONCLUSIONS

Short-term recovery favors limited incision over standard incision THA. The lack of consistent reporting for surgical outcomes, clinical outcomes, and complications continues to create difficulties when comparing limited and standard incision THAs.

The effect of femoral stem length on duration of hospital stay

Length of post-operative stay is an important factor in improving cost-effectiveness of total hip arthroplasty (THA). Short stem femoral components may reduce soft tissue and bone damage, permitting earlier mobilization and earlier safe discharge from hospital. This study compares the length of stay of patients undergoing THA using a short stem femoral component compared to an age matched group undergoing standard THA. The mean age in the standard stem group was 52.7 years and 50.4 years in the short femoral stem group (p=0.57). Total theatre time, blood loss and post-operative Oxford hip scores in the groups were not statistically different (p=0.11, p=0.91, p=0.16). Mean post-operative stay for the short stem group was shorter (3 vs 5 days, p=0.010), resulting in 10% cost saving per patient episode.

What is the role of minimally invasive surgery in a fast track hip and knee replacement pathway?

INTRODUCTION

Minimally invasive hip and knee replacement surgery (MIS) continues to receive coverage in both the popular press and scientific literature. The cited benefits include a smaller scar, less soft tissue trauma, faster recovery, reduced hospital stay, decreased blood loss and reduced post-operative pain. These outcomes are highly desirable and consistent with the aims of fast track hip and knee pathways. This paper evaluates the literature and discusses whether performing MIS over conventional surgical techniques offers advantages in a fast track hip and knee pathway.

METHODS

An English language literature search was performed using the MEDLINE and PubMed databases. Case series, randomised controlled trials and systematic reviews were included in the review.

RESULTS

The reported improvements in recovery brought about by MIS must be considered multifactorial. In combination with improved clinical pathways, MIS can be associated with quicker recovery and shorter length of hospital stay.

CONCLUSIONS

There is insufficient evidence to indicate that surgical technique alone makes a significant difference to recovery or reduces soft tissue trauma. No consensus on whether to use MIS techniques in fast track hip and knee replacement pathways can therefore be drawn. This is especially important given that the complication rates of MIS in the low to medium volume surgeon appear unacceptably high compared with standard approaches. It is also too early to assess the long-term effects of MIS on implant survival.

Randomized controlled trial of abductor muscle damage in relation to the surgical approach for primary total hip replacement: minimally invasive anterolateral versus modified direct lateral approach

INTRODUCTION

Minimally invasive total hip arthroplasty (THA) is claimed to be superior to the standard technique, due to the potential reduction of soft tissue damage via a smaller and tissue-sparing approach. As a result of the lack of objective evidence of fewer muscle and tendon defects, controversy still remains as to whether minimally invasive total hip arthroplasty truly minimizes muscle and tendon damage. Therefore, the objective was to compare the influence of the surgical approach on abductor muscle trauma and to analyze the relevance to postoperative pain and functional recovery.

MATERIALS AND METHODS

Between June 2006 and July 2007, 44 patients with primary hip arthritis were prospectively included in the study protocol. Patients underwent cementless unilateral total hip arthroplasty either through a minimally invasive anterolateral approach (ALMI) (n = 21) or a modified direct lateral approach (mDL) (n = 16). Patients were evaluated clinically and underwent MR imaging preoperatively and at 3 and 12 months postoperatively. Clinical assessment contained clinical examination, performance of abduction test and the survey of a function score using the Harris Hip Score, a pain score using a numeric rating scale (NRS) of 0-10, as well as a satisfaction score using an NRS of 1-6. Additionally, myoglobin and creatine kinase were measured preoperatively, and 6, 24 and 96 h postoperatively. Evaluation of the MRI images included fatty atrophy (rating scale 0-4), tendon defects (present/absent) and bursal fluid collection of the abductor muscle.

RESULTS

Muscle and tendon damage occurred in both groups, but more lateral gluteus medius tendon defects [mDL 3/12mth.: 6 (37%)/4 (25%); ALMI: 3 (14%)/2 (9%)] and muscle atrophy in the anterior part of the gluteus medius [mean-standard (12): 1.75 ± 1.8; mean-MIS (12): 0.98 ± 1.1] were found in patients with the mDL approach. The clinical outcome was also poorer compared to the ALMI group. Significantly, more Trendelenburg's signs were evident and lower clinical scores were achieved in the mDL group. No differences in muscle and tendon damage were found for the gluteus minimus muscle. A higher serum myoglobin concentration was measured 6 and 24 h postoperatively in the mDL group (6 h: 403 ± 168 μg/l; 24 h: 304 ± 182 μg/l) compared to the ALMI group (6 h: 331 ± 143 μg/l; 24 h: 268 ± 145 μg/l).

CONCLUSION

Abductor muscle and tendon damage occurred in both approaches, but the gluteus medius muscle can be spared more successfully via the minimally invasive approach and is accompanied by a better clinical outcome. Therefore, going through the intermuscular plane, without any detachment or dissection of muscle and tendons, truly minimizes perioperative soft tissue trauma. Furthermore, MRI emerges as an important imaging modality in the evaluation of muscle trauma in THA.

Age-related appearance of muscle trauma in primary total hip arthroplasty and the benefit of a minimally invasive approach for patients older than 70 years

Old age is frequently associated with a poorer functional outcome after THA. This might be based upon muscular damage resulting from surgical trauma. Minimally invasive approaches have been widely promoted on the basis of the muscle sparing effect. The aim of the study was to evaluate of the functional outcome and the grade of fatty muscle atrophy of the gluteus medius muscle by magnetic-resonance-imaging (MRI) in patients undergoing minimally invasive or traditional THA. Forty patients (21 female, 19 male) underwent THA either via a modified direct lateral (mDL) or a minimally invasive anterolateral (ALMI) approach. Patients were evaluated clinically and by MRI in terms of age (< or ≥70 y) preoperatively and at three and 12 months postoperatively. The Harris hip score and Trendelenburg's sign were recorded and a survey of a pain (using a numeric rating scale of 0-10) and satisfaction score (using a numeric rating scale of 1-6) was performed. Fatty atrophy (FA) of gluteus medius muscle was rated by means of a five-point rating scale (0 indicates no fat and 4 implies more fat than muscle). Younger patients reached a significantly higher Harris hip score, lower pain score and lower rate of positive Trendelenburg's sign accompanied by a significantly lower rate of postoperative FA (P = 0.03; young: FA (MW) = (preop. / 3 / 12 months), 0.15 / 0.7 / 0.7; old: FA (MW) = 0.18 / 1.3 / 1.36). Older patients with an mDL-approach had the significantly lowest clinical scores, the highest rate of positive Trendelenburg's sign and also the highest rate of fatty atrophy (P = 0.03; FA (old) mDL: 1.8; ALMI: 0.7). Interestingly, no influence of the approach could be detected within the younger group. Patients older than 70 years had a poorer functional outcome and a higher postoperative extent of FA when compared to younger patients, which must be based upon a higher vulnerability and a reduced regenerative capacity of their skeletal muscle. Through a minimally invasive approach the muscle trauma in older patients can be effectively reduced and thus the functional outcome significantly improved. Incision and detachment of tendons and muscles should be strictly avoided.

Factors influencing early rehabilitation after THA: a systematic review

A wide variation exists in rehabilitation after total hip arthroplasty (THA) in part due to a paucity of evidence-based literature. We asked whether a minimally invasive surgical approach, a multimodal approach to pain control with revised anesthesia protocols, hip restrictions, or preoperative physiotherapy achieved a faster rehabilitation and improved immediate short-term outcome. We conducted a systematic review of 16 level I and II studies after a strategy-based search of English literature on OVID Medline, PubMed, CINAHL, Cochrane, and EMBASE databases. We defined the endpoint of assessment as independent ambulation and ability to perform activities of daily living. Literature supports the use of a multimodal pain control to improve patient compliance in accelerated rehabilitation. Multimodal pain control with revised anesthesia protocols and accelerated rehabilitation speeds recovery after minimally invasive THA compared to the standard approach THA, but a smaller incision length or minimally invasive approach does not demonstrably improve the short-term outcome. Available studies justify no hip restrictions following an anterolateral approach but none have examined the question for a posterior approach. Preoperative physiotherapy may facilitate faster postoperative functional recovery but multicenter and well-designed prospective randomized studies with outcome measures are necessary to confirm its efficacy.

LEVEL OF EVIDENCE

Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.