Post-discharge pain management following elective primary total hip and total knee arthroplasty on patients discharged to home on pod 5 or earlier from an acute care facility

Evaluation of reduced ('Lite') compression versus brief bandaging to manage post-operative pain after total knee arthroplasty surgery; a single-centre randomised controlled trial

PURPOSE

Investigate efficacy of reduced compression bandage for the control of pain after total knee arthroplasty.

PATIENTS & METHODS

Prospective, single-centre, randomised controlled trial involving data for 56 out of 94 consented patients; 29 standard care versus 27 Andoflex TLC Calamine Lite. Comparison of standard care (non-compression bandage applied for up to one day) versus Andoflex TLC Calamine Lite (25-30 mmHg) two-layer compression bandage worn for five days. Outcomes measured with validated pain (McGill, 10-cm visual scale) and functionality (KOOS) tools.

RESULTS

At day 5 post-surgery, the median pain level was 3.0 cm vs 4.0 cm (p-value 0.47, Mann-Whitney U test) respectively. Generic pain levels, pain types, and knee functionality did not differ between the interventions at days 3/5/12 and week 6 post-surgery. An exception was the degree of 'tender' pain at day 12, which was significantly lower in the Andoflex TLC Calamine Lite arm (p-value 0.041, Mann-Whitney U test). Binary logistic regression analysis showed that application of Andoflex TLC Calamine Lite, administration of oxycodone, and male sex were all significantly associated with less 'tender' pain.

CONCLUSION

Reduced compression bandaging does not affect overall pain levels post knee arthroplasty surgery, but may alleviate pain experienced as 'tender', highlighting the different types of pain that may be experienced. Patients' need for, and the use of, opioid medication (oxycodone) is a significant confounding variable when assessing adjuvant therapy to control pain. The applicability of reduced compression bandaging may therefore be limited and is less efficient than medical pain control.

Patients' experiences following total knee arthroplasty: a qualitative evidence synthesis

PURPOSE

Total knee arthroplasty (TKA) is a common surgical intervention for patients with advanced arthritis. The aim of this qualitative evidence synthesis was to systematically review the qualitative literature on patients' experiences following primary TKA.

MATERIALS AND METHODS

Four electronic databases (PubMed, CINAHL, Cochrane and Embase) were searched from inception until October 2021. Pairs of reviewers independently screened search results for eligibility, analysed the quality of included studies and extracted data. We undertook a thematic synthesis and used an interpretive approach to identify recurring themes and draw a conclusion. Data were synthesised using thematic analysis and an interpretive approach was used to identify themes.

RESULTS

Twenty-three studies exploring patients' experiences following TKA were included. Five main themes emerged: (i) Experience of healthcare staff, (ii) Pain/Medications, (iii) Was it worth it? (iv) Social Support (v) Follow up.

CONCLUSIONS

This review highlights the variability in patients' experiences following TKA. Whether this experience detailed their pain, function, or encounter with healthcare staff or systems, patients reported a variety of both positive and negative sentiments. Each theme invites attention to an area in which healthcare can improve to enhance patients' experiences. The importance of patient support, individualised rehabilitation and appropriate follow-up are highlighted.

Examining pain before and after primary total knee replacement (TKR): A retrospective chart review

OBJECTIVE

The goal of total knee replacement is to improve function and reduce knee pain. The aim of this retrospective chart review was to assess the change in pain intensity from prior to TKR to after TKR at time of discharge from hospital.

METHOD

Consecutive charts of 595 patients who were discharged from the orthopaedic inpatient setting between January 2014 and July 2014 were reviewed.

RESULTS

The mean pre-operative pain intensity score was 7/10 (n = 473), and the mean pain intensity score prior to discharge from hospital was 3/10 (n = 548). Four hundred and fifty-six patients had both a pre-operative and pre-discharge pain intensity score documented; for those patients there was a significant change in pain intensity scores from prior to surgery to prior to discharge (p < 0.001).

CONCLUSION

Pain after TKR can be a limiting factor in rehabilitation activities. This retrospective chart review examined the pain intensity scores before and after primary TKR for patients in our facility. We found a significant difference in the pain intensity from before surgery to after surgery. However, further research needs to be conducted to examine the intensity and quality of pain as well as which analgesics patients are consuming after discharge from hospital at 6 weeks and 3 months.

Hip and knee arthroplasty - patient's experiences of pain and rehabilitation after discharge from hospital

BACKGROUND

Fast-track clinical pathways for hip and knee arthroplasty is being implemented in several western countries. The treatment entails patient involvement, optimal pain management, intensive mobilization and early discharge. Limited research has been carried out on patient's experiences after discharge.

PURPOSE

The purpose of the study is to describe how patients experience pain and manage the rehabilitation process the first six weeks after discharge.

METHOD

The study followed a qualitative descriptive design. Semi-structured interviews were conducted with 12 participants three months after discharge from hip or knee arthroplasty.

FINDINGS

Patients experienced varying degrees of pain the first three to five weeks after discharge. Walking-training and sleep were affected by pain or stiffness in joints and muscles, and several needed help from family members to perform activities of daily living (ADL). Several participants would have like more individualized information about pain and exercises before discharge. Some experienced that the municipal care services failed to follow up on issues related to pain.

CONCLUSION

The study illuminates that patients may need more individualized and adapted information prior to discharge, as well as more multidisciplinary follow-up by doctors, physiotherapists and possibly home care nurses. We recommend more studies examining how patients experience pain and rehabilitation during the first weeks after completing arthroplasty.

Patient experience in fast-track hip and knee arthroplasty--a qualitative study

AIMS AND OBJECTIVES

To explore the lived experience of patients in fast-track primary unilateral total hip and knee arthroplasty from the first visit at the outpatient clinic until discharge.

BACKGROUND

Fast-track has resulted in increased effectiveness, including faster recovery and shorter length of stay to about two days after hip and knee arthroplasty. However, the patient perspective in fast-track with a median length of stay of less than three days has been less investigated.

DESIGN

A qualitative design.

METHODS

A phenomenological-hermeneutic approach was used, inspired by Paul Ricoeur's theory of narrative and interpretation. Eight patients were included. Semi-structured interviews and participant observation were performed.

RESULTS

Three themes emerged: dealing with pain; feelings of confidence or uncertainty - the meaning of information; and readiness for discharge. Generally, the patients were resistant to taking analgesics and found it difficult to find out when to take supplementary analgesics; therefore, nursing staff needed enough expertise to take responsibility. Factors that increased patients' confidence: information about fast-track, meeting staff before admission and involving relatives. In contrast, incorrect or conflicting information and a lack of respect for privacy led to uncertainty. In preparing for early discharge, sufficient pain management, feeling well-rested and optimal use of time during hospitalisation were important.

CONCLUSION

The study shows the importance of dealing with pain and getting the right information and support to have confidence in the fast-track programme, to be ready for discharge and to manage postoperatively at home.

RELEVANCE TO CLINICAL PRACTICE

In fast-track focusing on early discharge, there is an increased need for evidence-based nursing practice, including a qualified judgement of what is best for the patient in certain situations. The knowledge should be gleaned from: research; the patients' expertise, understanding and situation; and nurses' knowledge, skills and experience.

Nursing in fast-track total hip and knee arthroplasty: A retrospective study

AIM

To describe the increased activity in total hip arthroplasty (THA) and total knee arthroplasty (TKA) from 2002 to 2012 in a single orthopaedic department, the organisation of fast-track and its consequences for nursing care.

METHODS

Retrospective, descriptive design. Data collection; from the hospital administrative database, local descriptions of fast-track, personal contact and discussion with staff.

RESULTS

The number of operations increased threefold from 351 operations in 2002 to 1024 operations in 2012. In 2012, THA/TKA patients had a postoperative mean LOS of 2.6/2.8 days. Nurses had gained tasks from surgeons and physiotherapists and thus gained more responsibility, for example, for pain management and mobilisation. Staffing levels in the ward in 2002 and 2012 were almost unchanged; 16.0 and 15.8 respectively. Nurses were undertaking more complicated tasks.

CONCLUSION

Nursing care must still focus on the individual patient. Nurses need to have enough education to manage the complex tasks and increased responsibility. To prevent undesirable outcomes in the future, there is a need to pay attention to the nursing quality in balance with the nursing budget. It may, therefore, be considered a worthwhile investment to employ expert/highly qualified professional nurses in fast-track THA and TKA units.

Postoperative pain management after total knee arthroplasty in elderly patients: treatment options

Total knee arthroplasty (TKA) is a common surgical procedure in the elderly and is associated with severe pain after surgery and a high incidence of chronic pain. Several factors are associated with severe acute pain after surgery, including psychological factors and severe preoperative pain. Good acute pain control can be provided with multimodal analgesia, including regional anesthesia techniques. Studies have demonstrated that poor acute pain control after TKA is strongly associated with development of chronic pain, and this emphasizes the importance of attention to good acute pain control after TKA. Pain after discharge from hospital after TKA is currently poorly managed, and this is an area where increased resources need to be focused to improve early pain control. This is particularly as patients are often discharged home within 4-5 days after surgery. Chronic pain after TKA in the elderly can be managed with both pharmacological and non-pharmacological techniques. After excluding treatable causes of pain, the simplest approach is with the use of acetaminophen combined with a short course of non-steroidal anti-inflammatory drugs (NSAIDs). Careful titration of opioid analgesics can also be helpful with other adjuvants such as the antidepressants or antiepileptic medications used especially for patients with neuropathic pain. Topical agents may provide benefit and are associated with fewer systemic side effects than oral administration. Complementary or psychological therapies may be beneficial for those patients who have failed other options or have depression associated with chronic pain.