Fast-track recovery technique applied to primary total hip and knee replacement surgery. Analysis of costs and complications

Assessment of Fast-Track Pathway in Hip and Knee Replacement Surgery by Propensity Score Matching on Patient-Reported Outcomes

Total hip (THA) and total knee (TKA) arthroplasty procedures have steadily increased over the past few decades, and their use is expected to grow further, mainly due to an increasing number of elderly patients. Cost-containment strategies, supporting a rapid recovery with a positive functional outcomes, high patient satisfaction, and enhanced patient reported outcomes, are needed. A Fast Track surgical procedure (FT) is a coordinated perioperative approach aimed at expediting early mobilization and recovery following surgery and, accordingly, shortening the length of hospital stay (LOS), convalescence and costs. In this view, rapid rehabilitation surgery optimizes traditional rehabilitation methods by integrating evidence-based practices into the procedure. The aim of the present study was to compare the effectiveness of Fast Track versus Care-as-Usual surgical procedures and pathways (including rehabilitation) on a mid-term patient-reported outcome (PROs), the SF12 (with regard both to Physical and Mental Scores), 3 months after hip or knee replacement surgery, with the use of Propensity score-matching (PSM) analysis to address the issue of the comparability of the groups in a non-randomized study. We were interested in the evaluation of the entire pathways, including the postoperative rehabilitation stage, therefore, we only used early home discharge as a surrogate to differentiate between the Fast Track and Care-as-Usual rehabilitation pathways. Our study shows that the entire Fast Track pathway, which includes the post-operative rehabilitation stage, has a significantly positive impact on physical health-related status (SF12 Physical Scores), as perceived by patients 3 months after hip or knee replacement surgery, as opposed to the standardized program, both in terms of the PROs score and the relative improvements observed, as compared with the minimum clinically important difference. This result encourages additional research into the effects of Fast Track rehabilitation on the entire process of care for patients undergoing hip or knee arthroplasty, focusing only on patient-reported outcomes.

Impact of enhanced recovery pathways on safety and efficacy of hip and knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

Over the past decades, clinical pathways (CPs) for hip and knee arthroplasty have been strongly and continuously evolved based on scientific evidence and innovation.

AIM

The present systematic review, including meta-analysis, aimed to compare the safety and efficacy of enhanced recovery pathways (ERP) with regular pathways for patients with hip and/or knee arthroplasty.

METHODS

A literature search in healthcare databases (Embase, PubMed, Cochrane Library, CINAHL, and Web of Science) was conducted from inception up to June 2018. Relevant randomized controlled trials as well as observational studies comparing ERP, based on novel evidence, with regular or standard pathways, prescribing care as usual for hip and/or knee arthroplasty, were included. The effect of both CPs was assessed for (serious) adverse events [(S)AEs], readmission rate, length of hospital stay (LoS), clinician-derived clinical outcomes, patient reported outcome measures (PROMs), and financial benefits. If possible, a meta-analysis was performed. In case of considerable heterogeneity among studies, a qualitative analysis was performed.

RESULTS

Forty studies were eligible for data extraction, 34 in meta-analysis and 40 in qualitative analysis. The total sample size consisted of more than 2 million patients undergoing hip or knee arthroplasty, with a mean age of 66 years and with 60% of females. The methodological quality of the included studies ranged from average to good. The ERP had lower (S)AEs [relative risk (RR): 0.9, 95% confidence interval (CI): 0.8-1] and readmission rates (RR: 0.8, 95%CI: 0.7-1), and reduced LoS [median days 6.5 (0.3-9.5)], and showed similar or improved outcomes for functional recovery and PROMs compared to regular pathways. The analyses for readmission presented a statistically significant difference in the enhanced recovery pathway in favor of knee arthroplasties (P = 0.01). ERP were reported to be cost effective, and the cost reduction varied largely between studies (€109 and $20573). The overall outcomes of all studies reported using Grading of Recommendation, Assessment, Development and Evaluation, presented moderate or high quality of evidence.

CONCLUSION

This study showed that implementation of ERP resulted in improved clinical and patient related outcomes compared to regular pathways in hip and knee arthroplasty, with a potential reduction of costs.

Physician induced demand for knee replacement surgery in Iran

BACKGROUND

The structure of the Iranian health system has raised this hypothesis that a part of the Knee Replacement Surgery (KRS) services are provided due to Physician-Induced Demand (PID).

METHODS

This paper used an unbalanced individual panel data covering the steady-state 15,729 KRSs performed by 995 surgeons provided by the Armed Forces Insurance Organization at the provincial level over the 60 months (2014-2018). We use a generalized method of moment's system (GMM-SYS) to obtain consistent and asymptotically efficient estimates, which provide a vital instrument for our dynamic panel data.

RESULTS

The outcomes show that with unequal increasing orthopedic surgeons to population ratio, both the number and size of KRS services were increased significantly at a 1 % level. Given that the positive elasticity obtained for the service size was significantly larger than the number of services, the findings give strong support for the existence of PID in the Iran system for KRS care. Also, the raw and population-adjusted number of KRS, cost, and the surgery per active physician increased significantly at the monthly province level.

CONCLUSIONS

This is the first time that the existence of PID in the Iranian health system is investigated using approved econometric models. The findings indicate that the health system structure has been provided the conditions for aggressive, costly, and high-risk services such as KRS to be exposed to PID.

Early Rehabilitation and Periprosthetic Bone Environment after Primary Total Hip Arthroplasty: A Randomized Controlled Trial

Objective

To investigate whether the periprosthetic bone environment could be affected by activity during the early rehabilitation period after primary total hip arthroplasty (THA) and to evaluate the safety and efficacy of activity during the early rehabilitation period.

Methods

This random clinical trial was conducted from January 2017 to July 2017. A total of 22 selected patients with advanced osteonecrosis of the femoral head (ONFH) who underwent primary unilateral THA were randomized (1:1) to a high activity level group (HA group) or a low activity level group (LA group). The HA group included nine men and two women, aged 53.18 ± 13.29 years. The LA group included five men and six women, aged 55.73 ± 11.73 years. The intervention was different postoperative daily walking distances guided by researchers: 1727.27 ± 564.08 m 0–2 months and 4272.73 ± 904.53 m 3–6 months postoperation for the HA group and 909.09 ± 583.87 m 0–2 months and 2409.09 ± 1068.13 m 3–6 months postoperation for LA group. The primary outcomes were radiographic evaluation (prosthetic stability and stress shielding based on the Engh scale) and bone mineral density (BMD) with a femoral prosthesis (individual and intergroup comparison using seven Gruen zones) at 6 months postoperatively. Secondary outcomes were set to confirm the safety and efficacy of activity during early rehabilitation, including day 1 erythrocyte sedimentation rate (ESR), day 1 hypersensitive C‐reactive protein (CRP), length of hospital stay (LOS), and the Harris hip score (HHS) at discharge, 2 months postoperatively, and 6 months postoperatively.

Results

Patients were followed up for 6 months after surgery. Regarding primary outcomes, all prostheses were assessed as stable, with bone in‐growth. There were no adverse events in any cases. The HA group had a higher incidence of stress shielding than the LA group, but there was no statistical significance (63.64% vs 18.18%; P > 0.05). The degree of stress shielding had a different distribution for the two groups (P < 0.05). In the HA group and the LA group, the median percentage difference of the BMD on the operated side was −25% and was −13% in Zone 1, −8% and − 1% in Zone 2, +1% and 3% in Zone 3, +6% and + 6% in Zone 4, −2% and +2% in Zone 5, −3% and −1% in Zone 6, and −24% and −12% in Zone 7 compared with the unoperated side. The BMD was significantly reduced in the medial proximal femur (Zone 1) and the lateral proximal femur (Zone 7) in both groups (P < 0.05). Furthermore, it was increased in the distal femur (Zone 4) in the HA group (P < 0.05). No difference was found in the BMD when comparing between groups. Regarding secondary outcomes, there was no statistical difference in day 1 ESR and day 1 CPR. The average LOS was similar in the HA and LA groups (7.00 days vs 7.18 days, P > 0.05). The HHS on day of discharge was higher in the HA group than in the LA group (60.73 ± 5.37 points vs 51.18 ± 8.05 points, P < 0.05); however, no statistically significant difference was found in postoperative the HHS at 2 months (81.73 ± 6.92 points vs 78.36 ± 9.18 points, P > 0.05) and 6 months (90.45 ± 5.24 points vs 91.55 ± 4.03 points, P > 0.05).

Conclusion

High activity levels during early rehabilitation after primary THA accelerate the process of bone remodeling and aggravate stress shielding, with no significant benefits for functional recovery.

Application of fast-track surgery combined with a clinical nursing pathway in the rehabilitation of patients undergoing total hip arthroplasty

Objective

Methods

Results

Conclusion

The results of a stepwise implementation of a fast-track program in total hip and knee replacement patients

Background

Several reports have shown that enhanced recovery or fast-track (FT) regime introduction in patients undergoing total knee replacement (TKR) and total hip replacement (THR) results in significant reduction in length of stay (LOS) with no associated increase of complications or readmission rate. Despite that, FT programs for arthroplasty have has not been uniformly recognized or accepted by many orthopaedic surgeons and there is still no consensus on the best implementation process. The aim of this study was to report the results of a stepwise implementation of a FT regime in TKR and THR patients in a general orthopaedic department.

Material and methods

This was a retrospective study of prospectively collected data (from 2014 to 2017) concerning all consecutive unselected patients who underwent TKR or THR on Monday morning. At stage 1 the rehabilitation and physiotherapy component was changed, at stage 2 and 3 a patient's blood management program and a pain management program were prospectively recorded (i.e. respectively Patients' demographics, ASA classification, Charlson index, LOS, blood loss, transfusion rate, complications and 30 - day readmissions).

Results

Four hundred and thirty four patients underwent either TKR (n: 302) or THR (n:132) and were included in this study. A gradual reduction of mean LOS was found in THR patients from 5.7 days to 3.0 days and in TKR patients from 5.6 days to 3.4 days. Furthermore, no significant difference was found in complications or regarding the 30-day readmission rate at the different stages of implementation of the different FT components (i.e. at the final stage 96.7% of THR and 86.7% of TKR patients were discharged to home by the fourth post-operative day).

Conclusion

The stepwise implementation of a FT program in an unelected population of THR and TKR patients was effective and safe, reducing the post-surgical recovery time and patients' LOS with no major complications and no increase of 30-day re-admissions.

Results of a fast-track knee arthroplasty according to the experience of a multidisciplinary team

Introduction

Fast-Track is a multidisciplinary system that has changed the perception of total knee arthroplasty surgery. It's based on the education of the patient, an increased autonomy, adequate pain control and early mobilization. In the bibliography, there are no articles that refer to the evolution of the protocol once established, and most of them are comparatives with the previously existing conventional system. For this reason, the objective of our work is to study the evolution of the clinical results obtained through a Fast-Track system according to the experience acquired by the multidisciplinary team in this protocol.

Material and methods

It's a prospective observational study. We have analyzed the results obtained in our center from its implementation in 2013 (n = 65) to the end of the study in 2016 (n = 60). We evaluated the pain at 24 and 48 h after surgery, the time until the first ambulation, the range of flexion and extension at discharge, and length of hospital stay.

Results

The results obtained at the beginning of the implantation of the Fast-Track protocol in our center and the present ones do not present statistically significant differences. Mean pain at 24 h was 1,65/10 in 2013 and 1,5/10 in 2016, and at 48 h 1,61/10 and 1,58/10 respectively. Most of the patients in both years scored a pain below 4/10 at 24 h and 48 h. Mean time of the first ambulation was 260 min in 2013 and 254 min in 2016 (most of the patients started walking in ≤5 h). Mean flexion at discharge was 90,3° in 2013 and 87,92° in 2016 (most of the patients presented a flexion between 80 and 100°). Mean extension at discharge was 6,95° in 2013 and 8,1° in 2016 (most of the patients presented an extension between 0 and 10°). Mean length of stay was 2,46 days in 2013 and 2,43 days in 2016 (most of the patients had a stay of fewer than 4 days).

Conclusions

When applying the Fast-Track protocol by a multidisciplinary team in primary knee prosthetic surgery, the clinical results obtained are independent of the experience of this team in the protocol. So, from our experience, we can affirm that the protocol has enough solidity since its beginning and it maintains similar results despite the years of execution.

No increase in readmissions or adverse events after implementation of fast-track program in total hip and knee replacement at 8 Swedish hospitals: An observational before-and-after study of 14,148 total joint replacements 2011-2015

Background and purpose - Fast-track care programs in elective total hip and knee replacement (THR/TKR) have been introduced in several countries during the last decade resulting in a significant reduction of hospital stay without any rise in readmissions or early adverse events (AE). We evaluated the risk of readmissions and AE within 30 and 90 days after surgery when a fast-track program was introduced in routine care of joint replacement at 8 Swedish hospitals. Patients and methods - Fast-track care programs were introduced at 8 public hospitals in Västra Götaland region from 2012 to 2014. We obtained data from the Swedish Hip and Knee Arthroplasty Registers for patients operated with THR and TKR in 2011-2015. All readmissions and new contacts with the health care system within 3 months with a possible connection to the surgical intervention were requested from the regional patient register. We compared patients operated before and after the introduction of the fast-track program. Results - Implementation of the fast-track program resulted in a decrease in median hospital length of stay (LOS) from 5 to 3 days in both THR and TKR. The total readmission rate <90 days for THR was 7.2% with fast-track compared with 6.7% in the previous program, and for TKR 8.4% in both groups. Almost half of the readmissions occurred without any AE identified. There was no statistically significant difference concerning readmissions or AE when comparing the programs. Interpretation - Implementation of a fast-track care program in routine care of elective hip and knee replacement is effective in reducing hospital stay without increasing the risk of readmissions or adverse events within 90 days after surgery.