Enhanced recovery in total hip replacement: a clinical review

The impact of enhanced recovery after surgery (ERAS) on opioid consumption and postoperative pain levels in elective spine surgery

OBJECTIVE

Enhanced Recovery after Surgery (ERAS) protocols were developed to counteract the adverse effects of the surgical stress response, aiming for quicker postoperative recovery. Initially applied in abdominal surgeries, ERAS principles have extended to orthopedic spine surgery, but research in this area is still in its infancy. The current study investigated the impact of ERAS on postoperative pain and opioid consumption in elective spine surgeries.

METHODS

A single-center retrospective study of patients undergoing elective spine surgery from May 2019 to July 2020. Patients were categorized into two groups: those enrolled in the ERAS pathway and those adhering to traditional surgical protocols. Data on demographics, comorbidities, length of stay (LOS), surgical procedures, and postoperative outcomes were collected. Postoperative pain was evaluated using the Numerical Rating Scale (NRS), while opioid utilization was quantified in morphine milligram equivalents (MME). NRS and MME were averaged for each patient across all days under observation. Differences in outcomes between groups (ERAS vs. treatment as usual) were tested using the Wilcoxon rank sum test for continuous variables and Pearson's or Fisher's exact tests for categorical variables.

RESULTS

The median of patient's mean daily NRS scores for postoperative pain were not statistically significantly different between groups (median = 5.55 (ERAS) and 5.28 (non-ERAS), p=.2). Additionally, the median of patients' mean daily levels of MME were similar between groups (median = 17.24 (ERAS) and 16.44 (non-ERAS), p=.3) ERAS patients experienced notably shorter LOS (median=2 days) than their non-ERAS counterparts (median=3 days, p=.001). The effect of ERAS was moderated by whether the patient had ACDF surgery. ERAS (vs. non-ERAS) patients who had ACDF surgery had 1.64 lower average NRS (p=.006). ERAS (vs. non-ERAS) patients who had a different surgery had 0.72 higher average NRS (p=.02) but had almost half the length of stay, on average (p<.001).

CONCLUSIONS

The current study underscores the dynamic nature of ERAS protocols within the realm of spine surgery. While ERAS demonstrates advantages such as reduced LOS and improved patient-reported outcomes, it requires careful implementation and customization to address the specific demands of each surgical discipline. The potential to expedite recovery, optimize resource utilization, and enhance patient satisfaction cannot be overstated. However, the fine balance between achieving these benefits and ensuring comprehensive patient care, especially in the context of postoperative pain management, must be maintained. As ERAS continues to evolve and find its place in diverse surgical domains, it is crucial for healthcare providers to remain attentive to patient needs, adapting ERAS protocols to suit individual patient populations and surgical contexts.

Is a Rapid Recovery Protocol for THA and TKA Associated With Decreased 90-day Complications, Opioid Use, and Readmissions in a Health Safety-net Hospital?

BACKGROUND

Patients treated at a health safety-net hospital have increased medical complexity and social determinants of health that are associated with an increasing risk of complications after TKA and THA. Fast-track rapid recovery protocols (RRPs) are associated with reduced complications and length of stay in the general population; however, whether that is the case among patients who are socioeconomically disadvantaged in health safety-net hospitals remains poorly defined.

QUESTIONS/PURPOSES

When an RRP protocol is implemented in a health safety-net hospital after TKA and THA: (1) Was there an associated change in complications, specifically infection, symptomatic deep venous thromboembolism (DVT), symptomatic pulmonary embolism (PE), myocardial infarction (MI), and mortality? (2) Was there an associated difference in inpatient opioid consumption? (3) Was there an associated difference in length of stay and 90-day readmission rate? (4) Was there an associated difference in discharge disposition?

METHODS

An observational study with a historical control group was conducted in an urban, academic, tertiary-care health safety-net hospital. Between May 2022 and April 2023, an RRP consistent with current guidelines was implemented for patients undergoing TKA or THA for arthritis. We considered all patients aged 18 to 90 years presenting for primary TKA and THA as eligible. Based on these criteria, 562 patients with TKAs or THAs were eligible. Of these 33% (183) were excluded because they were lost before 90 days of follow-up and had incomplete datasets, leaving 67% (379) for evaluation. Patients in the historical control group (September 2014 to May 2022) met the same criteria, and 2897 were eligible. Of these, 31% (904) were excluded because they were lost before 90 days of follow-up and had incomplete datasets, leaving 69% (1993) for evaluation. The mean age in the historical control group was 61 ± 10 years and 63 ± 10 years in the RRP group. Both groups were 36% (725 of 1993 and 137 of 379) men. In the historical control group, 39% (770 of 1993) of patients were Black and 33% (658 of 1993) were White, compared with 38% (142 of 379) and 32% (121 of 379) in the RRP group, respectively. English was the most-spoken primary language, by 69% (1370 of 1993) and 68% (256 of 379) of the historical and RRP groups, respectively. A total of 65% (245 of 379) of patients in the RRP group had a peripheral nerve block compared with 54% (1070 of 1993) in the historical control group, and 39% (147 of 379) of them received spinal anesthesia, compared with 31% (615 of 1993) in the historical control group. The main elements of the RRP were standardization of preoperative visits, nutritional management, neuraxial anesthesia, accelerated physical therapy, and pain management. The primary outcomes were the proportions of patients with 90-day complications and opioid consumption. The secondary outcomes were length of stay, 90-day readmission, and discharge disposition. A multivariate analysis adjusting for age, BMI, gender, race, American Society of Anaesthesiologists class, and anesthesia type was performed by a staff biostatistician using R statistical programming.

RESULTS

After controlling for the confounding variables as noted, patients in the RRP group had fewer complications after TKA than those in the historical control group (odds ratio 2.0 [95% confidence interval 1.3 to 3.3]; p = 0.005), and there was a trend toward fewer complications in THA (OR 1.8 [95% CI 1.0 to 3.5]; p = 0.06), decreased opioid consumption during admission (517 versus 676 morphine milligram equivalents; p = 0.004), decreased 90-day readmission (TKA: OR 1.9 [95% CI 1.3 to 2.9]; p = 0.002; THA: OR 2.0 [95% CI 1.6 to 3.8]; p = 0.03), and increased proportions of discharge to home (TKA: OR 2.4 [95% CI 1.6 to 3.6]; p = 0.01; THA: OR 2.5 [95% CI 1.5 to 4.6]; p = 0.002). Patients in the RRP group had no difference in the mean length of stay (TKA: 3.2 ± 2.6 days versus 3.1 ± 2.0 days; p = 0.64; THA: 3.2 ± 2.6 days versus 2.8 ± 1.9 days; p = 0.33).

CONCLUSION

Surgeons should consider developing an RRP in health safety-net hospitals. Such protocols emphasize preparing patients for surgery and supporting them through the acute recovery phase. There are possible benefits of neuraxial and nonopioid perioperative anesthesia, with emphasis on early mobility, which should be further characterized in comparative studies. Continued analysis of opioid use trends after discharge would be a future area of interest. Analysis of RRPs with expanded inclusion criteria should be undertaken to better understand the role of these protocols in patients who undergo revision TKA and THA.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Patient-reported outcomes the first thirty days after fast-track primary total hip arthroplasty. A prospective cohort study using a web-based registration tool for postoperative follow-up

INTRODUCTION

The documentation on patient reported outcomes the first weeks at home following total hip arthroplasty (THA) is sparse. Length of hospital stay after THA is substantially reduced. Therefore, knowledge on whether patients are managing their own postoperative rehabilitation early after discharge is important, in order to give the patients realistic preoperative information, to modify expectations and enable patients to monitor their own rehabilitation process.

METHODS

Eighty-two THA patients were included in a prospective cohort study. Patient-reported outcomes were collected twice a week thirty days postoperatively using a web-based registration tool. Numeric rating scales (0-10) for pain, function, and quality of life, EQ-5D, and the use of opioids were registered. Four weeks postoperatively a telephone interview were conducted. Pain, EQ5D and hip specific physical function score (HOOS-PS) were recorded preoperatively, at three- and twelve-months follow-up.

RESULTS

Pain was maintained the first days after hospital discharge. From day 0 to day 30, pain decreased from 4.0 (SD 2.23) to 2.3 (SD 1.75), function improved from 4.4 (SD 2.06) to 7 (SD 1.57), quality of life improved from 6.3 (SD 2.69) to 7.8 (SD 1.47), and EQ-5D improved from 0.4 to (SD 0.27) to 0.7 (SD 0.14). After 30 days, 32% still used opioids. All patients completed the web-registration. Pain, EQ-5D and HOOS-PS improved substantially from preoperatively to twelve months follow-up.

CONCLUSION

Fast-track THA patients can expect continued postoperative pain and impaired quality of life the first week at home, before gradually improvement. After thirty days, 32 % of the patients still used opioids.

Day-case hip and knee arthroplasty: stages of care and the development of an institutional pathway

Day-case, or outpatient, arthroplasty is growing and has been adopted in healthcare systems because of its cost-effectiveness. A number of studies that reported on day-case total hip arthroplasty, total knee arthroplasty and unicompartmental knee arthroplasty have shown that they can be performed successfully in a select group of patients. However, safety remains a concern, as a clear pathway, including discharge criteria, is not well described in the literature. This article outlines the stages of care involved in day-case hip and knee arthroplasty and gives insights from University College London Hospital's own evidence-based day-case arthroplasty pathway.

Functional and Radiological Outcomes Following Simultaneous Bilateral Total Hip Arthroplasty: Analysis of a Retrospective Series

Introduction The prevalence of bilateral hip arthritis continues to rise. With the dramatic change in the practice of modern-day arthroplasty with standard operating protocols and guidelines in place to reduce the incidence of surgical site infection and peri-operative thromboembolic events, simultaneous bilateral total hip replacement (THR) has been considered a viable option to reduce morbidity. The efficacy of simultaneous bilateral THR with regard to patient outcomes and complications has been debated. The aim of this study was to assess and compare the functional outcomes, radiological outcomes, and complications following bilateral simultaneous THR with the existing literature. Methods We conducted a retrospective study of 28 patients who underwent simultaneous bilateral THR by a single surgeon at a district general hospital in the United Kingdom between 2010 and 2019. All the patients in the study were operated on via the posterior approach to the hip and received uncemented implants. Data on blood loss and hospital stay were collected from the hospital records. The radiological outcomes were studied from the post-operative radiographs. The patient-reported outcomes were measured via a telephone session at an average follow-up of 7.8 years. Results Our results noted a statistically significant drop in haemoglobin after the procedure from a mean of 13.5 g/dl to 9.05 g/dl (t: -15.84, p < 0.00001). The average blood loss was 643 ml +/- 330 ml (200-1850 ml). Nine patients (32.1%) required blood transfusions and a total of 21 units were transfused. The mean duration of stay in the hospital was 6.7 days (three to 20 days). There were no intra-operative/immediate/early post-operative complications. The revision rate was 1.7%, as one patient had a revision of the femoral component following a peri-prosthetic fracture. The mean visual analogue scale pain score was 1.51 +/- 0.58 (1-3). The mean Oxford Hip Score improved from 19.5 (12-28) pre-operatively to 44.3 (37-48) post-operatively at the time of the study (t: -21.88945; p < 0.00001), with the difference being statistically significant using a paired t-test. From the series, 14 (50%) patients were found to have limb length discrepancies. The mean limb length discrepancy was found to be 2.3 mm (0-16 mm). In 13 of the 28 patients (46.4%), the global hip offset was equal on both sides. In two patients, the difference in the global hip offset was more than 10 mm. Conclusion We reported good patient-reported functional outcomes with simultaneous bilateral THR with a low complication rate. Despite the lack of opportunity to template the second hip, the limb length and global hip offset can be restored after a simultaneous bilateral THR.

Does Hand Grip Strength (HGS) Predict Functional Independence Differently in Patients Post Hip Replacement Due to Osteoarthritis versus Patients Status Post Hip Replacement Due to a Fracture?

Purpose

The aim of the study was to determine whether hand grip strength (HGS) predicts functional independence in older patients who have undergone hip replacement due to osteoarthritis versus older patients who have undergone hip replacement surgery due to fracture.

Patients and Methods

The study included 239 patients aged 65 and over in the first weeks after total hip replacement during rehabilitation treatment. Multivariate linear regression was used to determine HGS as a predictor of activities of daily living (ADL) and instrumental activities of daily living (IADL) in both groups: patients post hip replacement due to osteoarthritis and patients post hip replacement due to a fracture.

Results

Analysis showed that pre-rehab HGS in the osteoarthritis group predicts improved activities of daily living after rehabilitation (ADL, OR = 1.098; CI 95% 1.052-1.147 and IADL, OR = 1.182; CI 95% 1.103-1.267) and 6 months after (ADL, OR = 1.191; CI 95% 1.066-1.329 and IADL, OR = 1.096; CI 95% 1.012-1.186). In the fracture group, HGS predicts the ADL (OR = 1.081; CI 95% 1.015-1.152) after rehabilitation, and IADL after rehabilitation (OR = 1.122; CI 95% 1.046-1.205) and 6 months after (OR = 1.090; 95% CI 1.021-1.64).

Conclusion

HGS in patients after hip replacement surgery predicts functional independence in basic and complex activities of daily living. This can allow the identification of osteoarthritis patients with low hand grip - who can be considered as patients with a higher risk of an unsatisfying outcome of surgery. These patients should undergo pre-rehabilitation and should be monitored, and/or supported in terms of rehabilitation after discharge.

Total Hip Arthroplasty in fracture neck of femur: A review of the literature

Fracture Neck of Femur (FnF) is a major cause of loss of independence, morbidity and mortality in a vulnerable group of elderly patients; as well as a substantial economic burden on healthcare systems across the world. An increasingly ageing population has resulted in a rise in incidence and prevalence of FnF. Over 76,000 patients were admitted with FnF in the United Kingdom in 2018, with the resulting health and social costs estimated to be in excess of £2 billion. It is therefore important that the outcomes of all management options be evaluated to ensure constant improvement as well as allocation of resources as appropriate. It is widely agreed that patients presenting with displaced intracapsular FnF injuries are managed operatively; with options including internal fixation, hemiarthroplasty or Total Hip Arthroplasty (THA). The volume of THA performed for FnF has significantly increased in recent years. However, compliance with national guidelines on FnF patient selection for THA has been shown to be inconsistent. The aim of this study was to review current literature with regards to the use of THA in management of FnF patients. The literature describes managing FnF in ambulant and independent patients by THA with dual-mobility acetabular cup and cemented femoral component via the anterolateral approach. There is scope for further research in assessing the outcomes of different prosthetic femoral head sizes and choice of bearing surfaces (tribiology) used for THA as well as cementation of the acetabular cup component specifically in FnF patients.

A nomogram to predict the risk of prolonged length of stay following primary total hip arthroplasty with an enhanced recovery after surgery program

BACKGROUND

The aim of this study was to identify the risk factors associated with prolonged length of stay (LOS) in patients undergoing primary total hip arthroplasty (THA) managed with an enhanced recovery after surgery (ERAS) program and develop a prediction model for improving the perioperative management of THA.

METHODS

In this single-center retrospective study, patients who underwent primary THA in accordance with ERAS from May 2018 to December 2019 were enrolled in this study. The primary outcome was prolonged LOS (> 48 h) beyond the first postoperative day. We collected the clinical patient's clinical characteristics, surgery-related parameters, and laboratory tests. A logistic regression analysis explored the independent risk factors for prolonged LOS. According to published literature and clinical experience, a series of variables were selected to develop a nomogram prediction model to predict the risk of prolonged LOS following primary THA with an ERAS program. Evaluation indicators of the prediction model, including the concordance index (C-index), the receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis, were reported to assess the performance of the prediction model. The bootstrap method was conducted to validate the performance of the designed nomogram.

RESULTS

A total of 392 patients were included in the study, of whom 189 (48.21%) had prolonged LOS. The logistics regression analysis demonstrated that age, sex, hip deformities, intraoperative blood loss, operation time, postoperative Day 1 (POD) hemoglobin (Hb), POD albumin (ALB), and POD interleukin-6 (IL-6) were independent risk factors for prolonged LOS. The C-index was 0.863 (95% CI 0.808 to 0.918) and 0.845 in the bootstrapping validation, respectively. According to the results of the calibration, ROC curve, and decision curve analyses, we found that the nomogram showed satisfactory performance for prolonged LOS in this study.

CONCLUSIONS

We explored the risk factors for prolonged LOS following primary THA with an ERAS program and developed a prediction model. The designed nomogram was expected to be a precise and personalized tool for predicting the risk and prognosis for prolonged LOS following primary THA with an ERAS program.

Patient and Caregiver Perspectives on an eHealth Tool: A Qualitative Investigation of Preferred Formats, Features and Characteristics of a Presurgical eHealth Education Module

Introduction

Total hip and total knee replacement (THR and TKR) are suggested for reducing joint pain resulting from hip and knee osteoarthritis (OA), especially when other interventions have not resulted in desired outcomes. Providing prehabilitation education can improve patients' psychological and physical well-being before and after surgery. The use of electronic health (eHealth) tools can be considered an effective method to increase patients' access to prehabilitation, particularly for those facing barriers to attending diagnosis-specific in-person education sessions. However, limited attention is paid to both caregiver and patient perspectives regarding the delivery formats, features, and characteristics of eHealth tools.

Method

Patients with hip (n = 46) and knee OA (n = 14) and their family caregivers (n = 16) participated in in-person focus groups or phone interviews. Participants were shown a mock-up of an eHealth module, and asked to share their preferences regarding the formats, features, and characteristics of the eHealth prehabilitation tool. Data was transcribed verbatim and coded using primary thematic and secondary content analyses.

Result

Analyses revealed 3 main themes: 1. "easier to understand" emphasizes patients' preferences on delivery formats and features; 2. "what does that mean?" highlights requests for clear and simple information; and 3. "Preparation, right?" shows patients' perspectives on the best time to have access to the eHealth tool.

Discussion

Participants' preferences for prehabilitation tools included offering eHealth tools in multiple mediums of delivery (eg, written materials, pictures, videos). Participants preferred simplified information that emphasized the key points and rationale for the knowledge. There were differences in preferred timeline for having access to prehabilitation education, such as some participants wanting to receive prehabilitation well in advance, while others stated just before surgery was adequate. Our findings provide novel and actionable information about patient and caregiver perspectives on features and characteristics of prehabilitation education for patients with hip and knee OA.

Impacts of the perioperative fast track surgery concept on the physical and psychological rehabilitation of total hip arthroplasty: A prospective cohort study of 348 patients

Studies have shown that rapid rehabilitation surgery has a positive effect on recovery after major orthopedic surgery. However, very few studies have examined the impact of fast track surgery on physical and psychological rehabilitation in patients who have undergone total hip replacement.This study aimed to investigate the value of the rapid rehabilitation surgical model for patients undergoing total hip arthroplasty during the perioperative period.We conducted a prospective cohort study that included patients who underwent total hip arthroplasty at our hospital from January 2015 to December 2018. We divided the patients into 2 groups - the rapid rehabilitation group and the conventional rehabilitation group - and compared their length of hospital stay, time to off-bed activity, pain score, Self-Rating Anxiety Scale scores, Self-Rating Depression Scale scores, complication rate, and rate of satisfaction during hospitalization.A total of 348 patients were included in the study. Of these, 180 received rapid rehabilitation nursing and 168 patients received conventional nursing. Compared with the patients in the conventional rehabilitation group, those in the rapid rehabilitation group had shorter hospital stays (11.5 ± 1.2 day vs 15.5 ± 2.3 day, P = .021), resumed off-bed activities sooner (20.5 ± 3.4 hours vs 61.8 ± 4.7 hours, P = .001, had less postoperative pain (4.0 ± 1.2 vs 6.5 ± 1.1, P < .001), and lower anxiety and depression scores (anxiety score: 24.4 ± 2.1 vs 47.9 ± 2.9; depression score: 25.8 ± 1.8 vs 43.7 ± 1.7, P < .001).The application of rapid rehabilitation surgery in total hip arthroplasty can accelerate patients' postoperative recovery, relieve anxiety and depression, and increase the patient's satisfaction with the treatment.

Day-case unicompartmental knee arthroplasty: a literature review and development of a novel hospital pathway

INTRODUCTION

We have seen unparalleled changes in our healthcare systems globally as a result of the COVID-19 pandemic. As we strive to regenerate our full capacity elective services in order to contest the increasing demand for lower limb arthroplasty, this pandemic has allowed us a rare opportunity to revise and develop novel elective arthroplasty pathways intended to improve patient care and advance healthcare efficiency. We present an extensive evidence-based review of the approaches used to achieve day-case unicompartmental arthroplasty (UKA) as well as the development of a day-case UKA care pathway in a UK NHS institution based on the evidence provided in the literature.

METHODS

An extensive search of the literature was performed for articles that reported on readmission or complication rates ≥30 days postoperatively following day-case UKA.

FINDINGS

Fifteen manuscripts reporting the results of day-case UKA, defined as discharged on the same calendar day of surgery, were included in our review. Mean reported complication rates for day-case and inpatient UKA within the follow-up periods were 4.05% and 6.52%, respectively. Mean readmission rates were 2.71% and 4.36% for day-case and inpatient UKA, respectively. The mean rate of successful same-day discharge was 92.45%.

CONCLUSION

We introduce our institutional Elective Day Surgery Arthroplasty Pathway (EDSAP) founded upon the evidence presented in the literature. Stringent patient selection complimented by a well-defined day-case arthroplasty pathway is fundamental for successful commencement of day-case UKA in the NHS.

The Hip Instructional Prehabilitation Program for Enhanced Recovery (HIPPER) as an eHealth Approach to Presurgical Hip Replacement Education: Protocol for a Randomized Controlled Trial

Background

Osteoarthritis (OA), leading to hip replacement (THR), is a primary contributor to global mobility impairment. In 2018, more than 59,000 THR surgeries were performed in Canada. Health promotion education, such as prehabilitation, is vital to optimizing surgical outcomes.

Objective

This study aims to evaluate the feasibility of the Hip Instructional Prehabilitation Program for Enhanced Recovery (HIPPER), an eHealth approach to prehabilitation education.

Methods

A single-blind (assessor-blind), 2-arm, feasibility randomized controlled trial will be conducted. We will recruit 40 (HIPPER group, n=20; control group, n=20) older adults with hip OA and on a waitlist for a THR. The HIPPER intervention consists of 12 online, interactive modules. The control group will receive the current standard practice consisting of 2 online educational sessions lasting 2 hours each (webinars). Feasibility outcomes (eg, recruitment and retention rates) will be evaluated.

Results

Recruitment started in March 2021. As of April 20, 2021, 18 participants were recruited. All 18 completed T1 measures. Only 1 participant has been scheduled to have a surgery and therefore has been scheduled to complete T2 measures. The remainder of the participants are waiting to be notified of their surgery date. This project was funded by a Canadian Institutes of Health Research Project Grant. Our institute’s research ethics board approved this study in November 2016.

Conclusions

Results will lead to refinement of the HIPPER protocol in order to evaluate a standardized and geographically accessible prehabilitation program.

Trial Registration

ClinicalTrials.gov NCT02969512; https://clinicaltrials.gov/ct2/show/NCT02969512

International Registered Report Identifier (IRRID)

DERR1-10.2196/29322

Developing an enhanced recovery after surgery program for oncology patients who undergo hip or knee reconstruction surgery

Enhanced recovery after surgery (ERAS) protocols are applied in orthopedic surgery and are intended to reduce perioperative stress by implementing combined evidence-based practices with the cooperation of various health professionals as an interdisciplinary team. ERAS pathways include pre-operative patient counselling, regional anesthesia and analgesia techniques, post-operative pain management, early mobilization and early feeding. Studies have shown improvement in the recovery of patients who followed an ERAS program after hip or knee arthroplasty, compared with those who followed a traditional care approach. ERAS protocols reduce post-operative stress, contribute to rapid recovery, shorten length of stay (LOS) without increasing the complications or readmissions, improve patient satisfaction and decrease the hospital costs. We suggest that the ERAS pathway could reduce the LOS in hospital for patients undergoing total hip replacement or total knee replacement. These programs require good organization and handling by the multidisciplinary team. ERAS programs increase patient's satisfaction due to their active participation which they experience as personalized treatment. The aim of the study was to develop an ERAS protocol for oncology patients who undergo bone reconstruction surgeries using massive endoprosthesis, with a view to improving the surgical outcomes.

Evaluation of sleep disorder in orthopedic trauma patients: a retrospective analysis of 1129 cases

Background

In the trauma center wards, it is not unusual for patients to have sleep disorders, especially patients with an acute injury. Meanwhile, there is substantial evidence that sleep disorder is a predictor of depression and is an important feature of posttraumatic stress disorder.

Methods

All orthopedic trauma patients confined in a trauma ward in West China Hospital of Sichuan University between April 2018 and July 2019 were included in this retrospective study. Patients with mental impairment or craniocerebral injuries were excluded from the study. Basic demographic data and the Injury Severity Score (ISS) classification based on medical records were collected. The Pittsburgh sleep quality index (PSQI) was used to evaluate sleep quality, the visual analog scale (VAS) was used to evaluate physical pain, and the Barthel Index (BI) was used to evaluate activities of daily living (ADL). Univariate linear regression analysis and multivariate linear regression analysis were used to identify independently related factors.

Results

The average PSQI score was 6.3 (± 4.0). A total of 581 (51.4%) patients had a PSQI score > 5, indicating the presence of sleep disorders. The PSQI score was > 10 in 174 (15.4%) patients. Univariate statistical analysis showed that age, sex, education, ADL, and ISS classification were associated with increased PSQI scores. Marital status and pain were not associated with increased PSQI scores. When we used multivariate analysis to control for confounding variables, sex, ADL, and ISS classification remained independently associated with PSQI (P = 0.002, < 0.000, and 0.002, respectively).

Conclusions

In our study, sleep disorders were common (51.4% with PSQI > 5) and serious (15.4% with PSQI > 10) in patients with traumatic orthopedic injury. The following factors were closely associated with sleep disorders: sex, ADL, and ISS classification. Moreover, age and educational attainment have an independent impact on sleep quality. Unexpectedly, the VAS score for pain was not independently associated with the seriousness of sleep quality, which may be related to preemptive and multimodal analgesia. Further studies are required to clarify this ambiguity.

Gluteus maximus transfer and mass graft (Capsulorraphy) in recurrent hip dislocation with the history of total hip replacement: A case series

•

Post THR dislocation has been a significant complication.

•

Four patients operated by soft tissue procedure of gluteus maximus transfer as an abductor replacement and along with capsule augmentation using synthetic mesh as a synthetic capsule to strengthen and provide more stability.

•

The use of mesh in soft tissue procedures, such as capsulorraphy, with the addition gluteus maximus transfer may assist to prevent (re)dislocations of the hip.

Introduction

Post THR dislocation has been a significant complication that interferes with the patient’s life. Detection of risk factors, careful planning, proper operative procedures, and patient education is essential to prevent the incidence of dislocation. Several operative measures have been studied to achieve this, including the use of mesh for soft tissue procedures and capsulorraphy.

Case Presentation

A total of four patients is included in this case series. Two had a history of trauma that contributes to the necessity of the procedure while the other two had degenerative joint issues. All were operated by soft tissue procedure of gluteus maximus transfer as an abductor replacement and along with capsule augmentation using synthetic mesh as a synthetic capsule to strengthen and provide more stability.

Discussion

The abductor strength from this gluteus maximus procedure is sufficient to stabilize the pelvis and prevent pelvic sag. The primary material of the mesh should produce inflammatory reaction so that a fibro capsular structure is formed surrounding the hip joint to add stability.

Conclusion

The use of mesh in soft tissue procedures, such as capsulorraphy, with the addition gluteus maximus transfer may assist to prevent (re)dislocations of the hip. However, further study should be conducted to validate the routine use of mesh and gluteus maximus transfer to prevent dislocation after the procedure.

The introduction of day-case total knee arthroplasty in a national healthcare system: A review of the literature and development of a hospital pathway

INTRODUCTION

As we now drive to reinitiate our full capacity elective services in an attempt to tackle an ever-growing demand for lower limb arthroplasty, this pandemic has presented rare opportunities to revise and re-engage elective arthroplasty pathways aimed at improving patient care and healthcare efficiency.

AIMS

We present the development of an evidence-based multidisciplinary perioperative care pathway for day-case total knee arthroplasty (TKA) in a United Kingdom National Health Service (NHS) institution, in conjunction with a review of the literature upon which the protocol is founded.

METHODOLOGY

We performed a review of the literature reporting complication or readmission rates at ≥30 day postoperative following day-case TKA. Electronic searches were performed using four databases from the date of inception to November 2020. Relevant studies were identified, data extracted, and qualitative synthesis performed.

RESULTS

13 manuscripts with a total of 3370 day-case TKAs, defined as discharged on the same-calendar-day of surgery, were included in analysis. Mean 90-day complication rates (8.31% [range, 0-16.3%] vs 9.49% [range, 0-13.1%], respectively) and readmission rates (2.71% [range, 0-10.0%] vs 3.41% [range, 0-9.9%], respectively) were equivocal between day-case and inpatient TKA. The overall rate of successful same-calendar-day discharge was 95.8%. Our evaluation and critique of the evidence-based literature identifies day-case TKA to be safe, effective and economical, benefitting both patients and healthcare systems alike.

CONCLUSION

We further validate the introduction of our institutional Elective Day Surgery Arthroplasty Pathway (EDSAP) based on the evidence presented. Careful patient selection paralleled with well-defined care pathways are essential for successful introduction of day-case TKA into the NHS.

Reducing Acute Hospitalization Length of Stay After Total Knee Arthroplasty: A Quality Improvement Study

BACKGROUND

The introduction of bundled funding for total knee arthroplasty (TKA) has motivated hospitals to improve quality of care while minimizing costs. The aim of our quality improvement project is to reduce the acute hospitalization length of stay to less than 2 days and decrease the percentage of TKA patients discharged to inpatient rehabilitation using an enhanced recovery after surgery bundle.

METHODS

This study used a before-and-after design. The pre-intervention period was January to December 2017 and the post-intervention period was January 2018 to August 2019. A root cause analysis was performed by a multidisciplinary team to identify barriers for rapid recovery and discharge. Four new interventions were chosen as part of an improvement bundle based on existing local practices, literature review, and feasibility analysis: (1) perioperative peripheral nerve block; (2) prophylactic antiemetic medication; (3) avoidance of routine preoperative urinary catheterization; and (4) preoperative patient education.

RESULTS

The pre-intervention and post-intervention groups included 232 and 383 patients, respectively. Mean length of stay decreased from 2.82 to 2.13 days (P < .001). The need for inpatient rehabilitation decreased from 20.2% to 10.7% (P = .002). Mean 24-hour oral morphine consumption decreased from 60 to 38 mg (P < .001). The percentage of patients experiencing moderate-to-severe pain and postoperative nausea and vomiting within the first 24 hours decreased by 25% and 15%, respectively (P < .001). Thirty-day emergency department visits following discharge decreased from 12.9% to 7.3% (P = .030).

CONCLUSION

Significant improvements in the recovery of patients after TKA were achieved by performing a root cause analysis and implementing a multidisciplinary, patient-centered enhanced recovery after surgery bundle.

LEVEL OF EVIDENCE

Level III.

Perioperative Systemic Dexamethasone Reduces Length of Stay in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

The objective of this review is to examine the effect of perioperative systemic corticosteroids at varying doses and timings on early postoperative recovery outcomes following unilateral total knee and total hip arthroplasty. The primary outcome was length of stay (LOS).

METHODS

A systematic review and meta-analysis of randomized controlled trials was performed. MEDLINE, EMBASE, and Cochrane Library databases were searched from inception to June 1, 2020. Studies comparing the outcome of adult patients receiving a systemic steroid to patients who did not receive steroids were included.

RESULTS

Seventeen studies were included, incorporating 1957 patients. Perioperative corticosteroids reduced hospital LOS (mean difference [MD] = -0.39 days, 95% confidence interval [CI] -0.61 to -0.18). A subsequent dose of corticosteroid at 24 hours further reduced LOS (MD = -0.33, 95% CI -0.55 to -0.11). Corticosteroids resulted in reduced levels of pain on postoperative day (POD) 0 (MD = -1.99, 95% CI -3.30 to -0.69), POD1 (MD = -1.47, 95% CI -2.15 to -0.79), and POD2. Higher doses were more effective in reducing pain with activity on POD0 (P = .006) and 1 (P = .023). Steroids reduced the incidence of PONV on POD1 (log odds ratio [OR] = -1.05, 95% CI -1.26 to -0.84) and POD2, with greater effect at higher doses (P = .046). Corticosteroids did not increase the incidence of infection (P = 1.000), venous thromboembolism (P = 1.000), or gastrointestinal hemorrhage (P = 1.000) but were associated with an increase in blood glucose (MD = 5.30 mg/dL, 95% CI 2.69-7.90).

CONCLUSION

Perioperative corticosteroids are safe, facilitate earlier discharge, and improve patient recovery following unilateral total knee arthroplasty and total hip arthroplasty. Higher doses (15-20 mg of dexamethasone) are associated with further reductions in dynamic pain and PONV, and repeat dosing may further reduce LOS.

[Fast track in hip and knee arthroplasty]

Fast-track treatment concepts were developed decades ago in general and abdominal surgery and have been adapted in recent years for the special requirements of hip and knee arthroplasty. In this field, Hendrik Husted in particular was able to demonstrate scientific evidence for the components of fast-track concepts. The primary aim is not so much to shorten the patient's hospital length of stay (LOS) but rather to effectively increase the quality of medical treatment for the patient and to reduce complications. The optimization of organizational processes as well as intraoperative and perioperative surgical approaches are essential components regarding the introduction of fast track into the clinical routine. This article gives a comprehensive overview of fast-track treatment concepts and explains the scientific principles for the approach.

Development International Classification of Functioning, Disability and Health Core Set for Post Total Knee Replacement Rehabilitation Program: Delphi-Based Consensus Study in Taiwan

Osteoarthritis is one of the leading causes of disability. Total knee arthroplasty (TKA) is a surgical intervention for patients with severe osteoarthritis. Post TKA rehabilitation is crucial for improving patient's quality of life. However, traditional rehabilitation has only focused on physical function; a systemic analysis of other dimensions such as social participation and environmental factors of post TKA rehabilitation is lacking. The aim of this study was to develop a core set from the International Classification of Functioning, Disability and Health (ICF) to create a comprehensive rehabilitation program for patients with osteoarthritis post TKA. Before the Delphi-based consensus process, a literature review process was performed for related ICF categories selection. We used a three-round Delphi-based consensus among 20 physical therapists with orthopedic rehabilitation expertise in a university-based hospital. A five-point Likert scale was used to rate the importance of each item. The consensus of ratings was analyzed using Spearman's rho and semi-interquartile range indices. The ICF core set for post TKA rehabilitation was determined based on a high level of consensus and a mean score of ≥4.0 in the third Delphi-based consensus round. The ICF core set comprised 32 categories, with 13 regarding body function, four regarding body structures, nine regarding activities and participation, four regarding environmental factors, and two regarding personal factors. Our ICF core set for post TKA rehabilitation can provide information on effective rehabilitation strategies and goal setting for patients post TKA. However, further validation and feasibility assessments are warranted.

Day-case total hip arthroplasty: a literature review and development of a hospital pathway

Aims

We present the development of a day-case total hip arthroplasty (THA) pathway in a UK National Health Service institution in conjunction with an extensive evidence-based summary of the interventions used to achieve successful day-case THA to which the protocol is founded upon.

Methods

We performed a prospective audit of day-case THA in our institution as we reinitiate our full capacity elective services. In parallel, we performed a review of the literature reporting complication or readmission rates at ≥ 30-day postoperative following day-case THA. Electronic searches were performed using four databases from the date of inception to November 2020. Relevant studies were identified, data extracted, and qualitative synthesis performed.

Results

Our evaluation and critique of the evidence-based literature identifies day-case THA to be safe, effective, and economical, benefiting both patients and healthcare systems alike. We further validate this with our institutional elective day surgery arthroplasty pathway (EDSAP) and report a small cohort of successful day-case THA cases as an example in the early stages of this practice in our unit.

Conclusion

Careful patient selection and education, adequate perioperative considerations, including multimodal analgesia, surgical technique and blood loss management protocols and appropriate postoperative pathways comprising reliable discharge criteria are essential for successful day-case THA.

Cite this article: Bone Jt Open 2021;2(2):93–102.

What Is the Quality of Surgical Care for Patients with Hip Fractures at Critical Access Hospitals?

BACKGROUND

Critical access hospitals (CAHs) play an important role in providing access to care for many patients in rural communities. Prior studies have shown that these facilities are able to provide timely and quality care for patients who undergo various elective and emergency general surgical procedures. However, little is known about the quality and reimbursement of surgical care for patients undergoing surgery for hip fractures at CAHs compared with non-CAH facilities.

QUESTIONS/PURPOSES

Are there any differences in 90-day complications, readmissions, mortality, and Medicare payments between patients undergoing surgery for hip fractures at CAHs and those undergoing surgery at non-CAHs?

METHODS

The 2005 to 2014 Medicare 100% Standard Analytical Files were queried using ICD-9 procedure codes to identify Medicare-eligible beneficiaries undergoing open reduction and internal fixation (79.15, 79.35, and 78.55), hemiarthroplasty (81.52), and THA (81.51) for isolated closed hip fractures. This database was selected because the claims capture inpatient diagnoses, procedures, charged amounts and paid claims, as well as hospital-level information of the care, of Medicare patients across the nation. Patients with concurrent fixation of an upper extremity, lower extremity, and/or polytrauma were excluded from the study to ensure an isolated cohort of hip fractures was captured. The study cohort was divided into two groups based on where the surgery took place: CAHs and non-CAHs. A 1:1 propensity score match, adjusting for baseline demographics (age, gender, Census Bureau-designated region, and Elixhauser comorbidity index), clinical characteristics (fixation type and time to surgery), and hospital characteristics (whether the hospital was located in a rural ZIP code, the average annual procedure volume of the operating facility, hospital bed size, hospital ownership and teaching status), was used to control for the presence of baseline differences in patients presenting at CAHs and those presenting at non-CAHs. A total of 1,467,482 patients with hip fractures were included, 29,058 of whom underwent surgery in a CAH. After propensity score matching, each cohort (CAH and non-CAH) contained 29,058 patients. Multivariate logistic regression analyses were used to assess for differences in 90-day complications, readmissions, and mortality between the two matched cohorts. As funding policies of CAHs are regulated by Medicare, an evaluation of costs-of-care (by using Medicare payments as a proxy) was conducted. Generalized linear regression modeling was used to assess the 90-day Medicare payments among patients undergoing surgery in a CAH, while controlling for differences in baseline demographics and clinical characteristics.

RESULTS

Patients undergoing surgery for hip fractures were less likely to experience many serious complications at a critical access hospital (CAH) than at a non-CAH. In particular, after controlling for patient demographics, hospital-level factors and procedural characteristics, patients treated at a CAH were less likely to experience: myocardial infarction (3% (916 of 29,058) versus 4% (1126 of 29,058); OR 0.80 [95% CI 0.74 to 0.88]; p < 0.001), sepsis (3% (765 of 29,058) versus 4% (1084 of 29,058); OR 0.69 [95% CI 0.63 to 0.78]; p < 0.001), acute renal failure (6% (1605 of 29,058) versus 8% (2353 of 29,058); OR 0.65 [95% CI 0.61 to 0.69]; p < 0.001), and Clostridium difficile infections (1% (367 of 29,058) versus 2% (473 of 29,058); OR 0.77 [95% CI 0.67 to 0.88]; p < 0.001) than undergoing surgery in a non-CAH. CAHs also had lower rates of all-cause 90-day readmissions (18% (5133 of 29,058) versus 20% (5931 of 29,058); OR 0.83 [95% CI 0.79 to 0.86]; p < 0.001) and 90-day mortality (4% (1273 of 29,058) versus 5% (1437 of 29,058); OR 0.88 [95% CI 0.82 to 0.95]; p = 0.001) than non-CAHs. Further, CAHs also had risk-adjusted lower 90-day Medicare payments than non-CAHs (USD 800, standard error 89; p < 0.001).

CONCLUSION

Patients who received hip fracture surgical care at CAHs had a lower risk of major medical and surgical complications than those who had surgery at non-CAHs, even though Medicare reimbursements were lower as well. Although there may be some degree of patient selection at CAHs, these facilities appear to provide high-value care to rural communities. These findings provide evidence for policymakers evaluating the impact of the CAH program and allocating funding resources, as well as for community members seeking emergent care at local CAH facilities.

LEVEL OF EVIDENCE

Level III, therapeutic study.

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

Objective

Methods

Results

Conclusion

Enhanced recovery principles applied to revision hip and knee arthroplasty leads to better patient outcomes

Aims

There is very little published literature on Enhanced Recovery Principles (ERP) used in primary joint replacements applied to revision hip and knee arthroplasty (rTHA, rTKA).

Methods

Retrospective series of 268 rTHA and rTKA surgeries from 2010 -2018, treated with ERP, focusing on multimodal pain management, blood management and early functional recovery.

Results

No patients from the latest cohort required readmission within 6 weeks. Only 20 patients (7.5%) required a blood transfusion. Surgical site local anaesthetic infiltration was associated with lower PCA use in aseptic rTHA and rTKA (p<0.001; p<0.001). Revisions for infection had a longer length of stay (LOS) and increased PCA usage in both rTHA (6.5 vs. 5.2 days) and rTKA (10.1 vs. 5.3 days), similar to our previous study.¹ Use of an intra-articular catheter for analgesia in rTKA showed reduced PCA use. Tourniquets were not beneficial for blood loss in rTKA and had greater PCA use post-operatively (p<0.001).

Conclusion

The application of ERP to revision THA and TKA surgery is safe and effective.

Is kinesiophobia a predictor of early functional performance after total hip replacement? A prospective prognostic cohort study

BACKGROUND

Considerable attention has been paid to the role of kinesiophobia with respect to knee prosthesis but it has not yet been studied as a prognostic factor of short-term functional performance following total hip replacement. The main purpose of the present study is to examine the possible predictors of early functional performance of patients undergoing total primary hip arthroplasty, including demographics as age, sex and body mass index, preoperative functional ability, type of anaesthesia, level of haemoglobin, pain and level of kinesiophobia before surgery. Secondly, we want to describe the main characteristics of the population with the highest levels of kinesiophobia.

METHODS

A prospective, prognostic cohort study was carried out. Patients undergoing primary hip replacement were recruited consecutively. The main outcome is the early functional performance achieved by patients after surgery and measured using the Iowa Level of Assistance (ILOA) scale on the fifth postoperative day. Preoperative kinesiophobia was measured by the Tampa Scale and the preoperative functional ability by the Western Ontario and McMaster Osteoarthritis Index (WOMAC). The multivariate analysis was performed by the General Linear Model. The analysis of the population with high levels of kinesiophobia was conducted by identifying a cut-off of 40 compared to the Tampa Scale.

RESULTS

Statistical analysis was performed on 269 patients. The average ILOA score recorded was 19.5 (DS 8.3). The levels of kinesiophobia, showed an average score of 35.1 (7.8) and it was not associated with early functional performance. The independent predictive factors include age, sex and body mass index. Kinesiophobia high levels were recorded in 30% of the population and this population had a higher level of pre-operative WOMAC score.

CONCLUSIONS

Early functional performance after hip replacement surgery was not correlated with the level of kinesiophobia. Three significant factors that describe a population most at risk of not achieving optimal functional performance are increased age, being female and increase in body mass index. In the preoperative phase, high levels of kinesiophobia were associated with more impaired preoperative functional ability.

TRIAL REGISTRATION

Current Controlled Trials NCT02786121 , May 2016. Retrospectively registered.

Introducing enhanced recovery after surgery in a high-volume orthopaedic hospital: a health technology assessment

BACKGROUND

The number of patients undergoing joint arthroplasty is increasing worldwide. An Enhanced Recovery After Surgery (ERAS) pathway for hip and knee arthroplasty was introduced in an Italian high-volume research hospital in March 2018.

METHODS

The aim of this mixed methods observational study is to perform a health technology assessment (HTA) of the ERAS pathway, considering 938 procedures performed after its implementation, by means of a hospital-based approach derived from the EUnetHTA (European Network for Health Technology Assessment) Core Model. The assessment process is based on dimensions of general relevance, safety, efficacy, effectiveness, economic and financial impact, equity, legal aspects, social and ethical impact, and organizational impact. A narrative review of the literature helped to identify general relevance, safety and efficacy factors, and a set of relevant sub-dimensions submitted to the evaluation of the professionals who use the technology through a 7-item Likert Scale. The economic and financial impact of the ERAS pathway on the hospital budget was supported by quantitative data collected from internal or national registries, employing economic modelling strategies to identify the amount of resources required to implement it.

RESULTS

The relevance of technology under assessment is recognized worldwide. A number of studies show accelerated pathways to dominate conventional approaches on pain reduction, functional recovery, prevention of complications, improvements in tolerability and quality of life, including fragile or vulnerable patients. Qualitative surveys on clinical and functional outcomes confirm most of these benefits. The ERAS pathway is associated with a reduced length of stay in comparison with the Italian hospitalization average for the same procedures, despite the poor spread of the pathway within the country may generate postcode inequalities. The economic analyses show how the resources invested in training activities are largely depreciated by benefits once the technology is permanently introduced, which may generate hospital cost savings of up to 2054,123.44 € per year.

CONCLUSIONS

Galeazzi Hospital's ERAS pathway for hip and knee arthroplasty results preferable to traditional approaches following most of the HTA dimensions, and offers room for further improvement. The more comparable practices are shared, the before this potential improvement can be identified and addressed.

Enhanced Recovery After Surgery Trends in Adult Spine Surgery: A Systematic Review

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a multimodal, multidisciplinary approach to optimizing the postsurgical recovery process through preoperative, perioperative, and postoperative interventions. ERAS protocols are emerging quickly within orthopedic spine surgery, yet there is a lack of consensus on optimal ERAS practices.

OBJECTIVE

The aim of this systematic review is to identify and discuss the trends in spine ERAS protocols and the associated outcomes.

METHODS

A literature search on PubMed was conducted to identify clinical studies that implemented ERAS protocols for various spine procedures in the adult population. The search included English-language literature published through December 2019. Additional sources were retrieved from the reference lists of key studies. Studies that met inclusion criteria were identified manually. Data regarding the study population, study design, spine procedures, ERAS interventions, and associated outcome metrics were extracted from each study that met inclusion criteria.

RESULTS

Of the 106 studies identified from the literature search, 22 studies met inclusion criteria. From the ERAS protocols in these studies, common preoperative elements include patient education and modified preoperative nutrition regimens. Perioperative elements include multimodal analgesia and minimally invasive surgery. Postoperative elements include multimodal pain management and early mobilization/rehabilitation/nutrition regimens. Outcomes from ERAS implementation include significant reductions in length of stay, cost, and opioid consumption. Although these trends were observed, there remained great variability among the ERAS protocols, as well as in the reported outcomes.

CONCLUSIONS

ERAS may improve cost-effectiveness to varying degrees for spinal procedures. Specifically, the use of multimodal analgesia may reduce overall opioid consumption. However, the benefits of ERAS likely will vary based on the specific procedure.

CLINICAL RELEVANCE

This review contributes to the assessment of ERAS protocol implementation in the field of adult spine surgery.

Prognostic risk factors of surgical site infection after primary joint arthroplasty: A retrospective cohort study

Surgical site infection (SSI) can be a devastating complication in joint arthroplasty. Objective of this study was to identify potential risk factors associated with SSI following primary joint arthroplasty.This retrospective cohort study was performed from January 2016 to October 2017. A total of 986 patients were enrolled. We extracted the patients' baseline information, treatment-related variables and indexes of laboratory examination during their hospitalization. Receiver operating characteristic (ROC) analysis was performed to find the optimum cut-off value for serum albumin. Univariate and multivariate logistic analysis models were performed respectively to determine independent predictors of SSI.Nine hundred eighty-six patients with complete data were included in the final analysis. There were 314 male and 672 females in this study with a mean age of 64.6 years, and twenty patients developed SSI. The overall incidence of SSI was 2.03%, with 0.20% for deep infection and 1.83% for superficial SSI. Independent predictors of SSI identified by multivariate analysis were ALB < 36.7 g/L (odds ratio = 3.42; 95% CI = 1.24-9.48; P = .018), BMI ≥28 (odds ratio = 5.08; 95%CI = 1.52-17.01; P = .008) and ASA class 3 or higher (odds ratio = 3.36; 95% CI = 1.22-9.30; P = .019). Drain use was demonstrated as a protective factor of postoperative wound healing.The incidence of SSI following primary joint arthroplasty was 2.03%. ASA ≥3, BMI ≥28 and ALB < 36.7 g/L were demonstrated as risk factors of postoperative wound infection. Supplementary nutrition support is necessary to reduce the risk of infection in patients who underwent artificial joint arthroplasty.

Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations

Background and purpose - There is a large volume of heterogeneous studies across all Enhanced Recovery After Surgery (ERAS®) components within total hip and total knee replacement surgery. This multidisciplinary consensus review summarizes the literature, and proposes recommendations for the perioperative care of patients undergoing total hip replacement and total knee replacement with an ERAS program.Methods - Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies that evaluated the efficacy of individual items of the perioperative treatment pathway to expedite the achievement of discharge criteria. A consensus recommendation was reached by the group after critical appraisal of the literature.Results - This consensus statement includes 17 topic areas. Best practice includes optimizing preoperative patient education, anesthetic technique, and transfusion strategy, in combination with an opioid-sparing multimodal analgesic approach and early mobilization. There is insufficient evidence to recommend that one surgical technique (type of approach, use of a minimally invasive technique, prosthesis choice, or use of computer-assisted surgery) over another will independently effect achievement of discharge criteria.Interpretation - Based on the evidence available for each element of perioperative care pathways, the ERAS® Society presents a comprehensive consensus review, for the perioperative care of patients undergoing total hip replacement and total knee replacement surgery within an ERAS® program. This unified protocol should now be further evaluated in order to refine the protocol and verify the strength of these recommendations.

The impact of the enhanced recovery pathway and other factors on outcomes and costs following hip and knee replacement: routine data study

Background

There is limited evidence concerning the effectiveness of enhanced recovery programmes in hip and knee replacement surgery, particularly when applied nationwide across a health-care system.

Objectives

To determine the effect of hospital organisation, surgical factors and the enhanced recovery after surgery pathway on patient outcomes and NHS costs of hip and knee replacement.

Design

(1) Statistical analysis of national linked data to explore geographical variations in patient outcomes of surgery. (2) A natural experimental study to determine clinical effectiveness of enhanced recovery after surgery. (3) A qualitative study to identify barriers to, and facilitators of, change. (4) Health economics analysis to establish NHS costs and cost-effectiveness.

Setting

Data from the National Joint Registry, linked to English Hospital Episode Statistics and patient-reported outcome measures in both the geographical variation and natural experiment studies, together with the economic evaluation. The ethnographic study took place in four hospitals in a region of England.

Participants

Qualitative study – 38 health professionals working in hip and knee replacement services in secondary care and 37 patients receiving hip or knee replacement.

Interventions

Natural experiment – implementation of enhanced recovery after surgery at each hospital between 2009 and 2011. Enhanced recovery after surgery is a complex intervention focusing on several areas of patients’ care pathways through surgery: preoperatively (patient is in best possible condition for surgery), perioperatively (patient has best possible management during and after operation) and postoperatively (patient experiences best rehabilitation).

Main outcome measures

Patient-reported pain and function (Oxford Hip Score/Oxford Knee Score); 6-month complications; length of stay; bed-day costs; and revision surgery within 5 years.

Results

Geographical study – there are potentially unwarranted variations in patient outcomes of hip and knee replacement surgery. This variation cannot be explained by differences in patients, case mix, surgical or hospital organisational factors. Qualitative – successful implementation depends on empowering patients to work towards their recovery, providing post-discharge support and promoting successful multidisciplinary team working. Care processes were negotiated between patients and health-care professionals. ‘Good care’ remains an aspiration, particularly in the post-discharge period. Natural experiment – length of stay has declined substantially, pain and function have improved, revision rates are in decline and complication rates remain stable. The introduction of a national enhanced recovery after surgery programme maintained improvement, but did not alter the rate of change already under way. Health economics – costs are high in the year of joint replacement and remain higher in the subsequent year after surgery. There is a strong economic incentive to identify ways of reducing revisions and complications following joint replacement. Published cost-effectiveness evidence supports enhanced recovery pathways as a whole.

Limitations

Short duration of follow-up data prior to enhanced recovery after surgery implementation and missing data, particularly for hospital organisation factors.

Conclusion

No evidence was found to show that enhanced recovery after surgery had a substantial impact on longer-term downwards trends in costs and length of stay. Trends of improving outcomes were seen across all age groups, in those with and without comorbidity, and had begun prior to the formal enhanced recovery after surgery roll-out. Reductions in length of stay have been achieved without adversely affecting patient outcomes, yet, substantial variation remains in outcomes between hospital trusts.

Future work

There is still work to be done to reduce and understand unwarranted variations in outcome between individual hospitals.

Study registration

This study is registered as PROSPERO CRD42017059473.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 4. See the NIHR Journals Library website for further project information.

Assessment on patient outcomes of primary hip replacement: an interrupted time series analysis from 'The National Joint Registry of England and Wales'

OBJECTIVES

Effects of the UK Department of Health's national Enhanced Recovery After Surgery (ERAS) Programme on outcomes after primary hip replacement.

DESIGN

Natural experimental study using interrupted time series to assess the changes in trends before, during and after ERAS implementation (April 2009 to March 2011).

SETTING

Surgeries in the UK National Joint Registry were linked with Hospital Episode Statistics containing inpatient episodes from National Health Service trusts in England and patient reported outcome measures.

PARTICIPANTS

Patients aged ≥18 years from 2008 to 2016.

MAIN OUTCOME MEASURES

Regression coefficients of monthly means of length of hospital stay, bed day cost, change in Oxford Hip Scores (OHS) 6 months post-surgery, complications 6 months post-surgery and revision rates 5 years post-surgery.

RESULTS

438 921 primary hip replacements were identified. Hospital stays shortened from 5.6 days in April 2008 to 3.6 in December 2016. There were also improvements in bed day costs (£7573 in April 2008 to £5239 in December 2016), positive change in self-reported OHS from baseline to 6 months post-surgery (17.7 points in April 2008 to 22.9 points in December 2016), complication rates (4.1% in April 2008 to 1.7% March 2016) and 5 year revision rates (5.9 per 1000 implant-years (95% CI 4.8 to 7.2) in April 2008 to 2.9 (95% CI 2.2 to 3.9) in December 2011). The positive trends in all outcomes started before ERAS was implemented and continued during and after the programme.

CONCLUSIONS

Patient outcomes after hip replacement have improved over the last decade. A national ERAS programme maintained this improvement but did not alter the existing rate of change.

Thirty-Day Major and Minor Complications Following Total Hip Arthroplasty-A Comparison of the Direct Anterior, Lateral, and Posterior Approaches

BACKGROUND

The choice of surgical approach during total hip arthroplasty (THA) remains highly controversial. The aim of the present study was to compare 30-day major and minor complications, following primary THA between the direct anterior, lateral, and posterior approaches.

METHODS

Our hospital performs primary THAs using all 3 aforementioned approaches based on surgeon preference. Patients who underwent primary THA from August 2010 to August 2017 were identified using our institution's total joint registry, and their data were combined with prospectively collected data from the National Surgical Quality Improvement Program database (which evaluates a random sample of approximately 20% of all surgical patients in our hospital). Baseline characteristics, operative variables, and postoperative complications were then compared between the three groups.

RESULTS

The analysis comprised 1967 primary THAs (1913 patients), whereby 56%, 29%, and 15% were performed through a posterior, lateral, and direct anterior approach, respectively. Thirty-day major and minor complications occurred in 3.9% and 9.4% of surgeries, respectively. After adjusting for baseline patient characteristics, there was no significant difference in major or minor perioperative complications between the 3 approaches.

CONCLUSIONS

This study compared perioperative complications between the 3 most commonly used approaches for THA utilizing a synthesis of our institutional total joint registry and high-quality National Surgical Quality Improvement Program data. Thirty-day major and minor complications were similar regardless of the surgical approach employed, which may help surgeons and patients simplify the multiple considerations taken into account when deciding on surgical approach for primary THA.

LEVEL OF EVIDENCE

Therapeutic, Level III.

Relationship between exposure to the natural environment and recovery from hip or knee arthroplasty: a New Zealand retrospective cohort study

OBJECTIVES

Determine whether patients who live in greener and more walkable neighbourhoods live longer, and take fewer opioids, following hip or knee arthroplasty.

DESIGN

Retrospective cohort study.

SETTING

Residential environment following surgery at one of 54 New Zealand hospitals.

PARTICIPANTS

All people who received a total hip or knee arthroplasty at a publicly-funded hospital in New Zealand in 2006 and 2007 (7449 hip arthroplasties and 6558 knee arthroplasties).

PRIMARY AND SECONDARY OUTCOME MEASURE

Time to all-cause mortality and number of postsurgical opioid prescriptions.

RESULTS

Patients who lived in greener neighbourhoods, as measured by the Normalised Difference Vegetation Index, lived longer following hip or knee arthroplasty (standardised OR: 0.95, 95% CI 0.92 to 0.99). However, when we estimated separate hip-arthroplasty-only and knee-arthroplasty-only models, greenness was only significantly associated with greater longevity following hip arthroplasty. Similarly, patients who lived in greener neighbourhoods took fewer opioids in the 12 months following hip or knee arthroplasty (standardised OR: 0.97, 95% CI 0.95 to 0.99), but in separate hip-arthroplasty-only and knee-arthroplasty-only models, greenness was only significantly associated with lower opioid use following hip arthroplasty. Walkability was not significantly associated with postsurgical opioid use or postsurgical longevity. All ORs were adjusted for sex, ethnicity, age, presurgical chronic health conditions, presurgical opioid use, social deprivation and length of hospital stay.

CONCLUSIONS

Consistent with the literature on enhanced-recovery programme, people who lived in greener neighbourhoods took fewer opioids, and lived longer, following hip arthroplasty. Improving access to the natural environment may therefore be an effective component of postsurgical recovery programme.

[Fast track strategies in hip arthroplasty]

BACKGROUND

Fast track arthroplasty is becoming increasingly accepted in German-speaking countries. By optimizing treatment processes fast track programs promise faster recovery, increased patient satisfaction, quality improvement and reduction in the length of hospital stay.

OBJECTIVES

The philosophy and treatment principles of fast track hip arthroplasty during the pre, intra and postoperative phase are described in the light of the current body of evidence. The challenges concerning fast track arthroplasty within the German health system are discussed.

MATERIAL AND METHODS

Besides presenting our own data concerning a patient seminar and an opiate saving pain treatment, the most relevant literature related to fast track hip arthroplasty from a pubmed search is discussed.

RESULTS

Fast track concepts can only be successfully implemented through close interdisciplinary team work. Preoperatively, a patient seminar can help to prepare patients better for surgery. Postoperatively, early mobilisation and pain treatment play a central role, whereat a clear reduction in opiate application can be achieved.

CONCLUSION

Fast track hip arthroplasty makes rethinking with respect to traditional treatment principles necessary and demands a high degree of interdisciplinary team work. Particularly, as result of the specifics of the health system (DRG system and stationary rehabilitation), a nationwide establishment in Germany has not taken place so far.

Supplementation of enteral nutritional powder decreases surgical site infection, prosthetic joint infection, and readmission after hip arthroplasty in geriatric femoral neck fracture with hypoalbuminemia

BACKGROUND

Nearly half of elderly patients with hip fracture were malnourished, indicated with a serum marker of hypoalbuminemia. Malnutrition was a risk factor for poor outcomes in geriatrics after hip replacement. The purpose of this study was to investigate if oral nutritional supplementation after the procedure in geriatrics with hypoalbuminemia was beneficial for outcomes.

METHODS

A retrospective cohort study of older (≥ 65 years old) patients suffering femoral neck fracture and undergoing hip replacement with hypoalbuminemia was conducted. Outcomes were compared between patients with and without postoperative nutritional supplementation.

RESULTS

There were 306 geriatric patients met the criteria. Following adjustment for baseline characteristics, patients with nutritional supplementation showed a lower grade of wound effusion with adjusted OR 0.57 (95% confidence interval (CI), 0.36 to 0.91, P < 0.05). And also a lower rate of surgical site infection (5.5% compared with 13.0% [adjusted OR 0.40, 95% CI, 0.17 to 0.91, P < 0.05]), periprosthetic joint infection (2.8% compared with 9.9% [adjusted OR 0.26, 95% CI, 0.08 to 0.79, P < 0.05]), and 30 days readmission (2.1% compared with 8.7% [adjusted OR 0.22, 95% CI, 0.06 to 0.79, P < 0.05]). The average total hospital stay was longer in patients without nutritional supplementation (10.7 ± 2.0 compared with 9.2 ± 1.8 days, P < 0.05).

CONCLUSIONS

The data suggest that postoperative nutritional supplementation is a protective factor for surgical site infection, periprosthetic joint infection, and 30-days readmission in geriatric with hypoalbuminemia undergoing a hip replacement. Postoperative nutritional supplementation for these patients should be recommended.

Minor influence of patient education and physiotherapy interventions before total hip replacement on patient-reported outcomes: an observational study of 30,756 patients in the Swedish Hip Arthroplasty Register

Background and purpose - It is unclear whether physiotherapy interventions or patient education before total hip replacement (THR) is beneficial for patients postoperatively. Utilizing the Swedish Hip Arthroplasty Register (SHAR), we retrospectively studied the influence of preoperative self-reported exposure to physiotherapy and/or patient education on patient-reported outcomes 1 year after THR. Patients and methods - Data covering all THRs performed in Sweden for osteoarthritis, between the years 2012 and 2015, was obtained from SHAR. There were 30,756 patients with complete data. Multiple linear regression modelling was performed with 1-year postoperative PROMs (hip pain on a visual analogue scale [VAS], with the quality of life measures EQ-5D index and EQ VAS, and surgery satisfaction VAS) as dependent variables. Self-reported physiotherapy and patient education (yes or no) were used as independent variables. Results - Physiotherapy was associated with slightly less pain VAS (-0.7, 95% CI -1.1 to -0.3), better EQ-5D index (0.01, CI 0.00-0.01), EQ VAS (0.8, CI 0.4-1.2), and better satisfaction VAS (-0.7, CI -1.2 to -0.2). Patient education was associated with slightly better EQ-5D index (0.01, CI 0.00-0.01) and EQ VAS (0.7, CI 0.2-1.1). Interpretation - Even though we found statistically significant differences in favor of physiotherapy and patient education, the magnitude of those were too small and inconsistent to conclude a truly positive influence. Further research is needed with more specific and demarcated physiotherapy interventions.

Improving the Patient Experience Following Total Knee and Total Hip Arthroplasty: A Practice Development Project

BACKGROUND

The paradigm shift that has occurred for patients with total hip (THA) and knee (TKA) arthroplasty through enhanced recovery programs underscores the need for redesigning care provision.

LOCAL PROBLEM

In this hospital, the patient outcomes and experience anticipated from the implementation of enhanced recovery medical protocols were not fully realized.

METHODS

The Practice Development in Nursing and Healthcare model guided this project.

INTERVENTIONS

A nurse-led team designed a new care delivery model with patient/family-centered interventions based on the best evidence.

RESULTS

Outcomes included an increase in discharges of postoperative day 1 or less of 154% THA and 41.8% TKA and an increase in discharge to home by 24.6% THA and 18.7% TKA. In addition, 90-day readmissions were reduced for both patient groups.

CONCLUSIONS

An interprofessional team of clinicians made sustainable improvements in the experience and outcomes for the surgical patients with THA and TKA.

When do patients drive after minimally invasive anterior hip replacements? A single surgeon experience of 212 hip arthroplasties

Introduction: Patients desire to return to normal activities soon after hip arthroplasty, with driving often being an integral component. We aimed to determine when patients resumed driving following a minimally invasive anterior bikini hip replacement and when they returned to work.

Methodology: All consecutive patients undergoing elective primary bikini hip replacements between January 2017 and April 2018 were included in the study. Patients who did not drive were excluded. A detailed questionnaire was sent to patients 3–6 weeks after surgery to record their driving status. Fifty patients were randomly selected to assess flexion at the hip, knee and ankle joints while seated in the driver's seat of their own vehicle.

Results: Altogether 212 anterior bikini total hip replacements (L = 102, R = 108 and 1 bilateral one stage) were performed in 198 patients (F = 129 and M = 69) with a mean age of 69 years. A total of 76% patients returned to driving within the first 3 weeks after surgery, of which 25 (14%) resumed driving within the first post-operative week, 71 (39%) in the second week and 42 (23%) in the third week. Among them, 98.4% stated they were confident when they first started driving and 90.66% stated they were more comfortable driving after surgery than before. Employed patients returned to work within 1–79 days (mean = 24 days).

Conclusion: Surgeons may allow patients to resume driving within 1 week after anterior hip replacement and return to work within 3 weeks if they are medically fit and deemed safe.

Does Dexamethasone Reduce Hospital Readiness for Discharge, Pain, Nausea, and Early Patient Satisfaction in Hip and Knee Arthroplasty? A Randomized, Controlled Trial

BACKGROUND

Reduction in postoperative pain, nausea, and vomiting in patients undergoing total joint arthroplasty may facilitate earlier discharge from hospital and reduce healthcare costs. This study was performed to primarily assess whether perioperative dexamethasone reduced hospital length of stay and to assess the effect on pain, nausea and vomiting, and patient satisfaction.

METHODS

One hundred sixty-four patients undergoing total hip arthroplasty or total knee arthroplasty were randomized to receive either 8 mg intravenous dexamethasone (n = 86) or placebo (n = 78) at induction and at 24 hours postsurgery. The primary outcome was length of stay and secondary outcomes were pain and nausea visual analog scale scores, analgesic and antiemetic usage, blood glucose level, and patient satisfaction.

RESULTS

Participants in the study group achieved earlier readiness for discharge. There was a 20% reduction in pain scores and morphine usage was 27% lower in the study group. Nausea scores were similar in the 2 groups but there was lower antiemetic usage in the study group. Satisfaction scores at 6 weeks postsurgery in the dexamethasone group were significantly higher than the placebo group. There was no difference in complication rates between the 2 groups.

CONCLUSION

The administration of intravenous dexamethasone could lead to earlier readiness for discharge especially in patients undergoing elective total hip arthroplasty, primarily by a reduction in postoperative pain scores and/or morphine requirements.

Direct Anterior Approach Total Hip Arthroplasty: An Adjunct to an Enhanced Recovery Pathway: Outcomes and Learning Curve Effects in Surgeons Transitioning From Other Surgical Approaches

BACKGROUND

The aim of this study was to investigate whether the direct anterior approach (DAA) to total hip arthroplasty (THA) resulted in a shorter length of stay (LOS) in surgeons new to the approach when compared to their previously used approach. Perioperative complications were also assessed.

METHODS

We examined 93 DAA THA performed by 3 hip arthroplasty surgeons at a single institution comparing these to their previous 166 operations performed using the lateral or posterior approach.

RESULTS

Fixed-effects generalized linear modeling demonstrated that patients who underwent THA by the DAA had 26% shorter LOS than those who were operated on using lateral or posterior approaches (adjusted risk ratio = 0.74; 95% confidence interval = 0.65-0.84; P < .001). A greater proportion of DAA patients were discharged directly home (98% vs 87%, F (1,233) = 8.12, P = .005) and complication rates were comparable between groups.

CONCLUSION

The DAA can reduce patient LOS and may be a valuable addition to enhanced recovery pathways. Our findings also suggest that surgeons transitioning to the DAA do not have an increased complication rate when compared to their previous approach.

A feasibility randomised controlled trial to evaluate the effectiveness of a novel neuromuscular electro-stimulation device in preventing the formation of oedema following total hip replacement surgery

Aim

The aim of this feasibility study was to investigate the potential role of a novel neuromuscular electrical stimulation (NMES) device in preventing the formation of oedema following total hip replacement (THR).

Methods

Successive primary THR patients were recruited into a randomised controlled trial. Participants were randomised to wear either the NMES device or compression stockings continually from post-surgery until discharge.

The main outcome measure was presence of lower limb oedema, assessed by taking measurements of the circumference of the ankle, knee and thigh on the operated leg and non-operated leg, pre-operatively, post-operatively, at two days post-operatively and every day until discharge. Secondary objectives were to compare adverse events, the presence of asymptomatic and symptomatic deep vein thrombosis (DVT) and device tolerability between groups.

Results

Data from 40 participants were analysed (NMES (n = 20), compression stockings (n = 20)). The NMES group had significantly less oedema and the device was found to be tolerable and safe.

Conclusion

The results of this study suggest that the NMES is a safe and well tolerated alternative to compression stockings, which should be considered by clinicians seeking the additional benefit of reducing post-operative oedema. In addition the NMES device should be considered as part of a DVT prophylaxis.

Short-term outcomes of one-stage bilateral total hip arthroplasty in young patients (< 30 years old)

Total hip arthroplasty is one of the best treatments for restoring function and activity in young patients with advanced joint diseases. One-Stage Bilateral Total Hip Arthroplasty (BTHA) offers many advantages, which are important to younger patients and diminished costs and time in comparison with sequential THA. There is currently much concern about the safety of this procedure. The current study was designed to provide more information regarding THA in patients aged 30 years old or younger. Between April 2010 and September 2015, arthroplasty procedures were performed on 180 patients at the surgical centers of Erfan and Milad, Tehran, Iran. The patients that were entered in the study included those with bilateral hip involvement of Avascular Necrosis (AVN), Rheumatoid Arthritis (RA), Juvenile Rheumatoid Arthritis (JRA), Slipped Capital Femoral Epiphysis (SCFE), and Developmental Dysplasia of the Hip (DDH). The patients underwent one-stage bilateral total hip arthroplasties through the direct lateral approach. Standardized questionnaires were used to obtain mean Postel-Merle d'Aubigné (PMA) score, Oxford Hip Score (OHS), Visual Analogue Scale (VAS) Score, and Modified Harris Hip Score (MHHS), both preoperatively and post-operatively to evaluate functional outcomes. All patients were in the American Society of Anesthesiology (ASA) category 1 or 2. All complications were followed closely for a period of 4.67±0.54 years. From 141 males and 39 females, 84 patients had been recognized as ASA 1, and 96 as ASA 2. Mean age of patients was 27.04±2.74 years old (range: 16 to 30). The mean operation time and the average length of hospital stay were 156±23 minutes and 5.20±2.44 days, respectively. Overall, 3 patients developed unilateral temporary peroneal nerve palsy (1.66%), 2 intraoperative fracture (1.11%), and 2 patients (1.11%) showed deep vein thrombosis. There was no wound infection. Regarding the functional scores in the diagnosis of patients, improvement was better in AVN than, RA, JRA, SCFE, and DDH, respectively. There were significant differences between diagnosis and every functional score, individually (P<0.05). The current results showed that one-stage bilateral THA led to improvement in hip function and stable implant fixation at short to midterm follow up, which suggests the efficacy of one-stage cementless THA in bilateral advanced arthritis in patients younger than 30 years old.

Unplanned emergency department or urgent care visits after outpatient rotator cuff repair: potential for avoidance

BACKGROUND

With the cost of health care rising, the potential to avoid costs from an unplanned return to the emergency department (ED) or urgent care center (UC) after elective outpatient rotator cuff repair (RCR) has been discussed but not extensively assessed.

METHODS

Outpatient RCR procedures were queried in a closed health care system, and all unplanned ED and UC visits within 7 days of procedures were collected and compared with other typical outpatient orthopedic procedures (knee arthroscopy, carpal tunnel release, and anterior cruciate ligament reconstruction). Avoidable diagnoses (ADs) for the unplanned visits were defined in advance as visits for (1) constipation, (2) nausea or vomiting, (3) pain, and (4) urinary retention. Final tallies of all visits versus visits with ADs were compared.

RESULTS

From June 2015 to May 2016, 1306 outpatient RCRs were performed (729 male and 577 female patients; average age, 60 years). Of the patients, 90 returned for ED or UC visits (6.9%), with 34 for ADs (2.6%). Pain was the most common AD. However, when RCR was compared with other case types, ED or UC visits for urinary retention were significantly more common (P = .007), whereas there was no significant difference with the other ADs. The 1306 RCRs led to a greater proportion of ED or UC visits than the combined 5825 other cases studied (P < .001).

DISCUSSION AND CONCLUSIONS

Unplanned ED visits within 7 days of outpatient RCR are measurable and in many cases, such as ED or UC visits for pain, are avoidable. Visits for urinary retention are seen more commonly after RCR. Outpatient RCR led to more unplanned ED and UC visits than other common outpatient orthopedic surgical procedures.

Surgical Technical Evidence Review of Hip Fracture Surgery Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery

Background:

Enhanced recovery pathways (ERPs) have been shown to improve patient outcomes in a variety of contexts. This review summarizes the evidence and defines a protocol for perioperative care of patients with hip fracture and was conducted for the Agency for Healthcare Research and Quality safety program for improving surgical care and recovery.

Study Design:

Perioperative care was divided into components or “bins.” For each bin, a semisystematic review of the literature was conducted using MEDLINE with priority given to systematic reviews, meta-analyses, and randomized controlled trials. Observational studies were included when higher levels of evidence were not available. Existing guidelines for perioperative care were also incorporated. For convenience, the components of care that are under the auspices of anesthesia providers will be reported separately. Recommendations for an evidence-based protocol were synthesized based on review of this evidence.

Results:

Eleven bins were identified. Preoperative risk factor bins included nutrition, diabetes mellitus, tobacco use, and anemia. Perioperative management bins included thromboprophylaxis, timing of surgery, fluid management, drain placement, early mobilization, early alimentation, and discharge criteria/planning.

Conclusions:

This review provides the evidence basis for an ERP for perioperative care of patients with hip fracture.

A Consultation Phone Service for Patients With Total Joint Arthroplasty May Reduce Unnecessary Emergency Department Visits

BACKGROUND

Different measures for reducing costs after total joint arthroplasty (TJA) have gained attention lately. At our institution, a free-of-charge consultation phone service was initiated that targeted patients with TJA. This service aimed at reducing unnecessary emergency department (ED) visits and, thus, potentially improving the cost-effectiveness of TJAs. To our knowledge, a similar consultation service had not been described previously. We aimed at examining the rates and reasons for early postdischarge phone calls and evaluating the efficacy of this consultation service.

METHODS

During a 2-month period, we gathered information on every call received by the consultation phone service from patients with TJAs within 90 days of the index TJA procedure. Patients were followed for 2 weeks after making a call to detect major complications and self-initiated ED visits. Data were collected from electronic medical charts regarding age, gender, type of surgery, date of discharge, and length of hospital stay.

RESULTS

We analyzed 288 phone calls. Calls were mostly related to medication (41%), wound complications (17%), and mobilization issues (15%). Most calls were resolved in the phone consultation. Few patients (13%) required further evaluation in the ED. The consultation service failed to detect the need for an ED visit in 2 cases (0.7%) that required further care.

CONCLUSION

The consultation phone service clearly benefitted patients with TJAs. The service reduced the number of unnecessary ED visits and functioned well in detecting patients who required further care. Most postoperative concerns were related to prescribed medications, wound complications, and mobilization issues.

Surgical Technical Evidence Review for Elective Total Joint Replacement Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery

Background:

Use of enhanced recovery pathways (ERPs) can improve patient outcomes, yet national implementation of these pathways remains low. The Agency for Healthcare Research and Quality (AHRQ; funder), the American College of Surgeons, and the Johns Hopkins Medicine Armstrong Institute for Patent Safety and Quality have developed the Safety Program for Improving Surgical Care and Recovery—a national effort to catalyze implementation of practices to improve perioperative care and enhance recovery of surgical patients. This review synthesizes evidence that can be used to develop a protocol for elective total knee arthroplasty (TKA) and total hip arthroplasty (THA).

Study Design:

This review focuses on potential components of the protocol relevant to surgeons; anesthesia components are reported separately. Components were identified through review of existing pathways and from consultation with technical experts. For each, a structured review of MEDLINE identified systematic reviews, randomized trials, and observational studies that reported on these components in patients undergoing elective TKA/THA. This primary evidence review was combined with existing clinical guidelines in a narrative format.

Results:

Sixteen components were reviewed. Of the 10 preoperative components, most were focused on risk factor assessment including anemia, diabetes mellitus, tobacco use, obesity, nutrition, immune-modulating therapy, and opiates. Preoperative education, venous thromboembolism (VTE) prophylaxis, and bathing/Staphylococcus aureus decolonization were also included. The routine use of drains was the only intraoperative component evaluated. The 5 postoperative components included early mobilization, continuous passive motion, extended duration VTE prophylaxis, early oral alimentation, and discharge planning.

Conclusion:

This review synthesizes the evidence supporting potential surgical components of an ERP for elective TKA/THA. The AHRQ Safety Program for Improving Surgical Care and Recovery aims to guide hospitals and surgeons in identifying the best practices to implement in the surgical care of TKA and THA patients.

Factors Affecting Long-Term Postoperative Narcotic Use in Discectomy Patients

BACKGROUND

Long-term narcotic use has risks and potentially life-threatening opioid-related side effects. Extended narcotic use in patients undergoing discectomy raises concerns of other underlying causes of pain or overprescription and/or abuse. The goal of this study was to determine which factors have an effect on active narcotic prescription >3 months after discectomy.

METHODS

The PearlDiver Database was used in this study. Patients 30-55 years old undergoing discectomy without fusions were queried for active narcotic drug prescription occurring >30 days and >3 months after original surgery. Medical co-diagnoses were independently analyzed for effects on long-term active narcotic prescriptions. Prior narcotic use was defined by use within 4 months before surgery.

RESULTS

Of 1321 patients undergoing discectomy, 621 had actively prescribed narcotics >3 months after surgery. Preoperative narcotic use had the largest effect on odds of postoperative prescription (odds ratio [OR] = 3.4). Medical comorbidities increasing odds of long-term narcotic prescriptions included migraines (OR = 1.4), diabetes mellitus (OR = 1.4), depression (OR = 1.6), and smoking (OR = 1.9).

CONCLUSIONS

Narcotic abuse is a serious problem rooted in overprescription of these drugs, which has ultimately led to much more caution in prescribing among physicians. Because pain management and drug prescription must be balanced, identifying patients who may be susceptible to narcotic overprescription is important. Patients with co-diagnoses increasing odds of long-term narcotic prescriptions would benefit from early and continual postsurgical follow-up to ensure accurate pain management and to determine if narcotic prescriptions are justly warranted in the later postoperative period.