Fast-track procedures after primary total knee arthroplasty reduce hospital stay by unselected patients: a prospective national multi-centre study

Popliteal plexus block compared with tibial nerve block on rehabilitation goals following total knee arthroplasty: a randomized non-inferiority trial

This trial examined the effectiveness of the popliteal plexus block (PPB) and tibial nerve block (TNB) for early rehabilitation after total knee arthroplasty (TKA). We allocated 136 participants to receive PPB or TNB with 0.25% levobupivacaine 10 mL in a randomized, double-masked manner. The primary outcome was achieving rehabilitation goals with a non-inferiority 9-hour margin, including adequate pain relief, knee flexion angles over 90 degrees, and enabling ambulatory rehabilitation. The time to reach rehabilitation goals showed non-inferiority with 49.7 ± 10.5 h for TNB and 47.4 ± 9.7 h for PPB, whose mean difference (PPB - TNB) was - 2.3 h (95% CI -5.8 to 1.2 h; P < 0.001). PPB showed higher dorsal and plantar percentage of maximum voluntary isometric contraction (dorsal, PPB 87.7% ± 11.4% vs. TNB 74.0% ± 16.5%: P < 0.001; plantar, PPB 90.9% ± 10.3% vs. TNB 72.1% ± 16.0%; P < 0.001) at six hours after nerve block. No significant differences between the two groups emerged in pain scores, knee range of motion, additional analgesic requirements, success in the straight leg raise, and adverse events. PPB exhibited non-inferiority to TNB in achieving postoperative rehabilitation goals and had superiority in preserving foot motor strength after TKA. (200).

Complication Rates Are Not Higher After Outpatient Versus Inpatient Fast-Track Total Knee Arthroplasty: A Propensity-Matched Prospective Comparative Study

BACKGROUND

This prospective study aimed to compare the complication rates and clinical outcomes of propensity-matched patients who received fast-track total knee arthroplasty (FT TKA) in outpatient versus inpatient settings.

METHODS

Patients (n = 629) who received FT TKA at various outpatient (n = 176) and inpatient (n = 462) surgery rates were prospectively followed until 90 days after surgery. The decision between inpatient versus outpatient FT TKA was made on a case-by-case basis, depending on consultation between the surgeon and patient. Complications were collected to distinguish between intraoperative complications, complications with no readmission, complications with readmission, and complications with reoperation. Propensity scores based on age, sex, body mass index, and the American Society of Anesthesiologists score were used to match outpatient to inpatient FT TKA. A cumulative incidence function was computed by taking the time to diagnose any postoperative complication in the first 90 days as the end point.

RESULTS

Propensity score matching (1:2 ratio) for comparison resulted in 173 outpatient FT TKAs and 316 inpatient FT TKAs. No significant differences were observed between outpatient versus inpatient FT TKA for intraoperative complication rates (2% in both groups). At 90-day follow-up, no significant differences were observed between outpatient versus inpatient FT TKA for total complications with no readmission (8.0 versus 7.9%), complications with readmission but no reoperation (1.1 versus 0.6%), and complications with reoperation (4.0 versus 4.4%). A comparison of postoperative complication diagnosis time using the cumulative incidence function revealed no significant differences between outpatient versus inpatient FT TKA.

CONCLUSIONS

The present study revealed that there were no differences in 90-day postoperative complication rates between outpatient and inpatient FT TKA and that there were also no differences in rates of intraoperative complications, readmissions, or reoperations. These findings may encourage hesitant surgeons to move toward outpatient TKA pathways, as there is no greater risk of early postoperative complications that could be more difficult to manage after discharge.

LEVEL OF EVIDENCE

Level II.

Are patients ready for discharge from the hospital after fast-track total knee arthroplasty?-A qualitative study

BACKGROUND

The fast-track based on evidence-based medicine, has dramatically reduced the length of stay for patients undergoing total knee arthroplasty (TKA). Therefore, patients must assume the responsibility for self-functional exercise and care as early as possible. Also, higher standards and expectations of care delivery have been set. Studies into patients' experiences when faced with a discharge decision under a fast-track program are lacking.

OBJECTIVES

(1) Increase the knowledge about patients' experiences of discharged from hospital via a fast-track process after TKA. (2) Explore what gaps exist in the current discharge preparation care service for TKA under fast-track and what can be improved.

METHODS

A qualitative research design was chosen to conduct semi-structured face-to-face interviews with 21 patients from one Chinese hospital who successfully underwent TKA and received discharge orders. Interview data were meticulously analyzed, summarized and thematically distilled using Interpretative Phenomenological Analysis (IPA).

RESULTS

Three themes emerged from the structural analyses: a) Preparing for discharge despite concerns about symptoms-a sense of joy at discharge despite feelings of helplessness, stigmatisation, anxiety about prosthetic function. b) Managing the rehabilitation difficulties-vigilance is needed for medication management, environmental changes, and intimate relationships. c) Creating conditions for safe transition-compassionate bedside manner, listening to patients, and providing a humanized continuing care and referral services are important for safe transitions.

CONCLUSION

Findings suggest that patients undergoing fast-track TKA report good discharge preparation experiences. However, closer analysis reveals difficulties with this process and important directions in which discharge readiness care services can strive.

The alterations in nerve growth factor concentration in plasma and synovial fluid before and after total knee arthroplasty

Total knee arthroplasty (TKA) is an effective procedure for pain relief; however, the emergence of postsurgical pain remains a concern. In this study, we investigated the production of nerve growth factor (NGF) and mediators that affect NGF production and their function in the synovial fluid and plasma after TKA. This study included 19 patients (20 knees) who had rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and knee osteoarthritis (OA) who underwent TKA, categorized into OA and non-OA groups. The levels of NGF, inflammatory cytokines, and lipid mediators were analyzed before and after surgery. The intraoperative synovial fluid NGF concentration was more than seven times higher in the non-OA group than in the OA group. The intra-articular NGF levels increased significantly by more than threefold postoperatively in the OA group but not in the non-OA group. Moreover, the levels of inflammatory cytokines and lipid mediators were increased in the synovial fluid of both groups. The intra-articular cytokines or NGF concentrations positively correlated with postoperative pain. Targeted NGF control has the potential to alleviate postsurgical pain in TKA, especially in patients with OA, emphasizing the importance of understanding NGF dynamics under different knee conditions.

Multidisciplinary approach toward enhanced recovery after surgery for total knee arthroplasty improves outcomes

Knee osteoarthritis is a degenerative disorder of the knee, which leads to joint pain, stiffness, and inactivity and significantly affects the quality of life. With an increased prevalence of obesity and greater life expectancies, total knee arthroplasty (TKA) is now one of the major arthroplasty surgeries performed for knee osteoarthritis. When enhanced recovery after surgery (ERAS) was introduced in TKA, clinical outcomes were enhanced and the economic burden on the healthcare system was reduced. ERAS is an evidence-based scientific protocol aimed at ameliorating the surgical stress response. ERAS aims to enhance the recovery phase, which encompasses multidisciplinary strategies at every step of perioperative care, including the rehabilitation phase. Implementation of ERAS in TKA aids in reducing the length of hospital stay, improving pain management, reducing perioperative complications, and enhancing patient satisfaction. Multidisciplinary collaboration, integrating the expertise of anesthesiologists, orthopedic surgeons, nursing personnel, and other healthcare professionals, is the cornerstone of ERAS in patients undergoing TKA.

Enhanced Recovery after Total Joint Arthroplasty (TJA): A Contemporary Systematic Review of Clinical Outcomes and Usage of Key Elements

BACKGROUND

Enhanced recovery after surgery (ERAS) is a pathway designed to improve the care of surgical patients and achieve early recovery. The clinical outcomes and usage of key elements of ERAS pathways in total joint arthroplasty (TJA) need further reanalysis. This article aims to provide an overview of the latest clinical outcomes and current usage of key elements of ERAS pathways in TJA.

METHODS

We undertook a systematic review of the PubMed, OVID, and EMBASE databases in February 2022. Studies investigating the clinical outcomes and usage of key elements of ERAS in TJA were included. The components of successful ERAS programs and their usage were further determined and discussed.

RESULTS

Twenty-four studies involving 216,708 patients assessed ERAS pathways for TJA. A total of 95.8% (23/24) of studies reported a reduced length of stay (LOS), followed by reduce overall opioid consumption or pain (87.5% [7/8]), save costs (85.7% [6/7]), improvements in patient-reported outcomes or functional recovery (60% [6/10]), and reduced incidence of complications (50% [5/10]). In addition, preoperative patient education (79.2% [19/24]), anesthetic protocol (54.2% [13/24]), use of local anesthetics for infiltration analgesia or nerve blocks (79.2% [19/24]), perioperative oral analgesia (66.7% [16/24]), perioperative surgical factors including reduced use of tourniquets and drains (41.7% [10/24]), use of tranexamic acid (41.7% [10/24]) and early mobilization (100% [24/24]) were contemporary comparatively "active" components of ERAS.

CONCLUSIONS

ERAS for TJA has favorable clinical outcomes in terms of reducing LOS and overall pain, saving costs, accelerating functional recovery, and reducing complications, although the evidence is still low in quality. In the current clinical scenario, only some "active" components of the ERAS program are widely used.

Management of perioperative pain after TKA

Postoperative pain is the prime obstacle to recovery of motion and return to activity after total knee arthroplasty (TKA). Combating pain is a key point in enhanced recovery after surgery (ERAS) protocols. Outcome depends on the efficacy of pain relief, making it a major issue. The pain originates locally in the knee and also remotely via neural pathways. Regression can be slow, over several months. Pain may sometimes be definitive, to a varying degree. Pain should be managed at each step of ERAS, from the preoperative period to the last follow-up consultation, and most especially during the perioperative phase. Pain needs to be anticipated and limited for as long as necessary. The impact of analgesics should be enhanced by means of potentiators. Some are administered by general route, sometimes preoperatively; others are applied locally, directly in the surgical site by local injection, or close to the nerves, to reduce painful stimuli. The two main principles of pain management are preventive analgesia and multimodal analgesia associating various molecules and routes.

Enhanced recovery after surgery protocols in total knee arthroplasty via midvastus approach: a randomized controlled trial

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols were rapidly adopted in many surgeries such as fast-track arthroplasty. The study aimed to investigate the impact of ERAS protocols on the clinical effect of total knee arthroplasty (TKA) via the midvastus approach.

METHODS

A total of 69 patients who underwent primary unilateral TKA via the midvastus approach from October 2018 to June 2019 were enrolled and randomly divided into two groups: ERAS group and Control group. The ERAS protocols were adopted for the ERAS group and consisted of pure juice drinking 2 h before the surgery, optimization of the preoperative anesthesia plan, phased use of tourniquets, and the use of tranexamic acid as well as a drug cocktail. The operative time, first postoperative walking time, first straight leg elevation time, postoperative hospitalization time, visual analogue scale score (VAS score), Hospital for Special Surgery score (HSS score), conventional Knee Society score (KSS), and knee range of motion (ROM) were used to assess the clinical effects in the two groups. All the included patients were followed up for 12 months.

RESULTS

There were no significant differences in the basic demographic information and operation time between the ERAS and Control groups (P > 0.05). The first postoperative walking time (2.11 ± 0.11 h) and first postoperative straight leg elevation time (6.14 ± 1.73 h) in the ERAS group were significantly earlier than those in the Control group (P < 0.001) and the postoperative hospitalization time was significantly shorter (3.11 ± 0.32 days). The postoperative mean VAS scores in both groups were significantly reduced compared with those before surgery (P < 0.001). The VAS scores for the ERAS group were significantly lower than those for the Control group at 1, 2, and 7 days after surgery (P < 0.001). The mean HSS scores, KSS, and knee ROM were significantly increased in both the ERAS and Control groups at 1, 3, 6, and 12 months after surgery (P < 0.001). In addition, the HSS scores, KSS, and knee ROM in the ERAS group were significantly higher than those in the Control group at 1 month after surgery (P < 0.001).

CONCLUSIONS

ERAS protocols improved the clinical effects of TKA via the midvastus approach, facilitating early out-of-bed activity and comfortable postoperative rehabilitation exercise, and further increasing patient satisfaction.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04873544 .