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Driesman AS, Montgomery WC, Kleeman-Forsthuber LT, Johnson RM, Dennis DA, Jennings JM. Perioperative Sleep Quality Disturbances in Total Joint Arthroplasty is Multifactorial. J Arthroplasty 2024; 39:1474-1479. [PMID: 38072098 DOI: 10.1016/j.arth.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 12/30/2023] Open
Abstract
BACKGROUND Sleep quality following arthroplasty procedures is important for patient recovery and satisfaction, but remains poorly understood. The purpose of this study was to report risk factors for sleep disturbances in the perioperative period in patients undergoing primary total joint arthroplasty procedures. METHODS Sleep surveys were prospectively collected on 751 consecutive patients undergoing total joint arthroplasty at our institution between June 2019 and February 2021 at their preoperative and postoperative visits (2 and 6 weeks). Data were collected on patient demographics, opioid use (preoperatively and postoperatively) as well as tobacco and alcohol use, and specific medical diagnosis that may influence sleep patterns (ie, depression). Statistical analyses were performed using the Student's t-tests and 1-way analysis of variances. RESULTS For both total hip and total knee patients, worse sleep patterns preoperatively were found in patients who used opioids prior to surgery (P < .001), were current smokers (P < .001), and were aged less than 65 years (P < .001). Postoperative persistent opioid use (more than 3 months) was seen in patients who had worse reported sleep quality preoperatively (P < .001). In comparison to total hip arthroplasty, patients who underwent total knee arthroplasty were more likely to report less sleep in the postoperative period. Patients who were current smokers (compared to nonsmokers or previous smokers) (P = .014) had worse sleep quality at all time points that persisted at 6 weeks, although these differences were seen more in total hip patients than in total knee patients (P = .006 versus P = .059). CONCLUSIONS Sleep quality disturbances around the time of surgery appear to be multifactorial. LEVEL OF EVIDENCE Therapeutic Level III.
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Affiliation(s)
| | | | | | | | - Douglas A Dennis
- Colorado Joint Replacement, Denver, Colorado; Department of Mechanical and Materials Engineering, University of Denver, Denver, Colorado; Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado; Department of Biomedical Engineering, University of Tennessee, Knoxville, Tennessee
| | - Jason M Jennings
- Colorado Joint Replacement, Denver, Colorado; Department of Mechanical and Materials Engineering, University of Denver, Denver, Colorado
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Komann M, Dreiling J, Baumbach P, Weinmann C, Kalso E, Stamer U, Volk T, Pogatzki-Zahn E, Kehlet H, Meissner W. Objectively measured activity is not associated with average pain intensity 1 week after surgery: A cross-sectional study. Eur J Pain 2024. [PMID: 38450921 DOI: 10.1002/ejp.2260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/25/2024] [Accepted: 02/26/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Measures of physical activity and pain-related patient-reported outcomes are important components of patient recovery after surgery. However, little is known about their association in the early post-operative period. This study aims to increase this knowledge. Our primary objective was to determine the association between average pain intensity and activity (in steps) 1 week after surgery. Secondary objectives were the association of activity with other patient-reported outcomes, age, sex, comorbidities and body mass index. METHODS Data were obtained from the PROMPT sub-project of IMI-PainCare. Patients after breast and endometriosis-related surgery, sternotomy and total knee arthroplasty completed pain-related outcomes questionnaires and wore an ActiGraph activity-tracking device. We correlated steps with average pain intensity on post-operative days 6 and 7. Secondary analyses were done using correlations and t-tests. RESULTS In 284 cases, there was no statistically significant correlation between steps and average pain intensity. In addition, none of the 28 secondary analyses showed a statistically significant result. CONCLUSIONS Pain-related patient-reported outcome measures and physical activity are separate entities. Both should be measured after surgery to assess patient recovery and to identify treatment deficiencies. SIGNIFICANCE STATEMENT Measuring recovery is a multi-dimensional challenge. After surgery, clinicians need to be aware that neither pain intensity nor activity levels tell the whole story. Each can hint to problems and treatment requirements.
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Affiliation(s)
- M Komann
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - J Dreiling
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - P Baumbach
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - C Weinmann
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - E Kalso
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - U Stamer
- Department of Anaesthesiology and Pain Medicine, InselspitaL, Bern University Hospital, University of Bern, Bern, Switzerland
| | - T Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - E Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Münster, Germany
| | - H Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - W Meissner
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
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Owens MA, Mun CJ, Hamilton KR, Hughes A, Campbell CM, Edwards RR, Smith MT. Presurgical sleep and pain behaviors predict insomnia symptoms and pain after total knee arthroplasty: a 12-month longitudinal, observational study. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1224-1233. [PMID: 37578438 PMCID: PMC10628977 DOI: 10.1093/pm/pnad106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 05/31/2023] [Accepted: 06/06/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVE Up to 40% of individuals who undergo total knee arthroplasty (TKA) experience some degree of pain following surgery. Presurgical insomnia has been identified as a predictor of postsurgical pain; however, modifiable presurgical behaviors related to insomnia have received minimal attention. The objective of the present study was to develop a 2-item sleep and pain behavior scale (SP2) to investigate a maladaptive sleep and pain behavior and is a secondary analysis of a larger, parent study. METHODS Patients (N = 109) completed SP2 at baseline and 12 months and questionnaires assessing sleep and pain at baseline (pre-TKA), 6 weeks, 3, 6, and 12 months post-TKA. SP2 demonstrated adequate preliminary psychometric properties. RESULTS As hypothesized, even after controlling for baseline insomnia, pain, anxiety and other covariates, baseline SP2 predicted insomnia symptom severity at 6 weeks (β = 2.828), 3 (β = 2.140), 6 (β = 2.962), and 12 months (β = 1.835) and pain at 6 weeks (β = 6.722), 3 (β = 5.536), and 6 months (β = 7.677) post-TKA (P < .05). Insomnia symptoms at 6-weeks post-TKA mediated the effect of presurgical SP2 on pain at 3 (95% CI: 0.024-7.054), 6 (95%CI: 0.495-5.243), and 12 months (95% CI: 0.077-2.684). CONCLUSIONS This provides preliminary evidence that patients who cope with pain by retiring to their bed and bedroom have higher rates of post-surgical insomnia and pain and supports efforts to target this maladaptive sleep and pain behavior to reduce postsurgical pain.
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Affiliation(s)
- Michael A Owens
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21224, United States
| | - Chung Jung Mun
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21224, United States
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ 85004, United States
| | - Katrina R Hamilton
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21224, United States
| | - Abbey Hughes
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21224, United States
| | - Claudia M Campbell
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21224, United States
| | | | - Michael T Smith
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21224, United States
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4
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Bate GL, Kirk C, Rehman RZU, Guan Y, Yarnall AJ, Del Din S, Lawson RA. The Role of Wearable Sensors to Monitor Physical Activity and Sleep Patterns in Older Adult Inpatients: A Structured Review. SENSORS (BASEL, SWITZERLAND) 2023; 23:4881. [PMID: 37430796 DOI: 10.3390/s23104881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/05/2023] [Accepted: 05/07/2023] [Indexed: 07/12/2023]
Abstract
Low levels of physical activity (PA) and sleep disruption are commonly seen in older adult inpatients and are associated with poor health outcomes. Wearable sensors allow for objective continuous monitoring; however, there is no consensus as to how wearable sensors should be implemented. This review aimed to provide an overview of the use of wearable sensors in older adult inpatient populations, including models used, body placement and outcome measures. Five databases were searched; 89 articles met inclusion criteria. We found that studies used heterogenous methods, including a variety of sensor models, placement and outcome measures. Most studies reported the use of only one sensor, with either the wrist or thigh being the preferred location in PA studies and the wrist for sleep outcomes. The reported PA measures can be mostly characterised as the frequency and duration of PA (Volume) with fewer measures relating to intensity (rate of magnitude) and pattern of activity (distribution per day/week). Sleep and circadian rhythm measures were reported less frequently with a limited number of studies providing both physical activity and sleep/circadian rhythm outcomes concurrently. This review provides recommendations for future research in older adult inpatient populations. With protocols of best practice, wearable sensors could facilitate the monitoring of inpatient recovery and provide measures to inform participant stratification and establish common objective endpoints across clinical trials.
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Affiliation(s)
- Gemma L Bate
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE4 5PL, UK
| | - Cameron Kirk
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE4 5PL, UK
| | - Rana Z U Rehman
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE4 5PL, UK
| | - Yu Guan
- Department of Computer Science, University of Warwick, Coventry CV4 7EZ, UK
| | - Alison J Yarnall
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE4 5PL, UK
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK
- National Institute for Health and Care Research (NIHR), Newcastle Biomedical Research Centre (BRC), Newcastle University, Newcastle upon Tyne NE1 7RU, UK
| | - Silvia Del Din
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE4 5PL, UK
- National Institute for Health and Care Research (NIHR), Newcastle Biomedical Research Centre (BRC), Newcastle University, Newcastle upon Tyne NE1 7RU, UK
| | - Rachael A Lawson
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE4 5PL, UK
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Husby VS, Rian T, Klaksvik J, Wik TS, Winther SB. Physical activity in the first postoperative week in 132 knee arthroplasty patients randomized to 3 different analgesic regimens. Medicine (Baltimore) 2023; 102:e33471. [PMID: 37083790 PMCID: PMC10118326 DOI: 10.1097/md.0000000000033471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 03/17/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND The aim of this study was to investigate whether objectively recorded physical activity in the first week after surgery in total knee arthroplasty patients differed between patients allocated to 3 different analgesic regimens. METHODS A total of 132 total knee arthroplasty patients wore activity monitors 24 hours a day from day 1 after surgery for 6 consecutive days. The time mobilized (stepping/standing) and the number of steps were recorded. This study was a sub-study of a randomized controlled study comparing tapentadol extended-release (ER), oxycodone controlled-release (CR), or a non-opioid placebo analgesic regimen. RESULTS The placebo group spent significantly more time mobilized than the tapentadol ER and the oxycodone CR groups (P = .016 and .042, respectively), but no statistically significant differences were found between the groups in the number of steps taken. The activity levels of patients in all groups increased in the first week after surgery. CONCLUSION Patients in the non-opioid placebo group spent more time mobilized the first week after surgery than those in the tapentadol ER and the oxycodone CR groups, while the number of steps was not different between the groups.
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Affiliation(s)
- Vigdis Schnell Husby
- Department of Orthopaedic Surgery, Trondheim University Hospital, Trondheim, Norway
- Department of Health Sciences Aalesund, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Aalesund, Norway
| | - Torbjørn Rian
- Clinic of Anesthesia and Intensive Care, Trondheim University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jomar Klaksvik
- Orthopedic Research Center, Orthopaedic Department, Trondheim University Hospital, Trondheim, Norway
| | - Tina Strømdal Wik
- Department of Orthopaedic Surgery, Trondheim University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Siri Bjørgen Winther
- Orthopedic Research Center, Orthopaedic Department, Trondheim University Hospital, Trondheim, Norway
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Huang L, Kehlet H, Petersen RH. Functional recovery after discharge in enhanced recovery video-assisted thoracoscopic lobectomy: a pilot prospective cohort study. Anaesthesia 2022; 77:555-561. [PMID: 35261025 DOI: 10.1111/anae.15682] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2022] [Indexed: 12/14/2022]
Abstract
Little is known about functional recovery following patient discharge in an established enhanced recovery programme after video-assisted thoracoscopic lobectomy. We conducted a single-centre pilot prospective observational cohort study. We hypothesised that patients achieved early functional recovery after discharge. A total of 32 patients aged ≥ 18 years were enrolled. A digital device was used for objective activity measurements, and patient-reported outcomes were collected as subjective measurements. Primary outcomes were the difference in physical activity; sleep duration; pain; fatigue; and average quality of life scores between pre-operative baseline and 7 days following discharge. The secondary outcome was the reason for reduced daily activity during the first 7 days after discharge. Median (IQR [range]) length of stay was 3 (2-5 [1-13]) days. Up to post-discharge day 7, total, lower intensity and moderate-to-vigorous activities were lower than pre-operative activity (p < 0.001; p = 0.005 and p = 0.027, respectively). Numerical rating scale (0-10) pain scores increased postoperatively at rest (mean difference 1.2, p < 0.001) and during walking (mean difference 1.4, p < 0.001). Fatigue assessed by the Christensen Fatigue Scale (1-10) was also increased postoperatively (mean difference 1.7, p = 0.001). There was a reduction in quality of life scores, while sedentary activity and sleep duration were unchanged postoperatively. Dominant reasons for not recovering daily activity included fatigue in 43% and pain in 33% of patients. Despite compliance with an enhanced recovery programme with a median length of hospital stay of 3 days after video-assisted thoracoscopic lobectomy, functional recovery was not achieved within 7 days after hospital discharge. Reduction in postoperative pain and fatigue are important factors to enhance functional recovery.
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Affiliation(s)
- L Huang
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - H Kehlet
- Section of Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - R H Petersen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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7
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Factors Influencing Quality of Life in Older Adults Following Hip Surgery. AGEING INTERNATIONAL 2021. [DOI: 10.1007/s12126-021-09459-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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8
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Giordano NA, Kent M, Andersen SG, Scott-Richardson M, Highland KB. Postoperative Pain Mediates the Association Between Peripheral Nerve Blocks and Postoperative Sleep Following Lower Extremity Arthroplasty. Clin J Pain 2021; 37:487-493. [PMID: 33900213 DOI: 10.1097/ajp.0000000000000942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/30/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Despite substantial research showing the bidrectional relationship between sleep and pain, there remains a dearth of research examining the role of perioperative pain management interventions in mitigating postoperative sleep disturbances. This secondary analysis of a prospective observational multisite study examined the association between peripheral nerve block (PNB) use during total knee or total hip arthroplasty (TKA/THA) procedures and postoperative pain and sleep outcomes. MATERIALS AND METHODS Adult patients undergoing TKA or THA procedures were recruited from 2 tertiary care facilities. Average pain and sleep disturbance scores were collected preoperatively and at 1- and 2-week postoperatively. Participants were not randomized to receive PNB. Postoperative outcomes were compared based on receipt of PNB during surgery. Structural equation modeling path analysis was utilized to model multiple co-occurring relationships, including mediation pathways between perioperative pain management approaches, pain, and postoperative sleep outcomes. RESULTS Of the 197 participants, 53% received PNB. Mediation analyses indicated that PNB was indirectly associated with 1-week sleep disturbance via its effects on 1-week pain intensity (β=-0.02, 95% confidence interval [CI] -0.04, -0.001, P=0.04). In addition, PNB was indirectly associated with 2-week sleep disturbance, via its effects on 1-week pain intensity and 1-week sleep disturbance (β=-0.04, 95% CI -0.07, -0.02, P=0.04). Lastly, PNB was indirectly associated with 2-week pain intensity via its effects on 1-week pain intensity (β=-0.10, 95% CI -0.19, -0.02, P=0.02). CONCLUSIONS Receipt of PNB during TKA or THA was found to be associated with improved 1-week postoperative pain intensity, which in turn was found to be associated with lower sleep disturbances at both 1- and 2-week postoperative time points. Multimodal opioid sparing pain management interventions, capable of improving postoperative sleep, are vital to improving recovery and rehabilitation following arthroplasty.
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Affiliation(s)
| | - Michael Kent
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | | | - Maya Scott-Richardson
- Department of Anesthesiology, Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, Bethesda
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Rockville, MD
| | - Krista B Highland
- Department of Anesthesiology, Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, Bethesda
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Rockville, MD
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Azam MQ, Goyal T, Paul S, Yadav AK, Govil N. Enhanced recovery protocol after single-stage bilateral primary total knee arthroplasty decreases duration of hospital stay without increasing complication rates. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:711-717. [PMID: 34097154 DOI: 10.1007/s00590-021-03031-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 06/02/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE With an increasing number of total knee arthroplasty (TKA), protocols for better standard of patient care and shorter duration of hospital stay are necessary. Enhanced recovery (ER) protocols are becoming popular to meet these objectives. The current study aims to evaluate the clinical outcome of fast-track TKA using ER protocol in terms of length of hospital stay, perioperative complications and functional outcomes. METHODS Patients undergoing single-stage bilateral primary TKA were prospectively included in the study. All patients went through a pre-defined ER protocol of TKA. Length of hospital stay, readmission rates, pain scores and functional scores of patients operated under ER protocol were compared with another matched historical control-group. Factors delaying the discharge of the patients by 48 h after the surgery were noted. RESULTS We compared 275 patients undergoing single-stage bilateral primary TKA through ER protocol (Group 1) with 190 patients who had undergone bilateral primary TKA before the ER protocol was initiated (Group 2). The length of hospital stay (3.9 ± 2.1 days in group 1 and 7.5 ± 3.2 days in group 2, p 0.0001) and post-operative pain scores at 12 h (5.2 ± 2.9 in group 1 and 5.7 ± 2.1 in group 2, p 0.03) and 24 h (4.1 ± 1.6 in group 1 and 4.6 ± 1.4 in group 2, p 0.0005) were found to be significantly better with ER protocol. There was no difference in Oxford knee scores, infection rates, readmissions or mortality between the two groups. CONCLUSION ER protocol in single-stage bilateral primary TKA resulted in decreased length of hospital stay without increasing complications and compromising the clinical outcome. It requires an integrated approach and adherence to clinical pathways. LEVEL OF EVIDENCE Level II, Prospective comparative study.
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Affiliation(s)
- Md Quamar Azam
- Department of Trauma Surgery, All India Institute of Medical Sciences, Rishikesh, India
| | - Tarun Goyal
- Department of Orthopaedics, All India Institute of Medical Sciences, Bathinda, Punjab, 151001, India.
| | - Souvik Paul
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Arvind Kumar Yadav
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Nishith Govil
- Department of Anesthesiology, All India Institute of Medical Sciences, Rishikesh, India
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Levels of Physical Activity and Sedentary Behavior During and After Hospitalization: A Systematic Review. Arch Phys Med Rehabil 2020; 102:1368-1378. [PMID: 33347891 DOI: 10.1016/j.apmr.2020.11.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/09/2020] [Accepted: 11/20/2020] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To systematically review and synthesize the evidence on physical activity and sedentary behavior during and after hospitalization. DATA SOURCES Electronic databases and reference lists of relevant articles were searched from 2000 to April 2020. STUDY SELECTION Studies which continuously monitored physical activity and/or sedentary behavior in hospitalized adults across 2 settings (ie, without a break in measurement between settings). Monitoring could occur from an acute to a subacute or rehabilitation hospital setting, an acute setting to home, or from a subacute or rehabilitation setting to home. DATE EXTRACTION Data extraction and methodological quality assessments were independently performed by 2 reviewers using standardized checklists. DATA SYNTHESIS A total of 15 of the 5579 studies identified were included. The studies were composed of heterogenous patient populations. All studies monitored patients with either an accelerometer and/or pedometer and reported a variety of measures, including steps per day, sedentary time, and activity counts. The majority of studies (12 of 15) showed that patients engaged in 1.3 to 5.9 times more physical activity and up to 67% less daily sedentary behavior at home after discharge from acute or subacute settings. CONCLUSIONS Patients engaged in more physical activity and less sedentary behavior at home compared to both the acute and subacute hospital settings. This may reflect the natural course of recovery or the effect of setting on activity levels. Enabling early discharge home through the implementation of home-hospitalization models may result in increased patient physical activity and reduced sedentary behavior. Further experimental studies are required investigating the effect of home-based models of care on physical activity and sedentary behavior.
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11
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Smartphone App with an Accelerometer Enhances Patients' Physical Activity Following Elective Orthopedic Surgery: A Pilot Study. SENSORS 2020; 20:s20154317. [PMID: 32748876 PMCID: PMC7436024 DOI: 10.3390/s20154317] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/23/2020] [Accepted: 07/30/2020] [Indexed: 01/04/2023]
Abstract
Low physical activity (PA) levels are common in hospitalized patients. Digital health tools could be valuable in preventing the negative effects of inactivity. We therefore developed Hospital Fit; which is a smartphone application with an accelerometer, designed for hospitalized patients. It enables objective activity monitoring and provides patients with insights into their recovery progress and offers a tailored exercise program. The aim of this study was to investigate the potential of Hospital Fit to enhance PA levels and functional recovery following orthopedic surgery. PA was measured with an accelerometer postoperatively until discharge. The control group received standard physiotherapy, while the intervention group used Hospital Fit in addition to physiotherapy. The time spent active and functional recovery (modified Iowa Level of Assistance Scale) on postoperative day one (POD1) were measured. Ninety-seven patients undergoing total knee or hip arthroplasty were recruited. Hospital Fit use, corrected for age, resulted in patients standing and walking on POD1 for an average increase of 28.43 min (95% confidence interval (CI): 5.55-51.32). The odds of achieving functional recovery on POD1, corrected for the American Society of Anesthesiologists classification, were 3.08 times higher (95% CI: 1.14-8.31) with Hospital Fit use. A smartphone app combined with an accelerometer demonstrates the potential to enhance patients' PA levels and functional recovery during hospitalization.
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12
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[The effect of emotional stressors on postoperative skin conductance indices: a prospective cohort pilot study]. Rev Bras Anestesiol 2020; 70:325-332. [PMID: 32828549 DOI: 10.1016/j.bjan.2020.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 04/14/2020] [Accepted: 04/14/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Skin conductance response reflects the activity of the sympathetic nervous system and is used to measure acute pain. This pilot study examines correlations of skin conductance response with emotional stressors postoperatively. METHODS The correlation of skin conductance response with pain, anxiety, nausea and intellectual task performance was analyzed in postoperative patients. RESULTS Significant correlations were observed between anxiety and pain during physical activity on both postoperative day 1 and 2. No significant correlations were found between skin conductance response versus mild pain, nausea, anxiety or intellectual task performance. CONCLUSION This pilot study suggests that when the pain is well-controlled in the early postoperative period, skin conductance response monitoring may not be influenced by other emotional stressors.
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Gungor S, Storm H, Bae JJ, Rotundo V, Christos PJ. The effect of emotional stressors on postoperative skin conductance indices: a prospective cohort pilot study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 32828549 PMCID: PMC9373224 DOI: 10.1016/j.bjane.2020.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Skin conductance response reflects the activity of the sympathetic nervous system and is used to measure acute pain. This pilot study examines correlations of skin conductance response with emotional stressors postoperatively. Methods The correlation of skin conductance response with pain, anxiety, nausea and intellectual task performance was analyzed in postoperative patients. Results Significant correlations were observed between anxiety and pain during physical activity on both postoperative day 1 and 2. No significant correlations were found between skin conductance response versus mild pain, nausea, anxiety or intellectual task performance. Conclusion This pilot study suggests that when the pain is well-controlled in the early postoperative period, skin conductance response monitoring may not be influenced by other emotional stressors.
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von Lewinski G, Weber C, Tücking LR. [Pain concepts in fast-track endoprosthetics]. DER ORTHOPADE 2020; 49:313-317. [PMID: 32086550 DOI: 10.1007/s00132-020-03892-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
An effective and safe pain management is nowadays a pivotal component of fast-track endoprosthetics. The analgesic strategies should be opioid-sparing whenever possible because opioids induce side-effects that reduce the well-being of patients and are even associated with a risk of falling. This is not compatible with a fast mobilization. In order to achieve this goal, multimodal pain concepts have proven to be suitable. Decentralized analgesia with epidural and regional catheters as well as the use of local infiltration anesthesia (LIA) can be used; however, catheters are also associated with a muscular deficit and the danger of falling. Therefore, in the fast-track concepts LIA has become established. With respect to knee endoprosthetics many studies have shown that LIA achieves at least comparable results or even superiority in comparison with the use of catheters. It represents a safe and effective procedure with respect to postoperative analgesia and accelerated mobilization. A variety of protocols for the use of LIA can currently be found in the literature. In addition to analgesics the supportive administration of glucocorticoids is increasingly being used, which also reduce pain due to the anti-inflammatory effect; however, regarding this aspect relatively few prospective randomized studies in comparison to LIA are available in the literature.
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Affiliation(s)
- G von Lewinski
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37099, Göttingen, Deutschland.
| | - C Weber
- Orthopädische Klinik der Medizinischen Hochschule Hannover im DIAKOVERE Annastift, Hannover, Deutschland
| | - L-R Tücking
- Orthopädische Klinik der Medizinischen Hochschule Hannover im DIAKOVERE Annastift, Hannover, Deutschland
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Sleep improvement after hip arthroplasty: a study on short-stem prosthesis. INTERNATIONAL ORTHOPAEDICS 2019; 44:69-73. [PMID: 31352563 PMCID: PMC6938790 DOI: 10.1007/s00264-019-04375-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 07/08/2019] [Indexed: 11/02/2022]
Abstract
PURPOSE The purpose of this study was to evaluate sleep disturbance prospectively before and after short-stem hip arthroplasty. METHODS A prospective study on 25 patients undergoing a primary unilateral total short-stem hip replacement was conducted. Patients were observed for six months. To evaluate the sleep quality and daytime sleepiness, the Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale were used. To assess the general physical health status, we used the Short Form 36 Health Survey (SF-36). Pain was recorded on a visual analog scale. RESULTS The physical health status of the patients improved significantly (p < 0.05) during the six month follow-up period in seven out of nine categories. During the first post-operative week, the sleep quality stayed on an equal level to the pre-operative state, following a steady improvement over the next months (6 months p = 0.00). The daytime sleepiness showed a significant improvement during all the follow-ups (6 months p = 0.00). Pain decreased significantly from baseline to six months post-operatively (p = 0.00). There was no correlation between pain and sleep quality or pain and daytime sleepiness. CONCLUSION According to our results, patients undergoing short-stem total hip arthroplasty can expect a 50% improvement of sleep quality and physical function six months after surgery.
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16
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Ninomiya K, Hirakawa K, Ikeda T, Nakura N, Suzuki K. Patients 10 years after total hip arthroplasty have the deficits in functional performance, physical activity, and high fall rate compared to healthy adults. Phys Ther Res 2018; 21:53-58. [PMID: 30697510 DOI: 10.1298/ptr.e9941] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 08/07/2018] [Indexed: 12/23/2022]
Abstract
Background Long-term results in muscle strength, physical activity (PA), and functional improvement after total hip arthroplasty (THA) have not been studied. The purpose of this study was to evaluate the deficits in functional performance, PA, and high fall rate in patient 10 years after THA compared to healthy adults. Methods The subjects were 58 patients who underwent primary THA for unilateral hip osteoarthritis 10 years, and 46 healthy adults. Hip abductor strength, balance function (single-leg stance time), Maximal Walking Speed (MWS), fall rate, and PA (IPAQ short ver.) were evaluated. The unpaired t-test and χ2 test were used to assess differences between the groups. Statistical significance was set at p value <0.05. Results Compared to healthy adults, THA patients had 9.5% less hip abductor muscle strength on the operated side, 42.1% shorter single-leg stance time on the operated side, 14.8% slower MWS, 2.0 times less High-PA group, and 2.8 times higher fall rate (p<0.05). Conclusion This study showed that hip abductor muscle strength, gait speed, balance function, and PA were significantly lower in patients 10 years after THA than in healthy adults. Additionally, the fall rate was significantly higher in patients 10 years post-THA than in healthy adults.
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Affiliation(s)
| | | | - Takashi Ikeda
- Showa University Department of Nursing and Rehabilitation Sciences
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17
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Objectively measured early physical activity after total hip or knee arthroplasty. J Clin Monit Comput 2018; 33:509-522. [PMID: 30039461 DOI: 10.1007/s10877-018-0185-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 07/17/2018] [Indexed: 01/07/2023]
Abstract
Although reduced early physical function after total hip- and knee arthroplasty (THA/TKA) is well-described, the underlying reasons have not been clarified with detailed studies on pathophysiological mechanisms related to recovery, thereby prohibiting advances in rehabilitation. Thus, we aimed to describe early post-THA/TKA physical activity measured by actigraphy and potential underlying pathophysiological mechanisms related to recovery in a well-defined cohort of THA and TKA patients. Daytime-activity was measured from 2 days before until 13 (THA) or 20 (TKA) days after surgery. The primary outcome was individualized recovery in activity, with secondary analyses of activity-intensities and association to the perioperative factors: sex, age, BMI, hemoglobin (hgb), C-reactive protein and postoperative pain. Eighty-one THA/TKA-patients were examined. A large inter-individual variation in early physical activity was found. On a group level, activity was significantly reduced compared to preoperatively the first 2 (THA) or 3 (TKA) weeks after surgery (mean-difference - 64 counts × 103/day, p < 0.001 and - 78 counts × 103/day, p < 0.001, respectively). All activity-intensities were affected with the largest decline in high intense activity. A slight overall improvement in activity was seen during the postoperative phase [THA: 1%/day (SD 2.15); TKA: 0.7%/day (SD 1.04)], but approximately 30% of THA and 20% of TKA patients had reduced and declining activity. Hgb, CRP, BMI (THA) and postoperative pain (TKA) were only weakly associated with impaired physical activity. Physical activity was reduced the first weeks following THA/TKA, but with large inter-individual variations in recovery profiles. No single pathogenic factor was associated with a poor recovery. Early risk stratified interventions are needed in patients on a suboptimal course.
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Twiggs J, Salmon L, Kolos E, Bogue E, Miles B, Roe J. Measurement of physical activity in the pre- and early post-operative period after total knee arthroplasty for Osteoarthritis using a Fitbit Flex device. Med Eng Phys 2017; 51:31-40. [PMID: 29117912 DOI: 10.1016/j.medengphy.2017.10.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 09/29/2017] [Accepted: 10/09/2017] [Indexed: 12/22/2022]
Abstract
Total knee arthroplasty (TKA) is a standard treatment for patients with end stage knee Osteoarthritis (OA) to reduce pain and restore function. The aim of this study was to assess pre- and early post-operative physical activity (PA) with Fitbit Flex devices for patients with OA undergoing TKA and determine any benchmarks for expected post-operative activity. Significant correlations of pre-operative step count, post-operative step count, Body Mass Index (BMI) and Short Form 12 Physical Component Summaries (SF-12 PCS) were found. Mean step counts varied by 3,203 steps per day between obese and healthy weight patients, and 3,786 steps per day between those with higher and lower SF-12 PCS scores, suggesting the need for benchmarks for recovery that vary by patient pre-operative factors. A backwards stepwise regression model developed to provide patient specific step count predictions at 6 weeks had an R2 of 0.754, providing a robust patient specific benchmark for post-operative recovery, while population means from BMI and SF-12 subgroups provide a clinically practical alternative.
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Affiliation(s)
- Joshua Twiggs
- 360 Knee Systems Pty Ltd, Suite 3 Building 1, 20 Bridge Street, Pymble 2073, Australia; Biomedical Engineering, AMME, University of Sydney, Sydney, NSW 2006, Australia.
| | - Lucy Salmon
- North Sydney Orthopaedic & Sports Medicine Centre, Mater Hospital, NSW 2065, Australia.
| | - Elizabeth Kolos
- 360 Knee Systems Pty Ltd, Suite 3 Building 1, 20 Bridge Street, Pymble 2073, Australia.
| | - Emily Bogue
- 360 Knee Systems Pty Ltd, Suite 3 Building 1, 20 Bridge Street, Pymble 2073, Australia.
| | - Brad Miles
- 360 Knee Systems Pty Ltd, Suite 3 Building 1, 20 Bridge Street, Pymble 2073, Australia.
| | - Justin Roe
- North Sydney Orthopaedic & Sports Medicine Centre, Mater Hospital, NSW 2065, Australia.
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Luna IE, Kehlet H, Peterson B, Wede HR, Hoevsgaard SJ, Aasvang EK. Early patient-reported outcomes versus objective function after total hip and knee arthroplasty: a prospective cohort study. Bone Joint J 2017; 99-B:1167-1175. [PMID: 28860396 DOI: 10.1302/0301-620x.99b9.bjj-2016-1343.r1] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 04/11/2017] [Indexed: 12/27/2022]
Abstract
AIMS The purpose of this study was to assess early physical function after total hip or knee arthroplasty (THA/TKA), and the correlation between patient-reported outcome measures, physical performance and actual physical activity (measured by actigraphy). PATIENTS AND METHODS A total of 80 patients aged 55 to 80 years undergoing THA or TKA for osteoarthritis were included in this prospective cohort study. The main outcome measure was change in patient reported hip or knee injury and osteoarthritis outcome score (HOOS/KOOS) from pre-operatively until post-operative day 13 (THA) or 20 (TKA). Secondary measures were correlations to objectively assessed change in physical performance (paced-walk, chair-stand, stair-climb tests) at day 14 (THA) or 21 (TKA) and actual physical activity (actigraphy) measured at day 12 and 13 (THA) or 19 and 20 (TKA). RESULTS Patients reported improved physical function (HOOS or KOOS) pre-operatively until day 13 (THA) or 20 (TKA) with a mean difference of 7 (95% confidence interval (CI) 1 to 13, p = 0.033) and 6 (95% CI 1 to 12, p = 0.033) percentage points, respectively. By contrast, objectively assessed physical function and activity declined, with no correlations between subjective and objective assessments for either THA or TKA patients (r2 ≤ 0.16, p ≥ 0.314). CONCLUSIONS Early improvement in patient-reported physical function after THA/TKA does not correlate with objectively assessed function, and patient reported outcomes should not be used as the only measure of recovery. Cite this article: Bone Joint J 2017;99-B:1167-75.
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Affiliation(s)
- I E Luna
- Gentofte-Herlev Hospital, Copenhagen, Denmark
| | - H Kehlet
- The Lundbeck Centre for fast-track Hip and Knee Arthroplasty, Copenhagen, Denmark
| | - B Peterson
- Philips Healthcare, 920 SW Emkay Drive, Suite 100, Bend, OR 97702, USA
| | - H R Wede
- Gentofte-Herlev Hospital, University of Copenhagen, Kildegårdsvej 28, 2900 Hellerup, Denmark
| | | | - E K Aasvang
- The Lundbeck Centre for fast-track Hip and Knee Arthroplasty, Copenhagen, Denmark
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20
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Petersen PB, Jørgensen CC, Kehlet H. Delirium after fast-track hip and knee arthroplasty - a cohort study of 6331 elderly patients. Acta Anaesthesiol Scand 2017; 61:767-772. [PMID: 28681427 DOI: 10.1111/aas.12932] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/26/2017] [Accepted: 06/06/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Postoperative delirium (PD) is a well-known complication among elderly surgical patients and associated with increased morbidity, mortality and length of stay (LOS). In elective orthopedic surgery, including hip and knee arthroplasty (THA/TKA), most studies report incidences between 5% and 10%. The multimodal optimization of perioperative care (fast-track) aims to enhance recovery and reduce morbidity and LOS, but limited data are available on the effect on PD. Consequently, the study investigated signs of PD associated with LOS > 4 days. METHODS Prospective risk assessment study with retrospective analysis of discharge notes or medical records of signs of PD in 6331 elective primary unilateral THA and TKA patients ≥ 70 years, and LOS > 4 days. Preoperative patient characteristics collected from eight high volume centers with similar standardized fast-track protocols from January 2010 to November 2013. RESULTS We identified 43 (0.7%) cases of PD symptoms mentioned as a reason for LOS > 4 days among the 789 patients with LOS > 4 days (12.5% of all THA and TKA). PD patients had a mean age of 80.7 [[95% CI] 79.3-82.1] years, being 4.0 [[95% CI] 2.5-5.5] years older compared to patients without PD (P < 0.001). LOS was median 10 [[Q2-Q3] 7-14] days in the PD group vs. 3 [2-3] days in the non-PD group (P < 0.001), without differences in gender or site of arthroplasty (P = 0.139 and 0.499, respectively). CONCLUSION Postoperative delirium symptoms contributing to LOS > 4 days in fast-track THA and TKA are rare in elderly patients.
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Affiliation(s)
- P. B. Petersen
- Section for Surgical Pathophysiology; The Juliane Marie Centre; Rigshospitalet; Copenhagen Denmark
- Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement; Copenhagen Denmark
| | - C. C. Jørgensen
- Section for Surgical Pathophysiology; The Juliane Marie Centre; Rigshospitalet; Copenhagen Denmark
- Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement; Copenhagen Denmark
| | - H. Kehlet
- Section for Surgical Pathophysiology; The Juliane Marie Centre; Rigshospitalet; Copenhagen Denmark
- Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement; Copenhagen Denmark
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21
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Manning BT, Kearns SM, Bohl DD, Edmiston T, Sporer SM, Levine BR. Prospective Assessment of Sleep Quality Before and After Primary Total Joint Replacement. Orthopedics 2017; 40:e636-e640. [PMID: 28418577 DOI: 10.3928/01477447-20170411-01] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 02/27/2017] [Indexed: 02/03/2023]
Abstract
Sleep disruption is a common, yet rarely addressed, complaint among patients who have undergone total joint arthroplasty (TJA). This study assessed sleep quality before and after primary TJA. A total of 105 patients who underwent primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) prospectively completed questionnaires during the preoperative, early postoperative, and late postoperative periods. The survey included the Epworth Sleepiness Scale, current sleeping habits, and patient perspectives of sleep quality and duration. In the early postoperative period (4.7±2.0 weeks), patients reported significant increases in sleep disturbance as denoted by increased length of time to fall asleep (P=.006) and mean nightly awakenings (P=.002) compared with the preoperative baseline. At late postoperative follow-up (40.8±19.5 weeks), patients' sleep quality subsequently improved above the preoperative baseline. Approximately 40% of patients tried a new sleeping method postoperatively, the most common being new pillow placement. No significant differences in pre- or postoperative sleeping trends were noted between THA and TKA patients. These findings suggest transient sleep disturbance is common in the early postoperative period, with subsequent improvement by 10-month follow-up after a primary TJA. Given the growing importance of patient satisfaction in health care systems, orthopedic surgeons must manage patients' expectations while working with them to optimize sleep quality after TJA. A multimodal approach with preoperative counseling, early postoperative sleep modifications, and possibly preemptive use of medications may improve transient sleep disturbance among TJA patients. [Orthopedics. 2017; 40(4):e636-e640.].
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22
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Late Complications Following Elective Primary Total Hip and Knee Arthroplasty: Who, When, and How? J Arthroplasty 2017; 32:719-723. [PMID: 27682005 DOI: 10.1016/j.arth.2016.08.037] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 08/15/2016] [Accepted: 08/22/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Improved pain management and early mobilization protocols have increased interest in the feasibility of short stay (<24 hours) or outpatient total hip (THA) and total knee (TKA) arthroplasty. However, concerns exist regarding patient safety and readmissions. The purposes of this study were to determine the incidence of in-hospital complications following THA/TKA, to create a model to identify comorbidities associated with the risk of developing major complications >24 hours postoperatively, and to validate this model against another consecutive series of patients. METHODS We prospectively evaluated a consecutive series of 802 patients who underwent elective primary THA and TKA over a 9-month period. The mean age was 62.3 years. Demographic, surgical, and postoperative readmission data were entered into an arthroplasty database. RESULTS Of the 802 patients, 382 experienced a complication postoperatively. Of these, 152 (19%) required active management. Multiple logistic regression analysis identified cirrhosis (odds ratio [OR], 5.89; 95% confidence interval [CI], 1.05-33.07; P = .044), congestive heart failure (OR, 3.12; 95% CI, 1.50-6.44; P = .002), and chronic kidney disease (OR, 3.85; 95% CI, 2.21-6.71; P < .001) as risk factors for late complications. One comorbidity was associated with a 77% probability of developing a major postoperative complication. This model was validated against an independent dataset of 1012 patients. CONCLUSION With improved pain management and mobilization protocols, there is increasing interest in short stay and outpatient THA and TKA. Patients with cirrhosis, congestive heart failure, or chronic kidney disease should be excluded from early discharge total joint arthroplasty protocols.
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Gómez-Ríos MÁ. Why to use peripheral nerve blocks in orthopedic surgery? ACTA ACUST UNITED AC 2017; 64:181-184. [PMID: 28110944 DOI: 10.1016/j.redar.2016.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 11/23/2016] [Accepted: 11/24/2016] [Indexed: 11/18/2022]
Affiliation(s)
- M Á Gómez-Ríos
- Departamento de Anestesiología y Medicina Perioperatoria, Complejo Hospitalario Universitario de A Coruña, A Coruña, España; Head of the Anaesthesiology and Pain Management Research Group, Institute for Biomedical Research of A Coruña (INIBIC), A Coruña, España.
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24
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Luna IE, Peterson B, Kehlet H, Aasvang EK. Individualized assessment of post-arthroplasty recovery by actigraphy: a methodology study. J Clin Monit Comput 2016; 31:1283-1287. [DOI: 10.1007/s10877-016-9952-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 10/26/2016] [Indexed: 01/25/2023]
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Jans Ø, Bandholm T, Kurbegovic S, Solgaard S, Kjaersgaard-Andersen P, Johansson PI, Kehlet H. Postoperative anemia and early functional outcomes after fast-track hip arthroplasty: a prospective cohort study. Transfusion 2016; 56:917-25. [PMID: 26945552 DOI: 10.1111/trf.13508] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 10/22/2015] [Accepted: 10/30/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Postoperative anemia is prevalent in fast-track hip arthroplasty (THA) where patients are mobilized and discharged early, but whether anemia impairs functional recovery after discharge has not been adequately evaluated previously. This study aimed to evaluate whether postoperative anemia influenced recovery of mobility and quality of life (Qol) during the first 2 weeks after discharge from THA. STUDY DESIGN AND METHODS This was a prospective observational study in 122 THA patients more than 65 years of age. Mobility and Qol were assessed pre- and postoperatively by the 6-minute walk test (6MWT; primary outcome), the timed up-and-go test, and the FACT-anemia subscale. Twenty-four-hour mobility at home was assessed by activity monitoring on Days 1 to 6 after discharge. Hemoglobin (Hb) at discharge (HbD) and the Hb decrease from preoperatively (ΔHb) were compared to mobility and Qol the first 2 weeks after discharge using bivariate and multivariate linear regression. RESULTS Mean (±SD) HbD and ΔHb values were 11.1 (±1.4) and 2.8 (±1.2) g/dL and correlated weakly to 6MWT 2 weeks after discharge (r = 0.23 and r = -0.20 respectively; p < 0.05) but HbD levels were not correlated to other mobility or Qol measures. After adjustment for preoperative patient-related factors, HbD explained 6% (95% confidence interval, 0%-9%; p < 0.05) of the variation in 6MWT recovery. CONCLUSION Despite a weak, but significant, correlation between postoperative Hb and the recovery of 6MWT, all other mobility and Qol measures were not influenced by postoperative Hb. Thus, moderate postoperative anemia has limited impact on early postdischarge functional recovery after fast-track THA.
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Affiliation(s)
- Øivind Jans
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen University Hospital.,Lundbeck Foundation Centre for Fast-Track Hip and Knee Arthroplasty, Cophenhagen, Denmark
| | - Thomas Bandholm
- Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C), Department of Physical Therapy, Clinical Research Centre, and Department of Orthopedic Surgery, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Sorel Kurbegovic
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen University Hospital
| | - Søren Solgaard
- Department of Orthopedic Surgery, Gentofte Hospital, Gentofte, Denmark
| | | | | | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen University Hospital.,Lundbeck Foundation Centre for Fast-Track Hip and Knee Arthroplasty, Cophenhagen, Denmark
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Chen AF, Orozco FR, Austin LS, Post ZD, Deirmengian CA, Ong AC. Prospective Evaluation of Sleep Disturbances After Total Knee Arthroplasty. J Arthroplasty 2016; 31:330-2. [PMID: 26455403 DOI: 10.1016/j.arth.2015.07.044] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 07/08/2015] [Accepted: 07/31/2015] [Indexed: 02/01/2023] Open
Abstract
Sleep disturbance after total knee arthroplasty (TKA) has not been studied 6 months after surgery. A prospective study was conducted on 34 primary, unilateral TKA patients preoperatively until 6 months postoperatively. Sleep quality was measured using the Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale. Pain was measured on a visual analog scale. Sleep quality worsened from baseline during the first 6 weeks postoperatively (P = .03), but improved at 3 and 6 months (P = .003). Pain scores decreased from baseline over all time points, and there was no correlation between sleep quality and pain. The Epworth Sleepiness Scale did not change over time. This study can be used to counsel TKA patients to expect initial sleep disturbances that improve by 3 months.
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Affiliation(s)
| | | | | | | | | | - Alvin C Ong
- The Rothman Institute, Philadelphia, Pennsylvania
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27
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Aasvang E, Luna I, Kehlet H. Challenges in postdischarge function and recovery: the case of fast-track hip and knee arthroplasty. Br J Anaesth 2015. [DOI: 10.1093/bja/aev257] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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28
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Paxton RJ, Melanson EL, Stevens-Lapsley JE, Christiansen CL. Physical activity after total knee arthroplasty: A critical review. World J Orthop 2015; 6:614-622. [PMID: 26396937 PMCID: PMC4573505 DOI: 10.5312/wjo.v6.i8.614] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 05/07/2015] [Accepted: 07/02/2015] [Indexed: 02/06/2023] Open
Abstract
Total knee arthroplasty (TKA) is the most commonly performed elective surgery in the United States. TKA typically improves functional performance and reduces pain associated with knee osteoarthritis. Little is known about the influence of TKA on overall physical activity levels. Physical activity, defined as “any bodily movement produced by skeletal muscles that results in energy expenditure”, confers many health benefits but typically decreases with endstage osteoarthritis. The purpose of this review is to describe the potential benefits (metabolic, functional, and orthopedic) of physical activity to patients undergoing TKA, present results from recent studies aimed to determine the effect of TKA on physical activity, and discuss potential sources of variability and conflicting results for physical activity outcomes. Several studies utilizing self-reported outcomes indicate that patients perceive themselves to be more physically active after TKA than they were before surgery. Accelerometry-based outcomes indicate that physical activity for patients after TKA remains at or below pre-surgical levels. Several different factors likely contributed to these variable results, including the use of different instruments, duration of follow-up, and characteristics of the subjects studied. Comparison to norms, however, suggests that daily physical activity for patients following TKA may fall short of healthy age-matched controls. We propose that further study of the relationship between TKA and physical activity needs to be performed using accelerometry-based outcome measures at multiple post-surgical time points.
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Ho J, Meis JF, Nabuurs-Franssen M, Voss A. Hip and knee arthroplasty: quo vadis? Antimicrob Resist Infect Control 2015; 4:19. [PMID: 25987980 PMCID: PMC4435657 DOI: 10.1186/s13756-015-0060-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 04/18/2015] [Indexed: 11/10/2022] Open
Abstract
Despite of the steady decrease of surgical site infection (SSI) over the last two decades, the incidence of SSI after hip and knee arthroplasty has recently surged. This may be explained by technical changes that may result in an increased risk of SSI, such as the broad implementation of fast track programs, and/or early interventions on suspected SSI. By definition, early intervention may lead to a higher SSI score, even in the absence of a true SSI. In any case, the reverse trend of SSI warrants further investigations.
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Affiliation(s)
- Jeffery Ho
- School of Nursing, The Hong Kong Polytechnic University, Kowloon, Hong Kong ; Department of Anesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands ; Department of Medical Microbiology, Radboud university medical centre, Nijmegen, The Netherlands
| | - Marrigje Nabuurs-Franssen
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Andreas Voss
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands ; Department of Medical Microbiology, Radboud university medical centre, Nijmegen, The Netherlands
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Analgesic Effect of Perioperative Escitalopram in High Pain Catastrophizing Patients after Total Knee Arthroplasty. Anesthesiology 2015; 122:884-94. [DOI: 10.1097/aln.0000000000000597] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Abstract
Background:
Sufficient pain treatment remains a challenge after total knee arthroplasty (TKA), especially in high pain catastrophizing patients. Serotonergic signaling may be involved in pain processing, but the effect of selective serotonin reuptake inhibitors on well-defined postoperative pain has not previously been investigated. The authors hypothesized that perioperative escitalopram would reduce pain after TKA in high pain catastrophizing patients.
Methods:
A total of 120 pain catastrophizing patients (selected using the pain catastrophizing scale as preoperative screening tool) scheduled for TKA were randomized in a double-blind manner to either 10 mg escitalopram or placebo daily from preanesthesia to postoperative day 6 in addition to a standardized analgesic regime. The primary outcome was pain upon ambulation 24 h after surgery. Secondary outcomes were overall pain during well-defined mobilizations and at rest from 2 to 48 h and from days 2 to 6, morphine equivalents, anxiety, depression, and side effects.
Results:
Pain upon ambulation (mean [95% CI]) 24 h after surgery in the escitalopram versus placebo group was 58 (53 to 64) versus 64 (58 to 69), the mean difference being −5 (−13 to 3), P = 0.20. Overall pain upon ambulation and at rest from days 2 to 6 was lower in the escitalopram versus placebo group, as was depression score at day 6 (all P ≤ 0.01 in analyses uncorrected for multiple tests). Side effects were nonsignificant except for reduced tendency to sweat and prolonged sleep in the escitalopram group. No other between-group differences were observed.
Conclusions:
Escitalopram did not reduce pain upon ambulation 24 h after TKA in high pain catastrophizing patients. Future studies on optimal timing, dose, and duration of selective serotonin reuptake inhibitor treatment might be warranted.
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Shulman BS, Liporace FA, Davidovitch RI, Karia R, Egol KA. Sleep disturbance after fracture is related to emotional well-being rather than functional result. J Orthop Trauma 2015; 29:e146-50. [PMID: 25072285 DOI: 10.1097/bot.0000000000000217] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The aim of this study was to investigate the rate, longitudinal improvement, and risk factors of sleep disturbance after 4 common orthopaedic traumatic conditions. METHODS The functional status of 1095 patients was prospectively assessed using validated questionnaires for patients with acute proximal humerus (n = 111), distal radius (n = 440), tibial plateau (n = 109), and ankle fractures (n = 435). Patient reported sleep difficulty was compared with the overall functional and emotional status of each patient at 3, 6, and 12 months after treatment. RESULTS Sleep difficulty at 3-month follow-up was reported in 41% of patients with proximal humerus fracture, 25% of patients with distal radius fracture, 36% of patients with tibial plateau, and 19% of patients with ankle fracture. By 12-month follow-up, less than 20% of patients with all fracture types reported sleep difficulty. At 12-month follow-up, the SF-36 Mental Health category for patients with distal radius fractures (P = 0.001) and the Short Musculoskeletal Function Assessment Emotional category for patients with tibial plateau fractures (P = 0.024) and ankle fractures (P ≤ 0.001) were independent predictors of poor sleep, whereas the respective functional status categories were not. CONCLUSIONS At 12-month follow-up, poor sleep was independently associated with poor emotional status but not associated with poor functional status. The mental health status of patients with sleep difficulty in the latter stages of fracture healing should be carefully assessed to provide the highest level of care. The results of this study should allow orthopaedic trauma surgeons to counsel patients regarding expectations of difficulty sleeping after acute fractures. LEVEL OF EVIDENCE Prognostic level II. See Instructions for authors for a complete description of levels of evidence.
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Affiliation(s)
- Brandon S Shulman
- *NYU Department of Orthopaedic Surgery, Jamaica Hospital for Joint Diseases, New York, NY; and †Department of Orthoapedic Surgery Jamaica Hospital Medical Center, Jamaica, NY
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Physical health problems experienced in the early postoperative recovery period following total knee replacement. Int J Orthop Trauma Nurs 2015; 19:36-44. [DOI: 10.1016/j.ijotn.2014.03.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 03/25/2014] [Accepted: 03/27/2014] [Indexed: 11/20/2022]
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Patient activity after TKA depends on patient-specific parameters. Clin Orthop Relat Res 2014; 472:3933-40. [PMID: 25053290 PMCID: PMC4397766 DOI: 10.1007/s11999-014-3813-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 07/09/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Most patients expect an improvement of walking ability and an increase in activity levels after TKA. Unfortunately, few studies report qualitative and quantitative activity improvements after TKA. QUESTIONS/PURPOSES The aims of this study were (1) to evaluate quantity and quality of physical activity before and after TKA with an accelerometer, and to compare activity level with that of an age-matched control group without lower-extremity disorders. (2) Improvement in measured steps per day after TKA and the ability to meet physical activity guidelines were evaluated. (3) The influence of patient-specific and implant parameters were assessed. PATIENTS AND METHODS An accelerometer was used to measure activity in 97 patients who were assessed before TKA and 1 year after TKA. The measurements included the total number of steps, moderate to vigorous activity defined as at least 100 steps per minute, and time spent lying, sitting/standing, or walking. We then calculated the proportion of patients who met the 10,000 steps per day guideline recommendation and determined factors that predicted failure to meet that goal. Thirty-nine age-matched control subjects without lower-extremity disorders were selected and underwent the same assessments using the accelerometer for comparison with patients 1 year after TKA. RESULTS Measured steps per day improved from a mean of 5278 (SD, 2999) preoperatively to 6473 (SD, 3654) postoperatively (effect size, 1.23; 95% CI, 1.10-1.35; p < 0.001). Moderate to vigorous steps per day improved from a mean of 1150 (SD, 982) to 1935 (SD, 1728; p < 0.001). Times spent in lying, sitting, or standing position or during walking did not change after TKA. For all measured parameters, activity of the patients after TKA was considerably less than that of the age-matched control subjects, who walked a mean of 13,375 (SD, 4614) steps per day (p < 0.001), performed a mean of 6562 (SD, 3401) vigorous steps per day (p < 0.001), and spent a mean of 2.9 hours (SD, 1.1) per day walking (p < 0.001). Only 16 patients (16.5%) met physical activity guidelines after TKA. BMI (p = 0.017), sex (p = 0.027), and comorbidities (American Society of Anesthesiologists Grade, p = 0.042) were independent factors associated with steps per day after TKA. CONCLUSIONS One year after TKA, patients had increased walking and moderate to vigorous steps. However, only 16.5% achieved the guideline recommendations for walking activity. BMI, sex, and comorbidities are patient factors that are associated with activity after TKA. Even with improvements in walking, activity level after TKA remains less than that seen for age-matched control subjects. Surgeons should be aware of this when counseling patients undergoing TKA. LEVEL OF EVIDENCE Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
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Krenk L, Kehlet H, Bæk Hansen T, Solgaard S, Soballe K, Rasmussen LS. Cognitive Dysfunction After Fast-Track Hip and Knee Replacement. Anesth Analg 2014; 118:1034-40. [DOI: 10.1213/ane.0000000000000194] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Krenk L, Jennum P, Kehlet H. Postoperative sleep disturbances after zolpidem treatment in fast-track hip and knee replacement. J Clin Sleep Med 2014; 10:321-6. [PMID: 24634631 DOI: 10.5664/jcsm.3540] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Previous studies have demonstrated pronounced reduction of REM sleep on the first nights following major surgery which may influence pain, analgesic use, and recovery. This placebo-controlled, randomized, double-blind study set out to evaluate the effect of zolpidem on sleep architecture in an elderly population undergoing fast-track total hip and knee arthroplasty (THA/TKA) with length of stay < 3 days. METHODS Twenty patients (≥ 60 years) undergoing THA or TKA in a standardized setup with spinal anesthesia and multimodal opioid-sparing postoperative analgesia were included. Polysomnography measures were performed for 2 nights, 1 night at home prior to surgery and on the first night after surgery, when the patient received placebo or zolpidem 10 mg. Analgesic use, pain levels, and subjective measures of fatigue and sleep quality were recorded. Analysis of sleep data was performed according to the American Academy of Sleep Medicine manual. RESULTS Objective sleep data did not show a significant difference between groups in any of the sleep stages. However, subjective data on sleep quality and fatigue showed significantly less fatigue and better sleep quality in the zolpidem group (p < 0.05), and reduced objectively recorded number of arousals (p = 0.004). Levels of pain and opioid use were similar in the 2 groups. CONCLUSIONS Our objective data did not support the primary hypothesis that one night's treatment with zolpidem would significantly improve sleep architecture following major surgery, although there was improved feeling of sleep quality and fatigue associated with fewer postoperative arousals. CITATION Krenk L; Jennum P; Kehlet H. Postoperative sleep disturbances after zolpidem treatment in fast-track hip and knee replacement.
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Affiliation(s)
- Lene Krenk
- Section of Surgical Pathophysiology, Rigshospitalet, University of Copenhagen, Denmark ; Lundbeck Centre for Fast-Track Hip and Knee Arthroplasty, Denmark
| | - Poul Jennum
- Danish Centre for Sleep Medicine, Department of Clinical Neurophysiology, Glostrup Hospital, and Centre for Healthy Ageing, Faculty of Health, University of Copenhagen, Denmark
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, University of Copenhagen, Denmark ; Lundbeck Centre for Fast-Track Hip and Knee Arthroplasty, Denmark
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Kehlet H, Thienpont E. Fast-track knee arthroplasty -- status and future challenges. Knee 2013; 20 Suppl 1:S29-33. [PMID: 24034592 DOI: 10.1016/s0968-0160(13)70006-1] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 08/15/2013] [Accepted: 08/15/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fast-track programs have been developed for different surgical procedures leading to higher patient satisfaction and lower morbidity. This concept has been extended to knee arthroplasty in recent years. The purpose of this narrative review was to discuss the different aspects of fast-track knee arthroplasty. METHOD Both authors searched the contemporary literature on minimally invasive knee arthroplasty and review articles on fast-track surgery aiming to summarize recent developments. RESULTS Length of stay after knee arthroplasty is influenced by preoperative risk factors, anaesthetic and surgical techniques, pain, orthostatic intolerance, cognitive function, sleep disturbances, bleeding and anaemia and finally muscle function and rehabilitation. CONCLUSIONS Fast-track surgery reduces the length of stay and the morbidity after knee arthroplasty. CLINICAL RELEVANCE Optimisation of pre-, per- and postoperative pathway for knee arthroplasty reduces morbidity after this type of surgery and results in shorter length of stay.
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Affiliation(s)
- Henrik Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet Copenhagen University, Denmark and The Lundbeck Centre for fast-track hip and knee replacement, Av. Hippocrate 10, 1200 Brussels, Belgium.
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