Older patients have the most to gain from orthopaedic enhanced recovery programmes

Functional Outcomes and Satisfaction Rates in Patients Aged 80 Years or Older are Not Clinically Different From Their Younger (65 to 75 Years) Counterparts Following Total Hip Arthroplasty

BACKGROUND

As the population ages, the proportion of elderly patients requiring total hip arthroplasty (THA) increases, but it is not clear whether older age independently influences outcome. The aim was to assess function, quality of life, and satisfaction after THA in patients ≥ 80 years compared with those aged between 65 and 75 years when adjusting for confounding factors.

METHODS

A single-center retrospective cohort study was performed between 2010 and 2019. A total 2,367 THAs were performed on patients ≥ 80 years and 5,113 on patients aged 65 to 75 years. The demographic data and length of stay (LOS) were recorded. Preoperative and 2-year postoperative Oxford Hip Scores (OHS), EuroQol (EQ-5D), and satisfaction scores were collected. Clinically meaningful difference was defined as 5 points in OHS and utility of 0.085 in EQ-5D. Regression analyses were performed to adjust for confounding factors.

RESULTS

Patients in ≥ 80-years group were more likely women (P < .001), have higher American Society of Anesthesiolgists grade (P < .001), worse preoperative OHS (mean difference [MD] 2.3, P < .001), and EQ-5D (MD 0.087, P < .001). Both age groups achieved clinically meaningful and statistically significant (P < .001) improvement in OHS and EQ-5D utility at 2 years. When adjusting for confounding variables, the ≥ 80-year-old group had significantly (P < .001) lower improvement in OHS (MD -1.9 points) and EQ-5D (MD -0.055 utility), but these differences were not clinically meaningful. There was no difference (P = .813) in satisfaction between the groups. When adjusting for confounding variables, ≥ 80-year-old group had increased risk of longer LOS (odds ratio 1.27, P < .001).

CONCLUSIONS

There were no clinically meaningful differences in hip-specific outcome or health-related quality of life according to age group, and both were equally satisfied with their outcome. The older age group did, however, have longer LOS.

LEVEL OF EVIDENCE

Level III retrospective cohort study.

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

BACKGROUND

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

QUESTIONS/PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, therapeutic study.

Implementation of the Fast-track Protocol for Total Hip Arthroplasty in a Public Hospital in the State of São Paulo - Brazil

Objective  Evaluate the results of the implementation of the Fast Track Protocol (FTP), a medical practice based on scientific evidence, for elective total hip arthroplasty surgery, mainly comparing the National Average Hospital Admission Rate of 7.1 days. Methods  98 patients who underwent elective total hip arthroplasty surgery via the direct anterior approach, anterolateral approach and posterior approach were included in the FTP from December 2018 to March 2020, being followed up preoperatively, intraoperatively and immediately postoperatively. Results  The average length of hospital stay was 2.8 days, being 2.1 days for the direct anterior approach, 3.0 days for the anterolateral access approach and 4.1 days for the posterior access approach. The average surgery time was 90 minutes, 19 (19.39%) of the patients were referred to the ICU in the postoperative period, however, none of them underwent surgery using the direct anterior approach. We had no cases of deep vein thrombosis (DVT), pulmonary embolism (PTE) or neurological injury, 19 (19.39%) patients had postoperative bleeding requiring dressing change, 4 (4.08%) needed blood transfusion, 2 (2.04%) patients had implant instability, 1 (1.02%) patient had a fracture during surgery and 1 (1.02%) patient died of cardiac complications. Conclusion  FTP may be a viable alternative to reduce the length of stay and immediate postoperative complications for elective total hip arthroplasty surgery decreasing the length of stay of patients by 2 to 3 times when compared to the national average of 7.1 days.

A systematic review and meta-analysis of short-stay programmes for total hip and knee replacement, focusing on safety and optimal patient selection

BACKGROUND

Short-stay joint replacement programmes are used in many countries but there has been little scrutiny of safety outcomes in the literature. We aimed to systematically review evidence on the safety of short-stay programmes versus usual care for total hip (THR) and knee replacement (KR), and optimal patient selection.

METHODS

A systematic review and meta-analysis. Randomised controlled trials (RCTs) and quasi-experimental studies including a comparator group reporting on 14 safety outcomes (hospital readmissions, reoperations, blood loss, emergency department visits, infection, mortality, neurovascular injury, other complications, periprosthetic fractures, postoperative falls, venous thromboembolism, wound complications, dislocation, stiffness) within 90 days postoperatively in adults ≥ 18 years undergoing primary THR or KR were included. Secondary outcomes were associations between patient demographics or clinical characteristics and patient outcomes. Four databases were searched between January 2000 and May 2023. Risk of bias and certainty of the evidence were assessed.

RESULTS

Forty-nine studies were included. Based upon low certainty RCT evidence, short-stay programmes may not reduce readmission (OR 0.95, 95% CI 0.12-7.43); blood transfusion requirements (OR 1.75, 95% CI 0.27-11.36); neurovascular injury (OR 0.31, 95% CI 0.01-7.92); other complications (OR 0.63, 95% CI 0.26-1.53); or stiffness (OR 1.04, 95% CI 0.53-2.05). For registry studies, there was no difference in readmission, infection, neurovascular injury, other complications, venous thromboembolism, or wound complications but there were reductions in mortality and dislocations. For interrupted time series studies, there was no difference in readmissions, reoperations, blood loss volume, emergency department visits, infection, mortality, or neurovascular injury; reduced odds of blood transfusion and other complications, but increased odds of periprosthetic fracture. For other observational studies, there was an increased risk of readmission, no difference in blood loss volume, infection, other complications, or wound complications, reduced odds of requiring blood transfusion, reduced mortality, and reduced venous thromboembolism. One study examined an outcome relevant to optimal patient selection; it reported comparable blood loss for short-stay male and female participants (p = 0.814).

CONCLUSIONS

There is low certainty evidence that short-stay programmes for THR and KR may have non-inferior 90-day safety outcomes. There is little evidence on factors informing optimal patient selection; this remains an important knowledge gap.

Exploring Orthopedic Occupational Therapy in Korea: Insights from a Survey on Occupational Therapists' Perspectives

This study explores the perceptions and experiences of Korean occupational therapists (OTs) about their role in managing elderly patients with orthopedic conditions. The goal is to inform policy discussions for better integration of OT services in orthopedic care settings in Korea. A survey was conducted among Korean clinical OTs to gather data on their perceptions, experiences, and challenges in providing orthopedic OT services. Snowball sampling was used, and the survey addressed general characteristics, orthopedic OT status, perceptions, and competence. The data were analyzed using frequency and percentage calculations in SPSS 22.0. Out of 171 respondents, only 18 had experience working in orthopedic departments, while 78 (45.6%) had provided occupational therapy to orthopedic patients. Rehabilitation medicine physicians were the primary prescribers of orthopedic OT. Key challenges included a lack of awareness among professionals, an absence of appropriate fees, and insufficient knowledge among OTs. The majority of respondents agreed that providing OT in orthopedic departments was appropriate and expressed a need for education and clinical guidelines. The study examines the current state of orthopedic OT in Korea, showing low levels of experience and highlighting challenges, such as a lack of professional awareness, inadequate fees, and insufficient knowledge among OTs. Respondents mostly agreed on the necessity for education and clinical guidelines to improve their capabilities in orthopedic settings. This study emphasizes the need for healthcare system improvements that allow OTs to participate more widely without being confined to specific medical disciplines, promoting a more comprehensive approach to OT, especially as the aging population continues to grow.

Key Components, Current Practice and Clinical Outcomes of ERAS Programs in Patients Undergoing Orthopedic Surgery: A Systematic Review

Enhanced recovery after surgery (ERAS) protocols have led to improvements in outcomes in several surgical fields, through multimodal optimization of patient pathways, reductions in complications, improved patient experiences and reductions in the length of stay. However, their use has not been uniformly recognized in all orthopedic fields, and there is still no consensus on the best implementation process. Here, we evaluated pre-, peri-, and post-operative key elements and clinical evidence of ERAS protocols, measurements, and associated outcomes in patients undergoing different orthopedic surgical procedures. A systematic literature search on PubMed, Scopus, and Web of Science Core Collection databases was conducted to identify clinical studies, from 2012 to 2022. Out of the 1154 studies retrieved, 174 (25 on spine surgery, 4 on thorax surgery, 2 on elbow surgery and 143 on hip and/or knee surgery) were considered eligible for this review. Results showed that ERAS protocols improve the recovery from orthopedic surgery, decreasing the length of hospital stays (LOS) and the readmission rates. Comparative studies between ERAS and non-ERAS protocols also showed improvement in patient pain scores, satisfaction, and range of motion. Although ERAS protocols in orthopedic surgery are safe and effective, future studies focusing on specific ERAS elements, in particular for elbow, thorax and spine, are mandatory to optimize the protocols.

Same-day discharge to home is feasible and safe in up to 75% of unselected total hip and knee arthroplasty

PURPOSE

Though numerous studies highlighted benefits of ambulatory total joint arthroplasty (TJA), most had selected patients with age and comorbidities thresholds. We aimed to report proportions of unselected TJAs that could be scheduled for and operated in ambulatory settings, and to determine factors that hinder same-day discharge (SDD).

METHODS

We studied 1100 consecutive primary TJAs (644 THAs and 456 TKAs) that were prepared following a multidisciplinary protocol for patient education and logistical preparation. Data were stratified for THA vs TKA and for success vs failure of SDD to home and multivariable analysis was performed to determine factors associated with failure of scheduled SDD to home.

RESULTS

In total, 860 (78.2%) were scheduled for ambulatory surgery, but only 819 (74.5%) achieved SDD to home; 240 (21.8%) were scheduled for non-ambulatory surgery, but 103 (9.3%) achieved SDD to rehabilitation centre. Re-operations were required in 9 (1.0%) ambulatory TJAs vs 2 (0.8%) non-ambulatory TJAs (p = 0.769), while revisions were required in 13 (1.5%) ambulatory TJAs vs 1 (0.4%) non-ambulatory TJAs (p = 0.181). Multivariable analysis confirmed that failure of SDD to home was greater for women (OR 2.59; p = 0.011) and THA (vs TKA, OR 2.41; p = 0.023).

CONCLUSION

With appropriate education and preparation, 75% of unselected primary hip and knee arthroplasties achieved SDD to home without compromising risks of complications, re-operations, or revisions. A further 9% achieved SDD to rehabilitation centre, implying that 84% of patients did not require overnight stay. These findings suggest that ambulatory surgery is feasible and safe to implement in most unselected lower limb arthroplasties.

Enhanced Recovery after Surgery for Knee Arthroplasty in the Era of COVID-19

Enhanced recovery after surgery (ERAS) represents a paradigm shift in perioperative care, aimed at achieving early recovery for surgical patients, reducing length of hospital stay, and complications. The purpose of this study was to provide an insight of the impact of the COVID-19 on ERAS protocols for knee arthroplasty patients in a tertiary hospital and potential strategy changes for postpandemic practice. We retrospectively reviewed all cases that underwent surgery utilizing ERAS protocols in the quarter prior to the pandemic (fourth quarter of 2019) and during the first quarter of 2020 when the pandemic started. A review of the literature on ERAS protocols for knee arthroplasty during the COVID-19 pandemic was also performed and discussed. A total of 199 knee arthroplasties were performed in fourth quarter of 2019 as compared with 76 in the first quarter of 2020 during the COVID-19 outbreak. Patients who underwent surgery in the first quarter of 2020 had shorter inpatient stays (3.8 vs. 4.5 days), larger percentage of discharges by postoperative day 5 (86.8 vs. 74.9%), and a larger proportion of patients discharged to their own homes (68 vs. 54%). The overall complication rate (1.3 vs. 3%) and readmission within 30 days (2.6 vs. 2%) was similar between both groups. ERAS protocols appear to reduce hospital lengths of stay for patients undergoing knee arthroplasty without increasing the risk of short-term complications and readmissions. The beneficial effects of ERAS appear to be amplified by and are synchronous with the requirements of operating in the era of a pandemic.

Complications, readmission rates, and in-hospital lengths-of-stay in octogenarian vs. non-octogenarians following total knee arthroplasty: An analysis of over 1.7 million patients

INTRODUCTION

Studies investigating complications between octogenarians and non-octogenarians undergoing primary total knee arthroplasty (TKA) are limited. Therefore, we investigated whether octogenarians are at greater odds of: (1) in-hospital lengths of stay (LOS) (2) readmission rates, (3) medical complications, and (4) hardware complications compared to non-octogenarians following TKA.

METHODS

A retrospective query of the PearlDiver database isolated 1,775,460 patients who underwent primary TKA from 2005 to 2014. Patients aged 80 and above represented the study cohort (n = 295,908) and patients 65 to 79 represented the control cohort (n = 1,479,552). Study group patients were matched to controls in a 1:5 ratio according to gender and medical comorbidities. Pearson's Chi Square and logistic regression were used to analyze the primary outcomes of the study which included 90-day medical complications, 90-day readmission rates, 2-year implant-related complications, and in-hospital LOS. A p-value less than 0.001 was statistically significant.

RESULTS

Octogenarians were found to have significantly higher incidence and odds of 90-day readmission rates (10.59 vs. 9.35%; OR: 1.15, p < 0.0001) and significantly longer in-hospital LOS (3.69 days ± 1.95 vs. 3.23 days ± 1.83, p < 0.0001) compared to controls. Octogenarians also had equal incidence and odds of developing any medical complication (1.26 vs. 1.26%; OR: 0.99, p = 0.99) and lower incidence and odds (1.67 vs. 1.93%; OR: 0.86, p < 0.001) of implant-related complications compared to controls.

CONCLUSION

Octogenarians undergoing primary TKA have similar odds of medical related complications and lower odds of implant-related complications compared to non-octogenarian patients, whereas readmission rates and in-hospital LOS are greater.

Nutritional and Physical Prehabilitation in Elective Orthopedic Surgery: Rationale and Proposal for Implementation

In the past, good food and exercise were not considered effective interventions to promote recovery in orthopedic surgery, and prolonged bed rest with not many calories has been deemed sufficient for the proper health restoration until the end of the nineteenth century. The advancement of scientific knowledge proved just the opposite, thus pushing health professionals to sustain the nutritional status and physical fitness of surgical patients. Nevertheless, the impoverishment of lifestyles and the lengthening of life expectancy have invariably contrasted the strength of constitution, giving rise to two of the most hazardous conditions for orthopedic patients: malnutrition and sarcopenia, often hiding nutrient deficits and poor body composition. These conditions are known to be negative prognostic factors in several areas of major surgery, including hip replacement, knee replacement, and spine surgery. Scoring systems to screen for malnutrition and physical inabilities exist, but disciplined management of the derived risks remains untested, potentially hindering the implementation of research findings into practice. A methodical approach of preoperative analysis, critical monitoring, and risk correction before surgery could lead to a substantial improvement of the prognosis while warranting the safety of patients and the efficiency of enhanced recovery after surgery pathways. The aim of this article is to discuss from a dietetic and exercise perspective the ideal nutritional and physical prehabilitation to lay the foundations for designing the appropriate integration of dietitians and physiotherapists in a preoperative enhanced recovery pathway. This methodical analysis could effectively calculate the patient’s risks, detect the best choices for resolving the risk, underline the ignored aspects of perioperative care, and represent a concrete means to integrate novel discoveries.

Effectiveness of enhanced recovery after surgery in the perioperative management of patients with bone surgery in China

BACKGROUND

Enhanced recovery after surgery (ERAS) was introduced in China in 2007. Over time, the scope of ERAS has expanded from abdominal surgery to orthopedics, urology and other fields. Continuous development and research has contributed to progress of ERAS in China. In 2019, to promote the application of ERAS in bone tumor surgery, we formed the “Consensus of Experts on Perioperative Management of Accelerated Rehabilitation in Major Surgery of Bone Tumors in China”.

AIM

To evaluate the effect of enhanced recovery after bone tumor surgery in perioperative management in China.

METHODS

One hundred and seven patients who underwent bone tumor surgery at the Second Affiliated Hospital of Xi’an Jiaotong University between May 2019 and April 2021 were randomized into a study group (53 cases) and a control group (54 cases). The study group adopted the ERAS protocol and the control group adopted conventional care. Main outcome measures included postoperative length of stay (LOS), postoperative complications, mortality, and 30-d readmission rates. Secondary outcomes included postoperative visual analog scale (VAS) score of pain, number of blood transfusions, drainage volume in 24 h after operation, patient satisfaction 30 d after discharge, VAS score at 30 d after discharge, and daily standing walking time.

RESULTS

There were no significant differences in the baseline data, clinical features and surgical site between the two groups. The LOS in the study group with the ERAS protocol was 7.72 ± 3.34 d compared with 10.28 ± 4.27 d in the control group who followed conventional care. The incidence of postoperative nausea and vomiting (PONV) in the study group was 19% and 37% in the control group. The VAS scores of pain on postoperative day 1 (POD1) and POD3 in the study group were 4.79 ± 2.34 and 2.79 ± 1.53 compared with 5.28 ± 3.27 and 3.98 ± 2.27 in the control group. The drainage volume in 24 h after the operation was 124.36 ± 23.43 mL in the study group and 167.43 ± 30.87 mL in the control group. The number of blood transfusions in the study group was also lower. The patient satisfaction rate was higher in the study group than in the control group.

CONCLUSION

The ERAS protocol in the perioperative period of bone tumor surgery can decrease LOS, PONV, and postoperative pain, blood transfusion and 24-h drainage, improve patient satisfaction and accelerate recovery.

The impact of an enhanced recovery programme on length of stay and post-discharge resource usage following hip and knee arthroplasty : a service evaluation and cost analysis

Aims

The aim of this study is to assess the impact of a pilot enhanced recovery after surgery (ERAS) programme on length of stay (LOS) and post-discharge resource usage via service evaluation and cost analysis.

Methods

Between May and December 2019, 100 patients requiring hip or knee arthroplasty were enrolled with the intention that each would have a preadmission discharge plan, a preoperative education class with nominated helper, a day of surgery admission and mobilization, a day one discharge, and access to a 24/7 dedicated helpline. Each was matched with a patient under the pre-existing pathway from the previous year.

Results

Mean LOS for ERAS patients was 1.59 days (95% confidence interval (CI) 1.14 to 2.04), significantly less than that of the matched cohort (3.01 days; 95% CI 2.56 to 3.46). There were no significant differences in readmission rates for ERAS patients at both 30 and 90 days (six vs four readmissions at 30 days, and nine vs four at 90 days). Despite matching, there were significantly more American Society of Anesthesiologists (ASA) grade 3 patients in the ERAS cohort. There was a mean cost saving of £757.26 (95% CI £-1,200.96 to £-313.56) per patient. This is despite small increases in postoperative resource usage in the ERAS patients.

Conclusion

ERAS represents a safe and effective means of reducing LOS in primary joint arthroplasty patients. Implementation of ERAS principles has potential financial savings and could increase patient throughput without compromising care. In elective care, a preadmission discharge plan is key.

Cite this article: Bone Jt Open 2021;2(11):966–973.

Total Knee Arthroplasty in Octogenarians: Should We Still Be so Restrictive?

Demand for total knee arthroplasty (TKA) in octogenarians will increase in subsequent years as society ages. We conducted a retrospective observational study in octogenarians operated on with TKA between 2015 and 2019, comparing preoperative and postoperative Knee Society Score (KSS), Knee Society Function Score (KSFS), extension and flexion balance, and radiologic alignment using a paired Student t-test. A chi-squared test was used to correlate mortality with Charlson comorbidities index score and with ASA scale. Kaplan-Meier analysis was performed to calculate patient survival. In this period 36 patients ≥80 years underwent TKA, with a mean age of 81.6 years. Of these, 24 patients (66.7%) were classified as ASA II and 12 (33.3%) as ASA III. Sixteen patients (44.4%) were Charlson 0, 14 (38.9%) Charlson 1, two (5.6%) Charlson 2, and four (11.1%) Charlson 3. KSS, KSFS, flexion and extension range, and radiologic alignment were statistically significant (p < 0.001) when comparing preoperatory and post-operatory data. No correlation (p > 0.05) was found between mortality and ASA or Charlson score. Seven patients (19.4%) suffered a medical complication and two patients experienced surgical complications. Four patient died (11.1%) during follow-up. The mean patient survival was 67.4 months. Patients ≥80 years achieve clinical improvement after TKA. Comorbidities, not age, are the burden for surgery in older patients.

Implementing fast track surgery in hip and knee arthroplasty using the lean Six Sigma methodology

Purpose

One of the biggest challenges in the health sector is that of costs compared to economic resources and the quality of services. Hospitals register a progressive increase in expenditure due to the aging of the population. In fact, hip and knee arthroplasty surgery are mainly due to primary osteoarthritis that affects the elderly population. This study was carried out with the aim of analysing the introduction of the fast track surgery protocol, through the lean Six Sigma, on patients undergoing knee and hip prosthetic replacement surgery. The goal was to improve the arthroplasty surgery process by reducing the average length of stay (LOA) and hospital costs

Design/methodology/approach

Lean Six Sigma was applied to evaluate the arthroplasty surgery process through the DMAIC cycle (define, measure, analyse, improve and control) and the lean tools (value stream map), adopted to analyse the new protocol and improve process performance. The dataset consisted of two samples of patients: 54 patients before the introduction of the protocol and 111 patients after the improvement. Clinical and demographic variables were collected for each patient (gender, age, allergies, diabetes, cardiovascular diseases and American Society of Anaesthesiologists (ASA) score).

Findings

The results showed a 12.70% statistically significant decrease in LOS from an overall average of 8.72 to 7.61 days. Women patients without allergies, with a low ASA score not suffering from diabetes and cardiovascular disease showed a significant a reduction in hospital days with the implementation of the FTS protocol. Only the age variable was not statistically significant.

Originality/value

The introduction of the FTS in the orthopaedic field, analysed through the LSS, demonstrated to reduce LOS and, consequently, costs. For each individual patient, there was an economic saving of € 445.85. Since our study takes into consideration a dataset of 111 patients post-FTS, the overall economic saving brought by this study amounts to €49,489.35.

Implementation and results of an enhanced recovery (fast-track) program in total knee replacement patients at a French university hospital

INTRODUCTION

In total knee replacement (TKR) surgeries, "fast-track" or enhanced recovery after surgery (ERAS) programs are being developed, but their impact on care pathway quality and safety has not been fully explored in the French literature. The present study aimed to compare results in TKR between fast-track and conventional pathways, addressing the following questions: (1) Are 90-day rates of complications, readmission and surgical revision higher with fast-track? (2) Is mean length of stay (LoS) shorter with fast-track? (3) Are postoperative pain and clinical results improved by fast-track? And, (4) are patients and care staff satisfied with these new programs?

HYPOTHESIS

Implementing fast-track for TKR in a university hospital center is beneficial for the patient and does not impair the quality and safety of care.

PATIENTS AND METHOD

A case-control study was performed using a retrospective analysis of prospectively collected data. A fast-track program was implemented for TKR by modifying the care pathway. This involved instituting a therapeutic education consultation, optimizing blood sparing, modifying surgical practices, and hastening early mobilization thus actively involving patients in their own management. Between January 2017 and January 2019, 216 patients with a mean age of 69.23±7.80years and mean BMI of 30.15±4.79kg/m² were included in the fast-track group, with 335 matched patients included in the conventional group.

RESULTS

At 90days, there were no significant inter-group differences in rates of infection (fast-track=1.39%, conventional=0.90%; p=0.34), readmission (fast-track=3.24%, conventional=3.58%; p=0.49), or surgical revision (fast-track=2.78%, conventional=2.69%; p=0.298). The visual analog scale (VAS) pain rating was 1.56±1.36 in the fast-track group versus 5±2.41 in the conventional group; p<0.001. LoS was 3.17±1.59days in fast-track versus 7.25±1.85days in the conventional group; p<0.001. Ninety-five percent of patients and 96% of care staff were satisfied with the fast-track program.

DISCUSSION

Fast-track implementation ensured quality and safety of care; it did not increase the rate of complications in primary TKR. Mean length of stay was drastically reduced. Both patients and care staff were very satisfied with these new procedures.

LEVEL OF EVIDENCE

III; case-control study.

To Predict the Length of Hospital Stay After Total Knee Arthroplasty in an Orthopedic Center in China: The Use of Machine Learning Algorithms

Background and Objectives: Total knee arthroplasty (TKA) is widely performed to improve mobility and quality of life for symptomatic knee osteoarthritis patients. The accurate prediction of patients' length of hospital stay (LOS) can help clinicians for rehabilitation decision-making and bed assignment planning, which thus makes full use of medical resources.

Methods: Clinical characteristics were retrospectively collected from 1,298 patients who received TKA. A total of 36 variables were included to develop predictive models for LOS by multiple machine learning (ML) algorithms. The models were evaluated by the receiver operating characteristic (ROC) curve for predictive performance and decision curve analysis (DCA) for clinical values. A feature selection approach was used to identify optimal predictive factors.

Results: The areas under the ROC curve (AUCs) of the nine models ranged from 0.710 to 0.766. All the ML-based models performed better than models using conventional statistical methods in both ROC curves and decision curves. The random forest classifier (RFC) model with 10 variables introduced was identified as the best predictive model. The feature selection indicated the top five predictors: tourniquet time, distal femoral osteotomy thickness, osteoporosis, tibia component size, and post-operative values of Hb within 24 h.

Conclusions: By analyzing clinical characteristics, it is feasible to develop ML-based models for the preoperative prediction of LOS for patients who received TKA, and the RFC model performed the best.

Safety of Same and Next Day Discharge Following Revision Hip and Knee Arthroplasty Using Modern Perioperative Protocols

BACKGROUND

Advances in perioperative care have enabled early discharge and outpatient primary total joint arthroplasty (TJA). However, the safety of early discharge after revision TJA (rTJA) remains unknown and the COVID-19 pandemic will force decreased hospitalization. This study compared 90-day outcomes in patients undergoing aseptic rTJA discharged the same or next day (early) to those discharged 2 or 3 days postoperatively (later).

METHODS

In total, 530 aseptic rTJAs performed at a single tertiary care referral center (December 5, 2011 to December 30, 2019) were identified. Early and later discharge patients were matched as closely as possible on procedure type, sex, American Society of Anesthesiologists physical status classification, age, and body mass index. All patients were optimized using modern perioperative protocols. The rate of 90-day emergency department (ED) visits and hospital admissions was compared between groups.

RESULTS

In total, 183 early discharge rTJAs (54 hips, 129 knees) in 178 patients were matched to 183 later discharge rTJAs (71 hips, 112 knees) in 165 patients. Sixty-two percent of the sample was female, with an overall average age and body mass index of 63 ± 9.9 (range: 18-92) years and 32 ± 6.9 (range: 18-58) kg/m². There was no statistical difference in 90-day ED visit rates between early (6/178, 3.4%) and later (11/165, 6.7%) discharge patients (P = .214). Ninety-day hospital admission rates for early (7/178, 3.9%) and later (4/165, 2.4%) discharges did not differ (P = .545).

CONCLUSION

Using modern perioperative protocols with appropriate patient selection, early discharge following aseptic rTJA does not increase 90-day readmissions or ED visits. As hospital inpatient capacity remains limited due to COVID-19, select rTJA patients may safely discharge home the same or next day to preserve hospital beds and resources for more critical illness.

Prolonged length of stay (PLOS) in a high-volume arthroplasty unit

Introduction

The enhanced recovery after surgery (ERAS) concept in arthroplasty surgery has led to a reduction in postoperative length of stay in recent years. Patients with prolonged length of stay (PLOS) add to the burden of a strained NHS. Our aim was to identify the main reasons.

Methods

A PLOS was arbitrarily defined as an inpatient hospital stay of four days or longer from admission date. A total of 2,000 consecutive arthroplasty patients between September 2017 and July 2018 were reviewed. Of these, 1,878 patients were included after exclusion criteria were applied. Notes for 524 PLOS patients were audited to determine predominant reasons for PLOS.

Results

The mean total length of stay was 4 days (1 to 42). The top three reasons for PLOS were social services, day-before-surgery admission, and slow to mobilize. Social services accounted for 1,224 excess bed days, almost half (49.2%, 1,224/2,489) of the sum of excess bed days.

Conclusion

A preadmission discharge plan, plus day of surgery admission and mobilization on the day of surgery, would have the potential to significantly reduce length of stay without compromising patient care.

Cite this article: Bone Joint Open 2020;1-8:488–493.

Evaluating enhanced recovery after surgery: time to cover new ground and discover the missing patient voice

Multicomponent peri-operative interventions offer to accelerate patient recovery and improve cost-effectiveness. The recent National Institute of Health Research-commissioned evidence synthesis review by Nunns et al. considers the effectiveness and cost-effectiveness of all types of multicomponent interventions for older adults undergoing elective inpatient surgery. Enhanced recovery programmes (ERPs) were the most commonly evaluated intervention. An association between ERPs and decreased length of stay was observed, whilst complication rates and time to recovery were static or sometimes reduced. Important areas which lack research in the context of ERPs are patient-reported outcome measures, patients with complex needs and assessment of factors pertaining to successful ERP implementation. The next generation of ERP studies should seek to develop our understanding in these key areas.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Does Regional Anesthesia Reduce Complications Following Total Hip and Knee Replacement Compared With General Anesthesia? An Analysis From the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man

BACKGROUND

Regional anesthesia is increasingly used in enhanced recovery programs following total hip replacement (THR) and total knee replacement (TKR). However, debate remains about its potential benefit over general anesthesia given that complications following surgery are rare. We assessed the risk of complications in THR and TKR patients receiving regional anesthesia compared with general anesthesia using the world's largest joint replacement registry.

METHODS

We studied the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man linked to English hospital inpatient episodes for 779,491 patients undergoing THR and TKR. Patients received either regional anesthesia (n = 544,620, 70%) or general anesthesia (n = 234,871, 30%). Outcomes assessed at 90 days included length of stay, readmissions, and complications. Regression models were adjusted for patient and surgical factors to determine the effect of anesthesia on outcomes.

RESULTS

Length of stay was reduced with regional anesthesia compared with general anesthesia (THR = -0.49 days, 95% confidence interval [CI] = -0.51 to -0.47 days, P < .001; TKR = -0.47 days, CI = -0.49 to -0.45 days, P < .001). Regional anesthesia also had a reduced risk of readmission (THR odds ratio [OR] = 0.93, CI = 0.90-0.96; TKA OR = 0.91, CI = 0.89-0.93), any complication (THR OR = 0.88, CI = 0.85-0.91; TKA OR = 0.90, CI = 0.87-0.93), urinary tract infection (THR OR = 0.85, CI = 0.77-0.94; TKR OR = 0.87, CI = 0.79-0.96), and surgical site infection (THR OR = 0.87, CI = 0.80-0.95; TKR OR = 0.84, CI = 0.78-0.89). Anesthesia type did not affect the risk of revision surgery or mortality.

CONCLUSION

Regional anesthesia was associated with reduced length of stay, readmissions, and complications following THR and TKR when compared with general anesthesia. We recommend regional anesthesia should be considered the reference standard for patients undergoing THR and TKR.

Fast-track hip and knee arthroplasty in older adults-a prospective cohort of 1,427 procedures in patients ≥85 years

INTRODUCTION

fast-track protocols in total hip and knee arthroplasty (THA/TKA) have improved postoperative recovery and reduced postoperative morbidity. Additionally, increasing life expectancy and improved surgical techniques have led to an increasing number of older adult patients undergoing THA/TKA. However, no large detailed studies on fast-track THA/TKA in older adults are available. Consequently, we aimed to describe the length of stay (LOS) and postoperative morbidity in a large cohort of patients ≥85 years within a continuous multicentre fast-track collaboration.

METHODS

we used a prospective observational cohort design with unselected consecutive data between 2010 and 2017 on primary elective THA and TKA patients ≥85 years. Data were obtained from nine centres reporting to the Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement database and the Danish National Patient Registry on LOS, readmissions and mortality. Causes of morbidity were determined by review of health records.

RESULTS

we included 1,427 (3.9% of all THA/TKA) procedures with 62.3% THA. Median age was 87 (IQR: 85-88) years with 71% women. LOS decreased from median 4 (3-6) days in 2010 to 2 (2-3) days in 2017. The proportion with LOS > 4 days decreased from 32 to 18%. Readmission and mortality rate remained at about 11.7 and 0.9% after 30 days and 16.0 and 1.5% after 90 days, respectively.

CONCLUSION

this detailed large multicentre fast-track THA/TKA study in patients ≥85 years found major reductions in LOS without increase in readmission or mortality rates. The unchanged readmission rate poses an area for further improvements.

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

Background

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

Objectives

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

Design

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

Setting

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

Participants

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

Interventions

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

Main outcome measures

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

Results

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

Limitations

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

Conclusion

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

Future work

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

Study registration

This study is registered as PROSPERO CRD42017059473.

Funding

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

Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review

Background

Elective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.

Objectives

To evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.

Data sources

Seven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.

Review methods

Comparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.

Findings

A total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.

Limitations

Studies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.

Conclusions

Enhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.

Future work

Further studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.

Study registration

This study is registered as PROSPERO CRD42017080637.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

RATeS (Re-Admissions in Trauma and Orthopaedic Surgery): a prospective regional service evaluation of complications and readmissions

INTRODUCTION

All the surgeries carry risks, which may lead to readmission at a later date. At present, there is limited Trauma and Orthopaedic (T&O) specific data in the literature. As a result, a prospective regional service evaluation aimed to discover the current complication and readmission rates across all T&O procedures and identify any factors associated with these outcomes.

METHODS

Data were collected at six sites across Yorkshire and Humber for all T&O procedures during October 2016. Patient demographics and procedure-specific data were collected. Post-operative complications and length of stay were recorded. All the patients were then followed up for 30 days post-discharge to determine if they experienced complications which resulted in readmission and further surgical intervention.

RESULTS

1411 patients having a total of 64 operations were recorded with 1391 completing follow-up (98.5%). Overall in-patient complication rate was 8.4% with the readmission rate being 4.4%. An ASA grade of three or more was found to be associated with readmission. Procedure-related factors such as the use of VTE prophylaxis and prophylactic antibiotics, as well as the elective nature of certain operations were negatively associated with readmission. The largest subgroup of patients was those undergoing total hip (THR) or knee replacements (TKR). For these 234 patients, the readmission rate for TKR and THR being 3.77% and 3.13%, respectively.

CONCLUSIONS

This large, multi-centre project describes readmission rates following trauma and orthopaedic surgery. In the presented study, the elective nature of the procedure was associated with a reduced risk of readmission.

[Fast track strategies in hip arthroplasty]

BACKGROUND

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

OBJECTIVES

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Impact of a national enhanced recovery after surgery programme on patient outcomes of primary total knee replacement: an interrupted time series analysis from "The National Joint Registry of England, Wales, Northern Ireland and the Isle of Man"

OBJECTIVE

We aimed to test whether a national Enhanced Recovery After Surgery (ERAS) Programme in total knee replacement (TKR) had an impact on patient outcomes.

DESIGN

Natural-experiment (April 2008-December 2016). Interrupted time-series regression assessed impact on trends before-during-after ERAS implementation.

SETTING

Primary operations from the UK National Joint Registry (NJR) were linked with Hospital Episode Statistics (HES) data which contains inpatient episodes undertaken in National Health Service (NHS) trusts in England, and Patient Reported Outcome Measures (PROMs).

PARTICIPANTS

Patients undergoing primary planned TKR aged ≥18 years.

INTERVENTION

ERAS implementation (April 2009-March 2011).

OUTCOMES

Regression coefficients of monthly means of Length of stay (LOS), bed day costs, change in Oxford knee scores (OKS) 6-months after surgery, complications (at 6 months), and rates of revision surgeries (at 5 years).

RESULTS

486,579 primary TKRs were identified. Overall LOS and bed-day costs decreased from 5.8 days to 3.7 and from £7607 to £5276, from April 2008 to December 2016. Oxford knee score (OKS) change improved from 15.1 points in April 2008 to 17.1 points in December 2016. Complications decreased from 4.1 % in April 2008 to 1.7 % in March 2016. 5-year revision rates remained stable at 4.8 per 1000 implants years in April 2008 and December 2011. After ERAS, declining trends in LOS and bed costs slowed down; OKS improved, complications remained stable, and revisions slightly increased.

CONCLUSIONS

Different secular trends in outcomes for patients having TKR have been observed over the last decade. Although patient outcomes are better than a decade ago ERAS did not improve them at national level.

Outcomes in the elderly patient following enhanced recovery pathways for elective lower-limb arthroplasty surgery

INTRODUCTION

Enhanced recovery pathways (ERPs) have been shown to reduce both morbidity and mortality, as well as length of stay, in very elderly patients undergoing joint replacement surgery. However, their impact on patient-reported outcome measures (PROMs) in this vulnerable cohort of patients has not previously been investigated.

METHODS

Oxford Hip and Knee Scores were collected pre- and postoperatively for patients undergoing joint replacement surgery at Wrexham Maelor Hospital, along with data on patient demographics.

RESULTS

Of the 646 who had total hip replacements, 32 (4.95%) were aged 85 years or over, and of the 875 who had total knee replacements, 39 (4.46%) were aged 85 years or over. Similarly to younger patients, those over the age of 85 years saw a benefit in the outcome at 6 months and 24 months following elective hip and knee arthroplasty on an ERP. This was reflected by a significant increase in the outcome scores at 6 months postoperatively in both age groups undergoing either a total hip replacement or total knee replacement.

CONCLUSIONS

We found no detrimental effect of ERPs on PROMs data in older patients. In fact, these patients saw a similar benefit in outcome following elective hip and knee arthroplasty as the younger cohort.

Enhanced recovery after surgery program in older patients undergoing gynaecologic oncological surgery is feasible and safe

BACKGROUND

Enhanced Recovery After Surgery Programs (ERP) include multimodal approaches of perioperative patient's clinical pathways designed to achieve early recovery after surgery and a decreased length of hospital stay (LOS). By allowing patients to return rapidly to their everyday surroundings, older patients are those who could take the greatest benefit from ERP. This is the first study to date to assess feasibility and safety of ERP on older patients undergoing gynaecologic oncological surgery.

METHODS

Data were prospectively collected between December 2015 and September 2017 at the Institut Paoli-Calmettes, a French comprehensive cancer centre. All the patients included in the study were referred for hysterectomy and/or pelvic or para-aortic lymphadenectomy for gynaecological cancer. The primary objective was to achieve similar LOS in patients ≥70 years old compared to younger patients without increasing the proportion of complications and readmission rates. A binary (LOS < or ≥ 2 days) logistic regression was built, including age, Charlson score, BMI, ASA score, oncological indication, surgical procedures and surgical approaches. G8 score was estimated for all the ≥70 years old patients.

RESULTS

Of a total of 329 patients, 75 were ≥70 years old and 254 were <70. Except a disparity in oncological indications with a higher proportion of endometrial cancer in the ≥70 years old group (56% vs. 27%; p < 0.01), there were no differences in patient's characteristics and surgical procedures. Age ≥ 70 years was associated with a longer LOS (means, 3.88 vs. 3.11 days; p = 0.024) only in univariate analysis. Considering the logistic regression, age was no longer associated with LOS. Total hysterectomy with pelvic lymphadenectomy and ASA score ≥ 3 were independently associated with longer LOS while mini-invasive techniques were associated with a shorter LOS. Morbidities and readmissions occurred respectively in 23% and 8% of the total population without any difference between the two groups. In the ≥70 years old population, G8 score was not predictive of LOS, morbidities or readmissions.

CONCLUSION

Although it is already widely accepted that ERP improves early recovery, our study shows that ERP for patients over 70 years of age undergoing gynaecologic oncological surgery is as safe and feasible as on younger patients.

Enhanced recovery after surgery for primary hip and knee arthroplasty: a review of the evidence

Enhanced recovery after surgery (ERAS) protocols produce significant clinical and economic benefits in a range of surgical subspecialties. There is a long tradition of applying clinical pathways to the perioperative care of joint arthroplasty patients. Enhanced recovery after surgery represents the next step in the evolution of standardized care. To date, reports of full ERAS pathways for hip or knee arthroplasty are lacking. In this narrative review, we present the evidence base that can be usefully applied to constructing ERAS pathways for hip or knee arthroplasty. The history and rationale for applying ERAS to joint arthroplasty are explained. Evidence demonstrates improved outcomes after joint arthroplasty when a standardized approach to care is implemented. The efficacy of individual ERAS components in hip or knee replacement is considered, including preoperative education, intraoperative anaesthetic techniques, postoperative analgesia, and early mobilization after joint arthroplasty. Interventions lacking high-quality evidence are identified, together with recommendations for future research. Based on currently available evidence, we present a model ERAS pathway that can be applied to perioperative care of patients undergoing hip or knee arthroplasty.

Perioperative Nutritional Optimization in Spine Surgery

Nutritional optimization in patients undergoing spine surgery is important as improved surgical outcomes and decreased rates of complications have been noted in optimized patients. With the increasingly high numbers of elderly patient and patients with metabolic comorbidities undergoing spine procedures, perioperative nutritional status should be enhanced for the best possible surgical outcomes. Methods of optimization include preoperative screening with Nutritional Risk Score or other scoring systems, looking for changes in body mass index, detecting sarcopenia, and screening for metabolic abnormalities. Assessment of blood glucose, electrolytes, cholesterol, vitamin levels, visceral proteins, and lean body mass must be done preoperatively and close monitoring should be continued postoperatively. Albumin helps to determine the health status of patients before surgery and prealbumin as a predictor of surgical outcomes is being investigated. Malnourished patients should be given balanced diets replenishing key nutrient deficits, glucose should be maintained with sliding scale insulin or continuous infusions and immunonutrition may be implemented. Postoperatively, patients should initiate a diet as soon as possible to decrease overall length of stay and complication rates, facilitating return to normal activities.

Changing Patient Expectations Decreases Length of Stay in an Enhanced Recovery Program for THA

BACKGROUND

The implementation of care pathways in hip arthroplasty programs has been shown to result in a decreased length of stay (LOS), but often multiple elements of a care pathway are implemented at the same time. As a result, it is difficult to understand the impact each of the individual modifications has made to the patient's prepathway care. In particular, it is unknown what the role of patient expectations pertaining to anticipated LOS alone is on the LOS after primary THA.

QUESTIONS/PURPOSES

(1) Does changing the patient's expectations regarding his or her anticipated LOS, without intentionally changing the rest of the care pathway, result in a change in the patient's LOS after primary THA? (2) Is the resultant LOS associated with the patient's age, gender, or day of the week the surgery was performed?

METHODS

We retrospectively compared the LOS in 100 consecutive patients undergoing THA immediately after the implementation of a 4-day care pathway (4-day Group) with 100 consecutive patients, 3 months later, who were also in the same pathway but were told by their surgeon preoperatively and in the hospital to expect a LOS of 2 days (2-day Group). Aside from reeducation by the surgeon, there was no difference in the surgery or intentional changes to the intraoperative or postoperative management of the two groups. Only the patient and the surgeon were made aware of the accelerated discharge plan. We compared the LOS between the two groups and the number of patients who met their discharge goal. As well, the ability to meet the discharge goal for each group was further determined based on age, gender, and day of the week the surgery was performed.

RESULTS

Overall, patients in the 2-day Group had a shorter LOS than those in the 4-day Group (2.9 ± 0.88 days versus 3.9 ± 1.71 days; mean difference 1 day; 95% confidence interval [CI], 0.60-1.36; p = 0.001). In the 2-day Group, the LOS was 2 days in 32% compared with 8% in the 4-day Group (odds ratio, 4.0; 95% CI, 1.76-9.11; p < 0.001). Men in the 4-day Group had a shorter LOS than women (3.4 ± 1.22 days versus 4.2 ± 1.89 days; mean difference 0.8 days; 95% CI, 0.17-1.78; p = 0.019), but there was no difference in LOS by gender in the 2-day Group (2.8 ± 0.81 days versus 3.1 ± 0.93 days; mean difference 0.3 days; 95% CI, -0.14 to 0.61; p = 0.219). For all patients > 40 years and < 90 years of age, a greater percentage of patients in the 2-day Group went home by postoperative day 2 than those in the 4-day Group (32% compared with 7%; odds ratio, 4.6; p < 0.001). In both groups, there was no difference in the LOS if the surgery was on Friday compared with an earlier day of the week (4-day Group: 3.4 ± 0.67 days versus 4.0 ± 1.80 days; p = 0.477 and 2-day Group: 2.8 ± 0.62 days versus 3.0 ± 0.93 days; p = 0.547).

CONCLUSIONS

We found that a surgeon who sets a clear expectation in terms of LOS could achieve a reduction in this parameter. Although it is impossible to be certain in the context of a retrospective study whether other caregivers adjusted the pathway in response to the surgeon's preferences, and we suspect this probably did occur, this still points to an opportunity on the topic of expectations setting that future studies should explore. This study highlights the influence patient education and expectations has on the effectiveness of care pathways in THA as well as the importance of continuous reinforcement of discharge planning both preoperatively and in the hospital.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Trends and determinants of length of stay and hospital reimbursement following knee and hip replacement: evidence from linked primary care and NHS hospital records from 1997 to 2014

OBJECTIVES

To measure changes in length of stay following total knee and hip replacement (TKR and THR) between 1997 and 2014 and estimate the impact on hospital reimbursement, all else being equal. Further, to assess the degree to which observed trends can be explained by improved efficiency or changes in patient profiles.

DESIGN

Cross-sectional study using routinely collected data.

SETTING

National Health Service primary care records from 1995 to 2014 in the Clinical Practice Research Datalink were linked to hospital inpatient data from 1997 to 2014 in Hospital Episode Statistics Admitted Patient Care.

PARTICIPANTS

Study participants had a diagnosis of osteoarthritis or rheumatoid arthritis.

INTERVENTIONS

Primary TKR, primary THR, revision TKR and revision THR.

PRIMARY OUTCOME MEASURES

Length of stay and hospital reimbursement.

RESULTS

10 260 primary TKR, 10 961 primary THR, 505 revision TKR and 633 revision THR were included. Expected length of stay fell from 16.0 days (95% CI 14.9 to 17.2) in 1997 to 5.4 (5.2 to 5.6) in 2014 for primary TKR and from 14.4 (13.7 to 15.0) to 5.6 (5.4 to 5.8) for primary THR, leading to savings of £1537 and £1412, respectively. Length of stay fell from 29.8 (17.5 to 50.5) to 11.0 (8.3 to 14.6) for revision TKR and from 18.3 (11.6 to 28.9) to 12.5 (9.3 to 16.8) for revision THR, but no significant reduction in reimbursement was estimated. The estimated effect of year of surgery remained similar when patient characteristics were included.

CONCLUSIONS

Length of stay for joint replacement fell substantially from 1997 to 2014. These reductions have translated into substantial savings. While patient characteristics affect length of stay and reimbursement, patient profiles have remained broadly stable over time. The observed reductions appear to be mostly explained by improved efficiency.

Clinical Considerations for the Use Lower Extremity Arthroplasty in the Elderly

There is an increase in the aging population that has led to a surge of reported cases of osteoarthritis and a greater demand for lower extremity arthroplasty. This article aims to review the current treatment options and expectations when considering lower extremity arthroplasty in the elderly patient with an emphasis on the following subjects: (1) updated clinical guidelines for the management of osteoarthritis in the lower extremity, (2) comorbidities and risk factors in the surgical patient, (3) preoperative evaluation and optimization of the surgical patient, (4) surgical approach and implant selection, and (5) rehabilitation and life after lower extremity arthroplasty.

Enhanced recovery principles applied to revision hip and knee arthroplasty reduces length of stay and blood transfusion

INTRODUCTION

This is the first study reporting the application of Enhanced Recovery Principles (ERP) to revision arthroplasty.

METHOD

Retrospective series of 132 revision hip and knee replacements treated with ERP.

RESULTS

Infiltration was associated with reduced LOS in knees (6 vs 8.5 days), lower PCA usage and incidence of transfusion in knees (2 vs 3 days) and hips (1 vs 6 days). Revisions for infection had a longer LOS (5.4 vs 11.5 days p = 0.001), a greater use of PCA and a higher incidence of transfusion (5 vs 0) in both knees and hips.

DISCUSSION

The application of ERPs to revision arthroplasty is safe. Infiltration appears to be an important factor in improving outcome measures.

Discharge to Inpatient Facilities After Total Hip Arthroplasty Is Associated With Increased Postdischarge Morbidity

BACKGROUND

Discharge disposition accounts for significant variability in costs after elective total hip arthroplasty (THA). Therefore, institutions must evaluate the short-term clinical outcomes associated with postdischarge care options. The present study intends to characterize the associations between short-term morbidity after primary THA and discharge destination.

METHODS

Primary elective unilateral THA cases performed for osteoarthritis were identified in the American College of Surgeons National Surgical Quality Improvement Program registry from 2011 to 2014. Propensity scores were used to adjust for selection bias in discharge destination, based on demographics, obesity class, preoperative functional status, modified Charlson comorbidity index, American Society of Anesthesiologists (ASA) class, and the presence of predischarge complications. Propensity-adjusted multivariate logistic regressions were used to examine associations between discharge destination and postdischarge complications, controlling for selection bias based on observable patient characteristics.

RESULTS

Among 54,837 THA cases included in the study, 40,576 (74%) were discharged home, and 14,261 (26%) were discharged to inpatient facilities. In multivariate propensity-adjusted analyses, patients discharged to continued inpatient care after THA were more likely to have septic complications (odds ratio, 2.34; 95% confidence interval, 1.58-3.45), urinary complications (1.51; 1.21-1.90), readmission (1.44; 1.29-1.59), wound complications (1.31; 1.09-1.57), and respiratory complications (1.93; 1.21-3.07).

CONCLUSION

Discharge to continued inpatient care following THA is associated with increased odds of postdischarge morbidity and unplanned readmission, after propensity score adjustment for predischarge characteristics. Additional research is needed on the impact of devoting resources toward facilitating discharge to home after THA.

A Patient-Focused Technology-Enabled Program Improves Outcomes in Primary Total Hip and Knee Replacement Surgery

Background:

A patient-engagement and pathway-management program for patients undergoing primary total hip and knee replacement was evaluated. Health-service and multimedia features supported by technology were integrated with existing enhanced recovery after surgery (ERAS) practices. The primary objective was to demonstrate the impact on length of stay. The secondary objective was to assess the impact on clinical, patient-focused, and financial outcomes.

Methods:

Two thousand and eighty consecutive patients undergoing primary total hip replacement (n = 1,034) and total knee replacement (n = 1,046) were classified into “pre-program” (retrospectively assessed [n = 1,038]) and “program” (prospectively assessed [n = 1,042]) cohorts. Patients in the program cohort were subdivided according to those who were eligible for criteria-based outreach support (OS) (n = 401) and those who were ineligible for this service (NOS) (n = 641). Clinical outcomes were assessed for all patients, and patient-focused outcomes were assessed for a subset (n = 223).

Results:

The mean reduction in length of stay ranged from 20% (1.2 days) to 42% (2.5 days) following total hip replacement and from 9% (0.6 day) to 31% (2 days) following total knee replacement (p < 0.001). Clinical outcomes (readmissions, complications, emergency department re-attendance rates) were not significantly negatively impacted. The Oxford Hip Score had numerically larger improvement after total hip replacement in the OS group than in the pre-program group (4.1-point increase), and the Oxford Knee Score had numerically larger improvement after total knee replacement in the NOS group than in the pre-program group (0.8-point increase). The patients in the program cohort (either OS or NOS) rated overall health gain as higher than those in the pre-program cohort (gain in numerical rating scale, 1.4 points for patients managed with total hip replacement, 0.6 points for patients managed with total knee replacement). Older patients and those with higher comorbidity indices benefited most with respect to length of stay and multiple clinical outcomes. Patient experience was significantly improved across domains (p < 0.001 to p = 0.003). Potential savings for patients managed with total hip replacement (£401.64 [$267.76] per patient) exceeded estimated program charges of £50 [$33.33] to £60 [$40] per patient, whereas the potential savings for patients managed with total knee replacement (£76.67 [$51.11] per patient) were sufficient to achieve a reduction of total system costs.

Conclusions:

Technology-enabled programs may deliver enhanced care at lower costs for patients undergoing lower-limb arthroplasty. Shorter durations of inpatient stay without a negative impact on clinical outcomes and improved patient-focused outcomes and experience can deliver substantial value that can be especially beneficial for older patients and those with greater medical complexity.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Postoperative Morbidity and Discharge Destinations After Fast-Track Hip and Knee Arthroplasty in Patients Older Than 85 Years

BACKGROUND

Elderly patients are at risk of increased length of hospital stay (LOS), postoperative complications, readmission, and discharge to destinations other than home after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). Recent studies have found that enhanced recovery protocols or fast-track surgery can be safe for elderly patients undergoing these procedures and may result in reduced LOS. However, detailed studies on preoperative comorbidity and differentiation between medical and surgical postoperative morbidity in elderly patients are scarce. The aim of this study was to provide detailed information on postoperative morbidity resulting in LOS >4 days or readmissions <90 days after fast-track THA and TKA in patients ≥85 years.

METHODS

This is a descriptive, observational study in consecutive unselected patients ≥85 years undergoing fast-track THA/TKA. The primary outcome was the causes of postoperative morbidity leading to an LOS of >4 days. Secondary outcomes were 90-day surgically related readmissions, discharge destination, 90-day mortality, and role of disposing factors for LOS >4 days and 90-day readmissions. Data on preoperative characteristics were prospectively gathered using patient-reported questionnaires. Data on all admissions were collected using the Danish National Health Registry, ensuring complete follow-up. Any cases of LOS >4 days or readmissions were investigated through review of discharge forms or medical records. Backward stepwise logistic regression was used for analysis of association between disposing factors and LOS >4 days and 90-day readmission.

RESULTS

Of 13,775 procedures, 549 were performed in 522 patients ≥85 years. Median age was 87 years (interquartile range, 85-88) and median LOS of 3 days (interquartile range, 2-5). In 27.3% procedures, LOS was >4 days, with 82.7% due to medical causes, most often related to anemia requiring blood transfusion and mobilization issues. Use of walking aids was associated with LOS >4 days (odds ratio [OR], 1.99; 95% confidence interval [CI], 1.26-3.15; P = 0.003), whereas preoperative anemia showed borderline significance (OR, 1.52; 95% CI, 0.99-2.32; P = 0.057). Thirty-eight patients (6.9%) were not discharged directly home, of which 68.4% had LOS >4 days. Readmission rates were 14.2% and 17.9% within 30 and 90 days, respectively, and 75.5% of readmissions within 90 days were medical, mainly due to falls and suspected but disproved venous thromboembolic events. Preoperative anemia was associated with increased (OR, 1.81; 95% CI, 1.13-2.91; P = 0.014) and living alone with decreased (OR, 0.50; 95% CI, 0.31-0.80; P = 0.004) risk of 90-day readmissions. Ninety-day mortality was 2.0%, with 1.0% occurring during primary admission.

CONCLUSIONS

Fast-track THA and TKA with an LOS of median 3 days and discharge to home are feasible in most patients ≥85 years. However, further attention to pre- and postoperative anemia and the pathogenesis of medical complications is needed to improve postoperative outcomes and reduce readmissions.

Fast track in hip arthroplasty

‘Fast-track’ surgery was introduced more than 20 years ago and may be defined as a co-ordinated peri-operative approach aimed at reducing surgical stress and facilitating post-operative recovery.

The fast-track programmes have now been introduced into total hip arthroplasty (THA) surgery with reduction in post-operative length of stay, shorter convalescence and rapid functional recovery without increased morbidity and mortality. This has been achieved by focusing on a multidisciplinary collaboration and establishing ‘fast-track’ units, with a well-defined organisational set-up tailored to deliver an accelerated peri-operative course of fast-track surgical THA procedures.

Fast-track THA surgery now works extremely well in the standard THA patient. However, all patients are different and fine-tuning of the multiple areas in fast-track pathways to get patients with special needs or high co-morbidity burden through a safe and effective fast-track THA pathway is important.

In this narrative review, the principles of fast-track THA surgery are presented together with the present status of implementation and perspectives for further improvements.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160060. Originally published online at www.efortopenreviews.org

A comparison between the direct anterior and posterior approaches for total hip arthroplasty: the role of an 'Enhanced Recovery' pathway

AIMS

We assessed the difference in hospital based and early clinical outcomes between the direct anterior approach and the posterior approach in patients who undergo total hip arthroplasty (THA).

PATIENTS AND METHODS

The outcome was assessed in 448 (203 males, 245 females) consecutive patients undergoing unilateral primary THA after the implementation of an 'Enhanced Recovery' pathway. In all, 265 patients (mean age: 71 years (49 to 89); 117 males and 148 females) had surgery using the direct anterior approach (DAA) and 183 patients (mean age: 70 years (26 to 100); 86 males and 97 females) using a posterior approach. The groups were compared for age, gender, American Society of Anesthesiologists grade, body mass index, the side of the operation, pre-operative Oxford Hip Score (OHS) and attendance at 'Joint school'. Mean follow-up was 18.1 months (one to 50).

RESULTS

There was no significant difference in mean length of stay (p = 0.07), pain scores on the day of surgery, the first, second and third post-operative days (p = 0.36, 0.23, 0.25 and 0.59, respectively), the day of mobilisation (p = 0.12), the mean OHS at six and 24 months (p = 0.08, and 0.29, respectively), the incidence of infection (p = 1.0), dislocation (p = 1.0), re-operation (p = 0.21) or 28 days' re-admission (p = 0.06). Significantly more patients in the DAA group achieved a planned discharge target of three days post-operatively (68% vs 56%, p = 0.007). The rate of periprosthetic femoral fractures was significantly higher in the DAA group (p = 0.04).

CONCLUSION

We conclude that there is no difference in clinical outcomes between the DAA and the posterior approach in patients undergoing THA when an 'Enhanced Recovery' pathway is used. However, a significantly higher rate of periprosthetic femoral fractures remains a concern with the DAA, even in experienced hands.

TAKE HOME MESSAGE

Our results show that the DAA for THA is not superior to posterior approach when 'Enhanced Recovery' pathway is used. Cite this article: Bone Joint J 2016;98-B:754-60.

Preoperative education prior to elective knee arthroplasty surgery does not change patient outcomes

Enhanced recovery programmes have improved outcomes following elective arthroplasty surgery. There are few studies assessing the role of patient education. In our enhanced recovery programme, all patients are offered the chance to attend a preoperative education class. Not all patients attend, enabling a comparison of outcomes. We have published data demonstrating that patients undergoing hip arthroplasty have improved outcomes. In the present article, we present data for total knee arthroplasty. Using a prospectively collected database, we identified all patients undergoing elective primary total knee arthroplasty. Data were assessed to look at patient outcomes. This was analysed using non-parametric tests. Between April 2009 and March 2013, 563 patients underwent elective total knee replacement. A total of 503 attended the class and 60 did not. Patients attending had a reduced length of stay when compared with the non-attenders but this did not reach statistical significance (4.13 days versus 4.57 days; p = 0.118). The spread of length of stay was slightly larger in the group that attended. Our analysis demonstrated that, for these patients, there is no statistically significant difference in length of stay or outcome scores. Therefore, in tougher economic times it may be prudent to focus preoperative education on total hip arthroplasty patients if resources are limited.

How Receptive Are Patients With Late Stage Cancer to Rehabilitation Services and What Are the Sources of Their Resistance?

OBJECTIVE

To describe the proportion and characteristics of patients with late stage cancer that are and are not receptive to receiving rehabilitation services, and the rationale for their level of interest.

DESIGN

Prospective mixed-methods study.

SETTING

Comprehensive cancer center in a quaternary medical center.

PARTICIPANTS

Adults with stage IIIC or IV non-small cell or extensive stage small cell lung cancer (N=311).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Telephone-acquired responses to the administration of (1) the Activity Measure for Post Acute Care Computer Adaptive Test (AM-PAC-CAT); (2) numerical rating scales for pain, dyspnea, fatigue, general emotional distress, and distress associated with functional limitations; (3) a query regarding receptivity to receipt of rehabilitation services, and (4) a query about rationale for nonreceptivity.

RESULTS

Overall, 99 (31.8%) of the study's 311 participants expressed interest in receiving rehabilitation services: 38 at the time of enrollment and an additional 61 during at least 1 subsequent contact. Participants expressing interest were more likely to have a child as primary caregiver (18.18% vs 9.91%, P=.04) and a musculoskeletal comorbidity (42.4% vs 31.6%, P=.05). Function-related distress was highly associated with receptivity, as were lower AM-PAC-CAT scores. Reasons provided for lack of interest in receiving services included a perception of their limited benefit, being too busy, and prioritization below more pressing tasks/concerns.

CONCLUSIONS

One-third of patients with late stage lung cancer are likely to be interested in receiving rehabilitation services despite high levels of disability and related distress. These findings suggest that patient misperception of the role of rehabilitation services may be a barrier to improved function and quality of life. Efforts to educate patients on the benefits of rehabilitation and to more formally integrate rehabilitation as part of comprehensive care may curb these missed opportunities.

Incisional negative pressure wound therapy dressings (iNPWTd) in routine primary hip and knee arthroplasties: A randomised controlled trial

Objectives

Wound complications are reported in up to 10% hip and knee arthroplasties and there is a proven association between wound complications and deep prosthetic infections. In this randomised controlled trial (RCT) we explore the potential benefits of a portable, single use, incisional negative pressure wound therapy dressing (iNPWTd) on wound exudate, length of stay (LOS), wound complications, dressing changes and cost-effectiveness following total hip and knee arthroplasties.

Methods

A total of 220 patients undergoing elective primary total hip and knee arthroplasties were recruited into in a non-blinded RCT. For the final analysis there were 102 patients in the study group and 107 in the control group.

Results

An improvement was seen in the study (iNPWTd) group compared to control in all areas. Peak post-surgical wound exudate was significantly reduced (p = 0.007). Overall LOS reduction (0.9 days, 95% confidence interval (CI) -0.2 to 2.5) was not significant (p = 0.07) but there was a significant reduction in patients with extreme values of LOS in the iNPWTd group (Moses test, p = 0.003). There was a significantly reduced number of dressing changes (mean difference 1.7, 95% CI 0.8 to 2.5, p = 0.002), and a trend to a significant four-fold reduction in reported post-operative surgical wound complications (8.4% control; 2.0% iNPWTd, p = 0.06).

Conclusions

Based on the results of this RCT incisional negative pressure wound therapy dressings have a beneficial role in patients undergoing primary hip and knee arthroplasty to achieve predictable length of stay, especially to eliminate excessive hospital stay, and minimise wound complications.

Cite this article: S. L. Karlakki, A. K. Hamad, C. Whittall, N. M. Graham, R. D. Banerjee, J. H. Kuiper. Incisional negative pressure wound therapy dressings (iNPWTd) in routine primary hip and knee arthroplasties: A randomised controlled trial. Bone Joint Res 2016;5:328–337. DOI: 10.1302/2046-3758.58.BJR-2016-0022.R1

Enhanced recovery after surgery: An opportunity to improve fractured neck of femur management

Introduction Approximately 67,000 hip fractures occurred in England, Wales and Northern Ireland in 2014, and annual hospital costs for fracture are around £1.1 billion. We review the potential scope for improving length of stay (LOS). Methods Hospital Episode Statistics data on non-elective admissions to 137 hospital trusts between November 2013 and October 2015 with a primary diagnosis of fractured neck of femur were analysed. The primary outcome was superspell LOS, which is the total LOS for all related spells for a single patient during an episode of care. Secondary outcomes were discharge to home, readmission at 28 days and in-hospital mortality. Results The mean observed LOS was 22.1±3.8 days (range 12.3-33.7 days). The range for case mix-adjusted expected LOS was 21.5-24.4 days. On average, 6.7±1.5% (range 3.6%-10.9%) of patients died while in hospital, at a relative risk of in-hospital mortality of 28.2-182.9. A mean of 12.3±3.2% (range 3.9% to 23.0%) of patients were readmitted at 28 days, at a relative relative risk of 34.8-203.2. Conclusions The wide range of observed LOS in our study is unlikely to be due to the case mix, as the case mix-adjusted range of LOS is less than 3 days, but rather due to local processes and pathways. There is therefore considerable scope for quality and efficiency of care improvements in our hospitals. We propose this could be best achieved if clinicians experienced in enhanced recovery focused on FNOF pathways.