Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: a systematic review

Multi-domain Postoperative Recovery Trajectories after Lumbar and Thoracolumbar Spine Surgery

BACKGROUND CONTEXT

Understanding early postoperative recovery is crucial for improving perioperative care and long-term outcomes. Traditional recovery assessments relying primarily on cross-sectional patient-reported measures may not fully capture the complexity of the recovery process.

PURPOSE

Our study evaluates early postoperative recovery using mobile health assessment and explores the relationship between early recovery patterns, multi-domain recovery, and long-term outcomes.

STUDY DESIGN/SETTING

A prospective observational study.

PATIENT SAMPLE

A total of 129 patients were included in the analysis.

OUTCOME MEASURES

Patient-reported outcome measures (PROMs) of pain, physical function, and disability at 1, 6 and 12 months postoperatively.

METHODS

This study recruited patients aged 21-85 undergoing lumbar/thoracolumbar surgery for degenerative diseases. During the first month postoperatively, patients completed daily Ecological Momentary Assessment (EMA) surveys assessing pain, depression, and physical function and were passively monitored with Fitbit. EMA and Fitbit data (steps per minute, Maximum 30-minute cadence, and activity bout number) were clustered using functional principal component analysis.

RESULTS

129 patients were included (median age: 62; 56% female). Two dominant recovery patterns were identified across all domains. At 12 months, patients with more favorable recovery across all domains except for activity bout number and depression, showed better outcomes. Favorable recovery in pain intensity and steps per minute was associated with greater improvements in all outcomes, while favorable recovery in maximum 30-minute cadence was associated with greater improvement in disability and physical function. Patients with less favorable pain recovery had a significantly higher complication rate (23 vs 7%). A greater number of favorable recovery domains was associated with better 12-month outcomes improvement and demonstrated superior prognostic value compared to traditional patient assessment methods.

CONCLUSION

Early postoperative recovery patterns and multi-domain recovery, captured using mHealth tools, provide valuable insights into long-term outcomes. With further validation, these findings highlight the potential of integrating mHealth into clinical practice to personalize rehabilitation strategies, improve resource allocation, and enhance patient care.

Enhanced Recovery With Combined Epidural and General Anesthesia in Children With Cerebral Palsy Undergoing Hip Reconstructive Surgery: A National Cohort Study

BACKGROUND

Pediatric patients with cerebral palsy (CP) undergoing hip reconstruction face significant postoperative pain challenges. This study aimed to assess the efficacy and safety of epidural anesthesia combined with general anesthesia compared with general anesthesia alone in reducing postoperative opiate usage, postoperative complications, and length of hospital stay in this vulnerable population.

METHODS

A retrospective cohort study was conducted, analyzing medical records of pediatric CP patients who underwent bilateral proximal femoral osteotomy between 2003 and 2023, using a large national US health care database. Patients were dichotomized into 2 groups based on anesthesia technique: general anesthesia only (General) and general anesthesia with adjunct epidural anesthesia (Epidural). The primary outcome measured was the use of IV opiates within the first 3 days postoperation. Secondary outcomes included the use of per os (PO) opiates, length of stay (LOS), and postoperative complications such as ICU admission, mortality, pneumonia, respiratory failure, urinary retention, and urinary tract infections within 90 days postoperatively. Patient characteristics, including age, BMI percentile, gastrostomy and tracheostomy status, as well as concomitant hamstring lengthening and pelvic osteotomy, were propensity matched between groups.

RESULTS

In total, 1303 CP patients were identified, including 502 patients with general plus epidural anesthesia and 801 patients with general anesthesia only. After matching, there remained 361 patients in each group (a total of 722 patients who were included for analysis). The Epidural group demonstrated a significantly lower proportion of IV opiate usage within the first 3 days postoperation. There were no significant differences in the rates of ICU admissions, mortality, pneumonia, respiratory failure, urinary retention, or urinary tract infections between groups. However, the general plus epidural anesthesia group demonstrated lower usage of PO opiates 90 days postoperatively compared with the general anesthesia only group. The epidural group further demonstrated a 1.3-days shorter LOS.

CONCLUSIONS

The addition of epidural anesthesia to general anesthesia in pediatric CP patients undergoing proximal femoral osteotomy reduces hospital stay and IV opioid use postoperatively, without increasing complications. These findings support considering epidural anesthesia to enhance recovery and reduce opioid-related side effects in these patients.

LEVEL OF EVIDENCE

Level III-therapeutic study.

Weekend versus Weekday Procedures for Total Knee Arthroplasty

This study compares the outcomes of elective total knee arthroplasty (TKA) on a weekday versus the weekend. Patients undergoing elective TKA from 2016 to 2020 were identified using the Healthcare Cost and Utilization Project database. Demographics and hospital-related outcomes including length of stay (LOS), total charges, pain, wound disruption, implant infection, and mortality, were collected. Perioperative outcomes were assessed from each patient's concurrent diagnoses. Multivariable analysis was performed. A total of 586,285 patients who underwent elective TKA were identified, of which 2,199 (0.37%) were performed on the weekend. Patients undergoing weekend TKA were slightly older (68.055 ± 9.882 vs. 66.699 ± 9.454, p < 0.001), and had a statistically significant predilection toward Asians, Hispanics, and Blacks (p < 0.001). No significant difference was present in gender, obesity, or preoperative conditions. Weekend TKA patients had increased odds of prolonged LOS (odds ratio [OR]: 1.154 for LOS ≥3 days, p = 0.002) and higher total charges (OR: 1.328, p < 0.001), along with higher odds of uncontrolled pain (OR: 1.257, p = 0.001) and implant infection (OR: 1.418, p = 0.004). No significant differences in wound disruption or mortality were found. Our findings indicate an association between weekend TKA and increased pain, implant infection, LOS, and cost, validating the presence of a weekend effect on TKA. Future research is needed to clarify the underlying causes of this association and feasible ways to mitigate its impact.

Radiographic and Clinical Outcomes After Direct Anterior Versus Mini Posterior Total Hip Arthroplasty

Background

Total hip arthroplasty (THA) is a successful surgical treatment for end-stage hip arthritis. There is controversy over whether the surgical approach leads to any differences in implant sizing, implant positioning, and clinical outcomes. This study sought to compare radiographic and clinical outcomes when performing primary THA through the direct anterior approach (DAA) and posterior approach (PA).

Methods

In this retrospective cohort study of patients undergoing primary THA, 198 DAA patients were matched to 198 PA patients. Surgeries were performed by 3 fellowship-trained surgeons. Radiographic parameters analyzed were acetabular cup anteversion and abduction angles, femoral stem coronal alignment, femoral offset, and leg-length discrepancy. Postoperative complications, including periprosthetic joint infection, wound complications, periprosthetic fracture, and dislocation, were extracted from the medical record. Statistical analysis was performed to compare radiographic and clinical outcomes between groups.

Results

There were no statistically significant differences for any postoperative complications between the 2 groups. One dislocation occurred in the PA group, and no dislocations occurred in the DAA group. DAA had a longer operative time (117 vs 79 minutes, P < .01). PA had a higher increase in femoral offset compared to the contralateral limb (2.76 mm vs 1.01 mm, P < .01), higher cup anteversion (26.17° vs 23.44°, P < .001), and higher use of dual mobility components (6.06% vs 1.01%, P = .007).

Conclusions

Both DAA and PA lead to acceptable clinical and radiographic outcomes for primary THA, with significant differences noted for cup position, femoral offset, and use of dual mobility components. These differences likely represent surgeon factors to help mitigate the risk for dislocation.

Atraumatic Dislocation After Arthroscopic Capsular Release in a Patient With Pseudocholinesterase Deficiency

A 68-year-old woman underwent arthroscopic capsular release and manipulation under general anesthesia for adhesive capsulitis. Six hours postoperatively, she suffered an anterior glenohumeral joint dislocation with passive forward flexion while working with physical therapy. Postoperative workup revealed pseudocholinesterase deficiency. Pseudocholinesterase deficiency may increase the risk of atraumatic glenohumeral dislocation in the immediate postoperative period. Caution should be taken concerning early physical therapy in these patients to minimize the risk of dislocation.

Thromboprophylaxis in patients admitted to inpatient rehabilitation and skilled nursing facilities post total joint arthroplasty

PURPOSE

Thromboprophylaxis has significantly reduced the incidence of venous thromboembolic events (VTE) after total joint arthroplasty (TJA). Recent studies have established protocols for VTE prevention using aspirin, given its comparable efficacy to prophylactic anticoagulants and a lower risk of bleeding complications. However, patients admitted to inpatient rehabilitation (IPR) or skilled nursing facilities (SNF) after TJA may require more potent agents due to an increased risk of VTE. This study aims to compare the incidence of symptomatic VTE and postoperative complications in TJA patients receiving aspirin versus anticoagulants in the setting of IPR and SNF.

METHODS

We reviewed an all-payer, national database for patients who had hip and/or knee osteoarthritis who underwent primary TJA between October 1, 2015 and April 30, 2021 (n = 713,548). Patients discharged to IPR or SNF were identified using CPT codes. A propensity score match was performed to limit potential confounders. Patients were stratified into aspirin (n = 2,343) and anticoagulant (n = 2,343) cohorts based on the postoperative VTE prophylaxis they received; anticoagulants included dabigatran, enoxaparin, heparin, rivaroxaban, and warfarin. Complications were identified using ICD-10 codes and included VTE, aseptic revision, cardiac complications, periprosthetic joint infections, surgical site infections, the need for transfusion, and wound complications 90 days after surgery.

RESULTS

The aspirin cohort had a VTE incidence of 4.4% compared to 2.3% in the anticoagulant cohort (p <.001), indicating nearly double the odds of VTE with aspirin use compared to anticoagulant. The odds ratio for VTE was 0.52 (95% CI: 0.37-0.72), with the aspirin cohort as the reference. Incidence rates of other complications were similar between the two cohorts.

CONCLUSION

This study demonstrates a higher risk of VTE with aspirin compared to anticoagulant in patients discharged to IPR or SNF after primary TJA. Surgeons should consider using rivaroxaban, enoxaparin, heparin, dabigatran, or warfarin for VTE prophylaxis instead of aspirin in these high-risk patients.

Effectiveness of a Supervised Patient Ambulation Program in Reducing Fall Risk Following Total Joint Arthroplasty

BACKGROUND

Total hip arthroplasty and total knee arthroplasty rank among the most prevalent orthopaedic procedures performed globally. Early mobilization postarthroplasty reduces complications, shortens length of stay, and optimizes recovery. However, the incidence of falls remains high, leading to complications and increased costs. Ensuring patient safety during mobilization is critical to minimizing fall risks.

METHODS

In 2014, our institution created a supervised patient ambulation program called "No One Walks Alone" (NOWA). A retrospective review of patients undergoing total knee arthroplasty or total hip arthroplasty between 2011 and 2017 was conducted. The inclusion criteria spanned the preimplementation group (2011 to 2013) (N = 3069) and the postimplementation group (2015 to 2017) (N = 3947). Patients in the postimplementation group were enrolled in the "No One Walks Alone" supervised ambulation program. Data on patient demographics, procedures, hospital stay, fall rates, and postfall complications were collected. A logistic regression analysis was done to identify fall risk factors, and statistical analyses were used to compare outcomes between the patient groups.

RESULTS

Inpatient fall rates decreased from 2.5 to 1.0 per 1000 inpatient days between the preimplementation and postimplementation groups, respectively. The difference in fall rates between the two periods was statistically significant (P value < 0.002). Fall-related complications were notably reduced in the postimplementation group. In addition, the postimplementation group saw a statistically and clinically notable reduction in average length of stay in the hospital compared with the preimplementation group by 0.75 days (P value < 0.001).

CONCLUSION

Implementation of a supervised ambulation program was found to markedly reduce fall rates, length of stay, and fall-related complications, demonstrating the importance of proactive interventions to improve patient safety following arthroplasty.

Postoperative delirium following total joint arthroplasty: epidemiology, risk factors, and associated complications

INTRODUCTION

Postoperative delirium (POD) is a feared complication following major surgery in elderly patients. Further investigation of the risk factors and consequences of POD following total joint arthroplasty is warranted.

METHODS

Patients who underwent total knee arthroplasty (TKA) or total hip arthroplasty (THA) were identified using PearlDiver. Patients were filtered into 2 cohorts based on the presence or absence of POD within 7 days of surgery. Epidemiological analyses were performed to examine trends in POD following TKA and THA by age group and year. Comparative analyses were performed on patient demographics and baseline cognitive status. After matching by age, sex, and comorbidities, electrolyte disturbances and 90-day postoperative complications were analysed.

RESULTS

Among 2,518,918 (99.7%) no POD and 7240 (0.3%) POD patients who underwent total knee or hip arthroplasty, mean age was 65.58 years, 60.2% were female, and mean CCI was 1.50 for the whole cohort. POD patients frequently had baseline cognitive impairment (P < 0.001). Incidence of POD decreased from 0.54% in 2010 to 0.10% in 2022 (P < 0.001) and increased with age (P < 0.001). POD patients had higher 90-day costs (TKA = $19,572 vs. $10,397, P < 0.001; THA = $18,496 vs. $9,877 P < 0.001). After matching, POD TKA patients had higher rates of hypernatraemia (6.1% vs 4.5%, P = 0.001) and POD THA patients had higher rates of hyponatraemia (26.5% vs 23.1%, P = 0.008). POD patients had higher rates of 90-day postoperative medical and surgical complications (P < 0.05) than no POD patients.

CONCLUSIONS

Nearly 0.3% of patients who underwent either TKA or THA between 2010 and 2022 developed transient delirium. POD was most common in elderly patients with baseline cognitive impairment undergoing revision surgery. POD patients had higher rates of 90-day postoperative surgical and joint-related complications. While POD rates have decreased, continued initiative to prevent POD in total joint arthroplasty patients is imperative.

Postoperative outcomes in patients operated for extra- and intracapsular hip fractures - a secondary analysis of two randomized controlled trials

BACKGROUND

Hip fractures are among the most common and serious injuries in older adults. There has been a perception that extracapsular hip fractures have worse outcome than intracapsular hip fractures. We aimed to examine postoperative outcomes in patients operated for extra- and intracapsular hip fractures.

METHODS

This is a secondary analysis of data from two randomized controlled trials evaluating the effect of orthogeriatric care. Bivariate analyses were conducted, comparing patients with extracapsular fracture to patients with intracapsular fracture. Mortality, length of hospital stay (LOS), new nursing home admissions, operative data and measures of functional and cognitive performance were assessed as endpoints.

RESULTS

The primary analysis included 711 patients; 283 patients had an extracapsular fracture and 428 an intracapsular fracture. At four months follow-up, the intracapsular fracture group had significantly better Short Physical Performance Battery (SPPB) (5.0 vs. 4.0, p = 0.007), personal Activities of Daily Living (p-ADL) (17.0 vs. 16.0, p = 0.007) and instrumental ADL (i-ADL) (32.5 vs. 28.0, p = 0.049). There were no statistically significant differences between the groups at 12 months.

CONCLUSIONS

Patients with an extracapsular fracture had worse mobility and ADL levels four months postoperatively, but there were no clinically relevant differences at 12 months postoperatively.

The factors determining early mobilization in elderly patients undergoing total knee replacement

BACKGROUND

Postoperative early mobilization after total knee replacement (TKR) is essential for preventing complications and offers numerous benefits. The purpose of this study was to evaluate the factors determining early mobilization (EM) after primary TKR and the effects on risk of falls and length of stay (LOS).

METHODS

This retrospective study recruited elder participants undergoing primary TKR. All patients were classified as EM(+), early mobilization (EM) within 24 h, or EM(-), delayed mobilization over 24 h. Demographic data, pain Visual Analog Scale (VAS), American Society of Anesthesiologists (ASA) score, perioperative blood pressure, postoperative pain control mode, medical catheters, dizziness or nausea/vomiting (PONV), falls during admission, and the LOS were collected.

RESULT

A total of 1759 elder participants undergoing primary TKR were enrolled. Mean age was 73.00 ± 8.11 years. Among them, there were 1260 EM(-) and 499 EM(+) cases, with no significant differences in sex, BMI, PONV, postoperative Patient Controlled Analgesia (PCA) mode, or the use of medical catheters, but age, higher ASA score, VAS, muscle strength, postoperative nausea, and substantial changes of blood pressure were significantly different between the two groups. A greater reduction in systolic blood pressure, when compared to the preoperative baseline blood pressure, was found in EM(-) patients than EM(+) patients on the operative day (13 vs. 4 mmHg, P < 0.001) and first day post-TKR (20 vs. 17 mmHg, P = 0.005). LOS in EM(-) patients was significant longer than that in EM(+) patients, but risk of falls was not significantly different.

CONCLUSIONS

Multiple factors influence patients' willingness to mobilize or ambulate earlier. However, more blood pressure reduction impeding early mobilization after TKR should be addressed. Maintaining post-TKR blood pressure without significant decreases is recommended for the successful mobilization after surgery. Early mobilization within 24 h after TKR may be beneficial in reducing the LOS and did not increase risk of falls.

Pericapsular Nerve Group Block Plus Lateral Femoral Cutaneous Nerve Block vs. Fascia Iliaca Compartment Block in Hip Replacement Surgery

Background: Optimal pain control with limited muscle weakness after total hip arthroplasty (THA) is paramount for a swift initiation of physical therapy and ambulation, thus expediting hospital discharge. FICB (Fascia Iliaca Compartment Block) has been recommended because it offers pain control with a low risk of motor block. PENG (Pericapsular Nerve Group) block with LFCN (Lateral Femoral Cutaneous Nerve) has been proposed as an alternative that offers comparable pain control with a lower risk of motor block; however, evidence is limited. We aimed to investigate the degree of muscle weakness and pain control with PENG + LFCN. Methods: Patients undergoing elective THA from November 2022 to October 2023 have been retrospectively analyzed. The degree of quadriceps femoris muscle paresis was assessed with the MRC scale at 6 h postoperatively. Secondary outcomes: NRS score at 6, 12, and 24 h, total opioid consumption, and time to first rescue opioid. Results: In total, 80 patients were included in the study, 57 received PENG + LFCN, and the remaining 23 received FICB. PENG + LCFN resulted in a higher MRC at 6 h (4 [4; 5] vs. 3 [2; 4] p = 0.0001) and better pain control (mean difference [95% CI] at 6 h, 0.93 [0.14; 1.72], at 12 h, 0.47 [-0.49; 1.43], and at 24 h, 0.39 [0.25; 1.2], p = 0.0006). Less PRN opioids were requested in the PENG + LFCN vs. FICB groups (7.5 [0; 15] MME vs. 60 [40; 80], p = 0.001). Conclusions: PENG + LFCN was associated with less muscle weakness, better pain control, and less rescue opioids in patients undergoing elective THA. A larger prospective study is needed to confirm this finding.

Immediate Versus Delayed Mobilization After Cubital Tunnel Release Surgery: A Systematic Review and Meta-analysis

Purpose: It is unknown whether early mobilization after cubital tunnel decompression improves functional outcomes without increasing complication risks. This systematic review aims to evaluate the effectiveness of early mobilization compared to delayed mobilization of the elbow after ulnar nerve decompression. Methods: Randomized controlled trials (RCTs) and observational studies comparing adults who received early mobilization or late mobilization were included. Embase, MEDLINE, CENTRAL, PEDro, clinicaltrials.gov, and the World Health Organization database were systematically searched from inception to January 2023. Results: Of the 2183 studies identified and screened, five studies (two RCT and three observational) totaling 224 patients (232 elbows) were included in this review. Evidence from two RCTs (100 patients) suggests that early mobilization may result in a large reduction in the amount of time needed to return to work (mean difference 40.1 days, 95% confidence interval [CI] 16-64 days earlier, I 2 = 85%, low-certainty evidence) and little to no difference in grip strength (0 kg, 95% CI = -0.17 to 0.17, I 2 = 0%, low-certainty evidence). There was little to no difference in adverse events or range of motion (low to very-low certainty evidence). Pooled results from the three observational studies showed similar findings (very low-certainty evidence). There were no studies that evaluated upper extremity related quality of life. Conclusion: Immobilizing patients for periods longer than 3 days appears to delay patient's return to work with no appreciable clinical benefit.

The anesthetic and recovery profiles of low-dose hypobaric mepivacaine and bupivacaine for spinal anesthesia in total hip and knee arthroplasty: a prospective observational study

PURPOSE

Same-day mobilization and early hospital discharge is increasingly emphasized following hip and knee arthroplasty. One challenge of spinal anesthesia in this setting is achieving adequate block height while avoiding excessively large local anesthetic doses and prolonged motor and sensory blockade. Using a hypobaric local anesthetic solution is one potential strategy, as its intrathecal distribution can be reliably manipulated by patient positioning to achieve adequate block height independent of dose.

METHODS

We conducted a prospective observational study to determine the clinical characteristics of spinal anesthesia with low-dose hypobaric mepivacaine and bupivacaine in patients undergoing hip and knee arthroplasty. Thirty patients scheduled for same-day discharge received 51 mg of hypobaric 1.5% mepivacaine and 30 patients scheduled for inpatient stay received 10 mg of hypobaric 0.33% bupivacaine.

RESULTS

The mean (standard deviation) time to achieve sensory blockade at or above L1 and T10 in the operative limb was 5.7 (1.8) and 7.3 (3.3) min with mepivacaine and 6.2 (2.6) and 8.1 (4.8) min with bupivacaine, respectively. Anesthesia was adequate for surgical commencement in all patients regardless of spinal injection level. Four patients required anesthetic supplementation for surgical completion. Sensory block duration at or above T10 and L1 in the operative limb was 97 (27) and 115 (37) min with mepivacaine and 127 (32) and 161 (34) min with bupivacaine, respectively. Motor function returned by 145 (37) and 217 (43) min in mepivacaine and bupivacaine groups, respectively.

CONCLUSION

The anesthetic profiles of low-dose hypobaric mepivacaine and bupivacaine were favorable for fast-track hip and knee arthroplasty with short and predictable operating times.

Discharge Destination of Patients in Fast-Track Primary Hip and Knee Arthroplasty: Results From a Prospective Danish Cohort

BACKGROUND

Following the implementation of the fast-track protocol in total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA), the median length of stay (LOS) has been significantly reduced without an increase in readmissions. However, it is unclear if the reduction in LOS is at the expense of an increase in nonhome discharge. The aim of this study was to investigate the discharge destination among THA, TKA, and UKA patients.

METHODS

The prospective multicenter study included 6,856 patients undergoing primary THA, TKA, and UKA in a fast-track setting with an overall median LOS of one day. Outcomes were discharge destination, median LOS in each discharge destination category, and cause of rehabilitation center discharge. Data were gathered using preoperative questionnaires and a review of medical records. Discharge destination and LOS were registered at discharge.

RESULTS

We found that 99% of patients had been discharged to their own homes, of which 21% had been discharged to their own homes with home care. There were 1% who were discharged to a rehabilitation facility and 0.1% who were discharged to a nursing home. The THA (1%, 95% confidence interval [CI] 0.7 to 1) and TKA (1%, 95% CI 0.9 to 2) had a significantly higher rate of discharge to a rehabilitation facility compared to UKA (0.1%, 95% CI 0.0 to 0.5).

CONCLUSIONS

Despite a short LOS, 99% of patients were discharged to their own homes. Rehabilitation facility discharge was only 1% and was mostly caused by inadequate postoperative mobilization.

Comparison of pericapsular nerve group and lateral quadratus lumborum blocks on cumulative opioid consumption after primary total hip arthroplasty: a randomized controlled trial

INTRODUCTION

Both the quadratus lumborum block (QLB) and the pericapsular nerve group (PENG) block provide effective postoperative analgesia after hip surgery while minimizing the impact on motor function. This study aimed to compare QLB and PENG in patients undergoing primary total hip arthroplasty (THA).

METHODS

This superiority trial randomized patients scheduled for elective THA to receive a lateral QLB or a PENG with a lateral femoral cutaneous nerve (LFC) block for postoperative analgesia. Perioperative analgesic protocols were standardized. The primary outcome was postoperative cumulative opioid consumption measured over time up to 72 hours. Secondary outcomes included postoperative pain scores in the first 72 hours, time to ambulation, length of stay, and patient-reported functional outcome measures (Hip disability and Osteoarthritis Outcome Score for Joint Replacement and Patient-Reported Outcome Measures Information System-10 scores).

RESULTS

This trial consented and randomized 106 subjects and 101 were included in the analysis: PENG (n=50), QLB (n=51). Mean (95% CI) opioid consumption in intravenous morphine milligram equivalents differed at 36 hours (mean difference (95% CI), 18.0 (0.80, 35.1); p=0.040), 48 hours (23.0 (5.20, 40.8); p=0.011), 60 hours (28.0 (9.24, 46.7); p=0.004), and 72 hours (33.0 (13.0, 53.0); p=0.001). There were no significant differences between treatment arms in average resting pain score, time to ambulation, rate of same-day discharge, length of stay, or patient-reported functional outcomes.

CONCLUSION

While both lateral QLB and PENG block+LFC block are effective analgesic methods for patients undergoing THA, patients receiving lateral QLB had decreased cumulative opioid consumption from 36 to 72 hours postoperative and lower pain scores with movement compared with patients receiving PENG+LFC blocks.

TRIAL REGISTRATION NUMBER

NCT05710107.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level II.

Driving Forces for Outpatient Total Hip and Knee Arthroplasty with Enhanced Recovery After Surgery Protocols: A Narrative Review

PURPOSE OF REVIEW

To explore the recent developments and trends in the anesthetic and surgical practices for total hip and total knee arthroplasty and discuss the implications for further outpatient total joint arthroplasty procedures.

RECENT FINDINGS

Between 2012 and 2017 there was an 18.9% increase in the annual primary total joint arthroplasty volume. Payments to physicians falling by 7.5% (14.9% when adjusted for inflations), whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively. Total knee arthroplasty and total hip arthroplasty surgeries were removed from the Medicare Inpatient Only in January 2018 and January 2020, respectively leading to same-day TKA surgeries increases from 1.2% in January 2016 to 62.4% by December 2020 Same-day volumes for THA surgery increased from 2% in January 2016 to 54.5% by December 2020. Enhanced Recovery After Surgery (ERAS) protocols have revolutionized modern anesthesia and surgery practices. Centers for Medicare Services officially removed total joint arthroplasty from the inpatient only services list, opening a new door for improved cost savings to patients and the healthcare system alike. In the post-COVID healthcare system numerous factors have pushed increasing numbers of total joint arthroplasties into the outpatient, ambulatory surgery center setting. Improved anesthesia and surgical practices in the preoperative, intraoperative, and postoperative settings have revolutionized pain control, blood loss, and ambulatory status, rendering costly hospital stays obsolete in many cases. As the population ages and more total joint procedures are performed, the door is opening for more orthopedic procedures to exit the inpatient only setting in favor of the ambulatory setting.

Effect of bupivacaine concentration on ultrasound-guided pericapsular group nerve block efficacy in hip surgery patients: comparative, randomized, double-blinded clinical trial

Background

The pericapsular nerve group (PENG) block offers effective postoperative pain relief following hip fracture surgery. This research investigated three doses of bupivacaine, all administered in the same total volume, for performing ultrasound-guided PENG blocks during hip fracture procedures.

Methods

This randomized, double-blinded clinical trial was conducted on 135 patients aged between 18 and 70 years of both sexes who underwent hip fracture surgeries. Participants were randomized into three groups (n = 45). Ultrasound-guided PENG block was applied, the groups received 20 mL of local anesthetics. The first group received 0.5% bupivacaine, the second group received 0.375% bupivacaine, and the third group received 0.25% bupivacaine. The following parameters were recorded: onset of sensory block, resting NRS after passively raising the limb by 15° half an hour post-procedure, quality of recovery score (QoR-15) at 24 h postoperative.

Results

The 0.25% bupivacaine group exhibited a longer sensory block onset than the other groups (p ≤ .05). Significant differences were demonstrated between the groups regarding the time to 1st analgesia (p = .033) and total morphine consumption (p = .025). NRS at baseline and T30 post-block did not show significant differences between the studied groups. No significant differences were detected postoperatively in rest and dynamic NRS (p ≤ .05). Patient satisfaction, QoR-15 score, and ease of spinal positioning did not differ between the groups.

Conclusion

Compared to 0.25% bupivacaine, PENG block with 0.5% and 0.375% bupivacaine provided a rapid onset sensory block, delayed first analgesic requirements, and reduced total morphine consumption after hip surgeries.

Protocol Registration

The trial was registered at the clinicaltrials.gov with study number (Trial ID: NCT05788458).

Early implementation of MAK robotic device in total knee arthroplasty rehabilitation: A proof-of-concept study

BACKGROUND

Effective rehabilitation following total knee arthroplasty (TKA) is crucial for enhancing both range of motion (ROM) and functional outcomes. While robotics has demonstrated its potential in various medical contexts, the evidence on its application in TKA rehabilitation is still scarce. The marsi active knee (MAK), a robotic device that has already proven to be safe and beneficial in people with neurological disease, has been tested to facilitate the rehabilitation of TKA patients.

OBJECTIVE

This study aims to evaluate the safety, patient satisfaction, and clinical impact of integrating the MAK into an early rehabilitation regimen for TKA patients.

METHODS

The intervention comprised 14 one-hour sessions administered thrice a week, utilizing the MAK within 48 h post-TKA surgery. The rehabilitation sessions incorporated exercises involving passive mobilizations, sit-to-stand transitions, and gait training. Comprehensive data encompassing safety parameters, patient satisfaction, and clinical outcomes were meticulously collected and analyzed.

RESULTS

Six participants successfully completed the rehabilitation protocol with the MAK device. Notably, no significant adverse events were documented. Application of the device corresponded to perceptible reductions in self-reported pain levels. Vital signs remained within minimal variance pre- and post-rehabilitation. Participants proficiently engaged in all assisted exercises facilitated by the device, culminating in a high overall satisfaction rating of 4.6 ± 0.5 out of 5.

CONCLUSION

The findings indicate that the MAK device exhibits a commendable level of safety while obtaining considerable patient satisfaction during the early rehabilitation phase following TKA, suggesting this device may be a reliable adjunct to TKA protocols.

Surgeon Factors Rather Than Patient Factors Account for Variation in Recommended Treatment Strategy for Patients With Multiligament Knee Injury

OBJECTIVES

To seek the factors associated with timing, staging, and type of surgery in the management of multiligament knee injuries.

METHODS

DESIGN

Cross-sectional scenario-based experiment.

SETTING

Fifteen fictional patient scenarios with randomized elements.

PARTICIPANTS

Fracture surgeons of the Science of Variation Group, an international collaborative of musculoskeletal surgeons who studies variation in care, were invited to participate. Surgeons with limited experience treating multiligament knee injuries were asked to self-exclude.

OUTCOME MEASURES AND COMPARISONS

Surgeon recommendations for operative treatment, timing of surgery, and use of open surgery in addition to arthroscopy were measured. Patient factors (age, time from injury, contralateral fracture, knee dislocation, combinations of ruptured ligaments, and preexisting osteoarthritis) and surgeon factors (gender, practice location, years of experience, and supervision of trainees) associated with surgeon recommendations were assessed.

RESULTS

Eighty-five surgeons participated, of which most were men (89%) and practiced in the United States (44%) or Europe (38%). Operative treatment was less likely among older patients (odds ratio [OR] = 0.051) and preexisting osteoarthritis (OR = 0.32) and more likely in knee dislocation (OR = 1.9) and disruption of anterior cruciate ligament, posterior cruciate ligament, and lateral collateral ligament with or without medial collateral ligament (MCL; OR = 5.1 and OR = 3.1, respectively). Disruption of anterior cruciate ligament, posterior cruciate ligament, and medial collateral ligament was associated with shorter time to surgery (β = -11). Longer time to surgery was associated with contralateral fracture (β = 9.2) and surgeons supervising trainees (β = 23) and practicing in Europe (β = 13). Surgeon factors accounted for more variation in timing than patient and injury factors (5.1% vs. 1.4%, respectively). Open surgery was more likely in patients with lateral collateral ligament injury (OR = 2.9 to 3.3).

CONCLUSIONS

The observation that surgeons were more likely to operate in younger patients with more severe injury has face validity, while the finding that surgeon factors accounted for more variation in timing of surgery than patient or injury factors suggests that treatment variation is based on opinion more so than evidence.

LEVEL OF EVIDENCE

Prognostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Ankylosing spondylitis in patients undergoing total hip arthroplasty increases the risk of medical and implant-related complications: a case control analysis

INTRODUCTION

Ankylosing spondylitis (AS) is an inflammatory spondyloarthropathy, often involving the spine and sacroiliac joints. Total hip arthroplasty (THA) has been shown to be effective in improving pain and function in patients with AS with hip involvement. However, extraskeletal manifestations and altered mechanics in those with AS leads to increased complications. Thus, the aims of this study were to assess the effects that AS has on medical and implant complications, falls, length of stay, and readmissions following THA.

METHODS

A retrospective review of the Mariner private insurance claims database was conducted from 2010 to 2020. All cases of THA and those with AS were identified using Current Procedural Terminology, and International Classification of Disease 9th and 10th revision codes. Patients who underwent THA with a diagnosis of AS were matched to non-AS patients 1:5 based on demographic and comorbidity profiles. 90-day medical complications, falls, and readmission rates, as well as 2-year implant complications were compared between cohorts.

RESULTS

A total of 6509 AS patients were matched to 32,489 control patients. The AS group had significantly higher rates of myocardial infarction, cerebrovascular accident, deep vein thrombosis, pulmonary embolism, urinary tract infection, wound complications, acute kidney injury, pneumonia, sepsis, transfusions, and falls when compared to the control group. The AS group had significantly higher rates of prosthetic joint infection, dislocation, mechanical loosening, and periprosthetic fracture (all p < 0.0001). Likewise, mean length of stay and readmissions were significantly greater in the AS group.

CONCLUSIONS

Ankylosing spondylitis in patients undergoing THA is associated with significant risk of medical and implant complications, as well as fall risk, length of stay, and readmission rates. These findings may allow orthopaedic surgeons to be more attentive in identifying those patients at risk and allow for more educated patient counseling and perioperative planning.

Recovery of Muscular Strength Following Total Hip Replacement: A Narrative Review

This narrative review analyzes muscle strength recovery following total hip replacement (THR) and looks at various factors affecting postoperative muscle function restoration. The review synthesizes evidence from various studies regarding the timing and degree of muscular strength recovery, different rehabilitation protocols, and patient-specific variables such as age, preoperative physical condition, and comorbidities, among others. Overall, it appears that THR is associated with improved hip function and quality of life, but this usually takes a long time due to individualized physical therapy interventions. In addition, postoperative rehabilitation has been found not to exist without any personal factors involved such as age or gender whereby for instance senior citizens have no alternative but to go for THR surgery, making their lower limbs weaker than those who are younger. Based on the findings in this review on muscle recovery after THR surgeries, one may conclude that this endeavor should begin as early as possible and include regular resistance training programs with performance-focused functional training after surgery. In addition, more longitudinal studies should be conducted regarding post-surgical outcomes comparing other traditional medical practices.

Comparison of Pericapsular Nerve Group and Lateral Quadratus Lumborum Blocks for Analgesia after Primary Total Hip Arthroplasty: A Randomized Controlled Trial

Introduction

The quadratus lumborum block (QLB) and the pericapsular nerve group (PENG) block both provide effective postoperative analgesia after hip surgery while minimizing impact on motor function. This study aimed to compare QLB and PENG in patients undergoing primary total hip arthroplasty.

Methods

This superiority trial randomized patients scheduled for elective total hip arthroplasty to receive a lateral QLB or PENG with lateral femoral cutaneous nerve blocks for postoperative analgesia. Perioperative analgesic protocols were standardized. The primary outcome was postoperative cumulative opioid consumption at 72 hours. Secondary outcome was postoperative pain scores. Additional outcomes of interest included time to first ambulation, length of stay, patient reported outcome measures, and opioid-related side effects.

Results

This trial consented and randomized 106 subjects and 101 were included in analysis: PENG (n=50), QLB (n=51). Mean (95% CI) opioid consumption (IV MME) in the first 72 hours did not differ between PENG [109.6 (93.6, 125.6)] and QL [92.3 (76.6, 107.9)] groups (p=0.129) There were no significant differences between treatment arms in average pain score, time to ambulation, distance ambulated, rate of same day discharge, or hospital length of stay. There were also no differences in patient reported outcomes using HOOS-JR and PROMIS-10 scores.

Conclusion

Patients undergoing primary THA receiving preoperative PENG vs QLB had similar opioid consumption, pain scores, time to ambulation, and hospital length of stay. Both QL and PENG blocks are analgesic options in patients undergoing primary THA.

Clinical Trials Registration

NCT05710107; www.ClinicalTrial.gov IRB Protocol ID: Pro00124880.

Key message

Pericapsular nerve group (PENG) block may provide analgesia after hip arthroplasty and improve early functional recovery. This study evaluated postoperative opioid consumption in patients randomized to PENG or lateral quadratus lumborum block (QLB).Opioid consumption, pain scores, motor recovery, and functional outcome measures did not differ in patients randomized to PENG vs lateral QLB.PENG and lateral QLBs are analgesic options following total hip arthroplasty with similar rates of same day discharge.

Comparison of the Effects of Adductor Canal and Femoral Nerve Blocks on Postoperative Opioid Consumption and Inflammatory Factor Levels in Elderly Patients After Total Knee Arthroplasty: A Prospective Observational Study

Purpose

Total Knee Arthroplasty (TKA) is a highly invasive procedure causing severe postoperative pain, which hampers early mobility. Effective pain management is crucial for optimal recovery. This study aimed to evaluate how adductor canal block (ACB) and femoral nerve block (FNB) affect opioid use and inflammation factor levels in elderly TKA patients.

Methods

This prospective observational study included 120 patients who received TKA, and divided them into three groups, based on the different nerve block technique: ACB, FNB, and no intervention before general anesthesia (CON). Postoperative opioid consumption, pain assessment, inflammation factor, knee function recovery and other clinical indicators were recorded.

Results

The CON group had significantly higher cumulative sufentanil consumption compared to the ACB and FNB groups at both 12 h and 48h postoperative (P<0.001). Compared with the CON group, the ACB and FNB groups persistently had lower pain scores until 12 h at rest and 24 h during motion after surgery. The ACB group showed significantly lower serum concentrations of C-reactive protein (CRP) and interleukin-6 (IL-6) compared to the CON group at 24 h postoperative (P=0.017, P=0.009), and IL-6 levels remained significantly lower at 72 h postoperative (P=0.005). Both ACB and FNB groups achieved earlier ambulation compared to the CON group (P=0.002). On the first day postoperative, both the ACB and FNB groups showed significantly better knee motion (P<0.001), quadriceps strength (P<0.001), and daily mobilization (P<0.001) compared to the CON group. Additionally, the ACB group exhibited superior quadriceps strength (P<0.001) and daily mobilization (P<0.001) compared to the FNB group.

Conclusion

The ACB and FNB groups exhibited comparable clinical efficacy outcomes in terms of pain scores and opioid consumption. However, the ACB group experienced reduced postoperative inflammation and improved knee recovery, especially in quadriceps strength.

Effect of pericapsular nerve group block and suprainguinal fascia iliaca block on postoperative analgesia and stress response in elderly patients undergoing hip arthroplasty: a prospective randomized controlled double-blind trial

BACKGROUND

As a novel regional analgesic technique, ultrasound-guided pericapsular nerve group (PENG) block has some potential advantages, and we designed a randomized clinical trial (RCT) to investigate whether the ultrasound-guided PENG block combined with general anesthesia can better reduce stress response, maintain intraoperative hemodynamic stability, and reduce postoperative analgesia in elderly hip arthroplasty compared with ultrasound-guided suprainguinal fascia iliaca block (SIFIB) combined with general anesthesia.

METHODS

Seventy-four subjects were enrolled over an 8-month period (20 April 2023 to 31 December 2023). All patients were divided into the test group (group P) and the control group (group S) using the envelope as the randomization method. The test group was treated with preoperative ultrasound-guided PENG block analgesia combined with general anesthesia and the control group was treated with preoperative ultrasound-guided SIFIB analgesia combined with general anesthesia. The primary outcome selected was the patient Visual Analogue Scale (VAS) score at 12 h postoperatively.

RESULTS

After generalized estimating equations (GEE) analysis, there was a statistically significant difference in the main effect of postoperative VAS score in group P compared with group S (P = 0.009), the time effect of VAS score in each group was significantly different (P < 0.001), and there was no statistically significant difference in the group-time interaction effect (P = 0.069). There was no statistically significant difference in the main effect of intraoperative mean arterial pressure (MAP) change (P = 0.911), there were statistically significant differences in the time effect of MAP in each group (P < 0.001), and there were statistically significant differences in the interaction effect (P < 0.001).

CONCLUSIONS

In summary, we can conclude that in elderly patients undergoing hip fracture surgery, postoperative analgesia is more pronounced, intraoperative hemodynamic parameters are more stable, and intraoperative stress is less induced in patients receiving SIFIB than in patients receiving PENG block.

Total knee arthroplasty: does ultra-early physical therapy improve functional outcomes and reduce length of stay? A retrospective cohort study

BACKGROUND

The Enhanced Recovery After Surgery (ERAS) Society recommends that after total knee arthroplasty (TKA), patients should be mobilized early. However, there is no consensus on how early physical therapy should be commenced. We aim to investigate whether ultra-early physical therapy (< 12 h postoperatively) leads to better outcomes.

METHODS

This is a retrospective cohort study of 569 patients who underwent primary TKA from August 2017 to December 2019 at our institution. We compared patients who had undergone physical therapy either within 24 h or 24-48 h after TKA. Further subgroup analysis was performed on the < 24 h group, comparing those who had undergone PT within 12 h and within 12-24 h. The outcomes analyzed include the Oxford Knee Scoring System score, Knee Society Scores, range of motion (ROM), length of stay (LOS) and ambulatory distance on discharge. A student's t test, chi-squared test or Fisher's exact test was used where appropriate, to determine statistical significance of our findings.

RESULTS

LOS in the < 24 h group was shorter compared to the 24-48 h group (4.87 vs. 5.34 days, p = 0.002). Subgroup analysis showed that LOS was shorter in the ultra-early PT (< 12 h) group compared to the early PT (12-24 h) group (4.75 vs. 4.96 days, p = 0.009). At 3 months postoperatively, there was no significant difference in ROM, ambulatory distance or functional scores between the < 24 h group and 24-48 h group, or on subgroup analysis of the < 24 h group.

CONCLUSION

Patients who underwent physical therapy within 24 h had a shorter length of stay compared to the 24-48 h group. On subgroup analysis, ultra-early (< 12 h) physical therapy correlated with a shorter length of stay compared to the 12-24 h group (4.75 vs. 4.96 days, p = 0.009) - however, the difference is small and unlikely to be clinically significant. Ultra-early (< 12 h) physical therapy does not confer additional benefit in terms of functional scores, ROM or ambulatory distance. These findings reinforce the importance of early physical therapy after TKA in facilitating earlier patient discharge.

Early Discharge for Revision Total Knee and Hip Arthroplasty: Predictors of Success

BACKGROUND

The rate of revision total joint arthroplasties is expected to increase drastically in the near future. Given the recent pandemic, there has been a general push toward early discharge. This study aimed to assess for predictors of early postoperative discharge after revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA).

METHODS

There were 77 rTKA and 129 rTHA collected between January 1, 2019 and December 31, 2021. Demographic data, comorbidities, a comorbidity index, the modified frailty index (mFI-5), and surgical history were collected. The Common Procedural Terminology codes for each case were assessed. Patients were grouped into 2 cohorts, early discharge (length of stay [LOS] <24 hours) and late discharge (LOS >24 hours).

RESULTS

In the rTHA cohort, age >65 years, a history of cardiac or liver disease, an mFI-5 of >1, a comorbidity index of >2.7, a surgical time >122 minutes, and the need for a transfusion were predictors of prolonged LOS. Only the presence of a surgical time of >63 minutes or an mFI-5 >1 increased patient LOS in the rTKA cohort. In both rTHA and rTKA patients, periprosthetic joint infection resulted in a late discharge for all patients, mean 4.8 and 7.1 days, respectively. Dual component revision was performed in 70.5% of rTHA. Only 27.6% of rTKA were 2-component revisions or placements of an antibiotic spacer.

CONCLUSIONS

Several patient and surgical factors preclude early discharge candidacy. For rTHA, an mFI-5 of >2/5, comorbidity index of >4, or a surgical time of >122 minutes is predictive of prolonged LOS. For rTKA, an mFI-5 of >2/5, Charlson Comorbidity Index of >5, or a surgical time of >63 minutes predicts prolonged LOS.

Perioperative Differences Between Outpatient and Inpatient Pathways Following Hip and Knee Arthroplasty

Background

Optimization of clinical pathways and logistics led to the introduction of outpatient joint arthroplasty of the hip and knee. Nevertheless, little is known about what these current protocols look like and how they differ from "standard" inpatient protocols. This study aimed to find preoperative, intraoperative, and postoperative differences between outpatient and inpatient pathways.

Methods

A questionnaire (ranging between 23 and 37 items) was developed and administered by email to orthopedic surgeons who were a member of the Dutch Hip Society and Dutch Knee Society. Survey response rate was 38% (N = 117).

Results

No significant differences were found in preoperative pathway characteristics. The administration regime for tranexamic acid significantly differed between outpatient and inpatient pathways (P < .001 and P = .002 for hip and knee arthroplasty, respectively), with outpatient pathways using a combined (eg, oral and intravenous) administration regime more frequently. The perioperative antibiotic prophylaxis regime also significantly differed between outpatient and inpatient pathways (P < .001 and P = .014, respectively), with outpatient pathways more frequently incorporating fewer antibiotic doses. Same-day postoperative mobilization significantly less often occurred if surgery took place later that day in inpatient hip arthroplasty pathways (24%; P = .034). Postoperative hemoglobin-check occurred significantly more often on indication in outpatient than in inpatient hip and knee arthroplasty pathways (∼75% vs ∼25%; P = .001).

Conclusions

Few intraoperative and postoperative differences in outpatient and inpatient pathways were found and probably mainly relied on logistical grounds. Nonetheless, findings suggested that outpatient pathways tended to be more up-to-date and innovative than inpatient pathways.

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.

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

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

Efficacy of Supplemental Ultrasound-Guided Pericapsular Nerve Group (PENG) Block Combined with Lateral Femoral Cutaneous Nerve Block in Patients Receiving Local Infiltration Analgesia after Hip Fracture Surgery: A Prospective Randomized Controlled Trial

Background and Objectives: Local infiltration analgesia (LIA) represents a potential approach to reducing pain in patients undergoing total hip arthroplasty (THA). The pericapsular nerve group (PENG) block also provides adequate analgesia for fractures and THA. As most hip surgeries use a lateral incision, affecting the cutaneous supply by branches of the lateral femoral cutaneous nerve (LFCN), the LFCN block can contribute to postoperative analgesia. However, no studies have investigated the effectiveness of supplemental PENG block combined with LFCN block in patients undergoing LIA after hip fracture surgery. Our study aimed to assess the effectiveness of PENG combined with LFCN block following hip fracture surgery in patients who underwent LIA. Materials and Methods: Forty-six patients were randomly assigned to LIA or PENG + LFCN + LIA groups. The primary outcome was the pain score at rest and during movement at 2, 6, 12, 24, and 48 h postoperatively. The total opioid dose for postoperative analgesia was also measured at the same time points. Secondary outcomes included postoperative cognitive function assessment. Results: The median pain scores at rest and during movement were lower in the PENG + LFCN + LIA group throughout the study periods compared to the LIA group, except at 2 h (at rest) and 48 h (during movement) after surgery. The total fentanyl dose was lower in the PENG + LFCN + LIA group at all time points after surgery when compared to the LIA group. Postoperative delirium incidence and the median abbreviated mental test scores were not significantly different between the two groups. Conclusions: The combination of PENG and LFCN blocks may contribute to enhanced recovery for patients undergoing LIA after hip fracture surgery. However, further well-controlled research is necessary to determine the effectiveness of supplemental PENG combined with LFCN block in addressing cognitive deficits in these patients.

Early Weight-Bearing After Fibula Free Flap Surgery

Importance

Despite the widespread use of fibula free flap (FFF) surgery for head and neck reconstruction, there are no studies assessing if early weight-bearing (EWB) affects postoperative recovery, and the timing of weight-bearing initiation following FFF surgery varies considerably across institutions. Therefore, it is important to understand the effect of EWB in these patients and whether it could improve postoperative recovery.

Objective

To assess the association of EWB after FFF surgery with donor-site complications, length of stay, and discharge to home status.

Design, Setting, and Participants

This retrospective cohort study took place at Massachusetts Eye and Ear, a single tertiary care institution in Boston, Massachusetts. A total of 152 patients who received head and neck reconstruction with a fibula osteocutaneous free flap between January 11, 2010, and August 11, 2022, were included.

Exposure

EWB on postoperative day 1 vs non-EWB on postoperative day 2 or later.

Main Outcomes and Measures

Patient characteristics, including demographic characteristics and comorbidities, surgical characteristics, donor-site complications, length of stay, and discharge disposition, were recorded. Descriptive statistics and multivariate logistic regressions were used to compute effect sizes and 95% CIs to compare postoperative outcomes in EWB and non-EWB groups.

Results

A total of 152 patients (median [IQR] age, 63 [55-70] years; 89 [58.6%] male) were included. The median (IQR) time to postoperative weight-bearing was 3 (1-5) days. Among all patients, 14 (9.2%) had donor-site complications. EWB on postoperative day 1 was associated with shorter length of stay (adjusted odds ratio [AOR], 0.10; 95% CI, 0.02-0.60), increased rate of discharge to home (AOR, 7.43; 95% CI, 2.23-24.80), and decreased donor-site complications (AOR, 0.11; 95% CI, 0.01-0.94). Conversely, weight-bearing 3 or more days postoperatively was associated with an increased risk of pneumonia (AOR, 6.82; 95% CI, 1.33-34.99).

Conclusions and Relevance

In this cohort study, EWB after FFF surgery was associated with shorter length of stay, increased rate of discharge to home, and decreased donor-site complications. These findings support the role of early mobilization to optimize postoperative recovery after FFF surgery.

In Vitro Investigation of Column Fixation Constructs for Periacetabular Osteotomy: Which Provide the Greatest Stiffness and Strength?

Background

Periacetabular osteotomy (PAO) is an effective surgical procedure for managing acetabular dysplasia. The purpose of this study was to analyze the biomechanical properties of novel PAO constructs that incorporate orthopaedic trauma techniques. We hypothesize that these fixation methods will create a stiffer construct that tolerates higher loads to failure.

Methods

Twenty bio-composite hemi-pelvises underwent PAO with the following fixation configurations: Group A: 4 iliac crest (IC) screws; Group B: 3 IC screws; Group C: 2 IC screws, 1 retrograde anterior column (AC) screw, and 1 lateral compression type-2 (LC2) screw directed from the anterior inferior iliac spine to the posterior inferior iliac spine; Group D: 1 AC screw, 1 LC2 screw, 1 posterior column screw; Group E: 2 LC2 screws, 1 AC screw. Constructs were loaded to failure on a material testing hydraulic press, and ultimate strength, stiffness, and osteotomy displacement were measured.

Results

The highest load to failure was seen in group D (2511 N), which was significantly more than groups A (1528 N, P = .0114) and B (1348 N, P < .0001). The stiffest construct was group E (602 N/mm) compared to groups A (315 N/mm, P = .0439) and B (243 N/mm, P = .0008). Failure occurred most often with a fracture in the posterior column.

Conclusions

This study supports column fixation methods used in orthopaedic trauma for PAO as biomechanically advantageous to traditional fixation techniques. These constructs may be beneficial to patients with weight-bearing concerns or early rehabilitation needs.

Associations of parecoxib and other variables with recovery and safety outcomes in total knee arthroplasty: insights from a retrospective cohort study

Background

Early mobilization post-total knee arthroplasty (TKA) significantly affects patient outcomes. While parecoxib is known to reduce postoperative pain and morphine use with a favorable safety profile, its impact on mobilization timing post-TKA remains uncertain. This retrospective study aims to assess parecoxib's influence on postoperative mobilization timing in TKA patients without compromising safety.

Methods

This study included unilateral TKA patients treated for primary knee osteoarthritis under general anesthesia. We divided the study period into two intervals, 2007-2012 and 2013-2018, to evaluate temporal differences. Both the control group and parecoxib group received standard postoperative oral analgesics and as-needed intramuscular morphine. The control group did not receive parecoxib, while the parecoxib group did. Primary outcomes compared postoperative complications and mobilization timing between groups, with secondary outcomes including length of hospital stay (LOS), Visual Analog Scale (VAS) scores for pain, as-needed morphine use, and postoperative nausea/vomiting.

Results

Parecoxib did not increase postoperative complications. Unmatched comparison with patients in controlled group found that patients in parecoxib group had significantly shortened mobilization time (2.2 ± 1.1 vs. 2.7 ± 1.6 days, P < 0.001) and LOS (6.7 ± 2.5 vs. 7.2 ± 2.1 days, P = 0.01). Multivariate analysis linked parecoxib use with faster mobilization (β = -0.365, P < 0.001) but not LOS. Males showed increased mobilization time and LOS compared to females during the period of 2007-2018, but gender had no significant association with LOS during the period of 2013-2018. The 2013-2018 period saw significant reductions in both mobilization time and LOS. Use of a tourniquet and local infiltration analgesia showed no significant impact. ASA classification 1-2 was positively associated with faster mobilization but not LOS. Longer operation times were linked to delayed mobilization and increased LOS.

Conclusion

In this study, intravenous parecoxib injection, female gender, and shorter OP time had consistent positive association with shorter time to mobilization after individual multivariate analysis in 2 different period. The use of parecoxib had consistent no significant association with LOS. Only shorter OP time was consistent positive associated with shorter LOS.

The Impact of Sarcopenia Risk on Postoperative Walking Independence in Older Adults Undergoing Total Joint Arthroplasty

BACKGROUND AND PURPOSE

Sarcopenia is known to be associated with poor outcomes after arthroplasty; however, no study has reported the relationship between sarcopenia and postoperative walking independence. This study aimed to determine the impact of sarcopenia risk screening using the SARC-CalF questionnaire and calf circumference on the time to walk independently after total hip or knee arthroplasty in older patients.

METHODS

We included 599 nonobese patients aged 65 years and older who underwent unilateral and primary total hip or knee arthroplasty. Preoperative sarcopenia risk was assessed using the SARC-CalF or calf circumference. The outcome of this study was the time to independent walking after surgery; it was calculated as the number of days from the date of surgery to the date when the patient was able to walk independently. The association between preoperative sarcopenia risk and time to independent walking after surgery was analyzed using Kaplan-Meier curves and Cox proportional hazards models.

RESULTS

Among the 599 patients undergoing total joint arthroplasty, 175 (29.2%) were determined to be at risk of sarcopenia using SARC-CalF and 193 (32.2%) using calf circumference. The Kaplan-Meier curve showed that sarcopenia risk assessed by SARC-CalF or calf circumference was associated with a prolonged time to independent walking in patients undergoing hip arthroplasty (log-rank test, P < .001 and P < .001, respectively). In patients undergoing hip arthroplasty, the Cox proportional hazards model showed that SARC-CalF score of 11 points and greater or a calf circumference less than the cutoff was a risk factor for delayed time to independent walking (hazard ratios: 0.55 and 0.57, P < .001 and P = .001, respectively). There was no association between preoperative sarcopenia risk and postoperative time to independent walking in patients who underwent knee arthroplasty.

CONCLUSIONS

Sarcopenia screening tools, such as SARC-CalF or calf circumference, should be useful for planning postoperative rehabilitation in older adults scheduled for hip arthroplasty. However, the accuracy of SARC-CalF or calf circumference measurement in patients scheduled for knee arthroplasty may be low.

A diarized journey: an interpretative phenomenological analysis of the older person's lived experience of a hip or knee replacement within a fast-track programme

BACKGROUND

For the older person living with end-stage hip or knee osteoarthritis, a hip or knee replacement can be a traumatic event, influencing the physical, physiological, psychological, social and economic facets of daily living. This interpretative phenomenological study aimed to reveal and interpret the daily lived experiences of the older person before, during and after a primary total hip or knee replacement surgery in a fast-track programme in South Africa.

METHODS

A qualitative interpretive phenomenological study, collecting data through solicited diaries and reflexive member validation interviews from seven participants aged 65-75 years, who underwent a primary elective hip or knee replacement surgery. The surgical fast-track process and data collection process happened simultaneously. Data collection from the solicited diary started before surgery, continued during the surgery process and finished six weeks after surgery and this was followed with reflexive member validation interviews. Interpretative phenomenological analysis was used throughout the three phases of the fast-track programme.

RESULTS

Three superordinate themes developed during the three phases of surgery: "The holistic impact of pain on daily quality of life", "Finding ways to cope", and "Transition between independence and dependence and back". Although former research confirms the physical impact of osteoarthritis on the older person and the success of fast-track programmes for subsequent hip and knee replacements, this study contributes to the holistic impact of the surgery on participants' daily lives. The diarized journey of individuals through the psychological, psychosocial, physical, professional, and spiritual experience are described and interpreted in this study.

CONCLUSIONS

Across the solicited diaries, it was clear that pain as catalyst impacted the daily activities of the individual physically, psychologically, and psychosocially. Pain was subjectively present at different intensities during all the phases of the replacement surgery, impairing mobilization and triggering roller-coaster emotions. In order to cope with physical and emotional difficulties while preparing and adjusting to the environment, participants reflected on social support, physical and professional support, and spirituality. Throughout the preparation, hospitalization and the recovery process, the transition between independence, dependence, and back to independence was significant, reinforcing the individual's determination to recover.

Which items of the modified Barthel Index can predict functional independence at discharge from inpatient rehabilitation? A secondary analysis retrospective cohort study

The modified Barthel Index (mBI) is a well-established patient-centered outcome measure commonly administrated in rehabilitation settings to evaluate the functional status of patients at admission and discharge. This study aimed to detect which mBI items collected on admission can predict the total mBI at discharge from first inpatient rehabilitation in large cohorts of orthopedic (n = 1864) and neurological (n = 1684) patients. Demographic and clinical data (time since the acute event 11.8 ± 17.2 days) at patients' admission and mBI at discharge were collected. Univariate and multiple binary logistic regressions were performed to study the associations between independent and dependent variables for each cohort separately. In neurological patients, the shorter time between the acute event and rehabilitation admission, shorter length of stay, and being independent with feeding, personal hygiene, bladder, and transfers were independently associated with higher total mBI at discharge (R 2  = 0.636). In orthopedic patients, age, the shorter time between the acute event and rehabilitation admission, shorter length of stay, and being independent with personal hygiene, dressing, and bladder were independently associated with higher total mBI at discharge (R 2  = 0.622). Our results showed that different activities in neurological (i.e. feeding, personal hygiene, bladder, and transfer) and orthopedic sample (i.e. personal hygiene, dressing, and bladder) are positively associated with better function (measured by mBI) at the discharge. Clinicians have to take into account these predictors of functionality when they plan an appropriate rehabilitation treatment.

The effect of pregabalin on postoperative pain after anterior cruciate ligament reconstruction: A systematic review of randomized clinical trials

Background

Despite the enormous success of anterior cruciate ligament (ACL) reconstruction, acute neuropathic pain can develop postoperatively and is both distressing and difficult to treat once established. Pregabalin, an anticonvulsant agent that selectively affects the nociceptive process, has been used as a pain relief agent. The purpose of this systematic review of randomized controlled trials (RCTs) was to evaluate the pain control effect of pregabalin versus placebo after ACL reconstruction.

Method

A search of the literature was performed from inception to June 2022, using PubMed, Scopus, Google Scholar, Web of Science, Cochrane and EBSCO. Studies considered for inclusion were RCTs that reported relevant outcomes (postoperative pain scores, cumulative opioid consumption, adverse events) following administration of pregabalin in patients undergoing ACL reconstruction.

Result

Five placebo-controlled RCTs involving 272 participants met the inclusion criteria. 75 mg and 150 mg oral pregabalin was used in included trials. Two studies used a single dose of pregabalin one hour before anesthesia induction. Two studies used pregabalin 1 hour before anesthesia induction and 12 hours after. One study used daily pregabalin 7 days before and 7 days after surgery. Out of five papers, three papers found significantly lower pain intensity and cumulative opioid consumption in pregabalin group compared with placebo group. However, a decrease in pain scores was found in all trials. Pregabalin administration was associated with dizziness and nausea.

Conclusion

The use of pregabalin may be a valuable asset in pain management after ACL reconstruction. However, future studies with larger sample size and longer follow-up period are required.

Guidelines on perioperative optimization protocol for the adult patient 2023

OBJECTIVE

The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs.

DESIGN

A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format.

RESULTS

The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations.

CONCLUSIONS

Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.

Oral enzyme combination with bromelain, trypsin and the flavonoid rutoside reduces systemic inflammation and pain when used pre- and post-operatively in elective total hip replacement: a randomized exploratory placebo-controlled trial

Background

Early mobilization after total hip replacement (THR) is key for fast recovery but is often limited by pain. Oral enzyme combinations (OECs) have demonstrated anti-inflammatory and pain-relieving effects.

Objectives and design

This prospective, randomized, double-blind, placebo-controlled exploratory trial evaluated the effects of pre- and post-operative use of OEC (90 mg bromelain, 48 mg trypsin, 100 mg rutoside) following elective THR, on post-operative recovery.

Methods

Candidates for primary elective cementless THR owing to osteoarthritis were eligible for participation [age ⩾50 years, body mass index 25-35 kg/m2, C-reactive protein (CRP) ⩽6 mg/L]. Following randomization to OEC or placebo, intervention started pre-operatively and continued onwards until day 42. Main outcomes included post-operative CRP levels (days 1-7), self-reported hip pain at rest (by 0-10 cm visual analogue scale on post-operative days 1-42), post-operative analgesic use [by cumulative analgesic consumption score (CACS) days 7-42], tolerability and adverse events.

Results

Patients (N = 34) were recruited from a tertiary orthopaedic hospital in the Czech Republic, of whom 33 completed the study (OEC/placebo: n = 15/18). Baseline characteristics across the groups were comparable. Compared with placebo, the OEC group had numerically lower CRP levels on post-operative days 1-7, including peak level [mean (standard deviation) OEC versus placebo: 81.4 (28.3) versus 106.7 (63.3) mg/L], which translated into a significant 32% lower CRP area under the curve (p = 0.034). The OEC group reported significantly less pain during post-operative days 1-7 versus placebo (analysis of variance treatment × visit [F(4) = 3.989]; p = 0.005). Analgesic use was numerically reduced as assessed through an accumulated CACS. No deleterious effects on haemorheological parameters were observed in either group.

Conclusions

Pre- and post-operative use of OEC significantly reduced CRP levels and patient self-reported pain. OEC may be an efficacious and safe treatment option to facilitate post-operative recovery following THR.

Trial registration

EudraCT number 2016-003078-41.

Influence of Intraoperative Nociception during Hip or Knee Arthroplasty with Supplementary Regional Anaesthesia on Postoperative Pain and Opioid Consumption

Background and Objectives: Early postoperative mobilization is central for postoperative outcomes after lower extremity joint replacement surgery. By providing adequate pain control, regional anaesthesia plays an important role for postoperative mobilization. It was the objective of this study to investigate the use of the nociception level index (NOL) to determine the effect of regional anaesthesia in hip or knee arthroplasty patients undergoing general anaesthesia with additional peripheral nerve block. Materials and Methods: Patients received general anaesthesia, and continuous NOL monitoring was established before anaesthesia induction. Depending on the type of surgery, regional anaesthesia was performed with a Fascia Iliaca Block or an Adductor Canal Block. Results: For the final analysis, 35 patients remained, 18 with hip and 17 with knee arthroplasty. We found no significant difference in postoperative pain between hip or knee arthroplasty groups. NOL increase at the time of skin incision was the only parameter associated with postoperative pain measured using a numerical rating scale (NRS > 3) after 24 h in movement (-12.3 vs. +119%, p = 0.005). There was no association with intraoperative NOL values and postoperative opioid consumption, nor was there an association between secondary parameters (bispectral index, heart rate) and postoperative pain levels. Conclusions: Intraoperative NOL changes may indicate regional anaesthesia effectiveness and could be associated with postoperative pain levels. This remains to be confirmed in a larger study.

Considerations for an ideal post-surgical wound dressing aligned with antimicrobial stewardship objectives: a scoping review

OBJECTIVE

Most surgical wounds heal by primary or secondary intention. Surgical wounds can present specific and unique challenges including wound dehiscence and surgical site infection (SSI), either of which can increase risk of morbidity and mortality. The use of antimicrobials to treat infection in these wounds is prevalent, but there is now an imperative to align treatment with reducing antimicrobial resistance and antimicrobial stewardship (AMS). The aim of this review was to explore the published evidence identifying general considerations/criteria for an ideal post-surgical wound dressing in terms of overcoming potential wound healing challenges (including infection) while supporting AMS objectives.

METHOD

A scoping review examining evidence published from 1954-2021, conducted by two authors acting independently. Results were synthesised narratively and have been reported in line with PRISMA Extension for Scoping Reviews.

RESULTS

A total of 819 articles were initially identified and subsequently filtered to 178 for inclusion in the assessment. The search highlighted six key outcomes of interest associated with post-surgical wound dressings: wound infection; wound healing; physical attributes related to comfort, conformability and flexibility; fluid handling (e.g., blood and exudate); pain; and skin damage.

CONCLUSION

There are several challenges that can be overcome when treating a post-surgical wound with a dressing, not least the prevention and treatment of SSIs. However, it is imperative that the use of antimicrobial wound dressings is aligned with AMS programmes and alternatives to active antimicrobials investigated.

Association between early ambulation exercise and short-term postoperative recovery after open transforaminal lumbar interbody fusion: a single center retrospective analysis

BACKGROUND

Early ambulation in patients undergoing transforaminal lumbar interbody fusion (TLIF) surgery is recommended, however, the precise time interval after open surgery has never been specified. Current retrospective analysis was conducted aiming to clarify an accurate time interval.

METHODS

A retrospective analysis of eligible patients was conducted using the databases of the Bone Surgery Department, Third Affiliated Hospital of Sun Yat-sen University from 2016 to 2021. Data pertaining to postoperative hospital stay length, expenses, incidence of complications were extracted and compared using Pearson's χ2 or Student's t-tests. A multivariate linear regression model was conducted to identify the relationship between length of hospital stay (LOS) and other outcomes of interest. A propensity analysis was conducted to minimize bias and to evaluate the reliability of results.

RESULTS

A total of 303 patients met the criteria and were included for the data analysis. Multivariate linear regression results demonstrated that a high ASA grade (p = 0.016), increased blood loss (p = 0.003), cardiac disease (p < 0.001), occurrence of postoperative complications(p < 0.001) and longer ambulatory interval (p < 0.001) was significantly associated with an increased LOS. The cut-off analysis manifested that patients should start mobilization within 3 days after open TLIF surgery (B = 2.843, [1.395-4.292], p = 0.0001). Further comparative analysis indicated that patients who start ambulatory exercise within 3 days have shorter LOS (8.52 ± 3.28d vs 12.24 ± 5.88d, p < 0.001), total expenses ( 9398.12 ± 2790.82vs 10701.03 ± 2994.03 [USD], p = 0.002). Propensity analysis revealed such superiority was stable along with lower incidence of postoperative complications (2/61 vs 8/61, p = 0.0048).

CONCLUSIONS

The current analysis suggested that ambulatory exercise within 3 days for patients who underwent open TLIF surgery was significantly associated with reduced LOS, total hospital expenses, and postoperative complications. Further causal relationship would be confirmed by future randomized controlled trials.

Physical activity in the first postoperative week in 132 knee arthroplasty patients randomized to 3 different analgesic regimens

BACKGROUND

The aim of this study was to investigate whether objectively recorded physical activity in the first week after surgery in total knee arthroplasty patients differed between patients allocated to 3 different analgesic regimens.

METHODS

A total of 132 total knee arthroplasty patients wore activity monitors 24 hours a day from day 1 after surgery for 6 consecutive days. The time mobilized (stepping/standing) and the number of steps were recorded. This study was a sub-study of a randomized controlled study comparing tapentadol extended-release (ER), oxycodone controlled-release (CR), or a non-opioid placebo analgesic regimen.

RESULTS

The placebo group spent significantly more time mobilized than the tapentadol ER and the oxycodone CR groups (P = .016 and .042, respectively), but no statistically significant differences were found between the groups in the number of steps taken. The activity levels of patients in all groups increased in the first week after surgery.

CONCLUSION

Patients in the non-opioid placebo group spent more time mobilized the first week after surgery than those in the tapentadol ER and the oxycodone CR groups, while the number of steps was not different between the groups.

Comparison between pericapsular nerve group (PENG) block with lateral femoral cutaneous nerve block and supra-inguinal fascia iliaca compartment block (S-FICB) for total hip arthroplasty: a randomized controlled trial

PURPOSE

To assess the efficacy of pericapsular nerve group (PENG) block combined with lateral femoral cutaneous nerve (LFCN) block in controlling postoperative pain and promoting recovery of lower extremity after total hip arthroplasty (THA), and to compare its effectiveness with supra-inguinal fascia iliaca compartment block (S-FICB).

MATERIALS AND METHODS

92 patients undergoing THA with general anesthesia were randomly allocated to receive either a PENG with LFCN block (n = 46) using 30 ml 0.33% ropivacaine (20 ml for PENG block, 10 ml for LFCN block), or an S-FICB (n = 46) using 30 ml 0.33% ropivacaine. The primary outcome was the time to first postoperative walk. The secondary outcomes included intraoperative remifentanil consumption, postoperative hip flexion degree and muscle strength of the operative lower limbs in the supine position, pain scores (static and dynamic), rescue analgesia, postoperative nausea and vomiting (PONV), and nerve block-related complications.

RESULTS

The combination of PENG with LFCN blocks resulted in an earlier first postoperative walking time (19.6 ± 9.6 h vs 26.5 ± 8.2 h, P < 0.01), greater postoperative hip flexion degree at 6 h, 24 h and 48 h (all P < 0.01), and higher muscle strength of the operative lower limbs at 6 h after surgery (P = 0.03) compared to S-FICB. The difference in pain scores (static and dynamic) was only statistically significant at 48 h (P < 0.05). There were no differences in the other outcomes.

CONCLUSIONS

PENG with LFCN blocks is more effective than S-FICB in shortening the time to first postoperative walk and preservation hip motion after THA, which makes it a suitable addition to enhanced recovery programs following surgery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Key Elements of Enhanced Recovery after Total Joint Arthroplasty: A Reanalysis of the Enhanced Recovery after Surgery Guidelines

Recent guidelines have produced a consensus statement for perioperative care in hip and knee replacement. However, there is still a need for reanalysis of the evidence and recommendations. Therefore, we retrieved and reanalyzed the evidence of each recommended components of enhanced recovery after surgery (ERAS) based on the guidelines of total joint arthroplasty. For each one, we included for the highest levels of evidence and those systematic reviews and meta-analyses were preferred. The full texts were analyzed and the evidence of all components were summarized. We found that most of the recommended components of ERAS are supported by evidence, however, the implementation details of each recommended components need to be further optimized. Therefore, implementation of a full ERAS program may maximize the benefits of our clinical practice but this combined effect still needs to be further determined.

A New Dressing System for Wound in Enhanced-Recovery Total Hip Arthroplasty: A Randomized and Controlled Trial

BACKGROUND

Currently, there is a paucity of recommendations in regards to dressing selection within the enhanced recovery after surgery protocol. We devised a new dressing system to accelerate the recovery after total hip arthroplasty (THA). We aimed to present our experience with this new dressing system as an adjunct to wound management in THA and to evaluate its performance.

METHODS

From September 2020 to August 2021, we prospectively enrolled 124 patients who underwent a primary THA. The patients were randomly assigned to the intervention (the new dressing system group) or the control (the traditional gauze dressing) group. The primary outcome measures of this study were numbers of dressing changes, postoperative lengths of stay, wound scores including the Stony Brook Scar Evaluation Scale and ASEPSIS scores and wound-related complications. The secondary outcomes include satisfaction scores, dressing-related costs, and pain and functional recovery scores.

RESULTS

The intervention group numbers of dressing changes and postoperative lengths of stay were significantly less than the control group (P < .001, P < .001). During the one-month follow-up, the Stony Brook Scar Evaluation Scale in the intervention group was significantly better than that in the control group (P < .001). The intervention group satisfaction was significantly higher than that in the control group (P < .001). There were no statistically significant differences between the two groups in terms of dressing-related costs and pain and function scores.

CONCLUSION

The new dressing system could significantly reduce the number of dressing changes and postoperative lengths of stay and increase patient satisfaction scores, which can be an ideal adjunct to wound management in enhanced-recovery THA.