An evidence-based review of enhanced recovery interventions in knee replacement surgery

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

QUESTIONS/PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, therapeutic study.

Supervised versus unsupervised rehabilitation following total knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

Outcomes after total knee arthroplasty (TKA) are strongly influenced by the adequacy of rehabilitation and the consequent functional recovery. The economic impact of rehabilitation it is not negligible. Inpatient rehabilitation can be 5 to 26 times more expensive than the home-based rehabilitation. This topic is extremely relevant as the COVID-19 pandemic has highlighted the importance of unsupervised rehabilitation in orthopedic surgery. The aim of this review and meta-analysis is to investigate the scientific evidence regarding the comparison between supervised and unsupervised rehabilitation following TKA.

MATERIALS AND METHODS

Following PRISMA guideline, a comprehensive search of PubMed, Cochrane and Scopus databases using combinations of keywords and MeSH descriptors: "total "Knee replacement," "Arthroplasty", "Rehabilitation" was performed from inception to December 2021. All relevant articles were retrieved, and their bibliographies were searched for further relevant references. Only English written randomized controlled trials comparing supervised and unsupervised rehabilitation following TKA were included in this systematic review. The outcomes considered were long-term pain, physical function, knee flexion and extension ROM, 6 minute walking test (6MWT) and timed up and go test (TUG).

RESULTS

11 studies (2.181 patients in total) were included in this systematic review. The long-term pain outcome showed no significant differences (Std. Mean Difference [SMD] = 0.00, 95 % confidence interval [CI] -0.16, 0.017) between the supervised (n = 397) and unsupervised (n = 255). Physical function showed no significant differences among the two groups (mean difference [MD] = 0.84, 95 % CI = -1.82, 3.50). Non-significant differences were also found for knee ROM flexion (mean difference [MD] = -0.46, 95 % CI = -2.95, 2.04) and for knee extension (mean difference [MD] = 0.54, 95 % CI = -0.89, 1.97). At the 52-week follow-up, the unsupervised group showed significant better results in 6MWT (mean difference [MD] = -26.10, 95 % CI = -47.62, -4.59) and in Timed up and go test (mean difference [MD] = 1.33, 95 % CI = 0.50, 2.15).

CONCLUSION

This systematic review did not show a significant clinical difference in improving pain, function, and mobility outcomes after TKA between supervised PT and unsupervised PT. Therefore, it would appear that supervised rehabilitation did not had additional benefits compared to unsupervised rehabilitation.

Application of dexamethasone combined with tranexamic acid in perioperative period of total hip arthroplasty

OBJECTIVE

To evaluate the efficacy and safety of dexamethasone (DEXA) combined with tranexamic acid (TXA) in the perioperative period of total hip arthroplasty.

MATERIALS AND METHODS

A total of 100 cases were randomly divided into 2 groups (50 cases per group). All patients were given 15 mg/kg TXA before skin incision and 3 hours later. Patients in the intervention group (TXA + DEXA group) were given 20 mg dexamethasone intravenously after the onset of anesthesia, and the same dose of DEXA was administered again 24 hours later. Patients in the placebo group (TXA group) were only given the same dose of normal saline. Postoperative c-reactive protein and interleukin-6, postoperative nausea and vomiting, fatigue visual analogue scale score, postoperative length of stay, range of motion, and consumption of analgesic and antiemetics were statistically analyzed in the 2 groups.

RESULTS

The levels of c-reactive protein and interleukin-6 in the TXA + DEXA group were lower than those in the TXA group at 24, 48, 72 hours post-operatively (P < .001). Walking pain scores in the TXA + DEXA group were also significantly lower than those in the TXA group at 24 and 48 hours (P < .001); rest pain scores were lower at 24 hours (P < .001). Compared with the TXA group, the incidence of nausea VAS, postoperative nausea and vomiting, fatigue, analgesia and antiemetics consumption, postoperative length of stay, and range of motion were lower in the TXA + DEXA group (all P < .05), while there were no significant differences in postoperative hematocrit, total blood loss, and complications (P > .05).

CONCLUSION

The combination of TXA (15 mg/kg; before skin incision and 3 hours later) and DEX (20 mg dexamethasone intravenously after the onset of anesthesia, and again 24 hours later) is an effective and safe strategy for patients undergoing total hip arthroplasty.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sex-Specific Reduction in Inflammation of Osteoarthritic Human Chondrocytes and Nutraceutical-Dependent Extracellular Matrix Formation

Introduction

The aim of this study was to investigate the ability of osteoarthritic human chondrocytes to produce articular cartilage (AC) tissues with a reduced inflammatory environment in response to 4 anti-inflammatory nutraceuticals: alpha-tocopherol (Alpha), gallic acid (G), ascorbic acid (AA), and catechin hydrate (C).

Methods

Chondrocytes isolated from patients who underwent total knee arthroplasty surgeries were divided into groups (9 male; mean age, 66.2 ± 3.5 years and 11 female; mean age, 64.2 ± 3.1 years). Cells were cultured based on sex and supplemented with either a negative control (NC) medium or NC plus one of the nutraceuticals at a concentration of 50 μM. At day 21, cultures were characterized histologically, biochemically, and for gene expression of vital markers.

Results

At day 21, 62.3% and 66.2% reduction in nitric oxide (NO) content was evident for female and male cells, respectively. G-treatment of female cells resulted in the lowest expression of nitric oxide synthase-2 (NOS2), matrix metalloproteinase-13 (MMP13), and collagen type-10 (COL10). Alpha-treatment of male cells resulted in the lowest expression of NOS2, bone morphogenic protein-2, MMP13, COL10 and tumor necrosis factor alpha induced protein-6 (TNFAIP6) relative to NC. AA and Alpha treatment resulted in the highest glycosaminoglycan (GAG) content for female and male cultures, respectively.

Conclusion

A sex-dependent response of osteoarthritic chondrocytes to nutraceutical treatment was evident. Our results suggest the use of G for female cells and Alpha for male cells in OA applications seems to be favorable in reducing inflammation and enhancing chondrocytes' ability to form AC tissues.

Home-Based Intravenous Analgesia With an Elastomeric Pump After Medial Patellofemoral Ligament Repair: A Case Series

PURPOSE

The purpose of this study is to show our experience using elastomeric pumps for postoperative pain relief after outpatient medial patellofemoral ligament (MPFL) reconstruction.

DESIGN

Prospective case series.

METHODS

Patients (N = 78) with recurrent patella dislocation who underwent MPFL repair using an autogenous semitendinosus tendon graft were included. After discharge, pain was controlled using intravenous analgesia infused by an elastomeric pump for 48 hours. Outcomes regarding pain, complications, overall satisfaction, and knee functionality were assessed.

FINDINGS

Early postoperative pain was mild in 53.8% of patients, and 30.8% patients had no pain at all. Twenty-four hours after surgery, 38.5% patients presented no pain, which increased to 53.8% at 72 hours. Nausea was experienced by 2.6% patients as was vomiting (7.7%) and drowsiness (2.6%). The mean score for patient satisfaction regarding the treatment was 90.2 (60.0-100.0). Moreover, postoperative knee functionality 12 months after the procedure proved to be statistically significantly superior (P <0.05).

CONCLUSIONS

Postoperative analgesia using an intravenous elastomeric pump allows performance of MPFL reconstruction as an outpatient procedure with satisfactory pain control, complication rates and patient satisfaction.

Application of Enhanced Recovery after Surgical Treatment of the Occipitocervical Region

Objective

The concept of enhanced recovery after surgery (ERAS) has been proposed to provide guidance for the improved postoperative rehabilitation of patients with occipitocervical region disease (ORD).

Methods

This study retrospectively investigated 208 consecutive patients (116 men and 92 women) ranging in age from 22 to 76 years with ORD between July 2014 and June 2017 in our medical center, who were divided into three groups that received different preoperative, intraoperative, and postoperative management plans: traditional group (n = 73), ameliorated group (n = 70), and ERAS group (n = 65). We compiled a range of data relating to demographics and postoperative changes in hemoglobin and albumin, surgery duration, intraoperative blood loss, number of postoperative hospitalization days and expenses, readmission rates, and visual analog scale pain symptoms. Data were statistically evaluated using one‐way analysis of variance with Student–Newman–Keuls‐q post hoc tests or chi‐square tests.

Results

There were no significant differences in terms of age (P = 0.235), gender (P = 0.691), body mass index (P = 0.723), American Society of Anesthesiologists grade (0.747), lesion character (P = 0.337) and lesion site (P = 0.957) between the three groups. Within a 6 months follow‐up period, there was no significant difference between the three groups in terms of surgery duration (P = 0.225), blood loss (P = 0.172), changes in hemoglobin (P = 0.255) and albumin (P = 0.178). However, postoperative hospitalization days (P = 0.000), postoperative costs (P = 0.019) and improvement of pain symptoms (P = 0.000) in ERAS group were significantly lower or higher than those in traditional group or ameliorated group, respectively. There were 29 (39.73%), 22 (31.43%), and 13 (20.00%), recorded cases of postoperative complications in traditional group, ameliorated group and ERAS group, respectively; complications in ERAS group were significantly lower than those in other two groups (P = 0.043). Moreover, all of the complications were mitigated effectively by the infusion of fluid, analgesia, treatment of infections, or antiemetic medications. There were 2 (2.74%), 3 (4.29%) and 2 (3.08%), recorded cases of re‐admission in traditional group, ameliorated group and ERAS group, respectively, but there were no statistically significant differences when compared across the three groups (P = 0.866).

Conclusions

ERAS can provide benefits when it applied to patients undergoing ORD surgery mainly in terms of reducing postoperative complications, however, ERAS does not increase the economic burden of patients or decrease the risk of readmission.

Development and Validation of the Pain and State of Health Inventory (PHI): Application for the Perioperative Setting

Currently, general measurements and evaluations of the quality of recovery are difficult because no adequate measuring tools are available. Therefore, there is an urgent need for a universal tool that assesses patient-relevant criteria-postoperative pain, state of health, and somatic parameters. For this purpose, a pain and state of health inventory (PHI, Schmerz- und Befindlichkeitsinventar (SBI) in German) has been developed. In this study, we describe its development and validation. The development phase was led by an expert panel and was divided into three subphases: determining the conceptual structure, testing the first editions, and adjusting the inventory for a finalized edition. For the purpose of validation, the PHI was filled in by 132 patients who have undergone total knee replacement and was analyzed using principal component analysis. Construct validity was tested by correlating the items with validated questionnaires. The results showed that the inventory can test pain, state of health, and somatic parameters with great construct validity. Furthermore, the inventory is accepted by patients, map changes, and supports to initiate adequate treatment. In conclusion, the PHI is a universal tool that can be used to assess the quality of recovery in the perioperative setting and allow immediate intervention.

Financial analysis of revision knee surgery at a tertiary referral centre as classified according to the Revision Knee Complexity Classification (RKCC)

BACKGROUND

Revision total knee arthroplasty (rTKA) can be complex, with greater costs to the treating hospital than primary TKA. A rTKA regional network has been proposed in England. The aim of this work was to accurately quantify current costs and reimbursement for the rTKA service and to assess whether costs are proportional to case complexity at a tertiary referral centre within the National Health Service (NHS).

METHODS

A review of all rTKA performed at our institution over two consecutive financial years (2017-2019) was performed. Cases were classified according to the Revision Knee Complexity Classification (RKCC) and by mode of failure; "infected" and "non-infected". Financial data was acquired through Patient-Level Information and Costing System (PLICS). The primary outcome was the financial difference between tariff and cost per episode. Comparisons between groups were analysed using analysis of variance and two-tailed unpaired t-test as appropriate.

RESULTS

159 patients underwent 188 rTKA procedures. Length of stay and cost significantly increased between complexity groups (p < 0.0001) and for infected revisions (p < 0.0001). All groups sustained a mean deficit but this significantly increased with revision complexity (from £1,903 to £5,269 per case) and for infected revisions. The total deficit to the Trust for the two-year rTKA service was £667,091.

CONCLUSIONS

The current level of NHS reimbursement are inadequate for centres that offer rTKA and should be more closely aligned to case complexity. An increase in the most complex rTKA at major revision centres will undoubtedly place an even greater strain on the finances of these units.

Occupational advice to help people return to work following lower limb arthroplasty: the OPAL intervention mapping study

BACKGROUND

Hip and knee replacements are regularly carried out for patients who work. There is little evidence about these patients' needs and the factors influencing their return to work. There is a paucity of guidance to help patients return to work after surgery and a need for structured occupational advice to enable them to return to work safely and effectively.

OBJECTIVES

To develop an occupational advice intervention to support early recovery to usual activities including work that is tailored to the requirements of patients undergoing hip or knee replacements. To test the acceptability, practicality and feasibility of this intervention within current care frameworks.

DESIGN

An intervention mapping approach was used to develop the intervention. The research methods employed were rapid evidence synthesis, qualitative interviews with patients and stakeholders, a prospective cohort study, a survey of clinical practice and a modified Delphi consensus process. The developed intervention was implemented and assessed during the final feasibility stage of the intervention mapping process.

SETTING

Orthopaedic departments in NHS secondary care.

PARTICIPANTS

Patients who were in work and intending to return to work following primary elective hip or knee replacement surgery, health-care professionals and employers.

INTERVENTIONS

Occupational advice intervention.

MAIN OUTCOME MEASURES

Development of an occupational advice intervention, fidelity of the developed intervention when delivered in a clinical setting, patient and clinician perspectives of the intervention and preliminary assessments of intervention effectiveness and cost.

RESULTS

A cohort study (154 patients), 110 stakeholder interviews, a survey of practice (152 respondents) and evidence synthesis provided the necessary information to develop the intervention. The intervention included information resources, a personalised return-to-work plan and co-ordination from the health-care team to support the delivery of 13 patient and 20 staff performance objectives. To support delivery, a range of tools (e.g. occupational checklists, patient workbooks and employer information), roles (e.g. return-to-work co-ordinator) and training resources were created. Feasibility was assessed for 21 of the 26 patients recruited from three NHS trusts. Adherence to the defined performance objectives was 75% for patient performance objectives and 74% for staff performance objectives. The intervention was generally well received, although the short time frame available for implementation and concurrent research evaluation led to some confusion among patients and those delivering the intervention regarding its purpose and the roles and responsibilities of key staff.

LIMITATIONS

Implementation and uptake of the intervention was not standardised and was limited by the study time frame. Evaluation of the intervention involved a small number of patients, which limited the ability to assess it.

CONCLUSIONS

The developed occupational advice intervention supports best practice. Evaluation demonstrated good rates of adherence against defined performance objectives. However, a number of operational and implementation issues require further attention.

FUTURE WORK

The intervention warrants a randomised controlled trial to assess its clinical effectiveness and cost-effectiveness to improve rates and timing of sustained return to work after surgery. This research should include the development of a robust implementation strategy to ensure that adoption is sustained.

STUDY REGISTRATION

Current Controlled Trials ISRCTN27426982 and PROSPERO CRD42016045235.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 45. See the NIHR Journals Library website for further project information.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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

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

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

Enhanced recovery following hip and knee arthroplasty: a systematic review of cost-effectiveness evidence

OBJECTIVES

To assess cost-effectiveness of enhanced recovery pathways following total hip and knee arthroplasties. Secondary objectives were to report on quality of studies and identify research gaps for future work.

DESIGN

Systematic review of cost-utility analyses.

DATA SOURCES

Ovid MEDLINE, Embase, the National Health Service Economic Evaluations Database and EconLit, January 2000 to August 2019.

ELIGIBILITY CRITERIA

English-language peer-reviewed cost-utility analyses of enhanced recovery pathways, or components of one, compared with usual care, in patients having total hip or knee arthroplasties for osteoarthritis.

DATA EXTRACTION AND SYNTHESIS

Data extracted by three reviewers with disagreements resolved by a fourth. Study quality assessed using the Consensus on Health Economic Criteria list, the International Society for Pharmacoeconomics and Outcomes Research and Assessment of the Validation Status of Health-Economic decision models tools; for trial-based studies the Cochrane Collaboration's tool to assess risk of bias. No quantitative synthesis was undertaken.

RESULTS

We identified 17 studies: five trial-based and 12 model-based studies. Two analyses evaluated entire enhanced recovery pathways and reported them to be cost-effective compared with usual care. Ten pathway components were more effective and cost-saving compared with usual care, three were cost-effective, and two were not cost-effective. We had concerns around risk of bias for all included studies, particularly regarding the short time horizon of the trials and lack of reporting of model validation.

CONCLUSIONS

Consistent results supported enhanced recovery pathways as a whole, prophylactic systemic antibiotics, antibiotic-impregnated cement and conventional ventilation for infection prevention. No other interventions were subject of more than one study. We found ample scope for future cost-effectiveness studies, particularly analyses of entire recovery pathways and comparison of incremental changes within pathways. A key limitation is that standard practices have changed over the period covered by the included studies.

PROSPERO REGISTRATION NUMBER

CRD42017059473.

Regional anaesthesia for surgical repair of proximal humerus fractures: a systematic review and critical appraisal

INTRODUCTION

Regional anaesthesia (RA) is often used in shoulder surgery because it provides adequate postoperative analgesia and may enhance the patient outcome. RA reduces overall opioid consumption and is frequently used in enhanced recovery programs to decrease hospital stay. However, there is very limited literature confirming these advantages in the surgical repair of proximal humerus fractures. This paper reviews the current literature on the use of RA in pain management after surgical repair of these fractures and evaluates the effect of RA on the functional outcome, length of stay in hospital, and health care expenditure.

MATERIALS AND METHODS

The PubMed, Embase, Web of Science, and Cochrane Library databases were searched up to March 1, 2018. Studies investigating the use of RA in the management of proximal humerus fractures were included.

RESULTS

Eleven studies (containing 1872 patients) were eligible for inclusion. The analgesic effect of RA was investigated in eight studies that confirmed its pain-relieving ability. Two studies measured functionality and length of hospitalization and suggested that RA improved function and shortened the stay in hospital. Nine papers mentioned side effects associated with RA while three articles claim that RA decreases the incidence of adverse events associated with general anaesthesia.

CONCLUSIONS

This systematic review suggests that RA is a good option for postoperative analgesia in patients undergoing surgical repair of a proximal humerus fracture and is associated with fewer adverse events, a shorter recovery time, and a better functional outcome than those achieved by general anaesthesia alone. However, given the limited amount of data available, conclusions need to be made with caution and prospective studies are needed in the future.

Short term patient outcomes after total knee arthroplasty: Does the implant matter?

BACKGROUND

Newer implants for total knee arthroplasty (TKA) often gain market share at higher cost with little patient-reported and long-term clinical data. We compared outcomes after TKA using two different implants: DePuy PFC Sigma and Attune.

METHODS

Using a prospective data repository from an academic tertiary medical center, we analyzed 2116 TKAs (1603 Sigma and 513 Attune) from April 2011 through July 2016. Outcomes included length of surgery, length of stay, facility discharge, 90-day reoperation, range of motion (ROM) change, and patient-reported physical function (PCS).

RESULTS

There was no difference in length of surgery (Attune -2.87 min, P = 0.143). Implant type was not associated with extended LOS (>3 days) (OR 0.80, P = 0.439). There was no difference in facility discharge (OR 0.65, P = 0.103). Unadjusted 90-day reoperations were 0.3% for Sigma and 1.0% for Attune cohorts (P = 0.158). Sigma implants were associated with more ROM improvement in unadjusted analyses (+2.1 degree improvement P = 0.031). Fifty nine percent of the Sigma cohort and 49% of the Attune cohort achieved the minimal clinically important (MCID) change for PCS improvement, although there was no adjusted difference in achieving MCID (Attune OR 0.84, P = 0.435). There was no adjusted difference in absolute PCS improvement (Attune +0.12 score, P = 0.864).

CONCLUSIONS

Our data show no difference in physical function and most outcomes between Sigma and Attune. Attune implants had shorter absolute LOS, but there were no differences in extended LOS.

Intravenous Oxycodone Versus Other Intravenous Strong Opioids for Acute Postoperative Pain Control: A Systematic Review of Randomized Controlled Trials

Introduction

Optimal pain management is crucial to the postoperative recovery process. We aimed to evaluate the efficacy and safety of intravenous oxycodone with intravenous fentanyl, morphine, sufentanil, pethidine, and hydromorphone for acute postoperative pain.

Methods

A systematic literature search of PubMed, Cochrane Library, and EMBASE databases was performed for randomized controlled trials published from 2008 through 2017 (inclusive) that evaluated the acute postoperative analgesic efficacy of intravenous oxycodone against fentanyl, morphine, sufentanil, pethidine, and hydromorphone in adult patients (age ≥ 18 years). Outcomes examined included analgesic consumption, pain intensity levels, side effects, and patient satisfaction.

Results

Eleven studies were included in the review; six compared oxycodone with fentanyl, two compared oxycodone with morphine, and three compared oxycodone with sufentanil. There were no eligible studies comparing oxycodone with pethidine or hydromorphone. Overall, analgesic consumption was lower with oxycodone than with fentanyl or sufentanil. Oxycodone exhibited better analgesic efficacy than fentanyl and sufentanil, and comparable analgesic efficacy to morphine. In terms of safety, there was a tendency towards more side effects with oxycodone than with fentanyl, but the incidence of side effects with oxycodone was comparable to morphine and sufentanil. Where patient satisfaction was evaluated, higher satisfaction levels were observed with oxycodone than with sufentanil and comparable satisfaction was noted when comparing oxycodone with fentanyl. Patient satisfaction was not evaluated in the studies comparing oxycodone with morphine.

Conclusions

Our findings suggest that intravenous oxycodone provides better analgesic efficacy than fentanyl and sufentanil, and comparable efficacy to morphine with less adverse events such as sedation. No studies comparing intravenous oxycodone with pethidine or hydromorphone were identified in this review. Better alignment of study methodologies for future research in this area is recommended to provide the best evidence base for a meta-analysis.

Funding

Mundipharma Singapore Holding Pte Ltd, Singapore.

Electronic supplementary material

The online version of this article (10.1007/s40122-019-0122-4) contains supplementary material, which is available to authorized users.

What is the evidence to support early supervised exercise therapy after primary total knee replacement? A systematic review and meta-analysis

Background

Total knee replacement (TKR) patients participate in early supervised exercise therapy programs, despite a lack of evidence for such programs or the optimal type, duration or frequency to provide the best clinical outcomes. As hospital stay rates decrease worldwide, the first days after joint replacement surgery are of increasing clinical importance. The purpose of this study was to investigate any reported effects of published early exercise therapy following TKR surgery.

Methods

Databases PubMed, CINAHL, Embase, Cochrane, and Pedro were searched up to August 2018 for trials which investigated an early supervised exercise therapy, commencing within 48 h of surgery. Risk of bias was evaluated using a Modified Downs and Black Checklist and meta-analysis of results was conducted using Review Manager (RevMan). Standardised Mean Differences (SMD) or Mean Differences (MD) and 95% confidence intervals were calculated and combined in meta-analyses.

Results

Four studies (323 patients) that used four different interventions were identified, including Modified Quadriceps Setting, Flexion Splinting, Passive Flexion Ranging and a Drop and Dangle Flexion regime. Patients receiving the Drop and Dangle flexion protocol had superior flexion in the first 2 days after TKR and at discharge, the Flexion Splint patients were discharged earlier and had greater flexion at 6-weeks postoperatively, and the Modified Quadriceps Setting group showed greater hamstring and gluteal muscle strength. Results of the methodological quality assessment showed included studies were of moderate quality. The meta-analysis included 3 of the 4 trials and found no significant differences between groups in maximum knee flexion (MD = 1.34; 95% CI, − 5.55–8.24) or knee society scores (MD = − 1.17; 95% CI, − 4.32–1.98) assessed at 6 weeks post-operatively.

Conclusion

The paucity and heterogeneity of existing studies that examine early supervised exercise therapy following TKR surgery makes it challenging for clinicians to deliver high-quality evidence-based exercise programs in the early postoperative period. Although superior knee flexion range was found across differing regimes, the meta-analysis showed no significant difference in this outcome between groups at 6 weeks. The results of this review show high quality randomized clinical trials are urgently needed to evaluate the impact of early exercise following TKR surgery.

Trial Registration

This review was registered with PROSPERO (CRD42017081016).

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2415-5) contains supplementary material, which is available to authorized users.

[Comparison of early rehabilitation effects of total hip arthroplasty with direct anterior approach versus posterior approach]

Objective

To compare the early rehabilitation effects of total hip arthroplasty (THA) with direct anterior approach (DAA) versus posterior approach (PA).

Methods

A retrospective analysis was made in the data of 83 patients with unilateral osteonecrosis of the femoral head between March 2014 and May 2017. Forty-eight patients were treated with THA via PA (PA group) and 35 patients were treated with THA via DAA (DAA group). There was no significant difference in gender, age, body mass index, stage of osteonecrosis of the femoral head, and disease duration between 2 groups ( P>0.05). The length of incision, operation time, total amount of bleeding, the time of first postoperative walking with crutch, the time of first postoperative walking without crutch, the Harris scores, and the visual analogue scale (VAS) scores of 2 group were recorded and compared.

Results

All incisions healed primarily and no infection, dislocation, or fracture occurred. All patients were followed up 30.2 months on average (range, 6-44 months). The numbness symptom caused by the lateral femoral cutaneous nerve injury occurred in 2 patients of DAA group and released after symptomatic treatment. The length of incision, total amount of bleeding, the time of first postoperative walking with crutch, and the time of first postoperative walking without crutch of DAA group were significantly superior to those of PA group ( P<0.05). The Harris scores of DAA group were significantly higher than those of PA group at 2 weeks and 1 month after operation ( P<0.05), while no significant difference was found between 2 groups before operation and at 3 months and 6 months after operation ( P>0.05). The VAS scores of DAA group were significantly lower than those of PA group at 1 day, 4 days, 1 week, and 2 weeks after operation ( P<0.05), while no significant difference was found between 2 groups before operation ( P>0.05).

Conclusion

DAA is meaningful to enhanced recovery after THA. But it should be chosen carefully because of the disadvantages, such as long learning curve, limited indications, and requirements of specific instruments.

Updates in Enhanced Recovery Pathways for Total Knee Arthroplasty

Enhanced recovery after surgery (ERAS) programs for orthopedics involve a multidisciplinary approach to accelerating return to function, reducing pain, improving patient comfort and satisfaction, reducing complications from the surgical procedure, reducing hospital length of stay, and reducing costs. ERAS pathways for patients receiving total knee arthroplasty are different from those having intracavitary surgery; they are less focused on fluid homeostasis and gut motility than they are with optimizing systemic and local analgesics and providing a balance between the highest quality pain control and accelerated return to ambulation.

Accuracy of bone resection in total knee arthroplasty using CT assisted-3D printed patient specific cutting guides

Introduction: We conducted this study to determine if the pre-surgical patient specific instrumented planning based on Computed Tomography (CT) scans can accurately predict each of the femoral and tibial resections performed through 3D printed cutting guides. The technique helps in optimization of component positioning determined by accurate bone resection and hence overall alignment thereby reducing errors.

Methods: Prophecy evolution medial pivot patient specific instrumented knee replacement systems were used for end stage arthrosis in all consecutive cases over a period of 20 months by a single surgeon. All resections (4 femoral and 2 tibial) were measured using a vernier callipers intraoperatively. These respective measurements were then compared with the preoperative CT predicted bone resection surgical plan to determine margins of errors that were categorized into 7 groups (0 mm to ≥2.6 mm).

Results: A total of 3618 measurements (averaged to 1206) were performed in 201 knees (105 right and 96 left) in 188 patients (112 females and 76 males) with an average age of 67.72 years (44 to 90 years) and average BMI of 32.3 (25.1 to 42.3). 94% of all collected resection readings were below the error margin of ≤1.5 mm of which 90% showed resection error of ≤1 mm. Mean error of different resections were ≤0.60 mm (P ≤ 0.0001). In 24% of measurements there were no errors or deviations from the templated resection (0.0 mm).

Conclusion: The 3D printed cutting blocks with slots for jigs accurately predict bone resections in patient specific instrumentation total knee arthroplasty which would directly affect component positioning.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION AND CONCLUSIONS

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

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

Background:

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

Study Design:

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

Results:

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

Conclusions:

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

[The hardware techniques for the restoration of the gait stereotype in the patients following total hip replacement: the personalized approach]

BACKGROUND

total hip replacement has long ago become the «golden standard» for the treatment of dysplastic coxarthrosis in thousands of the patients receiving it every year. In the meantime, the analysis of the specialized literature gives evidence of the lack of a systematic and personified approach to the rehabilitation treatment.

AIM

The objective of the present study was to improve medical rehabilitation of the patients following the total hip replacement and to develop the personalized programs for walking modality reconstruction taking into consideration the age and the body weight of the patients.

PATIENTS AND METHODS

A total of 240 patients were available for the observation including 184 women and 56 men. They were divided into three study groups and one control group, with the differentiation into the following three subgroups: one comprised of the patients of moderate acerage age and body weight, the other containing the obese patients (BMI>35), and the third one involving the elderly patients (age >70 years); each subgroup consisted of 20 patients. All the patients received the early basic rehabilitation treatment, those in the study groups had to perform in addition the robotic training based on the use of hardware techniques supplemented by passive mechanotherapy and electromyostimulation designed to restore the walking stereotype with three types of devices: body weight unloading, video-reconstruction associated with biological feedback and robototherapy.

RESULTS

The comparative analysis of the effectiveness of various methods of gait reconstruction has demonstrated the high effectiveness of the application of the hardware technique in the patients of moderate acerage age and body weight. At the same time, the elderly patients had a significantly higher rate of successful walking reconstruction efficiency under the influence of the video-associated training with biological feedback (3 times that achieved with training using the device for unloading the body weight and 4 times compared with the result of a course of robotic walk. The evaluation of the application of the techniques for the gait stereotype reconstruction in the obese patients gave evidence of the advantage of the Lokomat robotic trainings that produced 6 times better results than unloading of the body weight and 5 times better ones than the video-associated training with biological feedback.

DISCUSSION

The results of the present study are on the whole comparable with the data reported by other authors although its design was different from that of the majority of the published studies in that our patients were allocated to different subgroups for the further personalization of the methods applied to restore the gait stereotype. The factors limiting the use of the results of this study include the medium-high level of the patients' welfare most of whom are residents of the city of Moscow and Moscow region characterized by a relatively high quality and accessibility of health care. It means that the results of such studies as the one described in the present article are directly related to the quality and accessibility of health care and can be extrapolated only to the socially safe and well-to-do patients.

CONCLUSIONS

All the hardware techniques are equally effective in the patients of moderate average age and body weight. The elderly patients showed the best results using the video-reconstruction associated with biological feedback, while the Locomat technique was especially useful for the obese patients.

Perioperative Nutritional Optimization in Spine Surgery

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

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

Background:

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

Study Design:

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

Results:

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

Conclusion:

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

Optimizing the dose of local infiltration analgesia and gabapentin for total knee arthroplasty, a randomized single blind trial in 128 patients

BACKGROUND AND PURPOSE

Effective analgesia is essential for postoperative recovery and rehabilitation in TKA. The challenge of analgesic regimes is to obtain adequate pain relief and maximum muscle control to mobilize and rehabilitate patients early. However, the optimal dose and best composition are not known. We hypothesized that there would be no differences in reported postoperative pain on the day of the TKA surgery as well as the first day after surgery when different combinations of ropivacain for LIA and gabapentin are given.

METHODS

This prospective randomized trial examined 128 TKA patients treated with LIA and gabapentin in four groups. Group A: 300-mg ropivacain/600-300-300-mg gabapentin. Group B: 150-mg ropivacain/600-300-300-mg gabapentin. Group C: 300-mg ropivacain/300-100-100-mg gabapentin. Group D: 150-mg ropivacain/300-100-100-mg gabapentin. Primary endpoint was pain (NRS) at multiple moments. Secondary endpoints were number of adverse effects, length of hospital stay (LOS), the amount of consumption of pain medication, and wound leakage. Generalized estimating equation (GEE) was used to detect differences between the four groups regarding the course of pain.

RESULTS

No differences regarding adverse effects, LOS, and wound leakage were found. GEE revealed a significant difference in course of pain between group A and B, with group B experiencing higher NRS scores postoperatively than group A (p=0.021). No differences between the other groups were found.

INTERPRETATION

The results of the current study suggest that LIA with 300-mg (150ml) ropivacain might be more effective than 150-mg (75ml) ropivacain. Alteration in dose of gabapentin appears not to have influence on the course of pain.

In-home versus hospital preoperative balance and proprioceptive training in patients undergoing TKR; rationale, design, and method of a randomized controlled trial

Background

Severe knee osteoarthritis, as well as the surgical procedure of total knee replacement that aims to reduce its symptoms, cause great deterioration on the proprioceptive system. Taking this fact into account, and considering that balance abilities positively influence the capacity to perform basic functional tasks, this trial aims to find the short and mid-term effects of a preoperative balance and proprioceptive training when conducted by patients undergoing total knee replacement. Along with the effects, it is intended to determine whether in-home based training can be as effective as hospital training. The results will help to conclude whether the possible benefits may outweigh the health costs.

Methods

Seventy-five participants will take part. The trial will include in-home and supervised hospital experimental training compared to a non-active control group in order to estimate the actual effect of the proposal against the benefits due exclusively to the surgical procedure. Interventions last 4 weeks prior to surgery, and the follow-up will be at 2w, 6w, and 1y following the operation. The primary outcomes are in agreement with the goals: self-reported functionality in terms of KOOS and overall balance in terms of the Berg Balance Scale. The secondary outcomes will include the measurements of static and dynamic balance abilities, pain, function, and quality of life.

Discussion

It is expected for the results of this trial to provide relevant information in order to decide if a specific intervention is cost-effective to be implemented in clinical practice.

Trial registration

Clinicaltrials.gov identifier NCT03100890. Registered in April 4, 2017.

The role of elastomeric pumps in postoperative analgesia in orthopaedics and factors affecting their flow rate

Elastomeric pumps are mechanical devices composed of an elastomeric balloon reservoir into which the drug to be infused is stored, a protective casing (used by some manufacturers), a flow controller and a wound catheter. In orthopaedics they are used to provide continuous local infiltration analgesia. In this way patients rely less on other routes of analgesia and thus avoid their systemic side effects. Studies have shown good response to analgesia with these pumps for the first 24 hours but their benefit is not as clear at 48 and 72 hours. There are numerous factors that affect the flow rate of elastomeric pumps. Some are inherent to all elastomeric pumps such as: the pressure exerted by the elastomeric balloon, catheter size, the vertical height of the pump in relation to the wound, viscosity and partial filling. There are also other factors which vary according to the manufacturer such as: the optimal temperature to obtain the desired flow rate as this directly affects viscosity, the dialysate that the analgesic drug is mixed with (ie normal saline or 5% dextrose), and the storage conditions of the fluid to be infused. It is thus essential to follow the clinical guidelines provided by the manufacturer in order to obtain the desired flow rate.

Enhanced recovery programmes for lower limb arthroplasty in the UK

INTRODUCTION

Enhanced recovery programmes (ERPs) reduce patient morbidity and mortality, and provide significant cost savings by reducing length of stay. Currently, no uniform ERP guidelines exist for lower limb arthroplasty in the UK. The aim of this study was to identify variations in ERPs and determine adherence to local policy.

METHODS

Hospitals offering elective total knee arthroplasty (TKA) and total hip arthroplasty (THA) (23 and 22 centres respectively) contributed details of their ERPs, and performed an audit (15 patients per centre) to assess compliance.

RESULTS

Contrasting content and detail of ERPs was noted across centres. Adherence to ERPs varied significantly (40-100% for TKA, 17-94% for THA). Analysis identified perioperative use of dexamethasone, tranexamic acid and early mobilisation for TKA, and procedures performed in teaching hospitals for THA as being associated with a reduced length of stay.

CONCLUSIONS

This study highlights variation in practice and poor compliance with local ERPs. Given the proven benefits of ERPs, evidence-based guidelines in the context of local skillsets should be established to optimise the patient care pathway.

The Effect of a Rapid Rehabilitation Program on Patients Undergoing Unilateral Total Knee Arthroplasty

BACKGROUND

Few studies have looked at longer term functional outcomes of rapid rehabilitation (physical therapy in the postanesthesia care unit on the day of surgery) for patients undergoing total knee arthroplasty.

PURPOSE

The purpose of this interdisciplinary study (physical therapy and nursing) was to assess the effect of a rapid rehabilitation program on inpatient length of stay (LOS) and functional recovery.

METHODS

Functional outcomes were measured by the Knee Injury Osteoarthritis Outcome Score presurgically and at 4 and 12 weeks postoperatively and by progression along a physical therapy rehabilitation pathway.

RESULTS

Experimental group LOS was significantly shorter than the control group (p = .0261). Multilevel regression modeling showed that KOOS and physical therapy clinical pathway score trajectories did not differ significantly between groups. Patients receiving rapid rehabilitation were 2.5 (95% CI [0.958, 6.53]) times more likely to have a positive physical therapy rehabilitation trajectory than patients in the control group.

CONCLUSION

Findings validated earlier study results in terms of LOS; however, further research is needed to assess the effect of rapid rehabilitation on longer term functional outcomes.

Enhanced recovery after surgery: Current research insights and future direction

Since the concept of enhanced recovery after surgery (ERAS) was introduced in the late 1990s the idea of implementing specific interventions throughout the peri-operative period to improve patient recovery has been proven to be beneficial. Minimally invasive surgery is an integral component to ERAS and has dramatically improved post-operative outcomes. ERAS can be applicable to all surgical specialties with the core generic principles used together with added specialty specific interventions to allow for a comprehensive protocol, leading to improved clinical outcomes. Diffusion of ERAS into mainstream practice has been hindered due to minimal evidence to support individual facets and lack of method for monitoring and encouraging compliance. No single outcome measure fully captures recovery after surgery, rather multiple measures are necessary at each stage. More recently the pre-operative period has been the target of a number of strategies to improve clinical outcomes, described as prehabilitation. Innovation of technology in the surgical setting is also providing opportunities to overcome the challenges within ERAS, e.g., the use of wearable activity monitors to record information and provide feedback and motivation to patients peri-operatively. Both modernising ERAS and providing evidence for key strategies across specialties will ultimately lead to better, more reliable patient outcomes.

The constraints on day-case total knee arthroplasty: the fastest fast track

Total knee arthroplasty (TKA) is a major orthopaedic intervention. The length of a patient's stay has been progressively reduced with the introduction of enhanced recovery protocols: day-case surgery has become the ultimate challenge. This narrative review shows the potential limitations of day-case TKA. These constraints may be social, linked to patient's comorbidities, or due to surgery-related adverse events (e.g. pain, post-operative nausea and vomiting, etc.). Using patient stratification, tailored surgical techniques and multimodal opioid-sparing analgesia, day-case TKA might be achievable in a limited group of patients. The younger, male patient without comorbidities and with an excellent social network around him might be a candidate. Demographic changes, effective recovery programmes and less invasive surgical techniques such as unicondylar knee arthroplasty, may increase the size of the group of potential day-case patients. The cost reduction achieved by day-case TKA needs to be balanced against any increase in morbidity and mortality and the cost of advanced follow-up at a distance with new technology. These factors need to be evaluated before adopting this ultimate 'fast-track' approach.

Is Single-Radius Design Better for Quadriceps Recovery in Total Knee Arthroplasty?

Purpose

Although single-radius (SR) designs have a theoretical advantage in quadriceps recovery following total knee arthroplasty (TKA), there has been a paucity of objective evaluation studies.

Materials and Methods

One hundred and twenty minimally invasive TKAs were prospectively randomized by a single surgeon into 2 groups: SR design TKA group and multi-radius design TKA group. Quadriceps force and power were assessed using a dynamometer, and clinical data were investigated preoperatively and 6 weeks, 3 months, 6 months and 1 year postoperatively.

Results

There were no differences between two groups in quadriceps recovery and clinical results throughout the follow-up period. Furthermore, the proportion of patients whose postoperative quadriceps force and power reached preoperative level was similar in both groups.

Conclusions

Femoral component design itself would not significantly influence quadriceps recovery after TKA.

Enhanced recovery after surgery (ERAS) and its applicability for major spine surgery

This article examines the relevance of applying the Enhanced Recovery after Surgery (ERAS) approach to patients undergoing major spinal surgery. The history of ERAS, details of the components of the approach and the underlying rationale are explained. Evidence on outcomes achieved by using the ERAS approach in other orthopaedic and complex surgical procedures is then outlined. Data on major spinal surgery rates and current practice are reviewed; the rationale for using ERAS in major spinal surgery is discussed, and potential challenges to its adoption are acknowledged. A thorough literature search is then undertaken to examine the use of ERAS pathways in major spinal surgery, and the results are presented. The article then reviews the evidence to support the application of individual ERAS components such as patient education, multimodal pain management, surgical approach, blood loss, nutrition and physiotherapy in major spinal surgery, and discusses the need for further robust research to be undertaken. The article concludes that given the rising costs of surgery and levels of patient dissatisfaction, an ERAS pathway that focuses on optimising clinical procedures by adopting evidence-based practice and improving logistics should enable major spinal surgery patients to recover more quickly with lower rates of morbidity and improved longer-term outcomes.

Enhanced recovery programmes can reduce length of stay after total knee replacement without sacrificing functional outcome at one year

INTRODUCTION

Enhanced recovery programmes (ERPs) are being widely adopted in total knee replacement (TKR) procedures but studies confirming that they have no adverse effects on functional outcomes are lacking. The aim of this study was to compare length of stay, postoperative functional outcome and range of motion at one year postoperatively between patients undergoing TKR with an ERP and those with traditional rehabilitation.

METHODS

A total of 165 consecutive patients undergoing primary unilateral TKR were included in the study. Overall, 84 patients undergoing TKR with an ERP were compared with a series of 81 patients undergoing primary unilateral TKR with traditional rehabilitation, immediately before the introduction of the ERP.

RESULTS

The median postoperative length of stay was 3 days in the ERP cohort and 4 in the traditionally rehabilitated cohort (p<0.001). There were no significant differences in the preintervention characteristics of the groups and there was no significant difference in operative time, transfusion or rates of manipulation under anaesthesia. There was no difference in magnitude of improvement in American Knee Society score (p=0.12) or range of motion (p=0.81) between the groups.

CONCLUSIONS

ERP can reduce length of stay after TKR while offering improvements in knee function equivalent to those experienced by patients undergoing TKR with traditional rehabilitation. Furthermore, ERP can be implemented successfully in the setting of a district general hospital.

Predictive factors of length of hospital stay after primary total knee arthroplasty

PURPOSE

To reduce post-operative length of hospital stay (PLOS) after primary total knee arthroplasty (TKA), the fast-track method was introduced which focusses on mobilising the patient within 2 h after surgery. The aim of this prospective study was to identify the factors that predict PLOS using the fast-track method.

METHODS

In a consecutive series from July 2012 to November 2012, all patients who were admitted for a primary TKA (Genesis II prosthesis, Smith and Nephew, Memphis, TN) were included in a prospective study. Demographic and relevant preoperative, perioperative and post-operative parameters for PLOS were collected. Multivariate linear regression analysis was performed to identify predictive factors.

RESULTS

In total, 240 patients were included (59.6% female) with a median age of 64.1 years (range 38-90). Median PLOS was 5 days (range 3-19). The predictive model suggested that ASA score (American Society of Anesthesiologists' physical status classification) wound exudate and range of motion (ROM) at the day of surgery (day 0) were significant predictive factors for PLOS using the fast-track procedure after TKA (adjusted R(2) = 0.43).

CONCLUSIONS

Predictive factors for PLOS after TKA were ASA score, wound exudate and ROM at day 0. Adjustments in patient counselling, nursing ward, mode of physiotherapist training and discharge criteria regarding wound exudate may result in a further reduction of post-operative length of hospital stay.

LEVEL OF EVIDENCE

Prognostic studies: high-quality prospective cohort study, Level I.

Financial analysis of revision knee surgery based on NHS tariffs and hospital costs: does it pay to provide a revision service?

Revision total knee arthroplasty (TKA) is a complex procedure which carries both a greater risk for patients and greater cost for the treating hospital than does a primary TKA. As well as the increased cost of peri-operative investigations, blood transfusions, surgical instrumentation, implants and operating time, there is a well-documented increased length of stay which accounts for most of the actual costs associated with surgery. We compared revision surgery for infection with revision for other causes (pain, instability, aseptic loosening and fracture). Complete clinical, demographic and economic data were obtained for 168 consecutive revision TKAs performed at a tertiary referral centre between 2005 and 2012. Revision surgery for infection was associated with a mean length of stay more than double that of aseptic cases (21.5 vs 9.5 days, p < 0.0001). The mean cost of a revision for infection was more than three times that of an aseptic revision (£30 011 (sd 4514) vs £9655 (sd 599.7), p < 0.0001). Current NHS tariffs do not fully reimburse the increased costs of providing a revision knee surgery service. Moreover, especially as greater costs are incurred for infected cases. These losses may adversely affect the provision of revision surgery in the NHS.

Short-stretch inelastic compression bandage in knee swelling following total knee arthroplasty study (STICKS): study protocol for a randomised controlled feasibility study

Background

Enhanced recovery programmes in total knee arthroplasty are well established. Post-operative knee swelling is common and impairs early post-operative function. The use of a short-stretch, inelastic compression bandage is hypothesised to reduce knee swelling and improve pain and early function. A study was designed to test feasibility with a view to informing a larger, future trial and to provide preliminary data.

Methods/design

This is a randomised controlled feasibility study. Fifty consecutive patients selected for primary total knee arthroplasty will be enrolled in the trial. Patients with a BMI >35, latex allergy or neurological or peripheral vascular disease are excluded. Patients are randomised by distance randomisation to receive a compression bandage for 24 hours after surgery or a standard wool and crepe bandage. The bandages are applied by one of two consultant surgeons who have had training with their application. Knee swelling, range of motion and pain scores will be compared pre-operatively and at day 1, day 2 and at 6 weeks between groups. The Oxford knee score and EQ-5D health status will be compared pre-operatively and at 6 months between groups. Recruitment rates, retention rates, resource allocation, completeness of data collection, and tolerance and complications with the compression bandage are recorded. Descriptive statistics are used to calculate a standard deviation for post-operative knee swelling in the groups and to perform a power calculation incorporating anticipated patient retention rates to inform a future trial. Preliminary data will be analysed using the independent samples t-test for equal distributions and the Mann-Whitney U for unequal distributions with the significance denoted at P <0.05.

Discussion

Enhanced recovery programmes have revolutionized the management of total knee arthroplasty. There is a paucity of clinical data regarding the efficacy of compression bandages. Large, randomised controlled trials are uncommon in orthopaedic surgery. The results of this study will provide feasibility and preliminary data prior to the construction of a larger, multicentre study.

Trial registration

The study was registered with Current Controlled Trials (ISRCTN86903140) on 30 May 2013.

Is a preoperative group and save necessary for enhanced recovery joint replacement patients?

AIM

To consider the financial benefit to the authors' trust of omitting a preoperative group and save in enhanced recovery arthroplasty patients, and to estimate the scope for national savings. Patient safety was considered to determine acceptability for routine practice.

METHODS

A total of 121 patients receiving a total knee replacement or total hip replacement on the authors' enhanced recovery protocol were selected. Pre- and postoperative haemoglobin levels were obtained. The transfusion team were contacted when the postoperative haemoglobin level was ≤8 g/dl to determine whether blood products had been issued. Costs for group and save were obtained from the pathology department.

RESULTS

Mean postoperative reduction in haemoglobin level was 2.6 g/dl (P≤0.001) and 2.1 g/dl (P≤0.001) for total hip replacement and total knee replacement respectively. No patients were transfused. One group and save costs £12.00, and omission of this test in these patients would have saved £1452.00. Potentially, £1 605 408 could have been saved in the 133 784 patients undergoing NHS arthroplasty in 2012. Group and save omission would not affect management of intraoperative haemorrhage where O negative blood would be available. If a transfusion is required postoperatively it would take 100 minutes to issue crossmatched blood - a time delay unlikely to compromise patient safety.

CONCLUSIONS

These results suggest that a preoperative group and save could be omitted in arthroplasty patients on this enhanced recovery programme to prevent needless expenditure, but more long-term follow up is required to ensure patients are not put at risk.

Postoperative pain management after total knee arthroplasty in elderly patients: treatment options

Total knee arthroplasty (TKA) is a common surgical procedure in the elderly and is associated with severe pain after surgery and a high incidence of chronic pain. Several factors are associated with severe acute pain after surgery, including psychological factors and severe preoperative pain. Good acute pain control can be provided with multimodal analgesia, including regional anesthesia techniques. Studies have demonstrated that poor acute pain control after TKA is strongly associated with development of chronic pain, and this emphasizes the importance of attention to good acute pain control after TKA. Pain after discharge from hospital after TKA is currently poorly managed, and this is an area where increased resources need to be focused to improve early pain control. This is particularly as patients are often discharged home within 4-5 days after surgery. Chronic pain after TKA in the elderly can be managed with both pharmacological and non-pharmacological techniques. After excluding treatable causes of pain, the simplest approach is with the use of acetaminophen combined with a short course of non-steroidal anti-inflammatory drugs (NSAIDs). Careful titration of opioid analgesics can also be helpful with other adjuvants such as the antidepressants or antiepileptic medications used especially for patients with neuropathic pain. Topical agents may provide benefit and are associated with fewer systemic side effects than oral administration. Complementary or psychological therapies may be beneficial for those patients who have failed other options or have depression associated with chronic pain.