Abstract
Introduction
Gastrointestinal complications after total hip (THA) and knee arthroplasty (TKA) have been reported to be between 0.3 and 2.6% with bleeding and C. difficile infection in 0–1%, and 0.1–1.7%, respectively. The use of enhanced recovery or “fast-track” protocols have focused on optimizing all aspects of perioperative care resulting in reduced length of hospital stay (LOS) and potentially also gastrointestinal complications. This study is a detailed analysis on the occurrence of postoperative gastrointestinal complications resulting in increased hospital stay or readmissions in a large consecutive cohort of fast-track THA and TKA with complete 90 days follow-up.
Materials and methods
This is an observational study on a consecutive cohort of primary unilateral THAs and TKAs performed between January 2010 and August 2017 in nine Danish high-volume fast-track centers. Discharge summaries and relevant patient records were reviewed in patients with readmissions within 90 days or LOS > 4 days caused by gastrointestinal complications.
Results
The cohort included 36,932 patients with 58.3% females and 54.1% THAs. Mean age and BMI were 68 years and 28. Median postoperative LOS was 2 days. Only n: 276 (0.75 %) had a LOS > 4 days or a readmission within 90 days due to a gastrointestinal complication (CI 0.67%–0.84%). Of these, only 34 (0.09%) were graded as severe ileus or gastrointestinal bleeding.
Conclusions
The risk of GI-complications within the first 90 postoperative days after fast-track THA and TKA was low (0.75%).
Similar content being viewed by others
Introduction
Gastrointestinal complications, including postoperative ileus (POI), gastrointestinal bleeding (GIB) and infection with Clostridium difficile are rare but potentially serious adverse events after total hip (THA) and knee arthroplasty (TKA). In a recent review on gastrointestinal complications after THA and TKA the overall incidence of complications was 0.3–2.6%, with GIB and C. difficile infection between 0–1% and 0.1–1.7%, respectively [1]. However, the included studies were often large database studies using administrative data [2,3,4,5] with no details on perioperative care and with the majority of data being collected before 2010 [1] thereby limiting interpretation in relation to contemporary fast-track protocols with short length of stay and fewer complications [6]. Thus, the risk of POI may be related to opioid-induced constipation [7] while GIB may be related to type and duration of postoperative thromboprophylaxis [8] as well as non-steroidal anti-inflammatory drugs (NSAIDs) [9] and C. difficile infections to type of antibiotics and extended stay in hospital [10]. In this context, the use of enhanced recovery or fast-track protocols have focused on optimizing all aspects of perioperative care, including use of opioid-sparing multimodal analgesia with NSAIDs/Cox-2 inhibitors, early mobilization, and in-hospital only thromboprophylaxis, resulting in reduced postoperative morbidity and consequently shorter length of hospital stay (LOS) [6]. It could be speculated that the use of enhanced recovery protocols may also reduce the incidence of gastrointestinal complications after THA and TKA, but detailed large-scale data on gastrointestinal complications after THA and TKA with a fully implemented enhanced recovery protocol is limited.
The aim of the present study was to analyze the occurrence of postoperative gastrointestinal complications resulting in either a LOS > 4 days or readmission within 90-days after fast-track THA and TKA in a large consecutive cohort with complete 90 days follow-up.
Methods
Study design
This is an observational study based on a consecutive cohort of fast-track THAs and TKAs performed between January 2010 and August 2017 in nine centers contributing to the Centre for Fast-track Total Hip and Knee Replacement database [11]. The findings of this study are presented in accordance with the STROBE statement [12].
Data source
The Centre for Fast-track Hip and Knee replacement has since 2009 functioned as a multi-center collaboration of Danish high-volume departments with well-established fast-track protocols, including preference for spinal anesthesia, multi-modal opioid-sparing analgesia, early mobilization, only in-hospital thromboprophylaxis if LOS ≤ 5 days, and discharge to own home based on functional discharge criteria. All patients completed a questionnaire on demographic information and comorbidities prior to surgery, with nurse assistance if necessary.
Information on use of anticoagulants, psychopharmacological treatment, and antidiabetics was acquired through the National Danish National Database on Reimbursed Prescriptions (DNDRP). The DNDRP collects data on all prescriptions with reimbursement dispensed at Danish pharmacies and has shown a high degree (> 85%) of completeness for most drugs [13].
Data on LOS, 90-days readmissions and mortality was retrieved from the Danish National Patient Registry (DNPR). The DNPR collects information on all somatic admissions in both the public and private sector, ensuring follow-up of > 99% [14].
The medical discharge summary was reviewed in cases of LOS > 4 days or 90-day readmission to identify the reason for admission. In case of insufficient information and in all cases of mortality, the entire medical record was reviewed.
We secondarily reviewed the complete medical records of all patients with initially recorded gastrointestinal complications for information on onset and severity. In case of GI-complications during primary admission without well-defined time of onset, but subsequent endoscopy or transfer to surgical ward we used onset as day of procedure/transfer. In case of readmission, we defined onset as day of readmission.
In 20 (16.4 % of GI-complications during primary admission) cases of GI-complications during primary admission it was not possible to retrieve information on onset of symptoms, day of performed procedure or transfer to a surgical ward.
Study cohort
The cohort included consecutive elective unilateral primary THAs and TKAs performed between January 2010 and August 2017 [11] with a completed preoperative questionnaire. We excluded patients < 18 years, those with prior major lower extremity surgery within 90 days of the THA or TKA procedure, simultaneous bilateral procedures, procedures due to fractures, cancer, or severe congenital disorder.
Assessments
GIB was defined according to the European Perioperative Clinical Outcome definitions, where gastrointestinal bleeding is an “unambiguous clinical or endoscopic evidence of blood in the gastrointestinal tract,” and severity is graded into mild (temporary harm, usually no specific treatment), moderate (no permanent harm but usually requires treatment), and severe (significantly prolonged LOS and/or permanent functional limitation or death, always requires treatment) [15].
POI was graded according to Venara et al classification proposed in 2017. The grades are A (no consequence of POI except an increase in LOS), B (need for treatments such as laxatives, etc. or diagnostic examination), C (need for nasogastric tube or readmission), D1 (systemic complication, e.g., ionic imbalance), D2 (ICU or further surgery) and E (death) [16].
Statistics
The frequency and percentage of each included gastrointestinal complication was calculated in SPSS Statistics 28.0 by IBM. 95% Confidence Intervals (CI) for proportions were calculated with the use of Vassarstats.net.
Ethics and permits
This study has been approved by the National Board of Health (3-3013-56/1/), the Capital Region of Denmark (R-20073405) and the center for Regional Development (RH-2007-30-0623). The National Committee on Health Research Ethics waivered the need for permission as this was an observational study.
Results
The mean age was 68 years (SD: 10.6), mean BMI was 28 (SD: 5.2), 54.1% had THA and 58.3% were females (Table 1). The median postoperative LOS was 2 days and time from surgery to onset of GI-complication was overall a median of 6 (IQR: 3–23) days, but 2 (IQR: 1–3) days for complications during primary admission and 19 (IQR: 7–36.8) days at readmission.
Out of the 36,932 included fast-track THA and TKA procedures a total of 276 (0.75%) experienced GI-complications. Of these 123 (0.33%) resulted in a LOS > 4 days and 153 (0.42%) in readmission within 90 days. The primary incidence of GIB, POI and C. difficile was 37 (0.1%), 19 (0.05%) and 2 (0.01%), while the incidences of these at readmission were 46 (0.12%), 9 (0.02%) and 11 (0.03%).
Of the 83 (0.22%) patients who experienced GIB, 17 (0.05%), 49 (0.13%) and 17 (0.05%) experienced mild, moderate, and severe bleeding, respectively. Out of the 83 patients that experienced a GIB, only 8 took potent anticoagulants. The respective mean LOS at primary admission and readmission was 5.3 days and 6.4 days.
Of the 28 (0.07%) patients that experienced POI 2 (0.01%), 5 (0.01%), 4 (0.01%), 13 (0.04%) and 4 (0.01%) were graded as A, B, C, D2 and E. The respective mean LOS at primary admission and readmission was 5.0 days and 5.2 days.
For information on the incidences of the other included gastrointestinal complications see Table 2.
Discussion
This study on GI-complications after fast-track THA and TKA found lower rates of POI, GIB and C. Difficile infections than previously reported. A comparable study from the US [17], including > 1.5 million THA and TKA patients and reporting a declining incidence of GI-complications between 2006 and 2016 found an incidence of acute GI-complications of 1.03% and 0.79% in THA and TKA, respectively compared with a 90-day incidence of 0.75% in total, whereof the incidences of POI, GIB, and C. difficile were 0.07%, 0.22% and 0.04%.
It has previously been theorized that the implementation of enhanced recovery pathways may reduce the number of GI-complications [17], as several elements such as multimodal analgesia, early mobilization, only in-hospital thromboprophylaxis and reduced need of hospitalization may reduce the risks of GI-complications such as GIB and constipation [17,18,19] as demonstrated in our study.
Thromboprophylaxis after THA and TKA surgery is a complicated task due to the opposite risks of VTE and GIB, which was the most common GI-complication in our cohort. The risk of GIB after THA and TKA remained increased for 6 weeks after surgery for osteoarthritic patients in a study by Lalmohamad et al. [3]. This increased risk may be related to the use of thromboprophylaxis, although most patients received subcutaneous low molecular weight heparin, which is generally not associated with a higher risk of GIB [3]. In addition, NSAIDS, which are often used in a multi-modal opioid-sparing protocol, have not been found to increase the risk of GIBs after THA or TKA if appropriate precautions are taken as it pertains to patients with a higher risk of GIB [19]. The individual pain treatment plans and use of proton-pump inhibitors were not reviewed in this study.
The low incidence of GIB in this study may also be related to a short duration of thromboprophylaxis in most Danish THA and TKA patients who receive only in-hospital thromboprophylaxis when LOS is ≤ 5 days. [20]. Although such a thromboprophylaxis regimen contest most international guidelines, which recommend thromboprophylaxis for 10–35 days, the safety of in-hospital only thromboprophylaxis in fast-track THA and TKA has previously been documented [20].
THA and TKA along with an elderly population, immobility, and side effects of medication such as opioids may lead to constipation and ileus [21]. A very low number of the included patients in our study experienced clinically relevant constipation—52 patients (0.14%) compared to up to 65% in a RCT by Ross-Adijie et al. [22]. This finding makes sense in a fast-track enhanced recovery setting, since the protocol ensures early mobilization, minimal use of opioids potentially reducing the risk of constipation.
POI is a complication that occurs with an incidence of 0–2.1% [1] or 0.3–4% [23] in THA and TKA. In this study, only 28 patients (0.08 %) experienced ileus. The main risk factors of POI have been found to be older age, male gender, hip arthroplasty, chronic kidney disease, prior history of myocardial infarction and/or previous abdominal surgery [23, 24]. Despite that these risk factors are difficult to modify, fast-track surgery does not seem to increase the risk of POI. The results of this study may even suggest that it decreases the risk of POI.
The incidence of C. Difficile has been found to between 0 and 1.7% after THA and TKA surgery [1]. Antibiotics are used to prevent deep joint infection after surgery [25], and meta-analyses have found broad spectrum antibiotics, especially cephalosporins and clindamycin, to increase the risk of C. difficile infection 2-3-fold [26]. The increased risk of contracting C. difficile remains for up to 90 days. However, in a study by Al-Tawil et al. the use of 3 peri- and postoperative doses of cefuroxime did not appear to be associated with an increase in C. difficile rates [26]. In this study, it was not possible to specify which antibiotics were used during the 7-year period in the 9 included high-volume centers since each region followed individual guidelines. Out of the included patients in our study, 13 had negative C. difficile toxin tests and six patients only had nausea, corresponding to a maximum of 29 (0.08%) with potential C. difficile infection within the 90 postoperative days, matching the incidences of most studies on this subject [1, 27]
The main limitation of this study is that many minor to moderate GI-complications such as nausea might not have been mentioned in patients’ medical records and thereby not included. Pertaining thereto, any GI complication that did not result in a LOS > 4 days or a readmission within 90 days was not included. Yet, it can be argued that all clinically relevant GI-complications have been included since all patients with an acknowledged GI-complication have had their records and discharge resumes read and evaluated by the author group. Another limitation is the observational study design which may provide associations, but not causation, that the use of an enhanced recovery protocol may reduce occurrence of GI-complications. In this context, the lack of a control group not having fast-track surgery also hinders direct comparisons. The strengths of this study include that the cohort accounts for about 50% of the Danish THA and TKA production [11]. Due to the Danish tax-based healthcare system discharged patients would not have an economic reason to remain at home if faced with GI-complications, wherefore the results may provide a realistic incidence estimate.
Conclusion
We found an incidence of GI-complications after fast-track THA and TKA to be 0.75% within the first 90 postoperative days. The incidences of POI, GIB, and C. difficile were 0.07%, 0.22% and 0.04%, respectively. These low occurrences of gastrointestinal complications could be related to the use of established enhanced recovery protocols with early mobilization, opioid sparing analgesia and only in-hospital thromboprophylaxis if LOS ≤5 days.
Data availability
Anonymous data are available from the authors upon request.
References
Klasan A, Putnis SE, Heyse TJ, Madzarac G, Gotterbarm T, Neri T (2020) Ileus, gastrointestinal bleeding and clostridium difficile colitis after hip and knee replacement—a systematic review. Surg Technol Int 28(37):377–384
Bederman SS, Betsy M, Winiarsky R, Seldes RM, Sharrock NE, Sculco TP (2001) Postoperative ileus in the lower extremity arthroplasty patient. J Arthroplasty 16(8):1066–70. https://doi.org/10.1054/arth.2001.27675
Lalmohamed A, Vestergaard P, Javaid MK, de Boer A, Leufkens HG, van Staa TP, de Vries F (2013) Risk of gastrointestinal bleeding in patients undergoing total hip or knee replacement compared with matched controls: a nationwide cohort study. Am J Gastroenterol 108(8):1277–85. https://doi.org/10.1038/ajg.2013.108
Maltenfort MG, Rasouli MR, Morrison TA, Parvizi J (2013) Clostridium difficile colitis in patients undergoing lower-extremity arthroplasty: rare infection with major impact. Clin Orthop Relat Res 471(10):3178–85. https://doi.org/10.1007/s11999-013-2906-x
Bovonratwet P, Bohl DD, Malpani R, Nam D, Della Valle CJ, Grauer JN (2018) Incidence, risk factors, and impact of clostridium difficile colitis following primary total hip and knee arthroplasty. J Arthroplasty 33(1):205-210.e1. https://doi.org/10.1016/j.arth.2017.08.004
Wainwright TW, Kehlet H (2019) Fast-track hip and knee arthroplasty—have we reached the goal? Acta Orthop 90(1):3–5. https://doi.org/10.1080/17453674.2018.1550708
Schwenk ES, Grant AE, Torjman MC, McNulty SE, Baratta JL, Viscusi ER (2017) The efficacy of peripheral opioid antagonists in opioid-induced constipation and postoperative ileus: a systematic review of the literature. Reg Anesth Pain Med 42(6):767–777. https://doi.org/10.1097/AAP.0000000000000671
Feng W, Wang X, Huang D, Lu A (2021) Ranking the efficacy of anticoagulants for the prevention of venous thromboembolism after total hip or knee arthroplasty: a systematic review and a network meta-analysis. Pharmacol Res 166:105438. https://doi.org/10.1016/j.phrs.2021.105438
Domper Arnal MJ, Hijos-Mallada G, Lanas A (2022) Gastrointestinal and cardiovascular adverse events associated with NSAIDs. Expert Opin Drug Saf 21(3):373–384. https://doi.org/10.1080/14740338.2021.1965988
Leffler DA, Lamont JT (2015) Clostridium difficile infection. N Engl J Med 372(16):1539–48. https://doi.org/10.1056/NEJMra1403772
Petersen PB, Kehlet H, Jørgensen CC, Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement Collaborative Group (2020) Improvement in fast-track hip and knee arthroplasty: a prospective multicentre study of 36,935 procedures from 2010 to 2017. Sci Rep 10(1):21233. https://doi.org/10.1038/s41598-020-77127-6
von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, STROBE Initiative (2008) The Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 61(4):344–9. https://doi.org/10.1016/j.jclinepi.2007.11.008
Johannesdottir SA, Horváth-Puhó E, Ehrenstein V, Schmidt M, Pedersen L, Sørensen HT (2012) Existing data sources for clinical epidemiology: the Danish national database of reimbursed prescriptions. Clin Epidemiol 4:303–13. https://doi.org/10.2147/CLEP.S37587
Schmidt M, Schmidt SA, Sandegaard JL, Ehrenstein V, Pedersen L, Sørensen HT (2015) The Danish national patient registry: a review of content, data quality, and research potential. Clin Epidemiol 17(7):449–90. https://doi.org/10.2147/CLEP.S91125
Jammer I, Wickboldt N, Sander M, Smith A, Schultz MJ, Pelosi P, Leva B, Rhodes A, Hoeft A, Walder B, Chew MS, Pearse RM, European Society of Anaesthesiology (ESA) and the European Society of Intensive Care Medicine (ESICM); European Society of Anaesthesiology; European Society of Intensive Care Medicine (2015) Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions: a statement from the ESA-ESICM joint taskforce on perioperative outcome measures. Eur J Anaesthesiol 32(2):88–105. https://doi.org/10.1097/EJA.0000000000000118
Venara A, Slim K, Regimbeau JM, Ortega-Deballon P, Vielle B, Lermite E, Meurette G, Hamy A (2017) Proposal of a new classification of postoperative ileus based on its clinical impact-results of a global survey and preliminary evaluation in colorectal surgery. Int J Colorectal Dis 32(6):797–803. https://doi.org/10.1007/s00384-017-2788-6
Bekeris J, Fiasconaro M, Della Valle AG, Liu J, Shanaghan KA, Poeran J, Wilson LA, Memtsoudis SG (2020) Modifiable analgesia-/anesthesia-related factors and risk of severe gastrointestinal complications after lower extremity total joint arthroplasty: a nationwide analysis. J Arthroplasty 35(9):2624-2630.e2. https://doi.org/10.1016/j.arth.2020.04.008
Yue C, Liu Y, Zhang X, Xu B, Sheng H (2020) Randomised controlled trial of a comprehensive protocol for preventing constipation following total hip arthroplasty. J Clin Nurs 29(15–16):2863–2871. https://doi.org/10.1111/jocn.15299
Fleischman AN, Li WT, Luzzi AJ, Van Nest DS, Torjman MC, Schwenk ES, Arnold WA, Parvizi J (2021) Risk of gastrointestinal bleeding with extended use of nonsteroidal anti-inflammatory drug analgesia after joint arthroplasty. J Arthroplasty 36(6):1921-1925.e1. https://doi.org/10.1016/j.arth.2021.02.015
Petersen PB, Kehlet H, Jørgensen CC, Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement Collaborative Group (2018) Safety of in-hospital only thromboprophylaxis after fast-track total hip and knee arthroplasty: a prospective follow-up study in 17,582 procedures. Thromb Haemost 118(12):2152–2161. https://doi.org/10.1055/s-0038-1675641
Linari LR, Schofield LC, Horrom KA (2011) Implementing a bowel program: is a bowel program an effective way of preventing constipation and ileus following elective hip and knee arthroplasty surgery? Orthop Nurs 30(5):317–21. https://doi.org/10.1097/NOR.0b013e31822c5c10
Ross-Adjie GM, Monterosso L, Bulsara M (2015) Bowel management post major joint arthroplasty: results from a randomised controlled trial. Int J Orthop Trauma Nurs 19(2):92–101. https://doi.org/10.1016/j.ijotn.2014.04.002
Klasan A, Amic F, Dworschak P, Madzarac G, Heyse TJ, Neri T (2019) Risk factors for ileus after hip and knee arthroplasty. Int J Colorectal Dis 34(2):261–267. https://doi.org/10.1007/s00384-018-3184-6
Parvizi J, Han SB, Tarity TD, Pulido L, Weinstein M, Rothman RH (2008) Postoperative ileus after total joint arthroplasty. J Arthroplasty 23(3):360–5. https://doi.org/10.1016/j.arth.2007.12.019
Jenkins PJ, Teoh K, Simpson PM, Dave J, Simpson AH, Breusch S (2010) Clostridium difficile in patients undergoing primary hip and knee replacement. J Bone Joint Surg Br 92(7):994–8. https://doi.org/10.1302/0301-620X.92B7.23412
Al-Tawil K, Babu A, Loeffler M, Williams T (2017) Second generation cephalosporin antibiotic prophylaxis and clostridium difficile infection in hip and knee arthroplasty. Ann R Coll Surg Engl 99(5):351–354. https://doi.org/10.1308/rcsann.2017.0025
Partridge T, Jameson S, Baker P, Deehan D, Mason J, Reed MR (2018) Ten-year trends in medical complications following 540,623 primary total hip replacements from a national database. J Bone Joint Surg Am 100(5):360–367. https://doi.org/10.2106/JBJS.16.01198
Munting KE, Klein AA (2019) Optimisation of pre-operative anaemia in patients before elective major surgery—why, who, when and how? Anaesthesia 74(Suppl 1):49–57. https://doi.org/10.1111/anae.14466. (PMID: 30604424)
Shander A, Corwin HL, Meier J, Auerbach M, Bisbe E, Blitz J, Erhard J, Faraoni D, Farmer S, Frank SM, Girelli D, Hall T, Hardy JF, Hofmann A, Lee CK, Leung TW, Ozawa S, Sathar J, Spahn DR, Torres R, Warner MA, Muñoz M (2022) Recommendations from the international consensus conference on anemia management in surgical patients (ICCAMS). Ann Surg. https://doi.org/10.1097/SLA.0000000000005721. (Epub ahead of print. PMID: 36134567)
Acknowledgements
The Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement Collaborative Group. Frank Madsen (Department of Orthopedics, Aarhus University Hospital, Aarhus, Denmark), Torben Bæk Hansen (Department of Orthopedics, Regional Hospital Holstebro and University of Aarhus, Holstebro, Denmark), Kirill Gromov (Department of Orthopedics, Hvidovre Hospital, Hvidovre, Denmark), Lars Tambour Hansen (Department of Orthopedics, Sydvestjysk Hospital Esbjerg/Grindsted, Grindsted, Denmark), Claus Varnum (Department of Orthopedics, Vejle Hospital, Vejle, Denmark), Mikkel Rathsach Andersen (Department of Orthopedics, Gentofte University Hospital, Copenhagen, Denmark), Niels Harry Krarup (Department of Orthopedics, Viborg Hospital, Viborg, Denmark) & Søren Overgaard (Department of Orthopedic Surgery, Copenhagen University Hospital Bispebjerg, Copenhagen, NV, Denmark).
Funding
Open access funding provided by Royal Danish Library. None was received for this study.
Author information
Authors and Affiliations
Consortia
Contributions
All authors were included in the planning and execution of the study. PBP and CCJ included the original cohort. PBP, CCJ and LOHD retrieved and analyzed the included data. LOHD and HK wrote the initial manuscript. All authors revised the manuscript and accepted the final version. PBP receives payment from Sanofi Aventis as a steering group-member and for consulting work in regarding thrombosis prophylaxis and fast-track surgery. The remaining authors have no conflicts of interest to disclose.
Corresponding author
Ethics declarations
Conflict of interest
PP receives payment from Sanofi Aventis as a steering group-member and for consulting work in regarding thrombosis prophylaxis and fast-track surgery. The remaining authors have no conflicts of interest to disclose.
Ethical approval
This study has been approved by the National Board of Health (3-3013-56/1/), the Capital Region of Denmark (R-20073405) and the center for Regional Development (RH-2007-30-0623).
Informed consent
The National Committee on Health Research Ethics waivered the need for permission as this was an observational study.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
The complete details of author involved in The Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement collaborative Group are givenin Acknowledgement section.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Daugberg, L.O.H., Kehlet, H., Petersen, P.B. et al. Gastrointestinal complications after fast-track total hip and knee replacement: an observational study in a consecutive 36,932 patient cohort. Arch Orthop Trauma Surg 143, 6033–6038 (2023). https://doi.org/10.1007/s00402-023-04887-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00402-023-04887-x