The increasing demand for total knee arthroplasty (TKR) and the initiatives to reduce health care spending have put the responsibility for efficient care on hospitals and providers. Multidisciplinary care pathways have been shown to shorten length of stay and result in improved short-term outcomes. However, common problems such as post-op nausea, orthostasis, and quad weakness remain, while reliance on discharge to rehabilitation facilities may also prolong hospital stay.
Our aim was to document that combined modifications of our traditional clinical pathway for unilateral TKR could lead to improved short-term outcomes. We pose the following research questions. Can pathway modifications which include intra-articular infusion and saphenous nerve block (SNB) provide adequate pain relief and eliminate common side effects promoting earlier mobilization? Can planning for discharge to home avoid in-patient rehab stays? Can these combined modifications decrease length of stay even in patients with complex comorbidities indicated by higher ASA class? Will discharge to home incur an increase in complications or a failure to achieve knee range of motion?
Patients and Methods
A retrospective review was performed and identified two cohorts. Group A included 116 patients that underwent unilateral TKR for osteoarthritis between August 2009 and August 2010. Group B included 171 patients that underwent unilateral TKR for osteoarthritis between February 2012 to February 2013. Group A patients were treated with spinal anesthesia with patient-controlled epidural analgesia (PCEA)/femoral nerve block (FNB) for the first 48 h after surgery. Discharge planning was initiated after admission. Group B had spinal anesthesia with SNB and received a continuous intra-articular infusion of 0.2% ropivicaine for 48 h post-op. Discharge planning was initiated with a case manager prior to hospitalization and discharge to home was declared the preferred approach. An intensive home PT program was made available through a program with our local home care agency. Outcomes assessed and compared between groups included length of stay, incidence of post-op nausea, dizziness, in-hospital falls, occurrence of complications including wound infection and the recovery of range of motion at 6 weeks, 3 months, and 1 year post-op.
Pain control was similar between the groups but Group B had fewer side effects. With the new pathway, length of stay (LOS) was reduced from 4.32 to 3.64 days with a similar LOS reduction across all ASA classes. There was no increase in Group B wound or other complications. Return of ROM was similar between groups.
Our findings suggest that replacing PCEA and FNB with intra-articular analgesia with a SNB allows for improved early recovery following TKR. That, combined with pre-op discharge planning and initiation of an intensive home PT program, reduced average length of stay.
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We are grateful for the technical assistance of Kathy Kujawa, Clinical Data Manager at HSS in the preparation of this manuscript. We are also indebted to the Visiting Nurse Service of Greater New York for their willingness to partner with us on developing our intensive in-home physical therapy protocol. As always, we thank our anesthesia colleagues who assisted us with this study.
Conflict of Interest:
Shivi Duggal, BS, MBA, Susan Flics, RN, MA, MBA and Charles Cornell, MD have declared that they have no conflict of interest.
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 .
Informed consent was waived from all patients for being included in the study.
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Disclosure forms provided by the authors are available with the online version of this article.
Level of Evidence: Therapeutic Study Level III
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Duggal, S., Flics, S. & Cornell, C.N. Intra-articular Analgesia and Discharge to Home Enhance Recovery Following Total Knee Replacement. HSS Jrnl 11, 56–64 (2015). https://doi.org/10.1007/s11420-014-9414-8
- clinical pathways
- intra-articular analgesia