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Enhanced recovery after surgery (ERAS) in hip and knee replacement surgery: description of a multidisciplinary program to improve management of the patients undergoing major orthopedic surgery

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MUSCULOSKELETAL SURGERY Aims and scope Submit manuscript

Abstract

Purpose

Enhanced recovery after surgery (ERAS) protocols aim to develop peri-operative multidisciplinary programs to shorten length of hospital stay (LOS) and reduce complications, readmissions and costs for patients undergoing major surgery. The aim of this study is to evaluate the effects of an ERAS pathway for total hip (THR) and knee (TKR) replacement surgery in terms of length of stay, incidence of complications and patient satisfaction.

Methods

Patients scheduled for hip and knee replacement were included in the study. The main aspects of this program were preoperative education/physical therapy, rational choice of the anesthetic technique, optimization of multimodal analgesia, reduction of incidence of urinary retention and catheterization, active management of risk for blood loss and deep vein thrombosis, and early mobilization of the patients. All patients had 6 months predicted and planned follow-up appointments. Primary outcomes of the study were the mean LOS, readmission and complication rates. Secondary Outcomes were percentage of Knee Injury & Osteoarthritis Outcome Score (KOOS) and Hip disability and Osteoarthritis Outcome Score (HOOS) increase and patient’s satisfaction.

Results

We consecutively enrolled 207 patients who underwent total joint arthroplasty, 78 hip and 129 knee joint replacements. The mean length of stay (LOS) for patients of the two groups was 4.3 days for ASA 3-4 patients subjected to TKR and THR, in ASA 1-2 patients 3.6 days for TKR and 3.9 days for THR respectively. Postoperative satisfaction level was higher than 7 (very satisfied) in 94.4% of the cases. All patients were discharged home: 61.8% continued physical therapy in complete autonomy, 23.7% supported by a home-physiotherapist and only 14.5% needed the attendance to a physiotherapy center on a daily basis. The overall incidence of major complications was 3.4%.

Conclusions

The implementation of an ERAS program for hip and knee replacement surgery allows early patient’s discharge and a quick return to independency in the daily activities.

Level of evidence

IV.

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References

  1. Ljungqvist O, Scott M, Fearon KC (2017) Enhanced recovery after surgery: a review. JAMA Surg 152:292–298

    Article  Google Scholar 

  2. Scott MJ, Baldini G, Fearon KCH, Feldheiser A, Feldman LS, Gan TJ, Ljungqvist O, Lobo DN, Rockall TA, Schricker T, Carli F (2015) Enhanced recovery after surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations. Acta Anaesthesiol Scand 59(10):1212–1231

    Article  CAS  Google Scholar 

  3. Torre M, Romanini E, Zanoli G, Carrani E, Luzi I, Leone L, Bellino S (2016) Progetto Registro Italiano Artroprotesi—Controllo e Qualità dei Dati 2016: Istituto Superiore di Sanità

  4. Jones EL, Wainwright TW, Foster JD, Smith JRA, Middleton RG, Francis NK (2014) A systematic review of patient reported outcomes and patient experience in enhanced recovery after orthopaedic surgery. Ann R Coll Surg Engl 96:89–94

    Article  CAS  Google Scholar 

  5. Stambough JB, Nunley RM, Curry MC, Steger-May K, Clohisy JC (2015) Rapid recovery protocols for primary total hip arthroplasty can safely reduce length of stay without increasing readmissions. J Arthroplasty 30:521–526

    Article  Google Scholar 

  6. McDonald S, Page MJ, Beringer K, Wasiak J, Sprowson A (2014) Preoperative education for hip or knee replacement. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD003526.pub3

    Article  PubMed  PubMed Central  Google Scholar 

  7. Snow R, Granata J, Ruhil AV, Vogel K, McShane M, Wasielewski R (2014) Associations between preoperative physical therapy and post-acute care utilization patterns and cost in total joint replacement. JBJS 96:e165

    Article  Google Scholar 

  8. Memtsoudis SG, Sun X, Chiu Y-L, Stundner O, Liu SS, Banerjee S, Mazumdar M, Sharrock NE (2013) Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anesthesiol J Am Soc Anesthesiol 118:1046–1058

    Google Scholar 

  9. Johnson RL, Kopp SL, Burkle CM, Duncan CM, Jacob AK, Erwin PJ, Murad MH, Mantilla CB (2016) Neuraxial vs general anaesthesia for total hip and total knee arthroplasty: a systematic review of comparative-effectiveness research. Br J Anaesth 116:163–176

    Article  CAS  Google Scholar 

  10. Frassanito L, Rodola F, Concina G, Messina A, Chierichini A, Vergari A (2008) The efficacy of the psoas compartment block versus the intrathecal combination of morphine, fentanyl and bupivacaine for postoperative analgesia after primary hip arthroplasty: a randomized single-blinded study. Eur Rev Med Pharmacol Sci 12:117–122

    CAS  PubMed  Google Scholar 

  11. Vergari A, Frassanito L, Nestorini R, Caputo CT, Chierichini A, Di Stasio E, Rossi M (2017) Hypobaric versus isobaric spinal levobupivacaine for total hip arthroplasty. Minerva Anestesiol 83:361–368

    PubMed  Google Scholar 

  12. Kopp SL, Børglum J, Buvanendran A, Horlocker TT, Ilfeld BM, Memtsoudis SG, Neal JM, Rawal N, Wegener JT (2017) Anesthesia and analgesia practice pathway options for total knee arthroplasty: an evidence-based review by the american and european societies of regional anesthesia and pain medicine. Reg Anesth Pain Med 42:683–697

    Article  Google Scholar 

  13. Memtsoudis SG, Poeran J, Cozowicz C, Zubizarreta N, Ozbek U, Mazumdar M (2016) The impact of peripheral nerve blocks on perioperative outcome in hip and knee arthroplasty - a population-based study. Pain 157:2341–2349

    Article  Google Scholar 

  14. Frassanito L, Vergari A, Zanghi F, Messina A, Bitondo M, Antonelli M (2010) Post-operative analgesia following total knee arthroplasty: comparison of low-dose intrathecal morphine and single-shot ultrasound-guided femoral nerve block: a randomized, single blinded, controlled study. Eur Rev Med Pharmacol Sci 14:589–596

    CAS  PubMed  Google Scholar 

  15. Sankineani SR, Reddy ARC, Ajith Kumar KS, Eachempati KK, Reddy AVG (2018) Comparative analysis of influence of adductor canal block and multimodal periarticular infiltration versus adductor canal block alone on pain and knee range of movement after total knee arthroplasty: a prospective non-randomised study. Musculoskelet Surg 102(2):173–177

    Article  CAS  Google Scholar 

  16. McGraw-Tatum MA, Groover MT, George NE, Urse JS, Heh V (2017) A prospective, randomized trial comparing Liposomal Bupivacaine vs Fascia Iliaca compartment block for postoperative pain control in total hip arthroplasty. J Arthroplasty 32:2181–2185

    Article  Google Scholar 

  17. Bjerregaard LS, Bogø S, Raaschou S, Troldborg C, Hornum U, Poulsen AM, Bagi P, Kehlet H (2015) Incidence of and risk factors for postoperative urinary retention in fast-track hip and knee arthroplasty: a prospective, observational study. Acta Orthop 86:183–188

    Article  Google Scholar 

  18. Tischler EH, Restrepo C, Oh J, Matthews CN, Chen AF, Parvizi J (2016) Urinary retention is rare after total joint arthroplasty when using opioid-free regional anesthesia. J Arthroplasty 31:480–483

    Article  Google Scholar 

  19. Eachempati KK, Gurava Reddy AV, Apsingi S, Sankineani SR, Shaheed J, Dannana C (2017) A comparative analysis of the role of Tranexamic acid as an independent variable in reducing intraoperative blood loss in patients undergoing conventional total knee arthroplasty versus computer-assisted total knee arthroplasty. Musculoskelet Surg 101(3):255–259

    Article  CAS  Google Scholar 

  20. Guerra ML, Singh PJ, Taylor NF (2015) Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: a systematic review. Clin Rehabil 29:844–854

    Article  Google Scholar 

  21. Jans Ø, Kehlet H (2017) Postoperative orthostatic intolerance: a common perioperative problem with few available solutions. Can J Anesth 64:10–15

    Article  Google Scholar 

  22. Administration F and D (2009) Guidance for industry: patient-reported outcome measures: use in medical product development to support labeling claims. Fed Regist 74:65132–65133

  23. Desmeules F, Hall J, Woodhouse LJ (2013) Prehabilitation improves physical function of individuals with severe disability from hip or knee osteoarthritis. Physiother Can 65:116–124

    Article  Google Scholar 

  24. Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD (1998) Knee Injury and Osteoarthritis Outcome Score (KOOS)—development of a self-administered outcome measure. J Orthop Sports Phys Ther 28:88–96

    Article  CAS  Google Scholar 

  25. Klässbo M, Larsson E, Mannevik E (2003) Hip disability and osteoarthritis outcome score An extension of the Western Ontario and McMaster Universities Osteoarthritis Index. Scand J Rheumatol 32:46–51

    Article  Google Scholar 

  26. Kelly E, Campbell J, Murray P (2013) Total hip replacement: patient satisfaction and early outcomes. Int J Health Care Qual Assur 26:262–268

    Article  CAS  Google Scholar 

  27. Blom AW, Rogers M, Taylor AH, Pattison G, Whitehouse S, Bannister GC (2008) Dislocation following total hip replacement: the Avon Orthopaedic Centre experience. Ann R Coll Surg Engl 90:658–662

    Article  Google Scholar 

  28. Lindahl H (2007) Epidemiology of periprosthetic femur fracture around a total hip arthroplasty. Injury 38:651–654

    Article  Google Scholar 

  29. Ghanem E, Jaberi FM, Parvizi J (2007) Periprosthetic infection in a nutshell. Am J Orthop Belle Mead NJ 36:520–525

    PubMed  Google Scholar 

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Authors and Affiliations

  1. Area Anestesiologia, Rianimazione, Terapie Intensive e Terapia del Dolore, Fondazione Policlinico A. Gemelli, Rome, Italy

    L. Frassanito, A. Vergari, R. Nestorini & M. Rossi

  2. Area Invecchiamento, Ortopedia e Riabilitazione, Fondazione Policlinico A. Gemelli, Rome, Italy

    G. Cerulli

  3. U. O. Ortopedia e Traumatologia, Azienda Ospedaliera Regionale San Carlo, Potenza, Italy

    G. Placella

  4. Royal National Orthopedic Hospital, Stanmore, London, UK

    V. Pace

  5. Istituto di Anestesia e Rianimazione, Fondazione Policlinico A. Gemelli, Largo A. Gemelli n. 8, 00168, Rome, Italy

    L. Frassanito

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  1. L. Frassanito
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  2. A. Vergari
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  3. R. Nestorini
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  7. M. Rossi
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Correspondence to L. Frassanito.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Frassanito, L., Vergari, A., Nestorini, R. et al. Enhanced recovery after surgery (ERAS) in hip and knee replacement surgery: description of a multidisciplinary program to improve management of the patients undergoing major orthopedic surgery. Musculoskelet Surg 104, 87–92 (2020). https://doi.org/10.1007/s12306-019-00603-4

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