Early Mobilization After Total Knee Arthroplasty

May 22, 2012 updated by: Andreas Harsten, Region Skane

A Randomized Study of Whether General or Regional Anesthesia for Patients Undergoing Elective Total Knee Arthroplasty Could Effect Length of Hospital Stay

Patients undergoing elective total knee arthroplasty are randomized to either intrathecal anesthesia, wound infiltration with local anesthetics and standardized postoperative care (NA = neuraxial anesthesia) or general anesthesia, intraoperative glucocorticoids with accelerated postoperative care principles (GA). The study hypothesis is that GA would reduce length-of-hospital stay. Outcome variables are postoperative nausea and vomiting, mobilization rate, pain, requirement of analgesics, and length-of-hospital stay.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

Study design. The study design is consecutive and randomized. Patients with osteoarthritis scheduled for TKA at the department of orthopedic surgery, Hässleholm Hospital, Sweden, are eligible for participation in the study. Exclusion criteria are body mass index (BMI) > 35 m/kg2, prior major knee surgery to the ipsilateral knee, ongoing infection, known immunological deficiency or ASA physical status category > IV.

Randomization and blinding procedure Randomization is performed by an employee, not involved in the study, who prepared non-transparent, sealed envelopes each containing a slip of paper with descriptions of whether the patient should receive GA or NA. The randomization is computerized. On the study day a nurse, likewise not involved in the study, opens the appropriate envelope and prepared accordingly the procedures. From the point where anaesthesia is delivered both patients and staff in the operating theatre and in the recovery unit are, for obvious reasons, aware of the method of anaesthesia being used. However, once the patients leaves the recovery unit staff members assessing home readiness are blinded to group allocation.

Assessments All patients are familiarized with a horizontal visual analogue scale (VAS, [100 mm]) used for assessment of pain and PONV (0 = no symptom, 100 = worst symptom possible). Assessments of pain are made pre-operatively, upon arrival to the post-anesthesia care unit (PACU), every second hour the first day, twice a day during the remaining hospital stay and at follow-up visits 3 and 12 months after surgery. Plasma levels of troponin T (TNT) are measured three times during the first 24 postoperative hours in order to evaluate signs of myocardial ischemic events. The Short Portable Mental State Questionnaire (SPMSQ) is used to evaluate the cognitive function pre-operatively, at the discharge and at follow-up visits 3 and 12 months after surgery. Global satisfaction score is assessed with a VAS (0 = best possible satisfaction, 100 = least possible satisfaction) at follow-up visits 3 and 12 months after surgery.

Anesthesia Oral premedication, administered 1 hour before surgery, is with midazolam 2.5 mg, paracetamol 2 g, meclozine 10 mg, celecoxib 200 mg and oxycodone 10 mg. A low-volume fluid regimen is used with 1000 mL of Ringer's solution (Fresenius-Kabi AB, 751 74 Uppsala, Stockholm) and 1000 mL of glucose 2.5% during the first 24 hrs.

In the NA group an indwelling urethral catheter is inserted prior to surgery. Intrathecal anesthesia is with bupivacaine 12.5-15.0 mg, morphine 0.2 mg and clonidine 30 µg (total volume (3.2-3.7 mL). During surgery an infusion of propofol (0.8-2.5 mg/min) is used to induce a light level of sedation. At the end of surgery a mixture of ropivacaine 110 mg, epinephrine 0.5 mg and morphine 10 mg (total volume 21 mL) is injected into the peri-surgical area. The mixture is injected using a systematic technique ensuring uniform delivery of the local anaesthetic to all tissues incised, handled or instrumented during the procedure. The first 7 mL of the mixture are injected into the posterior joint capsule and both collateral ligaments after the bone cuts had been performed. After insertion of the prosthesis another 7 mL are to be injected along the borders of and into the capsule and cut quadriceps tendon, infra-patellar ligament, possible remnants of the fat pad, cruciate ligaments and the soft tissues surrounding the joint. The last 7 mL is infiltrated into the subcutaneous tissues before wound closure.

In the GA group patients are asked to void before the transfer to the OR. The patients are draped before induction of anesthesia. Induction of anesthesia is with propofol and remifentanil, and endotracheal intubation is facilitated by succinylcholine. Maintenance of anesthesia is with target-controlled infusion (Marsh and Minto algorithm) with propofol (Braun Medical, Germany) and remifentanil (GlaxoSmithKline, Great Britain) aiming at initial concentrations of 5 µg/ml and 5 ng/ml, respectively. Ventilation is mechanical with oxygen in air (FIO2 = 0.45) and aiming at ETCO2 4.5 kPa. Betamethasone (Swedish Orphan Biovitrum, Sweden) 4 mg i.v. is given during surgery. At the end of surgery a mixture of ropivacaine 250 mg and epinephrine 0.3 mg (100 mL) is injected in the tissues in the same way as described above. Twenty min before the end of anesthesia an i.v. bolus dose of oxycodone 7.5-10 mg is given.

Surgery In the NA-group a tourniquet is applied around the thigh before the start of surgery. The GA-group does not receive a tourniquet. The surgeries are performed via a ventral incision with a parapatellar medial entrance to the joint. The patella is everted. A cemented single radius cruciate retaining (CR) total knee is used (the TriathlonTM Knee System (Stryker, Mahwah, New Jersey, USA)) for all patients. Appropriate guide instruments are used according to the surgical-technique manual supplied with the knee system.

PACU In the PACU intermittent doses of oxycodone 2-8 mg i.v. is given as rescue medication. Patients complaining of PONV are given ondansetron 4 mg i.v.

In the GA group bladder scans are done every second hour during the first 24 post-op hours. If the bladder contains > 400 ml an intermittent catheterization is performed. Mobilisation is started within 2 hrs of arrival to the PACU. A physiotherapist does passive bending of the knee to 90˚ and walks 10 meters with the patient on the floor.

In the NA group mobilization is not started until the day after surgery, due to residual motor and sensory blockade.

Ward In the NA group the indwelling urethral catheter is removed the day after surgery. Patients are considered ready to be discharged from the hospital when they are able to get in and out of bed, get dressed, sit down and get out of a chair, able to walk 50 m with or without walking aid, flex the knee to at least 70 º, fit for staircase climbing under supervision of a physiotherapist and accepting to be discharged. LOS is measured from end of surgery to time of discharge.

Study Type

Interventional

Enrollment (Actual)

60

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Sweden
    • Skane
      • Hässleholm, Skane, Sweden, 381 25
        • Lund University, Hässleholm Hospital

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

40 years to 85 years (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • Patients with osteoarthritis scheduled for TKA at the department of orthopedic surgery, Hässleholm Hospital, Sweden, are eligible for participation in the study.

Exclusion Criteria:

  • body mass index (BMI) > 35 m/kg2,
  • prior major knee surgery to the ipsilateral knee,
  • ongoing infection, known immunological deficiency or ASA physical status category > IV.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Double

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: treatment
Receives General Anesthesia as described above
Drug: General Anesthesia
General Anesthesia as described above
Other Names:
  • Remifentanil
  • Propofol
Placebo Comparator: Placebo
Patients receives neuraxial anesthesia as described above
Drug: Neuraxial anesthesia
Neuraxial anesthesia as described above
Other Names:
  • Bupivacaine

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Length of hospital stay
Time Frame: participants will be followed for the duration of hospital stay, an expected average of 3 days").
Length of hospital stay is defined as teh time from end of surgery until the patient is ready to be discharged
participants will be followed for the duration of hospital stay, an expected average of 3 days").

Secondary Outcome Measures

Outcome Measure
Time Frame
Post operative pain
Time Frame: measured the first 48 hrs after surgery
measured the first 48 hrs after surgery

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Region Skane

Investigators

  • Study Director: Mads Werner, M.D. PhD, Multidisciplinary Pain Center, Copenhagen, Denmark

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start

September 1, 2008

Primary Completion (Actual)

May 1, 2009

Study Completion (Actual)

June 1, 2010

Study Registration Dates

First Submitted

May 20, 2012

First Submitted That Met QC Criteria

May 22, 2012

First Posted (Estimate)

May 23, 2012

Study Record Updates

Last Update Posted (Estimate)

May 23, 2012

Last Update Submitted That Met QC Criteria

May 22, 2012

Last Verified

May 1, 2012

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • HLM-2012-CPH

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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