Orthopaedic Enhanced Recovery Programme for Elective Hip and Knee Arthroplasty - Could a Regional Programme be Beneficial?

Adam Tucker, Darren McCusker, Nidhi Gupta, Jonathon Bunn, Mark Murnaghan, Adam Tucker, Darren McCusker, Nidhi Gupta, Jonathon Bunn, Mark Murnaghan

Abstract

Introduction: Arthroplasty is commonplace in orthopaedic practice, and post operative pain has been shown to substantially hinder recovery and discharge from hospital.

Objectives: The current study assessed a multidisciplinary, multimodal Orthopaedic ERP in terms of its effect on patient perceived post operative pain in hip and knee arthroplasty. Secondary outcome was in the form of a cost analysis.

Methods: A prospective study was performed on consecutive arthroplasty patients across a 6 week period in a district orthopaedic unit. A multidisciplinary approach to devising an ERP was undertaken between anaesthetists, surgeons and physiotherapists. Domains included optimising pre-operative nutrition, anaesthetic pre-meds, standardised anaesthetic technique, standardised intra-operative technique and use of locally infiltrated anaesthetic (LIA), as well as a post operative pain regimen. The multidisciplinary team (MDT) involved physiotherapy for the patient on day 0. Demographic data, day 1 and day 2 post operative subjective pain scores using an analogue scale were recorded. Data was collated and analysed using appropriate statistical methods. A p-value of <0.05 was considered significant.

Results: A total of 40 patients (25 total hip replacements and 15 total knee replacements) were included. All conformed to the ERP. Reductions in patient reported pain scores were observed. Specifically, in total hip arthroplasty (THA), day 1 scores were not significantly improved (p=0.25), however day 2 scores improved significantly (p=0.02). For total knee arthroplasty (TKA), both day 1 and day 2 scores improved significantly (p=0.02 & p<0.001, respectively) Analgesic requirements were not significantly different between hip and knee replacements. Early mobilization occurred in 95% of patients. Length of stay was reduced significantly in hip (1.8 days, p=0.003) and knee (1.9 days(p<0.001) replacements following ERP. Cost analysis demonstrated a potential annual saving of approximately £200,000 for the study unit if ERP was applied to all elective hip and knee arthroplasty procedures.

Conclusions: The study demonstrates that a tailored, MDT orientated ERP can be beneficial in elective hip and knee arthroplasty. Reductions in pain scores, early ambulation and facilitated early discharge are beneficial to the patient, and cost effective for the unit. The implementation across the region may result in further cost savings.

Keywords: Arthroplasty; Enhanced Recovery Protocol; Hip; Knee.

Figures

Fig 1a and b
Fig 1a and b
Trends in postoperative patient reported pain scores on days 1 and 2 following TKA and THA

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