Quality of recovery after total hip and knee arthroplasty in South Africa: a national prospective observational cohort study

Ulla Plenge, Romy Parker, Shamiela Davids, Gareth L Davies, Zahnne Fullerton, Lindsay Gray, Penelope Groenewald, Refqah Isaacs, Ntambue Kauta, Frederik M Louw, Andile Mazibuko, David M North, Marc Nortje, Glen M Nunes, Neo Pebane, Chantal Rajah, John Roos, Paul Ryan, Winlecia V September, Heidi Shanahan, Ruth E Siebritz, Rian W Smit, Simon Sombili, Alexandra Torborg, Johan F van der Merwe, Nico van der Westhuizen, Bruce Biccard, Ulla Plenge, Romy Parker, Shamiela Davids, Gareth L Davies, Zahnne Fullerton, Lindsay Gray, Penelope Groenewald, Refqah Isaacs, Ntambue Kauta, Frederik M Louw, Andile Mazibuko, David M North, Marc Nortje, Glen M Nunes, Neo Pebane, Chantal Rajah, John Roos, Paul Ryan, Winlecia V September, Heidi Shanahan, Ruth E Siebritz, Rian W Smit, Simon Sombili, Alexandra Torborg, Johan F van der Merwe, Nico van der Westhuizen, Bruce Biccard

Abstract

Background: Encouraged by the widespread adoption of enhanced recovery protocols (ERPs) for elective total hip and knee arthroplasty (THA/TKA) in high-income countries, our nationwide multidisciplinary research group first performed a Delphi study to establish the framework for a unified ERP for THA/TKA in South Africa. The objectives of this second phase of changing practice were to document quality of patient recovery, record patient characteristics and audit standard perioperative practice.

Methods: From May to December 2018, nine South African public hospitals conducted a 10-week prospective observational study of patients undergoing THA/TKA. The primary outcome was 'days alive and at home up to 30 days after surgery' (DAH30) as a patient-centred measure of quality of recovery incorporating early death, hospital length of stay (LOS), discharge destination and readmission during the first 30 days after surgery. Preoperative patient characteristics and perioperative care were documented to audit practice.

Results: Twenty-one (10.1%) out of 207 enrolled patients had their surgery cancelled or postponed resulting in 186 study patients. No fatalities were recorded, median LOS was 4 (inter-quartile-range (IQR), 3-5) days and 30-day readmission rate was 3.8%, leading to a median DAH30 of 26 (25-27) days. Forty patients (21.5%) had pre-existing anaemia and 24 (12.9%) were morbidly obese. In the preoperative period, standard care involved assessment in an optimisation clinic, multidisciplinary education and full-body antiseptic wash for 67 (36.2%), 74 (40.0%) and 55 (30.1%) patients, respectively. On the first postoperative day, out-of-bed mobilisation was achieved by 69 (38.1%) patients while multimodal analgesic regimens (paracetamol and Non-Steroid-Anti-Inflammatory-Drugs) were administered to 29 patients (16.0%).

Conclusion: Quality of recovery measured by a median DAH30 of 26 days justifies performance of THA/TKA in South African public hospitals. That said, perioperative practice, including optimisation of modifiable risk factors, lacked standardisation suggesting that quality of patient care and postoperative recovery may improve with implementation of ERP principles. Notwithstanding the limited resources available, we anticipate that a change of practice for THA/TKA is feasible if 'buy-in' from the involved multidisciplinary units is obtained in the next phase of our nationwide ERP initiative.

Trial registration: The study was registered with ClinicalTrials.gov ( NCT03540667 ).

Keywords: DAH30; Enhanced recovery protocols; Low-and middle-income countries; Perioperative arthroplasty practice; Quality of recovery; South Africa; Total hip arthroplasty; Total knee arthroplasty.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Flowchart of perioperative data capture. * TUG test was performed on day two for patients discharged before day three. If day three after surgery was on a weekend and the physiotherapist was not available to perform the test, patients would have their TUG tests on the first coming weekday i.e. day four or five after surgery
Fig. 2
Fig. 2
Flow diagram of the study cohort. n = patients
Fig. 3
Fig. 3
Distribution of DAH30. a DAH30 for District and Regional Hospitals (n = 57). b DAH30 for Tertiary and Central Hospitals (n = 129). c DAH30 for the full patient cohort (n = 186). Y-axis = Number of patients, X-axis = Days alive and at home up to 30 days after surgery (DAH30). The smoothing line represents normal distribution

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