Fall-related admissions after fast-track total hip and knee arthroplasty - cause of concern or consequence of success?

Christoffer C Jørgensen, Henrik Kehlet, Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement Collaborative Group, Kjeld Soeballe, Torben B Hansen, Henrik Husted, Mogens B Laursen, Lars T Hansen, Per Kjaersgaard-Andersen, Christoffer C Jørgensen, Henrik Kehlet, Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement Collaborative Group, Kjeld Soeballe, Torben B Hansen, Henrik Husted, Mogens B Laursen, Lars T Hansen, Per Kjaersgaard-Andersen

Abstract

Background: Total hip (THA) and knee arthroplasty (TKA) are common procedures in elderly persons, who are at potential increased risk of postoperative fall due to loss of muscle strength and impaired balance. Fast-track surgery with early mobilization and opioid-sparing analgesia have improved outcomes after these procedures, but early mobilization and short hospitalization length of stay (LOS) could potentially increase the risk of falls after discharge. We investigated injuries, circumstances, and the timing of fall-related hospital admissions 90 days after fasttrack THA and TKA.

Methods: This was a prospective, descriptive multicenter study on fall-related hospital admissions, in 5145 elective fast-track THA and TKA patients, with complete 90-day follow up through the Danish National Patient registry and medical charts.

Results: Of 83 (1.6%) fall-related hospital admissions, 43 (51.8%) were treated in the Emergency Room and 40 (48.2%) were admitted to a regular ward. The median LOS after surgery was 3 days (interquartile range [IQR]: 2-3) in fallers versus (vs) 2 days (IQR: 2-3) (P=0.022) in patients without falls. Injuries were classified as "none" or minor in 39.8%, moderate in 9.6%, and major in 50.6%. Most falls (54.8%) occurred within 1 month of discharge. Falls due to physical activity (12.0%) and extrinsic factors (14.5%) occurred later than did surgery-related falls (73.5%), contributing to 40% of all falls >30 days after discharge. In multivariate analysis, age (odds ratio [OR]: 1.05; 95% confidence interval [CI]: 1.0-1.08) (P=0.001), living alone (OR: 2.09; 95% CI: 1.20-3.62) (P=0.009), and psychiatric disease (OR: 2.80; 95% CI: 1.42-5.50) (P=0.001) were associated with surgery-related falls, whereas the use of a walking aid (OR: 1.20; 95% CI: 0.67-2.16) (P=0.544) and LOS ≤4 days (OR:1.19; 95% CI: 0.52-1.28) (P=0.680) was not.

Conclusion: Hospital admissions due to falls are most frequent within the first month after fast-track THA and TKA. The overall incidence of surgery-related falls amongst these patients is low, declines after the first month, and is related to patient characteristics rather than short LOS. The effect of interventions aimed at surgery-related falls should focus on the first 30 days after surgery and differentiate between the causes of falling.

Keywords: falls; orthopedic; osteoarthrosis; postoperative; risk.

Figures

Figure 1
Figure 1
Flow chart of the study population. Abbreviations: THA, total hip arthroplasty; TKA, total knee arthroplasty.
Figure 2
Figure 2
Falls according to treatment (emergency room vs regular ward) and injury type. Abbreviations: ER, Emergency Room; THA, total hip arthroplasty; TKA, total knee arthroplasty; vs, versus.
Figure 3
Figure 3
Cumulated incidence of falls: (A) according to circumstances and (B) according to injury. Abbreviations: THA, total hip arthroplasty; TKA, total knee arthroplasty.

References

    1. Mandl LA, Lyman S, Quinlan P, Bailey T, Katz J, Magid SK. Falls among patients who had elective orthopaedic surgery: a decade of experience from a musculoskeletal specialty hospital. J Orthop Sports Phys Ther. 2013;43(2):91–96.
    1. Ackerman DB, Trousdale RT, Bieber P, Henely J, Pagnano MW, Berry DJ. Postoperative patient falls on an orthopedic inpatient unit. J Arthroplasty. 2010;25(1):10–14.
    1. Health Quality Ontario Prevention of falls and fall-related injuries in community-dwelling seniors: an evidence-based analysis. Ont Health Technol Assess Ser. 2008;8(2):1–78.
    1. Memtsoudis SG, Dy CJ, Ma Y, Chiu YL, Della Valle AG, Mazumdar M. In-hospital patient falls after total joint arthroplasty: incidence, demographics, and risk factors in the United States. J Arthroplasty. 2012;27(6):823–828.e1.
    1. Robinovitch SN, Feldman F, Yang Y, et al. Video capture of the circumstances of falls in elderly people residing in long-term care: an observational study. Lancet. 2013;381(9860):47–54.
    1. Morris ME. Preventing falls in older people. BMJ. 2012;345:e4919.
    1. Clemson L, Fiatarone Singh MA, Bundy A, et al. Integration of balance and strength training into daily life activity to reduce rate of falls in older people (the LiFE study): randomised parallel trial. BMJ. 2012;345:e4547.
    1. Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RN, Garry PJ. Fear of falling and restriction of mobility in elderly fallers. Age Ageing. 1997;26(3):189–193.
    1. Johnson RL, Kopp SL, Hebl JR, Erwin PJ, Mantilla CB. Falls and major orthopaedic surgery with peripheral nerve blockade: a systematic review and meta-analysis. Br J Anaesth. 2013;110(4):518–528.
    1. Mion LC, Chandler AM, Waters TM, et al. Is it possible to identify risks for injurious falls in hospitalized patients? Jt Comm J Qual Patient Saf. 2012;38(9):408–413.
    1. Oliver D, Connelly JB, Victor CR, et al. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. BMJ. 2007;334(7584):82.
    1. Kirksey M, Chiu YL, Ma Y, et al. Trends in in-hospital major morbidity and mortality after total joint arthroplasty: United States 1998–2008. Anesth Analg. 2012;115(2):321–327.
    1. Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR. Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991–2010. JAMA. 2012;308(12):1227–1236.
    1. Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008;248(2):189–198.
    1. Malviya A, Martin K, Harper I, et al. Enhanced recovery program for hip and knee replacement reduces death rate. Acta Orthop. 2011;82(5):577–581.
    1. Kehlet H. Fast-track hip and knee arthroplasty. Lancet. 2013;381(9878):1600–1602.
    1. Jørgensen CC, Kehlet H, Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement Collaborative Group Role of patient characteristics for fast-track hip and knee arthroplasty. Br J Anaesth. 2013;110(6):972–980.
    1. Husted H, Jensen CM, Solgaard S, Kehlet H. Reduced length of stay following hip and knee arthroplasty in Denmark 2000–2009: from research to implementation. Arch Orthop Trauma Surg. 2012;132(1):101–104.
    1. Holm B, Thorborg K, Husted H, Kehlet H, Bandholm T. Surgery-induced changes and early recovery of hip-muscle strength, leg-press power, and functional performance after fast-track total hip arthroplasty: a prospective cohort study. PLoS One. 2013;8(4):e62109.
    1. Schwendimann R, Bühler H, De Geest S, Milisen K. Characteristics of hospital inpatient falls across clinical departments. Gerontology. 2008;54(6):342–348.
    1. Pulido L, Parvizi J, Macgibeny M, et al. In hospital complications after total joint arthroplasty. J Arthroplasty. 2008;23(6 Suppl 1):139–145.
    1. Husted H, Solgaard S, Hansen TB, Søballe K, Kehlet H. Care principles at four fast-track arthroplasty departments in Denmark. Dan Med Bull. 2010;57(7):A4166.
    1. Rigshospitalet Length of Stay and Complications in High-risk Patients Receiving Fast-track Total Hip (THA) or Knee- Alloplasty (TKA) Available from . NLM identifier: NCT01515670Accessed February 1, 2013
    1. Lynge E, Sandegaard JL, Rebolj M. The Danish National Patient Register. Scand J Public Health. 2011;39(Suppl 7):30–33.
    1. Fleming J, Brayne C, Cambridge City Over-75s Cohort (CC75C) Study Collaboration Inability to get up after falling, subsequent time on floor, and summoning help: prospective cohort study in people over 90. BMJ. 2008;337:a2227.
    1. Vogler CM, Sherrington C, Ogle SJ, Lord SR. Reducing risk of falling in older people discharged from hospital: a randomized controlled trial comparing seated exercises, weight-bearing exercises, and social visits. Arch Phys Med Rehabil. 2009;90(8):1317–1324.
    1. Mahoney JE, Palta M, Johnson J, et al. Temporal association between hospitalization and rate of falls after discharge. Arch Intern Med. 2000;160(18):2788–2795.
    1. Swanson EA, Schmalzried TP, Dorey FJ. Activity recommendations after total hip and knee arthroplasty: a survey of the American Association for Hip and Knee Surgeons. J Arthroplasty. 2009;24(Suppl 6):120–126.
    1. Holm B, Kristensen MT, Bencke J, Husted H, Kehlet H, Bandholm T. Loss of knee-extension strength is related to knee swelling after total knee arthroplasty. Arch Phys Med Rehabil. 2010;91(11):1770–1776.
    1. Bandholm T, Kehlet H. Physiotherapy exercise after fast-track total hip and knee arthroplasty: time for reconsideration? Arch Phys Med Rehabil. 2012;93(7):1292–1294.
    1. Jakobsen TL, Husted H, Kehlet H, Bandholm T. Progressive strength training (10 RM) commenced immediately after fast-track total knee arthroplasty: is it feasible? Disabil Rehabil. 2012;34(12):1034–1040.
    1. Davis CL, Pierce JR, Henderson W, et al. Assessment of the reliability of data collected for the Department of Veterans Affairs national surgical quality improvement program. J Am Coll Surg. 2007;204(4):550–560.
    1. Close JC, Lord SL, Menz HB, Sherrington C. What is the role of falls? Best Pract Res Clin Rheumatol. 2005;19(6):913–935.

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren