Enhanced recovery program for hip and knee replacement reduces death rate

Ajay Malviya, Kate Martin, Ian Harper, Scott D Muller, Kevin P Emmerson, Paul F Partington, Mike R Reed, Ajay Malviya, Kate Martin, Ian Harper, Scott D Muller, Kevin P Emmerson, Paul F Partington, Mike R Reed

Abstract

Background and purpose: Multimodal techniques can aid early rehabilitation and discharge of patients following primary joint replacement. We hypothesized that this not only reduces the economic burden of joint replacement by reducing length of stay, but also helps in reduction of early complications.

Patients and methods: We evaluated 4,500 consecutive unselected total hip replacements and total knee replacements regarding length of hospital stay, mortality, and perioperative complications. The first 3,000 underwent a traditional protocol while the other 1,500 underwent an enhanced recovery protocol involving behavioral, pharmacological, and procedural modifications.

Results: There was a reduction in 30-day death rate (0.5% to 0.1%, p = 0.02) and 90-day death rate (0.8% to 0.2%, p = 0.01). The median length of stay decreased from 6 days to 3 days (p < 0.001), resulting in a saving of 5,418 bed days. Requirement for blood transfusion was reduced (23% to 9.8%, p < 0.001). There was a trend of a reduced rate of 30-day myocardial infarction (0.8% to 0.5%. p = 0 .2) and stroke (0.5% to 0.2%, p = 0.2). The 60-day deep vein thrombosis figures (0.8% to 0.6%, p = 0.5) and pulmonary embolism figures (1.2% to 1.1%, p = 0.9) were similar. Re-admission rate remained unchanged during the period of the study (4.7% to 4.8%, p = 0.8).

Interpretation: This large observational study of unselected consecutive hip and knee arthroplasty patients shows a substantial reduction in death rate, reduced length of stay, and reduced transfusion requirements after the introduction of a multimodal enhanced recovery protocol.

Figures

Figure 1.
Figure 1.
Box plot to compare the length of stay between the tradiional (Trad) and the enhanced recovery (ER) groups.
Figure 2.
Figure 2.
Trend of various complications through the study period. Grouping of patients is explained in the footnote to Figure 1.

References

    1. Andersen KV, Pfeiffer-Jensen M, Haraldsted V, Soballe K. Reduced hospital stay and narcotic consumption, and improved mobilization with local and intraarticular infiltration after hip arthroplasty: a randomized clinical trial of an intraarticular technique versus epidural infusion in 80 patients. Acta Orthop. 2007;78(2):180–6.
    1. Andersen LO, Husted H, Otte KS, Kristensen BB, Kehlet H. A compression bandage improves local infiltration analgesia in total knee arthroplasty. Acta Orthop. 2008a;79((6)):806–11.
    1. Andersen LO, Husted H, Otte KS, Kristensen BB, Kehlet H. High-volume infiltration analgesia in total knee arthroplasty: a randomized, double-blind, placebo-controlled trial. Acta Anaesthesiol Scand. 2008b;52(10):1331–5.
    1. Bozic KJ, Saleh KJ, Rosenberg AG, Rubash HE. Economic evaluation in total hip arthroplasty: analysis and review of the literature. J Arthroplasty. 2004;19(2):180–9.
    1. Danish National Board of Health D, Centre for Evaluation and Health Technology Assessment, Evaluation of patient path for patients undergoing primary total hip or knee arthroplasty. 2006.
    1. Essving P, Axelsson K, Kjellberg J, Wallgren O, Gupta A, Lundin A. Reduced hospital stay, morphine consumption, and pain intensity with local infiltration analgesia after unicompartmental knee arthroplasty. Acta Orthop. 2009;80(2):213–9.
    1. Fender D, Harper WM, Thompson JR, Gregg PJ. Mortality and fatal pulmonary embolism after primary total hip replacement. Results from a regional hip register. J Bone Joint Surg (Br) 1997;79(6):896–9.
    1. Ho KM, Ismail H. Use of intravenous tranexamic acid to reduce allogeneic blood transfusion in total hip and knee arthroplasty: a meta-analysis. Anaesth Intensive Care. 2003;31(5):529–37.
    1. Husted H, Holm G, Jacobsen S. Predictors of length of stay and patient satisfaction after hip and knee replacement surgery: fast-track experience in 712 patients. Acta Orthop. 2008;79(2):168–73.
    1. Isaac D, Falode T, Liu P, I'Anson H, Dillow K, Gill P. Accelerated rehabilitation after total knee replacement. Knee. 2005;12(5):346–50.
    1. Jones R. Costing orthopaedic interventions. Br J Helthcare Management. 2008;14(12):539–47.
    1. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630–41.
    1. Kerr DR, Kohan L. Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: a case study of 325 patients. Acta Orthop. 2008;79(2):174–83.
    1. Kinninmonth A WG, Lamont E, Monaghan H, Lawson C, Brown J, Siegmeth R, Scott N. British Hip Society; Manchester: 2009a. A peri-operative regime, including high volume, intermittent ropivacaine via an intra-articular catheter, allowing early mobilisation in total hip arthroplasty.
    1. Kinninmonth A WG, Lamont E, Monaghan H, Lawson C, Brown J, Siegmeth R, Scott N. British Association for Surgery of the Knee; Edinburgh: 2009b. A peri-operative regime, including high volume, intermittent ropivacaine via an intra-articular catheter, allowing early mobilisation in total knee arthroplasty.
    1. Larsen K, Sorensen OG, Hansen TB, Thomsen PB, Soballe K. Accelerated perioperative care and rehabilitation intervention for hip and knee replacement is effective: a randomized clinical trial involving 87 patients with 3 months of follow-up. Acta Orthop. 2008;79(2):149–59.
    1. National Joint Registry Fifth Annual Report. Journal 2008; 27/07/2009)
    1. Nechleba J, Rogers V, Cortina G, Cooney T. Continuous intra-articular infusion of bupivacaine for postoperative pain following total knee arthroplasty. J Knee Surg. 2005;18(3):197–202.
    1. Parvizi J, Johnson BG, Rowland C, Ereth MH, Lewallen DG. Thirty-day mortality after elective total hip arthroplasty. J Bone Joint Surg (Am) 2001a;83(10):1524–8.
    1. Parvizi J, Sullivan TA, Trousdale RT, Lewallen DG. Thirty-day mortality after total knee arthroplasty. J Bone Joint Surg (Am) 2001b;83(8):1157–61.
    1. Reilly KA, Beard DJ, Barker KL, Dodd CA, Price AJ, Murray DW. Efficacy of an accelerated recovery protocol for Oxford unicompartmental knee arthroplasty–a randomised controlled trial. Knee. 2005;12(5):351–7.
    1. Rostlund T, Kehlet H. High-dose local infiltration analgesia after hip and knee replacement–what is it, why does it work, and what are the future challenges? Acta Orthop. 2007;78(2):159–61.
    1. Seagroatt V, Tan HS, Goldacre M, Bulstrode C, Nugent I, Gill L. Elective total hip replacement: incidence, emergency readmission rate, and postoperative mortality. Bmj. 1991;303(6815):1431–5.

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel