Enhanced Recovery Protocol After Single-stage Bilateral Primary Total Knee Arthroplasty Decreases Duration of Hospital Stay Without Increasing Complication Rates

Overview

Journal Eur J Orthop Surg Traumatol

Specialty Orthopedics

Date 2021 Jun 7

PMID 34097154

Citations 1

Authors

Md Quamar Azam

Tarun Goyal

Souvik Paul

Arvind Kumar Yadav

Nishith Govil

Affiliations

Soon will be listed here.

Abstract

Purpose: With an increasing number of total knee arthroplasty (TKA), protocols for better standard of patient care and shorter duration of hospital stay are necessary. Enhanced recovery (ER) protocols are becoming popular to meet these objectives. The current study aims to evaluate the clinical outcome of fast-track TKA using ER protocol in terms of length of hospital stay, perioperative complications and functional outcomes.

Methods: Patients undergoing single-stage bilateral primary TKA were prospectively included in the study. All patients went through a pre-defined ER protocol of TKA. Length of hospital stay, readmission rates, pain scores and functional scores of patients operated under ER protocol were compared with another matched historical control-group. Factors delaying the discharge of the patients by 48 h after the surgery were noted.

Results: We compared 275 patients undergoing single-stage bilateral primary TKA through ER protocol (Group 1) with 190 patients who had undergone bilateral primary TKA before the ER protocol was initiated (Group 2). The length of hospital stay (3.9 ± 2.1 days in group 1 and 7.5 ± 3.2 days in group 2, p 0.0001) and post-operative pain scores at 12 h (5.2 ± 2.9 in group 1 and 5.7 ± 2.1 in group 2, p 0.03) and 24 h (4.1 ± 1.6 in group 1 and 4.6 ± 1.4 in group 2, p 0.0005) were found to be significantly better with ER protocol. There was no difference in Oxford knee scores, infection rates, readmissions or mortality between the two groups.

Conclusion: ER protocol in single-stage bilateral primary TKA resulted in decreased length of hospital stay without increasing complications and compromising the clinical outcome. It requires an integrated approach and adherence to clinical pathways.

Level Of Evidence: Level II, Prospective comparative study.

Citing Articles

A systematic review and meta-analysis of short-stay programmes for total hip and knee replacement, focusing on safety and optimal patient selection.

Berkovic D, Vallance P, Harris I, Naylor J, Lewis P, de Steiger R BMC Med. 2023; 21(1):511.

PMID: 38129857 PMC: 10740291. DOI: 10.1186/s12916-023-03219-5.

References

McDonald D, Siegmeth R, Deakin A, Kinninmonth A, Scott N . An enhanced recovery programme for primary total knee arthroplasty in the United Kingdom--follow up at one year. Knee. 2011; 19(5):525-9. DOI: 10.1016/j.knee.2011.07.012. View

Malviya A, Martin K, Harper I, Muller S, Emmerson K, Partington P . Enhanced recovery program for hip and knee replacement reduces death rate. Acta Orthop. 2011; 82(5):577-81. PMC: 3242954. DOI: 10.3109/17453674.2011.618911. View

Larsen K, Hvass K, Hansen T, Thomsen P, Soballe K . Effectiveness of accelerated perioperative care and rehabilitation intervention compared to current intervention after hip and knee arthroplasty. A before-after trial of 247 patients with a 3-month follow-up. BMC Musculoskelet Disord. 2008; 9:59. PMC: 2396162. DOI: 10.1186/1471-2474-9-59. View

Scott N, McDonald D, Campbell J, Smith R, Carey A, Johnston I . The use of enhanced recovery after surgery (ERAS) principles in Scottish orthopaedic units--an implementation and follow-up at 1 year, 2010-2011: a report from the Musculoskeletal Audit, Scotland. Arch Orthop Trauma Surg. 2012; 133(1):117-24. DOI: 10.1007/s00402-012-1619-z. View

Isaac D, Falode T, Liu P, IAnson H, Dillow K, Gill P . Accelerated rehabilitation after total knee replacement. Knee. 2005; 12(5):346-50. DOI: 10.1016/j.knee.2004.11.007. View

Kumar L, Kumar A, Grant S, Gadsden J . Updates in Enhanced Recovery Pathways for Total Knee Arthroplasty. Anesthesiol Clin. 2018; 36(3):375-386. DOI: 10.1016/j.anclin.2018.04.007. View

Galbraith A, McGloughlin E, Cashman J . Enhanced recovery protocols in total joint arthroplasty: a review of the literature and their implementation. Ir J Med Sci. 2017; 187(1):97-109. DOI: 10.1007/s11845-017-1641-9. View

Zhu S, Qian W, Jiang C, Ye C, Chen X . Enhanced recovery after surgery for hip and knee arthroplasty: a systematic review and meta-analysis. Postgrad Med J. 2017; 93(1106):736-742. PMC: 5740550. DOI: 10.1136/postgradmedj-2017-134991. View

Rutherford R, Jennings J, Dennis D . Enhancing Recovery After Total Knee Arthroplasty. Orthop Clin North Am. 2017; 48(4):391-400. DOI: 10.1016/j.ocl.2017.05.002. View

10.

Nagra N, Hamilton T, Strickland L, Murray D, Pandit H . Enhanced recovery programmes for lower limb arthroplasty in the UK. Ann R Coll Surg Engl. 2017; 99(8):631-636. PMC: 5696927. DOI: 10.1308/rcsann.2017.0124. View

11.

Kehlet H . Enhanced recovery after surgery for hip and knee arthroplasty: where is the evidence?. Br J Anaesth. 2017; 118(4):628. DOI: 10.1093/bja/aex058. View

12.

Stambough J, Nunley R, Curry M, Steger-May K, Clohisy J . Rapid recovery protocols for primary total hip arthroplasty can safely reduce length of stay without increasing readmissions. J Arthroplasty. 2015; 30(4):521-6. PMC: 4607279. DOI: 10.1016/j.arth.2015.01.023. View

13.

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. DOI: 10.1080/17453670710014941. View

14.

Jorgensen C, Kehlet H . Role of patient characteristics for fast-track hip and knee arthroplasty. Br J Anaesth. 2013; 110(6):972-80. DOI: 10.1093/bja/aes505. View

15.

Krenk L, Jennum P, Kehlet H . Activity, sleep and cognition after fast-track hip or knee arthroplasty. J Arthroplasty. 2013; 28(8):1265-9. DOI: 10.1016/j.arth.2013.02.013. View

16.

Fuzier R, Serres I, Bourrel R, Palmaro A, Montastruc J, Lapeyre-Mestre M . Analgesic drug consumption increases after knee arthroplasty: a pharmacoepidemiological study investigating postoperative pain. Pain. 2014; 155(7):1339-1345. DOI: 10.1016/j.pain.2014.04.010. View

17.

Courtney P, Boniello A, Berger R . Complications Following Outpatient Total Joint Arthroplasty: An Analysis of a National Database. J Arthroplasty. 2016; 32(5):1426-1430. DOI: 10.1016/j.arth.2016.11.055. View

18.

Lovald S, Ong K, Lau E, Joshi G, Kurtz S, Malkani A . Patient selection in outpatient and short-stay total knee arthroplasty. J Surg Orthop Adv. 2014; 23(1):2-8. DOI: 10.3113/jsoa.2014.0002. View

19.

Auyong D, Allen C, Pahang J, Clabeaux J, MacDonald K, Hanson N . Reduced Length of Hospitalization in Primary Total Knee Arthroplasty Patients Using an Updated Enhanced Recovery After Orthopedic Surgery (ERAS) Pathway. J Arthroplasty. 2015; 30(10):1705-9. DOI: 10.1016/j.arth.2015.05.007. View

20.

Klement M, Bullock W, Nickel B, Lampley A, Seyler T, Green C . Continuous adductor canal blockade facilitates increased home discharge and decreased opioid consumption after total knee arthroplasty. Knee. 2019; 26(3):679-686. DOI: 10.1016/j.knee.2019.01.020. View