Background and purpose Length of stay (LOS) following total hip and knee arthroplasty (THA and TKA) has been reduced to about 3 days in fast-track setups with functional discharge criteria. Earlier...

Why still in hospital after fast-track hip and knee arthroplasty?

Postoperative pain has been poorly managed for decades. Recent surveys from USA and Europe do not show any major improvement. Persistent postoperative pain is common after most surgical procedures, and after thoracotomy and mastectomy, about 50% of patients may experience it. Opioids remain the mainstay of postoperative pain treatment in spite of strong evidence of their drawbacks. Multimodal analgesic techniques are widely used but new evidence is disappointing. Regional anaesthetic techniques are the most effective methods to treat postoperative pain. Current evidence suggests that epidural analgesia can no longer be considered the 'gold standard'. Perineural techniques are good alternatives for major orthopaedic surgery but remain underused. Infiltrative techniques with or without catheters are useful for almost all types of surgery. Simple surgeon-delivered local anaesthetic techniques such as wound infiltration, preperitoneal/intraperitoneal administration, transversus abdominis plane block and local infiltration analgesia can play a significant role in improvement of postoperative care, and the last of these has changed orthopaedic practice in many institutions. Current postoperative pain management guidelines are generally 'one size fits all'. It is well known that pain characteristics such as type, location, intensity and duration vary considerably after different surgical procedures. Procedure-specific postoperative pain management recommendations are evidence based, and also take into consideration the role of anaesthetic and surgical techniques, clinical routines and risk-benefit aspects. The role of acute pain services to improve pain management and outcome is well accepted but implementation seems challenging. The need for upgrading the role of surgical ward nurses and collaboration with surgeons to implement enhanced recovery after surgery protocols with regular audits to improve postoperative outcome cannot be overstated.

Current issues in postoperative pain management.

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 burd...

https://www.tandfonline.com/doi/pdf/10.3109/17453674.2011.618911

Enhanced recovery program for hip and knee replacement reduces death rate

Background. Total knee arthroplasty (TKA) is associated with severe pain and inflammation despite an extensive multimodal analgesic approach, but the effect of high-dose glucocorticoid administration has not been studied. Methods. Forty-eight patients undergoing unilateral TKA were included in a randomized, double-blind, placebo-controlled trial receiving preoperative methylprednisolone (MP) 125 mg i.v. or saline. All surgery was performed under lumbar spinal anaesthesia and patients received a standardized, multimodal analgesic regime. The primary endpoint was pain during walking 24 h after surgery, and secondary endpoints were pain at rest, pain upon hip flexion, and pain upon knee flexion. Pain assessments were performed repeatedly for the first 48 h after surgery, in a questionnaire from days 2 to 10, and at follow-up on days 21 and 30. Tertiary endpoints were postoperative nausea and vomiting (PONV), plasma Creactive protein (CRP) concentrations, fatigue, sleep quality, and rescue analgesic and antiemetic requirements. Results. Pain during walking was significantly lower in the MP group up to 32 h after operation. Overall pain and cumulative pain scores (2–48 h) were lower for all pain assessments (P,0.04). Consumption of rescue oxycodone was lower from 0 to 24 h (P¼0.02) and PONV, consumption of ondansetron reduced (P,0.05), and CRP concentrations were lower at 24 h (P,0.000001). Fatigue throughout the day of surgery was lower (P¼0.02), but sleep quality was worse on the first night (P¼0.002). No side-effects or complications were observed in other respects. Conclusions. MP 125 mg before surgery improves analgesia and immediate recovery after TKA, even when combined with a multimodal analgesic regime. These findings call for further studies on safety aspects. Registered with ClinicalTrails.gov under the US National Library of Medicine (registration number: NCT00968578).

Effect of high-dose preoperative methylprednisolone on pain and recovery after total knee arthroplasty: a randomized, placebo-controlled trial

Fast-track hip and knee arthroplasty aims at giving the patients the best available treatment at all times, being a dynamic entity. Fast-track combines evidence-based, clinical features with organizational optimization including a revision of traditions resulting in a streamlined pathway from admission till discharge – and beyond. The goal is to reduce morbidity, mortality and functional convalescence with an earlier achievement of functional milestones including functional discharge criteria with subsequent reduced length of stay and high patient satisfaction. Outcomes are traditionally measured as length of stay; safety aspects in the form of morbidity/mortality; patient satisfaction; and – as a secondary parameter – economic savings. Optimization of the clinical aspects include focusing on analgesia; DVT-prophylaxis; mobilization; care principles including functional discharge criteria; patient-characteristics to predict outcome; and traditions which may be barriers in optimizing outcomes. Patients should be informed and motivated to be active participants and their expectations should be modulated in order to improve satisfaction. Also, organizational aspects need to be analyzed and optimized. New logistical approaches should be implemented; the ward ideally (re)structured to only admit arthroplasties; the staff educated to have a uniform approach; extensive preoperative information given including discharge criteria and intended length of stay. This thesis includes 9 papers on clinical and organizational aspects of fast-track hip and knee arthroplasty (I–IX). A detailed description of the fast-track set-up and its components is provided. Major results include identification of patient characteristics to predict length of stay and satisfaction with different aspects of the hospital stay (I); how to optimize analgesia by using a compression bandage in total knee arthroplasty (II); the clinical and organizational set-up facilitating or acting as barriers for early discharge (III); safety aspects following fast-track in the form of few readmissions in general (IV) and few thromboembolic complications in particular (V); feasibility studies showing excellent outcomes following fast-track bilateral simultaneous total knee arthroplasty (VI) and non-septic revision knee arthroplasty (VII); how acute pain relief in total hip arthroplasty is not enhanced by the use of local infiltration analgesia when multi-modal opioid-sparing analgesia is given (VIII); and a detailed description of which clinical and organizational factors detain patients in hospital following fast-track hip and knee arthroplasty (IX). Economic savings following fast-track hip and knee arthroplasty is also documented in studies, reviews, metaanalyses and Cochrane reviews – including the present fast-track (ANORAK). In conclusion, the published results (I–IX) provide substantial, important new knowledge on clinical and organizational aspects of fast-track hip and knee arthroplasty – with concomitant documented high degrees of safety (morbidity/mortality) and patient satisfaction. Future research strategies are multiple and include both research strategies as efforts to implement the fast-track methodology on a wider basis. Research areas include improvements in pain treatment, blood saving strategies, fluid plans, reduction of complications, avoidance of tourniquet and concomitant blood loss, improved early functional recovery and muscle strengthening. Also, improvements in information and motivation of the patients, preoperative identification of patients needing special attention and detailed economic studies of fast- track are warranted.

https://www.tandfonline.com/doi/pdf/10.3109/17453674.2012.700593

Fast-track hip and knee arthroplasty: clinical and organizational aspects

Background We have developed a multimodal technique for the control of pain following knee and hip surgery, called "local infiltration analgesia" (LIA). It is based on systematic infiltration of a mixture of ropiva-caine, ketorolac, and adrenaline into the tissues around the surgical field to achieve satisfactory pain control with little physiological disturbance. The technique allows virtually immediate mobilization and earlier discharge from hospital. Patients and methods In this open, nonrandomized case series, we used LIA to manage postoperative pain in all 325 patients presenting to our service from Jan 1, 2005 to Dec 31,2006 for elective hip resurfacing (HRA), primary total hip replacement (THR), or primary total knee replacement arthroplasty (TKR). We recorded pain scores, mobilization times, and morphine usage for the entire group. Results Pain control was generally satisfactory (numerical rating scale pain score range 0-3). No morphine was required for postoperative pain control in two-thirds of the patients. Most patients were able to walk with assistance between 5 and 6 h after surgery and independent mobility was achieved 13-22 h after surgery. Orthostatic hypotension, nausea, and vomiting were occasionally associated with standing for the first time, but other side effects were unremarkable. 230 (71%) of the 325 patients were discharged directly home after a single overnight stay in hospital. Interpretation Local infiltration analgesia is simple, practical, safe, and effective for pain management after knee and hip surgery.

https://www.tandfonline.com/doi/pdf/10.1080/17453670710014950

Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: A case study of 325 patients

There has been a rapid increase in the number of hip resurfacing procedures for the treatment of symptomatic osteoarthritis over the last decade. We examine our early complications associated with this procedure. Eight hundred forty consecutive hip resurfacing procedures by 1 surgeon using 1 prosthesis were assessed. The complications seen within the first 12-month postoperative period were analyzed. Specific patient selection criteria were used. Complications such as loosening, femoral neck notching, femoral neck fracture, deep vein thrombosis, stress fracture, nerve palsy, and infection were noted. Complications linked with loosening were categorized to either the femoral or acetabular component. A total of 86 early complications were observed in the 840 resurfacings. Twenty-three (2.7%) required operative intervention, and 10 (1.2%) were converted to stemmed hip arthroplasties. Of these 86 complications, the most common complication was deep vein thrombosis, 19 instances (2.26% occurrence in 840), followed by femoral neck fracture, 11 (1.31%); infection, 10 (1.19%); femoral notching, 10 (1.19%); transient nerve palsy, 8 (0.95%); acetabular loosening, 6 (0.71%); hematoma, 5 (0.60%); and stress fracture, 4 (0.48%). The fractures occurred mostly in patients older than 60 years.

Early complications of hip resurfacing.

Aims The aim of this study was to report the implant survival and patient-reported outcome measures (PROMs) in a consecutive series of patients aged less than 50 years at the time of arthroplasty u...

The outcome and survival of metal-on-metal hip resurfacing in patients aged less than 50 years: a prospective observational cohort study with minimum ten-year follow-up

We describe a case of Nocardia nova septic arthritis following a total knee replacement. A 55-year-old obese woman was admitted to hospital 5 months after knee surgery with a 3-week history of pain, swelling, and restricted mobility in her left knee but no preceding trauma/injury. 30 ml of cloudy joint fluid was aspirated and an arthroscopic examination showed extensive fibrin formation and synovitis. An arthroscopic washout was carried out using 16 litres of saline, followed by total synovectomy and intensive antibiotic therapy (clarithromycin 500 mg twice daily and co-trimoxazole [sulphamethoxazole 400 mg and trimethoprim 80 mg] once daily and augmentin duo forte 875 mg twice daily). At 2.5 years, the patient had recovered completely with no prosthetic loosening.

https://journals.sagepub.com/doi/pdf/10.1177/230949900701500332

Nocardia Nova Septic Arthritis following Total Knee Replacement: A Case Report:

We evaluated the effect of local infiltration of NSAIDs on prosthetic fixation at mid- to long-term follow-up of total hip arthroplasties. Intra-articular local NSAID (ketorolac) was injected into hip joints and surrounding tissues intraoperatively and postoperatively as a part of multimodal pain management protocol. Clinical and radiographic evaluation was performed for any evidence of component loosening or failure and clinical outcomes in 100 total hip joint arthroplasties with a mean follow-up of 7.3 years (4.9 to 11 yrs). Radiographic analysis at the most recent follow-up showed no evidence of loosening, subsidence, or migration and no evidence of impending failure. Clinical outcomes showed improved Harris hip scores. Intra-articular NSAID used in the intraoperative/postoperative period in hip arthroplasty showed no evidence of prosthetic loosening at mid- to long-term follow-up.

/pdf/do-nonsteroidal-anti-inflammatory-drugs-cause-endoprosthetic-4p4wvpvf80.pdf

Do Nonsteroidal Anti-Inflammatory Drugs Cause Endoprosthetic Loosening? Mid- to Long-Term Follow-Up of 100 Total Hip Arthroplasties after Local NSAID Infiltration.

Dennis Kerr

Papers

Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: A case study of 325 patients

Early complications of hip resurfacing.

The outcome and survival of metal-on-metal hip resurfacing in patients aged less than 50 years: a prospective observational cohort study with minimum ten-year follow-up

Nocardia Nova Septic Arthritis following Total Knee Replacement: A Case Report:

Do Nonsteroidal Anti-Inflammatory Drugs Cause Endoprosthetic Loosening? Mid- to Long-Term Follow-Up of 100 Total Hip Arthroplasties after Local NSAID Infiltration.