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

Pharmaceutical drugs for the treatment of metabolic bone diseases lead to a number of side effects due to the their uncontrollable dispersion throughout the body. [1] Therefore, many groups directed their research to develop devices that are targeted to specific organs or tissues and release the encapsulated drug in a highly regulated way. [2―7] The development of completely resorbable bone-filling biomaterials delivering drugs would offer a therapeutic approach of drug release and bone augmentation in a simple one-step process. [8―11] The biomaterials selected needs custom designs, to control the quantity and the duration of drug release and at the same time inducing desirable host cell responses and preventing bacterial infection. [12―15] Current synthetic biomaterials produced as drug delivery microspheres due to production difficulties contain not very well designed interconnected pores and fail to fill these pertinent requirements. Turning directly to nature such as marine structures for inventive solutions can help to solve these problems due to their structure, chemistry and architecture and their unique designs. [16―20] We demonstrate -for the first time- the potential of unique coral shells with specific microspherical structure and highly organised interconnected intra-pore designs to offer a number of desired functions for targeted delivery of Bisphosphonate (BP) (paminodrate) and an antibiotic (Gentamicin) for bone regeneration, repair and preventive antibacterial slow drug delivery.

Targeting and Dissolution Characteristics of Bone Forming and Antibacterial Drugs by Harnessing the Structure of Microspherical Shells from Coral Beach Sand

In the assessment of acute knee pain following recent trauma frequently related to sporting activities, bone scintigraphy was performed on 52 patients; in 40 of these patients, scintigraphy immediately preceded arthroscopy. SPECT was critical in providing delineation and sitting of the abnormalities; this would not have been feasible with conventional planar imaging in 45 of the patients. Multiple sites of focal uptake were frequently visualized at ligamentous insertions or in intra-articular areas of cartilaginous erosion. Damaged anterior cruciate ligaments were only identified in 5 out of 10 patients, occurring when there was avulsion of the tibial attachment, but changes resulting from patellar injury were demonstrated in all 8 patients. The most characteristic scintigraphic change resulted from meniscal tears, which was diagnosed in 31 out of 35 patients in whom the lesion had been suspected clinically. In the identification of this common injury, SPECT had a sensitivity of 88%, specificity of 87%, and diagnostic accuracy of 88%. Thus, although trauma readily induces scintigraphic abnormalities in and around the knee, the patterns of alteration associated with particular lesions can be identified by SPECT and can provide considerable assistance in management, particularly in determining the need for arthroscopy.

SPECT for acute knee pain.

The new generation short-stem hip implants are designed to encourage physiological-like loading, to minimize stress-strain shielding and therefore implant loosening in the long term. As yet there are no long-term clinical studies available to prove the benefits of these short-stem implants. Owing to this lack of clinical data, numerical simulation may be used as a predictor of longer term behaviour. This finite element study predicted both the primary stability and long-term stability of a short-stem implant. The primary implant stability was evaluated in terms of interface micromotion. This study found primary stability to fall within the critical threshold for osseointegration to occur. Longer term stability was evaluated using a strain-adaptive bone remodelling algorithm to predict the long-term behaviour of the bone in terms of bone mineral density (BMD) changes. No BMD loss was observed in the classical Gruen zones 1 and 7 and bone remodelling patterns were comparable with hip resurfacing results in the literature.

Primary and long-term stability of a short-stem hip implant.

Twenty-six children between the ages of ten months and 15 years with closed fractures of the femoral shaft treated by closed means were reviewed to determine whether shortening at the time of fracture union overcame the problem of subsequent limb overgrowth. The mean shortening at the time of union was 9.8 millimeters. The mean overgrowth was 8.8 mm. The initial shortening and subsequent limb overgrowth were related, with a correlation coefficient of 0.63 (p less than 0.01). The greater the initial shortening, the stronger appeared to be the stimulus for overgrowth.

Lawrence Kohan

Papers

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

Targeting and Dissolution Characteristics of Bone Forming and Antibacterial Drugs by Harnessing the Structure of Microspherical Shells from Coral Beach Sand

SPECT for acute knee pain.

Primary and long-term stability of a short-stem hip implant.

Femoral shaft fractures in children: the effect of initial shortening on subsequent limb overgrowth.