Rapid recovery protocol after Total Hip and Knee Arthroplasty that is safe and effective in most clinical environments

Abstract

Background: Rapid recovery protocols, as well as minimally invasive techniques, are used in daily practice in almost all surgical specialties. Rapid Rehabilitation Protocols are the most modern multifactorial approach for patients with hip, knee or spine surgery. Fast track protocols consist of a combination of minimally invasive surgical techniques, modified anesthesia, staged and personalized analgesia. These protocols have a steep learning curve and require the cooperation of all involved specialties (Orthopaedic surgeon, anesthesiologist, physiotherapist, nursing staff).

Material and Methods: The study was conducted simultaneously at the 2nd Orthopaedic Department of the National & Kapodistrian University of Athens, and other private hospitals for a period of 7 years (2013-2020). In total, 826 arthroplasties were performed by the senior author (GCB), of which 515 were total hip arthroplasties (THA) and 311 total knee arthroplasties (TKA). The patients underwent combined spinal, epidural and intravenous general anesthesia with preservation of automatic breathing as it is considered to contribute to decreased length of stay (LOS), short-term complications, and transfusions. The rapid recovery protocol includes minimal invasive techniques, use of local infiltration anesthesia (LIA), use of tranexamic acid, low transfusion threshold, early mobilization, and immediate initiation of oral nutrition as well as complete abstinence from intravenous or intramuscular opioids that may cause nausea and vomiting.

Results: LOS range was 0-2 days for THAs with mean value: 1.33, and 1-2 days for TKAs with mean value: 1.54. Transfusion with 1 unit of packed Red Blood Cells (PRBCs) was carried out for 14 patients undergoing THA (2.7%), and 4 patients undergoing TKA (1.3%). The difference in hemoglobin values preoperative and postoperative was -2.47 g/dL for THAs and -1.83 g/dL for TKAs. Two THA patients (0.3%) were re-admitted on day 17 with acute infection and were treated with DAIR and exchange of the modular parts of the arthroplasty. One patient (0.2%) was re-admitted on day 25 due to anterior dislocation and 2 more patients had posterior dislocations. All cases were treated with closed reduction and were discharged at home on the same or next day. Another patient had recurrent dislocations and is scheduled for revision. Two TKA patients (0.6%) were re-admitted on day 15 and 18 with acute PJI and were treated successfully with DAIR. One patient (0.4%) was admitted on day 21 with periprosthetic fracture of the femur, related to a fall, treated with ORIF. One patient (0.4%) was admitted 2 months post-op with periprosthetic joint infection, treated with 2-stage revision (using a spacer). One elderly patient died at home on the 3rd postop day due to MI.

Conclusions: Rapid recovery protocols are feasible and can be applied both at academic departments within NHS as well as private clinics. “Ownership” of these protocols by a small team of surgeons, anesthetists, physiotherapists and nursing staff is the most important requirement for success.