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Nurse Director
Jun 8, 2007
The North
United Kingdom United Kingdom
Enhanced recovery program for hip and knee replacement reduces death rate
Acta Orthop. 2011 Oct; 82(5): 577–581. Published online 2011 Nov 24.

The “enhanced recovery” protocol was introduced in May, 2008.
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.

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.

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.

Anesthesis involved the use of low-dose spinal anesthesia combined with sedation, or light general anesthesia with the patient breathing spontaneously. Local anesthetic infiltration technique (Kerr and Kohan 2008) is simple, safe, cheap, and requires no special technical skill (Rostlund and Kehlet 2007). It was used in all patients after May, 2008.

Intraoperative infiltration of 80 mL 0.125% levobupivicaine using a standardized technique ensures wide-field infiltration to include joint capsule, muscles, fat, and skin. During closure, an epidural catheter is placed within the joint to exit away from the surgical field, through which a further 20 mL of levobupivicaine is infiltrated after closure. A microbiological filter is attached and this catheter is used to infuse 3 postoperative boluses of levobupivicaine 4–6 h postoperatively, again after a further 6-to 8-h interval, and lastly on the morning of day 1, before removal of the catheter.

The postoperative boluses consisted of 20 mL levobupivacaine (1.25 mg/mL) for total hip replacement and 40 mL levobupivacaine (1.25 mg/mL) for total knee replacement. The larger volume used for knee replacement was based upon the larger intraarticular space in the knee compared to the hip.

To avoid loss of local anesthetic (Nechleba et al. 2005), drains were not used in any of the patients. Knee replacements received a single wool and crepe bandage and a Cryo-Cuff (Aircast; DJO UK Ltd., Guildford, Surrey, UK) was applied to the recovery area. This has been shown to enhance and prolong analgesia (Andersen et al. 2008b).

Early postoperative mobilization started within the first 3–5 h, aiming at discharge to home once the patient was independently mobile with the help of appropriate walking aids and the standard unchanged hospital discharge criteria had been met. Patients were educated to expect some discomfort, and were required to be active participants in their recovery. Positive encouragement from all team members was considered important. Patient education is considered a key component of the enhanced recovery protocol and a common message was transmitted by each member of the team at various stages of preoperative assessment. Currently, an information DVD is provided to every patient at the time of booking for surgery.

Postoperative analgesia included gabapentin (300 mg BD for 5 days) and oxycontin (5–20 mg twice daily for 2 days) followed by Tramadol (50–100 mg every 4–6 h). Post-discharge pain treatment was similar for both groups, with paracetamol, NSAIDs, and weak opioids only. Patients were reassured that despite earlier discharge they had not been abandoned, and they were all supplied with ward contact details and recommendations if they had any concerns.

Venous thromboembolism prophylaxis changed during the study period—from mechanical and aspirin to extended tinzaparin, in keeping with the evolving NICE guidance.

We present the results of the first 1,500 primary hip and knee replacement patients who went through the enhanced recovery protocol from May, 2008 to November, 2009. We compared the results with those from an unselected, consecutive series of 3,000 of our own total hip and knee replacement patients treated with traditional techniques (January, 2004 to April, 2008) immediately before the introduction of the enhanced recovery protocol.

There was a highly significant reduction in 30- and 90-day mortality. The overall length of stay (LOS) decreased from a mean of 8.5 to 4.8 days and from a median of 6 to 3 days (p < 0.001). Some of the comorbidities were commoner in the enhanced recovery group.

There was a statistically non-significant reduction in myocardial and cerebrovascular complications. Thromboembolic renal impairment requiring high-dependency care, re-admission, and return-to-theater complications remained unchanged.

To our knowledge, this is the largest reported observational study to have direct comparison before and after implementation of the protocol. In an unselected consecutive group of 4,500 hip and knee arthroplasty patients, we have demonstrated a highly significant reduction in death rate, reduced length of stay, and reduced transfusion requirements after the introduction of a multimodal enhanced recovery protocol.


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