Billy B. Kristensen

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

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 studies have identified patient characteristics predicting LOS, but little is known about specific reasons for being hospitalized following fast-track THA and TKA. Patients and methods To determine clinical and logistical factors that keep patients in hospital for the first postoperative 24–72 hours, we performed a cohort study of consecutive, unselected patients undergoing unilateral primary THA (n = 98) or TKA (n = 109). Median length of stay was 2 days. Patients were operated with spinal anesthesia and received multimodal analgesia with paracetamol, a COX-2 inhibitor, and gabapentin—with opioid only on request. Fulfillment of functional discharge criteria was assessed twice daily and specified reasons for not allowing discharge were registered. Results Pain, dizziness, and general weakness were the main clinical reasons for being hospitalized at 24 and 48 hours postoperatively while nausea, vomiting, confusion, and sedation delayed discharge to a minimal extent. Waiting for blood transfusion (when needed), for start of physiotherapy, and for postoperative radiographic examination delayed discharge in one fifth of the patients. Interpretation Future efforts to enhance recovery and reduce length of stay after THA and TKA should focus on analgesia, prevention of orthostatism, and rapid recovery of muscle function.

Fascia iliaca compartment blockade for acute pain control in hip fracture patients: a randomized, placebo-controlled trial.

Background:Hip fracture patients are in severe pain upon arrival at the emergency department. Pain treatment is traditionally based on systemic opioids. No study has examined the effect of fascia iliaca compartment blockade (FICB) in acute hip fracture pain management within a double-blind, randomized setup. Methods:Forty-eight patients with suspected hip fracture were included immediately after arrival in the emergency department, before x-ray confirmation of their fracture. Included patients were randomly assigned to two groups of 24. In the FICB group, the patients received an FICB with 1.0% mepivacaine and a placebo intramuscular injection of isotonic saline. In the morphine group, the patients received a placebo FICB with 0.9% saline and an intramuscular injection of 0.1 mg/kg morphine. Patients received intravenous rescue morphine when necessary. Results:Maximum pain relief was superior in the FICB group both at rest (P < 0.01) and on movement (P = 0.02). The median total morphine consumption was 0 mg (interquartile range, 0–0 mg) in the FICB group and 6 mg (interquartile range, 5–7 mg) in the morphine group (P < 0.01). More patients (P = 0.05) were sedated in the morphine group at 180 min after block placement as compared with the FICB group. Conclusion:Pain relief was superior at all times and at all measurements in the FICB group. The study supports the use of FICB in acute management of hip fracture pain because it is an effective, easily learned procedure that also may reduce opioid side effects in this fragile, elderly group of patients.

Pathogenesis of and management strategies for postoperative delirium after hip fracture: A review

Background Postoperative delirium is a frequent and serious complication in elderly patients following operation for hip fracture, leading to an increased risk of complications. The pathophysiological mechanisms are unresolved, but probably multifactorial. The purpose of this review is to summarize current knowledge about the pathogenesis of postoperative delirium with a view to finding strategies for prevention and management. Method We conducted an Internet search through the Medline database (1966–March 2003) and supplemented it with a manual search. We included 12 studies which specifically discussed pathogenic factors or interventions against postoperative delirium following operation for hip fracture. Results 1 823 patients were included with an average incidence of delirium of 35%. We concentrated on pre-, intra-, and postoperative risk factors. Only advanced age and dementia met our fixed criterion of “strong evidence” for a significant association. Hence, from the studies that we reviewed we were unable to find intraoperative or postoperative factors with “strong evidence“ for a significant association with delirium. Interpretation Postoperative delirium is a serious complication. The pathophysiology leading to delirium after hip fracture surgery still remains to be clarified and no single drug or surgical regimen has proven to be preventive. This calls for more detailed investigations of the differential role of different pathogenic mechanisms, as well as an aggressive multimodal approach to enhance recovery and reduce morbidity, as has proven to be successful in a variety of elective surgical procedures. Such multimodal interventional studies represent a major task for orthopedic departments in collaboration with anesthesiologists, geriatricians, physiotherapists and nursing staff.

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

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 C-reactive 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 (P=0.02) 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 (P=0.02), but sleep quality was worse on the first night (P=0.002). 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.

Effect of postoperative epidural analgesia on rehabilitation and pain after hip fracture surgery: a randomized, double-blind, placebo-controlled trial.

Background:Hip fracture surgery usually carries a high demand for rehabilitation and a significant risk of perioperative morbidity and mortality. Postoperative epidural analgesia may reduce morbidity and has been shown to facilitate rehabilitation in elective orthopedic procedures. No studies exist on the effect of postoperative epidural analgesia on pain and rehabilitation after hip fracture surgery. Methods:Sixty elderly patients were included in a randomized, double-blind study comparing 4 days of continuous postoperative epidural infusion of 4 ml/h bupivacaine, 0.125%, and 50 &mgr;g/ml morphine versus placebo. Both patient groups received balanced analgesia and intravenous nurse-controlled analgesia with morphine. All patients followed a well-defined multimodal rehabilitation program. Pain, ability to participate in four basic physical functions, and any factors restricting participation were assessed on the first 4 postoperative days during physiotherapy. Results:Epidural analgesia provided superior dynamic analgesia during all basic physical functions, and patients were significantly less restricted by pain, which was the dominating restricting factor in the placebo group. Motor blockade was not a restricting factor during epidural analgesia. Despite improved pain relief, scores for recovery of physical independence were not different between groups. Conclusion:Postoperative epidural analgesia after hip fracture surgery provides superior analgesia attenuating pain as a restricting factor during rehabilitation without motor dysfunction. However, superior analgesia did not translate into enhanced rehabilitation. Future studies with multimodal rehabilitation are required to establish whether superior analgesia can be translated into enhanced rehabilitation and reduced morbidity in hip fracture patients.

Subacute pain and function after fast-track hip and knee arthroplasty

In a well‐defined fast‐track setup for total hip and knee arthroplasty, with a multimodal analgesic regimen consisting of intra‐operative local anaesthetic infiltration and oral celecoxib, gabapentin and paracetamol for 6 days postoperatively, we conducted a prospective, consecutive, observational study. The purpose was to describe the prevalence and intensity of subacute postoperative pain and opioid related side effects, use of analgesics and functional ability 1–10 and 30 days postoperatively. Fast‐track total hip and knee arthroplasty with early discharge (< 3 days) resulted in acceptable levels of pain and postoperative nausea and vomiting with concomitant low use of opioids in > 95% of patients after discharge before day 10 after total hip arthroplasty. However, after total knee arthroplasty 52% patients reported moderate pain (VAS 30–59 mm), and 16% severe pain (VAS ≥ 60 mm) when walking 1 month after surgery with a concomitant increase in the use of strong opioids. These results emphasise the need for improvement in analgesia after discharge following total knee arthroplasty, to facilitate rehabilitation.

Low risk of thromboembolic complications after fast-track hip and knee arthroplasty

Background and purpose Pharmacological prophylaxis can reduce the risk of deep venous thrombosis (DVT), pulmonary embolism (PE), and death, and it is recommended 10–35 days after total hip arthroplasty (THA) and at least 10 days after total knee arthroplasty (TKA). However, early mobilization might also reduce the risk of DVT and thereby the need for prolonged prophylaxis, but this has not been considered in the previous literature. Here we report our results with short-duration pharmacological prophylaxis combined with early mobilization and reduced hospitalization. Patients and methods 1,977 consecutive, unselected patients were operated with primary THA, TKA, or bilateral simultaneous TKA (BSTKA) in a well-described standardized fast-track set-up from 2004–2008. Patients received DVT prophylaxis with low-molecular-weight heparin starting 6–8 h after surgery until discharge. All re-admissions and deaths within 30 and 90 days were analyzed using the national health register, concentrating especially on clinical DVT (confirmed by ultrasound and elevated D-dimer), PE, or sudden death. Numbers were correlated to days of prophylaxis (LOS). Results The mean LOS decreased from 7.3 days in 2004 to 3.1 days in 2008. 3 deaths (0.15%) were associated with clotting episodes and overall, 11 clinical DVTs (0.56%) and 6 PEs (0.30%) were found. The vast majority of events took place within 30 days; only 1 death and 2 DVTs occurred between 30 and 90 days. During the last 2 years (854 patients), when patients were mobilized within 4 h postoperatively and the duration of DVT prophylaxis was shortest (1–4 days), the mortality was 0% (95% CI: 0–0.5). Incident cases of DVT in TKA was 0.60% (CI: 0.2–2.2), in THA it was 0.51% (CI: 0.1–1.8), and in BSTKA it was 0% (CI: 0–2.9). Incident cases of PE in TKA was 0.30% (CI: 0.1–1.7), in THA it was 0% (CI: 0–1.0), and in BSTKA it was 0% (CI: 0–2.9). Interpretation The risk of clinical DVT, and of fatal and non-fatal PE after THA and TKA following a fast-track set-up with early mobilization, short hospitalization, and short duration of DVT prophylaxis compares favorably with published regimens with extended prophylaxis (up to 36 days) and hospitalization up to 11 days. This calls for a reconsideration of optimal duration of chemical thromboprophylaxis.

Liberal versus restrictive fluid management in knee arthroplasty : A randomized, double-blind study

BACKGROUND:There are few data describing the relationship between amount of perioperative fluid and organ function. In this study we investigated the effects of two levels of intravascular fluid administration (“liberal” versus “restrictive”) in knee arthroplasty on physiological recovery as the primary outcome variable. METHODS:In a double-blind study, 48 ASA I–III patients undergoing fast-track elective knee arthroplasty were randomized to restrictive or liberal perioperative intravascular fluid administration. Patients received a fixed rate infusion of Ringer’s lactate solution with a standardized volume of colloid. All other aspects of perioperative management (including anesthesia, preoperative fluid status, and postoperative management) were standardized. Primary outcome variables included pulmonary function (spirometry), exercise capacity (“timed up and go” test), coagulation (Thrombelastograph®), postoperative hypoxemia (nocturnal pulse oximetry), postoperative ileus (defecation), and subjective patient recovery (visual analog scales). Hospital stay and complications were also noted. RESULTS:Fluid guidelines were followed strictly in all patients. Liberal (median 4250 mL, range 3150–5200 mL) compared with restrictive (median 1740 mL, range 1100–2165 mL) intravascular fluid administration led to improved pulmonary function 6 h postoperatively, significant hypercoagulability 24–48 h postoperatively, and reduced incidence of vomiting. There were no overall differences in the other assessed perioperative physiological recovery variables (postoperative hypoxemia, exercise capacity or subjective patient recovery variables). No difference was found in hospital stay (median 4 days in both groups, not significant). CONCLUSION:A liberal compared to a restrictive intravascular fluid regimen may lead to significant hypercoagulability and a reduction in vomiting, but without differences in other recovery variables or hospital stay after fast-track knee arthroplasty.

A compression bandage improves local infiltration analgesia in total knee arthroplasty.

Background High-volume local infiltration analgesia has been shown to be an effective pain treatment after knee replacement, but the role of bandaging to prolong analgesia has not been evaluated. Methods 48 patients undergoing fast-track total knee replacement with high-volume (170 mL) 0.2% ropivacaine infiltration analgesia were randomized to receive a compression or a non-compression bandage, and pain was assessed at rest and with mobilization at regular intervals for 24 h postoperatively. Results Pain at rest, during flexion, or on straight leg lift was lower for the first 8 h in patients with compression bandage than in those with non-compression bandage and with a similar low use of oxycodone. Mean hospital stay was similar (2.8 days and 3.3 days, respectively). Interpretation A compression bandage is recommended to improve analgesia after high-volume local infiltration analgesia in total knee arthroplasty.

Intraoperative local infiltration analgesia for early analgesia after total hip arthroplasty: a randomized, double-blind, placebo-controlled trial.

Background and Objectives: High-volume local infiltration analgesia (LIA) is widely applied as part of a multimodal pain management strategy in total hip arthroplasty (THA). However, methodological problems hinder the exact interpretation of previous trials, and the evidence for LIA in THA remains to be clarified. Therefore, we evaluated whether intraoperative high-volume LIA, in addition to a multimodal oral analgesic regimen, would further reduce acute postoperative pain after THA. Methods: Patients scheduled for unilateral, primary THA under spinal anesthesia were included in this randomized, double-blind, placebo-controlled trial receiving high-volume (150 mL) wound infiltration with ropivacaine 0.2% with epinephrine (10 &mgr;g/mL) or saline 0.9%. A multimodal oral analgesic regimen consisting of slow-release acetaminophen 2 g, celecoxib 400 mg, and gabapentin 600 mg was instituted preoperatively. Rescue analgesic consisted of oral oxycodone. Pain was assessed repeatedly the first 8 hrs after surgery using the 100-mm visual analog scale. The primary end point was pain during walking (5 m) 8 hrs after surgery. Secondary end points were pain at rest, pain on 45 degrees of passive flexion of the hip with the leg straight, and cumulative consumption of oxycodone. Results: A total of 120 patients were included. Pain during walking (median [interquartile range] [95% confidence interval]) was low in the ropivacaine versus the placebo group (20 [14-38] [0-93] vs 22 [10-40] [0-83]) and did not differ significantly (P = 0.71). Consumption of rescue oxycodone (5 mg [0-10 mg] [0-24 mg] vs 10 mg [0-15 mg] [0-29 mg]) did not differ (P = 0.45). Conclusions: Intraoperative high-volume LIA with ropivacaine 0.2% provided no additional reduction in acute pain after THA when combined with a multimodal oral analgesic regimen consisting of acetaminophen, celecoxib, and gabapentin and is therefore not recommended.