Data show fast-track arthroplasty ‘package of care management’ reduces length of stay, early complications

The concept of “fast-track” or “rapid recovery” surgery has evolved during the past 2 decades and has recently been applied and developed in total hip and knee arthroplasty settings with evidence-based support of its benefits; however, the widespread implementation of this approach in major joint arthroplasty settings has not occurred.

“Fast-track surgery is a package of care management that aims to reduce morbidity to deliver a pain and risk free procedure that significantly reduces the number of days a patient is in the hospital,” said Henrik Kehlet, MD, PhD, of Rigshospitalet Copenhagen University, Denmark, who has been called the pioneer of fast-track surgery.

Peter Pilot, PhD, of Reinier de Graaf Hospital in the Netherlands, defined the rapid recovery multi-modal approach as, “the use of a critical care pathway, combining perioperative pain management with a shift from general to local anaesthesia and opioid sparing, besides careful fluid management and a restrictive transfusion policy. [This] is the best option for most patients.”

Speakers at a rapid recovery symposium held in Barcelona late last year addressed key practical issues, such as early mobilization, surgical traditions, pharmacologic interventions and program implementation.

Henrik Husted, MD, of Hvidovre University Hospital in Denmark, presented data from his center. Since 2003, all total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients there have been fast-tracked. Patients are mobilized within 2 hours after surgery and deep venous thrombosis (DVT) prophylaxis is initiated 6 hours after surgery and discontinued upon discharge.

Data from a series of 1,977 operations performed from 2004 to 2008 showed three deaths possibly related to clotting episodes. Results from the last 2 years showed that the risk of pulmonary embolism was 0.30% after TKA and 0% after THA.

“We found a low risk of clinically symptomatic VTE [venous thromboembolism] and deaths potentially related to the operation. Early mobilization may play an important role in the reduction of VTE and our study appears to confirm this,” Husted said. He added that recommendations to provide extended thromboprophylaxis following discharge should be considered in context of the time of first mobilization.

Traditional techniques

A discussion following a presentation by Husted addressed several traditional THA and TKA techniques and their influence on outcome in relation to infection, the need for blood transfusion, length of stay, pain and DVT.

The faculty concluded the following traditions were unsupported by evidence of beneficial outcome: hair removal, plastic drapes, pre-emptive analgesia, tourniquets (except for better visibility during surgery), drains, continuous passive motion, urinary catheters, bed rest and compression stockings.

Pilot added, “There is insufficient evidence from randomized trials to support the routine use of closed suction drainage in orthopaedic surgery,” noting that drains do not reduce joint effusion or have any effect on wound healing — although they do reduce hematoma formation.

Readmission rates, complications

To address concerns as to whether fast-track surgery and reduced length of stay leads to an increase in readmissions, Husted presented data from his unit based on a series of fast-track THA and TKA with varying lengths of stay. As average length of stay has decreased from 6 to 3 days over the past 6 years, he reported no increase in readmissions and complications.

“Specifically, dislocation following THA does not increase — on the contrary — and neither does manipulation after TKA,” he reported.

Trauma and Orthopaedics Consultant, Mike Reed, MBBS, MD, FRCS, FRCS(Tr & Orth), from Wansbeck General Hospital in Northumberland, U.K., also presented data that showed fast-track joint replacement surgery reduces early complications. Based on an evaluation of 5,000 consecutive unselected total hip and knee patients, Reed explained that the 2,060 patients who underwent a rapid recovery protocol experienced an average reduced length of stay of 4.7 days compared to an average 8.5 days for patients who underwent a traditional protocol.

Moreover, he reported a significant reduction in death rate amongst the fast-track group (0.5% vs. 0.14%) and blood transfusion requirement was reduced from 22.8% to 9.8%. Gastrointestinal bleeding was also significantly reduced from 0.6% to 0.2%. There was a trend towards a decreased rate of 30-day myocardial infarction, stroke and 60-day DVT.

Interdepartmental relationships

David Houlihan-Burne, BSc(Hons), MBBS(Hons), MRCS, FRCS(Orth), of Hillingdon Hospital in London, presented his take on the role of the quality road map to help implement rapid recovery programs.

“Breaking down traditional barriers for implementation, including the ability to work closely with management and interdepartmental relationships between anaesthetists and surgeons is paramount to the successful launch and perseverance of these programs,” Houlihan-Burne said, and advised those wishing to implement a rapid recovery program to approach it with small, stepwise changes in mind.

“If you need to change something big, you need to change small things first and systematically. Set out with a clear aim, implement change strategies and then keep measuring what you are doing to be clear on the improvements any changes are bringing,” he added.

Reference:

• Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008; 248:189-198.
• Rapid Recovery Symposium 2010. November 4-5, 2010. Barcelona.

• David Houlihan-Burne, BSc(Hons), MBBS(Hons), MRCS, FRCS(Orth), can be reached at Hillingdon Hospital, London, U.K.; +44 1895 279190; e-mail: dhbsurgery@googlemail.com.
• Henrik Husted, MD, can be reached at Hvidovre University Hospital, 2650 Hvidovre, Denmark; +45-3632-6297; e-mail: henrik.husted@hvh.regionh.dk.
• Henrik Kehlet, MD, PhD, can be reached at Rigshospitalet Copenhagen University, Denmark.
• Peter Pilot, PhD, can be reached in the Department of Orthopaedics at Reinier de Graaf Hospital, Delft, the Netherlands; +31-15-2603257; e-mail: p.pilot@rdgg.nl.
• Mike Reed, MBBS, MD, FRCS, FRCS(Tr & Orth), can be reached at Wansbeck General Hospital, Northumberland, U.K.; +44 1670 529191; e-mail: mike.reed@nhs.net.
• Disclosures: All symposium speakers have received funding for their presentations. Houlihan-Burne, Husted, Kehlet and Pilot are members of the Biomet Rapid Recovery advisory board and have received benefits for personal or professional use. The Rapid Recovery Symposium 2010 was funded by Biomet.