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‘Father of fast-track surgery’ calls for more research into ways to improve recovery after THA, TKA
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Multidisciplinary teams and focused research into practices that lead to a shorter length of hospital stay are among the strategies that can result in improved safety for patients who undergo total hip arthroplasty and total knee arthroplasty, according to a presenter at the 15th EFORT Congress — a combined programme in partnership with the BOA.
In an instructional lecture, Henrik Kehlet, MD, PhD, said that the orthopaedic surgeon plays a key role in ensuring early and safe discharge from hospital for patients who have had total hip arthroplasty (THA) and total knee arthroplasty (TKA). Kehlet has authored several papers on the topic of fast-track treatment and is often referred to as the father of fast-track surgery,
The orthopaedic surgeon should focus on the pathophysiology mechanisms that affect their patients and determine from that which strategies will lead to a timely discharge, he said.
“Therefore in every operation – and I will be talking about hip and knee arthroplasty – you have to ask why is the patient in hospital in order to define the patient problems for early recovery,” Kehlet said.
During his lecture, Kehlet, who is head of surgical pathology at Rigshospitalet Copenhagen University, in Copenhagen, Denmark, discussed the evidence that supports the need to manage various problems associated with an extended hospital stay after THA and TKA. These problems include pain, dizziness, weakness, lack of an organized discharge strategy, reduced ambulation, anaemia, cognitive dysfunction and loss of muscle function.
According to Kehlet, a study of his published in Lancet in 2013 showed median hospital stays in Europe for THA and TKA range from 4 days to 11 days. Although he focused on safety issues and surgical management during his presentation rather than the economic aspects of adopting fast-track surgical protocols, Kehlet said, “You save a lot of money if you do the fast-track approach.”
Kehlet also discussed pain management after THA and TKA. “We have to strive for dynamic, balanced anaesthesia if we want to improve outcome and recovery. That is a prerequisite and that is the first factor you have to look at.”
He said physicians interested in fast-track techniques for the increased safety of their patients who undergo THA and TKA should be aware there is sufficient evidence a multidisciplinary team approach to blood and anaemia management, as well as transfusions, supports fast-track protocols. Haemostasis should be optimized and blood loss and bleeding minimized, he said.
In terms of whether prehabilitation — intense exercise prior to surgery — supports fast-track hospital discharge, Kehlet said, “In my opinion the data are inconclusive and it is a waste of money.”
Rehabilitation and early strength training after discharge following THA and TKA probably does not work. “The randomized trials are negative,” he said, noting that is probably because a few hours of exercise daily are unable to counteract the changes associated with a general lack of activity postoperatively.
Reference:
Kehlet H. Patients safety in fast-track treatment in THR & TKR. Presented at: 15th EFORT Congress — A combined programme in partnership with the BOA; 4-6 June, 2014; London.
Source info:
Henrik Kehlet, MD, PhD, can be reached at Rigshospitalet Copenhagen University, Section for Surgical Pathophysiology and the Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement, Blegdamsvej 9, 2100 Copenhagen, Denmark; email: henrik.kehlet@rh.regionh.dk.
Disclosure:
Kehlet is a member of the Biomet Rapid Recovery advisory board and has received benefits for personal or professional use.