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Optimized recovery is a key component of joint reconstruction fast-track protocol
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Modern total joint reconstruction has been increasingly focused on improved recovery and outcomes for patients. Information presented at a 2-day master class on fast-track or “rapid-recovery” surgery held late last year showed research and developments in the aspects of total hip replacement and total knee replacement that emphasize recovery and patient-reported outcomes now even support the discharge of some patients on the day of their total knee or total hip replacement surgery.
Same-day discharge is not the only changed practice related to these surgeries. According to presenters at the meeting, anesthesiologists need to be involved in fast-track total joint reconstruction (TJR) at their hospitals as it relates to recovery and pain management.
Blood management is another direction in fast-track TJR management that is being emphasized. It was discussed at the meeting in terms of how it can help improve patient outcomes.
Address all aspects of recovery
Experts from Europe who discussed these and other topics related to fast-track TJR noted the continued progress and adoption of these principles requires that orthopaedic surgeons be committed to these principles and trained in their implementation. Surgeons also must be willing to change how they think about a variety of TJR-related practices and collaborate with other experts at their hospitals to optimize patient recovery, according to Zimmer Biomet experts who organized the meeting, which delegates from 11 European countries and Australia attended.
“We have to look into all of the details of recovery — there is no simple solution. At this meeting, we cover them: blood management; pain management; [and] physiotherapy, especially to understand the physiology,” fast-track innovator Henrik Kehlet, MD, professor of perioperative therapy at Copenhagen University in Copenhagen, Denmark, said at the meeting.
He mentioned the phenomenon of substantial muscle loss that occurs within 48 hours of total knee replacement (TKR) or total hip replacement (THR) surgery and said it remains a major obstacle to postoperative recovery.
“When we know how to interfere with the loss of muscle function and solve the pain problem better, the whole physical recovery will be solved. Orthopaedic surgeons need to collaborate with those who know about physiology — many anesthesiologists have a strong role in this research,” Kehlet said.
Evidence needed for anesthesia
Kehlet provided delegates with an overview of the TKR and THR pain management literature and said there is little evidence to support the use of a standard pain management approach for patients who are non-responders. He noted gabapentin should not be used in TKR cases and said, based on the evidence, femoral nerve blocks should not constitute standard practice due to inhibition of quadriceps function.
“Adductor canal block may be beneficial in specific patients,” Kehlet said.
Chiara Caparrini, MD, who was one of the anesthesiologists who presented at the meeting, discussed the challenges of pain management in patients who undergo fast-track TJR.
“There are a huge number of possibilities to control pain, and it is hard to say which rescue is best. For me, local or regional anesthesia can be great as a rescue. It is difficult for anesthetists to choose the best treatment for fast-track surgery as we need to reduce side effects,” Caparrini, of IFCA Villa Ulivella e Glicini, in Florence, Italy, said.
Caparrini said a study she and orthopaedic surgeon Andrea Baldini, MD, PhD, who is also at IFCA Villa Ulivella e Glicini and is a Zimmer Biomet Rapid Recovery Advisory Board member, are conducting will add to the body of scientific evidence in this area. They are investigating adductor canal block used during local infiltration analgesia (LIA) vs. ultrasound-guided anesthesia after surgery, Caparrini noted.
Blood management practices
The inclusion of anesthesiologists on the program is always an important part of the meeting. A change from previous meetings on fast-track protocols was the discussion of blood management by Emmanuel Thienpont, MD, MBA, PhD, of Brussels, who is a member of the Orthopaedics Today Europe Editorial Board and is a member of the Rapid Recovery Advisory Board, and anesthesiologist Nadia Rosencher, MD, of Paris.
Thienpont and Rosencher said anemia should be treated, especially with better screening, prior to surgery, and it should be standard practice to administer tranexamic acid to prevent major bleeding.
Practices to reduce morbidity
“The surgical part of blood management asks for good anatomical knowledge to be able to identify areas for potential bleeders,” Thienpont told Orthopaedics Today Europe.
Another effective practice is plugging the femoral hole created when an intramedullary guide is used in TKR, which will significantly reduce the amount of intra-articular blood loss, he said.
“Injections with LIA contribute to a blood loss reduction due to local constrictive effects,” Thienpont said.
Anesthesiologist Rienk van Beek, MD, of Westfriesgasthuis in Hoorn, The Netherlands, debated Mike R. Reed, MBBS, MD, FRCS, FRCS(Tr & Orth), clinical lead for quality at Northumbria Healthcare NHS Foundation Trust, United Kingdom, on bridging warfarin with low-molecular-weight heparin (LMWH) vs. not using bridging medication in TJR patients with various risks of cardiovascular events. van Beek spoke in favor of bridging warfarin with LMWH to avoid or minimize medication-related morbidity in specific groups of patients.
Reed, who also presented on thromboembolic prophylaxis, said, “The BRIDGE trial shows that if we have a patient at low cardiovascular risk, we can avoid bridging. Ninety-five percent of patients do not need bridging, 5% might.”
Day and bilateral simultaneous cases discussed
Kehlet and two other presenters discussed day TJR surgery, a newer topic within the framework of fast-track procedures.
“This is a natural evolution of Rapid Recovery programs. There is only one question remaining, and that is the proof of safety. That will take a couple of thousand cases to answer,” Kehlet said.
Henrik Husted, MD, DMSc, of Hvidovre University Hospital in Hvidovre, Denmark, said, “Bilateral simultaneous TKR is a great opportunity for patients if they are up to it, but we should have definite exclusion criteria, including cardiopulmonary disease.”
Husted said his other exclusion criteria for simultaneous bilateral TKR include anxiety or depression, but patient age and BMI are not exclusion criteria. He mentioned these patients need extra information preoperatively and to be told just how difficult the first 24 hours after surgery will be for them. – by Susan M. Rapp
References:
Ilfed BM, et al. J Arthroplasty. 2015;doi:10.1016/j.arth.2014.11.031.
Masterclass Rapid Recovery. The 4th Expert User Meeting; Nov. 17-18, 2016; Milan.
For more information:
Chiara Caparrini, MD, can be reached at IFCA Villa Ulivella e Glacini, Via del Pergolino, 6, 50139 Florence, Italy; email: chiara.caparrini@gmail.com.
Henrik Husted, MD, DMSc, can be reached at Hvidovre University Hospital, 2650 Hvidovre, Denmark; email: henrik.husted@hvh.regionh.dk.
Henrik Kehlet, MD, PhD, can be reached at Rigshospitalet Copenhagen University, Denmark; email: Henrik.kehlet@regionh.dk.
Mike R. Reed, MBBS, MD, FRCS, FRCS(Tr & Orth), can be reached at Northumbria Healthcare NHS Foundation Trust; email: mike.reed@nhs.net.
Emmanuel Thienpont, MD, MBA, PhD, can be reached at University Hospital Saint Luc, Avenue Hippocrate, 10 B-1200, Brussels, Belgium; email: emmanuel.thienpont@uclouvain.be.
Disclosures: Caparrini reports no relevant financial disclosures. Husted reports he is a consultant for Zimmer Biomet (health care initiatives, Rapid Recovery). Kehlet reports he receives honoraria as a member of the Zimmer Biomet Rapid Recovery advisory board. Reed reports he is on the speaker’s bureau for Zimmer Biomet. Thienpont reports he is an advisor on the Rapid Recovery board of Zimmer Biomet.
Perspective
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Luigi Zagra, MD
So-called fast-track total joint replacement (TJR) surgery is probably better described by a term like, rapid-recovery. It does not matter if the discharge is the same day or the day after or 2 days after surgery. Its focus should be on what can optimize the entire process of TJR surgery and recovery to reduce the period of hospitalization, avoid useless added procedures and costs, and, at the same time, improve the satisfaction of the patients and minimize the risks of complications. All the stakeholders involved in the process play an important role: the surgeon, both with the surgical technique and the education of the patients; and the anesthetist, both in the OR and in the patients immediate postoperative medical care, pain control and blood management. Even more important is the nursing done by the department nurses and the treatment by physiotherapists.
But, the key to the entire process is the cooperation of the patient. There are several factors that influence the compliance of the patient. The health conditions, comorbidities and the age are, of course, of great importance. But what is more important is the patients mental status and the understanding of the patient of what is expected, and collaboration with the patients family.
The main obstacles we find are the changes in the TJR culture. The previous, common practice after TJR was a long recovery with rehabilitation. Therefore, surgeons must reorganize their routines and should be able to follow the patients after discharge in a safe way. From this point of view, the culture and local organization are different in each European country, as well as within the same country. In the future, we will know more about when the right time is to convert to a simple, rational TJR fast-track recovery system that can improve early discharge of our patients without increasing complications and readmissions to the hospital.
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