Objectives To identify predictors of length of stay (LOS) after total hip arthroplasty (THA) in an enhanced recovery after surgery (ERAS) program and evaluate the safety and cost‐efficiency of the ERAS program with reduced LOS for unselected patients in a Chinese population. Methods A total of 311 consecutive, unselected patients undergoing primary THA at a single institution were retrospectively reviewed and divided into two groups: LOS ≤ 3 and LOS > 3 group. All patients were managed with the same ERAS protocol and went back home after discharge. Multivariate logistic regression analysis was used to determine independent risk factors for LOS > 3. Harris Hip Score at 90‐day follow‐up, 90‐day readmission rate, and hospitalization costs were compared between two groups. Results Multivariate regression analysis identified female gender (odds ratio [OR] = 2.623), living alone (OR = 4.127), and primary osteoarthritis of hip (OR = 3.565) to be correlated with LOS > 3. Preoperative hemoglobin (HB), postoperative HB, drain use, blood transfusion, diabetes, respiratory disease, osteoporosis, number of comorbidities, and CCI score showed no significant influence on LOS after adjusting for other risk factors in the multivariate model. Harris Hip Score and readmission rate at 90‐day follow‐up showed no significant differences between two groups. Patients in LOS > 3 group had approximately 3948.6 Chinese yuan higher hospital costs. Conclusion Female gender, living alone, and primary osteoarthritis of hip were identified as independent risk factors for prolonged LOS. The experience from our institution suggested aggressive management of comorbidities in the ERAS program can minimize the influence of comorbidities on LOS. The safety, efficiency, and costs‐saving benefits of the ERAS program with reduced LOS for unselected patients was confirmed in this study.

Background To investigate the analgesic effect of perioperative use of duloxetine in patients received total knee arthroplasty (TKA). Method This prospective randomized, double-blind, placebo-controlled trial study was registered in the Chinese Clinical Trial Registry (ChiCTR2000033910). 100 patients were finally enrolled. The hospital pharmacy prepared small capsules containing either duloxetine or starch (placebo) which were all identical in appearance and weight (50:50). The 100 enrolled patients were given a capsule (containing either 60 mg duloxetine or 60 mg placebo) every night before sleep since preoperative day 2 till postoperative day 14 (17 days in all) by a nurse who were not involved in this trial. Other perioperative managements were the same in the two groups. The primary outcome was the VAS score, including rVAS (visual analogue scale at rest) and aVAS (visual analogue scale upon ambulation) throughout the perioperative period. The secondary outcomes included opioid consumption, range of motion, including both active range of motion (aROM) and passive range of motion (pROM) and adverse events. The patients were followed up everyday until 7 days after TKA, afterwards, they were followed up at the time of 3 weeks and 3 months after TKA. Result rVAS in duloxetine group were significantly less than placebo group throughout the postoperative period: 4.7 ± 2.3 vs 5.9 ± 2.6 (P = 0.016) at 24 h postoperative; 2.1 ± 1.6 vs 2.8 ± 1.7 (P = 0.037) at 7 days postoperative. In terms of aVAS, similarly, duloxetine group had less aVAS than placebo group throughout the postoperative period: 6.2 ± 2.1 vs 7.1 ± 2.2 (P = 0.039) at 24 h postoperative; 3.3 ± 1.7 vs 4.1 ± 2.0 (P = 0.034) at 7 days postoperative. Patients in duloxetine group consumed significantly less opioids per day than the placebo group: 24.2 ± 10.1 g vs 28.5 ± 8.3 g (P = 0.022) at 24 h postoperative; 2.7 ± 2.5 g vs 4.1 ± 2.6 g (P = 0.007) at 7 days postoperative. aROM in duloxetine group were significantly better than placebo group until postoperative day 6, the aROM became comparable between the two groups: 110.2 ± 9.9° in duloxetine group vs 107.5 ± 11.5° in control group (P = 0.211). In terms of pROM, duloxetine group had significantly better pROM until postoperative day 5, the pROM became comparable between the two groups: 103.8 ± 12.1° in duloxetine group vs 99.5 ± 10.8° in control group (P = 0.064). No significant difference was found between the two groups in the rates of dizziness, bleeding, sweating, fatigue and dryness of mouth. In the placebo group, more patients got nausea/vomiting and constipation (P < 0.05). However, in terms of drowsiness, duloxetine group was reported higher rate (P < 0.05). Conclusion Several other RCTs have already mentioned the analgesic effect of duloxetine, but not in the immediate postoperative period. In this study, we found duloxetine could reduce acute postoperative pain in the immediate postoperative period and decrease the opioids consumption as well as accelerating postoperative recovery, without increasing the risk of adverse medication effects in patients undergoing TKA. Duloxetine could act as a good supplement in multimodal pain management protocol for patients undergoing TKA. Trial registration statement This study was registered in the Chinese Clinical Trial Registry (ChiCTR2000033910). The date of registration was 06/16/2020.

Background The risk factors of postoperative delirium (POD), a serious while preventable complication, developed by patients undergoing knee and replacement surgery are still under investigation. In this systematic review and meta-analysis, we identified risk factors associated with POD in knee and hip replacement. Methods PubMed, Ovid MEDLINE, and Ovid EMBASE were used to identify original researches. The studies evaluating the risk factors of POD after knee and hip replacement were reviewed, and the qualities of the included studies were assessed with Newcastle–Ottawa Scale. Data were extracted, pooled, and a meta-analysis was completed Result Twenty-two studies were finally included with a total of 11934 patients who underwent knee or hip replacement and 1841 developed POD with an incidence of 17.6% (95% confidential interval (CI) 13.2–22.0%). Eighteen significant risk factors were identified including advanced age (odds ratio (OR) 1.15 95% CI 1.08–1.22), cognitive impairment (OR 6.84, 95% CI 3.27–14.33), history of cerebrovascular events (OR 2.51, 95% CI 1.28–4.91), knee replacement (OR 1.42, 95% CI 1.00–2.02), blood loss (standardized mean difference (SMD) 0.30, 95% CI 0.15–0.44), dementia (OR 3.09, 95% CI 2.10–4.56), neurologic disorders (OR 2.26, 95% CI 1.23–4.15), psychiatric illness (OR 2.74, 95% CI 1.34–5.62), and obstructive sleep apnea (OR 4.17, 95% CI 1.72–10.09) along with several comorbidity evaluation scores and laboratory markers. Conclusion We identified risk factors consistently associated with the incidence of POD in knee and hip replacement. Strategies and interventions should be implemented to the patients receiving knee or hip replacement with potential risk factors identified in this meta-analysis.

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Background Previous studies have demonstrated the efficacy of duloxetine in reducing postoperative pain and opioid consumption. However, the effect of duloxetine on total hip arthroplasty (THA) remains unclear. The objective of this study was to assess the efficacy of oral duloxetine in THA. Methods We enrolled 96 patients in this randomized controlled trial. These patients were randomized (1,1) to either the duloxetine group or the placebo group and received daily doses of 60 mg duloxetine or placebo, respectively, from 2 d pre-operation to 14 d after surgery. The primary outcome was pain severity upon movement measured by a visual analogue scale (VAS). The secondary outcomes included VAS scores for resting pain, morphine consumption, Harris Hip Score, patient satisfaction at discharge, length of postoperative hospital stay, and adverse events. Results Patients in the duloxetine group had significantly lower pain severity scores upon movement within 3 postoperative weeks (p < 0.05) while none of the differences met the minimum clinically important difference (MCID). Moreover, patients in the duloxetine group performed better in terms of resting pain (in 3 weeks after surgery), morphine requirements, and satisfaction level at discharge (all p < 0.05). There was no difference between groups in the prevalence of adverse events. Conclusions Although it did not result in a clinically meaning reduction in pain after total hip arthroplasty, perioperative administration of 60 mg of duloxetine daily significantly alleviated pain in the postoperative 3 weeks and morphine requirements during the postoperative 48 h. Therefore, duloxetine still shows promise in optimizing the multimodal pain-management protocols in total hip arthroplasty. Trial registration Chinese Clinical Trial Registry, ChiCTR2000033606, 06/06/2020.