A Multidisciplinary Enhanced Recovery Programme Allows Discharge within Two days of Total Hip Replacement; Three- to Five-Year Results of 100 Patients

Abstract

We present three- to five- year results of 100 sequential patients undergoing total hip replacement (THR) through a multidisciplinary rapid recovery programme, with mean length of stay (LOS) 1.99 nights. Patients attend pre-admission 'bone school', with talks and assessments by the senior sister, physiotherapist and occupational therapist. All receive an uncemented Corail-Pinnacle THR via piriformis-sparing mini-posterior approach. 'Low dose' spinal plus light general anaesthesia provides sensory block whilst retaining motor function; painfree mobilisation is predictably achieved within four hours. Following radiograph and haemoglobin check next morning, patients are discharged on meeting specific nursing/physiotherapy criteria. Those within 20 miles receive outreach follow-up. Follow-up assessment is undertaken using SF36, Visual Analogue, Merle d'Aubigné-Postel and Oxford Hip Scores. Mean age was 65 years (25-91), mean BMI 28.7 (19-43). ASA ranged 1-3 (mode 2), Charlson comorbidity index from 0-9 (mode 3). Major complications were: one dislocation with deep infection; one myocardial infarction; one trochanteric bursitis requiring exploration; one ceramic fracture; and three metal debris reactions. Several more minor complications occurred. LOS was longer in older patients (p = 0.03) and those with higher Charlson index (p = 0.02).Eighty-two patients remain under follow-up, (mean 37.8 months, range 36-61). Six have died; five underwent revision; seven have moved away or been lost. Ninety-seven percent remain quite or very satisfied. Our LOS is amongst the shortest in the United Kingdom, with encouraging outcomes. The SSP succeeds by involving all team-members, and managing patient expectation. At a time of limited healthcare resources we propose that our SSP could readily be reproduced elsewhere with similar benefits.

Risk Factors Associated With Health Care Utilization and Costs of Patients Undergoing Lower Extremity Joint Replacement

“…The most frequently reported measure was the American Society of Anesthesiologists physical classification system score, 42 reported in 12 of the 22 studies. 34 , 41 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 The strongest evidence supported increased LOS associated with perioperative risk factors. 21 , 34 , 41 , 43 , 44 , 45 , 46 , 48 , 51 , 53 , 54 , 55 , 56 , 57 , 58 …”

“…Lower socioeconomic status, 14 , 39 , 41 , 59 female sex, 21 , 34 , 35 , 36 , 38 , 39 , 40 , 41 , 43 , 45 , 46 , 48 , 53 , 60 , 61 , 62 , 63 and increased age 21 , 22 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 43 , 44 , 45 , 46 , 48 , 51 , 53 , 54 , 59 , 63 , 64 , 65 were also risk factors for longer LOS.…”

Enhanced recovery principles applied to revision hip and knee arthroplasty reduces length of stay and blood transfusion

“…The LoS and patient discharge destination for our series of revisions was comparable with other series of primary joints, with similar Charlson indexes. 28 We acknowledge that there are limitations to this study. It is a retrospective observational study of small heterogenous cohorts, without a control group for comparison, and as such the impact of our statistical analysis is limited.…”

Patient-reported importance of assistive devices in hip and knee replacement Enhanced Recovery after Surgery (ERAS) pathways

“…In the United Kingdom (UK), occupational therapy is a routine part of hip and knee replacement pathways (Dawson-Bowling et al., 2014; Wainwright and Middleton, 2010), Occupational therapists assess the individual needs of the patients and provide assistive devices to facilitate discharge and aid return to function at home. Due to the multi-modal nature of ERAS it can be difficult to have an understanding of the effects of occupational therapy and the provision of assistive devices within the ERAS protocol.…”