Challenges in postdischarge function and recovery: the case of fast-track hip and knee arthroplasty

Abstract

This narrative review updates the recent advances in our understanding of the multifactorial pathogenesis for reduced postdischarge physical and cognitive function after fast-track surgery, using total hip and knee arthroplasty as surgical models. Relevant factors discussed include the surgical stress responses and potential methods for controlling postsurgical inflammation, pain, and cognitive dysfunction. The continuation of moderate to severe pain in up to 30% of patients for 2-4 weeks calls for better understanding of the underlying mechanisms and development of effective multimodal opioid-sparing analgesic regimens. The need for the development of effective physiotherapy programmes on a patient-specific basis is discussed, along with the need for optimal assessment of postoperative function to guide rehabilitation. Other relevant factors discussed include the role of orthostatic intolerance, sleep disturbances, and blood management, and specific patient populations at risk for adverse outcomes, including psychiatric disorders, to identify and guide future interventions for optimizing functional postdischarge outcomes after fast-track surgery.

Clinical, nociceptive and psychological profiling to predict acute pain after total knee arthroplasty

“…The results are stronger than in previous predictive models for post‐TKA pain with R 2 < 0.10 and AUC < 0.65, but the complexity of acute post‐TKA pain remains evident, emphasizing the need to also consider the surgical trauma and individual post‐operative stress response as well as other pre‐operative predictive factors for post‐operative pain. Nevertheless, the suggested model should be considered for identification of patients in risk of high post‐operative pain due to their nociceptive and psychological profile aiming to intervene pre‐ and post‐operatively against underlying pathophysiological mechanisms . Furthermore, the results emphasizes the need of a varied and multidisciplinary approach including psychological as well as pharmacological aspects …”

Enhanced recovery after surgery (ERAS) and its applicability for major spine surgery

“…Aasvang et al's [20] conclusions are confirmed in a study comparing 1500 primary hip and knee replacement patients on an enhanced recovery pathway with 3000 patients on a traditional protocol, the median length of stay decreased from 6 to 3 days, saving 5418 bed…”

“…In their recent review article, Aasvang et al [20] summarise that ERAS can be routinely applied to all hip and knee replacement patients (with no age, pre-operative functional ability, or co-morbidity restrictions) to achieve a length of hospital stay from 1-3 days with discharge to home, and a reduced incidence of cardiac and venous thromboembolism complications, and reduced postoperative delirium and cognitive dysfunction.…”

Patient experience with early discharge after total knee arthroplasty: a focus group study

“…A recent qualitative study finds that knowledge increases the patients' sense of control and that patient education has a relational/psychosocial dimension which creates a trustful relationship with the staff and the hospital (41). Exploring patient expectations and educating patients to make realistic goals for functional activity have been suggested to improve satisfaction after TKA (42,43) whereas inconsistent and poor communication among healthcare providers can influence patient trust negatively (44,45). In our study, the unified fast-track programme with trained nurses and physiotherapists who strengthened the participants coping resources seems to have made them believe they were capable of dealing with the challenges at home.…”