Optimising perioperative care for hip and knee arthroplasty in South Africa: a Delphi consensus study

Abstract

BackgroundA structured approach to perioperative patient management based on an enhanced recovery pathway protocol facilitates early recovery and reduces morbidity in high income countries. However, in low- and middle-income countries (LMICs), the feasibility of implementing enhanced recovery pathways and its influence on patient outcomes is scarcely investigated. To inform similar practice in LMICs for total hip and knee arthroplasty, it is necessary to identify potential factors for inclusion in such a programme, appropriate for LMICs.MethodsApplying a Delphi method, 33 stakeholders (13 arthroplasty surgeons, 12 anaesthetists and 8 physiotherapists) from 10 state hospitals representing 4 South African provinces identified and prioritised i) risk factors associated with poor outcomes, ii) perioperative interventions to improve outcomes and iii) patient and clinical outcomes necessary to benchmark practice for patients scheduled for primary elective unilateral total hip and knee arthroplasty.ResultsThirty of the thirty-three stakeholders completed the 3 months Delphi study. The first round yielded i) 36 suggestions to preoperative risk factors, ii) 14 (preoperative), 18 (intraoperative) and 23 (postoperative) suggestions to best practices for perioperative interventions to improve outcomes and iii) 25 suggestions to important postsurgical outcomes. These items were prioritised by the group in the consecutive rounds and consensus was reached for the top ten priorities for each category.ConclusionThe consensus derived risk factors, perioperative interventions and important outcomes will inform the development of a structured, perioperative multidisciplinary enhanced patient care protocol for total hip and knee arthroplasty. It is anticipated that this study will provide the construct necessary for developing pragmatic enhanced care pathways aimed at improving patient outcomes after arthroplasty in LMICs.

Development of a Personalized m/eHealth Algorithm for the Resumption of Activities of Daily Life Including Work and Sport after Total and Unicompartmental Knee Arthroplasty: A Multidisciplinary Delphi Study

“…The three Delphi studies mentioned in the previous paragraph reached consensus in three or four Delphi rounds [38][39][40]. In line with these studies and an earlier Delphi study from our research group for the development of recovery recommendations after abdominal surgery, we reached consensus after four Delphi rounds [26].…”

“…The authors concluded, amongst other things, that supervised rehabilitation interventions and short-term follow-up care in the first two years after surgery is recommended for improving the quality of the rehabilitation [38]. A second Delphi study by Plenge et al examined factors that could optimize perioperative care for knee arthroplasty patients and patient outcomes after knee arthroplasty [39]. This Delphi study concluded that poor general health and impaired cardiovascular functional status are one of the most important determinants for poor patient outcomes after surgery, including postoperative pain and immobilisation.…”

Same-day discharge after early mobilisation and increased frequency of physiotherapy following hip and knee arthroplasty

“…Individuals living with symptomatic hip and/or knee OA number an estimated 242 million (3.8% of the world population) people worldwide (Carlesso et al 2016 ). Musculoskeletal and orthopaedic diseases such as OA are on the rise in South Africa (SA) because of lifestyle changes, obesity, increased life expectancy, trauma and the high incidence of human immunodeficiency virus (HIV) (Plenge et al 2018 ).…”

Physiotherapy in an advanced rehabilitation pathway for patients after hip and knee arthroplasty: A proposal

“…Increased life expectancy, lifestyle changes, obesity and non-communicable diseases, trauma and HIV contribute to increased musculoskeletal and orthopaedic diseases such as osteoarthritis (OA) in South Africa (SA) (Plenge et al 2018). OA is one of the leading causes of pain in patients' hips and knees and chronic disability, with a resulting adverse effect on quality of life and function (Lespasio et al 2017).…”

“…A variety of names are used in the literature for these advanced protocols. Advanced clinical pathway (Plenge et al 2018), fast track (Tayrose et al 2013), accelerated rehabilitation protocol (Robertson et al 2015) and rapid recovery are drawing more and more attention worldwide for an alternative method of management and rehabilitation of patient undergoing total hip and knee arthroplasty surgeries.…”