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Presentation from the Current Controversies in Orthopaedic Enhanced Recovery. 31st January 2014, Beardmore Hotel and Conference Centre, Glasgow, Scotland.

Presentation from the Current Controversies in Orthopaedic Enhanced Recovery. 31st January 2014, Beardmore Hotel and Conference Centre, Glasgow, Scotland.

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  • 30 mins 10:45 -11:15 <br />
  • Kehlet’s definition <br />
  • While I was away on holiday earlier in the summer I read Richard Moore’s book ‘Heroes, Villains, & Velodromes’ which tells the story of Chris Hoy who went on to win three gold medals in Beijing. While Chris’s achievements are not surprisingly the focus of the book, there’s some intriguing insight into the infrastructure that sits behind Chris, namely British Cycling. <br /> Britain failed to win an Olympic cycling medal during the whole on the 1980’s. At Atlanta where Britain only won one gold medal in all events (rowing), cycling contributed two medals. Thereafter, guided initially by Peter Keen and later Dave Brailsford, a steady transformation was initiated that culminated in the team winning seven out of the ten available track cycling gold medals on offer in Beijing, and with only one of the track team – Mark Cavendish who had to console himself with his four Tour De France stage wins earlier in the summer – not winning a medal. <br /> While British Cycling has undoubtedly benefited from an influx of lottery funding, so too have many sports which haven’t gone on to create similar results. What stands out with British Cycling is the quality of infrastructure that has been built up and the complete professionalism of the team. There’s a nice quote in Moore’s book from Dave Brailsford that summarises the whole ethos, attributing success to ‘performance by the aggregation of marginal gains. It means taking the 1 per cent from everything you do; finding a 1 per cent margin for improvement in everything you do’. <br />
  • Table 1 Patients’ perceptions of physiotherapyCommentAdequate Inadequate Reason for physiotherapy being inadequate No physiotherapy was provided Lack of outpatient physiotherapyNot enough physiotherapy received OtherUnknown/not statedNumber of comments (%)65% (1365/2085) 35% (720/2085)11% (226/2085) 9% (179/2085)8% (166/2085) 5% (115/2085)2% (34/2085)Examples of commentsNo physiotherapy was provided No outpatient physiotherapy provided, provision was delayed and should have started sooner Physiotherapy did not last long enough, should have been more frequent Lack of advice, ineffective, lack of modalities, under-resourced, too self-motivated, too intenseWhen the inpatient physiotherapy notes of 20 patients who indicated that they had not received any physiother- apy were analysed, it was found that they had all received physiotherapy, with a physiotherapy assessment on the first postoperative day. Patients had had a minimum of three con- tacts with a physiotherapist (median 5, range 3–24). All patients had been taught bed exercises, hip/knee exercises, how to transfer to a chair, how to mobilise with a Zimmer frame and sticks, and how to climb stairs.DiscussionThis survey found that while the majority of patients thought that the physiotherapy they received in relation to their joint replacement was adequate, 35% of patients thought that it was inadequate. Analysis of patient explanations about why the physiotherapy was inadequate found that the main theme was there was not enough physiotherapy provided, par- ticularly outpatient physiotherapy. Reviewing the inpatient physiotherapy notes of 20 patients who indicated that they had not received any physiotherapy revealed that they did, in fact, have the standard hospital physiotherapy provision. Therefore, their comments most likely refer to outpatient phy- siotherapy, which is not undertaken routinely at this centre.Therefore, the largest problem identified with physiother- apy provision in this centre was a lack of outpatient physio- therapy. However, the results are limited to one orthopaedic centre, which does not refer patients for outpatient physio- therapy routinely. Further research needs to be undertaken in other centres that do refer patients for outpatient physiother- apy in order to determine other areas of patient dissatisfaction with physiotherapy, with the aim of improving physiotherapy provision for joint replacement patients.DemographicsIn total, 3260 patients had a primary joint replacement between April 2004 and April 2006. At the time of the postal survey, 135 patients were deceased; therefore, questionnaires were sent to 3125 patients. Completed questionnaires were received from 2085 patients, giving an overall response rate of 67% (2085/3125). Overall, 911 patients had a total hip replacement, 157 patients had a hip resurfacing, 866 patients had a total knee replacement, 100 patients had a unicompartmental knee replacement and 51 patients had a patellar resurfacing. The mean age of patients at the time of surgery was 67 years, and 58% (1218/2085) were female.Perceived physiotherapy provisionOf the 2085 respondents, 65% (1365/2085) indicated that their physiotherapy provision was adequate and 35% (720/2085) indicated that it was inadequate. Overall, 676 patients provided a reason why the physiotherapy was inadequate. Of these patients, 26% (179/676) commented specifically on outpatient physiotherapy provision, with the remaining comments reflecting patients’ overall expe- rience of the physiotherapy they received in relation to their joint replacement. Reasons given about why physio- therapy provision was inadequate were coded independently into the key thematic categories by two of the authors (VW and CL), and the codes were compared and discussed until agreement was reached. The results are displayed in Table 1. <br />
  • Abstract <br /> Background: A fast-track intervention with a short preoperative optimization period and short postoperative hospitalization has a potential for reduced convalescence and thereby a reduced need for postoperative rehabilitation. The purpose of this study was to describe patient-related outcomes, the need for additional rehabilitation after a fast-track total hip arthroplasty (THA), and the association between generic and disease specific outcomes. <br /> Methods: The study consisted of 196 consecutive patients of which none received additional rehabilitation beyond an instructional exercise plan at discharge, which was adjusted at one in-patient visit. The patients filled in 3 questionnaires to measure health-related quality-of-life (HRQOL) and hip specific function (EQ-5 D, SF36, and Harris Hip Score (HHS)) at 2 time points pre- and 2 time points postoperatively. The observed results were compared to normative population data for EQ-5 D, SF36, and HHS. <br /> Results: 3-months postoperatively patients had reached a HRQOL level of 0.84 (SD, 0.14), which was similar to the population norm (P = 0.33), whereas they exceeded the population norm at 12 months postoperatively (P &lt; 0.01). For SF36, physical function (PF) was 67.8 (SD, 19.1) 3 months postoperatively, which was lower than the population norm (P &lt; 0.01). PF was similar to population norm 12-months postoperatively (P = 0.35). For HHS, patients never reached the population norm within 12 months postoperatively. Generic and disease specific outcomes were strongly associated. <br /> Conclusions: If HRQOL is considered the primary outcome after THA, the need for additional postoperative rehabilitation for all THA patients following a fast-track intervention is questionable. However, a pre- or early postoperative physical intervention seems relevant if the PF of the population norm should be reached at 3 months. If disease specific outcome is considered the primary outcome after fast-track THA, clear goals for the rehabilitation must be established before patient selection, intervention type and timing of intervention can be made. <br />
  • Background: Information on early recovery after arthroplasty is needed to help benchmark progress and make appropriate decisions concerning patient rehabilitation needs. The purpose of this study was to model early recovery of physical function in patients undergoing total hip (THA) and knee (TKA) arthroplasty, using physical performance and self-report measures.Methods: A sample of convenience of 152 subjects completed testing, of which 69 (mean age: 66.77 ± 8.23 years) underwent THA and 83 (mean age: 60.25 ± 11.19 years) TKA. Postoperatively, patients were treated using standardized care pathways and rehabilitation protocols. Using a repeated measures design, patients were assessed at multiple time points over the first four postoperative months. Outcome measures included the Lower Extremity Function Scale (LEFS), the physical function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC PF), the 6 minute walk test (6 MWT), timed up and go test (TUG) and a timed stair test (ST). Average recovery curves for each of the measures were characterized using hierarchical linear modeling. Predictors of recovery were sequentially modeled after validation of the basic developmental models.Results: Slopes of recovery were greater in the first 6 to 9 weeks with a second-degree polynomial growth term (weeks squared) providing a reasonable fit for the data over the study interval. Different patterns of recovery were observed between the self-report measures of physical function and the performance measures. In contrast to the models for the WOMAC PF and the LEFS, site of arthroplasty was a significant predictor (p = 0.001) in all of the physical performance measure models with the patients post TKA initially demonstrating higher function. Site of arthroplasty (p = 0.025) also predicted the rate of change for patients post THA and between 9 to 11 weeks after surgery, the THA group surpassed the function of the patients post TKA.Conclusion: Knowledge about the predicted growth curves will assist clinicians in referencing patient progress, and determining the critical time points for measuring change. The study has contributed further evidence to highlight the benefit of using physical performance measures to learn about the patients&apos; actual level of disability. <br />
  • Major surgery, including total hip and knee arthroplasty (THA and TKA, respectively), is followed by a convalescence period, during which the loss of muscle strength and function is considerable, especially early after surgery. In recent years, a combination of unimodal evidence-based perioperative care components has been demonstrated to enhance recovery, with decreased need for hospitalization, convalescence, and risk of medical complications after major surgery – the fast-track methodology or enhanced recovery programs. It is the nature of this methodology to systematically and scientifically optimize all perioperative care components, with the overall goal of enhancing recovery. This is also the case for the care component “physiotherapy exercise” after THA and TKA. The two latest meta-analyses on the effectiveness of physiotherapy exercise after THA and TKA generally conclude that physiotherapy exercise after THA and TKA does either not work, or is not very effective. The reason for this may be that the “pill” of physiotherapy exercise typically offered after THA and TKA does not contain the right active ingredients (too little intensity), or is offered at the wrong time (too late after surgery). We propose changing the focus to earlier-initiated, and more intensive physiotherapy exercise after THA and TKA (fast-track physiotherapy exercise), to reduce the early loss of muscle strength and function after surgery. Ideally, the physiotherapy exercise interventions after THA and TKA should be simple, using few and well chosen exercises that are described in detail, adhering to basic exercise-physiology principles, if possible. <br />
  • AbstractObjectives To determine whether the addition of bed exercises after primary total hip replacement (THR) improves functional outcomes and quality of life, in adult patients, during the first six postoperative weeks. Design Single-blind randomised controlled trial. Setting Inpatient and outpatient orthopaedic departments at a National Health Service hospital.Participants Sixty primary elective THR patients. Intervention Patients were assigned at random to receive either a standard gait re-education programme and bed exercises, or the standard gait re-education programme without bed exercises after THR. The bed exercises consisted of active ankle dorsiflexion/plantarflexion, active knee flexion, and static quadriceps and gluteal exercises. Main outcome measures Iowa Level of Assistance Scale (ILOA), the Short Form-12 Health Survey (SF-12), duration of hospital admission and postoperative complications were assessed at baseline, and 3 days and 6 weeks postoperatively. Results There was no statistically significant difference in ILOA scores between the two groups on the third postoperative day [gait re- education and bed exercise group median 40.5, interquartile range (IQR) 17.5 to 44.5; gait re-education alone group median 38, IQR 22.0 to 44.5; P = 0.70]. Although there was a small difference between the median ILOA scores at Week 6 between the two groups (3.5, IQR 0 to 6.4 and 5.0, IQR 3.5 to 12.5; P = 0.05), this difference was not statistically or clinically significant. There was no difference between the groups in duration of hospital admission, SF-12 scores or postoperative complications at Week 6. Conclusion This study suggests that during the first six postoperative weeks, the addition of bed exercises to a standard gait re-education programme following THR does not significantly improve patient function or quality of life. <br />
  • Have sent you the paper <br /> Exercise is therefore the only action, which can break the destructive cycle. Professional cyclists are the best example. Osteoarthritis of the hip is relatively common in the peleton. The cause is secondary to avasclar necrosis cased by hip fractures or steroid abuse. Despite arthritic hips many professional cyclists ride at the highest level and win. Floyd Landis even won the Tour de France with an arthritic hip. Not bad function, however he was later stripped of his title for abusing steroids! Cycling (a low impact exercise) is the key but other factors about a cyclist are also important. They have a low BMI, don’t smoke, don’t drink, eat a Mediterranean diet and avoid all forms of high impact exercise. <br />   <br /> So why is cycling so good? Firstly it’s low impact. Secondly it allows high reps. If you cycle at 50-100 rpm for 30 minutes you complete 1500-3000 reps. Try doing that with any other exercise! Exercise regimes and programs previously used for the treatment of osteoarthritis may have been ineffective as the dose was too low. Cycling also loads the hip and knee differently from walking, so it can mobilize the joint without causing pain. It’s just like a physiotherapist mobilizing a stiff joint using passive movement and accessory movement techniques. The accessory movements of the joint provide afferent input, stimulating the mechanoreceptors around the hip and knee joints, causing down regulation of pain sensation. <br />
  • Background and purpose Length of stay (LOS) following total hip and knee arthroplasty (THA and TKA) has been reduced to about 3 days in fast-track setups with functional discharge cri- teria. Earlier studies have identified patient characteristics pre- dicting LOS, but little is known about specific reasons for being hospitalized following fast-track THA and TKA. <br /> Patients and methods To determine clinical and logistical fac- tors that keep patients in hospital for the first postoperative 24–72 hours, we performed a cohort study of consecutive, unselected patients undergoing unilateral primary THA (n = 98) or TKA (n = 109). Median length of stay was 2 days. Patients were oper- ated with spinal anesthesia and received multimodal analgesia with paracetamol, a COX-2 inhibitor, and gabapentin—with opioid only on request. Fulfillment of functional discharge crite- ria was assessed twice daily and specified reasons for not allowing discharge were registered. <br /> Results Pain, dizziness, and general weakness were the main clinical reasons for being hospitalized at 24 and 48 hours postop- eratively while nausea, vomiting, confusion, and sedation delayed discharge to a minimal extent. Waiting for blood transfusion (when needed), for start of physiotherapy, and for postoperative radiographic examination delayed discharge in one fifth of the patients. <br /> Interpretation Future efforts to enhance recovery and reduce length of stay after THA and TKA should focus on analgesia, pre- vention of orthostatism, and rapid recovery of muscle function. <br />
  • Purpose: To explore the feasibility of progressive strength training commenced immediately after total knee arthroplasty (TKA). Methods: A pilot study was conducted at an outpatient training facility. Fourteen patients with unilateral TKA were included from a fast-track orthopedic arthroplasty unit. They received rehabilitation including progressive strength training of the operated leg (leg press and knee-extension), using relative loads of 10 repetition maximum with three training sessions per week for 2 weeks. Rehabilitation was commenced 1 or 2 days after TKA. At each training session, knee pain, knee joint effusion and training load were recorded. Isometric knee-extension strength and maximal walking speed were measured before the first and last session. Results: The training load increased progressively (p &lt; 0.0001). Patients experienced only moderate knee pain during the strength training exercises, but knee pain at rest and knee joint effusion (p &lt; 0.0001) were unchanged or decreased over the six training sessions. Isometric knee-extension strength and maximal walking speed increased by 147 and 112%, respectively. Conclusion: Progressive strength training initiated immediately after TKA seems feasible, and increases knee-extension strength and functional performance without increasing knee joint effusion or knee pain. <br /> Implications for Rehabilitation <br /> Rehabilitation with progressive strength training initiated early after total knee arthroplasty (TKA) seems feasible. <br /> Rehabilitation with progressive strength training increases knee-extension strength and maximal walking speed without increasing knee joint effusion and knee pain during the first 2 weeks after TKA. <br /> During the progressive strength training exercises, patients with TKA may experience moderate knee pain, which seems to decrease over time. Resting knee pain before and after each training session is none to mild. <br /> The results of this pilot study are encouraging, but a larger randomized controlled trial, which compares rehabilitation with or without progressive strength training, is needed to confirm our findings <br /> Posted online on November 15, 2011. (doi:10.3109/09638288.2011.629019) <br /> HTML <br /> PDF (814 KB) <br /> PDF Plus (815 KB) <br /> Reprints <br /> Permissions <br /> Thomas Linding JakobsenMSc1, Henrik HustedMD2, Henrik KehletPhD3, Thomas BandholmPhD4 <br /> Read More: http://informahealthcare.com/doi/abs/10.3109/09638288.2011.629019 <br /> Read More: http://informahealthcare.com/doi/abs/10.3109/09638288.2011.629019 <br />
  • Abstract <br /> Holm B, Kristensen MT, Bencke J, Husted H, Kehlet H, Bandholm T. Loss of knee-extension strength is related to knee swelling after total knee arthroplasty. <br /> Objective <br /> To examine whether changes in knee-extension strength and functional performance are related to knee swelling after total knee arthroplasty (TKA). <br /> Design <br /> Prospective, descriptive, hypothesis-generating study. <br /> Setting <br /> A fast-track orthopedic arthroplasty unit at a university hospital. <br /> Participants <br /> Patients (N=24; mean age, 66y; 13 women) scheduled for primary unilateral TKA were investigated 1 week before surgery and on the day of hospital discharge 2.4 days postsurgery. <br /> Interventions <br /> Not applicable. <br /> Main Outcome Measures <br /> We assessed all patients for knee-joint circumference, knee-extension strength, and functional performance using the Timed Up & Go, 30-second Chair Stand, and 10-m fast speed walking tests, together with knee pain during all active test procedures. <br /> Results <br /> All investigated variables changed significantly from pre- to postsurgery independent of knee pain. Importantly, knee circumference increased (knee swelling) and correlated significantly with the decrease in knee-extension strength (r=−.51; P=.01). Reduced fast-speed walking correlated significantly with decreased knee-extension strength (r=.59; P=.003) and decreased knee flexion (r=.52; P=.011). Multiple linear regression showed that knee swelling (P=.023), adjusted for age and sex, could explain 27% of the decrease in knee-extension strength. Another model showed that changes in knee-extension strength (P=.009) and knee flexion (P=.018) were associated independently with decreased performance in fast-speed walking, explaining 57% of the variation in fast-speed walking. <br /> Conclusions <br /> Our results indicate that the well-known finding of decreased knee-extension strength, which decreases functional performance shortly after TKA, is caused in part by postoperative knee swelling. Future studies may look at specific interventions aimed at decreasing knee swelling postsurgery to preserve knee-extension strength and facilitate physical rehabilitation after TKA. <br />
  • It is expected that the device will function on virtually all patients with up to a leg circumference of 24 inches (61cm), at the location that the device is secured to the leg. Muscle relaxants may also impact device performance. We believe that muscle relaxants may impede performance. <br /> You will observe the geko™ device working physically on the patient. You will see a minor visible movement of the lower leg and an outward movement of the foot. <br />   <br /> There are 4 key points to remember – <br /> one marker, <br /> one button, <br /> one light and <br /> two legs <br />   <br /> The raised marker is a guide to ensure correct fitting placement <br />   <br /> One button turns the device on, off and adjusts the level of stimulation (up and down). <br />   <br /> The light indicates that the device is switched on and the level stimulation set <br />
  • Every second, the gekoTM device stimulates the common peroneal nerve. This “naturally” causes the calf muscle pump to activate. IPC compresses the leg OR foot. (one or the other) externally at a rate of once per minute. <br /> The gekoTM stimulates this superficial nerve to contract the calf muscle pump once per second….60x more often than IPC and in line with normal cardiac function. <br /> This stimulation results in blood volume and velocity movement in the range of 50-70% to that generated by continuous walking, based on studies in healthy volunteers. <br />

The case for physiotherapy following discharge after arthroplasty surgery Presentation Transcript

  • 1. Current Controversies in Orthopaedic Enhanced Recovery The case for physiotherapy following discharge after arthroplasty surgery 31st January 2014, Glasgow, Scotland. Tom Wainwright @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 2. The next step in enhanced recovery. @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 3. Enhanced Recovery is an ongoing process… Recovery does not stop from the patient’s perspective when they go home “Enhanced Recovery is an evidence“Enhanced Recovery is an evidencebased approach to care. It is designed based approach to care. It is designed to prepare patients for, and reduce to prepare patients for, and reduce the total impact of, surgery, helping the total impact of, surgery, helping them to recover more quickly. It is aa them to recover more quickly. It is multi-modal approach similar to that multi-modal approach similar to that of care bundles” of care bundles” @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 4. Improvements are the result of the aggregation of marginal gains – what can we optimize further? ‘you can achieve optimal performance by the aggregation of marginal gains. It means finding a 1 per cent margin for improvement in everything you do’ Dave Brailsford @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 5. Influencing outcome measures • • • • • • Length of stay Re-admissions Mortality Complications Patient Experience PROMs @twwainwright @twwainwright The outcomes focused on to date in ERAS Have we focused enough on these areas to date? enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 6. Patient Experience @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 7. • 35% of patients thought that physiotherapy provision was inadequate. • Analysis of patient explanations about why the physiotherapy was inadequate found that the main theme was there was not enough physiotherapy provided @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 8. Improving PROMs scores @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 9. RBCH 2012-13 Oxford Hip Score @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 10. RBCH 2012-13 EQ5D Hip Score @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 11. Improvement will be when we out perform current models of recovery of physical and functional performance • Limited research evidence on the potential, and time period for improvement post THR and TKR @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 12. Why it is time for reconsideration? • The two latest meta-analyses on the effectiveness of physiotherapy exercise after THA and TKA generally conclude that physiotherapy exercise after THA and TKA does either not work, or is not very effective. • The reason for this may be that the “pill” of physiotherapy exercise typically offered after THA and TKA does not contain the right active ingredients (too little intensity), or is offered at the wrong time (too late after surgery). Bandholm T, Kehlet K (2012) Physiotherapy Exercise After Fast-Track Total Hip and Knee Arthroplasty: Time for Reconsideration? Archives of Physical Medicine and Rehabilitation Vol. 93, Issue 7, Pages 1292-1294, DOI: 10.1016/j.apmr.2012.02.014. @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 13. Physiotherapy post-discharge @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 14. @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 15. What does physiotherapy include? • Study suggests that during the first six postoperative weeks, the addition of bed exercises to a standard gait re-education following THR does not significantly improve patient function or quality of life. @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 16. What could/should physiotherapy include? @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 17. Improving functional capacity with enhanced rehabilitation at both pre and post-discharge @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 18. Unilateral hip OA is characterized by generalized muscle weakness of the affected leg. @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 19. Exercise reduces pain and improves physical function for people awaiting hip replacement surgery @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 20. Preoperative greater knee extensor strength of the operated site is associated with better physical function at 12 weeks post-op @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 21. Example - “Size of dose” What does cycling have to offer? Participants significantly improved in the timed chair rise, in the 6minute walk test, in the range of walking speeds, in the amount of overall pain relief, and in aerobic capacity. @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 22. @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 23. Areas for optimisation - example 682 Acta Orthopaedica 2011; 82 (6): 679–684 679 Why still in hospital after fast-track hip and knee arthroplasty? Table 2. Reasons for patients not being able to be discharged at 9 a.m. and 2 p.m. on various days. The accumulated proportions of patients not discharged are shown at the top of the table. Below that, reasons for not ful lling the speci ed discharge criteria are shown (as number of patients with each clinical problem divided by the number of patients remaining in hospital) Henrik Husted1,4, Troels H Lunn2,4, Anders Troelsen 1,4, Lissi Gaarn-Larsen 4, Billy B Kristensen2,4, and Henrik Kehlet 3,4 Op-day 2 p.m. Evaluation 2D e p a r t m e n t o f O r t h o p a e d i c S u r g e r y a n d e p a r t m e n t o f A n a e s t h e s i o lo g y , H v i d o v r e U n i v e r s it y H o s p i t a l; U n i v e r s it y ; 4 T h e L u n d b e c k C e n t r e fo r F a s t - t r a c k H i p a n d K n e e A r t h r o p l a s t y , C o p e n h a g e n , D e n m a r k . C o r r e s p o n d e n c e : h e n r i k h u s t e d @ d a d l n e t .d k S u b m it t e d 1 1 - 0 5 - 2 4 . A c c e p t e d 1 1 - 0 8 - 0 2 • • • • • • Pain Dizziness PONV Confusion Sedation Muscle Weakness • Logistical B a c k g r o u n d a n d p u r p o s e L e n g th o f s ta y (L O S ) fo llo w in g to ta l h ip a n d k n e e a r th r o p la s ty (T H A a n d T K A ) h a s b e e n r e d u c e d to a b o u t 3 d a y s in f a s t -t r a c k s e t u p s w ith fu n c tio n a l d is c h a r g e c r it e r ia . E a r lie r s t u d ie s h a v e id e n t ifi e d p a t ie n t c h a r a c t e r is t ic s p r e d ic tin g L O S , b u t little is k n o w n a b o u t s p e c ifi c r e a s o n s fo r b e in g h o s p ita liz e d fo llo w in g fa s t-tr a c k T H A a n d T K A . P a tie n ts a n d m e th o d s T o d e te r m in e c lin ic a l a n d lo g is tic a l fa c t o r s t h a t k e e p p a t ie n t s i n h o s p i ta l fo r t h e fi r s t p o s t o p e r a t iv e 2 4 – 7 2 h o u r s , w e p e r fo r m e d a c o h o r t s tu d y o f c o n s e c u tiv e , u n s e le c te d p a tie n ts u n d e r g o in g u n ila te r a l p r im a r y T H A (n = 9 8 ) o r T K A ( n = 1 0 9 ) . M e d ia n le n g th o f s ta y w a s 2 d a y s . P a tie n ts w e r e o p e r a t e d w it h s p in a l a n e s th e s ia a n d r e c e iv e d m u lt im o d a l a n a l g e s ia w ith p a r a c e ta m o l, a C O X - 2 in h ib it o r, a n d g a b a p e n t in — w ith o p io id o n ly o n r e q u e s t . F u lfi llm e n t o f f u n c tio n a l d is c h a r g e c r ite r ia w a s a s s e s s e d t w ic e d a ily a n d s p e c ifi e d r e a s o n s fo r n o t a l lo w in g d is c h a r g e w e r e r e g is te r e d . R e s u lt s P a in , d iz z in e s s , a n d g e n e r a l w e a k n e s s w e r e th e m a in c lin ic a l r e a s o n s fo r b e in g h o s p ita liz e d a t 2 4 a n d 4 8 h o u r s p o s to p e r a t iv e ly w h ile n a u s e a , v o m iti n g , c o n f u s io n , a n d s e d a ti o n d e la y e d d is c h a r g e to a m in im a l e x te n t. W a itin g fo r b lo o d tr a n s fu s io n (w h e n n e e d e d ), fo r s ta r t o f p h y s io th e r a p y , a n d fo r p o s to p e r a tiv e r a d io g r a p h ic e x a m in a tio n d e la y e d d is c h a r g e in o n e fi fth o f th e p a tie n ts . I n te r p r e ta tio n F u tu r e e ffo r ts to e n h a n c e r e c o v e r y a n d r e d u c e le n g th o f s t a y a f te r T H A a n d T K A s h o u ld fo c u s o n a n a lg e s ia , p r e v e n tio n o f o r th o s ta tis m , a n d r a p id r e c o v e r y o f m u s c le fu n c tio n . Total hip and total knee arthroplasty (THA and TKA) are frequent operations with an average length of stay (LOS) of about 6–12 days in the United Kingdom, Germany, and Denmark (Husted et al. 2006, Bundesauswertung 2009, NHS 2010). During the last decade, however, there has been increased interest in optimal multimodal perioperative care to enhance recovery (the fast-track methodology). Improvement of anal- 3 S e c t io gesia; reduction of surgical stress responses and organ dysfunctions including nausea, vomiting, and ileus; early mobilization; and oral nutrition have been of particular interest (Kehlet 2008, Kehlet and Wilmore 2008). These principles have also been applied to THA and TKA, resulting in improvements in pain treatment with multimodal opioid-sparing regimens including a local anesthetic infiltration technique (LIA) or peripheral nerve blocks to facilitate early mobilization (Ilfeld et al. 2006a, b, 2010a, Andersen et al. 2008, Kerr and Kohan 2008), and allowing functional rehabilitation to be initiated a few hours postoperatively (Holm et al. 2010)—ultimately leading to a reduction in LOS (Husted et al. 2008, Barbieri et al. 2009, Husted et al. 2010a, b). Using these evidence-based regimens combined with an improved logistical setup, LOS is reduced to about 2–4 days (Kerr and Kohan 2008, Husted et al. 2010 a,b,c, Lunn et al. 2011). H a v in g w e ll-d e fi n e d fu n c tio n a l d is c h a rg e c rite ria is im p e ra tiv e in o r d e r to e n s u r e a s a f e d is c h a rg e — a n d it is m a n d a to r y if m e a n in g f u l c o m p a ris o n o f L O S is d o n e fo llo w in g a lte ra tio n s in th e tra c k (H u s te d e t a l. 2 0 0 8 ). In th e s a m e fa s t- tra c k s e ttin g , a n e a rlie r s tu d y fo c u s e d o n p a tie n t c h a ra c te ris tic s p r e d ic tin g L O S (H u s te d e t a l. 2 0 0 8 ). H o w e v e r, little is k n o w n a b o u t th e s p e c ifi c re a s o n s fo r w h y p a tie n ts a re h o s p ita liz e d d u rin g th e fi rs t 1 – 3 d a y s a fte r T H A o r T K A ; i.e . w h y c a n p a tie n ts n o t b e d is c h a rg e d ? We therefore analyzed clinical and organizational factors responsible for being hospitalized in a well-defined prospective setup in a fast-track unit. This unit had previously documented LOS of about 2–3 days (Andersen et al. 2008, Holm et al. 2010, Husted et al. 2010b, c, Lunn et al. 2011). Day 1 2 p.m. Day 2 9 a.m. Day 2 2 p.m. Day 3 9 a.m. Day 3 2 p.m. Not discharged TKA THA Pain a TKA THA Dizziness TKA THA PONV c TKA THA Confusion TKA THA Sedation TKA THA Muscle weakness d TKA THA Technical e TKA THA “Logistics” f TKA THA 100% 100% 94% 87% 80% 60% 33% 22% 27% 20% 7% 9% 5% 6% 53% 47% 43% b 24% b 29% 22% 19% 18% 0% b 20% b 0% 11% 0% 0% 11% 15% 24% 21% 15% 17% 17% 14% 17% 20% 13% 11% 0% 0% 13% 11% 8% 5% 7% 5% 3% 5% 7% 5% 0% 0% 0% 0% 1% 2% 0% 2% 0% 2% 3% 0% 4% 0% 0% 0% 0% 0% 3% 1% 5% 7% 6% 5% 6% 5% 4% 0% 13% 0% 20% 0% 16% b 29% b 18% 28% 13% b 26% b 25% 18% 8% 13% 13% 44% 20% 17% 16% 15% 10% 12% 2% 9% 0% 5% 8% 0% 13% 0% 20% 0% 22% 18% 27% 35% 20% 20% 33% 36% 21% 20% 25% 44% 40% 50% a Pain > 5 with activity b Signi cant di erence between TKA and THA Patients and methods According to Danish law, this quality-assurance study did not require approval by an ethics committee. It was registered at ClinicalTrials.gov (NTC01047371). Open Access - This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the source is credited. DOI 10.3109/17453674.2011.636682 @twwainwright @twwainwright Day 1 9 a.m. n o f S u r g i c a l P a t h o p h y s i o l o g y , R ig s h o s p i t a l e t , C o p e n h a g e n Acta Orthop Downloaded from informahealthcare.com by 82.20.71.193 on 02/21/12 For personal use only. 1D Acta Orthopaedica 2011; 82 (6 c Postoperative nausea and vomiting d or lack of su cient control to ambulate e Ongoing intravenous transfusion of blood or plasma e xpander, or urinary catheter due to urinary retention f Waiting for physiotherapy or postoperative radiographs 2008, 2010a) but the drawback is a risk of muscle weakness, a need for adjustment of infusion dose of local anesthetics, and risk of falls (Kandasami et al. 2009, Ilfeld et al. 2010b, Sharma et al. 2010). Optimization of analgesia may include a high dose of glucocorticoids preoperatively (Lunn et al. 2011) or use of other In other studies, short hospital stays of 1–2 days h achieved in selected patients, but no specific inf was provided on potential discharge problems (Ilfe 2006a,b, Kerr and Kohan 2008), except in one study et al. 2009). In this latter study on THA patients o charge criteria were similar to ours, but patients we enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 24. Exercise prescription: Progressive strength training (10 RM) commenced immediately after fast-track total knee arthroplasty: is it feasible? • • • The training load increased progressively (p < 0.0001). Patients experienced only moderate knee pain during the strength training exercises, but knee pain at rest and knee joint effusion (p < 0.0001) were unchanged or decreased over the six training sessions. Isometric knee-extension strength and maximal walking speed increased by 147 and 112%, respectively. @twwainwright @twwainwright Linding Jakobson et al. 2012 enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 25. Recovery of function following hip resurfacing arthroplasty: a randomized controlled trial comparing an accelerated versus standard physiotherapy rehabilitation programme. Barker et al. (2013) Clin Rehabil published online 10 April 2013 DOI: 10.1177/0269215513478437 @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 26. Loss of Knee-Extension Strength Is Related to Knee/Thigh Swelling After TKR • Measures: knee-joint circumference, knee-extension strength, Timed Up & Go, 30-second Chair Stand, and 10-m fast speed walking test, and knee pain • Knee circumference increased (knee swelling) and correlated significantly with the decrease in knee-extension strength • Decreased knee-extension strength, which decreases functional performance shortly after TKA, is caused in part by postoperative knee swelling. Holm et al. 2012 @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 27. Cryo-therapy can be effective @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 28. Cryo-compression Therapy Hip Int. 2012 Sep-Oct;22(5):527-33. doi: 10.5301/HIP.2012.9761. Cryocompression therapy after elective arthroplasty of the hip. Leegwater NC, Willems JH, Brohet R, Nolte PA. @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 29. New Modalities such as the Geko Device can also help to reduce swelling http://gekodevices.com/ @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 30. The Geko - How it works and mechanism of action • The gekoTM device stimulates the common peroneal nerve to activate the calf muscle pumps • Increases blood flow volume and velocity • Achieves a blood flow rate of 50-70% of walking - measured by duplex ultrasound in the femoral vein A. T. Tucker, A. Maass, D. S. Bain et al. Augmentation of venous, arterial, and microvascular blood supply in the leg by isometric neuromuscular stimulation via the peroneal nerve. Int. J. Angiol. 2010; 19 (1): e31-e37 @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 31. • Results: A statistically significant increase in walking speed was observed in the treatment group in relation to the control group at both 6 weeks (P=0.0002) and 12 weeks (P=0.0001) postoperatively @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 32. Alter-G Anti-gravity treadmill @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 33. • Strength is lost rapidly. Longitudinal studies show that at age 75 years, strength is lost at a rate of 3–4% per year in men and 2.5–3% per year in women. @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 34. • We should consider the effect of Sarcopenia in patients undergoing hip and knee replacement surgery • Conclusions of the above study - Adaptations to RET are markedly blunted in the elderly @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 35. Differences in Muscle Protein Synthesis and Anabolic Signaling in the Postabsorptive State and in Response to Food in 65–80 Year Old Men and Women Gord on I. Smit h 1 . , Philip At hert on 2 . , Dennis T. Villareal 1 , Tiff any N. Frimel 1 , Deb bie Rank in 2 , Michael J. Rennie2 , Bet t ina Mit t end orfer 1 * 1 School of Medicine, Washington University, St. Louis, Missouri, United States of America, 2 School of Graduate Entry Medicine and Health, University of Nottingham, Derby, United Kingdom Abst ract Women have less muscle than men but lose it more slowly during aging. To discover potential underlying mechanism(s) for this we evaluated the muscle protein synthesis process in postabsorptive conditions and during feeding in twenty-nine 65– 80 year old men (n = 13) and women (n = 16). We discovered that the basal concentration of phosphorylated eEF2T h r 5 6 was , 40% less (P, 0.05) and the basal rate of MPSwas , 30% greater (P= 0.02) in women than in men; the basal concentrations of muscle phosphorylated Akt T h r 3 0 8 , p70s6kT h r 3 8 9 , eIF4ES e r 2 0 9 , and eIF4E-BP1T h r 3 7 / 4 6 were not different between the sexes. Feeding increased (P, 0.05) Akt T h r 3 0 8 and p70s6kT h r 3 8 9 phosphorylation to the same extent in men and women but increased (P, 0.05) the phosphorylation of eIF4ES e r 2 0 9 and eIF4E-BP1T h r 3 7 / 4 6 in men only. Accordingly, feeding increased MPS in men (P, 0.01) but not in women. The postabsorptive muscle mRNA concentrations for myoD and myostatin were not different between sexes; feeding doubled myoD mRNA (P, 0.05) and halved that of myostatin (P, 0.05) in both sexes. Thus, there is sexual dimorphism in MPS and its control in older adults; a greater basal rate of MPS, operating over most of the day may partially explain the slower loss of muscle in older women. Elderly individuals have an ‘anabolic resistance’ which is essentially a concept of having a diminished response to exercise and feeding (protein) Citat ion: Smith GI, Athert on P, Villareal DT, Frimel TN, Rankin D, et al. (2008) Differences in Muscle Protein Synthesis and Anabolic Signaling in the Postabsorptive State and in Response to Food in 65–80 Year Old Men and Women. PLoS ONE 3(3): e1875. doi:10.1371/journal.pone.0001875 Ed itor: Alejandro Lucia, Universidad Europea de Madrid, Spain Received January 3, 2008; Accept ed February 21, 2008; Published March 26, 2008 Copyright : ß 2008 Smith et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The study was supported by US National Institutes of Health grants AR 49869, AG 025501, RR 00036 (General Clinical Research Center), RR 00954 (Biomedical Mass Spectrometry Resource), and DK 56341 (Clinical Nutrition Research Unit), the University of Nottingham, the UK Biotechnology and Biological Sciences Research Council grants BB/XX510697/1 and BB/C516779/1, and a European Union EXEGENESISprogram grant. Philip Atherton is a designated Research Councils UK fellow. Compet ing Int erest s: The authors have declared that no competing interests exist. * E-mail: mittendb@ wustl.edu . These authors contributed equally to this work. Int roduct ion Adequate maintenance of muscle mass throughout life is @twwainwright locomotor functions and diminish the risk @twwainwright important to preserve The fact that no sex differences in MPS have been reported in the literature might be because these studies were conducted in young and middle-age adults with a constant muscle mass during postabsorptive conditions, when sex differences may be small or enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 36. The next step in the evolution of enhanced recovery? @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 37. @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 38. @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 39. Summary • Rehabilitation pathways need to change if we are to improve function, activity levels and outcomes further • Changing the type, dose, timing of interventions is vital if outcomes are to be optimised @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 40. One final thought… What rehabilitation pathway would you like your mum to have? @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com
  • 41. Thank you @twwainwright @twwainwright enhancedrecoveryblog.com enhancedrecoveryblog.com