Enhancing Quality and Recovery - NHS Kent, Surrey and Sussex. Enhanced Recovery in Orthopaedics.


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Enhanced Recovery in Orthopaedics.

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  • 30 mins 10:45 -11:15
  • cemented q1 06/07 to q1 07/08 The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust 785 760 760 6,042 7.8 8 0.1 1,415 4 TH LARGEST BY VOLUME – 760 SPELLS AV LOS 8 DAYS EXPECTED LOS 7.8 DAYS
  • cemented q1 06/07 to q1 07/08 The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust 785 760 760 6,042 7.8 8 0.1 1,415 4 TH LARGEST BY VOLUME – 760 SPELLS AV LOS 8 DAYS EXPECTED LOS 7.8 DAYS
  • Kehlet ’s definition
  • 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. 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. 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’.
  • J QUAL CLIN PRACT 2000 DEC;20(4):145-9
  • Abstract 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. 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. 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 < 0.01). For SF36, physical function (PF) was 67.8 (SD, 19.1) 3 months postoperatively, which was lower than the population norm (P < 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. 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.
  • 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' actual level of disability.
  • 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.
  • 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.
  • 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.
  • 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. 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. 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. 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.
  • Abstract 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. Objective To examine whether changes in knee-extension strength and functional performance are related to knee swelling after total knee arthroplasty (TKA). Design Prospective, descriptive, hypothesis-generating study. Setting A fast-track orthopedic arthroplasty unit at a university hospital. Participants 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. Interventions Not applicable. Main Outcome Measures 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. Results 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. Conclusions 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.
  • 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. 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.   There are 4 key points to remember – one marker, one button, one light and two legs   The raised marker is a guide to ensure correct fitting placement   One button turns the device on, off and adjusts the level of stimulation (up and down).   The light indicates that the device is switched on and the level stimulation set
  • Every second, the geko TM 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. The geko TM 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. 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.
  • 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 < 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. 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. Implications for Rehabilitation Rehabilitation with progressive strength training initiated early after total knee arthroplasty (TKA) seems feasible. 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. 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. 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 Posted online on November 15, 2011. (doi:10.3109/09638288.2011.629019) HTML PDF (814 KB) PDF Plus (815 KB) Reprints Permissions Thomas Linding JakobsenMSc1, Henrik HustedMD2, Henrik KehletPhD3, Thomas BandholmPhD4 Read More: http://informahealthcare.com/doi/abs/10.3109/09638288.2011.629019 Read More: http://informahealthcare.com/doi/abs/10.3109/09638288.2011.629019
  • Enhancing Quality and Recovery - NHS Kent, Surrey and Sussex. Enhanced Recovery in Orthopaedics.

    1. 1. Enhancing Quality and RecoveryNHS Kent, Surrey, and SussexEnhanced Recovery – What next?5th June 2013, Holiday Inn, Gatwick.Tom Wainwright@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    2. 2. Orthopaedic DepartmentThe Royal Bournemouth Hospital@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    3. 3. Results of Implementing Enhanced Recovery@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    4. 4. Results – Reducing length of stayIntroduction of pathway in 2007 = 50% reduction in LOS@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    5. 5. Results – Benchmarking case mix adjustedlength of stay-4-3-2-10123456AVLOS greater thanexpected for case mix.Hospital placed in lowerhalf of UK hospitalsAVLOS greater thanexpected for case mix.Hospital placed in lowerhalf of UK hospitals@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    6. 6. Results – Benchmarking case mix adjustedlength of stay-3-2-1012345AVLOS significantlyshorter than expected forcase mix. Hospital placedtop of all UK hospitalsAVLOS significantlyshorter than expected forcase mix. Hospital placedtop of all UK hospitals@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    7. 7. Outline for today• Applying the principles of enhanced recoveryto other orthopaedic procedures e.g.Fractured Neck of Femur• Sustaining the improvements you haveachieved to your hip and knee pathways• Continuous improvement of hip and kneepathways – Changing the focus of ourimprovement efforts@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    8. 8. National Hip FractureDatabase National Report2012• 59,365 cases• Illustrates progress…– Mean total LOS reduced from 21.2 days to20.2 days– Decreased in hospital mortality (9.5% to9.1%)– Pre-op assessment by an orthogeriatrician– (increased from 37% to 43%)• and challenges…– 52% of pts admitted to an orthopaedicward within 4hrs (Down from 56% in2011) and 83% receive surgery within48hrs (down from 87%)@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    9. 9. @twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    10. 10. ER in Fractured Neck of Femur - PGH@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    11. 11. Outline• Applying the principles of enhanced recoveryto other orthopaedic procedures e.g.Fractured Neck of Femur• Sustaining the improvements you haveachieved to your hip and knee pathways• Continuous improvement of hip and kneepathways – Changing the focus of ourimprovement efforts@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    12. 12. Enhanced Recovery is an ongoingprocess“Enhanced Recovery is an evidence-based approach to care. It is designedto prepare patients for, and reducethe total impact of, surgery, helpingthem to recover more quickly. It is amulti-modal approach similar to thatof care bundles”“Enhanced Recovery is an evidence-based approach to care. It is designedto prepare patients for, and reducethe total impact of, surgery, helpingthem to recover more quickly. It is amulti-modal approach similar to thatof care bundles”@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    13. 13. An enhanced recovery pathway is a multi-step process.Every step must continue to be deliveredNo single magic stepNo single magic step@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    14. 14. Improvements are the result of the aggregation ofmarginal gains – what can be optimized further?‘you can achieve optimalperformance by theaggregation of marginal gains.It means finding a 1 per centmargin for improvement ineverything you do’Dave Brailsford@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    15. 15. The 95% ruleA ten step process@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    16. 16. No.processstepsProbability of Success, Each Process Step125501000.95 0.990 0.999 0.9999990.95 0.990 0.999 0.99990.28 0.78 0.98 0.9980.08 0.61 0.95 0.9950.006 0.37 0.90 0.99Improve the quality of each stepRemove the steps….Why measure compliance to a pathway?Probability of Performing Perfectly@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    17. 17. Variance is always higher than you think• Variance analysis in clinical pathways for total hip andknee joint arthroplasty is vital Clinical pathways help to incorporate evidenced-basedmedicine into clinical practice Variance analysis can be utilised as a process of qualitycontrol and a driver for improving patient outcomes (Variances in this study were higher than expected)Dalton et al 2000@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    18. 18. How many patients received all fivepathway steps as intended?@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    19. 19. Enhanced Recovery = 100% of patients getting the intended pathwayWe need to do the right things right for every patientClinical DecisionsProcess/SystemchangesGood Patient CareDo right things (EBM)Do things right (QI)Do rightthings rightAdapted from Glasziou et al. BMJ Qual Saf 2011;20(Suppl 1): i13-i17@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    20. 20. Conclusion – Key factors for quality improvement success• Leadership• Organisational culture• Data infrastructure and information systems• Experience of quality improvementWe must appreciate the role of both context and also the key factorsrequired for ongoing success@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    21. 21. Outline• Applying the principles of enhanced recoveryto other orthopaedic procedures e.g.Fractured Neck of Femur• Sustaining the improvements achieved to yourhip and knee pathways• Continuous improvement of hip and kneepathways – Changing the focus ofimprovement
    22. 22. Why are we introducing andimplementing enhanced recovery?To improve the quality of care for our patients(It is a quality improvement initiative)The IOM Specific Aims for Quality in Healthcare (2001):States that healthcare should be: Safe, Effective, Patient-Centered, Timely, Efficient, and Equitable.@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    23. 23. Influencing outcome measures• Length of stay• Re-admissions• Mortality• Complications• Patient Experience• PROMsThe outcomes focused onto date in ERAS@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    24. 24. Patient Experience@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    25. 25. @twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.comEnhanced Recovery has beenfound to Improve PROMs scores
    26. 26. What are your PROMs scores?@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    27. 27. @twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    28. 28. Improving functional capacity with enhancedrehabilitation at both pre and post-discharge@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    29. 29. We need to out perform current rates of recovery ofphysical and functional performance• In all of the physical performancemeasure models patients post TKRinitially demonstrate higherfunction.• The THR group surpassed thefunction of the patients post TKR.@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    30. 30. Physiotherapy exercise after fast-track total hip andknee arthroplasty: is it time for reconsideration?• The two latest meta-analyses on the effectiveness ofphysiotherapy exercise after THA and TKA generally concludethat physiotherapy exercise after THA and TKA does eithernot work, or is not very effective.• The reason for this may be that the “pill” of physiotherapyexercise typically offered after THA and TKA does not containthe right active ingredients (too little intensity), or is offeredat 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, Pages1292-1294, DOI: 10.1016/j.apmr.2012.02.014.@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    31. 31. What does physiotherapyinclude?• Study suggests that during the first six postoperative weeks,the addition of bed exercises to a standard gait re-educationfollowing THR does not significantly improve patient functionor quality of life.@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    32. 32. • 35% of patients thought that physiotherapyprovision was inadequate.• Analysis of patient explanations about whythe physiotherapy was inadequate found thatthe main theme was there was not enoughphysiotherapy provided@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    33. 33. Acta Orthopaedica 2011; 82 (6): 679–684 679Why still in hospital after fast-track hip and knee arthroplasty?Henrik Husted1,4, Troels H Lunn2,4, Anders Troelsen1,4, Lissi Gaarn-Larsen4, Billy B Kristensen2,4, and HenrikKehlet3,41 D e p a r tm e n t o f O r th o p a e d ic S u rg e r y a n d 2 D e p a r tm e n t o f A n a e s th e s io lo g y , H v id o v re U n iv e r s ity H o s p ita l; 3 S e c tio n o f S u rg ic a l P a th o p h y s io lo g y , R ig s h o s p ita le t, C o p e n h a g e nU n iv e rs ity ; 4 T h e L u n d b e c k C e n tre fo r F a s t-tra c k H ip a n d K n e e A r th ro p la s ty , C o p e n h a g e n , D e n m a r k .C o r re s p o n d e n c e : h e n rik h u s te d @ d a d ln e t.d kS u b m itt e d 1 1 -0 5 -2 4 . A c c e p te d 1 1 -0 8 -0 2Open 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 10.3109/17453674.2011.636682B a c k g r o u n d a n d p u r p o s e L e n g t h o f s t a y ( L O S ) fo llo w in g t o t a lh i p a n d k n e e a r t h r o p l a s t y ( T H A a n d T K A ) h a s b e e n r e d u c e d t oa 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 it h fu n c t io n a l d is c h a r g e c r i-t 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 i c t in g L O S , b u t lit t le is k n o w n a b o u t s p e c ifi c r e a s o n s f o r b e in gh o s p it a liz e d f o llo w in g f a s t - t r a c k T H A a n d T K A .P a t i e n t s a n d m e t h o d s T o d e t e r m in e c l in i c a l a n d l o g i s t ic a l f a 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 t a 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 2h o u r s , w e p e r fo r m e d a c o h o r t s t u d y o f c o n s e c u t iv e , u n s e le c t e dp a t ie n t s u n d e r g o in g u n ila t e 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 t h o f s t a y w a s 2 d a y s . P a t ie n t s w e r e o p e r -a t e d w it h s p in a l a n e s t h 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 iaw i t h p a r a c e t a 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 it ho 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 t io n a l d is c h a r g e c r it e -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 f o r n o t a l lo w in gd is c h a r g e w e r e r e g is t e 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 t h e m a inc lin ic a l r e a s o n s fo r b e in g h o s p it a liz e d a t 2 4 a n d 4 8 h o u r s p o s t o p -e r a t iv e ly w h ile n a u s e a , v o m it i n g , c o n f u s io n , a n d s e d a t i o n d e la y e dd i s c h a r g e t o a m in i m a l e x t e n t . W a it in g fo r b l o o d t r a n s f u s io n( w h e n n e e d e d ) , f o r s t a r t o f p h y s io t h e r a p y , a n d fo r p o s t o p e r a t iv er a d i o g r a p h ic e x a m in a t io n d e la y e d d i s c h a r g e in o n e fi f t h o f t h ep a t ie n t s .I n t e r p r e t a tio n F u t u r e e f f o r t s t o e n h a n c e r e c o v e r y a n d r e d u c ele n g t h o f s t a y a f te r T H A a n d T K A s h o u ld f o c u s o n a n a lg e s ia , p r e -v e n t i o n o f o r t h o s t a t is m , a n d r a p id r e c o v e r y o f m u s c le f u n c t io n .Total hip and total knee arthroplasty (THA and TKA) are fre-quent operations with an average length of stay (LOS) of about6–12 days in the United Kingdom, Germany, and Denmark(Husted et al. 2006, Bundesauswertung 2009, NHS 2010).During the last decade, however, there has been increasedinterest in optimal multimodal perioperative care to enhancerecovery (the fast-track methodology). Improvement of anal-gesia; reduction ofsurgical stress responses and organ dysfunc-tions including nausea, vomiting, and ileus; early mobiliza-tion; and oral nutrition have been of particular interest (Kehlet2008, Kehlet and Wilmore 2008). These principles have alsobeen applied to THA and TKA, resulting in improvementsin pain treatment with multimodal opioid-sparing regimensincluding a local anesthetic infiltration technique (LIA) orperipheral nerve blocks to facilitate early mobilization (Ilfeldet al. 2006a, b, 2010a, Andersen et al. 2008, Kerr and Kohan2008), and allowing functional rehabilitation to be initiateda few hours postoperatively (Holm et al. 2010)—ultimatelyleading to a reduction in LOS (Husted et al. 2008, Barbieri etal. 2009, Husted et al. 2010a, b). Using these evidence-basedregimens combined with an improved logistical setup, LOS isreduced to about 2–4 days (Kerr and Kohan 2008, Husted etal. 2010 a,b,c, Lunn et al. 2011).H a v i n g w e ll - d e fi n e d f u n c tio n a l d i s c h a r g e c r i te r i a i s i m p e r a -t iv e i n o r d e r t o e n s u r e a s a f e d i s c h a r g e — a n d i t i s m a n d a t o r y i fm e a n i n g f u l c o m p a r i s o n o f L O S i s d o n e f o l l o w i n g a l t e r a t i o n s i nt h e t r a c k ( H u s t e d e t a l . 2 0 0 8 ) . I n t h e s a m e f a s t - t r a c k s e t t i n g , a ne a r l i e r s t u d y f o c u s e d o n p a t i e n t c h a r a c t e r i s t i c s p r e d i c t i n g L O S( H u s t e d e t a l . 2 0 0 8 ) . H o w e v e r, l i t t l e i s k n o w n a b o u t t h e s p e c i fi cr e a s o n s f o r w h y p a t i e n t s a r e h o s p i t a l i z e d d u r i n g t h e fi r s t 1 – 3d a y s a f t e r T H A o r T K A ; i .e . w h y c a n p a t i e n t s n o t b e d i s c h a r g e d ?We therefore analyzed clinical and organizational factorsresponsible for being hospitalized in a well-defined prospec-tive setup in a fast-track unit. This unit had previously docu-mented LOS of about 2–3 days (Andersen et al. 2008, Holm etal. 2010, Husted et al. 2010b, c, Lunn et al. 2011).Patients and methodsAccording to Danish law, this quality-assurance study did notrequire approval by an ethics committee. It was registered atClinicalTrials.gov (NTC01047371).@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com682 Acta Orthopaedica 2011; 82 (62008, 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 glu-cocorticoids preoperatively (Lunn et al. 2011) or use of otherIn other studies, short hospital stays of 1–2 days hachieved in selected patients, but no specific infwas provided on potential discharge problems (Ilfe2006a,b, Kerr and Kohan 2008), except in one studyet al. 2009). In this latter study on THA patients ocharge criteria were similar to ours, but patients weTable 2. Reasons for patients not being able to be discharged at 9 a.m. and 2 p.m. on various days. The accumulated pro-portions of patients not discharged are shown at the top of the table. Below that, reasons for not ful lling the speci eddischarge criteria are shown (as number of patients with each clinical problem divided by the number of patients remainingin hospital)Op-day Day 1 Day 1 Day 2 Day 2 Day 3 Day 3Evaluation 2 p.m. 9 a.m. 2 p.m. 9 a.m. 2 p.m. 9 a.m. 2 p.m.Not dischargedTKA 100% 94% 80% 33% 27% 7% 5%THA 100% 87% 60% 22% 20% 9% 6%Pain aTKA 53% 43% b 29% 19% 0% b 0% 0%THA 47% 24% b 22% 18% 20% b 11% 0%DizzinessTKA 11% 24% 15% 17% 17% 13% 0%THA 15% 21% 17% 14% 20% 11% 0%PONV cTKA 13% 8% 7% 3% 7% 0% 0%THA 11% 5% 5% 5% 5% 0% 0%ConfusionTKA 1% 0% 0% 3% 4% 0% 0%THA 2% 2% 2% 0% 0% 0% 0%SedationTKA 3% 5% 6% 6% 4% 13% 20%THA 1% 7% 5% 5% 0% 0% 0%Muscle weakness dTKA 16% b 18% 13% b 25% 8% 13% 20%THA 29% b 28% 26% b 18% 13% 44% 17%Technical eTKA 16% 10% 2% 0% 8% 13% 20%THA 15% 12% 9% 5% 0% 0% 0%“Logistics”fTKA 22% 27% 20% 33% 21% 25% 40%THA 18% 35% 20% 36% 20% 44% 50%a Pain > 5 with activityb Signi cant di erence between TKA and THAc Postoperative nausea and vomitingd or lack of su cient control to ambulatee Ongoing intravenous transfusion of blood or plasma expander, or urinary catheter due to urinary retentionf Waiting for physiotherapy or postoperative radiographsActaOrthopDownloadedfrominformahealthcare.comby82.20.71.193on02/21/12Forpersonaluseonly.Reasons for delayed discharge• Pain• Dizziness• PONV• Confusion• Sedation• MuscleWeakness• Logistical
    34. 34. Loss of Knee-Extension Strength Is Related toKnee Swelling After Total Knee Arthroplasty• Measures: knee-joint circumference, knee-extensionstrength, Timed Up & Go, 30-second Chair Stand, and 10-mfast speed walking test, and knee pain• Knee circumference increased (knee swelling) and correlatedsignificantly with the decrease in knee-extension strength• Decreased knee-extension strength, which decreasesfunctional performance shortly after TKA, is caused in part bypostoperative knee swelling.Holm et al. 2012@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    35. 35. Cryo-therapy can be effective@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    36. 36. New Modalities such as the Geko Devicemay also help to reduce swellinghttp://gekodevices.com/Comparison of true blood volumemovement per minute per device050100150200Kendall Calf FlowtronCalfFlowtronFootOnPulsedevice typevolumeflow(ml)perminute@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    37. 37. The Geko - How it works andmechanism of action• The gekoTMdevice stimulates thecommon peroneal nerve toactivate the calf muscle pumps• Increases blood flow volumeand velocity• Achieves a blood flow rate of50-70% of walking - measuredby duplex ultrasound in thefemoral veinA. T. Tucker, A. Maass, D. S. Bain et al. Augmentation of venous, arterial, and microvascular blood supply inthe leg by isometric neuromuscular stimulation via the peroneal nerve. Int. J. Angiol. 2010; 19 (1): e31-e37@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    38. 38. Progressive strength training (10 RM) commencedimmediately after fast-track total knee arthroplasty:is it feasible?• The training load increasedprogressively (p < 0.0001).• Patients experienced onlymoderate knee pain during thestrength training exercises, butknee pain at rest and knee jointeffusion (p < 0.0001) wereunchanged or decreased over thesix training sessions.• Isometric knee-extensionstrength and maximal walkingspeed increased by 147 and112%, respectively.Linding Jakobson et al. 2012@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    39. 39. @twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.comPhysiotherapy post-discharge
    40. 40. • We should consider the effect of Sarcopeniain patients undergoing hip and kneereplacement surgery• Conclusions of the above study - Adaptationsto RET are markedly blunted in the elderly@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    41. 41. Elderly individuals have an ‘anabolic resistance’which is essentially a concept of having adiminished response to exercise and feeding(protein)Differences in Muscle Protein Synthesis and AnabolicSignaling in the Postabsorptive State and in Response toFood in 65–80 Year Old Men and WomenGordon I. Smith1 ., Philip Atherton2 ., Dennis T. Villareal1, Tiffany N. Frimel1, Debbie Rankin2, Michael J.Rennie2, Bettina Mittendorfer1*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 KingdomAbstractWomen have less muscle than men but lose it more slowly during aging. To discover potential underlying mechanism(s) forthis 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 6was, 40% less (P, 0.05) and the basal rate of MPSwas , 30% greater (P= 0.02) in women than in men; the basal concentrationsof muscle phosphorylated AktT 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 6were not different between the sexes.Feeding increased (P, 0.05) AktT h r 3 0 8and p70s6kT h r 3 8 9phosphorylation to the same extent in men and women butincreased (P, 0.05) the phosphorylation of eIF4ES e r 2 0 9and eIF4E-BP1T h r 3 7 / 4 6in men only. Accordingly, feeding increasedMPS in men (P, 0.01) but not in women. The postabsorptive muscle mRNA concentrations for myoD and myostatin werenot 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 MPSand its control in older adults; a greater basal rate of MPS, operating over most ofthe day may partially explain the slower loss of muscle in older women.Citation: Smith GI, Atherton P, Villareal DT, Frimel TN, Rankin D, et al. (2008) Differences in Muscle Protein Synthesisand Anabolic Signaling in the PostabsorptiveState and in Response to Food in 65–80 Year Old Men and Women. PLoS ONE 3(3): e1875. doi:10.1371/journal.pone.0001875Editor: Alejandro Lucia, Universidad Europea de Madrid, SpainReceived January 3, 2008; Accepted February 21, 2008; Published March 26, 2008Copyright: ß 2008 Smith et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permitsunrestricted 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 BiologicalSciences Research Council grants BB/XX510697/1 and BB/C516779/1, and a European Union EXEGENESISprogram grant. Philip Atherton is a designated ResearchCouncils UK fellow.Competing Interests: The authors have declared that no competing interests exist.* E-mail: mittendb@wustl.edu. These authors contributed equally to this work.IntroductionAdequate maintenance of muscle mass throughout life isimportant to preserve locomotor functions and diminish the riskThe fact that no sex differences in MPS have been reported inthe literature might be because these studies were conducted inyoung and middle-age adults with a constant muscle mass duringpostabsorptive conditions, when sex differences may be small or@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    42. 42. • Strength is lost rapidly. Longitudinal studiesshow that at age 75 years, strength is lost at arate of 3–4% per year in men and 2.5–3% peryear in women.@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    43. 43. Summary• Implementing Enhanced Recovery – A great successto date…• But, still work to do in spreading the principles toother procedures• At the same time we need to sustain progress andmake further improvements• Leading centers will focus on post-discharge in orderto improve physical and functional recovery(PROMs).@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com
    44. 44. Thank you@twwainwright enhancedrecoveryblog.com@twwainwright enhancedrecoveryblog.com