Research Review By Dr. Jeff Muir©


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Date Posted:

February 2014

Study Title:

Enhanced recovery in total hip replacement: a clinical review


Ibahim MS, Twaij H, Giebaly DE et al.

Author's Affiliations:

University College Hospital, Department of Trauma & Orthopaedics, London, United Kingdom; The Epworth Centre, Victoria, Australia.

Publication Information:

The Bone & Joint Journal 2013; 95-B: 1587–94.

Background Information:

Total hip replacement (THR) is an effective treatment option for patients with severe osteoarthritis and for whom conservative care has failed (1). The number of procedures increases each year and, with increasing budgetary considerations in hospitals, methods to minimize hospital stays and improve recovery from THR continue to grow in importance.

In the 1990s, “enhanced recovery programs” (ERPs) were developed in an attempt to improve rehabilitation from surgical procedures. While several such programs have been proposed and the evidence suggests that these programs are effective at reducing recovery time following THR (2-4), there is no consensus regarding which factors are most important or effective. This review compiled all available evidence to determine the most effective aspects of ERPs in THR. Clinicians providing manual therapy and rehabilitation should be aware of this body of work, as they are ideally positioned to assist these patients.

Pertinent Results:

Enhanced recovery programs were evaluated based on the type of intervention: non-surgical or surgical.

Non-surgical Interventions:

Pre-Operative Patient Education:
The goal of patient education programs is to make the patient an active part of their recovery. Such programs have demonstrated improvements in patient-related outcome measures, although there is often a discrepancy between patient and surgeon expectations, with patients generally having higher post-surgical expectations. Length of hospital stay has been shown to decrease by up to 1 day when utilizing such programs (5), although significant initial costs can be associated with establishing such a program.

Peri-Operative Hemoglobin Levels:
Low (< 8 g/dL) pre-operative hemoglobin (Hb) levels are associated with post-operative transfusion and increased length of stay (5). Patients with a pre-operative Hb level of > 14 g/dL had a significantly shorter length of stay (6). Increasing pre-operative Hb to a minimum of 12 g/dL pre-operatively through treatment with erythropoietin and iron supplements is effective at minimizing post-operative transfusion and length of hospital stay (7).

Pre-Operative Patient Nutrition:
Malnutrition can lead to infection, sepsis and delayed healing and is associated with prolonged hospital stays following surgery (8). Triceps skin fold thickness is inversely proportional to the post-operative risk of infection (9) and increased BMI is associated with longer surgical times and increased blood loss (10). While weight loss prior to surgery decreases the rate of complications (11), malnutrition can still exist in obese patients and, when weight loss prior to surgery is not possible, an approach employing calorie loading 48 hours prior to surgery and reduced fasting was associated with a significant decrease in length of stay following surgery (6).

Pre-Emptive Analgesia:
Post-operative pain decreases both patient satisfaction and patient mobility and can have a significant negative impact on recovery in both the short-term and long-term (12-16), although there is no consensus regarding the effect on length of stay. Pre-emptive application of pain relief medication has been suggested as an effective method for minimizing post-operative pain and immobility. However, there is minimal evidence supporting this approach, with the use of opiates associated with slowed rehabilitation and reduced patient satisfaction (17) and NSAIDs associated with adverse gastro-intestinal effects, cardiac risks and adverse effects on renal function.

Local-Infiltration Analgesia (LIA):
The intra-operative infiltration of drugs, which may also be followed by post-operative bolus administration, has been reported to allow mobilization within 4-6 hours of surgery and allowed discharge after one overnight stay (18). Other studies have shown an improvement in pain and mobility between days 1 and 4 post-operatively, although no effect was detected after 7 days (19, 20).

American Society of Anesthesiologists (ASA) Grade:
The ASA grades range from 1 (healthy) to 6 (declared brain-dead). Length of stay is significantly lower in ASA grade 1 or 2 patients versus grade 3 (21, 22).

Pulsed Electromagnetic Fields (PEMF):
PEMF is a commonly used, safe and non-invasive pain relief and healing modality with a strong anti-inflammatory effect. One study demonstrated an improvement in functional recovery following PEMF treatment (23), although there is a lack of sufficient evidence to broadly support its use in THR patients.

Peri-Operative Rehabilitation Programs:
Highly organized and multidisciplinary programs with a focus on patient education, nutrition, exercise, mobilization and pain relief medication have demonstrated effectiveness at decreasing length of stay, even in patients with ASA grade 3, lowered Hb and increased BMI (6). A coordinated program of pre-operative rehabilitation involving physiotherapy, water therapy and ice has also been shown to decrease length of stay (6, 20, 24).

Post-Operative Hip Precautionary Measures:
Normally, THR patients are given certain instructions for the post-surgical period. One prospective RCT found that patients without restrictions on sleeping position, sitting height and car use (as a passenger) recovered faster than patients with traditional post-operative limitations on these movements (25) – a slightly counterintuitive yet interesting finding that requires more research.

No effect on length of stay was noted in patients using a traditional wound dressing, as compared with more modern plastic film dressings.

Surgical Interventions:

Conventional Surgery vs. Minimally-Invasive Surgery:
Minimally-invasive surgery (MIS) is defined by an incision length of between 10 and 12 cm. Such methods are associated with less soft-tissue damage and therefore better post-surgical outcomes and recovery (26, 27). Several MIS approaches can be employed for THR, including posterior, direct anterior and anterolateral approaches, using either one or two incisions. The use of two incisions (is this still minimal?) is associated with significantly shorter time-to-walking and shorter length of stay but is also associated with increased operating time and more complications (28). The majority of these approaches have fallen out of favor, with the exception of the direct anterior approach, which is now considered to provide the best post-operative results (29, 30).

Fast-Track Joint Replacement Units:
Some hospitals have instituted specialized units to provide ERP for patients, with the goal of fast(er) recovery (31). These units combine pre-operative and pre-emptive analgesia with education, physiotherapy and/or water therapy, with generally positive results, although the logistics of organizing such a program are considerable and may be prohibitive for some facilities.

Clinical Application & Conclusions:

Early recovery programming for THR patients has been widely implemented and appears to improve patient care and function while reducing length of stay, although there is great variability in the type of program and each program’s components. The possibility of THR becoming a day-case or outpatient procedure for certain patients is certainly becoming more achievable, although for the majority of patients, THR remains an in-patient procedure associated with a short hospital stay. Evidence informed manual medicine and rehabilitation providers should continue to actively work with patients before and after these procedures to prepare, rehabilitate and strengthen their bodies while improving overall function.

Study Methods:

Search Strategy:
This clinical review used a systematic search strategy, although did not extract data as per a systematic review protocol. Instead, as a clinical review, any evidence was summarized and presented without statistical analysis.

MEDLINE, EMBASE, AMED and the Cochrane library databases were searched from over a period 10 years. Keywords for searches included: ‘enhanced recovery’, ‘accelerated recovery’, ‘fast track’, ‘rapid recovery’, ‘total hip replacement’ and ‘total hip arthroplasty’. All studies concerning ERPs and THR were included and papers not published in English were excluded.

Study Strengths / Weaknesses

  • As a clinical review, the search strategy was less robust than in a systematic review, and
  • The lack of pooling of results or statistical analysis limit the application of the findings to clinical settings.
  • The authors acknowledge the above limitations and present their findings as clinical observations, without extrapolating the results, and
  • The broad search strategy allowed for inclusion of a large number of studies of various types, bolstering the clinical findings.

Additional References:

  1. Ethgen O, Bruyère O, Richy F et al. Health-related quality of life in total hip and total knee arthroplasty: a qualitative and systematic review of the literature. J Bone Joint Surg (Am) 2004; 86-A: 963–974.
  2. Kehlet H, Wilmore DW. Fast-track surgery. Br J Surg 2005; 92: 3–4.
  3. Larsen K, Hansen TB, Thomsen PB, Christiansen T, Søballe K. Cost-effectiveness of accelerated perioperative care and rehabilitation after total hip and knee arthroplasty. J Bone Joint Surg (Am) 2009; 91-A: 761–772.
  4. Husted H, Hansen HC, Holm G, et al. What determines length of stay after total hip and knee arthroplasty?: a nationwide study in Denmark. Arch Orthop Trauma Surg 2010; 130: 263–268.
  5. Bierbaum BE, Callaghan JJ, Galante JO, et al. An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg (Am) 1999; 81-A: 2–10.
  6. Dwyer AJ, Tarassoli P, Thomas W, Porter P. Enhanced recovery program in total hip arthroplasty. Indian J Orthop 2012; 46: 407–412.
  7. Rogers BA, Cowie A, Alcock C, Rosson JW. Identification and treatment of anaemia in patients awaiting hip replacement. Ann R Coll Surg Engl 2008; 90: 504–507.
  8. Berend KR, Lombardi AV Jr, Mallory TH. Rapid recovery protocol for peri-operative care of total hip and total knee arthroplasty patients. Surg Technol Int 2004; 13: 239–247.
  9. Font-Vizcarra L, Lozano L, Rios J, Forga MT, Soriano A. Preoperative nutritional status and post-operative infection in total knee replacements: a prospective study of 213 patients. Int J Artif Organs 2011; 34: 876–881.
  10. Hallert O, Li Y, Brismar H, Lindgren U. The direct anterior approach: initial experience of a minimally invasive technique for total hip arthroplasty. J Orthop Surg Res 2012; 7: 17.
  11. Riddle DL, Singh JA, Harmsen WS et al. Clinically important body weight gain following total hip arthroplasty: a cohort study with 5-year follow-up. Osteoarthritis Cartilage 2013; 21: 35–43.
  12. Crawford RW, Murray DW. Total hip replacement: indications for surgery and risk factors for failure. Ann Rheum Dis 1997; 56: 455–457.
  13. Brokelman RB, van Loon CJ, Rijnberg WJ. Patient versus surgeon satisfaction after total hip arthroplasty. J Bone Joint Surg (Br) 2003; 85-B: 495–498.
  14. Cross M, Lapsley H, Barcenilla A, et al. Patient expectations of hip and knee joint replacement surgery and postoperative health status. Patient 2009; 2: 51–60.
  15. Haanstra TM, van den Berg T, Ostelo RW, et al. Systematic review: do patient expectations influence treatment outcomes in total knee and total hip arthroplasty? Health Qual Life Outcomes 2012; 10: 152.
  16. Luan Yeap Y, Butterworth JF. Analgesic techniques after total hip arthroplasty. Anesth Analg 2011; 113: 687–688.
  17. Ali M, Pagnano MW, Horlocker T, Lennon RL. How I manage pain after total hip arthroplasty. Semin Arthroplasty 2008; 19: 231–236.
  18. Kerr DR, Kohan L. Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: a case study of 325 patients. Acta Orthop 2008; 79: 174–183.
  19. Kang H, Ha YC, Kim JY, et al. Effectiveness of multimodal pain management after bipolar hemiarthroplasty for hip fracture: a randomized, controlled study. J Bone Joint Surg (Am) 2013; 95-A: 291–296.
  20. Husted H, Solgaard S, Hansen TB et al. Care principles at four fast-track arthroplasty departments in Denmark. Dan Med Bull 2010; 57: A4166.
  21. No authors listed. New classification of physical status. Anesthesiology 1963; 24: 111.
  22. Husted H, Holm G, Jacobsen S. Predictors of length of stay and patient satisfaction after hip and knee replacement surgery: fast-track experience in 712 patients. Acta Orthop 2008; 79: 168–173.
  23. Moretti B, Notarnicola A, Moretti L, et al. I-ONE therapy in patients undergoing total knee arthroplasty: a prospective, randomized and controlled study. BMC Musculoskelet Disord 2012; 13: 88.
  24. Malviya A, Martin K, Harper I, et al. Enhanced recovery program for hip and knee replacement reduces death rate. Acta Orthop 2011; 82: 577–581.
  25. Ververeli PA, Lebby EB, Tyler C, Fouad C. Evaluation of reducing postoperative hip precautions in total hip replacement: a randomized prospective study. Orthopedics 2009; 32: 889.
  26. Goosen JH, Kollen BJ, Castelein RM et al. Minimally invasive versus classic procedures in total hip arthroplasty: a double-blind randomized controlled trial. Clin Orthop Relat Res 2011; 469: 200–208.
  27. Khan RJ, Maor D, Hofmann M, Haebich S. A comparison of a less invasive piriformis-sparing approach versus the standard posterior approach to the hip: a randomised controlled trial. J Bone Joint Surg (Br) 2012; 94-B: 43–50.
  28. Lutzner J, Gunther KP, Kirschner S. Functional outcome after computer-assisted versus conventional total knee arthroplasty: a randomized controlled study. Knee Surg Sports Traumatol Arthrosc 2010; 18: 1339–1344.
  29. Kennon RE, Keggi JM, Wetmore RS, et al. Total hip arthroplasty through a minimally invasive anterior surgical approach. J Bone Joint Surg (Am) 2003; 85-A(Suppl): 39–48.
  30. Moskal JT, Capps SG. Is limited incision better than standard total hip arthroplasty?: a meta-analysis. Clin Orthop Relat Res 2013; 471: 1283–1294.
  31. Husted H. Fast-track hip and knee arthroplasty: clinical and organizational aspects. Acta Orthop Suppl 2012; 83: 1–39.

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