CHAPTER OUTLINE
Surgical Factors 225
Minimally Invasive Surgical Techniques 226
Patient Factors 226
Nursing Issues 228
Aggressive Postoperative Physical Therapy 228
Proper Pain Management 228
Pre-emptive Analgesia 228
Modified Anesthesia Program 229
Discharge 230
Summary 230
Total hip arthroplasty (THA) is a very successful operation to relieve pain and reduce disability in patients with end-stage arthritis of the hip. The long-term goals of THA, which include improving function, relieving pain, and obtaining stability, are realized in the majority of cases. Thus, the focus has evolved to extend these goals to the perioperative period. This has manifested in trying to decrease complications, accelerate rehabilitation goals, and decrease hospital stay.
As technology and surgical techniques improve, so do patient expectations from THA, including an early return to normal physical function and activities. Specifically, the recovery of normal ambulatory function after hip surgery is a major goal of treatment and is a key component in patients regaining function and independence. With end-stage hip arthritis, ambulatory function is impaired, owing to a combination of pain, poor range of hip joint motion, and weak abductor strength.
Aggressive perioperative programs have been conceived that aim to hasten recovery, decrease morbidity and complications, and establish a program of efficiency while maintaining a high level of patient care.
The goals of a rapid recovery program for THA are to hasten functional return for the patient, reduce length of hospital stay and overall cost, and reduce overall patient discomfort. However, at the same time, the quality of the THA must not be compromised. To achieve these goals requires the participation of many—the patient, family, surgeon, anesthesia team, nurses, rehabilitation team, and social services personnel.
In this chapter we outline the different factors that constitute a rapid recovery program, from surgical and patient factors, to aggressive postoperative physical therapy, proper pain management, modified anesthesia programs, and a team approach to the rehabilitation protocol.
SURGICAL FACTORS
To achieve a successful rehabilitation protocol, a surgeon must be attentive to the technical aspects of the surgery to create a stable joint. This will allow the rehabilitation process to be started in the perioperative period.
Inherently, the anterolateral and anterior approaches are more stable and have been associated with a lower dislocation rate. If a posterior approach is used, meticulous attention should be made to capsular closure to decrease the dislocation rate.
Postoperative restrictions after THA also play a major role in prolonging rehabilitation, because the patient is concerned about dislocation rather than progress with his or her rehabilitation regimen. In a prospective randomized study, the role of postoperative functional restrictions on the prevalence of dislocation after uncemented THA through an anterolateral approach was studied.
In this study 265 patients (303 hips) were randomized into one of two groups: the restricted versus unrestricted groups. Both groups were instructed on limiting hip flexion to less than 90 degrees and external/internal rotation to 45 degrees. The patients in the restricted group were instructed to comply with additional hip precautions during the first 6 weeks postoperatively. There was one occurrence of postoperative dislocation that occurred in the restricted group. No dislocations occurred in the unrestricted group.
The authors concluded that removal of several restrictions did not increase the prevalence of dislocation after primary hip arthroplasty. However, it did promote substantially lower costs and was associated with a higher level of patient satisfaction as patients achieved a faster return to daily functions in the early postoperative period.
One of the surgical factors that can help reduce the rate of dislocation is the femoral head size. With newer material designs and features, there has been a propensity toward placing the largest femoral head size possible. One must be aware not to compromise the thickness of the polyethylene when doing so.
Also, using an implant that allows immediate full weight bearing is a key component of accelerated rehabilitation in the perioperative period. In our institution, our bias has been toward using a collarless, tapered, porous-coated femoral stem. These stems have withstood the test of time. In a 15-year follow-up study on the Trilock and Taperloc stems, 96% of the patients in the Trilock group and 100% of the patients in the Taperloc group had radiographic evidence of bone ingrowth. The design features virtually ensure bone ingrowth and are thought to be responsible for the excellent clinical results and longevity.
Several studies have evaluated weight bearing after THA to substantiate its safety with the newer femoral stem designs. Woolson and Adler assessed the effects of full weight bearing versus 50 pounds or less of weight bearing for 6 weeks in patients who underwent THA using a fully porous-coated collared femoral component. All femoral components in both groups had radiographic evidence of bone ingrowth fixation at the 2-year follow-up.
These researchers concluded that when solid initial fixation is obtained intraoperatively using a fully porous-coated anatomic medullary locking (AML) femoral component, it seems that bone ingrowth fixation reliably occurs whether a partial or full weight-bearing postoperative protocol is followed.
The radiographic subsidence of the uncemented Taperloc stem and clinical results after unilateral and simultaneous bilateral uncemented THA were compared. Patients who had bilateral THA began weight bearing as tolerated on both lower extremities the day after surgery. Patients who had undergone unilateral THA were maintained at 10% weight bearing on the operative limb for 6 weeks after surgery. All femoral prostheses in both groups appeared radiographically stable with evidence of bone ingrowth and no indications of loosening. Patients in both groups obtained satisfactory clinical results.
In another study, a prospective review of two groups of patients undergoing cementless THA was undertaken. The first group was allowed full weight bearing immediately after the operation, and the other group underwent protected weight bearing for 6 weeks. Patients were matched for sex, age at surgery, height, weight, and follow-up period. There were no significant differences in hip scores between the two groups, and all patients showed bone ingrowth radiographically. Protected weight bearing resulted in a longer hospital stay.
Minimally Invasive Surgical Techniques
The advent of minimally invasive surgery initiated a desire and willingness for quicker recovery programs. However, one must be cautious about attributing faster recovery to minimally invasive surgical techniques or minimal incision surgery because the incision size does not appear to be the most critical aspect of the rapid recovery program.
Uncontrolled postoperative pain has a more deleterious effect on the recovery of function than the length of the incision. The marketing claims made by proponents of minimally invasive surgery for THA have given misguided perceptions to the public regarding the current standard of care. It appears that pain control plays a much larger role in functional recovery than incision length.
Many advocates of minimally invasive surgery assert faster recovery and rehabilitation of their patients. Yet, the definition of minimally invasive surgery has not been accurately illustrated.
In many cases, in our attempts at performing minimally invasive surgery, we end up with a minimal incision surgery instead, without minimizing trauma to the soft tissues, or in some cases with increased traumatic injury to the tissues.
The definition of minimally invasive surgery should entail a smaller incision with direct visualization and a modified technique. But we should not deviate from the classic surgical principles, which should include:
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Good visualization
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Gentle and atraumatic handling of the soft tissues
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Avoidance of neurovascular injury
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Achieving homeostasis
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Proper fixation and positioning of the components
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Performing surgery in a timely fashion
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Not overcommitting on the incision, making it longer as needed
Adhering to these principles would enable us to ensure a faster rehabilitation program for our patients.
PATIENT FACTORS
Patient Education
Patient expectations and education preoperatively are important predictors of improved functional outcomes and satisfaction after THA.
In a study looking at preoperative rehabilitation advice reinforced by a patient information booklet, 35 patients were recruited and randomly allocated before admission to receive either the standard pathway of care or the rehabilitation program and booklet. The preoperative class and booklet seemed to have the greatest impact on length of hospital stay, reducing the hospital stay by 3 days, and the therapy input required, significantly influencing the cost of the procedure ($810 savings per patient). In addition, patients attending the class reported higher levels of satisfaction at 3 months postoperatively and had more realistic expectations of surgery.
In a similar study, the impact of a social work preadmission program on length of stay of orthopedic patients undergoing elective THA or total knee arthroplasty (TKA) was evaluated. The social work interventions included preadmission psychosocial evaluation and preliminary discharge planning. Mean length of stay was reduced significantly in the intervention patient groups, as compared with the pre-intervention patient groups in the same hospital. They concluded that preadmission screening and case management by a social worker can contribute to the efforts to decrease length of stay of orthopedic patients by early multidisciplinary evaluations, discharge planning, and coordination of services.
Daltroy and coworkers, in another study, further illustrated that educational intervention reduced length of stay. Also found was a reduction in the use of pain medication for patients who exhibited most denial and reduced postoperative anxiety.
Nutritional Status
The preoperative nutritional state of the patient has an immense impact on wound healing postoperatively. In addition, it has a predictive role in morbidity and length of hospital stay. Accordingly, special attention should be made to this aspect of patient care.
Del Savio and associates sought to identify preoperative nutritional factors that could be used to define a subgroup of patients undergoing elective THA who are at high risk for poor postoperative outcome. They found an inverse relationship between serum albumin value and length of hospital stay. Patients with an albumin level less than 3.9 were twice as likely to require prolonged hospitalization. They concluded that preoperative malnutrition appears to be associated with the in-hospital postoperative recovery but unrelated to long-term recovery.
Conversely, Gherini and colleagues found that preoperative serum transferrin levels showed significant value in predicting which patients would have delayed wound healing. None of the other serologic variables, including serum albumin and total lymphocyte count, proved to be a predictor of delayed wound healing. When combined with bilateral surgery and advanced age, serum transferrin levels resulted in a correct prediction of delayed wound healing in 79% of cases.
Thus, improving the nutritional status of patients undergoing elective hip surgery can have an enormous impact on the perioperative period. One must be cautious about certain nutritional supplements that may have a negative effect on the patient. An example of this would be omega-3 fatty acids, which can increase bleeding when taken in moderate amounts.
Smoking
In evaluating the effect of smoking, Moller and coworkers studied 811 consecutive patients who had undergone THA or TKA. They found that smoking was the single most important risk factor for the development of postoperative complications, particularly those relating to wound healing, cardiopulmonary complications, and the requirement of postoperative intensive care.
In those patients requiring prolonged hospitalization the proportion of smokers with wound complications was twice that of nonsmokers. Hence, counseling patients preoperatively on smoking cessation is crucial to decrease smoking-related complications and improve outcome and should be an integral part of the rapid recovery protocol for patients undergoing elective hip surgery.
Pre-arthroplasty Rehabilitation
Perioperative customized exercise programs are effective in improving the rate of recovery and ambulatory function in the first 6 months after THA. Providing a high level of education for the patient and family appears to help in facilitating the rehabilitation in the early perioperative period.
In a randomized controlled study, 28 subjects scheduled for THA were randomized to either the exercise group and received a perioperative customized exercise program or the control group and received the routine perioperative care. Ambulatory function was assessed by measurement of gait parameters during a 25-meter walk test, and walking endurance was assessed by a 6-minute walk test.
Exercise group subjects demonstrated greater stride length and gait velocity at 3 weeks after surgery. At 12 and 24 weeks after surgery, gait velocity was greater and the 6-minute walking distance was significantly greater than in the control group.
Crowe and Henderson evaluated the effect on length of stay of individually tailored rehabilitation for clients who were undergoing THA or TKA. One hundred thirty-three patients were randomly assigned to receive the preoperative usual care or a tailored rehabilitation program, which included a multidisciplinary rehabilitation to optimize functional capacity, education about the in-hospital phase, and early discharge planning. All rehabilitation subjects received interdisciplinary counseling/education focused on preparation for discharge home. They found that patients receiving the tailored rehabilitation protocol achieved discharge criteria earlier and had a shorter actual length of stay (average of 5.4 days vs. 8 days).
Munin and colleagues demonstrated that early transfer from acute care to inpatient rehabilitation is associated with a more rapid attainment of goals; however, no studies have prospectively evaluated the benefit of inpatient rehabilitation after elective THA or TKA.
In a prospective, randomized study, an 8-week customized exercise program was applied to patients scheduled for THA, followed by a postsurgery exercise program. They were compared with a control group who received no additional exercise apart from routine in-hospital physical therapy. Significant improvements in outcome measures for the exercise group were observed throughout the postoperative phase from weeks 3 to 24.
All these studies illustrate that a perioperative customized exercise program is well tolerated in the elderly patient with end-stage hip arthritis and is effective in improving the rate of recovery in ambulatory function in the first 6 months after THA.
Clinical Pathways Programs
The effectiveness of clinical pathways in reducing length of hospital stay and cost has been studied extensively. The principle behind it is creating a framework for managing patients in the perioperative period. This will help streamline patient care and allow for a more efficient method in managing a patient’s stay in the hospital.
In one prospective randomized controlled study, the authors sought to establish the effectiveness of clinical pathways for improving patient outcomes and decreasing lengths of stay after THA and TKA. One hundred sixty-three patients undergoing primary THA or TKA were randomly allocated to the clinical pathway or the control group. Clinical pathway patients had a shorter mean length of stay, earlier ambulation, a lower readmission rate, and a closer matching of discharge target.
In a meta-analysis, several articles assessing clinical pathways for THA and TKA were reviewed. Patients treated using pathways experienced shorter hospital stays and lower costs, with comparable clinical outcomes as compared with patients treated without clinical pathways. They concluded that clinical pathways appear successful in reducing costs and length of stay in the acute care hospital, with no compromise in patient outcomes.
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