Reduced Length of Hospitalization in Primary Total Knee Arthroplasty Patients Using an Updated Enhanced Recovery After Orthopedic Surgery (ERAS) Pathway

doi:10.1016/j.arth.2015.05.007

The Journal of Arthroplasty

Volume 30, Issue 10, October 2015, Pages 1705-1709

https://doi.org/10.1016/j.arth.2015.05.007 Get rights and content

Abstract

Decreasing hospital length of stay may attenuate costs associated with total knee arthroplasty. The purpose of this study was to determine if updates to an existing orthopedic enhanced recovery after surgery (ERAS) pathway would improve length of hospitalization. Clinical and demographic data were collected on 252 primary total knee arthroplasties between January 2012 and July 2013. Pre-updated and post-updated ERAS pathway cohorts were analyzed for length of stay, clinical outcomes, and re-admissions. The mean length of stay decreased from 76.6 hours to 56.1 hours after implementation of the evidence-based orthopedic enhanced recovery after surgery pathway (P < 0.001). This improvement was possible without a concomitant increase in readmission rates.

Section snippets

Study Design

After approval from the internal review board, all patients who had undergone primary TKA at our institution were retrospectively identified over a period from January 2012 to July 2013. Inclusion criteria consisted of patients who had undergone surgery with a standardized care pathway that included femoral nerve block and those who had undergone surgery with the updated ERAS pathway (Table 1). Implementation of the updated ERAS pathway occurred in early 2013. Moving retrospectively from early

Results

Two hundred and fifty two subjects total were retrospectively analyzed before and after the implementation of the updated ERAS pathway. There were no significant differences in gender, body mass index, the use of spinal anesthesia as the primary anesthetic, or frequency of surgeon intra-articular injection between groups (Table 2). Mean age was 68.4 and 66 years in the pre and post pathway groups, respectively (P = 0.056).

The primary outcome of this investigation was hospital LOS. Median LOS was

Discussion

Our study reveals that incorporation of recent innovations in the perioperative care of TKAs can result in clinically meaningful decreases in post-operative length of stay without increasing readmission rates. In this evolving health care environment, decreasing costs while improving outcomes should be a primary goal of any health care delivery system. The data presented here demonstrate that multiple key evidence-based improvements to an existing clinical value stream likely had a tremendous

Acknowledgments

The authors would like to acknowledge Dr. Stuart A. Grant for his encouragement and mentorship throughout the research process. We also acknowledge the contribution of April E. Slee, MS, our statistical consultant from Axio Research, Seattle, WA USA.

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Enhanced recovery after surgery (ERAS) in total knee arthroplasty (TKA) has reduced the length of stay (LOS) and cost of TKA in the Western population. Asians had been identified to be at higher odds of non-home discharge following TKA due to cultural differences. The efficacy of ERAS in TKA for Asian patients is less known. We aimed to investigate the efficacy of ERAS in reducing the LOS, transition to ambulatory surgery, improving home discharges, and reducing cost in an Asian population following TKA.
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ERAS after TKA was able to safely achieve LOS comparable to the western population and allowed transition to ambulatory knee replacement in the Asian population. Consequently, this led to higher proportion of home discharges and achieved significant cost saving and hospital bed days.
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HS was the most influential factor in predicting both operative time and LOS after RSA, with strong associations indicated by standardized β coefficients of 0.234 for operative time and 0.432 for LOS. Subcutaneous tissue size, deltoid size, and DHR also showed stronger predictive values than BMI for both outcomes. In terms of prosthetic joint infection, HS, deltoid size, and DHR were significant predictors, with HS demonstrating the highest predictive power (Nagelkerke R² = 0.44), whereas BMI did not show a statistically significant association with infection. Low event counts resulted in wide confidence intervals for odds ratios in the infection analysis.
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Existe un incremento de las artropatías degenerativas como consecuencia del aumento en la longevidad de la población mundial, haciendo de las artroplastias primarias de rodilla un procedimiento para recuperar calidad de vida sin dolor. Existen factores asociados al tiempo de estancia hospitalaria después de este procedimiento.
Determinar los factores que influyen en la estancia hospitalaria durante el postoperatorio de pacientes sometidos a artroplastia primaria total de rodilla con un protocolo de recuperación mejorada después de la cirugía (ERAS).
Se realiza un estudio retrospectivo de pacientes sometidos a artroplastia primaria total de rodilla en un hospital universitario en el período 2017-2020 mediante el protocolo ERAS, durante el cual se realizaron 957 cirugías.
La edad media fue de 71,7 ± 8,2 años, el 62,4% fueron mujeres y mayoritariamente ASA II (77,3%).
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There is an increase in degenerative arthropathies because of the increase in the longevity of world's population, making primary knee arthroplasties a procedure to recover quality of life without pain. There are factors associated with the length of hospital stay after this procedure.
To determine the risk factors influencing the hospital stay during the postoperative period of patients undergoing primary total knee arthroplasty with an enhanced recovery after surgery protocol (ERAS).
A retrospective study is carried out on patients undergoing primary total knee arthroplasty at an University Hospital in the period 2017-2020 using the ERAS protocol, during which 957 surgeries were performed.
Average age of 71.7 ± 8.2 years, 62.4% were women and the 77.3% were classified as ASA II. The significantly associated factors to an increased length of stay are: age (P = .001), ASA scale (P = .04), day of surgery (P < .001), blood transfusion (P < .001), postoperative hemoglobin level at 48-72 h (P < .001), the time of first postoperative mobilization to ambulate and climb stairs (P < .001), the need for analgesic rescues (P = .003), and the presence of postoperative nausea and vomiting (P = .008).
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A retrospective analysis was performed for 111 consecutive patients who had undergone primary unilateral TKA from November 2019 to October 2020 at a single tertiary hospital by fellowship-trained arthroplasty surgeons. Three independent, blinded observers extracted patient data from our institution's Electronic Medical Records. The ERAS protocol included preoperative smoking and alcohol cessation, preoperative physiotherapy, intraoperative local infiltration analgesia using a drug cocktail, postoperative multimodal analgesia and postoperative day 0 physiotherapy, while any patient who deviated from any step were classified as non-ERAS. Two-sample t-tests, Wilcoxon rank-sum tests and Chi-squared tests were used to compare the outcome variables between ERAS and non-ERAS patients.
Patients under the ERAS protocol (n = 67) reported a significantly lower postoperative day 0 pain score (p = .0480) and a shorter hospital LOS (p = .0189) than non-ERAS patients (n = 44). No significant difference (p > .05) was observed for ROM and distance walked on days 1–2.
Our study demonstrates that the ERAS protocol improves day 0 postoperative pain and shortens hospital LOS while being non-inferior for ROM and distance walked on days 1–2.
Ultrasound-guided paravertebral nerve block anesthesia for percutaneous endoscopic laser unroofing treatment of symptomatic simple renal cysts—An innovative ambulatory surgery mode
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Postoperative pain is the prime obstacle to recovery of motion and return to activity after total knee arthroplasty (TKA). Combating pain is a key point in enhanced recovery after surgery (ERAS) protocols. Outcome depends on the efficacy of pain relief, making it a major issue. The pain originates locally in the knee and also remotely via neural pathways. Regression can be slow, over several months. Pain may sometimes be definitive, to a varying degree. Pain should be managed at each step of ERAS, from the preoperative period to the last follow-up consultation, and most especially during the perioperative phase. Pain needs to be anticipated and limited for as long as necessary. The impact of analgesics should be enhanced by means of potentiators. Some are administered by general route, sometimes preoperatively; others are applied locally, directly in the surgical site by local injection, or close to the nerves, to reduce painful stimuli. The two main principles of pain management are preventive analgesia and multimodal analgesia associating various molecules and routes.

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: One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.05.007.

¹: Contribution: Study design, data collection, data analysis, manuscript preparation.

²: Attestation: This author reviewed the original study data and data analysis, and approved the final manuscript.

³: Conflicts of Interest: None.

⁴: Contribution: Data analysis and manuscript preparation.

⁵: Attestation: This author approved the final manuscript.

⁶: Contribution: Study design, manuscript preparation.

⁷: Attestation: This author approved the final manuscript.

View full text

Reduced Length of Hospitalization in Primary Total Knee Arthroplasty Patients Using an Updated Enhanced Recovery After Orthopedic Surgery (ERAS) Pathway

Abstract

Section snippets

Study Design

Results

Discussion

Acknowledgments

J Arthroplasty

J Arthroplasty

Orthop Traumatol Surg Res

J Arthroplasty

J Arthroplasty

Gastroenterology

The dramatic increase in total knee replacement utilization rates in the United States cannot be fully explained by growth in population size and the obesity epidemic

J Bone Joint Surg Am

Estimating the burden of total knee replacement in the United States

J Bone Joint Surg Am

Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030

Clin Orthop Relat Res

Hospital economics of primary total knee arthroplasty at a teaching hospital

Clin Orthop Relat Res

Methods for the economic evaluation of health care programmes

The triple aim: care, health, and cost

Health Aff

Clinical Guidelines Committee of the American College of P. High-value, cost-conscious health care: concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions

Ann Intern Med