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Results of enhanced recovery after primary ankle replacements
Accepted Manuscript Title: Results of Enhanced Recovery after Primary Ankle Replacements Authors: K. Jain, P. Murphy, T. Karim, M. Karski, T.M. Clough PII: DOI: Reference:
S0958-2592(16)30045-1 http://dx.doi.org/doi:10.1016/j.foot.2017.01.001 YFOOT 1450
To appear in:
The Foot
Received date: Accepted date:
8-8-2016 5-1-2017
Please cite this article as: Jain K, Murphy P, Karim T, Karski M, Clough T.M.Results of Enhanced Recovery after Primary Ankle Replacements.The Foot http://dx.doi.org/10.1016/j.foot.2017.01.001 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Results of Enhanced Recovery after Primary Ankle Replacements
Authors: K Jain1, P Murphy2, T Karim1, M Karski1 & T M Clough1 1=Wrightington Hospital, UK 2=Edge Hill University, UK
Corresponding author Mr Kowshik Jain 8, Fairhurst Drive Parbold, UK Email: [email protected] Telephone: 07749760579
Highlights
First study to investigate ER after ankle replacemets Prospective data collection A new ER pathway has been developed For the first time LIA technique for ankle replacements has been described
Background Enhanced recovery pathways for total hip and knee arthroplasty are known to reduce length of hospital stay and perioperative morbidity [1, 2 and 3]. Factors that improve outcomes include use of pre-emptive and multimodal analgesia regimens to reduce opioid consumption, identification of patients with poor nutritional status, provision of supplements preoperatively to improve wound healing and reduce length of hospital stay, use of warming systems, avoidance of drains to reduce operative blood loss and subsequent transfusion, and early ambulation with pharmacological and mechanical prophylaxis to reduce venous thromboembolism and to speed recovery [4]. A combination of pre-, intra-, and post-operative care interventions can promote a wellness model of care, avoid unnecessary medicalisation of a patient, and improve patient knowledge for their active involvement in perioperative care. This standardised perioperative care pathway is known as enhanced recovery (ER). Local infiltration analgesia (LIA) is a technique originally developed to facilitate enhanced recovery following knee replacements [5]. LIA provides good pain relief allowing a reduction in postoperative opiate use and so helps avoid the undesirable side effects of morphine such as nausea, confusion and sedation. This enables early mobilisation and discharge [6 & 7]. Postoperative pain is usually severe after ankle arthroplasty. This study was conducted to analyse the effects of enhanced recovery (ER) on postoperative stay, pain, nausea, sedation and readmission following primary ankle replacements, by comparing a consecutive group of 30 patients on the ER pathway, with a consecutive group of 30 immediately preceding patients, who were on the pre-ER pathway. Material & Methods After consultations with multidisciplinary team comprising of anaesthetists, staff nurses, physiotherapists, hospital managers, pre-operative assessment team and foot and ankle consultants, we developed an ER protocol for ankle replacement surgery, which was agreed and implemented on 01 November 2014. All patients undergoing primary total ankle replacement were included in this enhanced recovery pathway (Fig 1). 30 consecutive patients who underwent primary TAR on the ER pathway were compared with a cohort of 30 consecutive pre-ER patients (who underwent primary TAR surgery immediately prior to the implementation of ER). None of the ER patients were prescribed parenteral morphine in the immediate postoperative period. Postoperative pain was managed by a combination of paracetamol, Ibuprofen and Oxynorm 5-10 mg. Either general (plus popliteal block) or spinal anaesthesia was used in all patients, as per Anaesthetist and patient preference. Diamorphine was the preferred agent for spinal anaesthesia. All patients received 30 to
50 mls of Bupivacaine as LIA intra-operatively. Adrenaline was avoided to reduce risk of vasoconstriction leading to wound healing problems. We recommend the following technique for the LIA to be used to achieve maximum pain control: the posterior ankle capsule is injected after bone preparation and before the insertion of implants, and the anterior capsule, deltoid ligament, lateral collateral ligament, extensor retinacular layer and subcutaneous fat are injected, after insertion of the implants and before closure. A team of physiotherapists encouraged early mobilisation in these patients. All patients were allowed immediate full weight bearing as comfortable. Patients who underwent primary TAR with concomitant calcaneal osteotomy and those with intra-operative fractures were excluded from the study. Data pertaining to postoperative pain, nausea, mobilisation, complications, anaesthesia and length of stay was collected prospectively. Pain, nausea and sedation were scored on a 4 point scale (0 (no pain or no nausea), 1 mild, 2 moderate and 3 severe. Any hospital readmission within the first 30 days, was also collected.
Statistical Analysis The distributions for zero and 1-day postoperative scores for pain, nausea, and sedation, together with length of stay, showed significant deviations from a normal distribution with regard to z-scores for skewness and kurtosis. Consequently, nonparametric MannWhitney tests were used for all inter-group comparisons. Inter-group differences for both of the pain, sedation and nausea measures, and for length of stay, were tested as onetailed, with lower values predicted for the ER patients. Table 1 shows the mean scores for these variables.
Results Data was analysed from 60 adult patients (30 ER and 30 pre-ER). The age ranged from 52 to 84 years and 56 to 83 years in the ER and non ER groups respectively, with mean ages of 64 and 65 years respectively. There were 15 males and 15 females in the ER group and 16 males and 14 females in the non ER group. In the pre ER group, there were 28 osteoarthritis and 2 rheumatoid arthritis, whereas in the ER group, there were 27 osteoarthritis and 3 rheumatoid arthritis. The operation was done on the right side in 28 and left side in 32 patients. In the pre ER group the operation was performed under spinal anaesthesia in 25 patients and GA in 5 patients, in the ER group the Spinal to GA ratio was 26/4. All patients having surgery under GA underwent popliteal block in both groups. There was no statistical difference in the demographic data between the 2 groups. No complications relating to LIA injection were noted. There were no hospital readmissions within the first 30 days in either group. Delayed wound healing was reported in 2 and 3 patients in the ER and pre-ER groups respectively. All these 5 wounds healed with conservative dressing therapy.
Patients in the ER group reported significantly less pain on Day 1 post-operation (0.063 v 0.347; p=0.012) and had significantly shorter hospital stays (2.3 days v 3.6 days; p= 0.01) than did the pre-ER group. The inter-group difference for sedation on Day 1 post-operation showed a trend approaching significance. No significant difference was found between the
patient groups for pain or sedation on Day 0 post-operation, nor for nausea on either Day 0 or Day 1 post-operation.
Discussion ER is now considered best practice for hip and knee joint replacement surgery [8 & 4]. The ER principles prepare the patients for the upcoming significant surgery, ensure early mobilisation and achieve significant postop pain relief. No study has investigated the impact of ER principles in TARs. Our study shows that ER principles work for TAR patients as well. We have demonstrated both a significant improvement in pain scores on Day1 post surgery and significant reduction in length of stay (2.3 days versus 3.6 days), with the introduction of the enhanced recovery protocol. The reduction in LOS will automatically translate into reduction in the treatment costs, with each bed day in the hospital costing £244 (Moulton et al). At our Unit, we have managed to reduce LOS for primary TAR by 33%, from 3.6 days to 2.3 days, with the introduction of ER protocol. This translates into a saving of £317 per patient. As shown by Moulton et al [1] pre-operative education reduces LOS by three ways. Firstly, patients are given advice on how to optimise their homes prior to admission, meaning that potential problems that may delay discharge will be addressed preoperatively. Secondly, the patient is aware of the restrictions and limitations required following TARs, meaning that physiotherapists are able to mobilise them sooner, as they do not have to spend their first postoperative session teaching them this. Finally, patients are educated that they are not sick, and the importance of early mobilisation is stressed. All this means the patients are more receptive to being mobilised sooner. Pain management following TAR is crucial for early mobilisation and short hospital stay. LIA is aimed at managing the acute postoperative pain phase lasting about 16hrs. Postoperative morphine is still routinely used in many hospitals to control postoperative pain. The side effects of this are nausea, vomiting, constipation and delayed mobilisation [5]. Since its introduction LIA is steadily gaining popularity and is routinely used in knee and hip replacements and our study clearly shows the benefits of the procedure in TAR. The strengths of our study are that it is the first study to investigate the effects of ER principles in TARs, the flowchart in the paper very clearly gives the ER pathway to be used and this could act as a guide to those who want to implement ER for TARs, the technique described for LIA could be replicated by other clinicians as it results in excellent postop pain control and finally the data was collected prospectively in all patients. The limitation is that this is not a RCT, which could potentially introduce bias.
Funding No funding has been received.
Conclusions ER with LIA achieves significant post-operative pain relief allowing for a 33% reduction in LOS (now 2.3 days) in patients undergoing primary TAR, without compromising on patient safety. We recommend ER for all patients undergoing primary TARs.
References 1.
2.
3. 4.
5.
6.
7. 8.
Moulton LS, Evans PA, Starks I, Smith T. Pre-operative education prior to elective hip arthroplasty surgery improves postoperative outcome. Int Orthop 2015;39(8):14836. Larsen K, Hvass KE, Hansen TB, Thomsen PB, Soballe K. Effectiveness of accelerated perioperative care and rehabilitation intervention compared to current intervention after hip and knee arthroplasty. A before-after trial of 247 patients with a 3-month follow-up. BMC Musculoskelet Disord 2008;9:59. Ditmyer MM, Topp R, Pifer M. Prehabilitation in preparation for orthopaedic surgery. Orthop Nurs 2002;21:43–51. Marinus DJ Stowers, Daniel P Lemanu, Brendan Coleman, Andrew G Hill, Jacob T Munro. Review Article: Perioperative care in enhanced recovery for total hip and knee arthroplasty. Journal of Orthopaedic Surgery 2014;22(3):383-92. Essving P, Axelsson K, Kjellberg J, Wallgren O, Gupta A, Lundin A. Reduced morphine consumption and pain intensity with local infiltration analgesia (LIA) following total knee arthroplasty. Acta Orthop 2010;81(3):354-360. 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(2):174-83. Kehlet H, Andersen LØ. .Local infiltration analgesia in joint replacement: the evidence and recommendations for clinical practice. Acta Anaesthesiol Scand 2011;55(7):778-84. Peterson MG, Cioppa-Mosca J, Finerty E, Graziano S, King S, Sculco TP. Effectiveness of best practice implementation in reducing hip arthroplasty length of stay. J Arthroplasty 2008;23:69–73.
Figure 1 ER pathway
Table 1 Summary of comparisons between patient groups Measure Pre-enhanced recovery protocol patients (n = 30) Mean (SD) pain scores 0.207 (0.451) Day 0 post-operation Mean (SD) pain scores 0.347 (0.590) Day 1 post-operation Mean (SD) nausea scores Day 0 postoperation Mean (SD) nausea scores Day 1 postoperation Mean (SD) sedation scores Day 0 postoperation Mean (SD) sedation scores Day 1 postoperation Mean (SD) length of stay (Days)
0.070 (0.274)
Enhanced Sig. recovery protocol patients (n = 30) U = 405.5 0.103 (0.281) ns. U = 339.0 0.063 (0.221) P = .012 onetailed U = 448.0 0.027 (0.105) ns.
0.027 (0.146)
0.030 (0.121)
U = 436.0 ns.
0.080 (0.261)
0.027 (0.105)
U = 433.0 ns.
0.050 (0.201)
0.000 (0.000)
3.57 (3.44)
2.33 (1.12)
U = 420.0 P = .077 onetailed U = 304.0 P = .010 onetailed
S0958-2592(16)30045-1 http://dx.doi.org/doi:10.1016/j.foot.2017.01.001 YFOOT 1450
To appear in:
The Foot
Received date: Accepted date:
8-8-2016 5-1-2017
Please cite this article as: Jain K, Murphy P, Karim T, Karski M, Clough T.M.Results of Enhanced Recovery after Primary Ankle Replacements.The Foot http://dx.doi.org/10.1016/j.foot.2017.01.001 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Results of Enhanced Recovery after Primary Ankle Replacements
Authors: K Jain1, P Murphy2, T Karim1, M Karski1 & T M Clough1 1=Wrightington Hospital, UK 2=Edge Hill University, UK
Corresponding author Mr Kowshik Jain 8, Fairhurst Drive Parbold, UK Email: [email protected] Telephone: 07749760579
Highlights
First study to investigate ER after ankle replacemets Prospective data collection A new ER pathway has been developed For the first time LIA technique for ankle replacements has been described
Background Enhanced recovery pathways for total hip and knee arthroplasty are known to reduce length of hospital stay and perioperative morbidity [1, 2 and 3]. Factors that improve outcomes include use of pre-emptive and multimodal analgesia regimens to reduce opioid consumption, identification of patients with poor nutritional status, provision of supplements preoperatively to improve wound healing and reduce length of hospital stay, use of warming systems, avoidance of drains to reduce operative blood loss and subsequent transfusion, and early ambulation with pharmacological and mechanical prophylaxis to reduce venous thromboembolism and to speed recovery [4]. A combination of pre-, intra-, and post-operative care interventions can promote a wellness model of care, avoid unnecessary medicalisation of a patient, and improve patient knowledge for their active involvement in perioperative care. This standardised perioperative care pathway is known as enhanced recovery (ER). Local infiltration analgesia (LIA) is a technique originally developed to facilitate enhanced recovery following knee replacements [5]. LIA provides good pain relief allowing a reduction in postoperative opiate use and so helps avoid the undesirable side effects of morphine such as nausea, confusion and sedation. This enables early mobilisation and discharge [6 & 7]. Postoperative pain is usually severe after ankle arthroplasty. This study was conducted to analyse the effects of enhanced recovery (ER) on postoperative stay, pain, nausea, sedation and readmission following primary ankle replacements, by comparing a consecutive group of 30 patients on the ER pathway, with a consecutive group of 30 immediately preceding patients, who were on the pre-ER pathway. Material & Methods After consultations with multidisciplinary team comprising of anaesthetists, staff nurses, physiotherapists, hospital managers, pre-operative assessment team and foot and ankle consultants, we developed an ER protocol for ankle replacement surgery, which was agreed and implemented on 01 November 2014. All patients undergoing primary total ankle replacement were included in this enhanced recovery pathway (Fig 1). 30 consecutive patients who underwent primary TAR on the ER pathway were compared with a cohort of 30 consecutive pre-ER patients (who underwent primary TAR surgery immediately prior to the implementation of ER). None of the ER patients were prescribed parenteral morphine in the immediate postoperative period. Postoperative pain was managed by a combination of paracetamol, Ibuprofen and Oxynorm 5-10 mg. Either general (plus popliteal block) or spinal anaesthesia was used in all patients, as per Anaesthetist and patient preference. Diamorphine was the preferred agent for spinal anaesthesia. All patients received 30 to
50 mls of Bupivacaine as LIA intra-operatively. Adrenaline was avoided to reduce risk of vasoconstriction leading to wound healing problems. We recommend the following technique for the LIA to be used to achieve maximum pain control: the posterior ankle capsule is injected after bone preparation and before the insertion of implants, and the anterior capsule, deltoid ligament, lateral collateral ligament, extensor retinacular layer and subcutaneous fat are injected, after insertion of the implants and before closure. A team of physiotherapists encouraged early mobilisation in these patients. All patients were allowed immediate full weight bearing as comfortable. Patients who underwent primary TAR with concomitant calcaneal osteotomy and those with intra-operative fractures were excluded from the study. Data pertaining to postoperative pain, nausea, mobilisation, complications, anaesthesia and length of stay was collected prospectively. Pain, nausea and sedation were scored on a 4 point scale (0 (no pain or no nausea), 1 mild, 2 moderate and 3 severe. Any hospital readmission within the first 30 days, was also collected.
Statistical Analysis The distributions for zero and 1-day postoperative scores for pain, nausea, and sedation, together with length of stay, showed significant deviations from a normal distribution with regard to z-scores for skewness and kurtosis. Consequently, nonparametric MannWhitney tests were used for all inter-group comparisons. Inter-group differences for both of the pain, sedation and nausea measures, and for length of stay, were tested as onetailed, with lower values predicted for the ER patients. Table 1 shows the mean scores for these variables.
Results Data was analysed from 60 adult patients (30 ER and 30 pre-ER). The age ranged from 52 to 84 years and 56 to 83 years in the ER and non ER groups respectively, with mean ages of 64 and 65 years respectively. There were 15 males and 15 females in the ER group and 16 males and 14 females in the non ER group. In the pre ER group, there were 28 osteoarthritis and 2 rheumatoid arthritis, whereas in the ER group, there were 27 osteoarthritis and 3 rheumatoid arthritis. The operation was done on the right side in 28 and left side in 32 patients. In the pre ER group the operation was performed under spinal anaesthesia in 25 patients and GA in 5 patients, in the ER group the Spinal to GA ratio was 26/4. All patients having surgery under GA underwent popliteal block in both groups. There was no statistical difference in the demographic data between the 2 groups. No complications relating to LIA injection were noted. There were no hospital readmissions within the first 30 days in either group. Delayed wound healing was reported in 2 and 3 patients in the ER and pre-ER groups respectively. All these 5 wounds healed with conservative dressing therapy.
Patients in the ER group reported significantly less pain on Day 1 post-operation (0.063 v 0.347; p=0.012) and had significantly shorter hospital stays (2.3 days v 3.6 days; p= 0.01) than did the pre-ER group. The inter-group difference for sedation on Day 1 post-operation showed a trend approaching significance. No significant difference was found between the
patient groups for pain or sedation on Day 0 post-operation, nor for nausea on either Day 0 or Day 1 post-operation.
Discussion ER is now considered best practice for hip and knee joint replacement surgery [8 & 4]. The ER principles prepare the patients for the upcoming significant surgery, ensure early mobilisation and achieve significant postop pain relief. No study has investigated the impact of ER principles in TARs. Our study shows that ER principles work for TAR patients as well. We have demonstrated both a significant improvement in pain scores on Day1 post surgery and significant reduction in length of stay (2.3 days versus 3.6 days), with the introduction of the enhanced recovery protocol. The reduction in LOS will automatically translate into reduction in the treatment costs, with each bed day in the hospital costing £244 (Moulton et al). At our Unit, we have managed to reduce LOS for primary TAR by 33%, from 3.6 days to 2.3 days, with the introduction of ER protocol. This translates into a saving of £317 per patient. As shown by Moulton et al [1] pre-operative education reduces LOS by three ways. Firstly, patients are given advice on how to optimise their homes prior to admission, meaning that potential problems that may delay discharge will be addressed preoperatively. Secondly, the patient is aware of the restrictions and limitations required following TARs, meaning that physiotherapists are able to mobilise them sooner, as they do not have to spend their first postoperative session teaching them this. Finally, patients are educated that they are not sick, and the importance of early mobilisation is stressed. All this means the patients are more receptive to being mobilised sooner. Pain management following TAR is crucial for early mobilisation and short hospital stay. LIA is aimed at managing the acute postoperative pain phase lasting about 16hrs. Postoperative morphine is still routinely used in many hospitals to control postoperative pain. The side effects of this are nausea, vomiting, constipation and delayed mobilisation [5]. Since its introduction LIA is steadily gaining popularity and is routinely used in knee and hip replacements and our study clearly shows the benefits of the procedure in TAR. The strengths of our study are that it is the first study to investigate the effects of ER principles in TARs, the flowchart in the paper very clearly gives the ER pathway to be used and this could act as a guide to those who want to implement ER for TARs, the technique described for LIA could be replicated by other clinicians as it results in excellent postop pain control and finally the data was collected prospectively in all patients. The limitation is that this is not a RCT, which could potentially introduce bias.
Funding No funding has been received.
Conclusions ER with LIA achieves significant post-operative pain relief allowing for a 33% reduction in LOS (now 2.3 days) in patients undergoing primary TAR, without compromising on patient safety. We recommend ER for all patients undergoing primary TARs.
References 1.
2.
3. 4.
5.
6.
7. 8.
Moulton LS, Evans PA, Starks I, Smith T. Pre-operative education prior to elective hip arthroplasty surgery improves postoperative outcome. Int Orthop 2015;39(8):14836. Larsen K, Hvass KE, Hansen TB, Thomsen PB, Soballe K. Effectiveness of accelerated perioperative care and rehabilitation intervention compared to current intervention after hip and knee arthroplasty. A before-after trial of 247 patients with a 3-month follow-up. BMC Musculoskelet Disord 2008;9:59. Ditmyer MM, Topp R, Pifer M. Prehabilitation in preparation for orthopaedic surgery. Orthop Nurs 2002;21:43–51. Marinus DJ Stowers, Daniel P Lemanu, Brendan Coleman, Andrew G Hill, Jacob T Munro. Review Article: Perioperative care in enhanced recovery for total hip and knee arthroplasty. Journal of Orthopaedic Surgery 2014;22(3):383-92. Essving P, Axelsson K, Kjellberg J, Wallgren O, Gupta A, Lundin A. Reduced morphine consumption and pain intensity with local infiltration analgesia (LIA) following total knee arthroplasty. Acta Orthop 2010;81(3):354-360. 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(2):174-83. Kehlet H, Andersen LØ. .Local infiltration analgesia in joint replacement: the evidence and recommendations for clinical practice. Acta Anaesthesiol Scand 2011;55(7):778-84. Peterson MG, Cioppa-Mosca J, Finerty E, Graziano S, King S, Sculco TP. Effectiveness of best practice implementation in reducing hip arthroplasty length of stay. J Arthroplasty 2008;23:69–73.
Figure 1 ER pathway
Table 1 Summary of comparisons between patient groups Measure Pre-enhanced recovery protocol patients (n = 30) Mean (SD) pain scores 0.207 (0.451) Day 0 post-operation Mean (SD) pain scores 0.347 (0.590) Day 1 post-operation Mean (SD) nausea scores Day 0 postoperation Mean (SD) nausea scores Day 1 postoperation Mean (SD) sedation scores Day 0 postoperation Mean (SD) sedation scores Day 1 postoperation Mean (SD) length of stay (Days)
0.070 (0.274)
Enhanced Sig. recovery protocol patients (n = 30) U = 405.5 0.103 (0.281) ns. U = 339.0 0.063 (0.221) P = .012 onetailed U = 448.0 0.027 (0.105) ns.
0.027 (0.146)
0.030 (0.121)
U = 436.0 ns.
0.080 (0.261)
0.027 (0.105)
U = 433.0 ns.
0.050 (0.201)
0.000 (0.000)
3.57 (3.44)
2.33 (1.12)
U = 420.0 P = .077 onetailed U = 304.0 P = .010 onetailed