[Total knee and hip arthroplasty within 2 days : The Danish Fast-Track Model]. / Knie- und Hüfttotalendoprothese in 2 Tagen : Das dänische Fast-Track-Modell.

BACKGROUND: Patients in Denmark undergoing total knee or hip replacement are routinely discharged within 2 days of surgery. A critical examination of traditional treatment methods, combined with focused research, has during the last 20 years increasingly optimized the treatment course in such a way that it has become possible to radically reduce the length of stay (LOS). BASICS OF THE FAST-TRACK MODEL: The most important elements of this Fast-Track model are described. The patient motivation and transfer of partial responsibility to the patient through intensive information, optimized operation techniques, as well as modern multi-modal pain therapy with early mobilization are key issues. The relatively small and homogenous health care system of Denmark offers good research conditions and the possibility of a fast implementation of the latest results, as well as a lump-sum based re-imbursement system without minimum stay-both factors have been favorable for the development of the Fast-Track model.

Outpatient total hip or knee arthroplasty in ambulatory surgery center versus arthroplasty ward: a randomized controlled trial.

Background and purpose - Discharge on the day of surgery (DOS) in selected patients operated with total hip arthroplasty (THA) or total knee arthroplasty (TKA) has been shown to be feasible, but different factors may determine whether patients are discharged on the DOS or not and setting may be one of them. We investigated the importance of the setting in which the short stay following outpatient THA or TKA takes place: was there a difference between the proportion of patients being discharged on the DOS from an ambulatory surgery center (ASC) compared with patients staying on an arthroplasty ward?Patients and methods - 50 patients (30 TKA, 20 THA) were included in the study and postoperatively randomized to either staying in the ASC or the arthroplasty ward until discharge. All patients were operated under general anesthesia by the same experienced surgeon (HH) and were discharged upon fulfillment of standardized discharge criteria.Results - 24/25 of the patients who stayed in the ASC compared with 20/25 of the patients on the arthroplasty ward were discharged on the DOS following fulfillment of discharge criteria (p = 0.08). All THA patients were discharged on the DOS and significantly more TKA patients were discharged from the ASC (15/16) vs. from the ward (9/14) (p = 0.04).Interpretation - Despite fixed discharge criteria, the logistical setting may play a role for achieving discharge on DOS and the ASC may facilitate achieving discharge criteria earlier especially in TKA.

Time-driven activity-based cost of outpatient total hip and knee arthroplasty in different set-ups.

Background and purpose - Length of stay (LOS) following total hip and knee arthroplasty (THA and TKA) has been reduced over the years due to fast-track. Short stays of 2 days in fast-track departments in Denmark have resulted in low total costs of around US$2,550. Outpatient THA and TKA is gaining popularity, albeit in a limited and selected group of patients; however, the financial benefit of outpatient arthroplasty remains unknown. We present baseline detailed economic calculations of outpatient THA and TKA in 2 different settings: one from the hospital and another from the ambulatory surgery department. Patients and methods - Data from 6 patients (1 TKA, 1 uncemented THA, 1 cemented THA in each department) were collected prospectively using the Time Driven Activity Based Costing method (TDABC). Time consumed by different staff members involved in patient treatment in the perioperative period of outpatient THA and TKA was calculated in 2 different settings: one in the orthopedic department and one in the ambulatory surgery department. Results - LOS was around 11 h in the orthopedic department and around 7 h in the ambulatory surgery department, respectively. TDABC revealed minor differences in the operative settings between departments and similar expenses occurred during the short stay of US$777 and US$746, respectively. Adding the preoperative preparation and postoperative follow-up resulted in total cost of US$951 and US$942 for the ward and the ambulatory surgery department, respectively. Interpretation - Outpatient THA and TKA in hospital and ambulatory surgery departments results in similar cost using the TDABC method. Compared with the cost associated with 2-day stays, outpatient procedures are around two-thirds cheaper provided no increase occurs in complications or readmissions.

Analgesic effect of ultrasound-guided transversus abdominis plane block after total abdominal hysterectomy: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To assess the effect of bilateral ultrasound-guided transversus abdominis plane block with ropivacaine compared with placebo as part of a multimodal analgesic regimen. DESIGN: A randomized, double-blind, placebo-controlled trial following the CONSORT criteria. SETTING: Hvidovre University Hospital. PATIENTS: Forty-six women scheduled for total abdominal hysterectomy. INTERVENTION: Women received either ropivacaine 0.75%, 20 mL (n = 24) or 0.9% saline, 20 mL (n = 24) in the transversus abdominis plane on each side. MAIN OUTCOME MEASURES: Primary outcome was the 24-h postoperative morphine consumption. Secondary outcomes were pain scores at rest and during coughing, postoperative nausea and vomiting at 1, 2, 4, 6, 8, and 24 h, and time to first mobilization. RESULTS: There was no difference in the mean 24-h postoperative morphine consumption between the two groups (p = 0.733). The ropivacaine group had significantly lower median pain scores at 1 h (p = 0.008) and 2 h (p = 0.027) postoperatively at rest and at 8 h (p = 0.028) during coughing. There was no significant difference in other secondary outcomes. CONCLUSION: There was no reduction in 24-h morphine consumption when using an ultrasound-guided transversus abdominis plane block in women undergoing total abdominal hysterectomy. As part of a multimodal regimen the transversus abdominis plane block showed some effect on pain scores at rest only in the early postoperative period.

Effect of systematic local infiltration analgesia on postoperative pain in vaginal hysterectomy: a randomized, placebo-controlled trial.

OBJECTIVE: To assess the effect of systematic local infiltration analgesia on postoperative pain in vaginal hysterectomy, and describe the technique in detail. DESIGN: A randomized, double-blind, placebo-controlled study following the CONSORT criteria. SETTING: A university hospital. PATIENTS: Thirty-seven patients undergoing vaginal hysterectomy. METHODS: Patients received high-volume (50 mL) ropivacaine 0.50% (n = 20) or saline (n = 17) infiltration using a systematic technique ensuring uniform delivery to all tissues incised, handled or instrumented during the procedure. MAIN OUTCOME MEASURES: Pain, nausea, vomiting and opioid requirements were assessed for 32 h as well as time spent in the post-anesthesia care unit and time to first mobilization. RESULTS: Pain at rest was significantly reduced after one, four and eight hours in the ropivacaine group (p ≤ 0.001-0.01). Pain during coughing was significantly reduced after one and four hours (p ≤ 0.001 and p ≤ 0.003), and pain during movement was significantly reduced after four hours (p ≤ 0.02). Opioid requirements and time spent in the post-anesthesia care unit were significantly reduced in the ropivacaine group (p < 0.001 and p < 0.001, respectively), as well as the time to first mobilization (p < 0.001). CONCLUSION: Intra-operative systematic local infiltration analgesia reduces postoperative pain in patients undergoing vaginal hysterectomy, facilities mobilization and improves early recovery.

Local infiltration analgesia in urogenital prolapse surgery: a prospective randomized, double-blind, placebo-controlled study.

OBJECTIVE: To evaluate the analgesic effect of high-volume infiltration analgesia in urogenital prolapse surgery and provide a detailed description of the infiltration technique. DESIGN: A randomized, double-blind, placebo-controlled study following the CONSORT criteria. SETTING: A university hospital. PATIENTS: 48 patients undergoing posterior wall repair and perineorraphy. METHODS: Patients received high-volume (26 ml) ropivacaine 1% with epinephrine (n=23) or saline (n=22) infiltration using a systematic technique ensuring uniform delivery to all tissues incised, handled or instrumented during the procedure. MAIN OUTCOME MEASURES: Pain and opioid requirements were assessed for 24 hours as well as time spent in the post-anesthesia care unit and time to first mobilization. RESULTS: Pain at rest, during coughing and movement was significantly reduced for the first four hours with the high-volume local anesthetic infiltration technique (p<0.001-0.006). Opioid requirements and time spent in the post-anesthesia care unit were significantly reduced in the ropivacaine group (p<0.001 and p<0.001, respectively) as well as the time to first mobilization (p<0.014). CONCLUSION: Systematic high-volume infiltration analgesia is an effective analgesic technique in patients undergoing posterior wall repair and perineorraphy, and improves early recovery.

Fast-track revision knee arthroplasty. A feasibility study.

BACKGROUND AND PURPOSE: Fast-track surgery has reduced the length of hospital stay (LOS), morbidity, and convalescence in primary hip and knee arthroplasty (TKA). We assessed whether patients undergoing revision TKA for non-septic indications might also benefit from fast-track surgery. METHODS: 29 patients were operated with 30 revision arthroplasties. Median age was 67 (34-84) years. All patients followed a standardized fast-track set-up designed for primary TKA. We determined the outcome regarding LOS, morbidity, mortality, and satisfaction. RESULTS: Median LOS was 2 (1-4) days excluding 1 patient, who was transferred to another hospital for logistical reasons (10 days). None of the patients died within 3 months, and 3 patients were re-admitted (2 for suspicion of DVT, which was not found, and 1 for joint mobilization). Patient satisfaction was high. INTERPRETATION: Patients undergoing revision TKA for non-septic reasons may be included in fast-track protocols. Outcome appears to be similar to that of primary TKA regarding LOS, morbidity, and satisfaction. Our findings call for larger confirmatory studies and studies involving other indications (revision THA, 1-stage septic revisions).

Why still in hospital after fast-track hip and knee arthroplasty?

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 criteria. Earlier studies have identified patient characteristics predicting 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 factors 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 operated with spinal anesthesia and received multimodal analgesia with paracetamol, a COX-2 inhibitor, and gabapentin-with opioid only on request. Fulfillment of functional discharge criteria 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 postoperatively 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, prevention of orthostatism, and rapid recovery of muscle function.

Readmissions after fast-track hip and knee arthroplasty.

INTRODUCTION: With the implementation of fast-track surgery with optimization of both logistical and clinical features, the postoperative convalescence has been reduced as functional milestones have been achieved earlier and consequently length of stay (LOS) in hospital has been reduced. However, it has been speculated that a decrease in LOS may be associated with an increase in readmissions in general, including risk of dislocation after total hip arthroplasty (THA) or manipulation after total knee arthroplasty (TKA). MATERIALS AND METHODS: 1,731 consecutive, unselected patients were operated with primary THA or TKA in a well-described standardized fast-track setup from 2004 to 2008. All readmissions and deaths within 90 days were analyzed using the national health register. RESULTS: Mean LOS decreased from 6.3 to 3.1 days. Within 90 days, 15.6% of patients following TKA were readmitted as opposed to 10.9% after THA (p = 0.005). Three deaths (0.17%) were associated with clotting episodes. Suspicion of DVT (not found) and suspicion of infection made up half of the readmissions. Readmissions in general and for thromboembolic events, dislocations and manipulations in specific did not increase with decreasing LOS. There was no difference between readmission rates per year for either TKA or THA but there was a significantly reduced risk of dislocation found with decreasing LOS comparing each year from 2005 to 2007 with the index year of 2004 (with the longest LOS and the highest incidence of dislocation). CONCLUSION: Fast-track TKA and THA do not increase the readmission rate. Readmissions are more frequent after TKA than THA, but dislocation after THA and manipulation after TKA do not increase as LOS is decreasing.

Low risk of thromboembolic complications after fast-track hip and knee arthroplasty.

BACKGROUND AND PURPOSE: Pharmacological prophylaxis can reduce the risk of deep venous thrombosis (DVT), pulmonary embolism (PE), and death, and it is recommended 10­35 days after total hip arthroplasty (THA) and at least 10 days after total knee arthroplasty (TKA). However, early mobilization might also reduce the risk of DVT and thereby the need for prolonged prophylaxis, but this has not been considered in the previous literature. Here we report our results with short-duration pharmacological prophylaxis combined with early mobilization and reduced hospitalization. PATIENTS AND METHODS: 1,977 consecutive, unselected patients were operated with primary THA, TKA, or bilateral simultaneous TKA (BSTKA) in a well-described standardized fast-track set-up from 2004­2008. Patients received DVT prophylaxis with low-molecular-weight heparin starting 6­8 h after surgery until discharge. All re-admissions and deaths within 30 and 90 days were analyzed using the national health register, concentrating especially on clinical DVT (confirmed by ultrasound and elevated D-dimer), PE, or sudden death. Numbers were correlated to days of prophylaxis (LOS). RESULTS: The mean LOS decreased from 7.3 days in 2004 to 3.1 days in 2008. 3 deaths (0.15%) were associated with clotting episodes and overall, 11 clinical DVTs (0.56%) and 6 PEs (0.30%) were found. The vast majority of events took place within 30 days; only 1 death and 2 DVTs occurred between 30 and 90 days. During the last 2 years (854 patients), when patients were mobilized within 4 h postoperatively and the duration of DVT prophylaxis was shortest (1­4 days), the mortality was 0% (95% CI: 0­0.5). Incident cases of DVT in TKA was 0.60% (CI: 0.2­2.2), in THA it was 0.51% (CI: 0.1­1.8), and in BSTKA it was 0% (CI: 0­2.9). Incident cases of PE in TKA was 0.30% (CI: 0.1­1.7), in THA it was 0% (CI: 0­1.0), and in BSTKA it was 0% (CI: 0­2.9). INTERPRETATION: The risk of clinical DVT, and of fatal and non-fatal PE after THA and TKA following a fast-track set-up with early mobilization, short hospitalization, and short duration of DVT prophylaxis compares favorably with published regimens with extended prophylaxis (up to 36 days) and hospitalization up to 11 days. This calls for a reconsideration of optimal duration of chemical thromboprophylaxis.

A compression bandage improves local infiltration analgesia in total knee arthroplasty.

BACKGROUND: High-volume local infiltration analgesia has been shown to be an effective pain treatment after knee replacement, but the role of bandaging to prolong analgesia has not been evaluated. METHODS: 48 patients undergoing fast-track total knee replacement with high-volume (170 mL) 0.2% ropivacaine infiltration analgesia were randomized to receive a compression or a non-compression bandage, and pain was assessed at rest and with mobilization at regular intervals for 24 h postoperatively. RESULTS: Pain at rest, during flexion, or on straight leg lift was lower for the first 8 h in patients with compression bandage than in those with non-compression bandage and with a similar low use of oxycodone. Mean hospital stay was similar (2.8 days and 3.3 days, respectively). INTERPRETATION: A compression bandage is recommended to improve analgesia after high-volume local infiltration analgesia in total knee arthroplasty.

Local anesthetics after total knee arthroplasty: intraarticular or extraarticular administration? A randomized, double-blind, placebo-controlled study.

BACKGROUND: High-volume local infiltration analgesia with additional intraarticular and wound administration of local anesthetic has been shown to be effective after knee replacement, but the optimum site of administration of the local anesthetic (i.e. intraarticular or extraarticular) has not been evaluated. PATIENTS AND METHODS: 32 patients undergoing total knee replacement with high-volume (170 mL) 0.2% ropivacaine infiltration analgesia were randomized to receive injection of 20 mL ropivacaine (0.2%) intraarticularly plus 30 mL saline in the extraarticular wound space 24 hours postoperatively or to receive 20 mL ropivacaine (0.2%) intraarticularly plus 30 mL ropivacaine (0.2%) in the extraarticular wound space 24 hours postoperatively. Pain intensity at rest and with mobilization was recorded for 4 hours after administration of additional local anesthetics. RESULTS: Intensity of pain at rest, during flexion, or straight leg lift was not statistically significantly different between the two groups, but there was a tendency of improved analgesia with administration of additional local anesthetic in the extraarticular wound space. INTERPRETATION: The optimal site of administration of local anesthetic in total knee arthroplasty cannot be determined from the present study. However, the insignificant analgesic effect from additional administration of extraarticular local anaesthetic may have been due to the relatively low pain scores observed 24 h postoperatively, confirming the efficiency of the high-volume infiltration analgesia technique. Further studies are required to define the optimal site of administration of local anesthetic following knee replacement surgery.

[Small amounts of milk added to coffee or tea can be allowed before surgery].

The ingestion of milk is not allowed within six hours before elective procedures requiring anaesthesia or sedation, because milk is considered a solid food. However, the impact of milk suspended in coffee or tea consumed up to two hours before anaesthesia is less certain, yet fasting guidelines demand surgery to be delayed or rescheduled. Studies investigating ingestion of liquids with small amounts of milk have not demonstrated delayed emptying of the stomach, thereby increasing the risk of aspiration in elective procedures. Maybe it is time to adjust the fasting recommendations.

Liberal versus restrictive fluid management in knee arthroplasty: a randomized, double-blind study.

BACKGROUND: There are few data describing the relationship between amount of perioperative fluid and organ function. In this study we investigated the effects of two levels of intravascular fluid administration ("liberal" versus "restrictive") in knee arthroplasty on physiological recovery as the primary outcome variable. METHODS: In a double-blind study, 48 ASA I-III patients undergoing fast-track elective knee arthroplasty were randomized to restrictive or liberal perioperative intravascular fluid administration. Patients received a fixed rate infusion of Ringer's lactate solution with a standardized volume of colloid. All other aspects of perioperative management (including anesthesia, preoperative fluid status, and postoperative management) were standardized. Primary outcome variables included pulmonary function (spirometry), exercise capacity ("timed up and go" test), coagulation (Thrombelastograph), postoperative hypoxemia (nocturnal pulse oximetry), postoperative ileus (defecation), and subjective patient recovery (visual analog scales). Hospital stay and complications were also noted. RESULTS: Fluid guidelines were followed strictly in all patients. Liberal (median 4250 mL, range 3150-5200 mL) compared with restrictive (median 1740 mL, range 1100-2165 mL) intravascular fluid administration led to improved pulmonary function 6 h postoperatively, significant hypercoagulability 24-48 h postoperatively, and reduced incidence of vomiting. There were no overall differences in the other assessed perioperative physiological recovery variables (postoperative hypoxemia, exercise capacity or subjective patient recovery variables). No difference was found in hospital stay (median 4 days in both groups, not significant). CONCLUSION: A liberal compared to a restrictive intravascular fluid regimen may lead to significant hypercoagulability and a reduction in vomiting, but without differences in other recovery variables or hospital stay after fast-track knee arthroplasty.

[Fast-track hip arthroplasty].

Fast-track surgery implies a coordinated perioperative approach aimed at reducing surgical stress and facilitating post-operative recovery. The fast-track programme has reduced post-operative length of stay and has led to shorter convalescence with more rapid functional recovery and decreased morbidity and mortality in total hip arthroplasty. It should now be a standard total hip arthroplasty patient pathway, but fine tuning of the multiple factors in the fast-track pathway is still needed in patients with special needs or high comorbidity burden.

[Fast-track total knee arthroplasty].

Fast-track total knee arthroplasty (TKA) is a well-established concept including optimized logistics and evidence-based treatment, focusing on minimizing surgical stress and improved post-operative recovery, thus leading to lower mortality and morbidity as well as high patient satisfaction. All patients are eligible for fast-track TKA, and hence the fast-track concept should be standard at all joint replacement facilities. Future challenges of fast-track TKA include safe introduction of outpatient protocols, acute and chronic pain after surgery and optimal utilization of post-operative physiotherapy.

Fluorescence versus X-ray cholangiography during laparoscopic cholecystectomy: protocol for a randomised trial.

INTRODUCTION: Intraoperative fluorescent cholangiography is a novel non-invasive imaging technique to visualise the extrahepatic biliary tract during laparoscopic cholecystectomy. It has been proven feasible, fast and cost effective. Never-theless, there is only sparse data on the capacity of fluorescent cholangiography to visualise the biliary anatomy. METHODS: Based on a non-inferiority design, patients with complicated gallstone disease are randomised to either -intraoperative conventional X-ray cholangiography (reference group, n = 60) or intraoperative fluorescent cholangiography (n = 60). The primary outcome is visualisation of the junction between the cystic duct, the common hepatic duct and the common bile duct. CONCLUSION: The present study may show that fluorescent cholangiography is as valid for visualisation of important structures of the extrahepatic biliary tract as conventional X-ray cholangiography. This may lead to the introduction of online imaging of the extrahepatic tract during dissection of the gallbladder during cholecystectomy. FUNDING: none. TRIAL REGISTRATION: This study was registered with clinicaltrials.gov (No. NCT02344654), with the National Committee on Health Research Ethics (Reg. no. H-15000817) and with the Danish Data Protection Agency (Reg no. AHH- 2015-005).

The Effect of Botulinum Toxin A Injections in the Spine Muscles for Cerebral Palsy Scoliosis, Examined in a Prospective, Randomized Triple-blinded Study.

STUDY DESIGN: A prospective, randomized triple-blinded cross-over design treating with either botulinum toxin A (BXT) or saline (NaCl). OBJECTIVE: To examine the efficacy of BTX treatment in cerebral palsy scoliosis (CPS). SUMMARY OF BACKGROUND DATA: Intramuscular injections with BTX have been used off label in treating CPS. 1 prospective study has been conducted, demonstrating in both radiological and clinical improvement, whereas showing no side effects or complications. METHODS: Subjects (brace-treated CPS between 2 and 18 yr) were injected using ultrasonic-guidance with either NaCl or BTX in selected spine muscles with 6 mo intervals (block randomization, sealed envelope). Radiographs of the spine and clinical follow-up were captured before and 6 weeks after each injection. Primary outcome parameter was radiological change in Cobb angle, where a 7° change was regarded as an effect (1 SD). Radiological parameters were measured before and 6 weeks after treatment by 3 experienced doctors separately. Moreover, clinical results were evaluated by the pediatric quality of life score and systematic open questioning of the parents about the child's wellbeing. Subjects, researchers, and monitors were blinded during the trial. Appropriate permissions (2008-004584-19) and no funding were obtained. RESULTS: 16 cerebral palsy patients (GFMCS III-V) with CPS were consecutively included, whereas 6 patients were excluded. There were no drop-outs to follow-up, but 1 possible serious adverse event of pneumonia resulting in death was recorded and the study was terminated. No significant radiological or clinical changes were detected when compared with NaCl injections using Wilcoxon matched pair signed-rank test. CONCLUSION: No positive radiological or clinical effects were demonstrated by this treatment, except for the parent's initial subjective but positive appraisal of the effect. However, the study was terminated due to 1 possible severe adverse event and scheduled numbers needed to treat (hence power) were not reached. LEVEL OF EVIDENCE: 1.

[Accelerated recovery program after hip fracture surgery]. / Acceleret operationsforløb efter hoftefraktur.

INTRODUCTION: A multimodal approach to minimise the effect of the surgical stress response can reduce complications and hospital stay after abdominal surgery and hip arthroplasty. The aim of the study was to assess the results of a well-defined rehabilitation programme after hip fracture. MATERIAL AND METHODS: In an open intervention study, we entered 200 consecutive patients with hip fracture allowing full weight-bearing after operative treatment. The effect of a revised, optimised perioperative care programme with continuous epidural analgesia, early oral nutrition, oxygen supplementation, restricted volume and transfusion therapy, and intensive physiotherapy and mobilisation was assessed (n = 100) and compared with the conventional perioperative treatment programme before the intervention (n = 100). The median age was 82 (56-96) years in the control group and 82 (63-101) years in the accelerated multimodal perioperative treatment group. RESULTS: The median hospital stay was reduced from 21 (range 1-162, mean 32) to 11 (range 1-100, mean 17) days. The total use of days in hospital was reduced from 3211 to 1667. There were fewer complications, whereas the need for home care after discharge was unchanged. CONCLUSION: An accelerated clinical pathway with focus on pain relief, oral nutrition, and rehabilitation may reduce hospital stay and improve recovery after hip fracture.