Fast-track hip and knee arthroplasty: clinical and organizational aspects

Figures & data

Table 1. RCT TKA with LIA. LIA+ = ropivacaine, adrenaline and ketorolac; LIA- = ropivacaine and adrenaline

Author	N	Analgesic technique	Reduced pain/opioid need	LOS (days), LIA vs. control	Reasons for being hospitalized	Well-defined discharge criteria
Vendittoli et al. 2006^24	42	LIA+ vs saline	yes/yes	4.8 vs 5.2 (NS)	not spec.	yes
Busch et al. 2006^25	64	LIA+ morphine vs no infiltration	yes/yes	5.2 vs 5.2 (NS)	not spec.	not spec.
Toftdahl et al. 2007^35	80	LIA+ vs femoral nerveblock	yes/yes	5 vs 6 (NS)	not spec.	not spec.
Andersen et al. 2008 (Bilat)^27	12	LIA- vs saline	yes/not relevant	not relevant	not spec.	yes
Andersen et al. 2008^33	32	LIA- intraarticular vs extraarticular	no difference	not relevant	not spec.	not spec.
Andersen et al. 2008^(II)	48	LIA- ± compression bandage	yes/not measured	2.8 vs 3.3 (NS)	not spec.	yes
Essving et al. 2010^26	48	LIA+ vs no infiltration	yes/yes	4 vs 6 (NS)	not spec.	yes
Andersen et al. 2010^31	60	LIA- intracapsular vs intraarticular	no difference	3 vs 2.9 (NS)	not spec.	yes
Andersen et al. 2010^37	40	LIA+ vs continuous epidural	yes/yes	4 vs 4	not spec.	yes
Andersen et al. 2010 (Bilat)^28	16	LIA- vs saline subcutaneous ± catheter	yes - subcut. infiltr. no - using catheter	3	not spec.	yes
Andersen et al. 2010^29	48	LIA- postop. volume vs concentration	no diff./no diff.	3 vs 2.5 (NS)	not spec.	yes
Carli et al. 2010^36	40	LIA+ cont. intraarticular vs cont. femoral nerveblock	yes/yes	5 vs 5	not spec.	yes
Spreng et al. 2010^38	102	LIA+ morphine vs epidural vs LIA given iv	yes/yes	3.5 vs 5.5 vs 4	not spec.	yes
Thorsell et al. 2010^39	85	LIA+ vs epidural	yes/no	4.7 vs 5 (NS)	not spec.	not spec.

Table 2. RCT THA with LIA. LIA+ = ropivacaine, adrenaline and ketorolac; LIA- = ropivacaine and adrenaline

Author	N	Analgesic technique	Reduced pain/opioid need	LOS (days), LIA vs. control	Reasons for being hospitalized	Well-defined discharge criteria
Andersen et al. 2007^42	80	LIA+ vs continuous epidural	yes/yes	4.5 vs 7 (p<0.001)	not spec.	yes
Andersen et al. 2007^43	40	LIA+ vs saline	yes/yes	2.6 vs 2.8 (NS)	not spec.	yes
Busch et al. 2010^44	64	LIA+ morphine vs no infiltration	yes/yes	5.3 vs 5.8 (NS)	not spec.	yes
Andersen et al. (Bilat)	12	LIA- vs saline	no/no	not relevant	not spec.	yes
Lunn et al. 2011^(VIII)	120	LIA- vs saline	no/no	2.7 vs 2.5 (NS)	not spec.	yes

Table 3. Care principles, patient-realted characteristics and satisfaction parameters of ANORAK-HH

Information

– oral and written information on intended LOS of 1–2 days and motivation of the patient to be active.

– detailed information to patients and relatives at a preoperative multidisciplinary patient clinic on hospital stay, nursing, pain treatment, and functional discharge criteria.

Staff and logistics

– dedicated staff. Physiotherapy once a day at weekdays. Nurse staffing identical to that of rest of ward.

– a specialized ward where all THA and TKA patients are admitted.

– patients admitted on day of surgery.

Operation and pain treatment

– use of regional analgesia: spinal exclusively for all patients (primary, bilateral, revision). LIA for TKA (primary, bilateral, and revision).

– preoperative loading: paracetamol 2 g, Celebra 400 mg, gabapentin 600 mg followed by paracetamol 2 g x 2, Celebra 200 mg x 2 and gabapentin 300 mg + 600 mg for 6 days; opioids in form of morpine 10–20 mg upon request only.

Drains

– not used (no effect, and increases the sickness role).

Blood transfusion

– is standardized (postoperative drop by 25% compared to preoperative level of Hgb. and clinical manifestation).

KAD

– not used (not needed in majority of patients, and increase of the sickness role)

Antithrombotic prophylaxis

– factor Xa inhibitor (Rivaroxaban), starting 6 h postoperatively and given only until discharge in patients mobilized within 24 hours and for 10 days (TKA) and 35 days (THA) in patients not able to mobilize within 24 hours.

Discharge criteria

– unchanged; the patients must be independent regarding personal care, able to walk with crutches or better, able to get in and out of bed, and into and up from a chair/toilet. Sufficient pain treatment (VAS < 5) and accept of discharge.

– all patients are discharged to their homes.

Monitoring ^a

– patient characteristics: age, sex, living situation, weight, height, body mass index (BMI), smoking, American Society of Anaesthesiology (ASA) score, pre- and postoperative hemoglobin, preoperative use of walking aid, intraoperative and total blood loss, blood transfusion, type of surgery, co-morbidities, surgeon, day of surgery and case number that day (1st, 2nd, 3rd), mobilization on the day of surgery, preoperative use of opioids, and participation in the patient seminar preoperatively.

– patient satisfaction parameters: information, patient meeting, operating room stay, recovery ward stay, nursing, doctors’ rounds, pain treatment, physiotherapy, LOS, physical conditions in the ward, and the entire stay.

^a 22 patient characteristics and 11 patient satisfaction parameters were registered in a database in order to monitor the stays continuously.

Figure 1. Factors affecting outcome in fast-track THA and TKA

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