Total Hip Replacement and Total Knee Replacement Outcomes in the Elderly - An Opportunity for Further Improvement of ERAS pathways.

Introduction Postoperative outcomes of total hip replacement (THR) and total knee replacement (TKR) have been improved by Enhanced Recovery after Surgery (ERAS) guidelines. The elderly population is increasing and successful fast-track rehabilitation can be achieved amongst this cohort. However, the cohorts studied in previous literature are generally younger, healthy patients, who would be expected to recover well from a multidisciplinary pathway. Literature to assess the role of enhanced recovery in the very elderly is limited. The aim of this study is to assess the current outcomes for elderly patients post THR and TKR and explore the opportunity for further application of ERAS pathways. Methods This retrospective study was completed by collecting UK acute NHS hospital data through Hospital Episode Statistics (HES), accessed via the Dr. Foster Healthcare Intelligence Portal. Length of stay, readmission rates, complication of care and mortality were recorded for all THR and TKR cases. Results Length of stay, readmission and complication of care rates increased linearly with age for both THR and TKR patients. For over 85’s, average length of stay was 5.0 and 4.5 days (THR and TKR respectively), 30 day re-admission was 9.4% and 9.9%, complication of care was 13.3% and 11.9% and mortality rate was 0.5% and 0.4%. Conclusions The very elderly have the most to gain from an ERAS programme but still have the longest stay in hospital and the greatest post-operative complications. Further work is required to determine how to reduce the risk of complications and increase functional recovery in elderly patients

Comments on Austronesian nominalism: A Mayan perspective

In the conclusion of his article on Austronesian voice and extraction, Kaufman suggests the possibility of extending his analysis of extraction facts in Tagalog to other ‘‘syntactically ergative’’ languages (i.e. languages in which ergative arguments are unable to undergo extraction), such as those in the Mayan family. In this commentary I do not attempt to evaluate Kaufman’s claims for Tagalog, but instead explore some of the interesting parallels – as well as important di¤erences–between languages of the Mayan family, and Austronesian languages as analyzed by Kaufman. I discuss ergative-genitive syncretism, nominalization, parallels between the clause and the DP, and extraction facts more generally

Do patient information booklets on total hip and knee replacement surgeries prescribe exercise regimes that follow ERAS principles?

Introduction Total hip replacement (THR) and total knee replacement (TKR) are two of the most common orthopaedic surgeries that occur in the United Kingdom (UK) each year. Enhanced recovery after surgery (ERAS) programmes aim to decrease convalescence across procedures, morbidity and length of stay. The post-operative physiotherapy routine is standardised across hospitals, however the pathway has been criticised for not containing the correct ingredients for promoting acceleration of return to function. This research aims to analyse the current exercise protocol prescribed to patients within information booklets following THR and TKR in comparison to ERAS principles. Methods A random sample of twenty UK NHS hospital THR and TKR patient information booklets were sourced using a web based methodology. A flowchart of exercise prescription components was formulated from a review of 5 trial booklets. A content analysis was conducted on the patient information booklets. Results 40% of the information booklets sourced identified their pathways to be ERAS. 50-55% of the hospitals stated their patients would be mobilised on the day of surgery. 90% of THR and 100% of TKR guidelines suggested the use of bed exercises for rehabilitation. 15% of THR and 35% of TKR booklets suggested functional exercise as a method of rehabilitation. Strength or resistance based exercises were proposed in 40% of THR and 55% of TKR booklets. Conclusions Many patient information booklets do not follow ERAS principles for fast-track rehabilitation. The exercise prescription procedure is non-specific, and the physiotherapy routines prescribed could be considered outdated

The role of physiotherapy in Enhanced Recovery after Surgery in the intensive care unit

Enhanced recovery after surgery (ERAS) is an evidence-based, multimodal approach to optimising patient outcomes following surgery. The role of physiotherapy within ERAS and intensive care units (ICU) is important. Patients admitted to an ICU following elective major surgery may suffer from physical, psychological and cognitive problems, which can impact their return to function and quality of life. ICU physiotherapists can enable patients to achieve ERAS programme aims throughout their stay in an ICU and this may accelerate the achievement of discharge criteria and subsequent return to function. Functional limitations and persistent weakness may exist long after discharge, and therefore there is a need to increase the awareness and involvement of physiotherapists within the outpatient setting. Establishing a standardised rehabilitation programme, informed by key ERAS principles and delivered by specialist physiotherapists supported by a well-informed ICU team can have long term benefits to patients post-discharge

What Is the Role of Nutritional Supplements in Support of Total Hip Replacement and Total Knee Replacement Surgeries? A Systematic Review

Nutritional supplements can influence outcomes for individuals undergoing major surgery, particularly in older persons whose functional reserve is limited. Accelerating recovery from total hip replacement (THR) and total knee replacement (TKR) may offer significant benefits. Therefore, we explored the role of nutritional supplements in improving recovery following THR and TKR. A systematic review was conducted to source randomized clinical trials that tested nutritional supplements in cohorts of THR or TKR patients. Our search yielded nine relevant trials. Intake of a carbohydrate-containing fluid is reported to improve insulin-like growth factor levels, reduce hunger, nausea, and length of stay, and attenuate the decrease in whole-body insulin sensitivity and endogenous glucose release. Amino acid supplementation is reported to reduce muscle atrophy and accelerate return of functional mobility. One paper reported a suppressive effect of beta-hydroxy beta-methylbutyrate, L-arginine, and L-glutamine supplementation on muscle strength loss following TKR. There is limited evidence for nutritional supplementation in THR and TKR pathways; however, the low risk profile and potential benefits to adjunctive treatment methods, such as exercise programs, suggest nutritional supplements may have a role. Optimizing nutritional status pre-operatively may help manage the surgical stress response, with a particular benefit for undernourished, frail, or elderly individuals

The inclusion of preoperative education in Eras spinal surgery pathways: A systematic review

Objectives: Enhanced Recovery after Surgery (ERAS) principles are starting to be adopted in major spinal procedures, and the high volume of surgeries, and wide variations in length of stay and complications rates suggest that improvements are both desirable and possible. Psychosocial factors related to different degrees of clinical impairment and quality of life in the preoperative period may influence outcomes, and patients have expressed a need for individualised information given in sufficient quantities and at the appropriate time to help attenuate preoperative anxiety. Preoperative education is a core component of ERAS that aims to empower patients to undertake positive health actions and support autonomous decision making. This review aims to summarise the current evidence for inclusion of a preoperative education session into ERAS spinal surgery pathways

Self-Management of Hip Osteoarthritis Five Years After a Cycling and Education Treatment Pathway

The Cycling against Hip Pain (CHAIN) programme is a six-week cycling and education treatment pathway for people with hip osteoarthritis. Preliminary results demonstrated significant improvements in clinical and patient-reported outcome measures following the course. Whilst the benefits of exercise for osteoarthritis are often reported in the short term, less is known about the long-term effects for this patient group. This study explores whether participants continued to selfmanage their hip osteoarthritis five years after completing the course. A cross-sectional survey was conducted to collect data from participants who completed the CHAIN programme between October 2013 and February 2015 (n = 96). Questionnaires were sent by post in April 2019, and then non-responders were followed up again four weeks later. Eighty-three (87%) participants responded to the survey. Five years (range 4–6) after completion of a six-week cycling and education programme, 37 (45%) participants had not returned to their general practitioner for further treatment of their hip pain, and 47 (57%) had not pursued surgical intervention. All participants were still engaged in at least one physical activity per week and many reported that they had purchased a bike (29%), joined a gym (30%) or cycled regularly (indoor cycling 25%, outdoor cycling 24%). Eighty (96%) participants reported an increase in knowledge of self-managing their symptoms. The findings from this study suggest that many patients are motivated to self-manage their hip osteoarthritis, five years following a six-week cycling and education treatment pathway that encourages lifestyle change