Fast-Track-Endoprothetik

Einführung Wesentliche Bestandteile von Fast-Track- oder Enhanced-Recovery-Programmen in der Endoprothetik sind die Optimierung der interdisziplinär-organisatorischen Abläufe sowie der prä-, intra- und postoperativen Vorgehensweisen im klinischen Alltag. Die frühpostoperative Mobilisation der Patienten ist nach Gelenkersatzoperation von zentraler Bedeutung, mit dem Ziel, Schmerzen und Komplikationen nachweislich zu vermeiden. Dieser Beitrag gibt einen detaillierten Überblick hinsichtlich der zwischenzeitlich zunehmend verbreiteten Fast-Track-Vorgehensweisen. Zudem zeigt er die klinischen Vorteile von Fast-Track für die Hüftendoprothetik im Rahmen eines randomisierten Studiendesigns evidenzbasiert auf. Material und Methoden Es wurden 194 Patienten mit primärer HTEP nach einfach verblindeter Randomisierung in zwei Gruppen untersucht: Fast-Track (n = 98) oder konventioneller Behandlungspfad (n = 96). Als primärer Outcomeparameter war die Mobilisierung definiert, gemessen mit dem Timed-Up-and-Go-Test (TUG) in Sekunden. Sekundäre Parameter waren erreichbare Gehstrecke in Metern sowie Schmerzen auf der Numerische Rating-Skala (NRS). Alle Parameter wurden präoperativ und täglich bis zum 6. postoperativen Tag erfasst. Ergebnisse Innerhalb der ersten postoperativen Woche wurden keine Komplikationen oder Revisionen verzeichnet. Die Fast-Track-Gruppe zeigte im Vergleich zur konventionellen Gruppe bis zum 6. postoperativen Tag signifikant bessere TUG-Werte sowie Gehstreckenergebnisse (jeweils p  0,05). Fazit Die Anwendung von Fast-Track-Konzepten in der Hüftendoprothetik kann evidenzbasiert die klinischen Ergebnisse verbessern. Diese prospektive, einfach verblindete randomisierte kontrollierte Studie konnte ein sehr gutes kurzfristiges Ergebnis mit vergleichbaren Schmerzen nach Fast-Track-HTEP im Vergleich zu einem konventionellen Behandlungspfad aufzeigen. Fast-Track-Konzepte sind hochwirksam in Bezug auf Frühmobilisierung und klinisches Ergebnis – ohne in der Frühphase ein höheres Komplikationsrisiko einzugehen

SOG – Spezielle Orthopädische Geriatrie

Hintergrund Für die Versorgung geriatrischer Patienten bei elektiven orthopädischen Operationen existieren in Deutschland bisher noch keine adäquaten Versorgungskonzepte. Die SOG-Studie evaluiert hierzulande erstmalig den Einfluss eines komplexen orthogeriatrischen Co-Managements auf das Outcome älterer Patienten mit elektivem Hüft- und Kniegelenkersatz im Vergleich zur orthopädischen Standardversorgung. Methodik In die Zwischenanalyse der noch laufenden Studie wurden 174 Patienten eingeschlossen, wovon 87 Patienten in die Interventionsgruppe und 87 Patienten in die Kontrollgruppe randomisiert wurden. Das SOG-Versorgungsmodell besteht aus Screening, präoperativem Assessment mit präoperativer Intervention/Optimierung, Operation nach dem Fast-Track-Prinzip und multimodaler perioperativer Versorgung im orthogeriatrischen Team. Die Kontrollgruppe erhielt eine orthopädische Standardbehandlung. Verglichen wurden Mobilität, Komplikationen und „patient-reported outcome measures“ (PROM). Ergebnisse Die Interventionsgruppe wies postoperativ gegenüber der Kontrollgruppe zu allen Erfassungszeitpunkten eine klinisch relevant verbesserte Mobilität auf (p < 0,01). Die Komplikationsauswertung zeigte eine signifikante Risikoreduktion für Minor-Komplikationen (p < 0,01) sowie einen deutlichen Trend zur Risikoreduktion für Major-Komplikationen. Die Auswertung der PROM zeigte unabhängig von der Intervention eine signifikante Verbesserung der Gelenkfunktion und der allgemeinen gesundheitsbedingten Lebensqualität. Schlussfolgerung Integrierte orthogeriatrische Modelle, wie die Spezielle Orthopädische Geriatrie, könnten zukünftig die Versorgung geriatrischer Patienten in der elektiven orthopädischen Chirurgie verbessern und vor allem sicherer gestalten

Impact of malnutrition and vitamin deficiency in geriatric patients undergoing orthopedic surgery

Background and purpose — There is growing evidence that hypoproteinemia is an important risk factor for adverse events after surgery. Less is known about the impact of vitamin deficiency on postoperative outcome. Therefore we evaluated the prevalence and impact of malnutrition and vitamin deficiency in geriatric patients undergoing elective orthopedic surgery. Patients and methods — In a retrospective analysis of 599 geriatric patients who had undergone elective orthopedic surgery in 2018 and 2019, hypoproteinemia, and deficiency of vitamin D, vitamin B12, and folate were assessed. Reoperation rates, readmission rates, complication rates, and transfusion rates were compared between malnourished patients and patients with normal parameters. Multivariable logistic regression models were used to assess the relationship between malnutrition and postoperative adverse events, controlling for confounding factors such as age, sex, diabetes mellitus, and frailty. Results — Patients with malnutrition showed a higher rate of reoperation (13% vs. 5.5%; p = 0.01) and exhibited more wound-healing disorders (7.4% vs. 1.3%, p = 0.001) as well as Clavien–Dindo IV° complications (7.4% vs. 2.4%; p = 0.03). Deficiency of vitamin D led to a higher rate of falls (8.4% vs. 2.9%, p = 0.006). Deficiency of vitamin B12 and folate did not affect postoperative adverse events. Although correlated to frailty (p = 0.004), multivariable regression analysis identified malnutrition as independent risk factor for reoperation (OR 2.6, 95% CI 1.1–6.2) and wound healing disorders (OR 7.1, CI 1.9–26). Interpretation — Malnutrition is common among geriatric patients undergoing elective orthopedic surgery and represents an independent risk factor for postoperative adverse events

Implementing a benchmarking and feedback concept decreases postoperative pain after total knee arthroplasty: A prospective study including 256 patients

Perioperative pain reduction, particularly during the first two days, is highly important for patients after total knee arthroplasty (TKA). Problems are not only caused by medical issues but by organization and hospital structure. The present study shows how the quality of pain management can be increased by implementing a standardized pain concept and simple, consistent benchmarking. All patients included into the study had undergone total knee arthroplasty. Outcome parameters were analyzed by means of a questionnaire on the first postoperative day. A multidisciplinary team implemented a regular procedure of data analyzes and external benchmarking by participating in a nationwide quality improvement project. At the beginning of the study, our hospital ranked 16(th) in terms of activity-related pain and 9(th) in patient satisfaction among 47 anonymized hospitals participating in the benchmarking project. At the end of the study, we had improved to 1(st) activity-related pain and to 2(nd) in patient satisfaction. Although benchmarking started and finished with the same standardized pain management concept, results were initially pure. Beside pharmacological treatment, interdisciplinary teamwork and benchmarking with direct feedback mechanisms are also very important for decreasing postoperative pain and for increasing patient satisfaction after TKA

Revision Surgery In Total Joint Replacement Is Cost-Intensive

Revisions after total joint replacement increase constantly. In the current study, we analyzed clinical outcome, complication rates, and cost-effectiveness of revision arthroplasty. In a retrospective analysis of 162 revision hip and knee arthroplasties from our institutional joint registry responder rate, patient-reported outcome measures (EQ-5D, WOMAC), complication rates, and patient-individual charges in relation to reimbursement were compared with a matched control group of primary total joint replacements. Positive responder rate one year postoperatively was lower for revision arthroplasties with 72.9% than for primary arthroplasties with 90.1% (OR=0.30, 95%CI= 0.18-0.59, p=0.001). Correspondingly, improvement in patient-reported outcome measures one year after surgery was lower in revision than in primary joint arthroplasty with EQ-5D 0.19 +/- 0.25 to 0.30 +/- 0.24 (p<0.001) and WOMAC 24.3 +/- 30.3 to 41.2 +/- 21.3 (p<0.001). Infection rate was higher in revision (6.8%) compared to primary replacements (0%, p=0.001). Mean charges in revision arthroplasty were 76.0% higher than in matched primary joint replacements (7110.8 +/- 2249.4$to 4041.1 +/- 975.7$, p<0.001), whereas reimbursement was only 23.6% higher (9243.3 +/- 2258.4$in revision and 74779 +/- 703.1$ in primary arthroplasty, p<0.001). Revision arthroplasty is associated with lower outcome and higher infection rate compared to primary replacements. The high financial expense of revision arthroplasty is only partly covered by a higher reimbursement

No Success without Effort: Follow-Up at Six Years after Implementing a Benchmarking and Feedback Concept for Postoperative Pain after Total Hip Arthroplasty

Background: Total hip arthroplasty (THA) is still ranked among the operations with the highest postoperative pain scores. Uncontrolled postsurgical pain leads to prolongated hospital stays, causes more frequent adverse reactions and can induce chronical pain syndromes. In 2014, we implemented a standardized, multidisciplinary pain management concept with continuous benchmarking at our tertiary referral center by using the “Quality Improvement in Postoperative Pain Management” (QUIPS) program with excellent results over a period of two years. The initial study ended in 2016 and we aimed to evaluate if it was possible to obtain the excellent short-term results over a period of six years without any extra effort within the daily clinical routine. Materials and Methods: In a retrospective study design, we compared postoperative pain, side effects and functional outcome after primary THA for 2015 and 2021, using validated questionnaires from the QUIPS project. In contrast to the implementation of the pain management concept in 2014, the weekly meetings of the multidisciplinary health care team and special education for nurses were stopped in 2021. Data assessment was performed by an independent pain nurse who was not involved in pain management. Results: Altogether, 491 patients received primary THA in 2015 and 2021 at our tertiary referral center. Collected data revealed significantly worse maximum and activity-related pain (both p < 0.001) in combination with significantly higher opioid consumption in comparison to implementation in 2015. Though the patients reported to be less involved in pain management (p < 0.001), the worse pain scores were not reflected by patient satisfaction which remained high. While the participation rate in this benchmarking program dropped, we still fell behind in terms of maximum and activity-related pain in comparison to 24 clinics. Conclusion: Significantly worse pain scores in combination with higher opioid usage and a lower hospital participation rate resemble a reduced awareness in postoperative pain management. The significantly lower patient participation in pain management is in line with the worse pain scores and indirectly highlights the need for special education in pain management. The fact patient satisfaction appeared to remain high and did not differ significantly from 2015, as well as the fact we still achieved an acceptable ranking in comparison to other clinics, highlight the value of the implemented multidisciplinary pain management concept

Comparison of postoperative isokinetic quadriceps and gluteal muscular strength after primary THA: is there an early benefit through enhanced recovery programs?

Purpose Although total hip arthroplasty (THA) is expected to result in a postoperative loss of muscular strength, no study investigated the benefit of an enhanced-recovery-after-surgery (ERAS) concept on the hip muscles in detail. We evaluated if (1) an ERAS-concept for primary THA results in reduced loss of muscular strength five days and four weeks postoperative. We (2) compared the two groups regarding Patient-Related-Outcome-Measures (PROMs), WOMAC-index (Western-Ontario-and-McMaster-Universities-Osteoarthritis-Index), HHS (Harris-Hip-Score) and EQ-5d-3L-score. Methods In a prospective, single-blinded, randomized controlled trial, we compared isokinetic muscular strength of 24 patients receiving primary THA with an enhanced recovery concept with early mobilization (n = 12, ERAS-group) and such receiving conventional THA (n = 12, non-ERAS). Isokinetic muscular strength was measured with a Biodex-Dynamometer before, as well as five days and four weeks after surgery (peak-torque, total-work, power). Furthermore, WOMAC, HHS, PROMs and EQ-5d-3L were imposed. Results The ERAS group revealed significant higher isokinetic strength (peak-torque, total-work, power) at both time points. Both groups showed a significant pain decrease at both time points meeting very high rates of patient satisfaction resembled by good results in PROMs, WOMAC, HHS, EQ-5d. There was no significant difference in any of the scores between both groups. Conclusion We proved a significant reduced loss of muscular strength five days and four weeks after primary THA in combination with an ERAS concept. However, the reduced loss of muscular strength is not reflected by patient’s functional outcome and quality of life, showing no significant differences in WOMAC, HHS, EQ-5d-3L, PROMs and NRS. Therefore, this study supports the implementation of an ERAS concept for primary THA in terms of isokinetic strength. Further studies are needed to evaluate the development of muscular strength over a long period

Can Consistent Benchmarking within a Standardized Pain Management Concept Decrease Postoperative Pain after Total Hip Arthroplasty? A Prospective Cohort Study including 367 Patients

Background: The number of total hip replacement surgeries has steadily increased over recent years. Reduction in postoperative pain increases patient satisfaction and enables better mobilization. Thus, pain management needs to be continuously improved. Problems are often caused not only by medical issues but also by organization and hospital structure. The present study shows how the quality of pain management can be increased by implementing a standardized pain concept and simple, consistent, benchmarking. Methods: All patients included in the study had undergone total hip arthroplasty (THA). Outcome parameters were analyzed 24 hours after surgery by means of the questionnaires from the German-wide project "Quality Improvement in Postoperative Pain Management" (QUIPS). A pain nurse interviewed patients and continuously assessed outcome quality parameters. A multidisciplinary team of anesthetists, orthopedic surgeons, and nurses implemented a regular procedure of data analysis and internal benchmarking. The health care team was informed of any results, and suggested improvements. Every staff member involved in pain management participated in educational lessons, and a special pain nurse was trained in each ward. Results: From 2014 to 2015, 367 patients were included. The mean maximal pain score 24 hours after surgery was 4.0 (+/- 3.0) on an 11-point numeric rating scale, and patient satisfaction was 9.0 (+/- 1.2). Over time, the maximum pain score decreased (mean 3.0, +/- 2.0), whereas patient satisfaction significantly increased (mean 9.8, +/- 0.4; p<0.05). Among 49 anonymized hospitals, our clinic stayed on first rank in terms of lowest maximum pain and patient satisfaction over the period. Conclusion: Results were already acceptable at the beginning of benchmarking a standardized pain management concept. But regular benchmarking, implementation of feedback mechanisms, and staff education made the pain management concept even more successful. Multidisciplinary teamwork and flexibility in adapting processes seem to be highly important for successful pain management

Differences in femoral component subsidence rate after THA using an uncemented collarless femoral stem: full weight-bearing with an enhanced recovery rehabilitation versus partial weight-bearing

Background Femoral component subsidence is a known risk factor for early failure of total hip arthroplasty (THA) using cementless stems. The aim of the study was to compare an enhanced recovery concept with early full weight-bearing rehabilitation and partial weight-bearing on stem subsidence. In addition, the influence of patient-related and anatomical risk factors on subsidence shall be assessed. Methods One hundred and fourteen patients underwent primary cementless THA and were retrospectively analyzed. Sixty-three patients had an enhanced recovery rehabilitation with early full weight-bearing and 51 patients had rehabilitation with partial weight-bearing (20 kg) for 6 weeks. Postoperative subsidence was analyzed on standing pelvic anterior–posterior radiographs after 4 weeks and 1 year. Subsidence was measured in mm. Anatomical and prosthetic risk factors (stem size, canal flare index, canal fill ratio as well as BMI and demographic data) were correlated. Results Femoral stem subsidence rate was significantly higher for the group with an enhanced recovery concept compared to the group with partial weight-bearing at the first radiological follow up after 4 weeks [2.54 mm (SD ± 1.86) vs. 1.55 mm (SD ± 1.80)] and the second radiological follow up after 1 year [3.43 mm (SD ± 2.24) vs. 1.94 (SD ± 2.16)] (p  3° had a significant influence on subsidence. Canal flare index and canal fill ratio showed no significant correlation with subsidence as well as BMI and age. Conclusion In the present study, cementless stem subsidence was significantly higher in the group with enhanced recovery rehabilitation compared to partial weight-bearing. Small absolute values and differences were demonstrated and therefore possibly below clinical relevance. Anatomical radiological parameters and anthropometric data did not appear to be risk factors for stem subsidence

Excellent Functional Outcome and Quality of Life after Primary Cementless Total Hip Arthroplasty (THA) Using an Enhanced Recovery Setup

Background: Total hip arthroplasty combined with the concept of enhanced recovery is of continued worldwide interest, as it is reported to improve early functional outcome and treatment quality without increasing complications. The aim of the study was to investigate functional outcome and quality of life 4 weeks and 12 months after cementless total hip arthroplasty in combination with an enhanced recovery concept. Methods: A total of 109 patients underwent primary cementless Total Hip Arthroplasty (THA) in an enhanced recovery concept and were retrospectively analyzed. After 4 weeks and 12 months, clinical examination was analyzed regarding function, pain and satisfaction; results were evaluated using Harris Hip score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), EQ-5D-5L, EQ-VAS and subjective patient-related outcome measures (PROMs). Preoperatively, HADS (Hospital Anxiety and Depression Scale) was collected. A correlation analysis of age, American Society of Anesthesiologists (ASA), HADS and comorbidities (diabetes mellitus, art. hypertension, cardiovascular disease) with WOMAC, Harris Hip score (HHS) and EQ-5D was performed. Results: Patients showed a significant improvement in Harris Hip score 4 weeks and 12 months postoperatively (p < 0.001). WOMAC total score, subscale pain, subscale stiffness and subscale function improved significantly from preoperative to 12 months postoperative (p < 0.001). EQ-5D showed a significant improvement preoperative to postoperative (p < 0.001). The influence of anxiety or depression (HADS-A or HADS-D) on functional outcome could not be determined. There was a high patient satisfaction postoperatively, and almost 100% of patients would choose enhanced recovery surgery again. Conclusion: Cementless THA with the concept of enhanced recovery improves early clinical function and quality of life. PROMs showed a continuous improvement over a follow-up of 12 months after surgery. PROMs can help patients and surgeons to modify expectations and improve patient satisfaction