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

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

Pseudoappendicitis: abdominal pain arising from thoracic spine dysfunction—a forgotten entity and a reminder of an important clinical lesson

Acute or chronic abdominal pain can be mimicked by thoracic spine dysfunction. However, it is comparatively rare and there is frequently a delay in its diagnosis that may lead to unnecessary surgery, or the patient's symptoms being undiagnosed or labelled psychosomatic. The failure to associate thoracic spine dysfunction with abdominal pain persists, despite it being first recognised over 80 years ago. 2 recent such cases are presented. The clinical presentation and diagnostic tests are described, with clear explanation of the treatment and outcome. The case for including the thoracic spine examination in the assessment of patients presenting with acute abdominal or postappendectomy pain that is of unexplained origin is made

Rehabilitation strategies for optimisation of functional recovery after major joint replacement

Exercise-based interventions applied before and after total hip and knee arthroplasty (THA and TKA, respectively) have been investigated for a number of years, based on the assumption that they will enhance post-operative recovery. Although recent studies suggest that high-volume, pre-operative exercise may enhance post-operative recovery after TKA, studies of post-operative exercise-based interventions, have not found superiority of one exercise regime over another. It seems, however, that post-operative, exercise-based, rehabilitation is superior to no or minimal rehabilitation after THA and TKA. The goal of this commentary is to summarize recent evidence for the efficacy of different peri-operative exercise-based interventions to enhance recovery after THA and TKA, and to propose new strategies to further enhance post-operative recovery. There is a major need to improve functional recovery after THA and TKA. We propose a strategy of “enriched” trials where specific rehabilitation interventions are applied to different patients based on, for example, their expectations for post-operative recovery, willingness to undertake exercise and physical activity, and pre-operative functional performance

A Novel Approach to Overcome Movement Artifact When Using a Laser Speckle Contrast Imaging System for Alternating Speeds of Blood Microcirculation

The laser speckle contrast imager (LSCI) provides a powerful yet simple technique for measuring microcirculatory blood flow. Ideal for blood dynamic responses, the LSCI is used in the same way as a conventional Laser Doppler Imager (LDI). However, with a maximum skin depth of approximately 1 mm, the LSCI is designed to focus on mainly superficial blood flow. It is used to measure skin surface areas of up to 15 cm x 20 cm. The new technique introduced in this paper accounts for alternating speeds of microcirculations; i.e. both slow and fast flow flux measurement using the LSCI. The novel technique also overcomes LSCI's biggest shortcoming, which is high sensitivity to artifact movement. An adhesive opaque patch (AOP) is introduced for satisfactory recording of microcirculatory blood flow, by subtracting the LSCI signal from the AOP from the laser speckle skin signal. The optimal setting is also defined because the LSCI is most powerful when flux changes are measured relative to a reference baseline, with blood microcirculatory flux expressed as a percentage change from the baseline. These changes may be used for analyzing the status of the blood flow syste