Patients undergoing total knee arthroplasty (TKA) experience significant post-operative pain. We report the results of a new comprehensive patient care plan to manage peri-operative pain, enable early mobilisation and reduce length of hospital stay in TKA.

A prospective audit of 1081 patients undergoing primary TKA during 2008 and 2009 was completed. All patients followed a planned programme including pre-operative patient education, pre-emptive analgesia, spinal/epidural anaesthesia with propofol sedation, intra-articular soft tissue wound infiltration, post-operative high volume intermittent ropivacaine boluses with an intra-articular catheter and early mobilisation. The primary outcome measure was the day of discharge from hospital. Secondary outcomes were verbal rating pain scores on movement, time to first mobilisation, nausea and vomiting scores, urinary catheterisation for retention, need for rescue analgesia, maximum flexion at discharge and six weeks post-operatively, and Oxford score improvement.

The median day of discharge to home was post-operative day four. Median pain score on mobilisation was three for first post-operative night, day one and day two. 35% of patients ambulated on the day of surgery and 95% of patients within 24 hours. 79% patients experienced no nausea or vomiting. Catheterisation rate was 6.9%. Rescue analgesia was required in 5% of cases. Median maximum flexion was 85° on discharge and 93° at six weeks post-operatively. Only 6.6% of patients had a reduction in maximum flexion (loss of more than 5°) at six weeks. Median Oxford score had improved from 42 pre-operatively to 27 at six weeks post-operatively. The infection rate was 0.7% and the DVT and PTE rates were 0.6% and 0.5% respectively.

This multidisciplinary approach provides satisfactory post-operative analgesia allowing early safe ambulation and discharge from hospital. Anticipated problems did not arise, with early discharge not being detrimental to flexion achieved at six weeks and infection rates not increasing with the use of intra-articular catheters.

Purpose

We report our initial results of a new comprehensive patient care plan to manage peri-operative pain, enable early mobilisation and reduce length of hospital stay in TKA.

Patients undergoing total knee arthroplasty (TKA) experience significant postoperative pain. This impedes early mobilization and delays hospital discharge. A prospective audit of 1081 patients undergoing primary TKA during 2008 was completed. All patients followed a programme including preoperative patient education, pre-emptive analgesia, spinal/epidural anaesthesia with propofol sedation, intra-articular soft tissue wound infiltration, postoperative high volume ropivacaine boluses with an intra-articular catheter and early mobilization. Primary outcome measure was length of stay. Secondary outcomes were verbal analogue pain scores on movement, time to mobilization, nausea and vomiting scores, urinary catheterization for retention, need for rescue analgesia, range of motion at discharge and six weeks postoperatively. The median day of discharge was postoperative day four. Median pain score on mobilization was three for first postoperative night, day one and two. 35% of patients ambulated on the day of surgery and 95% of patients within 24 hours. 79% patients experienced no nausea or vomiting. Catheterization rate was 6.9%. Rescue analgesia was required in 5% of cases. The median day of discharge was postoperative day four. Median range of motion was 85° on discharge and 93° at six weeks postoperatively. This comprehensive care plan provides satisfactory postoperative analgesia allowing early safe ambulation and discharge.

Purpose: We report an evolving technique for managing peri-operative pain relief that has enabled early mobilisation and facilitated early discharge after primary Total Knee Arthroplasty (TKA).

Methods and Results: Our organisation has instituted a regime covering all aspects of the peri-operative care for TKA. This includes: pre-operative counselling and preparation; multimodal anaesthesia and analgesia regime; intra-articular analgesia for 24 hours post-operation; early mobilisation regime. We carried out an audit of prospectively collected data of all patients undergoing primary TKA in the six months from January to June 2008 (total of 319 patients), including pain scores, discharge from physiotherapy and follow up data at six weeks.

A total of 305 TKAs with complete data sets were included in the analysis. Of these 36% were mobilised on the day of surgery and 93% by post-operative day 1. Catheterisation rates were 12% and the need for postoperative intra-venous fluids was 10%. In-house physiotherapy discharged 58% of patients by day 3 and 85% by day 5. The visual analogue pain scores (on movement) on day zero and day one were within acceptable limits (median = 3) and 80% of patients experienced no nausea or vomiting.

Functionally, the median range of movement at discharge was 85° with 31% of patients requiring out-patient physiotherapy assessment. At six weeks the median range of motion was 95° with only 5% of patients having a reduced range of motion (reduction of > 10°) when compared to discharge. The median Oxford scores improved from 43 pre-operatively to 26 at six weeks.

Conclusion: This regime offers an efficient method for post-operative pain relief and early mobilisation with the added benefit of reducing post-operative catheterisation, intra-venous fluid requirements and the need for post-operative physiotherapy. It compares very favourably with published data on other peri-operative regimes using regional anaesthesia.

Introduction: We report an evolving technique for managing peri-operative pain relief that has enabled early mobilisation and facilitated early discharge after primary Total Hip Arthroplasty (THA).

Methods: Our organisation has instituted a regime covering all aspects of the peri-operative care for THA. This includes: pre-operative counselling and preparation; multimodal anaesthesia and analgesia regime; intra-articular analgesia for 24 hours post-operation; early mobilisation regime. We carried out an audit of prospectively collected data of all patients undergoing primary THA in the six months from January to June 2008 (total of 138 patients), including pain scores, discharge from physiotherapy and follow up data at six weeks.

Results: A total of 122 THAs with complete data sets were included in the analysis. Of these 27% were mobilised on the day of surgery and 97% by post-operative day 1. Catheterisation rates were 16% and the need for post-operative intra-venous fluids was 15%. In-house physiotherapy discharged 58% of patients by day 3 and 87% by day 5. The visual analogue pain scores (on movement) on day zero and day one were within acceptable limits (medians were 2.5 and 2 respectively) and 84% of patients experienced no nausea or vomiting.

Functionally 14% of patients required out-patient physiotherapy assessment. At three months the median Oxford scores had improved from 43 pre-operatively to 20.

Discussion: This regime offers an efficient method for post-operative pain relief and early mobilisation with the added benefit of reducing post-operative catheterisation, intra-venous fluid requirements and the need for post-operative physiotherapy. It compares very favourably with published data on other peri-operative regimes using regional anaesthesia.