The outcome after total hip replacement has improved with the development of surgical techniques, better pain management and the introduction of enhanced recovery pathways. These pathways require a multidisciplinary team to manage pre-operative education, multimodal pain control and accelerated rehabilitation. The current economic climate and restricted budgets favour brief hospitalisation while minimising costs. This has put considerable pressure on hospitals to combine excellent results, early functional recovery and shorter admissions.

In this review we present an evidence-based summary of some common interventions and methods, including pre-operative patient education, pre-emptive analgesia, local infiltration analgesia, pre-operative nutrition, the use of pulsed electromagnetic fields, peri-operative rehabilitation, wound dressings, different surgical techniques, minimally invasive surgery and fast-track joint replacement units.

Cite this article: Bone Joint J 2013;95-B:1587–94.

Introduction. The Direct Anterior Approach (DAA) offers potential advantages of quicker rehabilitation compared to posterior approach THR. The aim of this study was to compare hospital based and early clinical outcomes between these two groups with utilisation of Enhanced Recovery After Surgery (ERAS) protocol. Patients/Materials & Methods. Prospectively collected data for both cohorts were matched for age, gender, ASA grade, BMI, operation side, Pre-operative Oxford Hip score (OHS) and attendance at multi-disciplinary joint school. The pain scores at 0,1,2,3 post-op days, the day of mobilization, inpatient duration, complications, 28 days readmission rates and OHS at 6 and 24 months were compared. Results. Four hundred and fifty two THR (DAA: 219, Posterior: 233) were matched. There was no difference in OHS at 6 months (p=0.07). There was also no difference in pain scores at 0, 1, 2, and 3rd post op days, the day of first mobilization (p=0.32), length of stay (p= 0.3), 28 days readmission (p=0.11) or OHS at 24 months (p=0. 09). 68% of DAA vs 58 % of posterior approach patients achieved planned in-patient duration target of 3 days (p= 0.04). There were six peri-prosthetic femoral fractures in DAA group vs one in posterior approach group (p=0.097). No significant difference was identified for complications, re-operation or 28 days readmission rates between two groups. Discussion. The DAA procedures were performed by two surgeons with extensive prior experience in DAA approach. The potential advantages and complications especially during early learning curve have to be carefully considered by operating surgeon who wishes to start performing DAA approach. The ERAS protocol can potentially reduce the difference in early recovery between two groups. Conclusion. There is no significant difference in clinical outcomes between DAA and posterior approach THR with utilisation of ERAS protocol except potential of discharge from the hospital within three days following the DAA procedure

Hyponatraemia is a potentially preventable post-operative complication following hip arthroplasty. There is a paucity of literature reporting its incidence and guidelines for prevention - unlike AKI which has been prioritised to great success. Hyponatraemia is now rife in elective orthopaedics causing multiple symptoms that delay ambulation and increase the length of hospital stay. We aim to assess the incidence of hyponatraemia and AKI as a benchmark following elective primary total hip arthroplasty (THA), as well as identify patients most at risk in a high volume arthroplasty centre.

Between April 2018 and September 2018 all primary THA surgeries performed in one hospital were retrospectively reviewed. Pre-operative and 1 day post operative bloods were analysed. Patients included had normal pre-operative sodium.

A total of 221 patients underwent THA. The mean age was 73.6 and ASA 2.1. No patients had a recorded AKI, however 42% of patients had a new post operative hyponatraemia. Of the hyponatraemia cases, 75% were mild, 18% were moderate, and 7% were severe. There was correlation between increased age and increased severity of hyponatraemia. The mean age of patients with mild hyponatraemia was 72.1, moderate was 77.7, and severe was 78.8. An association between ASA and severity of hyponatraemia was noted. In patients who had an ASA of 4 and hyponatraemia, 66% were moderate or severe, ASA 3 was 25%, ASA 2 was 24% and ASA 1 was 0%. The patients who had severe hyponatraemia received on average 3.5L fluid input perioperatively.

Rates of post op hyponatraemia are significantly higher than AKI in primary THA. Severity of hyponatraemia increases with age and ASA. Due to its negative outcomes on recovery the high levels of hyponatraemia are worrying. We have identified which patient cohorts are more at risk and recommend more care should be taken in their perioperative fluid balance. It may be beneficial to consider successful AKI prevention and management campaigns and apply them to the prevention of hyponatraemia following hip arthroplasty.

Introduction. Total Hip Replacement (THR) is an effective treatment for end stage degenerative disease of the hip and offers patients the prospect of long term pain relief, improved joint function and quality of life. Enhanced Recovery Programmes (ERP) aim to standardise routine perioperative care, reduce hospital length of stay (LOS) and promote rapid recovery after elective surgery. The aim of this study was to determine whether the implementation of an ERP could successfully reduce the length of hospital stay associated with primary THR and whether this could be achieved without compromising the expected functional outcome or risking an increased dislocation rate. Patients/Materials & Methods. Prospectively collected data on 1161 patients (611 managed with traditional rehabilitation and 550 with ERP) undergoing primary unilateral THR between 2005 and 2013 was retrospectively reviewed. Univariable statistical analysis was undertaken to identify factors that appeared to predict length of stay and a multiple linear regression model was then constructed to determine the significance and strength of effect of the individual predictors. Results. Median LOS was 5 days for those managed in the traditional method and 3 days for those managed with ERP (p<0.001). Multivariate regression models demonstrate that this effect on LOS is independent of and stronger than other factors affecting LOS and we did not observe increased rates of dislocation (1.03% versus 0.73%, p=0.75) or mortality (1.5% versus 0.6%, p=0.14) at one year postoperative in patients managed with ERP. Both groups demonstrated significant improvement in mean Harris Hip Score (+42.8 versus +41.5) at twelve to eighteen months postoperative and there was no significant difference in the magnitude of improvement between groups (p=0.09). Discussion. This is the first study to demonstrate the independent effect of ERP on LOS through multiple regression analysis and to directly compare functional outcomes of patients managed with ERP with the accepted gold standard (traditional rehabilitation) and these findings will be of use to surgeons counselling patients peiroperatively and healthcare planners. Conclusion. Implementation of ERP can reduce the hospital LOS for primary THR without adverse effects on dislocation rates and functional outcomes at 12 to 18 months postoperative

Aims

The primary aim of this study was to investigate the effect of an enhanced recovery program (ERP) on the short-term functional outcome after total hip arthroplasty (THA). Secondary outcomes included its effect on rates of dislocation and mortality.

The development and implementation of Enhanced Recovery After Surgery (ERAS) protocols are of particular interest in elective orthopaedics due to clinical benefits and cost effectiveness. The Wycombe Arthroplasty Rapid-Recovery Pathway (WARP) was designed to streamline hip and knee joint arthroplasty to reduce time spent in hospital whilst optimising outcomes in an NHS District General Hospital. 966 patients were admitted to Wycombe General Hospital for primary elective joint replacement (60 UKR, 446 THR, 460 TKR) during the period 1st September 2020 to 31st September 2022. The WARP pathway was used for 357 (37%) patients (32 UKR, 155 THR, 170 TKR) and the standard “non-WARP” pathway was used for 609 (63%) patients (28 UKR 291 THR, 290 TKR). Data was collected on length of stay, time of mobilisation, number of physiotherapy sessions, and inpatient morbidity. Average length of stay following UKR was 0.75 days for WARP vs 2.96 for non-WARP patients, following THR was 2.17 days for WARP vs 4.17 for non-WARP patients, following TKR was 3.4 days for WARP vs 3.92 for non-WARP patients. Day-0 mobilisation after UKR was achieved in 97% of WARP vs 12% of non-WARP patients, after THR in 43% of WARP vs 14% of non-WARP patients, after TKR in 33% of WARP vs 11% of non-WARP patients. Same-day discharge was achieved in the WARP cohort in 63% of UKR, 10% of THR, 2% of TKR patients. There were no same-day discharges in the non-WARP cohort. Complications delaying mobilisation (pain, nausea/vomiting, dizziness/low BP) were identified in 8.4% of WARP vs 25% of non-WARP patients. Our cohort study shows that the initiation of WARP Rapid Recovery pathway for joint arthroplasty decreased the average length of stay after UKR by 2.21 days, after THR by 2 days, after TKR by 0.52 days. Time to first mobilisation was decreased significantly by increased rates of same-day mobilisation and reduced rates of postoperative anaesthetic-related complications

Aims

The aim of this study was to examine the efficacy and safety of multiple boluses of intravenous (IV) tranexamic acid (TXA) on the hidden blood loss (HBL) and inflammatory response following primary total hip arthroplasty (THA).