A Propensity Score-Matched Analysis to Assess the Outcomes in Pre- and Post-Fast-Track Hip and Knee Elective Prosthesis Patients.

Luigi U Romano,Monica Morandi,Emanuele Torri,Marilena Nella,Giandomenico Nollo,Piergiorgio Casetti,Marta Rigoni

doi:10.3390/jcm10040741

Luigi U Romano, Monica Morandi + Show 5 more

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https://doi.org/10.3390/jcm10040741

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Abstract

Fast-track surgery is a multimodal evidence-based approach to perioperative care aimed at reducing complications and recovery time. We compared a fast-track protocol to standard care in the setting of a small Italian general hospital. Propensity score estimation before and after the study was performed to compare pre-fast-track (pre-FT; January 2013–March 2014) and fast-track (FT; January 2016–December 2016) patients undergoing elective hip and knee replacement surgery with a three-year follow-up (up to January 2020). The primary endpoints were the mean hemoglobin drop, mean predischarge hemoglobin, transfusion and reinfusion rates, pain, ambulation day, hospital length of stay (LOS), and discharge to home/outpatient care or rehabilitation hospital center. The secondary endpoints were the adherence measures to the FT protocol, namely, tourniquet and surgical times, use of drains and catheters, type of anesthesia administered, and complications within three years. The risk difference (RD) and the adjusted odds ratio (aOR) were calculated for each outcome. After the propensity score estimation, we analyzed 59 patients in the pre-FT and 122 in the FT categories. The FT patients, with respect to the pre-FT patients, ameliorated their mean hemoglobin drop from 3.7 to 3.1 g/dl (p < 0.01) and improved their predischarge mean hemoglobin (10.5 g/dL versus 11.0 g/dL; p = 0.01). Furthermore, the aOR of being transfused was reduced by 81% (p < 0,01); the RD of being reinfused was reduced by 63% (p < 0.01); the aOR of having low pain on the first day was increased by more than six times (p < 0.01); the RD of ambulating the first day increased by 91% (p < 0.01); the aOR of admission to a rehabilitation hospital center was reduced by 98% (p < 0.01); the aOR of home discharge increased by 42 times (p < 0.01); the median LOS, tourniquet and surgical times, and use of catheters and drains significantly decreased. Patients with complications at 1 month were 43.1% and 38.2%, respectively, of pre-FT and FT patients (p = 0.63). Complications at 6, 12, 24, and 36 months were significantly lower for the FT patients. This study showed that the uptake of enhanced recovery practices was successful and resulted in the improvement of clinical and organizational outcomes. The fast-track concept and related programs may optimize perioperative care and streamline surgical and rehabilitation care paths.

Highlights

Hip and knee replacement operations are among the most commonly performed surgeries in developed countries [1,2]
Treatment with FT reduced the Hospital length of stay, odds of having a transfusion by 81% with respect to the pre-FT
In relation to blood management practices, mean hemoglobin drop was reduced and predischarge hemoglobin was increased by the FT period

Summary

Introduction

Hip and knee replacement operations are among the most commonly performed surgeries in developed countries [1,2]. Total hip arthroplasty (THA) and total knee arthroplasty (TKA), whose use is expected to increase further because of the aging population and the growing prevalence of osteoarthritis and other severe joint diseases, result in excellent functional improvement and pain relief outcomes These procedures are subject to variation in quality and outcomes of care across providers and target populations. Fast-track surgery or ERAS may be defined as a coordinated perioperative approach aimed at reducing surgical stress and facilitating postoperative recovery [9] This method is based on the implementation of a protocol encompassing several evidence-based elements, including patient education and engagement, mini-invasive surgery, multimodal anesthesia, pain control, fluid management, thromboembolic prophylaxis, appropriate wound management, blood conservation, early mobilization, and physiotherapy. In addition to these key elements, the care process should engage all of the professionals involved in the surgical and presurgical pathways, as well as the patients themselves [10]

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