Management of patients in the post-operative period after the hip joint replacement accessed by low-invasive access

Abstract

Up to 1.5 million total hip arthroplasty is performed annually in the world. In Russia, at least 300 thousand patients a year need hip replacement surgery. High tissue invasiveness during surgical approaches presents special requirements for the rehabilitation process in the early postoperative period. Accelerating and making it more efficient is possible with the use of the least traumatic operating access. The purpose of the study is a comparative analysis of two models of the organization of rehabilitation in the postoperative period after hip arthroplasty: using standard Harding surgical access and the minimally invasive Rottinger access. Material of the study - patients operated on with standard Harding access (group I, n = 227) and front-external Rottinger access (group II, n = 266). Criteria for inclusion of patients in both groups are primary coxarthrosis without previous surgical interventions, exclusion criteria are connective tissue diseases, severe comorbidity. Group I patients underwent postoperative rehabilitation according to the standard protocol, group II - according to the rehabilitation concept "ERAS, fast-track". To assess the effectiveness of the rehabilitation at all stages in both groups, the rehabilitation potential was assessed on the rehabilitation routing scale (SRM), the dynamics of the pain syndrome on the visual analogue pain scale (VAS), the verticalization period was taken into account, the main assessment scales of the patient's motor functions and psychological status were used in hip arthroplasty: Harris scale, quality of life questionnaire (EQ - 5D), modified Rankin scale. Results and discussion. The proportion of hip arthroplasty using MIS access in the total number of operations increased from 0.7% in 2015 to 10.1% in 2018. The studied groups are comparable in terms of the ratio of men and women, average age, number of observations, BMI and the volume of blood loss. The surgeon duration and the duration of the stationary phase in group I exceeded the similar parameters of the II group. The modified Rankin scale at admission and discharge in all patients showed moderate disability, starting indicators and results after 3 months were more prosperous in group II. Both groups had an equivalent score on the Harris scale before surgery and after 3 months after it, more pronounced positive dynamics of the quality of life on the EQ-5D scale ("thermometer") was noted in group II. A decrease in pain after surgery compared with baseline, with regression to 0.8-1.0 points by 3 months after surgery, was noted in all patients. The assessment on the rehabilitation routing scale did not differ in both groups. At the stationary stage, group I patients walked with additional support on crutches (100%), group II - on a cane (92.5%). On long days 4-6, 82.8% of patients of group I and 91.7% of patients of group II passed long distances. At the end of stage I rehabilitation, 83.7% of group I patients and 92.5% of group II were sent to the outpatient rehabilitation stage, the rest were transferred to stage II of rehabilitation in a 24 - hour hospital. The third stage of rehabilitation, all patients went on an outpatient basis at the place of residence. At the follow-up stage, the data of a telephone survey of group II were analyzed (n = 68, 25.6% of the respondents). By 3 months, the Harris score exceeds 90 points, satisfaction with the operation is 97%. As a result of the use of surgical MIS access for hip arthroplasty, all patients had good rehabilitation indicators. Conclusions. The general approach to managing patients after hip arthroplasty is similar for all types of surgical access, however, MIS-access creates the most favorable conditions for the rehabilitation of patients in the early postoperative period: a positive attitude of the patient, reduced blood loss, reduced surgical incision, the possibility of early activation and transition to the general regime for 6-7 days. The results of the study showed the advantages of a model for the organization of rehabilitation in the postoperative period after hip arthroplasty using mini-invasive access over standard surgical access. Group II patients (MIS access) had a higher level of physical activity and a low level of pain in the early postoperative period.