Implementation of the Fast-track Protocol for Total Hip Arthroplasty in a Public Hospital in the State of São Paulo – Brazil

Abstract

Objective Evaluate the results of the implementation of the Fast Track Protocol (FTP), a medical practice based on scientific evidence, for elective total hip arthroplasty surgery, mainly comparing the National Average Hospital Admission Rate of 7.1 days.

Methods 98 patients who underwent elective total hip arthroplasty surgery via the direct anterior approach, anterolateral approach and posterior approach were included in the FTP from December 2018 to March 2020, being followed up preoperatively, intraoperatively and immediately postoperatively.

Results The average length of hospital stay was 2.8 days, being 2.1 days for the direct anterior approach, 3.0 days for the anterolateral access approach and 4.1 days for the posterior access approach. The average surgery time was 90 minutes, 19 (19.39%) of the patients were referred to the ICU in the postoperative period, however, none of them underwent surgery using the direct anterior approach. We had no cases of deep vein thrombosis (DVT), pulmonary embolism (PTE) or neurological injury, 19 (19.39%) patients had postoperative bleeding requiring dressing change, 4 (4.08%) needed blood transfusion, 2 (2.04%) patients had implant instability, 1 (1.02%) patient had a fracture during surgery and 1 (1.02%) patient died of cardiac complications.

Conclusion FTP may be a viable alternative to reduce the length of stay and immediate postoperative complications for elective total hip arthroplasty surgery decreasing the length of stay of patients by 2 to 3 times when compared to the national average of 7.1 days.

Keywords

arthroplasty, replacement, hip - arthroplasty, replacement, knee - clinical protocols

Work developed at the Hospital Regional de São José dos Campos – Instituto Sócrates Guanaes, São José dos Campos, SP, Brazil.

Publication History

Received: 21 September 2022

Accepted: 16 December 2022

Article published online:
10 April 2024

• Referências

• 1 IBGE/Diretoria de Pesquisas. Coordenação de População e Indicadores Sociais. Gerência de Estudos e Análises da Dinâmica Demográfica. Projeção da população do Brasil e Unidades da Federação por sexo e idade para o período 2010-2060. Disponível em: https://ftp.ibge.gov.br/Projecao_da_Populacao/Projecao_da_Populacao_2018/projecoes_2018_populacao_2010_2060_20200406.xls
• 2 Ferreira MC, Oliveira JCP, Zidan FF, Franciozi CES, Luzo MVM, Abdalla RJ. Artroplastia total de joelho e quadril: a preocupante realidade assistencial do Sistema Único de Saúde brasileiro. Rev Bras Ortop 2018; 53 (04) 432-440
• 3 Scott MJ, Baldini G, Fearon KCH. et al. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations. Acta Anaesthesiol Scand 2015; 59 (10) 1212-1231
• 4 Wainwright TW. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Acta Orthop 2020; 91 (03) 363
• 5 Starks I, Wainwright TW, Lewis J, Lloyd J, Middleton RG. Older patients have the most to gain from orthopaedic enhanced recovery programmes. Age Ageing 2014; 43 (05) 642-648
• 6 Keats AS. The ASA classification of physical status–a recapitulation. Anesthesiology 1978; 49 (04) 233-236
• 7 Bondy LR, Sims N, Schroeder DR, Offord KP, Narr BJ. The effect of anesthetic patient education on preoperative patient anxiety. Reg Anesth Pain Med 1999; 24 (02) 158-164
• 8 Halaszynski TM, Juda R, Silverman DG. Optimizing postoperative outcomes with efficient preoperative assessment and management. Crit Care Med 2004; 32 (4, Suppl) S76-S86
• 9 McDonald S, Hetrick S, Green S. Pre-operative education for hip or knee replacement. Cochrane Database Syst Rev 2004; (01) CD003526
• 10 Liu SS, Buvanendran A, Rathmell JP. et al. Predictors for moderate to severe acute postoperative pain after total hip and knee replacement. Int Orthop 2012; 36 (11) 2261-2267
• 11 Liu SS, Buvanendran A, Rathmell JP. et al. A cross-sectional survey on prevalence and risk factors for persistent postsurgical pain 1 year after total hip and knee replacement. Reg Anesth Pain Med 2012; 37 (04) 415-422
• 12 Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002; 183 (06) 630-641
• 13 Mudumbai SC, Kim TE, Howard SK. et al. Continuous adductor canal blocks are superior to continuous femoral nerve blocks in promoting early ambulation after TKA. Clin Orthop Relat Res 2014; 472 (05) 1377-1383
• 14 Lassen K, Soop M, Nygren J. et al; Enhanced Recovery After Surgery (ERAS) Group. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 2009; 144 (10) 961-969
• 15 Maltby JR, Pytka S, Watson NC, Cowan RA, Fick GH. Drinking 300. mL of clear fluid two hours before surgery has no effect on gastric fluid volume and pH in fasting and non-fasting obese patients. Can J Anaesth 2004; 51 (02) 111-115
• 16 Breuer JP, von Dossow V, von Heymann C. et al. Preoperative oral carbohydrate administration to ASA III-IV patients undergoing elective cardiac surgery. Anesth Analg 2006; 103 (05) 1099-1108
• 17 Svanfeldt M, Thorell A, Hausel J. et al. Randomized clinical trial of the effect of preoperative oral carbohydrate treatment on postoperative whole-body protein and glucose kinetics. Br J Surg 2007; 94 (11) 1342-1350
• 18 Guerra ML, Singh PJ, Taylor NF. Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: a systematic review. Clin Rehabil 2015; 29 (09) 844-854
• 19 Pua YH, Ong PH. Association of early ambulation with length of stay and costs in total knee arthroplasty: retrospective cohort study. Am J Phys Med Rehabil 2014; 93 (11) 962-970
• 20 Pearse EO, Caldwell BF, Lockwood RJ, Hollard J. Early mobilisation after conventional knee replacement may reduce the risk of postoperative venous thromboembolism. J Bone Joint Surg Br 2007; 89 (03) 316-322
• 21 Chandrasekaran S, Ariaretnam SK, Tsung J, Dickison D. Early mobilization after total knee replacement reduces the incidence of deep venous thrombosis. ANZ J Surg 2009; 79 (7-8): 526-529
• 22 Bower WF, Jin L, Underwood MJ, Lam YH, Lai PB. Peri-operative blood transfusion increases length of hospital stay and number of postoperative complications in non-cardiac surgical patients. Hong Kong Med J 2010; 16 (02) 116-120
• 23 Duncan CM, Moeschler SM, Horlocker TT, Hanssen AD, Hebl JR. A self-paired comparison of perioperative outcomes before and after implementation of a clinical pathway in patients undergoing total knee arthroplasty. Reg Anesth Pain Med 2013; 38 (06) 533-538
• 24 Pedersen SJ, Borgbjerg FM, Schousboe B. et al; Hip Fracture Group of Bispebjerg Hospital. A comprehensive hip fracture program reduces complication rates and mortality. J Am Geriatr Soc 2008; 56 (10) 1831-1838
• 25 Macfie D, Zadeh RA, Andrews M, Crowson J, Macfie J. Perioperative multimodal optimisation in patients undergoing surgery for fractured neck of femur. Surgeon 2012; 10 (02) 90-94
• 26 Gupta A. The effectiveness of geriatrician-led comprehensive hip fracture collaborative care in a new acute hip unit based in a general hospital setting in the UK. J R Coll Physicians Edinb 2014; 44 (01) 20-26
• 27 Wainwright TW, Middleton RG. PO019 What is the potential effect on national bed capacity if ERAS was applied to all fractured neck of femur patients? Abstracts of the World Congress of Enhanced Recovery After Surgery and Perioperative Medicine, Washington, DC, USA, 9–12 May 2015. Can J Anesth/J Can Anest 2015; ;6 2: 683-720
• 28 Hebl JR, Dilger JA, Byer DE. et al. A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. Reg Anesth Pain Med 2008; 33 (06) 510-517
• 29 Duncan CM, Hall Long K, Warner DO, Hebl JR. The economic implications of a multimodal analgesic regimen for patients undergoing major orthopedic surgery: a comparative study of direct costs. Reg Anesth Pain Med 2009; 34 (04) 301-307