Early mobilization after total hip or knee arthroplasty: a substudy of the POWER.2 study
Javier Ripollés-Melchor, César Aldecoa, Raquel Fernández-García, Marina Varela-Durán, Norma Aracil-Escoda, Daniel García-Rodríguez, Lucia Cabezudo-de-la-Muela, Lucía Hormaechea-Bolado, Beatriz Nacarino-Alcorta, Rolf Hoffmann, Juan V. Lorente, José M. Ramírez-Rodríguez, Ane Abad-Motos, POWER2 Study Investigators Group for the Spanish Perioperative Audit and Research Network (RedGERM-SPARN)
Early mobilization after surgery is a cornerstone of the Enhanced Recovery After Surgery (ERAS) programs in total hip arthroplasty (THA) or total knee arthroplasty (TKA). Our goal was to determine the time to mobilization after this surgery and the factors associated with early mobilization.
This was a predefined substudy of the POWER.2 study, a prospective cohort study conducted in patients undergoing THA and TKA at 131 Spanish hospitals. The primary outcome was the time until mobilization after surgery as well as determining those perioperative factors associated with early mobilization after surgery.
A total of 6093 patients were included. The median time to achieve mobilization after the end of the surgery was 24 hours [16–30]. 4,222 (69.3%) patients moved in ≤ 24 hours after surgery. Local anesthesia [OR = 0.80 (95% confidence interval [CI]: 0.72–0.90); p = 0.001], surgery performed in a self-declared ERAS center [OR = 0.57 (95% CI: 0.55–0.60); p < 0.001], mean adherence to ERAS items [OR = 0.93 (95% CI: 0.92–0.93); p < 0.001], and preoperative hemoglobin [OR = 0.97 (95% CI: 0.96–0.98); p < 0.001] were associated with shorter time to mobilization.
Most THA and TKA patients mobilize in the first postoperative day, Early time to mobilization was associated with the compliance with ERAS protocols, preoperative hemoglobin, and local anesthesia, and with the absence of a urinary catheter, surgical drains, epidural analgesia, and postoperative complications. The perioperative elements that are associated with early mobilization are mostly modifiable, so there is room for improvement.
1 M. Sloan, A. Premkumar, N.P. Sheth Projected Volume of Primary Total Joint Arthroplasty in the U.S., 2014 to 2030 J Bone Joint Surg Am, 100 (2018), pp. 1455-1460
2 H. Kehlet Enhanced Recovery After Surgery (ERAS): good for now, but what about the future? Can J Anaesth, 62 (2015), pp. 99-104
3 P.-A. Vendittoli, K. Pellei, F. Desmeules, et al. Enhanced recovery short-stay hip and knee joint replacement program improves patients outcomes while reducing hospital costs Orthop Traumatol Surg Res, 105 (2019), pp. 1237-1243
4 T.W. Wainwright, M. Gill, D.A. Mcdonald, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations Acta Orthop, 91 (2020), pp. 3-19
5 G. Tayrose, D. Newman, J. Slover, et al. Rapid mobilization decreases length-of-stay in joint replacement patients Bull Hosp Jt Dis, 71 (2013), pp. 222-226
6 J. Ripollés-Melchor, A. Abad-Motos, Y. Díez-Remesal, et al. Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Total Hip and Knee Arthroplasty in the Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty Study (POWER2) JAMA Surg, 155 (2020), Article e196024
7 J. Ripolles-Melchor, A. Abad-Motos, M. Logrono-Egea, et al. Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty. POWER.2 Study: Study Protocol for a Prospective, Multicentre, Observational Cohort Study Turkish J Anaesthesiol Reanim, 47 (2019), pp. 179-186
8 E. von Elm, D.G. Altman, M. Egger, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies Int J Surg., 12 (2014), pp. 1495-1499
9 E.M. Soffin, J.T. Yadeau Enhanced recovery after surgery for primary hip and knee arthroplasty: A review of the evidence Br J Anaesth, 117 (2016), pp. iii62-iii72
10 K. Rockwood, X. Song, C. MacKnight, et al. A global clinical measure of fitness and frailty in elderly people CMAJ, 173 (2005), pp. 489-495
11 A.F. Chen, M.K. Stewart, A.E. Heyl, et al. Effect of immediate postoperative physical therapy on length of stay for total joint arthroplasty patients J Arthroplasty, 27 (2012), pp. 851-856
12 T.B. Hansen, H.K. Bredtoft, K. Larsen Preoperative physical optimization in fast-track hip and knee arthroplasty Dan Med J, 59 (2012), p. A4381
13 O. Jans, C. Jorgensen, H. Kehlet, et al. Role of preoperative anemia for risk of transfusion and postoperative morbidity in fast-track hip and knee arthroplasty Transfusion, 54 (2014), pp. 717-726
14 M.K. Petersen, C. Madsen, N.T. Andersen, et al. Efficacy of multimodal optimization of mobilization and nutrition in patients undergoing hip replacement: a randomized clinical trial Acta Anaesthesiol Scand, 50 (2006), pp. 712-717
15 B. Kearney, J. To, K. Southam, et al. Anaemia in elective orthopaedic surgery - Royal Adelaide Hospital, Australia Intern Med J, 46 (2016), pp. 96-101
16 L.T. Goodnough, A. Maniatis, P. Earnshaw, et al. Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines Br J Anaesth, 106 (2011), pp. 13-22
17 A. Abad-Motos, J. Ripolles-Melchor, C. Jerico, et al. Patient Blood Management for primary hip and knee replacement. A survey among POWER.2 study researchers Rev Esp Anestesiol Reanim (Engl Ed), 67 (2020), pp. 237-244
18 C. Li, J. Qu, S. Pan, Y. Qu Local infiltration anesthesia versus epidural analgesia for postoperative pain control in total knee arthroplasty: a systematic review and meta-analysis J Orthop Surg Res, 13 (2018), p. 112
19 L.O. Andersen, H. Kehlet Analgesic efficacy of local infiltration analgesia in hip and knee arthroplasty: a systematic review Br J Anaesth, 113 (2014), pp. 360-374
20 Y. Ma, X. Lu Indwelling catheter can increase postoperative urinary tract infection and may not be required in total joint arthroplasty: a meta-analysis of randomized controlled trial BMC Musculoskelet Disord, 20 (2019), p. 11
21 T.W. Wainwright, M. Gill, D.A. McDonald, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations Acta Orthop, 91 (2020), pp. 3-19
22 H. Kehlet Fast-track hip and knee arthroplasty Lancet (London, England), 381 (2013), pp. 1600-1602
23 P. Cram, B.E. Landon, J. Matelski, et al. Utilization and Short-Term Outcomes of Primary Total Hip and Knee Arthroplasty in the United States and Canada: An Analysis of New York and Ontario Administrative Data Arthritis Rheumatol (Hoboken, NJ), 70 (2018), pp. 547-554
24 H. Kehlet History and future challenges in fast-track hip and knee arthroplasty Orthopade, 49 (2020), pp. 290-292