DOS Afhandlingsdatabase

Titel på arbejdetImprovements in fast-track hip and knee arthroplasty
NavnPelle Baggesgaard Petersen
Afdeling / StedEnhed for Kirurgisk Patofysiologi, Rigshospitalet
UniversitetKøbenhavns Universitet
  • Hip and knee surgery
Abstract / Summary

Total hip and knee arthroplasty (THA/TKA) are among the most frequent orthopedic procedures
worldwide. The introduction of enhanced recovery and fast-track protocols has drastically improved
postoperative recovery after a broad spectrum of procedures including THA and TKA. To date
limited large-scale detailed studies have investigated the potential effect of fast-track THA and TKA
on trends in postoperative length of stay (LOS) and morbidity. The Lundbeck Foundation Centre
for Fast-track Hip and Knee replacement collaboration (FTHK) adhering to similar fast-track
protocols with focus on continuous refinement of perioperative care with annual scientific and
clinical meetings including presentation of contemporary evidence and own data was formed in
2009. The unique possibilities of complete follow-up from national registers, prospective collection
of data on demographics and comorbidities, and chart review enabled us to perform large highly
detailed studies with complete follow-up on early (90 days) outcomes after fast-track THA and
TKA in a “real-life cohort” of unselected consecutive procedures.

The thesis is built upon three main questions
• What is the incidence of postoperative delirium (PD) leading to LOS > 4 days in patients ≥
70 years undergoing a THA or TKA?
• Is fast-track THA and TKA safe and feasible in older adults ≥ 85 years?
• What has 7 years of continuous focus on refinement of perioperative THA and TKA care
resulted in?

In answering this, we conducted three large detailed observational studies based on data from
FTHK, as explained above, including procedures from 2010 to 2013 for study 1 and 2010 to 2017
for study 2 and 3.

In study 1 we found a low (0.7%) incidence of PD contributing to LOS > 4 days after 6,331
procedures in patients ≥ 70 years, with increasing age as an independent risk-factor for PD. Study
2 including 1,427 procedures in older adults ≥ 85 years demonstrated a halving in both median LOS
from 4 to 2 days and proportion of patients admitted > 4 days from 32% to 18%, without subsequent
changes in 90-day readmission or mortality rates of 16% and 1.5%, respectively. In study 3 we
investigated monotonic trends in the entire cohort of 36,935 procedures and found a declining LOS
from 3 to 1 day, and a proportion with LOS > 4 days from 9.7% to 4.6% followed by a nonmonotonically declining 90-day readmission risk from 8.6% to 7.7%. Furthermore, stratification of complications into “medical” and “surgical” in study 2 and 3 demonstrated relevant differences in trends and incidences hereof, confirming the need for detailed analysis and stratification of
postoperative complications to further improve the perioperative care process.

In conclusion, fast-track THA and TKA is associated with a low 90-day incidence of PD, a
decreasing LOS, and fewer patients experiencing postoperative complications. Despite these
marked improvements, the goal of a “pain and risk free” procedure has yet to be achieved and
further investigations should focus on the unchanged readmission rate and identification of specific
high-risk patients.