Outcome of an “Enhanced Recovery” Program in Contemporary Total Hip Arthroplasty in Germany

Abstract

Background An inpatient hospital stay of up to 10 days after total hip arthroplasty (THA) is still common in Germany, mostly followed by inpatient rehabilitation. Internationally already widespread concepts for enhanced recovery are increasingly gaining popularity in Germany.

Objectives The presentation of content and results of a newly implemented enhanced recovery concept in THA.

Materials and Methods In this single-center, prospective observational study of a consecutive patient collective of a single surgeon, between January 2016 and July 2016, 103 short-stem THA patients were enrolled and treated using a newly introduced enhanced recovery concept. After 6 weeks and 6 months clinical examination was performed regarding function, pain, satisfaction and possible complications.

Results The goal of discharge on day 4 after operation was reached in 61.2% of the patients with a mean postoperative inpatient stay of 4.9 days. After 6 weeks and 6 months respectively, excellent clinical results were achieved with high patient satisfaction. The complication rate was found to be low. Mean hemoglobin concentration decreased by 2.1 g/dl. A fissure of the femur below the implant healed conservatively applying no weight bearing for a total of 6 weeks. A pulmonary embolism that occurred during rehabilitation was also successfully treated. After 6 months one case showed a bursitis trochanterica.

Conclusions Inpatient length of stay can be reduced by enhanced recovery concepts without increasing the risks to patients. Thus, in Germany these concepts will be applied increasingly.

Key words

total hip arthroplasty - enhanced recovery - fast-track - rehabilitation - Germany

• References/Literatur

• 1 Robert Koch-Institut (RKI). Gesundheit in Deutschland 2015. Gesundheitsberichterstattung des Bundes (03.12.2015). Im Internet: http://www.gbe-bund.de/pdf/GESBER2015.pdf Stand: 01.01.2018
• 2 Hanstein T, Kumpe O, Mittelmeier W. et al. Teilzementierte und unzementierte Hüftendoprothetik: Deckungsbeitrag im deutschen Fallpauschalensystem. Orthopäde 2015; 44: 617-622 doi:10.1007/s00132-015-3139-3
• 3 Biermann J, Neumann A, Hewer A. et al. Einfluss der demographischen Entwicklung auf die stationären Fallzahlen und Kosten deutscher Krankenhäuser. Med Klin 2010; 105: 876-881 doi:10.1007/s00063-010-1152-1
• 4 Blum K, Offermanns M. Krankenhäuser zwischen Innovations- und Kostendruck: Die stationäre Versorgung seit dem Jahr 2000. Das Krankenhaus 2009; 101: 295-302 Im Internet: https://www.kgsh.de/pub/lit/anl/kh0904a.pdf Stand: 01.09.2019
• 5 Zagra L. Advances in hip arthroplasty surgery: what is justified?. EFORT Open Rev 2017; 2: 171-178 doi:10.1302/2058-5241.2.170008
• 6 Pfeil J, Siebert WE. Minimally invasive Surgery in total Hip Arthroplasty. Berlin, Heidelberg: Springer; 2010
• 7 Jerosch J, Filler T, Koch FW, Kälicke T, Babisch J, Ishaque B, Lewinski G, Plaumann T, Horst F, Windhagen H, Rehbein P, Schneider M, Kutzner KP, Pfeil J. Allgemeine Aspekte. In: Jerosch J. Hrsg. Kurzschaftendoprothesen an der Hüfte. Berlin, Heidelberg: Springer; 2017: 1-107
• 8 Seeber GH, Wijnen A, Lazovic D. et al. Effectiveness of rehabilitation after a total hip arthroplasty: a protocol for an observational study for the comparison of usual care in the Netherlands versus Germany. BMJ Open 2017; 7: e016020 doi:10.1136/bmjopen-2017-016020
• 9 Melnyk M, Casey RG, Black P. et al. Enhanced recovery after surgery (ERAS) protocols: time to change practice?. Can Urol Assoc J 2011; 5: 342-348 doi:10.5489/cuaj.11002
• 10 Betz U, Goldhofer M, Klonschinski T. et al. A protocol for hip and knee replacement according to the principles of the ERAS society. Poster 091. 6th ERAS World Congress, Stockholm, Sweden; 2018.
• 11 Hoffmann H, Kettelhack C. Fast-Track-Chirurgie – Voraussetzungen und Herausforderungen in der Nachbehandlung. Ther Umschau 2012; 69: 9-13 doi:10.1024/0040-5930/a000244
• 12 Hansen TB, Gromov K, Kristensen BB. et al. [Fast-track hip arthroplasty]. Ugeskr Laeger 2017; 179: V03170252
• 13 Raue W, Neudecker J, Schwenk W. Grundlagen und Prinzipien der Fast-Track-Rehabilitation bei elektiven Kolonresektionen. Chir Gastroenterol Interdiszip 2005; 21: 311-316
• 14 Schwenk W, Müller JM. Was ist „Fast-track“-Chirurgie?. Dtsch Med Wochenschr 2005; 130: 536-540
• 15 Husted H, Hansen HC, Holm G. et al. What determines length of stay after total hip and knee arthroplasty? A nationwide study in Denmark. Arch Orthop Trauma Surg 2010; 130: 263-268 doi:10.1007/s00402-009-0940-7
• 16 Hansen TB. Fast track in hip arthroplasty. EFORT Open Rev 2017; 2: 179-188 doi:10.1302/2058-5241.2.160060
• 17 Seeber GH, Wijnen A, Lazovic D. et al. Effectiveness of rehabilitation after a total hip arthroplasty: a protocol for an observational study for the comparison of usual care in the Netherlands versus Germany. BMJ Open 2017; 7: e016020 doi:10.1136/bmjopen-2017-016020
• 18 den Hartog YM, Mathijssen NMC, Hannink G. et al. Which patient characteristics influence length of hospital stay after primary total hip arthroplasty in a ‘fast-track’ setting?. Bone Joint J 2015; 97-B: 19-23 doi:10.1302/0301-620X.97B1.33886
• 19 Husted H, Holm G, Jacobsen S. Predictors of length of stay and patient satisfaction after hip and knee replacement surgery: fast-track experience in 712 patients. Acta Orthop 2008; 79: 168-173 doi:10.1080/17453670710014941
• 20 Mahomed NN, Liang MH, Cook EF. et al. The importance of patient expectations in predicting functional outcomes after total joint arthroplasty. J Rheumatol 2002; 29: 1273-1279
• 21 Kutzner KP, Donner S, Schneider M. et al. One-stage bilateral implantation of a calcar-guided short-stem in total hip arthroplasty. Oper Orthop Traumatol 2017; 29: 180-192 doi:10.1007/s00064-016-0481-5
• 22 Kutzner KP, Pfeil J. Individualized stem-positioning in calcar-guided short-stem total hip arthroplasty. J Vis Exp 2018;
• 23 Kutzner KP, Hechtner M, Pfeil D. et al. Incidence of heterotopic ossification in minimally invasive short-stem THA using the modified anterolateral approach. Hip Int 2017; 27: 162-168 doi:10.5301/hipint.5000448
• 24 Hochreiter J, Hejkrlik W, Emmanuel K. et al. Blood loss and transfusion rate in short stem hip arthroplasty. A comparative study. Int Orthop 2017; 41: 1347-1353 doi:10.1007/s00264-016-3365-2
• 25 Lindman IS, Carlsson LV. Extremely low transfusion rates: contemporary primary total hip and knee arthroplasties. J Arthroplasty 2018; 33: 51-54 doi:10.1016/j.arth.2017.07.034
• 26 Hossain F, Konan S, Volpin A. et al. Early performance-based and patient-reported outcomes of a contemporary taper fit bone-conserving short stem femoral component in total hip arthroplasty. Bone Joint J 2017; 99-B: 49-55 doi:10.1302/0301-620X.99B4.BJJ-2016-1291.R1
• 27 Kutzner KP, Pfeil D, Kovacevic MP. et al. Radiographic alterations in short-stem total hip arthroplasty: a 2-year follow-up study of 216 cases. Hip Int 2016; 26: 278-283 doi:10.5301/hipint.5000339
• 28 Bürger W, Dietsche S, Morfeld M, Koch U. Ambulante und stationäre orthopädische Rehabilitation – Ergebnisse einer Studie zum Vergleich der Behandlungsergebnisse und Kosten. Rehabilitation 2002; 41: 92-102