gms | German Medical Science

Objectives: The possibility of carrying out early active rehabilitation of the patient is one of the main factors for achieving successful results in total knee replacement (TKR). But perioperative blood loss and pain syndrome can interfere with patient rehabilitation in the early postoperative period. The development and optimization of perioperative management is one of the most relevant areas of modern orthopedics since it allows to improve the results of the treatment, reduce economic costs and increase patients' satisfaction with the outcome of the surgery. However, the perioperative management protocols are diverse, not standardized, and can significantly differ in orthopedic clinics. The purpose of this study was to determine the effectiveness and safety of a multimodal approach to perioperative management of TKR.

Methods: The randomized prospective comparative clinical trial was carried out on 140 patients with osteoarthritis treated with primary TKR by one surgical team. For patients of the study group (n=70) we used multimodal approach to perioperative management which includes unilateral spinal anesthesia with preemptive analgesia (COX-2 specific inhibitors and Acetaminophen), inhibitors of fibrinolysis (Aminocaproic acid, intravenous and topical application) and local infiltration analgesia (Ropivacaine). For patients of the control group (n=70) we used standard spinal anesthesia and also did not use inhibitors of fibrinolysis and local infiltration analgesia. Volume of perioperative blood loss, the rates and costs for blood transfusions, the severity of pain, both at rest and during active movements in the knee joint and opiod administration were estimated. All statistical analyses were performed using „Statistica 10.0". For randomizing the sealed envelope method was used. The nonparametric data were presented as the mean [confidence interval 95%] and the Mann-Whitney U-test was used for the analysis. A statistic significance level of P<0.05 was taken.

Results: Perioperative blood loss was greater in the control group 1150 [970-1235] ml in comparison with the study group 824 [751-922] ml (P<0.05). Only in the control group 12 patients (17.1%) received blood transfusion after surgery, which significantly increased costs for blood management (P<0.05). The severity of pain at rest and during active movements and opiod administration during 24 hours after surgery were less in the study group (P<0.05).

Conclusion: Multimodal approach to the perioperative management of TKR allows to decrease total blood loss and the severity of pain after surgery that creates favorable conditions for early active rehabilitation of the patient and reduces economic costs.