gms | German Medical Science

Objectives: Enhanced recovery pathways (ERP) in joint arthroplasty have been shown to reduce length of stay (LOS) without compromising results. But effects depend on the health-economic context and in Switzerland there are only limited data for patients undergoing total knee arthroplasty (TKA). In 2018, we introduced an ERP protocol for patients undergoing TKA. Main goals were improving pain management and reducing LOS without compromising safety and patient's comfort.

Methods: Patients were documented prospectively and analyzed retrospectively. All patients with osteoarthritis requiring primary TKA with or without patellar resurfacing were included. Pain management was optimized via intraoperative local infiltration analgesia (LIA) and postoperative use of peroral NSAIDs/metamizole along with pain level adjusted opioids. Femoral catheter should no longer be used. Mobilization at day of surgery and full weight-bearing were encouraged. Continuous passive motion (CPM) treatment should no longer be used. Discharge was suggested when the patient fulfilled defined criteria and felt prepared to leave the hospital. Patients had follow-up at two, six weeks, and three months postoperatively. Three series of 50 patients each were analyzed: one before ERP introduction (2017) and two series afterwards (2018 and 2020).

Results: Patient demographics (age, BMI, ASA score) in all groups were comparable. Mean LOS was 6.7 in 2017 and decreased to 5.6 in 2018 and 5.1 in 2020 (p<0.001). Usage of a femoral catheter was 60% in 2017 and decreased to 2% in 2018 and 2020 (p<0.001). Use of opioids during hospital stay was 68% before ERP (2017) and increased to 92% in 2018 and 2020 (p<0.001). Before ERP, usage of CPM was 74% (2017) and reduced to 10% in 2018 and 4% in 2020 (p<0.001). Number of patients discharged directly home increased from 52% in 2017 to 76% and 64% (p=0.04). Rates of adverse events were similar (2%). Median ROM (flexion/extension) at last follow-up was 120°/0°/0° for all groups.

Conclusion: ERP was appreciated by patients and staff. Decreased LOS and increased discharge directly home was a consequence of the better integrated care process. Early mobilization was possible because femoral catheters could be avoided. In return, there was an increase in opioid use, but no increase of adverse events. Our study shows that ERPs are safely applicable for TKA in context of the Swiss health care system.