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Enhanced Recovery After Knee & Hip Replacement Surgery

“Big things are accomplished only through the perfection of minor details.” - John Wooden

WHAT IS THE ‘ENHANCED RECOVERY AFTER SURGERY’ CONCEPT? 

Enhanced recovery after surgery (ERAS) was pioneered by Henrik Kehlet in Denmark, in the 1990s as an effort to improve recovery after colorectal surgery. Kehlet hypothesized that surgical stress, metabolic and endocrine derangements, and prolonged immobilization contribute to ‘organ dysfunction’: pain, nausea, vomiting, ileus, fatigue, and cognitive disturbance. The extent of organ dysfunction thus determines recovery. 


According to Enhanced Recovery concepts, it is unlikely that any single surgical technique, anaesthetic intervention, or medication can significantly reduce organ dysfunction. Rather, recovery is facilitated by a multimodal approach directed towards global modulation of the surgical stress response. Enhanced recovery after joint replacement surgery has consistently been associated with superior recovery, decreased morbidity, reduced hospital length of stay, and cost savings.  

According to the ERAS Society, there are about 20 components of care that influence the stress response and enhance recovery. It can quickly be appreciated that designing and implementing an ERAS protocol is a multidisciplinary endeavour. The Enhanced Recovery Team should include expertise from surgery, anaesthesia, nursing, physiotherapy, nutrition and pharmacy. 




The enhanced recovery programme is about improving patient comfort & outcomes and speeding up a patient’s recovery after surgery. Patients never leave the hospital until they are ready and comfortable to walk independently.


The programme focuses on making sure that patients are active participants in their own recovery process. It also aims to ensure that patients always receive the right evidence based (proven) care at the right time. 


Enhanced recovery surgery: 

 - Allows patients to recover faster and more comfortably from major surgery 

 - Allows greater patient involvement in the early stages of recovery 

 - Gives better patient outcomes 

 - Reduces hospital stay 




PREOPERATIVE PATIENT EDUCATION


Anticipation of surgery can lead to anxiety and fear for many patients. An early study found that explicit preoperative education significantly relieved anxiety and emotional stress before hip or knee replacement. Preoperative education contributes to higher patient confidence, greater patient satisfaction, and early recovery and discharge. It is essential that a preoperative education program should establish achievable goals for postoperative oral intake, analgesia, physiotheapy, mobilization and home discharge. Preoperative education is mostly of benefit for patients with depression, anxiety, unrealistic expectations, or those with limited social support. 


All patients booked for joint replacement surgery will discuss in depth with Mr. Vioreanu during their consultation all aspects of their surgery, possible complications, post-operative rehabilitation and discharge plans. 

All patients will leave the office with realistic goals and expectations from the planned surgery. 

All patients will receive a book further detailing all these aspects of their surgery and will have a further opportunity to raise eventual questions they may have to our staff during the pre-assessment clinic (PAC).



INTRAOPERATIVE ANAESTHETIC & SURGICAL TECHNIQUES

Improvements in anaesthetic and perioperative medical techniques now allow patients to have a very comfortable surgical experience without opiate medications.  There is a physiological argument that regional anaesthesia is the optimal ERAS technique for hip & knee replacement. A body of evidence demonstrates a higher incidence of post- operative complications when primary hip or knee arthroplasty is performed under general compared with spinal/regional anaesthesia. 

Opiates make patients feel drowsy, nauseous and constipated. Avoidance of opiates through new pain management techniques avoids these problems. Techniques used include intraoperative infiltration of local anaesthetic into the soft tissues around the knee or hip. 


Postoperative nausea and vomiting (PONV) can be more distressing than pain. The best way to manage PONV is to avoid general anaesthesia if possible, minimize opioids and administer systemic steroid medication. All these methods are employed by our specialist aneasthetic team before, during and after surgery. 

Less invasive with minimal soft tissue damage surgical techniques, fast surgery along with improved surgical instrumentation and modern implant design and technology facilitates minimal blood loss and reduces the surgical insult ( bruising, swelling, inflammation ). All these factors, along with infiltration of large amount of local anaesthestetic during surgery allows pain free, early mobilization only a few hours after surgery.  


Mr. Vioreanu and his anaesthetic team employ modern, evidence-based surgical and anaesthetic techniques facilitating pain-free, early mobilisation immediately after surgery. 



POSTOPERATIVE MOBILISATION & EARLY HOME DISCHARGE 

This new approach aims to accelerate all aspects of a patient’s recovery process. This includes accelerating their physical, mental and physiological recovery following surgery. Physical recovery includes restoring a patient’s level of function, strength and range of movement. Mental recovery includes the elimination of concerns, and the return of self-confidence and the state of feeling balanced and whole. Physiological recovery takes all the major body systems into account and aims to avoid insult on the cardiovascular, respiratory, renal, gastro-intestinal and haematological systems during your surgery.

After the operation the programme focuses on getting patients out of bed and starting to move their joint as soon as possible with the support of good pain management.   This results in patients making a quicker recovery than average and being able to return to active life as soon as possible. 


Early mobilization is a key component of Enhanced Recovery program. Safe and effective analgesia is a prerequisite to encourage postoperative mobilization. There is good evidence that early mobilization is also associated with improved functional recovery and lower incidence of blood clots.

Our specialist physiotherapists will mobilise the patients in the few hours following surgery, when their sensory and motor reflexes have restored. They will further help all patients to walk independently with walking aids and return to routine activities of daily living during first two days after surgery.  


All patients will leave the hospital with the ‘Exercise Guide to Knee or Hip Replacement’ book that clearly outlines the expectations and provide specific exercises and advice for each week after surgery. 


Based on recent evidence coming from Canada, we recommend to our patients to progress in the first few weeks, whenever comfortable, from using crutches to using specialised walking poles to aid mobilisation and encourage normalising their gait pattern. 


When at home, all patients can contact our office directly by phone or email if they have any concerns regarding their progress or recovery and they will be attended promptly. 



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