The effect of peri-operative analgesia technique on outcomes following total knee arthroplasty.

McDonald DA, Deakin AH, Ellis BM, Robb Y, Howe TE, Kinninmonth AW, Scott NB. The technique of delivery of peri-operative analgesia does not affect the rehabilitation or outcomes following total knee arthroplasty. Bone Joint J. 2016 Sep;98-B(9):1189-96.

 

What is already known:

The introduction of ERAS programs in patient’s undergoing total knee arthroplasty have been shown to significantly reduce perioperative morbidity and mortality. During the implementation of these programs however, multiple aspects of perioperative care are altered simultaneously making it difficult to ascertain which components of the program are most important in achieving optimal outcomes.

What this paper adds:

This study was a non-blinded single-center randomised controlled trial comparing the outcomes of patient controlled epidural anaesthesia (PCEA) vs local anaesthetic infiltration (LAI) in total knee arthroplasty within an already established ERAS program.

There were no significant differences between the two groups. Variables analysed included length of stay, range of knee movement, additional analgesia requirements, nausea, time to discharge and one year follow up. This is one of the first trials to look at using epidurals without a background infusion; this technique appears to allow safe mobilization to occur earlier than has been seen in other trials where delayed mobilization following epidurals has often been a concern.

Emma Stewart, Guildford.


Enhanced recovery after surgery: An opportunity to improve fractured neck of femur management

Wainwright TW, Immins T, Middleton (2016) Enhanced recovery after surgery: An opportunity to improve fractured neck of femur management. Ann R Coll Surg Engl. 2016 Sep;98(7):500-6.

What is already known:

Up until now the focus of ERAS has been elective surgery but there is increasing interest in applying the principles to emergency surgery. Fractured neck of femurs are a particularly high risk group of patients, and annual hospital costs are over a billion pounds per year to the NHS.

What this paper adds:

This study looks at Hospital Episode Statistics from 137 different hospitals and examined length of stay and how when case-mixed was adjusted data suggested

that this is due to differences in practice, ie local processes and pathways rather than the nature of the patients treated. The authors suggest that the principles of ERAS could be used to improve the perioperative care of this patient group.

Chris Jones, Guildford.


ERAS for fractured neck of femurs

Talboys R, Mak M, Modi N, Fanous N, Cutts S. Enhanced recovery programme reduces opiate consumption in hip hemiarthroplasty. Eur J Orthop Surg Traumatol. 2016 Feb;26(2):177-81.

What is already known:

This is an interesting paper as it looks at the introduction of an ERAS program for fractured neck of femurs. This is a high risk emergency population with limited ERAS evidence.

What this paper adds:

This is a retrospective UK study. The authors used a more aggressive analgesic approach including a fascia iliaca block in the ED, a single shot spinal (with no opiate) intraoperatively with TCI propofol sedation. Local anaesthetic was also infiltrated by the surgeon at the end of the procedure. This was all strictly protocolised compared with the pre-ERAS group who either underwent a general anaesthetic with iv opiates or spinal anaesthesia depending on the anaesthetists preference. The authors demonstrated a significant reduction in opiate consumption in the ERAS group however this did not result in a reduced length of stay.

Chris Jones, Guildford.