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2.  Role of preoperative pain, muscle function, and activity level in discharge readiness after fast-track hip and knee arthroplasty 
Acta Orthopaedica  2014;85(5):488-492.
Background and purpose
The concept of fast-track surgery has led to a decline in length of stay after total hip arthroplasty (THA) and total knee arthroplasty (TKA) to about 2–4 days. However, it has been questioned whether this is only achievable in selected patients—or in all patients. We therefore investigated the role of preoperative pain and functional characteristics in discharge readiness and actual LOS in fast-track THA and TKA.
Methods
Before surgery, hip pain (THA) or knee pain (TKA), lower-extremity muscle power, functional performance, and physical activity were assessed in a sample of 150 patients and used as independent variables to predict the outcome (dependent variable)—readiness for hospital discharge —for each type of surgery. Discharge readiness was assessed twice daily by blinded assessors.
Results
Median discharge readiness and actual length of stay until discharge were both 2 days. Univariate linear regression followed by multiple linear regression revealed that age was the only independent predictor of discharge readiness in THA and TKA, but the standardized coefficients were small (≤ 0.03).
Interpretation
These results support the idea that fast-track THA and TKA with a length of stay of about 2–4 days can be achieved for most patients independently of preoperative functional characteristics.
doi:10.3109/17453674.2014.934186
PMCID: PMC4164866  PMID: 24954491
3.  Postoperative urinary retention (POUR) in fast-track total hip and knee arthroplasty 
Acta Orthopaedica  2014;85(1):8-10.
doi:10.3109/17453674.2014.881683
PMCID: PMC3940984  PMID: 24460110
4.  Should deep venous thrombosis prophylaxis be used in fast-track hip and knee replacement? 
Acta Orthopaedica  2012;83(2):105-106.
doi:10.3109/17453674.2012.672094
PMCID: PMC3339521  PMID: 22401677
5.  A new algorithm for hip fracture surgery 
Acta Orthopaedica  2012;83(1):26-30.
Background and purpose
Treatment of hip fracture patients is controversial. We implemented a new operative and supervision algorithm (the Hvidovre algorithm) for surgical treatment of all hip fractures, primarily based on own previously published results.
Methods
2,000 consecutive patients over 50 years of age who were admitted and operated on because of a hip fracture were prospectively included. 1,000 of these patients were included after implementation of the algorithm. Demographic parameters, hospital treatment, and reoperations within the first postoperative year were assessed from patient records.
Results
931 of 1,000 operative procedures were performed according to the algorithm, as compared to only 726 of 1,000 prior to its introduction (p < 0.001). After implementation of the algorithm, junior registrars still performed half of the operations, but unsupervised procedures declined from 192 of 1,000 to 105 of 1,000 (p < 0.001). The rate of reoperations declined from 18% to 12% (p < 0.001 in a multiple Cox regression analysis), with a decline of 24% to 18% for intracapsular fractures and a decline of 13% to 7% for extracapsular fractures. The proportion of bed-days caused by reoperations was reduced from 24% of total hospitalization before the algorithm was introduced to 18% after it was introduced.
Interpretation
It is possible to implement an algorithm for treatment of all hip fracture patients in a large teaching hospital. In our case, the Hvidovre algorithm both raised the rate of supervision and reduced the rate of reoperations. The reduced reoperation rate saved many hospital bed-days.
doi:10.3109/17453674.2011.652887
PMCID: PMC3278653  PMID: 22248165
6.  Early recovery after fast-track Oxford unicompartmental knee arthroplasty 
Acta Orthopaedica  2012;83(1):41-45.
Background and purpose
After total knee arthroplasty with conventional surgical approach, more than half of the quadriceps extension strength is lost in the first postoperative month. Unicompartmental knee arthroplasty (UKA) operated with minimally invasive surgery (MIS) results in less operative trauma. We investigated changes in leg-extension power (LEP) in the first month after MIS Oxford UKA and its relation to pain, knee motion, functional performance, and knee function.
Patients and methods
In 35 consecutive Oxford UKA patients, LEP was measured 1 week before and 1 month after surgery together with knee motion, knee swelling, the 30-second chair-stand test, and Oxford knee score. Assessment of knee pain at rest and walking was done using a visual analog scale.
Results
30 patients were discharged on the day after surgery, and 5 on the second day after surgery. LEP and functional performance reached the preoperative level after 1 month. Only slight postoperative knee swelling was observed with rapid restoration of knee flexion and function. A high level of pain during the first postoperative night and day fell considerably thereafter. None of the patients needed physiotherapy supervision in the first month after discharge.
Interpretation
Fast-track MIS Oxford UKA with discharge on the day after surgery is safe and leads to early recovery of knee motion and strength even when no physiotherapy is used.
doi:10.3109/17453674.2012.657578
PMCID: PMC3278656  PMID: 22313368
7.  Why still in hospital after fast-track hip and knee arthroplasty? 
Acta Orthopaedica  2011;82(6):679-684.
Background and purpose
Length of stay (LOS) following total hip and knee arthroplasty (THA and TKA) has been reduced to about 3 days in fast-track setups with functional discharge criteria. Earlier studies have identified patient characteristics predicting LOS, but little is known about specific reasons for being hospitalized following fast-track THA and TKA.
Patients and methods
To determine clinical and logistical factors that keep patients in hospital for the first postoperative 24–72 hours, we performed a cohort study of consecutive, unselected patients undergoing unilateral primary THA (n = 98) or TKA (n = 109). Median length of stay was 2 days. Patients were operated with spinal anesthesia and received multimodal analgesia with paracetamol, a COX-2 inhibitor, and gabapentin—with opioid only on request. Fulfillment of functional discharge criteria was assessed twice daily and specified reasons for not allowing discharge were registered.
Results
Pain, dizziness, and general weakness were the main clinical reasons for being hospitalized at 24 and 48 hours postoperatively while nausea, vomiting, confusion, and sedation delayed discharge to a minimal extent. Waiting for blood transfusion (when needed), for start of physiotherapy, and for postoperative radiographic examination delayed discharge in one fifth of the patients.
Interpretation
Future efforts to enhance recovery and reduce length of stay after THA and TKA should focus on analgesia, prevention of orthostatism, and rapid recovery of muscle function.
doi:10.3109/17453674.2011.636682
PMCID: PMC3247885  PMID: 22066560
8.  High-volume infiltration analgesia in bilateral hip arthroplasty 
Acta Orthopaedica  2011;82(4):423-426.
Background and purpose
High-volume infiltration analgesia may be effective in postoperative pain management after hip arthroplasty but methodological problems prevent exact interpretation of previous studies.
Methods
In a randomized, double-blind placebo-controlled trial in 12 patients undergoing bilateral total hip arthroplasty (THA) in a fast-track setting, saline or high-volume (170 mL) ropivacaine (0.2%) with epinephrine (1:100,000) was administered to the wound intraoperatively along with supplementary postoperative injections via an intraarticular epidural catheter. Oral analgesia was instituted preoperatively with a multimodal regimen (gabapentin, celecoxib, and acetaminophen). Pain was assessed repeatedly for 48 hours postoperatively, at rest and with 45° hip flexion.
Results
Pain scores were low and similar between ropivacaine and saline administration. Median hospital stay was 4 (range 2–7) days.
Interpretation
Intraoperative high-volume infiltration with 0.2% ropivacaine with repeated intraarticular injections postoperatively may not give a clinically relevant analgesic effect in THA when combined with a multimodal oral analgesic regimen with gabapentin, celecoxib, and acetaminophen.
doi:10.3109/17453674.2011.596063
PMCID: PMC3237031  PMID: 21751861
9.  Fast-track revision knee arthroplasty 
Acta Orthopaedica  2011;82(4):438-440.
Background and purpose
Fast-track surgery has reduced the length of hospital stay (LOS), morbidity, and convalescence in primary hip and knee arthroplasty (TKA). We assessed whether patients undergoing revision TKA for non-septic indications might also benefit from fast-track surgery.
Methods
29 patients were operated with 30 revision arthroplasties. Median age was 67 (34–84) years. All patients followed a standardized fast-track set-up designed for primary TKA. We determined the outcome regarding LOS, morbidity, mortality, and satisfaction.
Results
Median LOS was 2 (1–4) days excluding 1 patient, who was transferred to another hospital for logistical reasons (10 days). None of the patients died within 3 months, and 3 patients were re-admitted (2 for suspicion of DVT, which was not found, and 1 for joint mobilization). Patient satisfaction was high.
Interpretation
Patients undergoing revision TKA for non-septic reasons may be included in fast-track protocols. Outcome appears to be similar to that of primary TKA regarding LOS, morbidity, and satisfaction. Our findings call for larger confirmatory studies and studies involving other indications (revision THA, 1-stage septic revisions).
doi:10.3109/17453674.2011.584211
PMCID: PMC3237034  PMID: 21561311
10.  Low risk of thromboembolic complications after fast-track hip and knee arthroplasty 
Acta Orthopaedica  2010;81(5):599-605.
Background and purpose
Pharmacological prophylaxis can reduce the risk of deep venous thrombosis (DVT), pulmonary embolism (PE), and death, and it is recommended 10–35 days after total hip arthroplasty (THA) and at least 10 days after total knee arthroplasty (TKA). However, early mobilization might also reduce the risk of DVT and thereby the need for prolonged prophylaxis, but this has not been considered in the previous literature. Here we report our results with short-duration pharmacological prophylaxis combined with early mobilization and reduced hospitalization.
Patients and methods
1,977 consecutive, unselected patients were operated with primary THA, TKA, or bilateral simultaneous TKA (BSTKA) in a well-described standardized fast-track set-up from 2004–2008. Patients received DVT prophylaxis with low-molecular-weight heparin starting 6–8 h after surgery until discharge. All re-admissions and deaths within 30 and 90 days were analyzed using the national health register, concentrating especially on clinical DVT (confirmed by ultrasound and elevated D-dimer), PE, or sudden death. Numbers were correlated to days of prophylaxis (LOS).
Results
The mean LOS decreased from 7.3 days in 2004 to 3.1 days in 2008. 3 deaths (0.15%) were associated with clotting episodes and overall, 11 clinical DVTs (0.56%) and 6 PEs (0.30%) were found. The vast majority of events took place within 30 days; only 1 death and 2 DVTs occurred between 30 and 90 days. During the last 2 years (854 patients), when patients were mobilized within 4 h postoperatively and the duration of DVT prophylaxis was shortest (1–4 days), the mortality was 0% (95% CI: 0–0.5). Incident cases of DVT in TKA was 0.60% (CI: 0.2–2.2), in THA it was 0.51% (CI: 0.1–1.8), and in BSTKA it was 0% (CI: 0–2.9). Incident cases of PE in TKA was 0.30% (CI: 0.1–1.7), in THA it was 0% (CI: 0–1.0), and in BSTKA it was 0% (CI: 0–2.9).
Interpretation
The risk of clinical DVT, and of fatal and non-fatal PE after THA and TKA following a fast-track set-up with early mobilization, short hospitalization, and short duration of DVT prophylaxis compares favorably with published regimens with extended prophylaxis (up to 36 days) and hospitalization up to 11 days. This calls for a reconsideration of optimal duration of chemical thromboprophylaxis.
doi:10.3109/17453674.2010.525196
PMCID: PMC3214750  PMID: 20919815
11.  Fast-track hip and knee replacement — what are the issues? 
Acta Orthopaedica  2010;81(3):271-272.
doi:10.3109/17453674.2010.487237
PMCID: PMC2876825  PMID: 20446827
12.  Prefracture functional level evaluated by the New Mobility Score predicts in-hospital outcome after hip fracture surgery 
Acta Orthopaedica  2010;81(3):296-302.
Background and purpose
Clinicians need valid and easily applicable predictors of outcome in patients with hip fracture. Adjusting for previously established predictors, we determined the predictive value of the New Mobility score (NMS) for in-hospital outcome in patients with hip fracture.
Patients and methods
We studied 280 patients with a median age of 81 (interquartile range 72–86) years who were admitted from their own homes to a special hip fracture unit. Main outcome was the regain of independence in basic mobility, defined as. independence in getting in and out of bed, sitting down and standing up from a chair, and walking with an appropriate walking aid. The Cumulated Ambulation score was used to evaluate basic mobility. Predictor variables were NMS functional level before fracture, age, sex, fracture type, and mental and health status.
Results
Except for sex, all predictor variables were statistically significant in univariate testing. In multiple logistic regression analysis, only age, NMS functional level before fracture, and fracture type were significant. Thus, patients with a low prefracture NMS and/or an intertrochanteric fracture would be 18 and 4 times more likely not to regain independence in basic mobility during the hospital stay, respectively, than patients with a high prefracture level and a cervical fracture, respectively. The model was statistically stable and correctly classified 84% of cases.
Interpretation
The NMS functional level before fracture, age, and fracture type facilitate prediction of the in-hospital rehabilitation potential after hip fracture surgery.
doi:10.3109/17453674.2010.487240
PMCID: PMC2876830  PMID: 20450426

Results 1-12 (12)