Background: Accelerated perioperative rehabilitation protocols following total hip and knee arthroplasties are currently being implemented worldwide, but the cost-effectiveness of these protocols from a societal perspective is not known. We compared the cost-effectiveness of an accelerated perioperative care and rehabilitation protocol with that of a more standard protocol for patients treated with total hip and knee arthroplasty. Methods: A cost-effectiveness study was undertaken as a study piggybacked on a randomized clinical trial comparing early outcomes of an accelerated and intensive postoperative rehabilitation regimen with those of a more standard rehabilitation protocol. We assessed eighty-seven patients (forty-two who received the standard protocol and forty-five who received the accelerated protocol) for a total of twelve months. Costs from the time of the patient's visit immediately before the operation to one year postoperatively were calculated with use of activity-based costing analysis. Postoperative quality-adjusted life-years (QALYs) were calculated from validated patient diaries and questionnaires at fifteen time points. The primary objective was to determine whether one intervention was dominant over the other during a twelve-month period or, if neither was dominant, to determine the incremental cost-effectiveness ratio. Results: The result of the randomized clinical trial showed the accelerated intervention to be effective, with a reduction in the length of the hospital stay and a gain in health-related quality of life at the three-month follow-up time point. The cost-effectiveness study showed the accelerated protocol to be significantly less expensive than the standard protocol (p = 0.036), with an average reduction in cost of 18,880 Danish kroner (95% confidence interval, 1899 to 38,152) (approximately US $4000). Patients treated with the accelerated protocol following hip arthroplasty had an additional average gain of 0.08 QALY (95% confidence interval, 0.02 to 0.15) compared with the patients who received the standard protocol (p = 0.006); this led to a 98% dominance of the accelerated protocol over the standard protocol. No significant or clinically relevant difference in the numbers of QALYs associated with the two protocols was observed for the patients treated with knee arthroplasty. Conclusions: An accelerated perioperative care and rehabilitation protocol can be both cost-saving and clinically more effective after total hip arthroplasty, whereas it can be cost-saving with no observed significant difference in effect, from a societal perspective, after knee arthroplasty. Level of Evidence: Economic and decision analysis Level I. See Instructions to Authors for a complete description of levels of evidence.

Background Approximately 12,000 hip and knee replacements were performed in Denmark in 2005. Accelerated perioperative interventions are currently implemented, but there is conflicting evidence regarding the effect. We therefore performed an efficacy study of an accelerated perioperative care and rehabilitation intervention in patients receiving primary total hip replacement, and both total and unicompartmental knee replacement. Methods A randomized clinical trial was undertaken in which 87 patients were randomized to either a control group receiving the current perioperative procedure, or an intervention group receiving a new accelerated perioperative care and rehabilitation procedure. Outcome measures were length of stay (LOS) in hospital, and gain in quality of life (QOL) using EQ-5D from baseline to 3-month follow-up. Results Mean LOS was reduced (p < 0.001) from 8 days (95% CI: 7.1–8.4) in the control group to 5 days (95% CI: 4.2–5.6) in the intervention group. This was accompanied by a greater gain in QOL of 0.08 (95% CI: 0.004–0.16) in the intervention group (p = 0.03). Interpretation An accelerated perioperative care and rehabilitation intervention in patients undergoing primary total hip replacement, and total or unicompartmental knee replacement is indeed effective—and of advantage to both the hospital and the patient.

Objectives International guidelines recommend thrombosis prophylaxis after total hip arthroplasty (THA) and total knee arthroplasty (TKA) for up to 35 days. However, previous studies often have hospital stays (length of stay; LOS) of 8–12 days and not considering early mobilisation, which may reduce incidence of venous thromboembolic events (VTE). We investigated the incidence of any symptomatic thromboembolic events (TEEs) with only in-hospital prophylaxis if LOS ≤5 days after fast-track THA and TKA. Design A prospective descriptive multicentre cohort study in fast-track THA and TKA from February 2010 to December 2011, with complete 90-day follow-up through the Danish National Patient Registry and patient files. Setting 6 Danish high-volume centres with a similar standardised fast-track setup, including spinal anaesthesia, opioid-sparing analgesia, early mobilisation, functional discharge criteria and discharge to own home. Participants 4924 consecutive unselected unilateral primary THA and TKAs in patients ≥18 years with no preoperative use of continuous ‘potent’ anticoagulative therapy (vitamin K antagonists). Exposure Prophylaxis with low-molecular-weight heparin or factor Xa-inhibitors only during hospitalisation when LOS ≤5 days. Outcomes Incidence of symptomatic TEE-related, VTE-related and VTE-related mortality ≤90 days postoperatively. Results LOS ≤5 days and thromboprophylaxis only during hospitalisation occurred in 4659 procedures (94.6% of total). Median LOS and prophylaxis duration was 2 days (IQR 2–3) with 0.84% (95% CI 0.62% to 1.15%) TEE and 0.41% (0.26% to 0.64%) VTE during 90-day follow-up. VTE consisted of five pulmonary embolisms (0.11% (0.05% to 0.25%)) and 14 deep venous thrombosis (0.30% (0.18% to 0.50%)). There were four (0.09% (0.04% to 0.23%)) surgery-related deaths, of which 1 (0.02% (0.00% to 0.12%)) was due to pulmonary embolism, and 6 (0.13% (0.06% to 0.28%)) deaths of unknown causes after discharge. Conclusions The low incidence of TEE and VTE suggests that in-hospital prophylaxis only, is safe in fast-track THA and TKA patients with LOS of ≤5 days. Guidelines on thromboprophylaxis may need reconsideration in fast-track elective surgery. Trial Registration ClinicalTrials.gov: NCT01557725

Postoperative delirium (PD) is a serious complication after major surgery in elderly patients. PD is well defined and characterized by reduced attention and disorientation. Multimodal optimization of perioperative care (the fast-track methodology) enhances recovery, and reduces hospital stay and medical morbidity. No data on PD are available in fast-track surgery. The aim of this study was to evaluate the incidence of PD after fast-track hip (THA) and knee arthroplasty (TKA) with anticipated length of stay (LOS) of <3 days. In a prospective multicentre study to evaluate postoperative cognitive dysfunction, we included 225 non-demented patients with a mean age of 70 yr undergoing either THA or TKA in a fast-track set-up. Anaesthesia and postoperative pain management were standardized with limited opioid use. Nursing staff were trained to look for symptoms of PD which was assessed during interaction with healthcare professionals. Patients were invited for a clinical follow-up 1–2 weeks after surgery. Clinical follow-up was performed in 220 patients at a mean of 12.0 days after surgery while five patients were followed up by telephone. The mean LOS was 2.6 days (range 1–8 days). Twenty-two patients received general anaesthesia, and the rest had spinal anaesthesia. No patients developed PD (95% confidence interval 0.0–1.6%). A fast-track set-up with multimodal opioid-sparing analgesia was associated with lack of PD after elective THA and TKA in elderly patients.

Postoperative cognitive dysfunction (POCD) is reported to occur after major surgery in as many as 20% of patients, elderly patients may especially experience problems in the weeks and months after surgery. Recent studies vary greatly in methods of evaluation and diagnosis of POCD, and the pathogenic mechanisms are still unclear. We evaluated a large uniform cohort of elderly patients in a standardized approach, after major joint replacement surgery (total hip and knee replacement). Patients were in an optimized perioperative approach (fast track) with multimodal opioid-sparing analgesia, early mobilization, and short length of stay (LOS ≤3 days) and discharged to home. In a prospective multicenter study, we included 225 patients aged ≥60 years undergoing well-defined fast-track total hip or total knee replacement. Patients had neuropsychological testing preoperatively and 1 to 2 weeks and 3 months postoperatively. LOS, pain, opioid use, inflammatory response, and sleep quality were recorded. The practice effect of repeated cognitive testing was gauged using data from a healthy community-dwelling control group (n = 161). Median LOS was 2 days (interquartile range 2-3). The incidence of POCD at 1 to 2 weeks was 9.1% (95% confidence interval [CI], 5.4%-13.1%) and 8.0% (95% CI, 4.5%-12.0%) at 3 months. There was no statistically significant difference between patients with and without early POCD, regarding pain, opioid use, sleep quality, or C-reactive protein response, although the CIs were wide. Patients with early POCD had a higher Mini Mental State Examination score preoperatively (difference in medians 0.5 [95% CI, -1.0% to 0.0%]; P = 0.034). If there was an association between early POCD and late POCD, the sample size was unfortunately too small to verify this (23.6% of patients with early POCD had late onset vs 6.7% in non-POCD group; risk difference 16.9 (95% CI, -2.1% to 41.1%; P = 0.089). The incidence of POCD early after total hip and knee replacement seems to be lower after a fast-track approach than rates previously reported for these procedures, but late POCD occurred with an incidence similar to that in previous studies of major noncardiac elective surgery. No association between early and late POCD could be verified.

Background and purpose - Pain catastrophizing contributes to acute and long-term pain after total knee arthroplasty (TKA) but currently there are only limited treatment options. This study investigates the effectiveness of patient education in pain coping among patients with moderate to high pain catastrophizing score before TKA. Secondary outcomes were physical function, quality of life, self-efficacy, and pain catastrophizing.Patients and methods - The study was a parallel-group randomized controlled trial including patients with moderate to high levels of pain catastrophizing. 60 patients were recruited from December 2015 to June 2018. The mean age of the patients was 66 (47-82) years and 40 were women. The patients were randomized to either cognitive-behavioral therapy (CBT) based pain education or usual care. The primary outcome measure was pain under activity measured with the Visual Analog Scale (VAS). All outcomes were measured preoperatively, at 3 months, and at 1 year after surgery.Results - We found no difference in the primary outcome measure, VAS during activity, between the 2 groups but both groups had large reductions over time. The CBT-based pain education group reduced their VAS score by 37 mm (95% CI 27-46) and the control group by 40 mm (CI 31-49). We found no statistically significantly differences between the 2 groups in any of the secondary outcomes.Interpretation - Future research is warranted to identify predictors of persistent pain and interventions for the approximately 20% of patients with persisting pain after a TKA.