Developing an enhanced recovery after surgery program for oncology patients who undergo hip or knee reconstruction surgery

Enhanced recovery after surgery(ERAS) protocols are applied in orthopedic surgery and are intended to reduce perioperative stress by implementing combined evidence-based practices with the cooperation of various health professionals as an interdisciplinary team. ERAS pathways include pre-operative patient counselling, regional anesthesia and analgesia techniques, post-operative pain management, early mobilization and early feeding. Studies have shown improvement in the recovery of patients who followed an ERAS program after hip or knee arthroplasty, compared with those who followed a traditional care approach. ERAS protocols reduce post-operative stress, contribute to rapid recovery, shorten length of stay(LOS) without increasing the complications or readmissions, improve patient satisfaction and decrease the hospital costs. We suggest that the ERAS pathway could reduce the LOS in hospital for patients undergoing total hip replacement or total knee replacement. These programs require good organization and handling by the multidisciplinary team. ERAS programs increase patient's satisfaction due to their active participation which they experience as personalized treatment. The aim of the study was to develop an ERAS protocol for oncology patients who undergo bone reconstruction surgeries using massive endoprosthesis, with a view to improving the surgical outcomes.     

The effect of psychological status on pain and surgical outcome in patients requiring arthroscopic subacromial decompression

Background

We prospectively investigated the association between pre-operative psychological status and early post-operative shoulder pain and function in patients requiring arthroscopic subacromial decompression for impingement syndrome.

Methods

A consecutive series of patients in 2009/10 completed questionnaires 2?weeks pre-operatively and three and 6?weeks post-operatively that assessed psychological state, shoulder function and pain. The hospital anxiety and depression scale, the oxford shoulder score and a pain visual analogue scale assessed psychological status, shoulder function and shoulder pain, respectively.

Results

Thirty-one patients participated (21 women; 10 men; mean age 54.6?years; age range 21–89?years). Pre-operative anxiety was significantly associated with pre-operative shoulder pain (P?<?0.05). Pre-operative psychological status did not correlate with post-operative shoulder pain or function. Greater pre-operative anxiety and depression were significantly associated with post-operative psychological distress (P?<?0.05). Overall shoulder pain, function and psychological state improved significantly during the study (P?<?0.05) regardless of pre-operative psychological status.

Conclusion

Despite pre-operative associations between anxiety and shoulder pain, there were no associations between pre-operative psychological status and post-operative outcomes. There may be no justification for assessing psychological state in cases of ‘uncomplicated’ impingement syndromes requiring arthroscopic subacromial decompression. Abnormal pre-operative psychological status is not a justifiable reason for delaying or denying this effective operation.     

Do clinical presentation and pre-operative quality of life predict satisfaction with care after total hip or knee replacement?

We conducted a multicentre cohort study of 228 patients with osteoarthritis followed up after total hip or knee replacement. Quality of life and patient satisfaction were assessed by self-administered questionnaires. Patient satisfaction was the dependent variable in a multivariate linear regression model. Independent variables included sociodemographic factors, pre- and post-operative clinical characteristics and the pre-operative and post-discharge health-related quality of life. The mean age of the patients was 69 years (sd 9), and 43.8% were male. Pre- and postoperative clinical characteristics were not associated with satisfaction with health care. Only pre-operative bodily pain (p<0.01) and pre-operative social functioning (p<0.05) influenced patient satisfaction with care. The pre-operative health-related quality of life and patient characteristics have little effect on inpatient satisfaction with care. This suggests that the impact of the care process on satisfaction may be independent of observed and perceived initial patient-related characteristics.     

Enhanced recovery in intestinal surgery

Enhanced recovery after surgery (ERAS) programmes utilise a multi-modal and multidisciplinary approach to surgical care. The aim of ERAS is to reduce the surgical stress response, maintain physiological function and metabolic homeostasis and expedite patients' recovery to their baseline status. With its success in colorectal practice, ERAS is increasingly adopted in other surgical specialities. A good ERAS programme involves integrated pre-operative, intra-operative and post-operative evidence-based practice. Successful ERAS programme translates to a standardized patient care pathway, improved clinical outcomes and shorter hospital stay, all of which will help facilitate the increasing demand on healthcare and bed pressure. Its principles and many components are transferable to other surgical specialities including acute surgical services and medical specialities to improve patient care and recovery and will soon become the standard of care for the majority of hospital inpatients.     

Chronic pain following total hip arthroplasty: a nationwide questionnaire study

Background:  Chronic post-operative pain is a well-recognized problem after various types of surgery, but little is known about chronic pain after orthopedic surgery. Severe pre-operative pain is the primary indication for total hip arthroplasty (THA). Therefore, we examined the prevalence of chronic pain after THA in relation to pre-operative pain and early post-operative pain.
Methods:  A questionnaire was sent to 1231 consecutive patients who had undergone THA 12–18 months previously, and whose operations had been reported to the Danish Hip Arthroplasty Registry.
Results:  The response rate was 93.6%. Two hundred and ninety-four patients (28.1%) had chronic ipsilateral hip pain at the time of completion of the questionnaire, and pain limited daily activities to a moderate, severe or very severe degree in 12.1%. The chronic pain state was related to the recalled intensity of early post-operative pain [95% confidence interval (CI), 20.4–33.4%] and pain complaints from other sites of the body (95% CI, 20.7–32.1%), but not to the pre-operative intensity of pain.
Conclusion:  Chronic pain after THA seems to be a significant problem in at least 12.1% of patients. Our results suggest that genetic and psychosocial factors are important for the development of chronic post-THA pain.     

Effects of Pre-operative Psychological Status on Post-operative Recovery: A Prospective Study

Background

Often in clinical practice, a spectrum of outcomes from surgery may be observed ranging from a quick and comfortable recovery to a recovery punctuated by persistent pain and decreased quality of life. While there has been a fast pace of advances made in the field of operative surgery, surgeons seldom pay attention to factors such as the psychological profile of a patient that can affect recovery from surgery.

Objective

To study the effects of pre-operative psychological profile on post-operative recovery in terms of pain, return to work and quality of life.

Materials and methods

Consecutive patients undergoing laparoscopic surgeries at Sagar Hospitals, Jayanagar, were recruited. All patients were assessed for psychological status using the screening for illness behaviour questionnaire (SIBQ) and pain catastrophizing scale (PCS). Following surgery, they were followed up for a period of 3 months—on post-operative day 1, post-operative day 7, 1 month and 3 months from the date of surgery. Post-operative pain was measured using the visual analogue scale (Wong–Baker’s), return to work was documented in days and quality of life was measured using the Short Form-36 version 2 (SF-36v2) Health Survey. The Pearson’s correlation coefficients were used to compare variables with continuous data and Chi-square and Fisher’s tests were used to test categorical data for significance.

Results

In a total of 98 patients recruited, 50 patients had a complete follow-up of 3 months. Significant correlations existed between the pre-operative markers and markers of recovery. The Chi-square test and Fisher’s exact tests showed significant differences in the scores of pre-operative markers between the groups of patients who developed chronic pain and those who did not. Difference in scores with regard to quality of life was also noted.

Conclusion

Psychological status does play a role in post-operative recovery. This result opens up scope for counselling patients towards a healthy and comfortable recovery from surgery.

     

Six months post-operative clinical and 24 hour post-operative MRI examinations after nucleoplasty with radiofrequency energy

Summary Background. Minimally invasive techniques are gaining popularity for the treatment of discogenic low-back pain. Nucleoplasty is a relatively new procedure that uses radiofrequency energy to disintegrate and evacuate the disc material. The purpose of this study is to examine the early post-operative radiological changes after lumbar nucleoplasty and to assess the short-term effects of this procedure on discogenic lower back pain and leg pain. Methods. Twenty nine patients between the ages of 32 and 59 years (mean 44.14, SD 7.11 years) were included in the study. Visual Analogue Scale (VAS) scores of the patients were recorded in the pre-operative period and 24 hours, 3 months and 6 months after the procedure. Additionally, pre-operative and post-operative lumbar magnetic resonance imaging (MRI) examinations of these patients were compared. Findings. The mean pre-operative VAS score was 6.95 (range 3.0–10.0, SD 1.87) and the mean post-operative VAS scores at 24 hours, 3 months and 6 months were 2.46 (range 0–8.0, SD 2.07), 4.0 (range 0–10.0, SD 3.09) and 4.53 (range 0–10.0, SD 3.6), respectively. There were statistically significant reductions (p < 0.001) in VAS scores for all post-operative time points when compared to pre-operative values. Nucleoplasty did not produce obvious changes at least on the early post-operative MRI examination. Conclusions. Although, nucleoplasty appeared to be a safe minimally invasive procedure, the value of this new technique for the treatment of discogenic low-back pain remains as yet unproven. Further randomised placebo-controlled studies with longer follow-up are needed to elucidate the effects of nucleoplasty on discogenic low back and leg pain.     

An exploration of patients’ expectation of and satisfaction with surgical outcome

Purpose

The majority of studies of surgical outcome focus on measures of function and pain. Increasingly, however, the desire to include domains such as patients’ satisfaction and expectations had led to the development of simple measures and their inclusion into clinical studies. The purpose of this study was to determine patients’ pre-operative expectations of and post-operative satisfaction with the outcome of their spinal surgery.

Methods

As part of the FASTER randomised controlled trial, patients were asked pre-operatively to quantify their expected improvement in pain and health status at 6 weeks, 6 and 12 months following surgery using 100 mm visual analogue scales (VAS), and to indicate their confidence in achieving this result and also the importance of this recovery to them. Patients were then asked to rate their satisfaction with the improvement achieved at each post-operative review using 100 mm VAS.

Results

Although differences between patients’ expectation and achievement were minimal 6 weeks post-operatively, there was a clear discrepancy at 6 months and 1 year, with patient expectations far exceeding achievement. There were significant correlations between failure to achieve expectations and the importance patients attached to this recovery at each post-operative assessment, but not with their confidence in achieving this result. Satisfaction levels remained high despite expectations not being met, with discectomy patients being more satisfied than decompression patients.

Conclusions

Patients’ pre-operative expectations of surgical outcome exceed their long-term achievement. The more importance the patient attached to a good outcome, the larger is the discrepancy between expectation and achievement. Despite this, satisfaction levels remained high. The impact of unrealistic expectations on outcome remains unclear.     

Multi-modal pain management for total knee replacement

Multi-modal pain management is probably the most important method adopted in past 10 years to improve post-operative recovery of total knee replacement patients. The goal is to provide sufficient pain relief to perform rehabilitation, while minimizing side effects from the treatment. A reduction in narcotic use will lessen side effects such as sedation, nausea, vomiting, ileus, urinary retention, and respiratory depression. Medications, nerve blocks, and peri-articular injections are directed toward the brain, dorsal root ganglia, and peripheral nerves. Improved post-operative recovery can be achieved lessening hospital stays and facilitate outpatient surgery. The author’s current method of multi-modal pain management is described.     

经皮椎体后凸成形术在治疗多节段骨质疏松性椎体压缩骨折的应用

目的探讨经皮椎体后凸成形术治疗多节段骨质疏松性椎体压缩性骨折的疗效。方法对47例多节段骨质疏松性椎体压缩性骨折患者共104个伤椎实施经皮椎体后凸成形术。根据手术前后伤椎的椎体矢状面指数(VSI)、后凸Cobb角,评价椎体解剖形态的恢复情况。比较术前与术后1周、术后1年的模拟视觉类比评分(VAS)和功能障碍指数(ODI),评价疼痛缓解情况和脊柱功能恢复情况。结果患者均获得随访,时间12～24(17.3±2.7)个月。术前与术后1周、术后1年VSI分别为0.63±0.31、0.94±0.12和0.92±0.32,术后1周、术后1年与术前比较,差异有统计学意义(P<0.01);后凸Cobb角分别为39.12°±5.53°、8.24°±4.11°和8.66°±6.57°,术后1周、术后1年与术前比较差异有统计学意义(P<0.01);VAS分别为9.26分±0.60分、1.79分±1.21分和1.90分±0.86分,术后1周、术后1年与术前比较,差异有统计学意义(P<0.01)。ODI分别为82.71分±3.67分、19.50分±2.73分和24.14分±4.10分,术后1周、术后1年与术前比较,差异有统计学意义(F=261.32,P<0.01)。结论经皮椎体后凸成形术治疗多节段骨质疏松椎体压缩性骨折创伤小,能较好地恢复伤椎高度,矫正后凸Cobb角,止痛效果和脊椎功能恢复均满意。     

Patient expectations and satisfaction in orthopaedic surgery: A review of the literature

Patient expectations have been shown to be an independent predictor of outcomes in clinical medicine. In the orthopaedic literature, the majority of studies have focused on the relationship between pre-operative expectations and post-operative outcomes in patients undergoing total hip arthroplasty, total knee arthroplasty, shoulder surgery, and spine surgery. Various methodologies have been used to assess patient expectations in orthopaedic surgery, including direct questioning, short questionnaires, and validated surveys. Multiple patient factors have been associated with greater expectations prior to elective orthopaedic surgery, and greater pre-operative expectations have been shown to be associated with better subjective and objective outcomes after total hip and knee arthroplasty, shoulder surgery, and spine surgery. While there are very few validated measures of patient satisfaction after orthopaedic surgery, increased post-operative patient satisfaction is consistently associated with meeting pre-operative patient expectations. Given the relationship between pre-operative patient expectations and post-operative outcomes and patient satisfaction, understanding and defining expectations prior to elective orthopaedic surgery may optimize outcomes. In this review, we aim to summarize the current literature on patient expectations in orthopaedic surgery.     

Perioperative anaesthetic considerations for rotator cuff repair surgeries: A current concept review

Surgeries for Rotator Cuff (RC) pathologies are required for either trauma or degenerative related aetiologies. Various surgical techniques from open to arthroscopic repair, are being undertaken by orthopaedic surgeons. Peri-operative anaesthetic management of the patients undergoing rotator cuff repair requires understanding the surgical procedure and patient status for optimal anaesthetic planning. Such management mandates a thorough pre-operative evaluation, including clinical history, examination, and relevant investigations. Patients with acute trauma associated Rotator Cuff (RC) tears should be assessed for visceral injuries using appropriate injury evaluation systems before such repairs. On the other hand, patients with degenerative tears tend to be older with associated comorbidities. Hence pre-operative optimisation is necessary according to risk stratification. Anaesthetic techniques for Rotator Cuff (RC) surgery include general anaesthesia or regional anaesthesia. These are individualised according to patient assessment and surgical procedure planned. Knowledge of relevant surgical anatomy is essential for intra-operative, and post-operative neural blockade techniques since optimal peri-operative analgesia improve overall patient recovery. The occurrence of a peri-operative complication should be recognised as timely management improves the patient-related surgical outcomes. We describe the relevance of surgical anatomy, the effect of patient positioning, irrigating fluids, various anaesthetic techniques and an overview of regional and medical interventions to manage pain in patients undergoing for Rotator Cuff (RC) surgery.     

An unexpected mortality following cardiac surgery: a post-mortem diagnosis of cardiac amyloidosis

Amyloidosis is a rare systemic disease that is notoriously difficult to diagnose early. Cardiac involvement is associated with a poor prognosis. We present the case of a 72-year-old gentleman who underwent elective coronary artery bypass grafting and mitral valve repair. While initially making a good post-operative recovery, a sudden deterioration on post-operative day 3 led to an unexpected mortality. Post-mortem examination demonstrated previously undiagnosed severe systemic amyloidosis, which particularly affected his heart, due to underlying multiple myeloma. It is important to emphasise that due to the absence of the typical findings on routine pre-operative investigations suggestive of cardiac amyloidosis in this patient, cardiac surgeons should be aware that symptoms inconsistent with angiography findings should prompt consideration of amyloidosis. Diagnostic tools including cardiac MRI and ultimately endomyocardial biopsy could then facilitate earlier recognition of this enigmatic disease process.     

The analysis of renal function in off-pump coronary artery bypass grafting

OPCAB (off-pump coronary artery bypass grafting) is useful for preventing post-operative neurologic complications. On the other hand, the effect of OPCAB on post-operative renal function is still unclear. We analyzed the post-operative renal function in 39 patients. Thirty-two patients had normal pre-operative renal function (CRE < or = 1.4 mg/dl). Thirty-one patients were doing well in terms of post-operative renal function. Only 1 patient needed hemodialysis (HD) because of systemic infection in early post-operative period. Another 7 patients had pre-operative renal dysfunction (CRE > or = 1.5 mg/dl). Three cases with high-grade pre-operative renal dysfunction (CRE > 3.0 mg/dl and CCR < 20 ml/min) needed temporary HD or continuous hemo-diafiltration (CHDF) in early post-operative period, and then they needed maintenance HD for the treatment of chronic renal failure within 3 weeks after OPCAB. Three of 4 cases with low-grade pre-operative renal dysfunction (CRE: 1.9-2.7 mg/dl and CCR: 22-42 ml/min) needed temporary HD or CHDF in early post-operative period. These 3 patients were relieved of the early post-operative renal failure, but required maintenance HD in the late periods. In summary, OPCAB could not prevent the development of acute renal failure in the patients with pre-operative renal dysfunction.     

Enhanced recovery after surgery program

In recent years, various perioperative patient management programs have been proposed as "Enhanced recovery after surgery program" in order to improve patient prognosis. These programs are an evidence-based approach which does not use novel drugs or novel therapeutic intervention, but uses conventional medical therapy and skill. In the programs, primary outcome measure is "enhanced recovery after surgery", and secondary outcome measures are "reduced postoperative morbidity, improved safety, reduced hospital stay, and reduced cost". Specifically, early postoperative recovery will be carefully managed by evaluating clinical variables such as "postoperative pain, gut dysfunction, and immobility". These programs aim to keep the reduction of body functions as marginally as possible by minimizing surgical stress imposed on patients and then help shorten the recovery time after surgery.     

Factors contributing to poor post-operative abdominal pain management in adult patients: a review

Post-operative abdominal pain management can be a major issue facing medical and nursing staff in daily clinical practice. Effective pain control reduces post-operative morbidity as well as facilitates rehabilitation and accelerates recovery from surgery. In turn, poor pain control has been shown to alter body metabolic response that can lead to delayed recovery, with subsequent prolonged hospital stay and increased morbidity, and can lead to the development of a chronic pain state.Despite the significant developments in anaesthesia, delivery techniques and analgesia, post-operative abdominal pain management in adult patients remains suboptimal. Achieving effective pain management needs the implementation of an active approach in practice. This approach includes the provision of information and appropriate education tailored to the patients' needs and level of understanding, with the aim of reducing patient anxiety and avoiding unrealistic expectations. In addition, medical and nursing staff should continuously use the appropriate pain assessment tools to evaluate of post-operative pain in the surgical wards. Pain assessment needs to be regarded as the fifth vital sign and recorded on the patients observation chart.Analgesia should be used in a multimodal fashion and “by the clock” according to the patients needs. Moreover, governmental and professional guidelines need to be implemented to establish continuity of care, improve the quality of decision making and reduce unnecessary variations in practiceOverall, there is a need for improved post-operative abdominal pain management in adults to enhance recovery, patient safety and reduce morbidity. This can be achieved with the appropriate education backed up with robust policies and guidelines, supported by up to date evidence.     

胆囊十二指肠瘘伴胆石性肠梗阻1例分析并文献复习

目的:探讨胆囊十二指肠瘘合并胆石性肠梗阻的术前评估、诊断和手术方式。方法:回顾性分析1例胆囊十二指肠瘘合并胆石性肠梗阻术前及术中的临床资料,并复习相关文献。结果:患者术前CT检查考虑胆囊结石与胆石性肠梗阻。术中探查见回盲部40cm处结石嵌顿,随后成功行肠切开取石、十二指肠瘘口修补、胆囊切除。术后痊愈出院,随访至目前未见相关并发症。结论:胆囊十二指肠瘘合并胆石性肠梗阻临床罕见,早期的明确诊断及精确的评估是关键,应根据患者具体情况选择合适的手术方式。     

Does computer-assisted surgery benefit leg length restoration in total hip replacement? Navigation versus conventional freehand

Leg length discrepancy following total hip replacement (THR) can contribute to poor hip function. Abnormal gait, pain, neurological disturbance and patient dissatisfaction have all been described as a result of leg length inequality after THR. The purpose of this study was to determine whether the use of computer navigation in THR can improve limb length restoration and early clinical outcomes. We performed a matched-pair study comparing 48 computer-assisted THR with 48 THRs performed using a traditional freehand alignment method. The same implant with a straight non-modular femoral stem was used in all cases. The navigation system used allowed the surgeon to monitor both acetabular cup placement and all the phases of femoral stem implantation including rasping. Patients were matched for age, sex, arthritis level, pre-operative diagnosis and pre-operative leg length discrepancy. At a minimum follow-up of six months, limb length discrepancy was measured using digital radiographs and a standardised protocol. The number of patients with a residual discrepancy of 10 mm or more and/or a post-operative over-lengthening were measured. The clinical outcome was evaluated using both the Harris Hip Score and the normalised Western Ontario and McMaster Universities (WOMAC) Arthritis Index. Restoration of limb length was significantly better in the computer-assisted THR group. The number of patients with a residual limb length discrepancy greater than 10 mm and/or a post-operative over-lengthening was significantly lower. No significant difference in the Harris Hip Score or normalised WOMAC Arthritis Index was seen between the two groups. The surgical time was significantly longer in the computer-assisted THR group. No post-operative dislocations were seen.     

Hypoglossal neuroma following excision of a huge recurrent acoustic neuroma and facio-hypoglossal anastomosis. A complex management problem

A case of neuroma of the intracranial part of the hypoglossal nerve, not associated with neurofibromatosis, is presented. The patient had previously undergone surgery for the removal of a contralateral acoustic neuroma, and subsequent facio-hypoglossal anastomosis. The importance of early diagnosis, pre-operative clinical assessment and post-operative care is stressed.     

Hip arthroplasty patient-reported outcome unaffected by back pain in women

The effect of pre-operative back pain on outcome following total hip replacement (THR) is ill defined. Patient-reported outcome following THR was assessed using a general health status questionnaire (Short Form 36 Health Evaluation (SF-36)). A regional arthroplasty database was used. Pre-operatively, patients were asked regarding the presence or absence of back pain, and the Harris hip score (HHS) was used to objectively measure hip ‘health’. The SF-36, a general health questionnaire, was assessed pre-operatively and at follow-up intervals to 5 years. Bilateral procedures and patients with a post-operative complication recognised to adversely affect outcome were excluded. After exclusions, data from 860 patients were analysed. Proportionally, more women reported back pain pre-operatively. There was no difference in the pre-operative HHS. The post-operative patient-reported SF-36 scores for men with pre-operative back pain were significantly lower than their peers without back pain. This difference was not seen in women. Women with pre-operative back pain attained post-operative mean values in the SF-36 domains that were similar to their peers with no pre-operative back pain. The presence of pre-operative back pain does not affect patient-reported functional and quality of life outcome in women following THR. Men with pre-operative back pain may not obtain the same degree of improvement in general well-being when compared to their peers without back pain.