Optimising Perioperative Care in Elective Hip and Knee Arthroplasty

Abstract

Aim To improve perioperative care in total hip and knee arthroplasty (THA and TKA). Methods This thesis is divided into two distinct parts. In the first part an orthopaedic-specific standardised, Enhanced Recovery After Surgery (ERAS) programme was designed, implemented and evaluated. As part of a review of the literature tranexamic acid (TXA) was identified as an important component of an orthopaedic-specific ERAS programme by reducing blood loss and mitigating the need for allogenic blood transfusion perioperatively. A national survey of arthroplasty surgeons was performed to illustrate current perioperative care practices with a special interest in the use of TXA. Part 2 of the thesis investigated TXA in the setting of an orthopaedic-specific ERAS programme as a means to further hasten recovery and reduce perioperative morbidity. A review of the literature on TXA comparing the efficacy of systemic and topical routes was performed. In a multi-centred, randomised controlled trial (RCT) topical and systemic TXA was compared against a placebo group to determine if the route of administration influenced efficacy. Results An orthopaedic-specific ERAS programme was safely implemented into clinical practice at a single, public hospital in NZ and demonstrated a significant reduction in hospital length of stay (5 days v. 4 days; p < 0.001), less readmissions and less in-hospital costs. The survey of NZ arthroplasty surgeons revealed that the use of TXA in TKA and THA remained low perhaps due to concern regarding potential thromboembolic risks of systemic TXA. In the RCT, systemic and topical TXA, given as a single 1.5 g intraoperative dose, were found to be equally efficacious in reducing perioperative blood loss among TKA patients when compared with placebo (topical: 723 ml v. systemic: 749 ml v. placebo: 1090 ml; p < 0.0003 and p < 0.001). Conclusion An orthopaedic-specific ERAS programme in THA and TKA can successfully be implemented resulting in quicker, early recovery without compromising patient safety. Within the setting of an established ERAS programme, a single intraoperative dose of TXA given during TKA significantly reduces perioperative blood loss. While not powered for thromboembolism risk the efficacy of locally administered TXA may encourage arthroplasty surgeons to use TXA more in the future.