Why still in hospital after fast-track hip and knee arthroplasty?

Abstract

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.

Proportion of patients of the 2 cohorts (TKA, n = 107; THA, n = 98) still hospitalized during the first 72 hours, and reasons. Proportions are calculated as number of patients with each clinical problem divided by the total number of TKAs and THAs, respectively. PONV: postoperative nausea and vomiting. Technical reasons cover ongoing intravenous transfusion of blood or plasma expander, or urinary catheter due to urinary retention. “Logistical” covers waiting for physiotherapy or postoperative radiographs.