CHAPTER 29 The Rapid Recovery Program for Total Hip Arthroplasty
SURGICAL FACTORS
Inherently, the anterolateral and anterior approaches are more stable and have been associated with a lower dislocation rate. If a posterior approach is used, meticulous attention should be made to capsular closure to decrease the dislocation rate.1
Postoperative restrictions after THA also play a major role in prolonging rehabilitation, because the patient is concerned about dislocation rather than progress with his or her rehabilitation regimen. In a prospective randomized study, the role of postoperative functional restrictions on the prevalence of dislocation after uncemented THA through an anterolateral approach was studied.2
Also, using an implant that allows immediate full weight bearing is a key component of accelerated rehabilitation in the perioperative period. In our institution, our bias has been toward using a collarless, tapered, porous-coated femoral stem. These stems have withstood the test of time. In a 15-year follow-up study on the Trilock and Taperloc stems, 96% of the patients in the Trilock group and 100% of the patients in the Taperloc group had radiographic evidence of bone ingrowth. The design features virtually ensure bone ingrowth and are thought to be responsible for the excellent clinical results and longevity.3
Several studies have evaluated weight bearing after THA to substantiate its safety with the newer femoral stem designs. Woolson and Adler assessed the effects of full weight bearing versus 50 pounds or less of weight bearing for 6 weeks in patients who underwent THA using a fully porous-coated collared femoral component.4 All femoral components in both groups had radiographic evidence of bone ingrowth fixation at the 2-year follow-up.
The radiographic subsidence of the uncemented Taperloc stem and clinical results after unilateral and simultaneous bilateral uncemented THA were compared. Patients who had bilateral THA began weight bearing as tolerated on both lower extremities the day after surgery. Patients who had undergone unilateral THA were maintained at 10% weight bearing on the operative limb for 6 weeks after surgery.5 All femoral prostheses in both groups appeared radiographically stable with evidence of bone ingrowth and no indications of loosening. Patients in both groups obtained satisfactory clinical results.
In another study, a prospective review of two groups of patients undergoing cementless THA was undertaken. The first group was allowed full weight bearing immediately after the operation, and the other group underwent protected weight bearing for 6 weeks. Patients were matched for sex, age at surgery, height, weight, and follow-up period. There were no significant differences in hip scores between the two groups, and all patients showed bone ingrowth radiographically. Protected weight bearing resulted in a longer hospital stay.6
PATIENT FACTORS
Patient Education
In a study looking at preoperative rehabilitation advice reinforced by a patient information booklet, 35 patients were recruited and randomly allocated before admission to receive either the standard pathway of care or the rehabilitation program and booklet. The preoperative class and booklet seemed to have the greatest impact on length of hospital stay, reducing the hospital stay by 3 days, and the therapy input required, significantly influencing the cost of the procedure ($810 savings per patient). In addition, patients attending the class reported higher levels of satisfaction at 3 months postoperatively and had more realistic expectations of surgery.7
In a similar study, the impact of a social work preadmission program on length of stay of orthopedic patients undergoing elective THA or total knee arthroplasty (TKA) was evaluated. The social work interventions included preadmission psychosocial evaluation and preliminary discharge planning. Mean length of stay was reduced significantly in the intervention patient groups, as compared with the pre-intervention patient groups in the same hospital. They concluded that preadmission screening and case management by a social worker can contribute to the efforts to decrease length of stay of orthopedic patients by early multidisciplinary evaluations, discharge planning, and coordination of services.8
Daltroy and coworkers, in another study, further illustrated that educational intervention reduced length of stay. Also found was a reduction in the use of pain medication for patients who exhibited most denial and reduced postoperative anxiety.9
Nutritional Status
Del Savio and associates sought to identify preoperative nutritional factors that could be used to define a subgroup of patients undergoing elective THA who are at high risk for poor postoperative outcome.10 They found an inverse relationship between serum albumin value and length of hospital stay. Patients with an albumin level less than 3.9 were twice as likely to require prolonged hospitalization. They concluded that preoperative malnutrition appears to be associated with the in-hospital postoperative recovery but unrelated to long-term recovery.