What does ‘Enhanced Recovery’ mean for knee/hip replacement surgery? Mr Sharma answers the FAQs…
Mr Sanjeev Sharma, Consultant Orthopaedic Surgeon and member of Sheffield Orthopaedics Ltd (SOL). Claremont Clinics: Wednesday PM & Friday PM
What does ‘Enhanced Recovery’ mean for knee/hip replacement surgery?
The concept of enhanced recovery in orthopaedics has been inherited from colorectal surgery where it was first established in 1997 by Professor Henrik Kehlet in Denmark. The aim of the program is to promote early mobilisation after joint replacement surgery in order to optimise the functional outcome. It is a multi-disciplinary approach involving the surgeon, anaesthetist, physiotherapist, occupational therapist and nursing staff all working towards expediting your recovery from surgery and enabling an early and safe discharge from the hospital. This also helps to minimise the risks of deep vein thrombosis (clot in the calf) and chest infection.
How would I be prepared for this program?
When I list patients for surgery I would do a general assessment about their suitability to follow the enhanced recovery protocol (ERP) (most patients are suitable). I generally exclude the very elderly patients or those with serious medical problems. I would explain about the protocol and also provide an information leaflet that you can read at your leisure. You will then be seen in the pre-operative assessment clinic prior to your surgery date for routine investigations. In this clinic the nursing staff will also explain about what to expect in the process of enhanced recovery after surgery so that there are no surprises for you following your operation. This helps in preparing you psychologically for an enhanced recovery.
Your hip/knee replacement surgery can be performed under spinal (needle in the back) or general anaesthesia (a tube down the throat). Spinal anaesthesia is preferred for enhanced recovery since the potential side effects of general anaesthetic (nausea, vomiting, drowsiness) are minimised. The dose of the drug injected in your back is kept to a minimum in order to allow the muscle power in your leg to return as soon as possible after surgery. To ensure that this dose reduction in spinal anaesthetic does not affect pain control, I would also inject a long acting local anaesthetic in the tissues around the knee to minimise post-operative pain. A combination of painkillers and anti-inflammatory medications are also prescribed to control post-operative pain. This should enable you to mobilise out of bed within a few hours after surgery.
If you opt for general anaesthesia, you can still follow the enhanced recovery protocol (ERP). The anaesthetist will minimise the usage of morphine/related drugs to minimise the risk of post-operative nausea and vomiting. Nerve blocks to temporarily paralyse thigh muscles have traditionally been used for hip/knee replacement surgery with general anaesthesia. These delay mobilisation after surgery and are hence avoided. Instead the long acting local anaesthetic injected in the tissues around the knee helps to minimise post-operative pain. A combination of painkillers and anti-inflammatory medications are also prescribed to control post-operative pain which ensures early mobilisation.
Is the surgery any different compared to hip/knee replacement without enhanced recovery protocol?
Traditionally, it has been a routine practice to insert drains to drain the hematoma following surgery. These impede early mobilisation and are avoided in the enhanced recovery protocol. Bleeding during surgery is minimised by injecting an agent locally to minimise bleeding as well as an intravenous injection of a drug which helps the blood clot quicker. The type of implants used and the surgical procedure would otherwise be same with either approach.
How long will I be staying in the hospital?
Most patients are able to go home within two days of their surgery. The enhanced recovery program has been very successful in minimising the length of hospital stay for patients. This helps in minimising the risk of hospital acquired infections as well as a blood clot in the calf.
Are there any additional risks/complications specifically related to the Enhanced Recovery Program?
No, there are no additional risks with the enhanced recovery protocol. On the contrary research shows that there are fewer incidences of complications when using the ERP.
A private consultation with Mr Sharma at Claremont is £200 if you don’t have health insurance. To book an appointment, call our friendly Private Patient Team on 0114 263 2114 or email firstname.lastname@example.org. You will need a referral letter from your GP or you can see one of our Private GPs if you prefer.
Copyright S Sharma, October 2017.