In the present study, we evaluated whether FTS could reduce the hospital LOS, in comparison with conventional THA. It has been estimated that the number of THA operations performed will double within the next decade,3,18 and the economic burden associated with this increasing demand is high. In this context, one potential way to reduce hospitalization costs is to minimize the LOS. Indeed, data from the mid-1990s showed that the LOS could be reduced (from 8 to 3.8 days) without affecting patient outcomes.33
Recent advances in preoperative education, blood conservation, standardized anesthetic protocols, postoperative care with pain management and early mobilization have led to popularization of FTS for THA.5-7 A FTS protocol was introduced in our institution based on the best evidence for clinical practice, with the aims of increasing the safety of surgery, reducing and managing blood loss, controlling postoperative pain without adverse effects from opioids and providing optimized rehabilitation with increased patient satisfaction and shorter hospital stay. In the present prospective single-center study, it was observed that patients who underwent FTS stayed in hospital for a significantly shorter period of time (Figure 1).
Additionally, the implementation of this FTS protocol has included both preoperative education for patients and their family members and development of a multidisciplinary team that had previously not yet become integrated. The main outcome that was expected from implementation of this protocol was a reduction in the hospital LOS, along with decreased need for ICU support. After introduction of the FTS protocol, the number of THA procedures performed was significantly augmented without an increase in the occurrence of complications.
One prerequisite for promoting effective rehabilitation and optimizing mobilization in bed is to achieve adequate pain control with few adverse effects. This was achieved in the present study through using an opioid-free protocol consisting of a combination of bupivacaine and clonidine, for spinal anesthesia. Clonidine is a 2-adrenergic agonist that has analgesic properties and boosts the effects of local anesthetics when administered via the epidural route, with few postoperative adverse effects.21,22 This intervention was previously found to enable elimination of postoperative delayed bladder catheter use.20
In our study, a total of four cases of urinary retention occurred in the FTS group and required use of postoperative relief. In the control group, which underwent spinal anesthesia using morphine, all the patients received a delayed bladder catheter immediately after anesthesia. Other benefits of the opioid-free protocol were absence of or decreased adverse effects such as pruritus, constipation, malaise, nausea and postoperative vomiting.
Relief of acute pain after THA is a major therapeutic challenge, given that postoperative pain hinders early mobilization and rehabilitation, which subsequently leads to longer periods of resting in bed and prolonged hospital LOS.10,11 Administration of cocktails containing local anesthetics, anti-inflammatory agents and corticosteroids, as a PAI around the surgical site, can be implemented after surgery, to promote pain control without increasing the risk of surgical site infection.10,12,,23,24 In the FTS group, the PAI technique was implemented at the end of the operation, and this led to relief of acute postoperative pain, early mobilization and decreased hospital LOS.
Postoperative anemia is a very common clinical condition observed in THA, which requires blood transfusion in 33 to 74% of the cases.25 The costs and the risk of infection associated with blood transfusion, along with difficulty in obtaining blood products, have given rise to increased interest in blood conservation strategies.25,26
In the present study, in order to reduce the risks relating to blood transfusion in the postoperative period following FTS, the patients in this group were screened for transfusion risk factors and then treated when serum hemoglobin was < 12 g/dL.25 Closed suction drains were not used in either group, given their low benefit and the increased risk of postoperative transfusion.27
Another very useful strategy that was adopted in order to obtain good hemostasis during surgery was intravenous administration of TA in a single dose of 15-20 mg/kg, before induction of anesthesia.27 TA is a lysine analogue that inhibits activation of plasmin, thereby inhibiting tissue fibrinolysis and consequent clot stabilization.28
This measure drastically reduced the need for blood transfusion in the FTS group. Blood transfusion was only required in two patients. One of these patients had sickle cell anemia and the other had rheumatoid arthritis. Both of them showed acute signs of anemia, confirmed by laboratory tests, which therefore required two units of erythrocyte concentrate each. They underwent rehabilitation on the second postoperative day and remained hospitalized for four nights after surgery. It is important to note, in comparison, that as many as 74.5% of the patients in the control group required blood transfusion. Blood transfusion is considered to be an important predictor in relation to hospital discharge.25,33 Compared with the current FTS protocol, use of conventional THA was associated with greater need for supplies of blood products.
Only one patient in the FTS group required use of the ICU in the postoperative period. However, this was a preoperative indication based on the individual’s advanced age. This patient’s rehabilitation started after discharge from the ICU. Conversely, the majority (72.5%) of the patients in the control group required critical care support.
Regarding the surgical complications observed in the FTS group, one case of sciatic nerve paresthesia and one case of traumatic dislocation of THA were observed. These patients underwent appropriate treatment and stayed in hospital for five days. Two cases of periprosthetic fracture of type Vancouver B1 and one case of type Vancouver Al were radiographically identified in the immediate postoperative period. These patients then underwent conservative treatment with a six-week load restriction. Another case of fracture was identified at the level of the minor trochanter. The time until hospital discharge in these cases ranged from three to five days, and all of these patients evolved well, with fracture healing and no requirement for reoperation.
Another factor that needs to be observed is whether there is any family support.35 In the FTS group, we had two patients who stayed in hospital for four nights due to social need. These were patients with social problems, who were eligible for discharge after the second night after their surgery, but they lived in other cities and could not be discharged because they had no support for them to leave the hospital. This increased their hospital LOS to four nights. We called these cases “social internment”.
The time needed to reach hospital discharge in THA cases is a subject of great debate, and there is no consensus on the ideal criteria that should be met for safe hospital discharge. Normal vital signs, adequate pain control and safe mobilization are usually considered to be requirements.31 However, blood loss should also be taken into account, and patients with intraoperative blood loss < 500 mL or with hemoglobin > 9.7 g/dL may thus be considered eligible for hospital discharge.31 In the FTS protocol used, we adopted an evidence-based criterion for hospital discharge.30-33
The hospital LOS in our study was notably lower in the FTS group (mean 2.3 nights; range, 2 to 5 nights) than in the control group (mean 6.4 nights; range, 3 to 9 nights. The FTS group also had lower requirements for blood transfusion and ICU support during the postoperative period.
Overall, in addition to adequate pain control and mobilization in bed within the first postoperative hours, an absence of clinical changes (e.g. malaise, nausea or vomiting), stability of vital signs, a desire to go home and the existence of family support are relevant for achieving safe hospital discharge.29,35,36
It needs to be mentioned that this study had several limitations, including the small sample size, the evaluation at a single center and the fact that interventions were not performed in a parallel fashion in the two groups. Prospective multicenter cohort studies in this regard are thus warranted.