Abstract
Aim: The programme of research within this thesis was developed to evaluate the current literature base for Enhanced Recovery Programmes (ERP) in orthopaedics and to specifically compare two methods of peri-operative analgesia, epidural or local infiltration analgesia, as the primary analgesic technique as part of an established ERP program and their impact on rehabilitation outcomes at discharge from hospital, six weeks and one year post-surgery .
Methods: Fundamental to enabling rehabilitation is good pain control whilst ensuring adequate muscle power to facilitate early ambulation and functional recovery. Local Infiltration Analgesia (LIA) has become synonymous with enhanced recovery programmes. A structured literature review and meta analysis was developed to review the current literature and specifically whether local infiltration analgesia improved rehabilitation outcomes following total knee arthroplasty compared to other forms of regional analgesia. Six studies met the criteria for inclusion within the review which demonstrated low quality evidence in favour of infiltration, however of concern was the significant increase in adverse events recorded within the included trials. Therefore, following ethical approval a randomised controlled parallel group trial was carried out within an elective orthopaedic unit from April2010-August 2012. A total of 242 patients undergoing primary TKA for osteoarthritis were recruited and received standardised pre-operative education, multimodal analgesia, accelerated rehabilitation and were randomised using a simple unrestricted randomisation method to receive either Patient Controlled Epidural Analgesia (PCEA) or LIA. Primary outcome measure was the proportion of patients discharged from rehabilitation by day four. Statistical significance was set at p<o.o 1.
Results: Twenty patients were excluded due to failed spinal anaesthesia following randomisation, therefore 222 patients were included in the analysis (PCEA=109 & LIA=l13). The mean age was 67 (SD 8.1) and mean BMI 32(SD 6.1). No statistical difference was observed between the proportions of patients discharged from rehabilitation by day four, PCEA =77% and LIA=82% (p=O.33). Median hospital stay was four days for both groups(p=O.54). No difference was observed in post-operative catheterisation rates(p=O.16), pain scores (p=0.28), use of additional analgesia (p=O.55) or rates of ambulation on theatre day (p=O.013). No significant difference was recorded in the number of adverse events or complications between groupsup to one year following surgery (PCEA n=2 vs. LIA n= 6, p=O.281).
Conclusion: The work within this thesis has demonstrated that the two methods of perioperative analgesia investigated (PCEA and LIA) did not affect the attainment of rehabilitation discharge criteria following primary total knee arthroplasty as part of an Enhanced Recovery Programme. Both methods provided equitable analgesia, enabled early ambulation and progression of rehabilitation post-surgery. The method of peri-operative analgesia did not affect functional recovery or post-operative morbidity or mortality up to one year following surgery.
Methods: Fundamental to enabling rehabilitation is good pain control whilst ensuring adequate muscle power to facilitate early ambulation and functional recovery. Local Infiltration Analgesia (LIA) has become synonymous with enhanced recovery programmes. A structured literature review and meta analysis was developed to review the current literature and specifically whether local infiltration analgesia improved rehabilitation outcomes following total knee arthroplasty compared to other forms of regional analgesia. Six studies met the criteria for inclusion within the review which demonstrated low quality evidence in favour of infiltration, however of concern was the significant increase in adverse events recorded within the included trials. Therefore, following ethical approval a randomised controlled parallel group trial was carried out within an elective orthopaedic unit from April2010-August 2012. A total of 242 patients undergoing primary TKA for osteoarthritis were recruited and received standardised pre-operative education, multimodal analgesia, accelerated rehabilitation and were randomised using a simple unrestricted randomisation method to receive either Patient Controlled Epidural Analgesia (PCEA) or LIA. Primary outcome measure was the proportion of patients discharged from rehabilitation by day four. Statistical significance was set at p<o.o 1.
Results: Twenty patients were excluded due to failed spinal anaesthesia following randomisation, therefore 222 patients were included in the analysis (PCEA=109 & LIA=l13). The mean age was 67 (SD 8.1) and mean BMI 32(SD 6.1). No statistical difference was observed between the proportions of patients discharged from rehabilitation by day four, PCEA =77% and LIA=82% (p=O.33). Median hospital stay was four days for both groups(p=O.54). No difference was observed in post-operative catheterisation rates(p=O.16), pain scores (p=0.28), use of additional analgesia (p=O.55) or rates of ambulation on theatre day (p=O.013). No significant difference was recorded in the number of adverse events or complications between groupsup to one year following surgery (PCEA n=2 vs. LIA n= 6, p=O.281).
Conclusion: The work within this thesis has demonstrated that the two methods of perioperative analgesia investigated (PCEA and LIA) did not affect the attainment of rehabilitation discharge criteria following primary total knee arthroplasty as part of an Enhanced Recovery Programme. Both methods provided equitable analgesia, enabled early ambulation and progression of rehabilitation post-surgery. The method of peri-operative analgesia did not affect functional recovery or post-operative morbidity or mortality up to one year following surgery.
| Original language | English |
|---|---|
| Qualification | Ph.D. |
| Awarding Institution |
|
| Supervisors/Advisors |
|
| Publication status | Published - 2014 |