We read with interest the article published by Anderson et al. [1] proposing a fast-track approach to hip and knee arthroplasty based on multimodal peri-operative pain management to include intra-articular injections of  large doses of local anaesthetics (340 mg of ropivacaine). The authors based their approach on a variance of the pathway proposed by Kern and Kahan requiring the implantation of an intra-articular catheter and a re-injection of local anesthetic within 24 h following surgery [2]. Although the approach is interesting and does not require the implantation of an intra-articular catheter and a re-injection of local anaesthetic (less risk for infection), the authors did not provide convincing evidence that the proposed technique is really effective. Thus, the use of this technique was associated with a high percentage of patients experiencing severe pain during physical therapy on postoperative days 1 and 2 as indicated in figure 3 and 5 (45% and 25% for hip and 50% and 35% for knee).  In our experience only 26% of patients undergoing hip arthroplasty complained of pain of 60 or higher during physical therapy. Improvement in the surgical technique and the introduction of specific anaesthetics and peri-operative pain protocols by orthopaedic anaesthesiologists have led to a quicker recovery and discharge home from the hospital of patients undergoing hip and knee arthroplasty within  24 h or less [3-9] (not 2.5 days as described by Anderson et al). Such an approach requires significant resources from the hospital patient education, a dedicated ward, increased access to physical therapists etc. and teams working closely together (surgical, anaesthesiologist/acute peri-operative pain, nursing, physical therapist and even pharmacy) to allow an immediate recovery of the patient and 2 or 3 active physical therapy sessions per day including the day of surgery. Fast tracking also required an attentive selection of patients. The most likely patients to benefit from fast tracking are those who are young, fit, ASA 1 or 2 who benefit from a short surgical time and limited blood loss and an effective perioperative pain control [9]. Our approach as well of those who have achieved these results has been based on the use of regional anaesthesia as a part of a multimodal approach to pain management.

In conclusion, in the absence of objective evidence of the role that local infiltration as a part of a multimodal approach may facilitate the fast tracking of patients undergoing hip and knee arthroplasty, it seems that the use of regional anaesthesia remains the technique of choice for fast tracking patients undergoing hip and knee arthroplasty.

USA

References

1.  Andersen LO, Gaarn-Larsen L, Kristensen BB, Hudted K, Otte KS, Kehlet H. Subacte pain and function after fast-track hip and knee arthroplasty. Anaesthesia 2009; 64: 508-13.

2.  Kern DR, Kahan L. Local infiltration analgesia: a technique for the control of acute postoperative pain follwing knee and hip surgery: a case study of 325 patients. Acta Orthpeadica 2008; 79: 174-83.

3.  Mears DC. Development of a two incision minimally invasive total hip replacement. J Bone Joint Surg Am 2003; 85A: 2238-40.

4.  Berger RA, Jacobs JJ, Meneghini RM, Della Valle C, Paprosky W, Rosenberg AG. Rapid rehabilitation and recovery with minimal invasive total hip arthroplasty. Clin Orthop Relat Res 2004; 429: 239–47.

5.  Berger RA, Sanders S, Gerlinger T, Della Valle C, Jacobs JJ, Rosenberg AG. Outpatient total knee arthroplasty with a minimally invasive technique. J Arthroplasty 2005; 20: 33-8.

6.  Chelly JE, Ben-David B, Joshi R, et al. Minimally invasive total hip replacement as an ambulatory procedure. Int Anesth Clinics 2005; 43: 161-5.

7.  Buvanendran A, Tuman KJ, McCoy DD, Matusic B, Chelly JE. Anesthetic techniques for minimally invasive total knee arthroplasty. J Knee Surg 2006; 19: 133-6.

8.  Ilfeld BM, Gearen PF, Enneking FK, et al. Total knee arthroplasty as an overnight stay procedure using continuous femoral nerve blocks at home: A prospective feasibility study. Anesth Analg 2006; 102: 87–90.

9.  Mears DC, Mears SC, Chelly JE, Dai F, Vulakovich KL. THA with a minimally invasive technique, multi-modal anesthesia, and home rehabilitation: Factors associated with early discharge? Clin Orthop Relat Res 2009; 467: 1412-7.