[Influence of Enhanced Recovery Regime on Early Outcomes of Total Knee Arthroplasty]

PURPOSE OF THE STUDY Our study compared early outcomes of total knee arthroplasty performed in conventional and enhanced perioperative care regimes, i.e. without the use of Redon drain, with intensified perioperative analgesia and more frequent and intensive rehabilitation regime in the latter. MATERIAL AND METHODS The prospective study included 194 patients (76 men and 118 women) implanted with primary knee endoprosthesis. The mean age was 68.8 (44.7 - 88.0 years). The patients were divided into two groups - the "enhanced" and "conventional" procedures. In the first group, Redon suction drain was not inserted at the end of the surgery, and the patients commenced passive knee mobility exercise of the operated knee immediately after being brought back from the operating theatre. The general anaesthesia was supplemented by a combined femoral nerve block and wound infiltration with local anaesthetics. The second group comprised the patients who underwent conventional surgery, i.e. with the use of drain, without femoral nerve block, with no wound infiltration with local anaesthetics, and without immediate post-operative mobilization of the joint. The evaluation was carried out using regular clinical tools (subjective evaluation, objective examination, questionnaire and Knee Society Score (KSS)). Standard statistical methods were applied to data processing. RESULTS The patients under the "conventional regime" showed a significantly sharper drop in haemoglobin and haematocrit levels, higher consumption of blood transfusion and analgesics during the first three days after the surgery. The patients under the "enhanced regime" showed a better range of joint motion at hospital discharge, flexion in particular (p = 0.001). During the hospital stay no frequent swelling, secretion or wound reddening was reported in any of the monitored groups. In the "conventional" group, however, haematomas were more frequently present. The postoperative checks did not reveal any differences in satisfaction of the patients with the surgery. At the first follow-up examination at the outpatient department the "conventional" group patients more often reported knee pain and a feeling of a swollen knee. Nonetheless, their statements did not correspond with the VAS score. In the period between the 6th and 12th months following the surgery, the differences in the range of motion disappeared. The KSS showed a noticeable improvement in both the groups as against the preoperative values. In the "enhanced" group patients, the score increased dramatically at the beginning, whereas in the "conventional" group, the score was growing slowly and gradually until the last follow-up check after the surgery. The "conventional" group patients more frequently reported infectious complications (surface and deep wound infections: 4 vs. 2 patients) requiring a revision surgery (p = 0.024). DISCUSSION Recently, attention has been drawn to the rapid recovery approach, which eliminated postoperative immobilization and enabled the patient to start exercising already on the day of the surgery, with some patients even walking independently. The individual enhanced recovery regimes differ in details but mostly result in achieving the aim much sooner when compared to the conventional approaches. The patients under the enhanced recovery regimes can accomplish better functional outcomes in the first few months after the surgery than the patients undergoing the surgery under the conventional regime. The routine use of Redon drains in TKA is obviously unnecessary; it tends to be associated with a higher blood loss and a higher risk of prosthetic joint infection. CONCLUSIONS The TKA implant without suction drains combined with intensified perioperative analgesia and intensive postoperative rehabilitation is a safe way to earlier recovery of the function of the operated knee, or, by extension, the lower limb. The described approach is not associated with a higher risk of perioperative complications (bleeding, healing disorders or early infections). Patients also benefit from lower blood losses. Based on the results of our study, we recommend performing the TKA surgeries routinely without drains, with perioperative analgesia and immediate postoperative joint mobilization. Key words: total knee arthroplasty; perioperative care; rapid recovery; drainage; active movement; postoperative outcomes; pain; infection.