Quality of recovery after total hip and knee arthroplasty in South Africa: a national prospective observational cohort study

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Quality of recovery after total hip and knee arthroplasty in South Africa: a national prospective observational cohort study


JournalBMC Musculoskeletal Disorders
Article typeJournal research article – Clinical research
Publication date – Nov – 2020
Authors – Ulla Plenge, Romy Parker, Shamiela Davids, Gareth L. Davies, Zahnne Fullerton, Lindsay Gray, Penelope Groenewald, Refqah Isaacs, Ntambue Kauta, Frederik M. Louw, Andile Mazibuko, David M. North, Marc Nortje, Glen M. Nunes, Neo Pebane, Chantal Rajah, John Roos, Paul Ryan, Winlecia V. September, Heidi Shanahan, Ruth E. Siebritz, Rian W. Smit, Simon Sombili, Alexandra Torborg, Johan F. van der Merwe, Nico van der Westhuizen & Bruce Biccard
KeywordsDAH30, Enhanced recovery protocols, Low-and middle-income countries, Perioperative arthroplasty practice, Quality of recovery, South Africa, Total hip arthroplasty, Total knee arthroplasty
Open access – Yes
SpecialityTrauma and orthopaedic surgery
World region Southern Africa
Country: South Africa
Language – English
Submitted to the One Surgery Index on November 26, 2020 at 8:03 pm
Abstract:

Background
Encouraged by the widespread adoption of enhanced recovery protocols (ERPs) for elective total hip and knee arthroplasty (THA/TKA) in high-income countries, our nationwide multidisciplinary research group first performed a Delphi study to establish the framework for a unified ERP for THA/TKA in South Africa. The objectives of this second phase of changing practice were to document quality of patient recovery, record patient characteristics and audit standard perioperative practice.

Methods
From May to December 2018, nine South African public hospitals conducted a 10-week prospective observational study of patients undergoing THA/TKA. The primary outcome was ‘days alive and at home up to 30 days after surgery’ (DAH30) as a patient-centred measure of quality of recovery incorporating early death, hospital length of stay (LOS), discharge destination and readmission during the first 30 days after surgery. Preoperative patient characteristics and perioperative care were documented to audit practice.

Results
Twenty-one (10.1%) out of 207 enrolled patients had their surgery cancelled or postponed resulting in 186 study patients. No fatalities were recorded, median LOS was 4 (inter-quartile-range (IQR), 3–5) days and 30-day readmission rate was 3.8%, leading to a median DAH30 of 26 (25–27) days. Forty patients (21.5%) had pre-existing anaemia and 24 (12.9%) were morbidly obese. In the preoperative period, standard care involved assessment in an optimisation clinic, multidisciplinary education and full-body antiseptic wash for 67 (36.2%), 74 (40.0%) and 55 (30.1%) patients, respectively. On the first postoperative day, out-of-bed mobilisation was achieved by 69 (38.1%) patients while multimodal analgesic regimens (paracetamol and Non-Steroid-Anti-Inflammatory-Drugs) were administered to 29 patients (16.0%).

Conclusion
Quality of recovery measured by a median DAH30 of 26 days justifies performance of THA/TKA in South African public hospitals. That said, perioperative practice, including optimisation of modifiable risk factors, lacked standardisation suggesting that quality of patient care and postoperative recovery may improve with implementation of ERP principles. Notwithstanding the limited resources available, we anticipate that a change of practice for THA/TKA is feasible if ‘buy-in’ from the involved multidisciplinary units is obtained in the next phase of our nationwide ERP initiative.

OSI Number – 20776

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