Hoftealloplastik anno 2014 Hvor kom vi fra og hvor er vi nu?
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1 Hoftealloplastik anno 2014 Hvor kom vi fra og hvor er vi nu? Per Kjærsgaard-Andersen Overlæge, Sektorchef, Klinisk forskningslektor Section for Hip and Knee Replacement Vejle Hospital University of Southern Denmark DENMARK Per Kjaersgaard-Andersen Section for Hip and Knee Replacement
2 Hvor kom vi fra og hvor er vi nu? Vejle Sygehus en del af Sygehus Lillebælt Udviklingen fra 2000 til 2014 Resultater fra Dansk Hoftealloplastik Register Forløbet på Vejle Sygehus per 2014 Strategi ved valg af protese for den enkelte patient 6 weeks after THA surgery
3 Development of Accelerated Joint Replacement Programme at Vejle Hospital / Denmark Production 100 THA / 70 TKA 592 THA 573 TKA+UKR Surgeons 9 Senior surgeons all all doing TKR and THR (<20/year) 3½ THA surgeons 4½ TKA surgeons Beds Detailed patient programme and Standard treatment No Yes Average stay at hospital THA 11 days TKA 13 days THA 2 days TKA/UKR 1-3 days
4 Fast-Track Joint Replacement Programme at Vejle Hospital during
5 2002 Fast-Track Joint Replacement Programme in Denmark during
6 2007 Fast-Track Joint Replacement Programme in Denmark during
7 2014 Fast-Track Joint Replacement Programme in Denmark during
8 Fast-Track Joint Replacement Programme at Vejle Hospital during
9 Danmark delt i 5 regioner
10 Vejle Sygehus - en del af Sygehus Lillebælt
11 Incidensen af THA i Danmark
12 Total Hip Replacement Vejle Hospital Numbers Primary Revision Total Year
13 Antal Total Hoftealloplastik Region Syddanmark / %
14 Dansk Hoftealloplastik Register
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17 Offentlige versus Private Hospitaler Total Hoftealloplastik
18 Diagnose hos patienter der får indsat total hoftealloplastik
19 Fordeling kvinde / mand af THA i Danmark
20 Fordeling fiksations-type ved THA i Danmark
21 Størrelse af caput (kugle) ved THA i Danmark
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24 Overlevelse af THA Kvinder versus mænd / over og under 50 år
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26 Proteseoverlevelse ved patienter under 50 år
27 Proteseoverlevelse ved patienter år
28 Proteseoverlevelse ved patienter år
29 Proteseoverlevelse ved patienter over 75 år
30 Revisions Hoftealloplastik
31 Patient Seminar Rapid Recovery Programme Vejle Hospital 2014 Preoperative information by Consulting specialist Surgical procedure Anesthesiologist Anesthesia Pain treatment Physiotherapist Rehab programme
32 Slidgigt i højre hofteled Vejle Sygehus Ortopædkirurgisk Afdeling Ekstra knogle Øget knogletæthed Ledspalte Rask hofte
33 Protesekoncepter Under 70 år protese uden cement Over 70 år protese med cement Men altid en individuel vurdering Protesekonceptet besluttes ved det ambulante besøg Men kan i sjældne tilfælde ændres under operationen
34 Hofteskål
35 Exceed fra Biomet Standard hofteskål
36 Standard lårbensprotese Ucementeret Echo fra Biomet
37 Røntgen ucementeret
38 Standard lårbensprotese Cementeret Stanmore fra Biomet
39 Røntgen cementeret
40 Store hoveder ingen ledskred - ingen restriktioner
41 Udmåling før operation Vejle Sygehus Ortopædkirurgisk Afdeling Præcis udmåling før operation er vigtig Bunden af hofteskålen vurderes Størrelse og afskæring bestemmes
42 Lejring under operationvejle Sygehus Ortopædkirurgisk Afdeling Lejring er på raske side og bækkenet fikseres i lodret stilling Lejring vigtig for placering af hofteskålen
43 Kirurgisk adgang til hoften
44 Løs hofteprotese og udskiftningsprotese Vejle Sygehus Ortopædkirurgisk Afdeling
45 Hyppigste årsager til gen-operation of hofteprotesen Betændelse / Infektion Løsning af protesen i cementen / knoglen Kunstige hofteprotese glider / hopper ud af leddet Nedslidning af plastikdelen i hofteskålen Knoglebrud omkring hofteprotesen
46 Komplikationer Vejle Sygehus Ortopædkirurgisk Afdeling Smerter kvalme og opkast Ledskred af protesen (hofteluksationer) Forskellig benlængde efter operationen Infektion omkring hofteprotesen Blodpropper i benene Brud / revne i knoglen omkring protesen Nervebeskadigelse (Ischias-nerven)
47 Forsknings- og Udviklingsprojekter Forskningsaktiv afdeling Referencecenter Samarbejde med Lundbeckfonden
48 Fremtiden Vejle Sygehus Ortopædkirurgisk Afdeling
49 Joint Care Vejle Sygehus Ortopædkirurgisk Afdeling Tak for opmærksomheden
50 Several names Rapid Recovery ( RR ) Joint Care Fast-Track Accelerated patient treatment..
51 What is Rapid Recovery? A rehabilitation program with: Well organized patient pathway Information to patients & employes Education of patients & employes Pain management
52 Fast-Track Joint Replacement in Denmark during : Average waiting-time for THA/TKA was between 1-2 years 1999: Stay in hospital after surgery: days 1999: Stay in bed after surgery: 2-3 days National call for accelerated patient programs in more medical specialties to: Reduce waiting lists / increase production Earn money (DRG-reimbursement implemented) More effectively use of hospital beds
53 Fast-Track Joint Replacement Programme in Denmark during : Waiting-list for THA / TKA has disapered Challenges: You may have empty spots on OR tomorrow Politicians expect you to do other surgeries Patienst always expect surgery next day 2014: Stay in hospital after surgery average 2.3 / 2.5 days (THA / TKA) Challenges: Constant tuning of your team (nurse / phys / sec) for new activities Acceptance by patients and relatives when further reducing (quick in / quick out) High flow of patients with ultra-short stay = standardization of all procedures 2014: 98% mobilised on day of surgery / 82% within 3 hours Challenges: Team of anaesthesists Balanced pain programme Physiotherapist & nurses increased focus on mobilisation
54 Total Hip Replacement Vejle Hospital Numbers Primary Revision Total Year
55 Læge-teamet (Hofter) Vejle Sygehus Ortopædkirurgisk Afdeling Thomas Poulsen Overlæge Per Kjærsgaard- Andersen Sektorchef, overlæge Claus Varnum Afdelingslæge Christian Hofbauer Overlæge
56 Total Knee Replacement Vejle Hospital Numbers Uni Knee TKR Revision Total Joint Care Year Extra Surgeon
57 Læge-teamet (knæ) Bjørn Gottlieb Dan Blohm Poul Pedersen Thomas Lind-Hansen Per Wagner K. Overlæge Overlæge Overlæge Afdelingslæge Overlæge Knækirurg Knækirurg Knækirurg Knækirurg Knækirurg
58 Læge-teamet (knæ)
59 Accelerated Joint Replacement Programme 2014: Status and Benefits in Vejle Waiting lists for THA and TKA are gone Patients are mobilized on the day of surgery Patients are discharged to their home on day 1-3 Same or less number of complications Better THA / TKA-educated patients Higher percentage of satisfied patients Well-established expert-unit Several research projects established
60 Accelerated Joint Replacement Programme Key Issues during Why/Therefore RR history Clinical pathway Anesthesia - Patient seminar Pain treatment during and after surgery Surgical technique Patient Flow through the OR Rehabilitation Status and benefits Regularly survey of status and results
61 Development of Accelerated Joint Replacement Programme at Vejle Hospital What happened in between? Explanation please!
62 The Joint Care Story at Vejle Hospital... A team was created Doctors Nurses Anesthetist Physiotherapist Secretary Visited clinics (Biomet / Clearwater, FL, USA) Belgium (Stedelijk Ziekenhuis) Holland (Jeroen Bosch Hospital)
63 Rapid Recovery Programme Moving away from old standards Patients Used to stay long in clinics in DK small holiday Detailed informed in all procedure (Why, Rapid Recovery Programme, Experience) Key-issue: Pain, nausea, Patient Seminar Nurses Must believe in the programme education & information Must educate each other and take responsibility in new areas Physioterapists New trends, closer collaboration, more responsibility Personal at the OR Re-organisation of the personal, own anaesthesists and nurses
64 Accelerated Joint Replacement Programme Key Issues Why/Therefore RR history Clinical pathway - Patient seminar Anesthesia Pain treatment during and after surgery Surgical technique Patient Flow through the OR Rehabilitation Status and benefits Regularly survey of status and results
65 Rapid Recovery Programme Vejle Hospital 2014 Clinical pathway
66 Rapid Recovery programme Vejle Hospital 2014 Medical examination (outpatient clinic) Consulting specialist Referral General Practice Examination Date for surgery - surgeon Finalize all paper work Electronic Record Voice Recognition System
67 Rapid Recovery Programme Vejle Hospital 2014 Medical examination (outpatient clinic) Nurse Information about the Rapid Recovery Programme Leaflets Date for Patient Seminar Blood test, ECG, X-rays Evaluation by an anesthesiologist
68 Rapid Recovery Programme Vejle Hospital 2014 Clinical pathway
69 Patient Seminar Rapid Recovery Programme Vejle Hospital 2014 Every week - Next weeks patients - Coordinated by ward nurse 3 hours session
70 Patient Seminar Rapid Recovery Programme Vejle Hospital 2014 Patient education and motivation Detailed preoperative information High level of information The patients know what they can expect from the staff, and what the staff expect from the patients. The role of the patient has been changed from passive to active partner in the treatment plan.
71 Patient Seminar Rapid Recovery Programme Vejle Hospital 2014 Preoperative information by Consulting specialist Surgical procedure Anesthesiologist Anesthesia Pain treatment Physiotherapist Rehab programme
72 Patient Seminar Rapid Recovery Programme Vejle Hospital 2014 During hospitalization you are expected to Be mobilized on the day of surgery Frequent walks (even minor walks) Wear your own cloth Take all meals in the dining room Treatment in groups Team spirit - Friendly competition Social aspects
73 Rapid Recovery Programme Vejle Hospital 2014 Clinical pathway
74 Rapid Recovery Programme Vejle Hospital 2014 Planning of surgery Meeting every second week Participants All surgeons Ward nurses OR nurses Go through records and x-rays for difficult cases planned for next 2 weeks Decision about supplementary x-rays, examinations and choice of prosthesis Good planning Avoid cancellation S e c
75 Rapid Recovery Programme Vejle Hospital 2014 Clinical pathway
76 Rapid Recovery Programme Vejle Hospital 2014 Hospitalization Admission at the day of surgery 3-4 Total Joints in each OR
77 Rapid Recovery Programme Vejle Hospital 2014 Hospitalization Recovery room for only 1-2 hours Mobilization on the day of surgery
78 Rapid Recovery Programme Vejle Hospital 2014 Hospitalization Daily exercise Discharge day 0-3
79 Accelerated Joint Replacement Programme Key Issues Why/Therefore RR history Clinical pathway - Patient seminar Anesthesia Pain treatment during and after surgery Surgical technique Patient Flow through the OR Rehabilitation Status and benefits Regularly survey of status and results
80 Development of pain treatment on TKA and THA at Vejle Hospital 2006 Lenght of stay 7 days Admission day before OR + Epidural catheter + Drain + Bladder catheter + Epidural pain treatment + Paracetamol mm 2014 Lenght of stay 1-3 dage Admission on day of OR No epidural catheter No drain No bladder catheter LIA intraoperative (TKA) NSAID + Paracetamol Gabapentine Morphine pn.
81 Pain Treatment in THA-patients at Vejle Hospital: Acetaminophene Ibuprophene Gabapentin Morfin iv. pn. Fentanyl iv. pn. Epidural Oxycontin (slow) Oxycodone (PCA) Morphine (PCA) FICB/Marcain sc Local Infiltrat Analgesia (during surgery) Keterolac (iv) Celebra Local Infusion Analgesia (after surgery)
82 Local infusion analgesia after surgery
83 Total hip replacement VAS/NRS-score pain at rest (mean) VAS/NRS Preopr. Day 0 Day 1 Day 2 Discharge 6 weeks
84 Total hip replacement VAS/NRS-score pain at mobilization (mean) VAS/NRS Preopr. Day 0 Day 1 Day 2 Discharge 6 weeks
85 The Lundbeck Programme 2014 pain treatment for TKA & THA Pre-operative Acetaminophene 2 g Celecoxib 400 mg Gabapentin 600 mg* Lansoprazole 30 mg *only 300 mg if patient <50 kg, >65 years old or has a Kidney disease
86 The Lundbeck Programme 2014 pain treatment for TKA & THA Peri-operative and PACU THA Spinal: 0.5% 9,0-12,5mg Bupivacaine plain Propofol 1-5 mg/kg/hour TKA Spinal: 0.5% 7,5-9,0 mg Bupivacaine hyperbar Propofol 1-5 mg/kg/hour LIA (Local Infiltration Analgesia) PACU (Post Anaesthesia Care Unit): Caps. Oxycodone I/V Fentanyl
87 The Lundbeck Programme 2014 pain treatment for TKA & THA Post-operative Tablets: Acetaminophene 1 g x 4 Celecoxib 200 mg x 2 (after discharge: sep. Celecoxib) Ibuprophene 400 mg x 4 Lansoprazole 30 mg x 1 Gabapentin (on day of surgery) 300 mg (at 10 pm) Gabapentin (from day 1) 300 mg at 8 am, 600* mg 10pm (Oxycodone/Morphine (as PCA)) 5 mg/10 mg *only 300 mg if <50 kg, >65 years old or Kidney disease After day 7: Acetaminophene 1 g x 4 Ibuprophene 400 mg x 4 Lansoprazole 30 mg x 1
88 Accelerated Joint Replacement Programme Key Issues Why/Therefore RR history Clinical pathway - Patient seminar Anesthesia Pain treatment during and after surgery Surgical technique Patient Flow through the OR Rehabilitation Status and benefits Regularly survey of status and results
89 Surgical technique Small skin incisions (8-10 cm) Continuous suturing of the deep fascia with a double loop suture No drains in the wound
90 Accelerated Joint Replacement Programme Key Issues Why/Therefore RR history Clinical pathway - Patient seminar Anesthesia Pain treatment during and after surgery Surgical technique Patient Flow through the OR Rehabilitation Status and benefits Regularly survey of status and results
91 Rehabilitation Mobilized on the day of surgery Fully mobilized the day after surgery Discharge criteria Walking on crutches In and out of bed Restroom Bath and dressing Exercise programme
92 Mobilized on the day of surgery Hip Knee
93 Fast-Track: vs
94 Lundbeck Foundation Rapid Recovery Joint Replacement Research Programme 6 MIE Euro
95 Projektsygeplejersker Jane Charlotte Susanne Henriette Susanne
96 DVT / LE after THA in Rapid Recovery Prophylaxis only during the stay in hospital (2-3 days)
97 DVT / LE after THA in Rapid Recovery
98 DVT / LE after THA in Rapid Recovery
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100
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103 Accelerated Joint Replacement Programme Key Issues Why/Therefore RR history Clinical pathway - Patient seminar Anesthesia Pain treatment during and after surgery Surgical technique Patient Flow through the OR Rehabilitation Status and benefits Regularly survey of status and results
104 Patient Benefits Comprehensive education Streamlined phases of care Less anxious during stay in hospital Involvement and education of the family Earlier return to home Faster return to desired activities or normality Better outcomes and less complications
105 Team Benefits Optimised pre-admission Less cancellations Easier / more informed consent Improved patient education Improved pain management Standardised treatment pathways
106 Key Issues TEAM SPIRIT Why/Therefore RR history Clinical pathway -Patient seminar Anesthesia Pain treatment during and after surgery Surgical technique Patient Flow through the OR Rehabilitation Status and benefits Regularly survey of status and results
107 European in-difference THA fixation / bearings
108 Rapid Recovery after THA - European in-difference
109 Thank you for your attention
110 Fast-Track Joint Replacement in Denmark Overall impact in Denmark Impact at Vejle Hospital Key topics during the period Research in Fast-Track Questions
111 Total Hip Replacement Vejle Hospital Numbers Primary Revision Total Year
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