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
Hvor kom vi fra og hvor er vi nu? Vejle Sygehus en del af Sygehus Lillebælt - 2014 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
Development of Accelerated Joint Replacement Programme at Vejle Hospital / Denmark 2001 2013 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 31 21 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
Fast-Track Joint Replacement Programme at Vejle Hospital during 2002-2014
2002 Fast-Track Joint Replacement Programme in Denmark during 2002-2014
2007 Fast-Track Joint Replacement Programme in Denmark during 2002-2014
2014 Fast-Track Joint Replacement Programme in Denmark during 2002-2014
Fast-Track Joint Replacement Programme at Vejle Hospital during 2002-2014
Danmark delt i 5 regioner
Vejle Sygehus - en del af Sygehus Lillebælt
Incidensen af THA i Danmark 1995-2013
Total Hip Replacement Vejle Hospital 1998-2013 700 Numbers 600 500 400 300 200 Primary Revision Total 100 0 1998 2000 2002 2004 Year 2006 2008 2010 2012
Antal Total Hoftealloplastik Region Syddanmark 2013 492 785 2.490 / 10.988 23% 807 406
Dansk Hoftealloplastik Register
Offentlige versus Private Hospitaler Total Hoftealloplastik
Diagnose hos patienter der får indsat total hoftealloplastik
Fordeling kvinde / mand af THA i Danmark 1995-2013
Fordeling fiksations-type ved THA i Danmark 1995-2013
Størrelse af caput (kugle) ved THA i Danmark 1995-2013
Overlevelse af THA Kvinder versus mænd / over og under 50 år
Proteseoverlevelse ved patienter under 50 år
Proteseoverlevelse ved patienter 50-60 år
Proteseoverlevelse ved patienter 60-75 år
Proteseoverlevelse ved patienter over 75 år
Revisions Hoftealloplastik
Patient Seminar Rapid Recovery Programme Vejle Hospital 2014 Preoperative information by Consulting specialist Surgical procedure Anesthesiologist Anesthesia Pain treatment Physiotherapist Rehab programme
Slidgigt i højre hofteled Vejle Sygehus Ortopædkirurgisk Afdeling Ekstra knogle Øget knogletæthed Ledspalte Rask hofte
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
Hofteskål
Exceed fra Biomet Standard hofteskål
Standard lårbensprotese Ucementeret Echo fra Biomet
Røntgen ucementeret
Standard lårbensprotese Cementeret Stanmore fra Biomet
Røntgen cementeret
Store hoveder ingen ledskred - ingen restriktioner
Udmåling før operation Vejle Sygehus Ortopædkirurgisk Afdeling Præcis udmåling før operation er vigtig Bunden af hofteskålen vurderes Størrelse og afskæring bestemmes
Lejring under operationvejle Sygehus Ortopædkirurgisk Afdeling Lejring er på raske side og bækkenet fikseres i lodret stilling Lejring vigtig for placering af hofteskålen
Kirurgisk adgang til hoften
Løs hofteprotese og udskiftningsprotese Vejle Sygehus Ortopædkirurgisk Afdeling
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
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)
Forsknings- og Udviklingsprojekter Forskningsaktiv afdeling Referencecenter Samarbejde med Lundbeckfonden
Fremtiden Vejle Sygehus Ortopædkirurgisk Afdeling
Joint Care Vejle Sygehus Ortopædkirurgisk Afdeling Tak for opmærksomheden
Several names Rapid Recovery ( RR ) Joint Care Fast-Track Accelerated patient treatment..
What is Rapid Recovery? A rehabilitation program with: Well organized patient pathway Information to patients & employes Education of patients & employes Pain management
Fast-Track Joint Replacement in Denmark during 1999-2014 1999: Average waiting-time for THA/TKA was between 1-2 years 1999: Stay in hospital after surgery: 10-14 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
Fast-Track Joint Replacement Programme in Denmark during 1999-2014 2014: 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
Total Hip Replacement Vejle Hospital 1998-2013 700 Numbers 600 500 400 300 200 Primary Revision Total 100 0 1998 2000 2002 2004 Year 2006 2008 2010 2012
Læge-teamet (Hofter) Vejle Sygehus Ortopædkirurgisk Afdeling Thomas Poulsen Overlæge Per Kjærsgaard- Andersen Sektorchef, overlæge Claus Varnum Afdelingslæge Christian Hofbauer Overlæge
Total Knee Replacement Vejle Hospital 2001-2013 Numbers 700 600 500 400 300 200 Uni Knee TKR Revision Total 100 0 2001 2002 Joint Care 2003 2004 2005 2006 2007 2008 Year Extra Surgeon 2009 2010 2011 2012 2013
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
Læge-teamet (knæ)
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
Accelerated Joint Replacement Programme Key Issues during 2001-2014 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
Development of Accelerated Joint Replacement Programme at Vejle Hospital What happened in between? Explanation please!
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)
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
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
Rapid Recovery Programme Vejle Hospital 2014 Clinical pathway
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
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
Rapid Recovery Programme Vejle Hospital 2014 Clinical pathway
Patient Seminar Rapid Recovery Programme Vejle Hospital 2014 Every week - Next weeks patients - Coordinated by ward nurse 3 hours session
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.
Patient Seminar Rapid Recovery Programme Vejle Hospital 2014 Preoperative information by Consulting specialist Surgical procedure Anesthesiologist Anesthesia Pain treatment Physiotherapist Rehab programme
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
Rapid Recovery Programme Vejle Hospital 2014 Clinical pathway
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
Rapid Recovery Programme Vejle Hospital 2014 Clinical pathway
Rapid Recovery Programme Vejle Hospital 2014 Hospitalization Admission at the day of surgery 3-4 Total Joints in each OR
Rapid Recovery Programme Vejle Hospital 2014 Hospitalization Recovery room for only 1-2 hours Mobilization on the day of surgery
Rapid Recovery Programme Vejle Hospital 2014 Hospitalization Daily exercise Discharge day 0-3
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
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.
Pain Treatment in THA-patients at Vejle Hospital: 2002-2014 Acetaminophene 2002-03 2004 2005 2006 2007 2008 2009-11 2012-13 2014 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)
Local infusion analgesia after surgery
Total hip replacement VAS/NRS-score pain at rest (mean) VAS/NRS 10 9 8 7 6 5 4 3 2 1 0 2006 2010 2011 2013 Preopr. Day 0 Day 1 Day 2 Discharge 6 weeks
Total hip replacement VAS/NRS-score pain at mobilization (mean) VAS/NRS 10 9 8 7 6 5 4 3 2 1 0 2006 2010 2011 2013 Preopr. Day 0 Day 1 Day 2 Discharge 6 weeks
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
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
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
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
Surgical technique Small skin incisions (8-10 cm) Continuous suturing of the deep fascia with a double loop suture No drains in the wound
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
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
Mobilized on the day of surgery 100 90 80 70 60 50 40 30 20 10 0 95 98 92 95 96 95 97 88 64 58 2006 2008 2010 2011 2013 Hip Knee
Fast-Track: 2002-2005 vs 2006-2008
Lundbeck Foundation Rapid Recovery Joint Replacement Research Programme 6 MIE Euro 2010-2015
Projektsygeplejersker Jane Charlotte Susanne Henriette Susanne
DVT / LE after THA in Rapid Recovery Prophylaxis only during the stay in hospital (2-3 days)
DVT / LE after THA in Rapid Recovery
DVT / LE after THA in Rapid Recovery
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
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
Team Benefits Optimised pre-admission Less cancellations Easier / more informed consent Improved patient education Improved pain management Standardised treatment pathways
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
European in-difference THA fixation / bearings
Rapid Recovery after THA - European in-difference
Thank you for your attention
Fast-Track Joint Replacement in Denmark Overall impact in Denmark Impact at Vejle Hospital Key topics during the period Research in Fast-Track Questions
Total Hip Replacement Vejle Hospital 1998-2013 700 Numbers 600 500 400 300 200 Primary Revision Total 100 0 1998 2000 2002 2004 Year 2006 2008 2010 2012