Fast Track Protocols and Early Rehabilitation after Surgery in Total Hip Arthroplasty: A Narrative Review.

The Enhanced Recovery After Surgery (ERAS) or Fast Track is defined as a multi-disciplinary, peri- and post-operative approach finalized to reduce surgical stress and simplify post-operative recovery. It has been introduced more than 20 years ago by Khelet to improve outcomes in general surgery. Fast Track is adapted to the patient's condition and improves traditional rehabilitation methods using evidence-based practices. Fast Track programs have been introduced into total hip arthroplasty (THA) surgery, with a reduction in post-operative length of stay, shorter convalescence, and rapid functional recovery without increased morbidity and mortality. We have divided Fast Track into three cores: pre-, intra-, and post-operative. For the first, we analyzed the standards of patient selection, for the second the anesthesiologic and intraoperative protocols, for the third the possible complications and the appropriate postoperative management. This narrative review aims to present the current status of THA Fast Track surgery research, implementation, and perspectives for further improvements. By implementing the ERAS protocol in the THA setting, an increase in patient satisfaction can be obtained while retaining safety and improving clinical outcomes.

Prospective Prognostic Cohort Study of Pressure Injuries in Older Adult Patients with Hip Fractures.

OBJECTIVE: The aim of this study was to assess the rate of pressure injury and real predictors thereof in the older adult population with hip fractures in an orthopedic hospital. METHODS: In this prospective prognostic cohort study, all patients admitted with fragility hip fractures were monitored over a 12-month period. On a daily basis, ward nurses and physiotherapists assessed the condition of the patients' skin and collected data about all the predictors connected to their healthcare and hospital organization until the patients were discharged from hospital or until the onset of pressure injury. RESULTS: From October 1, 2013, to September 30, 2014, 467 older adult patients with fragility fractures were enrolled in the study. Of these, 27% (n = 127) developed a pressure injury. Multivariate analysis identified the following predictive factors: age older than 81 years, type of surgery, and placing the limb in a foam rubber splint. No other factor connected to the patient or medical, nursing, or rehabilitation treatment was significantly correlated to the onset of pressure injury, even when the univariate analysis showed some of them were possible predictors. CONCLUSIONS: Pressure injury in older adults with hip fractures is a relatively common complication, especially in high-risk patients or following certain treatments. These potential indicators could help provide safe and targeted care by preemptively identifying patients at highest risk of pressure injury.

Effectiveness of using a new polyurethane foam multi-layer dressing in the sacral area to prevent the onset of pressure ulcer in the elderly with hip fractures: A pragmatic randomised controlled trial.

Hip fractures in the elderly are a serious problem for the health service due to the high rate of complications. One of these complications is pressure ulcers that, according to the literature, occur in 8.8% to 55% of patients and mainly arise in the sacral area. The present randomised controlled trial tests whether applying a new innovative multi-layer polyurethane foam dressing (ALLEVYN LIFE™), reduces the onset of pressure ulcers in the sacral area. From March to December 2016, 359 fragility hip fracture patients were randomly divided into 2 groups: 182 in the control group and 177 in the experimental group. Pressure ulcers occurred overall in 36 patients (10%): 8 patients (4.5%) in the experimental group compared to 28 (15.4%) in the control group: P = 0.001, relative risk 0.29 (95% CI 0.14-0.61) with NNT of 9 (95% CI 6-21). In the experimental group the onset of pressure ulcers occurred on average on the 6th day compared to the 4th day in the control group (HR 4.4). Using polyurethane foam is effective at reducing the rate of pressure ulcers in the sacrum in elderly patients with hip fracture. The adhesiveness of this device also enables costs to be kept down.

[Effectiveness of the transparent sterile dressing vs standard to fix the peripheral venous catheter (PVC) on the incidence of phlebitis. A randomized controlled trial]. / Efficacia della medicazione sterile trasparente rispetto a quella standard per il fissaggio del catetere venoso periferico (CVP) sull'incidenza delle flebiti.Trial randomizzato e controllato.

UNLABELLED: Effectiveness of the transparent sterile dressing vs standard to fix the peripheral venous catheter (PVC), on the incidence of phlebitis. A randomized controlled trial. INTRODUCTION: The type of dressing could contribute to the incidence of phlebitis, infiltration and accidental removals but the results of the studies are contrasting and samples are limited. AIM: To compare the effectiveness of a transparent polyurethane sterile dressing on the rate of phlebitis associated to peripheral venous catheter (PVC) vs a non sterile sticking plaster in use in current practice (standard dressing). DESIGN: Randomized controlled trial. Participants. 1061 PVCs (703 patients, adults and children) at a research orthopedic hospital in the north of Italy; 540 PVCs allocated to receive the sterile and 521 the standard dressing. RESULTS: 96 PVCs were excluded for phlebitis, 48 (9.6%) in the sterile and 48 (10.1%) in the standard dressing group, RR 0.96 (95%CI 0.697 - 1.335). Accidental removal of the PVCs was more frequent with the sterile dressing (9.6% vs 6.3%) but the number of catheters removed without complications was larger in the standard dressing group (48.9% vs 54.9% P=0.0503). Eighty-five PVCs were replaced for detachment of the dressing (50, 9.2% sterile and 35, 6.7% standard dressing). The cheapest transparent sterile dressing costs 32 cents while the standard 9 cents. CONCLUSIONS: A sticking non sterile plasters is not influential on the rate of phlebitis and ensures an good fix of the PVC compared the transparent sterile dressing to of polyurethane film.

[Cohort study of peripheral catheter related complications and identification of predictive factors in a population of orthopedic patients]. / Studio di coorte sulla popolazione ortopedica delle complicanze correlate all'utilizzo del catetere venoso periferico e identificazione dei fattori predittivi.

INTRODUCTION: Peripheral venous catheters (PVC) may cause complications, specifically local. Their management varies across health care workers and wards, and guidelines recommendations are often weak and based on experts' opinion. AIM: To measure the incidence of PVCs phlebitis, occlusions, accidental removal and infiltrations and their predictive factors in an orthopedic population. METHODS: From may 4 2009 to 30, in an orthopedic hospital, data on patients to whom a PVC was inserted were collected: patient's and PVC characteristics, management and securing strategies, until one of the following outcomes: phlebitis, occlusion, accidental removal, infiltration or end of treatment. RESULTS: Overall, 873 patients were recruited and 139 PVCs. The following complications occurred: phlebitis 10.9%; occlusions 16.8%; accidental removals 5.8%, local infiltrations 14.4%; 648 PVCs (46.5%) were removed without complications. The risk for all complications (multivariate analysis) increased with age and for the other complications also with the administration of blood transfusions thorough PVC, irritant drugs and use >3 times/day for phlebitis; small gauge, not using PVC and surgical site infections for occlusions; positioning the PVC in the hand and fixing the PVC with the Chevron method for accidental removals; and female sex, transfusions and thromboembolic therapy for infiltrations. CONCLUSIONS: The incidence of phlebitis is high compared to the gold standard of 5%. Knowing the incidence of main complications is a requirement for any improvement strategy and may favor the abandonment of useless or dangerous practices.