Total joint replacements

Research strategy for Enhanced Recovery after Surgery – Total Joint Replacements Copenhagen (ERAS-TJR)

Aim
To combine the evidence from studies investigating the efficacy of unimodal perioperative care-components to form and implement an enhanced, evidence-based, cross-continuum, recovery program after total joint replacements to benefit both patients and society.

Approach
The experimental approach is a 4-phased model with initial quantification of problem areas. The key findings from this phase have been: substantial knee-extension strength-deficits early after surgery that may or may not resolve over time – but relate to post-operative knee swelling – large variability in indication and regimen for outpatient rehabilitation, and that surgical as well as rehabilitation traditions and myths determine clinical practice more than evidence-based principles. This phase has been followed by a second phase, in which we have investigated the preliminary efficacy of various exercise and surgical modalities aimed at identified problem areas, or developed and validated technology, such as the elastic exercise band-technology (please see pmrc.dk/exercise-adherence/), aimed at identified problem areas. The key findings from this phase have been: no symptom exacerbation by early implementation of progressive resistance training, increased voluntary activation of the quadriceps muscle during fatiguing contractions shortly after surgery, and validated technology that can objectively monitor adherence to home-based exercise.     

Currently, the strategy has a strong focus on phase-three, large-scale exploratory or confirmatory studies, using prospective cohorte or randomized controlled trial-designs, respectively, to investigate the effectiveness or efficacy of e.g. various anesthesia and analgesia, different drugs to reduce the surgical stress response, different surgical procedures and perioperative principles, as well as different postoperative exercise therapy-modalities in multi-center, cross-continuum, collaboration with the municipalities around the Copenhagen area. Efforts towards national implementation will follow in phase four.   

Collaborators
The research strategy involves ongoing collaboration with frontline research groups and programs, including: The Lundbeck Foundation Centre for Fast-Track Hip and Knee Replacements, Copenhagen, Denmark, Clinical Orthopedic Research Hvidovre, Copenhagen (CORH), Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen, Research Unit, Center for Elective Surgery, Silkeborg, Denmark, Research Unit for General Practice in Aalborg, Aalborg University, Denmark, 
Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland New Zealand, and the municipalities Hvidovre, Brøndby, and Copenhagen.  

Selected papers
Harsten A, Bandholm T, Kehlet H, Toksvig-Larsen S (2015). Tourniquet versus no tourniquet on knee-extension strength early after fast-track total knee arthroplasty; a randomized controlled trial. Knee 22: 126-130.     

Jans Ø, Bandholm T, Kurbegovic S, Solgaard S, Kjaersgaard-Andersen P, Johansson PI, Kehlet H, Lundbeck Foundation Centre for Fast-Track Hip and Knee Replacement Collaborative Group (2016). Postoperative anemia and early functional outcomes after fast-track hip arthroplasty: a prospective cohort study. Transfusion 56: 917-925.

Bandholm & Kehlet (2012). Physiotherapy exercise after fast-track total hip and knee arthroplasty: time for reconsideration? Arch Phys Med Rehabil 93: 1292-1294.

Jakobsen TL, Kehlet H, Husted H, Petersen J, Bandholm T (2014). Early progressive strength training to enhance recovery after fast-track total knee arthroplasty: a randomized controlled trial. Arthritis Care Res (Hoboken) 66: 1856-1866.

Kehlet H (2013). Fast-track hip and knee arthroplasty. Lancet 381: 1600-1602. 

Bandholm T, Thorborg K, Lunn TH, Kehlet H, Jakobsen TL (2014). Knee pain during strength training shortly following fast-track total knee arthroplasty: a cross-sectional study. PLoS One 9: e91107.

Mikkelsen LR, Mechlenburg I, Søballe K, Jørgensen LB, Mikkelsen S, Bandholm T, Petersen AK (2014). Effect of early supervised progressive resistance training compared to unsupervised home-based exercise after fast-track total hip replacement applied to patients with preoperative functional limitations. A single-blinded randomised controlled trial. Osteoarthritis Cartilage 22: 2051-2058.  

Examples of ongoing research under ERAS-TJR
Quadriceps exercise before total knee arthroplasty (The QUADX-1 trial), trial registration: NCT02931058
Pragmatic home-based exercise after total hip arthroplasty – Silkeborg 1, (The PHETAS-1 trial), pending trial registration

 

 


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