Hip replacement revision surgery: minmally invasive techniques and a faster recovery with the fast track protocol

Dr. Caldarella explains:

“The objectives of our FAST TRACK protocol are:

• REDUCTION of the surgery preparation time, concentrating all exams in a half-day of pre-hospitalization;
• AVOIDING of bladder catheter and the enema, thanks to advanced anesthetic techniques;
• ACCELERATION of surgery, thanks to the use of IT tools for preoperative planning;
• USE of tissue-saving techniques (so-called "minimally invasive" techniques);
• AVOIDANCE of donor blood transfusions and use of drainages thanks to dedicated surgical and anesthetic techniques;
• REDUCTION of postoperative pain thanks to the use of postoperative locoregional anesthesia methods;
• IMMEDIATE MOBILIZATION of the patient, who can start walking the same day, reducing post-operative immobilization to a few hours;
• AVOIDING elastic stockings, heparin injections and cutaneous stitches in favor of pharmacological approaches based on medical glue that do not require removal;
• REDUCTION of admission time, making patient eligible for discharge in 72 hours after surgery (3 nights of hospitalization);
• SIMULTANEOUS BILATERAL PROCEDURES when indicated.

These results, unthinkable by applying the classic admission protocols, are possible thanks to the capillary organization of work, adequate patient information and training, and the rigorous application of appropriate surgical, rehabilitative and anesthetic techniques.”

“If suitable for the Fast Track protocol, a patient is recruited and informed on the objectives that must be shared by him and his family. The patient will be able to begin a preoperative physiotherapy, in order to prepare properly for the surgery. A family 'caregiver' will be trained for helping the patient along his path,” explains Dr. Caldarella.

Explains Dr. Marco Antonio Fondi, anesthetist of the team:

“The goal is to obtain an optimal intraoperative anesthesia condition and a quick recovery at the same time. In the best case, patient can be mobilized, subjected to physiotherapy, sitting in an armchair and fed orally in 6 hours after the surgery.

Overall, the anesthetic technique provides for a subarachnoid spinal anesthesia, accompanied by more or less deep sedation depending on patient's request, associated with intra- and postoperative multimodal analgesia (i.e. the use of different types and classes of analgesic drugs in combination), and finally associated with mainly sensory postoperative analgesic nerve blocks performed at the end of the operation.”

What is subarachnoid spinal anesthesia

“Subarachnoid spinal anesthesia is a simple, safe and effective technique, which produces complete and profound insensitivity of the lower limbs and excellent surgical conditions. Compared to general anesthesia, spinal anesthesia offers some important advantages, such as:

• reduction of the duration of an intervention;
• reduction of intraoperative bleeding and need for transfusions;
• a reduced probability of deep vein thrombosis;
• better control of early postoperative pain.

For all these reasons, subarachnoid spinal anesthesia is the anesthesia of choice over general anesthesia,” explains Dr. Fondi.

"To reduce time of the surgery, it is important to have preoperative planning with IT tools which allow to carry out entire preliminary phase before the operation itself. Proper planning aims to:

• predetermine the correct reconstruction of joint relationships, offset and length of the limbs in the hip;
• predetermine the extent of bone resections in the knee and the reconstruction of the limb load axes.

Furthermore, a correct planning allows to choose type and size of an implant before starting the procedure.”

Use of minimally invasive implants and tissue saving techniques

"Whenever possible, use of minimally invasive implants will be privileged, that is:

• short stem prosthesis in the hip;
• unicompartmental prostheses of the knee, which significantly reduce surgical invasiveness.

Techniques aimed at tissue saving and functional optimization will be used, in particular:

• minimally invasive access routes to the hip that respect the musculature (such as the anterior or posterolateral route);
• kinematic alignment techniques of the knee that speed up recovery and reduce feeling of instability".

Bleeding is reduced by accelerating a surgery and carrying out some specific techniques:

• the femur first in the hip;
• avoidance of intramedullary alignment in the knee;
• use of local hemostatic agents.

The surgery is followed by an accurate reconstructive plasticization of the tissues, and the skin suture is performed with glue that do not require subsequent removal, thus avoiding the use of the classic stitches. When the patient is a candidate to carry out more than one surgery (for example right and left hip prostheses), thanks to the reduction of invasiveness of the single procedure, it is possible to proceed with both surgeries simultaneously, thus avoiding to subject a patient to a subsequent second admission”.

Thanks to the described anesthetic and surgical techniques, rehabilitation can begin immediately, explains Dr. Caldarella:

“As soon as the effect of spinal anesthesia ends a patient is invited to get up and take a few steps. Immediate mobilization has a beneficial effect on the body, stimulating the resumption of diuresis and intestinal motility, and reducing the risk of dizziness that can occur after a prolonged bed rest.

On the first day, the patient will be instructed on the basic techniques for recovering his/her personal autonomy (bed-chair movements, personal hygiene, moving around in the room, washing, walking with the walker).

On the second day, he/she is educated on the use of crutches and learn some rehabilitation exercises.

On the third day, he/she completes the rehabilitation exercise program and learns advanced autonomy recovery techniques (for example, walking up/down stairs). At this point the patient is ready for discharge.”

This protocol, although it is entirely applicable for the majority of patients, can also be adapted to each patient on the basis of their needs and general conditions. A fragile and elderly patient, for example, could greatly benefit from minimally invasive anesthetic techniques and reduced bed rest, but may not be eligible for a discharge in 72 hours after surgery. In this case, a more prolonged rehabilitation admission will be opted for.