Abstract:
BACKGROUND: Encouraged by the widespread adoption of enhanced recovery protocols (ERPs) for elective total hip
and knee arthroplasty (THA/TKA) in high-income countries, our nationwide multidisciplinary research group first
performed a Delphi study to establish the framework for a unified ERP for THA/TKA in South Africa. The objectives
of this second phase of changing practice were to document quality of patient recovery, record patient
characteristics and audit standard perioperative practice.
METHODS: From May to December 2018, nine South African public hospitals conducted a 10-week prospective
observational study of patients undergoing THA/TKA. The primary outcome was ‘days alive and at home up to 30
days after surgery’ (DAH30) as a patient-centred measure of quality of recovery incorporating early death, hospital
length of stay (LOS), discharge destination and readmission during the first 30 days after surgery. Preoperative
patient characteristics and perioperative care were documented to audit practice.
RESULTS: Twenty-one (10.1%) out of 207 enrolled patients had their surgery cancelled or postponed resulting in 186 study
patients. No fatalities were recorded, median LOS was 4 (inter-quartile-range (IQR), 3–5) days and 30-day readmission rate
was 3.8%, leading to a median DAH30 of 26 (25–27) days. Forty patients (21.5%) had pre-existing anaemia and 24 (12.9%)
were morbidly obese. In the preoperative period, standard care involved assessment in an optimisation clinic,
multidisciplinary education and full-body antiseptic wash for 67 (36.2%), 74 (40.0%) and 55 (30.1%) patients, respectively.
On the first postoperative day, out-of-bed mobilisation was achieved by 69 (38.1%) patients while multimodal analgesic
regimens (paracetamol and Non-Steroid-Anti-Inflammatory-Drugs) were administered to 29 patients (16.0%).
CONCLUSION: Quality of recovery measured by a median DAH30 of 26 days justifies performance of THA/TKA in South
African public hospitals. That said, perioperative practice, including optimisation of modifiable risk factors, lacked
standardisation suggesting that quality of patient care and postoperative recovery may improve with implementation of
ERP principles. Notwithstanding the limited resources available, we anticipate that a change of practice for THA/TKA is
feasible if ‘buy-in’ from the involved multidisciplinary units is obtained in the next phase of our nationwide ERP initiative.
