Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are among the most successful proce-
dures performed in terms of quality-of-life years gained. The long-term goals of arthroplasty, to relieve
pain, increase function, provide stability, and obtain durability, are accomplished in the vast majority of
cases. The short-term goals, however, have become the target of aggressive peri-operative programs that aim
to speed recovery, reduce morbidity and complications, and create a program of efficiency while maintain-
ing the highest level of patient care. The concept of rapid recovery is built upon the burgeoning interest in
less-invasive and small-incision surgeries for (THA and TKA). However, the incision size does not appear to
be the most critical aspect of the program. This article outlines the specific elements of the rapid-recovery
program for lower-extremity arthroplasty patients, including pre-operative patient education, peri-opera-
Rapid Recovery Protocol for
Peri-Operative Care of Total Hip and
Total Knee Arthroplasty Patients
KEITHR. BEREND, M.D.
ASSOCIATE
JOINTIMPLANTSURGEONS, INC.
CLINICALASSISTANTPROFESSOR
1
DIRECTOR, DIVISION OFADULTRECONSTRUCTION
ADOLPHV. LOMBARDI, J., M.D., F.A.C.S.
SENIORASSOCIATE
JOINTIMPLANTSURGEONS, INC.
CLINICALASSISTANTPROFESSOR
1
CLINICALASSISTANTPROFESSOR
BIOMEDICALENGINEERING
THOMASH. MALLORY, M.D., F.A.C.S.
SENIORASSOCIATE
JOINTIMPLANTSURGEONS, INC.
CLINICALPROFESSOR
1
1
DEPARTMENT OFORTHOPAEDICS
THEOHIOSTATEUNIVERSITY
COLUMBUS, OHIO
- 1 -
Orthopaedic Surgery
SURGICAL TECHNOLOGY INTERNATIONAL XIII
Berend - 02
ABSTRACT

- 2 -
The overwhelminglyfavorab e
results of modern total hip and total
knee arthroplasty (THA and TKA) are
undisputed. From the original descrip-
tions of Sir John Charnley to today,
THA and TKA are among the most
effective surgical or medical interven-
tions that consistently provide quality of
life and pain relief.
1-3
This r lief of pain
and improvement in quality of life
appears to be long-standing and THA
and TKA are being reported as success-
ful into the second and even third
decades of follow up.
4-12
The long-term goals of arthroplasty,
which include relieving pain, improving
function, providing stability, and obtain-
ing durability are achieved and main-
tained in the majority of cases.
Therefore, recent focus has centered
upon obtaining similar successes in the
peri-operative period. Reducing peri-
operative complications, increasing the
speed of recovery, and reducing the
length of hospital stay appear to be the
next set of goals in care of the hip and
knee arthroplasty patient. As noted by
Del Savio et al., a longer than necessary
hospital stay cannot be dismissed as
insignificant, as hospital stay is among
the more costly aspects of total joint
arthroplasty.
13
The concept of rapid
recovery is built upon the burgeoning
interest in less-invasive and small-inci-
sion surgeries for hip and knee arthro-
plasty. Implant manufacturers and the
medical industry are concentrating
efforts on these concepts. However,
minimally invasive techniques and small
incision surgery are not the keystone to
a rapid recovery. Instead, a holistic
approach concentrating on education,
information, and peri-operative man-
agement is likely to affect an even more
significant change. A complete Rapid
Recovery Program has become available
recently for use (Biomet Inc., Warsaw,
IN, USA). The short- and long-term
outcomes of these concepts have been
validated individually, but the holistic,
combined approach has not heretofore
een described.
T is Chap er reviews the current
knowledge of p -operative patient edu-
cation, peri-operative nutrition, vitamin
and herbal medication supplementation,
preemptive analgesia, post-operative
rehabilitation, and the possible benefi-
cial effects these have on peri-operative
recovery. We further present our early
exper ence with a holistic peri-opera-
tive rapid recovery program.
One of the eas est and safest ways to
increase the efficiency by which an
arthroplasty patient flows through the
peri-operative period appears to be by
providing a hig level of education for
the patient and family. Crowe and Hen-
derson evaluated the effectiveness of an
individu lly tailored, pre-operative
rehabilitati n program in patients who
undergo THA and TKA. This pre-oper-
ative multidisciplinary rehabilitation and
education included information about
the hospi al stay, early discharge plan-
ning, and focused preparation for the
patient's discharge home. The authors
demonstrated that patients who
received this focused pre-operative
rehabilitation achieved discharge crite-
ria sig ificantly earlier (5.4 days com-
pared with 8 days) and had shorter (6.5
days versus 10.5 days) hospital stays.
14
A similar study was performed to
examine the effects of pre-admission
social work interventions in the form of
education and discharge planning on
hospital length of stay. Patients who
received intense pre-admission screen-
ing with psychosocial evaluation, dis-
charge planning, coordination of
nursing and physical therapy interven-
ti ns, and monitoring of medical testing
before lective THA and TKA had
reduced ho pital stays compared with
Berend - 02
INTRODUCTION
tive nutrition, vitamin and herbal medication supplementation, preemptive analgesia, and post-operative
rehabilitation. A holistic peri-operative, rapid-recovery program has lead to a significantly decreased hospi-
tal length of stay and significantly lower hospital readmission rates in patients who undergo primary THAs
and TKAs. Combining these results with minimally invasive techniques and instrumentation should make
recovery even faster.
PRE-OPERATIVE EDUCATION AND PRE-
ARTHROPLASTY REHABILITATION
Figure 1. Soft-tissue and intra-articular injection of bupivacaine, epinephrine, and narcotic was determined
to be beneficial in reducing blood loss and improving immediate post-operative pain levels, and increasing
ROM following TKA.
Rapid Recovery Protocol for Peri-Operative Care of Total Hip and Total Knee Arthroplasty Patients
BEREND, LOMBARDI, MALLORY