International Journal of Orthopaedic and Trauma Nursing
Physical health problems experienced in the early postoperative recovery period following total knee replacement
Introduction
The number of patients who need knee replacement has increased during the last decade. It is estimated that 1.4 million knee replacement procedures will be performed in 2015 worldwide (Sorci, 2012). In Denmark approximately 9000 procedures are performed annually (Danish Knee Arthroplasty Register, 2012). The main clinical indication for total knee replacement (TKR) is osteoarthritis (Carr et al., 2012) which causes severe pain and substantial functional disabilities, leading to a decrease in health-related quality of life (Ethgen et al., 2004). The mean age for Danish patients who require TKR is 67 years. Twenty-two percent of patients are younger than 60 years old and 59% are female (Danish Knee Arthroplasty Register, 2012). The surgical intervention is a common procedure which, despite low level of mortality and complications, involves severe surgical trauma and a protracted recovery (Salmon et al., 2001). Three to six months after TKR physical health status is markedly better for the majority of patients compared to the preoperative level (Ethgen et al., 2004).
The implementation of fast-track programmes in Denmark for surgical procedures has reduced the length of stay in hospital following TKR from around 11 to 4 days between 2000 to 2009 (Husted et al., 2012). The length of stay is now 3 days in several surgical centres (Kehlet and Soballe, 2010) with an actual intention of reducing length of stay to 1–2 days (Husted, 2012).
The principles of fast track recovery programmes for TKR are based on perioperative care, multimodal pain treatment, aggressive postoperative rehabilitation including early mobilisation and early oral nutrition (Husted and Holm, 2006) and motivation of patients to be active participants (Husted 2012).
The Department of Orthopaedic Surgery at Gentofte University Hospital is a specialised ward for patients receiving knee or hip replacements. A total of 632 primary TKR procedures were performed in 2011 (Danish Knee Arthroplasty Register, 2012). Due to implementation of the fast track programme TKR-patients are admitted to the ward on the day of surgery or the evening before if the travel a long distance to the hospital. All preparatory examinations and tests are performed in the outpatient clinic. Patients also attend a multidisciplinary education seminar before admission. The seminar is conducted by a surgeon, an anaesthesiologist, a physiotherapist, an occupational therapist and a nurse. It is focused on the surgical intervention, anasesthetic, possible complications and risks, pain management, the admission course and expected length of stay, introduction to the physical exercise training and equipment.
Discharge from hospital is scheduled 2–3 days post-surgery. Patients are referred to physiotherapy in the community setting and instructed to complete a self-training programme until they start physiotherapy. Removal of stitches or staples is conducted by their general practitioner. One outpatient consultation with the surgeon is scheduled 3 months post-surgery.
Section snippets
Background
Due to the shortened length of stay in hospital, patients have to take responsibility for their rehabilitation following TKR at a very early stage. They are faced with the realities of caring for themselves or being cared for by their relatives during recovery.
Studies have mainly focused on the outcomes following TKR in regard to pain, physical function and performance, activities of daily living and health related quality of life from the time of discharge from hospital up to several years
Method
This study was conducted from May to September 2011 at the Department of Orthopaedic Surgery, Gentofte University Hospital in Denmark.
Results
The frequency of identified physical health problems are presented in Table 2. Symptoms such as leg oedema and pain were experienced by 90.7% (N = 78) and 81.4% (N = 70) of patients respectively. Sleeping disorders, problems with appetite and bowel function were identified as the most dominating physical health problems. Physical health problems not specified in the questionnaire were identified by 25.6% (N = 22) of patients. One of these patients identified two physical health problems while
Discussion
To our knowledge this is the first study exploring the prevalence of physical symptoms and level of exercising after discharge from TKR. A variety of physical health problems and impaired compliance with the recommended self-training programme were identified.
Early intensive mobilisation and physiotherapy is important to avoid complications such as prolonged stiffness and delay in recovery of strength of the knee (Holm et al., 2010b). Pain is considered the most important limiting factor for
Conclusion
This study is a snap shot of the early recovery period after discharge from TKR providing evidence for a broad variety of physical health problems, which TKR-patients face in the early recovery period after discharge from hospital. Motivation of patients to be active participants is prioritised in fast track programmes. The identification of several physical health problems frequently experienced in the early recovery period after discharge can support development of targeted and effective
Conflict of interest statement
The authors have no conflicts of interest.
Role of funding source
The authors received no funding for this article.
Ethical statement
The study was submitted to The Regional Committee on Health Research Ethics and approval was not required to initiate this cross sectional study (No. H-4-2011-FSP (43)). The Danish Protection Agency has approved the study (No. 2007-58-015).
The study was conducted according to the latest Declaration of Helsinki (World Medical Association, 2008). All eligible patients were informed about the study verbally and in writing and all participants signed written informed consent forms. They were
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