Early Mobilisation Program
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“Movement is life and life is movement”. Dr Dennis Kerr and Mr Lawrence Kohan published an excellent paper describing a technique for using a combination of analgesics (painkillers) injected into all the tissues that are disturbed during the course of surgery for hip resurfacing, total hip replacement and total knee replacement. They coined the technique “local infiltration analgesia” (LIA). In addition to these intra-operative injections, a fine tube can be used to drip feed more analgesic solution into a knee or hip joint for up to 24 hours post-operatively to improve your pain relief and so you can be given a “top up” of pain relief prior to starting physiotherapy the day after surgery.
Mr Robin learned this technique while performing total hip and total knee replacements during his post-fellowship training in Bristol and has adapted it to his own practice, using it in almost every hip and knee replacement performed. Certainly there is no shortage of video clips on the Web of patients still in their hospital gowns and with bandages on their limbs demonstrating their ability to walk shortly after total hip or total knee replacement, and most likely a high proportion of these patients have had LIA as part of their analgesic regimen.
In combination with a pre-surgery cocktail of oral analgesics and a potent but short-acting spinal anaesthetic (with mild sedation), LIA frequently affords patients substantially less early post-operative pain whilst allowing an early return of muscle control. This permits early movement with minimal (and in a lot of cases almost no) post-operative pain. In reasonably healthy/fit patients who have had this technique it is not unusual to be able to get out of bed 4-5 hours after a total hip or total knee replacement, with the help of a physiotherapist or nurse, and commencing walking around the ward with the assistance of a frame or some crutches and supervision.
On the first attempt, this Early Mobilisation may result in a temporarily low blood pressure and some dizziness or nausea, but again, this can usually be anticipated and managed pre-emptively to reduce its severity.
It’s worth noting that traditionally, after a total hip replacement, patients were initially kept in bed with traction on the operated leg for over a week to prevent dislocation, and in more recent decades the traction rule had been relaxed. It’s only been in the last couple of decades that surgeons have switched (from prolonged bedrest) to patients having a single day of bed rest post-operatively, and only in the last few years have patients been “mobilised on the same day as surgery”.
Aside from reduced post-operative pain, the advantages of LIA and Early Mobilisation include a theoretically lower chance of complications related to being bed-bound such as DVT and PE, pneumonia, bladder infections and pressure sores on heels and buttock, as well as possibly a shorter stay in the acute hospital, although this is not true for all cases.
The numbers of surgeons using this technique safely and effectively is steadily increasing and the analgesic/anaesthetic technique can be used safely in a very high proportion of patients undergoing total hip or total knee replacement. It may also have an application in other orthopaedic procedures apart from joint replacement.
It is important to note that with regards to and early post-op pain and mobility after total hip replacement and resurfacing, at the time of writing there is little or no high quality medical evidence to prove that the surgical technique by which the a total hip replacement is implanted (i.e. the “new” Direct Anterior Approach vs the “traditional” Posterior/Postero-lateral approach) necessarily results in less early post-operative pain or better mobility, and certainly there is no evidence to show that there is any advantage with either technique over the other in the long term outcome for your hip replacement – both techniques give excellent results (and have their own strengths and weaknesses) as long as a high-quality prosthesis has been implanted with well aligned components and good stability of those components. This is especially true if either approach incorporates the use of local infiltration analgesia and spinal anaesthetic.
Mr Robin learned this technique while performing total hip and total knee replacements during his post-fellowship training in Bristol and has adapted it to his own practice, using it in almost every hip and knee replacement performed. Certainly there is no shortage of video clips on the Web of patients still in their hospital gowns and with bandages on their limbs demonstrating their ability to walk shortly after total hip or total knee replacement, and most likely a high proportion of these patients have had LIA as part of their analgesic regimen.
In combination with a pre-surgery cocktail of oral analgesics and a potent but short-acting spinal anaesthetic (with mild sedation), LIA frequently affords patients substantially less early post-operative pain whilst allowing an early return of muscle control. This permits early movement with minimal (and in a lot of cases almost no) post-operative pain. In reasonably healthy/fit patients who have had this technique it is not unusual to be able to get out of bed 4-5 hours after a total hip or total knee replacement, with the help of a physiotherapist or nurse, and commencing walking around the ward with the assistance of a frame or some crutches and supervision.
On the first attempt, this Early Mobilisation may result in a temporarily low blood pressure and some dizziness or nausea, but again, this can usually be anticipated and managed pre-emptively to reduce its severity.
It’s worth noting that traditionally, after a total hip replacement, patients were initially kept in bed with traction on the operated leg for over a week to prevent dislocation, and in more recent decades the traction rule had been relaxed. It’s only been in the last couple of decades that surgeons have switched (from prolonged bedrest) to patients having a single day of bed rest post-operatively, and only in the last few years have patients been “mobilised on the same day as surgery”.
Aside from reduced post-operative pain, the advantages of LIA and Early Mobilisation include a theoretically lower chance of complications related to being bed-bound such as DVT and PE, pneumonia, bladder infections and pressure sores on heels and buttock, as well as possibly a shorter stay in the acute hospital, although this is not true for all cases.
The numbers of surgeons using this technique safely and effectively is steadily increasing and the analgesic/anaesthetic technique can be used safely in a very high proportion of patients undergoing total hip or total knee replacement. It may also have an application in other orthopaedic procedures apart from joint replacement.
It is important to note that with regards to and early post-op pain and mobility after total hip replacement and resurfacing, at the time of writing there is little or no high quality medical evidence to prove that the surgical technique by which the a total hip replacement is implanted (i.e. the “new” Direct Anterior Approach vs the “traditional” Posterior/Postero-lateral approach) necessarily results in less early post-operative pain or better mobility, and certainly there is no evidence to show that there is any advantage with either technique over the other in the long term outcome for your hip replacement – both techniques give excellent results (and have their own strengths and weaknesses) as long as a high-quality prosthesis has been implanted with well aligned components and good stability of those components. This is especially true if either approach incorporates the use of local infiltration analgesia and spinal anaesthetic.
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