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Edema (swelling) is amongst the most frequent reasons for 90-day emergency department visits and readmissions following elective hip and knee surgery

12th August 2020

Unplanned Hospital returns after total joint arthroplasty (TJA) represent a major economic burden on healthcare systems, reducing cost savings in bundled reimbursement models, particularly in the US healthcare system. Identifying and mitigating preventable causes of unplanned ED visits and readmissions is therefore now considered critical to improving care and controlling costs1.

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Recognising this, and based on thinking that previous studies evaluating reasons for 30-day readmissions following TJA may underestimate hospital-based utilization of healthcare resources during a patient’s episode-of-care, a study by Kelly et al1, sought to identify the common reasons for 90-day emergency department (ED) visits and hospital readmissions following primary TJA.

Using the Kaiser Permanente Total Joint Replacement Registry, the Kelly study looked for patients who had at least one 90-day postoperative ED-only visit and/or readmission for any reason. Chart reviews determined 13 surgical and 11 medical reasons.  2344 total hips and 5520 total knees were analysed and the results show that swelling, related to these procedures, was the most frequent reasons for 90-day ED visits, with readmissions most commonly due to infection.

  • Total hip arthroplasty (THA) – The incidence of at least one ED visit was 13.4% and 4.5% for readmissions. The most frequent reasons for ED visits were swelling (15.6%), then pain (12.8%); the most frequent reasons for readmissions were infection (12.5%) and unrelated elective procedures (9.0%).
  • Total knee arthroplasty (TKA) – the incidence of at least one ED visit was 13.8%, and the incidence of readmission was 5.5%. The most frequent reasons for ED visits were pain (15.8%), the swelling (15.6%); the most common readmission reasons were gastrointestinal (19.1%) and manipulation under anaesthesia (MUA) (9.4%).

The study shows that upwards of 1 in 10 patients will return to the ED within 90 days of TJA, and that ED-only visits are more common in the first 30 days following surgery, while readmissions are more common in the 31-90 day period. These findings are consistent with prior 30 day studies, which report knee swelling is most evident 3-5 days postoperatively in TKA patients2 and most evident 7 days postoperatively in THA patients.3

Aligned to the Kelly paper is a study by Loyd et al 4 which reports an approximate 10% per day swelling increase for the first 3 days following TKA surgery, with peak swelling occurring 6–8 days following surgery, and a rate of decline of swelling from days 15–50 following surgery – and this speaks to the importance of Kelly paper in analysing 90 day hospital-based episodes-of-care.

The Kelly findings, and a paper by Mont et al5, both conclude that swelling related ED-only visits are more frequent than in-patient readmissions. That ED visits may not necessarily result in an in-patient readmission but can be a measure of performance and that ED visits can incur costs related to clinician time and the high cost for diagnostic scans and tests to determine and prescribe appropriate treatments. In the drive to make  change to clinical practice, 30 and 90 day ED-only visits are now receiving increasing scrutiny by policy makers and hospitals, especially as compensation and bundled payment initiatives become more prevalent.

Of more than equal significance, however, is the physical impact of lower extremity edema on TJA, which is also described in a paucity of literature, and in particular, that TKA post-operative swelling can reduce functional performance, negatively impacting quadriceps muscle strength6, pain, mobility and rehabilitation2, and particularly in obese knee and hip arthroplasty patients7 due to decreased muscular activity, reduced range of motion, and subsequent venous stasis8.

Post-operative, edema-related surgical wound dehiscence and infection is also a recognised burden and again widely reported.6 edema is known to impair wound healing through several mechanisms. Excess fluid causes a distance to form between cells, acting as a barrier to growth factors and nutrients, making them relatively dilute in the fluid and less available to the cells – resulting in lower tissue pO2 and impaired oxygen delivery.

This combination of reduced functional performance and surgical wound dehiscence can negatively impact surgical outcomes.6 Strategies that can mitigate these complications therefore need to address the underlying edema.9

 

Current edema management strategies 

Cryotherapy, graduated compression stockings, pressure bandaging, continuous passive motion, pneumatic compression devices, and manual lymph drainage have been utilized among various studies and institutional protocols to improve patient mobility, function, pain control, swelling, and prevention of venous thromboembolism (VTE) in the immediate postoperative period. Each present challenges and are used along-side limb elevation, frequent repositioning, sodium restriction, and diuretic use are general edema management techniques are also utilized in post-operative orthopaedic rehabilitation patients. However, several of these modalities are poorly understood or lack adequate support from the low quality literature10.

An alternative therapy, heralding a paradigm shift in edema management, is the innovative geko™ device. Clinically proven to treat and prevent post-operative and trauma-based edema, and FDA cleared for edema reduction11, the geko™ device is also the first bioelectronic muscle pump activator of its kind to be cleared by the FDA for VTE prevention across all patients including non-surgical patients12 – providing adjunctive blood clot prevention to at-risk TJA patients, along-side edema reduction.

 

About the geko™ device

The size of a small wrist-watch, the geko™ device is battery powered, disposable, neuromuscular electro-stimulation therapy that is applied non-invasively to the skin over the common peroneal nerve at the side of the knee. It gently stimulates the nerve, once every second, activating the calf and foot muscle pumps resulting in increased blood flow in the deep veins of the calf, at rate equal to 60%13 of walking without the patient having to move.

Highly portable, the geko™ device is:

  • Disposable – no need to sterilise after single patient use.
  • No decontamination required – not the case with other mechanical devices.
  • Easy-to-fit – minimal training.
  • Less nurse-to-patient contact time – reduced exposure to C-19 viral load.
  • No tripping hazard – no leads or hoses.

 

The geko™ device has been shown to effectively prevent or treat leg edema in the following studies:

  • Wainwright et al compared the use of the geko™, a Neuromuscular Electrical Stimulation device vs. Thromboembolic Deterrent Stockings (TEDS) post Total Hip Replacement. The study consisted of 40 patients, N=20 geko™ and N=20 for TEDS. The results showed that the TED group had significantly more edema post-operatively compared to the geko™ device (p=0.03).14
  • Mahmood & Baker et al conducted a study to compare patients with an ankle fracture who were to undergo Open Reduction Internal Fixation (ORIF). Twenty (20) patients were compared to standard of care (bedrest, leg elevation and a backslab plaster cast) vs. those with the geko™ device. The results report 60% of patients were ready for theatre in 2 days, compared to 27% in control arm, a 122% improvement. Standard treatment = 3.66 days readiness to theatre (average) vs the geko™ device + plaster cast = 1.66 days readiness to theatre (average) (P=0.001).15
  • Shahid et al reported statistical significance was reached in all parameters with the most significant differences being leg edema (calf and thigh circumference measurement) P=0.001, in a randomized clinical trial (RCT) conducted at London Health Sciences Centre (LHSC), in London, Ontario. 221 patients who underwent kidney and kidney-pancreatic transplant were followed from post-op day 1-6. The study compared the geko™ device to standard of care using anti-thrombotic (TED) stockings and Intermittent Pneumatic Compression (IPC). Parameters measured included: leg edema, weight gain, urine output, high femoral velocity, length of stay, patient’s satisfaction, mobility and comfort level.16

 

References

  1. Kelly M, et a Reasons for Ninety-Day Emergency Visits and Readmissions After Elective Total Joint Arthroplasty: Results From a US Integrated Healthcare System. J Arthroplasty. 2018 Jul;33(7):2075-2081. doi: 10.1016/j.arth.2018.02.010. Epub 2018 Feb 12.
  2. Fu-qiang G, et al. Risk factors for lower limb swelling after primary total knee arthroplasty. Chinese Medical Journal, 124(23), 3896-3899. doi:10.3760/cma.j.issn.0366-6999.2011.23.012.
  3. Holm B, et al. Thigh and knee circumference, knee-extension strength, and functional performance after fast-track total hip arthroplasty. The American Academy of Physical Medicine and Rehabilitation, 3(2), 117-124. doi:10.1016/j.pmrj.2010.10.019.
  4. Loyd B, et al. Development of a reference chart to monitor postoperative swelling following total knee arthroplasty. Disabil Rehabil. 2020 Jun;42(12):1767-1774. doi: 10.1080/09638288.2018.1534005. Epub 2019 Jan 22.
  5. Saleh & Mont, et al. Emergency department visits within thirty days of discharge after primary total Hip arthroplasty: A Hidden Quality Measure. J Arthroplasty. 2019 Jan;34(1):20-26. doi: 10.1016/j.arth.2018.08.032. Epub 2018 Aug 31.
  6. Brock T, et al. Short-stretch inelastic compression bandage in knee swelling following total knee arthroplasty study (STICKS): Study protocol for a randomized controlled feasibility study. Trials, 16(1), 618. doi:10.1186/s13063-015-0618-0.
  7. Friedman R, Hess S, Berkowitz S & Homering M. Complication rates after knee or hip arthroplasty in morbidly obese patients. Clinical Orthopaedics and Related Research, 471(10), 3358-3366. doi:10.1007/s11999-013-3049-9
  8. Bertelli D, de Oliveira P, Gimenes A, & Moreno M. Postural drainage and manual lymphatic drainage for lower limb edema in women with morbid obesity after bariatric surgery: A randomized controlled trial. American Journal of Physical Medicine and Rehabilitation, 92, 697-703. doi:10.1097/PHM.0b013e318282c721.
  9. Pichonnaz C, et al. Bioimpedance spectroscopy for swelling evaluation following total knee arthroplasty: a validation study. BMC Musculoskelet Disord. 2015; 16: 100. Published online 2015 Apr 25. doi: 10.1186/s12891-015-0559-5.
  10. Kluga, et al. Improving Orthopedic-Related Postoperative Edema Management in a Rehabilitative Nursing Setting. Rehabilitation Nursing:  5/6 2019 – Volume 44 – Issue 3 – p 151 – 160. doi: 10.1097/rnj.0000000000000104.
  11. FDA 510k clearance: For the reduction of oedema. Data on file Firstkind Ltd.
  12. FDA 510K clearance: For immediate post-surgical stimulation of the calf muscles to prevent venous thrombosis. For stimulation of the calf muscles to prevent venous thrombosis in non-surgical patients at risk for venous thromboembolism. Data on file Firstkind Ltd.
  13. Tucker A, et al. Augmentation of venous, arterial and microvascular blood supply in the leg by isometric neuromuscular stimulation via the peroneal nerve. The International journal of angiology: official publication of the International College of Angiology, Inc. 2010 Spring; 19(1): e31-7.
  14. Wainwright T, et al. A feasibility randomised controlled trial to evaluate the effectiveness of a novel neuromuscular electro-stimulation device in preventing the formation of oedema following total hip replacement surgery. Heliyon. 2018 Jul; 4(7): e00697. Published online 2018 Jul 18. doi:  10.1016/j.heliyon.2018.e00697.
  15. Mahmood & Baker, et al. Neuromuscular Electrostimulation Device Reduces Preoperative Edema and Accelerates Readiness for Theater in Patients Requiring Open Reduction Internal Fixation for Acute Ankle Fracture. Techniques in Foot & Ankle Surgery. December 06, 2019 – Volume Publish ahead of print – Issue. 1097/BTF.0000000000000257.
  16. Shahid A, et al. Improved Lower Limb Edema, Lower Limb Blood Flow, and Urine Output Compared With Standard TED Stockings and Compression Devices Following Kidney Transplant: A Randomized Controlled Trial. Transplantation proceedings. Volume 51, Issue 6, July-August 2019, pages 1838-1844.

Sue Davenport – VP Marketing Communications
12th August 2020