**6.3 Post-operative**

During the post-operative period, the primary aim is to ensure the patient is at full function as soon as possible. This is assisted by ensuring there is adequate analgesia, and the patient is mobilised at the day of operation. Patients are deemed safe for discharge when satisfy the following criteria.


Appropriate education for ongoing rehabilitation is crucial to ensure that they will continue to progress their mobility, strength and range of motion [8].

#### *6.3.1 Block (wound) catheter management*

The use of the wound catheter post operatively has varied between different protocols in the literature [11, 12]. The method initially described by Kerr & Kohen was a 50 mL top-up of the anaesthetic mixture used intraoperatively 15–20 hours post operatively with 15 mL injected primarily then the remaining injected as the catheter was removed [10]. Nassar et al. describe a top-up with their anaesthetic mixture 18–24 hours post operatively where 20 mL was injected then the catheter was removed [14].

Alternative protocols which have been used include continuous infusion of 250 mL ropivacaine 0.2% over 48 hrs at which case the catheter is removed. If bolus regimes are used the doses involved the first bolus 12 hours post-operatively and the last (second) bolus at 24 hours post-operatively, each under aseptic technique then removal of the catheter where each injection contains 10 ml of 1% ropivacaine, made up to 20mLs with 0.9% saline.

#### *6.3.2 Mobilisation and function*

Early mobilisation is a core component to fast-track arthroplasty protocols. Multiple studies have shown that early (ideally day of operation) mobilisation postoperatively reduced length of stay, thromboembolic risk, and mortality [42, 67]. A systematic review and meta-analysis of 5 RCTs performed by Guerra et al. showed that early mobilisation was associated with reduced length of stay by 1.8 days with no increased incidence of negative events or complications [68]. Consequently, all patients should be mobilised with physiotherapy on the day of their operation and if this is not possible due to a late return to ward, at a minimum they must be transferred to sit out of bed. With the use of LIA there is the advantage of having no motor blockade [8] which further facilitates early mobilisation. In fact, day of surgery mobilisation in TKA has been shown to reduce LOS and improve the likelihood of discharge home rather than to a rehabilitation facility [69]. A haemoglobin level is not required prior to mobilisation, and mobilisation must not be delayed awaiting routine blood results. If there are symptomatic concerns, then an urgent medical review should be requested. To further encourage mobilisation simulating home life is encouraged by having all meals, including the first meal, sitting out of bed along with mobilising to bathroom to open bladder or bowels instead of using bedpans or commodes.

The use of corticosteroids is controversial due to the theoretical risk of infection. As mentioned in Section 2.3 there is no increased risk associated with corticosteroid use of periarticular injection. A systematic review and meta-analysis by Yue et al. showed corticosteroid (dexamethasone 0.1 mg/kg) had reduced PONV and pain within 24 hours post operatively [70]. They also showed systemic steroid use had faster functional rehabilitation with no increased risk of infection however, there was increased rates of high serum glucose levels post-operative [70]. Thus, improved patient well-being and analgesia will encourage early mobilisation and facilitate in early discharge and improved post-operative function.

Early mobilisation does not include sitting. We strongly reinforce to our patients that if not mobilising, it is better to lay down than to sit down. Sitting and using a footstool is not helpful, the wound is too low relative to the heart, the veins are potentially occluded in the groin. We recommend patients minimise sitting to 5-10 minutes at a time - it is better to lay on the bed or lounge suite than allow the leg to become swollen. We use 20 mmHg compression stocking during daylight hours. This approach we expect will diminish the readmisssions after arthroplasty caused by swelling, pain, and potentially thrombosis.
