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Le cadrage fonctionnel dans la récupération améliorée après chirurgie (RAAC) : application aux interventions du membre inférieur.
Abstract
FUNCTIONAL ORGANISATION IN AFTER-SURGERY RECOVERY :
application to lower limb interventions
Ambulatory hospitalization for hip and knee arthroplasty is an upset of practices. Physiotherapy must adapt to this new medical care. We present in this article our experience and our practice inspired by the anglo-saxon protocols of fast-track.
A first consultation with the physiotherapist of the clinic makes it possible to establish a functional assessment and to realize a rehabilitation and education session in order to prepare the patient to the postoperative suites. This care is supplemented by a traditional preoperative rehabilitation with a physiotherapist close to home.
In the afternoon of the surgery, the aim of the rehabilitation is to obtain the patient functional independence. This physiotherapy treatment is relatively technical and requires a stepwise progression so that the patient returns to his home on the evening of the surgery under good conditions.
The recommendations of the French National Authority for Health (HAS) in 2016 on fast-track corroborate our practice and encourage us to continue this process, which reflects an innovative vision of rehabilitation.
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Objectifs
Élaborer des recommandations concernant la prise en charge en rééducation précédant une arthroplastie totale de hanche ou de genou.
Méthode
La méthodologie utilisée, proposée par la Société française de médecine physique et réadaptation (Sofmer), associe une revue systématique de la littérature, un recueil des pratiques professionnelles, une validation par un panel pluridisciplinaire d'experts. Les critères d'analyse concernent les déficiences et l'incapacité fonctionnelle, les données médicoéconomiques et les complications postopératoires.
Résultats
Une rééducation préopératoire qui doit comporter au minimum de la kinésithérapie associée à de l'éducation est recommandée avant arthroplastie totale de hanche et de genou. De l'ergothérapie pouvant comporter une visite à domicile peut être également être proposée. La kinésithérapie isolée avant arthroplastie totale de genou n'est pas recommandée. Pour les patients les plus fragiles du fait de capacités fonctionnelles altérées, de comorbidités, et/ou de problèmes sociaux une rééducation pluridisciplinaire comportant au minimum de l'ergothérapie et une éducation est souhaitable. Il est souhaitable d'entreprendre des études complémentaires afin de confirmer l'intérêt de la rééducation précédant une arthroplastie totale de la hanche (PTH) ou du genou (PTG), d'en préciser les modalités et de mieux définir les patients les plus susceptibles d'en bénéficier.
Conclusion
La réalisation d'une rééducation avant arthroplastie totale de la hanche ou du genou contribue à réduire la durée de séjour et à modifier les modalités de retour à domicile. Cette prise en charge doit faire appel à des professionnels de santé compétents dans l'éducation des patients et la préparation du retour à domicile. L'évaluation préopératoire des besoins des patients est également capitale.
To evaluate the effect of modifying perioperative care in noncardiac surgical patients on morbidity, mortality, and other outcome measures.
New approaches in pain control, introduction of techniques that reduce the perioperative stress response, and the more frequent use of minimal invasive surgical access have been introduced over the past decade. The impact of these interventions, either alone or in combination, on perioperative outcome was evaluated.
We searched Medline for the period of 1980 to the present using the key terms fast track surgery, accelerated care programs, postoperative complications and preoperative patient preparation; and we examined and discussed the articles that were identified to include in this review. This information was supplemented with our own research on the mediators of the stress response in surgical patients, the use of epidural anesthesia in elective operations, and pilot studies of fast track surgical procedures using the multimodality approach.
The introduction of newer approaches to perioperative care has reduced both morbidity and mortality in surgical patients. In the future, most elective operations will become day surgical procedures or require only 1 to 2 days of postoperative hospitalization. Reorganization of the perioperative team (anesthesiologists, surgeons, nurses, and physical therapists) will be essential to achieve successful fast track surgical programs.
Understanding perioperative pathophysiology and implementation of care regimes to reduce the stress of an operation, will continue to accelerate rehabilitation associated with decreased hospitalization and increased satisfaction and safety after discharge. Developments and improvements of multimodal interventions within the context of "fast track" surgery programs represents the major challenge for the medical professionals working to achieve a "pain and risk free" perioperative course.
Minimally invasive hip surgery has stimulated a new process in hip arthroplasty. There is consensus among surgeons about the benefits of anesthesia, pain management, and rapid recovery protocols. The benefits of the surgical technique for small incision surgery remain controversial. Some patients influence this controversy because they prefer minimally invasive hip surgery: they associate less body violation and better cosmesis with smaller incisions. Small incision surgery is associated with a learning curve and requires specialized instruments for favorable outcomes. Despite being a more difficult operation to perform, in skilled hands it is a safe procedure that does not increase complication rates as shown by recent prospective, randomized studies. Correct component positioning has been achieved consistently with these procedures and short-term results of small incision surgery are the same as with long incisions. New anesthesia and pain management techniques have led to remarkable early functional results, making same-day surgery possible. With improved instrumentation such as computer navigation, minimally invasive total hip arthroplasty will become more prevalent.
Minimally invasive surgery (MIS) techniques for total hip arthroplasty (THA) have the potential for reduced tissue trauma, leading to more rapid recovery and return to function than with traditional approaches to THA. However, to achieve these potential benefits, all other aspects of patient care need to be modernized. Development and implementation of these newer anesthetic and rehabilitation protocols allow MIS-THA to be done safely on an outpatient basis in select patients.
Programme de récupération améliorée après chirurgie (RAAC) : état des lieux et perspectives. Rapport d'orientation
- Haute Autorité De Santé
Haute Autorité de Santé. Programme de récupération améliorée après
chirurgie (RAAC) : état des lieux et perspectives. Rapport d'orientation : https://www.has-sante.fr/portail/upload/docs/application/forcedownload/2016-09/rapport_orientation_raac.
pdf
Can early rehabilitation after total hip arthroplasty reduce its major complications and medical expenses? Report from a nationally representative cohort
- Chiung-Jui Su
- D Yuan
- K S Weng
- S F Hong
- R B Wu
- M P Wu
- H M Chou
Chiung-Jui Su D, Yuan KS, Weng SF, Hong RB, Wu MP, Wu HM, and
Chou W. Can early rehabilitation after total hip arthroplasty reduce
its major complications and medical expenses? Report from a nationally representative cohort. BioMed Res Int 2015;2015:641958.
Critères de suivi en rééducation et d'orientation en ambulatoire ou en SSR après ligamentoplastie du croisé antérieur du genou. Recommandations professionnelles
- Haute Autorité De Santé
Haute Autorité de Santé. Critères de suivi en rééducation et d'orientation en ambulatoire ou en SSR après ligamentoplastie du croisé antérieur du genou. Recommandations professionnelles, janvier 2008 :
http://www.has-sante.fr/portail/upload/docs/application/pdf/
reeducation_genou_lca_-_recommandations.pdf
Critères de suivi en rééducation et d'orientation en ambulatoire ou en soins de suite ou de réadaptation après prothèse totale du genou
- Haute Autorité De Santé
Haute Autorité de Santé. Critères de suivi en rééducation et d'orientation en ambulatoire ou en soins de suite ou de réadaptation après
prothèse totale du genou. Recommandations professionnelles :
http://www.has-sante.fr/portail/upload/docs/application/pdf/
reeducation_genou_ptg_-_argumentaire.pdf