CORR Insights®: Which Interventions Are Effective in Treating Sleep Disturbances After THA or TKA? A Systematic Review

Where Are We Now?

Achieving adequate pain control and consistently obtaining a meaningful clinical improvement after surgery would reduce the suffering of patients and diminish the use of healthcare resources after arthroplasty, such as emergency/urgent care visits, telephone calls to doctors, and the need for prolonged use of medications such as opioids. These goals are particularly important from the standpoint of healthcare costs, as the volume of total joint arthroplasties is expected to increase [6]. The subspecialty is moving in the direction of outpatient surgery, and using enhanced recovery after surgery (ERAS) protocols makes it possible for many of these procedures to be done without an inpatient stay, which seems to reduce costs without compromising outcomes [5]. However, ERAS protocols do not specifically address sleep.

Human beings require sleep. Many of us have likely experienced the detrimental effects of not getting enough of it. And for patients undergoing total joint arthroplasty, sleep disturbances are common—especially during the first month after the procedure—and can worsen pain and delay or impair the likelihood of achieving the desired functional outcomes [4]. With this in mind, many postoperative order sets include pain medications, sedatives (such as benzodiazepines), and melatonin in their regimens, but they are included to address other things, such as pain and nutrition, not sleep. In this issue of Clinical Orthopaedics and Related Research®, Pilc et al. [4] conducted a systematic review to determine which regimens are better suited for addressing postoperative insomnia. They found that sleep quality was better for up to 1 week following total hip replacement with the use of melatonin. They also noted better sleep quality using an anti-inflammatory medication called rofecoxib (marketed in the United States as Vioxx) after total knee replacement, but bear in mind that rofecoxib was taken off the market in 2004. Other medications such as pregabalin, morphine, zolpidem, nitroglycerin, and methylprednisolone—all of which still are commercially available—were not found to have any beneficial effects on sleep.

Given that sleep quality has an impact on outcomes following joint replacement, surgeons may wish to consider adding a sleep aide for those who need it, especially for those who are discharged home on the same day from a surgery facility without being monitored by a medical professional. Patients who stay overnight at a facility following surgery should also be given consideration to sleep aide interventions.

Where Do We Need To Go?

The presumption is that if postoperative pain can be controlled, patients will have better sleep. While Pilc et al. [4] reviewed various pharmacologic and nonpharmacologic interventions for sleep disturbances, there are other possible factors that merit study such as meditation, eliminating hip dislocation precautions from our usual approaches, a patient’s diet, caffeine intake, or a sleep hygiene program. As more total joint arthroplasties are being done in outpatient settings, it would be good to know if there’s a difference between a patient staying overnight in a hospital or facility versus sleeping at home in one’s own bed. Does the bed mattress quality, room temperature, and use of white noise generators make a difference? Additionally, it would be interesting to know whether dedicated teams focused on throughput have an effect on pain management and sleep during postoperative recovery. In an outpatient surgery center, a patient who stays overnight typically has a dedicated nurse, whereas in a hospital, a nurse will usually have several patients to manage concurrently rather than be able to provide one-on-one care.

How Do We Get There?

Potential factors that affect sleep should be investigated with respect to functional outcomes after total joint arthroplasty. Patient questionnaires on quality of sleep administered preoperatively and postoperatively would be a good next step, perhaps comparing those who had procedures in a hospital to those who underwent surgery in an ambulatory surgery center, as well as those who were discharged home same day versus discharged on the next day. Certain medical comorbidities deserve special attention, such as treated or untreated sleep apnea. In addition to questions about insomnia, consider asking about sleep quality. Finally, it’s important to distinguish between difficulty falling asleep and difficulty staying asleep; validated outcomes tools related to sleep cover these topics and others, and they should be used in these studies.

We also need more data on the various medications currently being used for postoperative management to see whether they have an effect on sleep quality (and whether there are differences according to age, race, or gender). Future randomized trials could look at specific interventions and medication quantities to see what improves sleep the most. It would also be interesting to know if better sleep quality has an effect on the amount of time needed for recovery, patient satisfaction, and whether or not a patient will regain muscle strength and function sooner if they have better sleep. Ultimately, the data on sleep are already suggesting that we have another modifiable factor that could improve outcomes in our value-based system.

Read This Next

• An excellent review published in Arthroplasty Today reviews sleep pathophysiology, the importance of sleep after joint replacement surgery, the risk factors for sleep disturbances, and how to improve sleep by modifying preoperative, intraoperative, and postoperative factors [3].

• Another interesting study prospectively examined the use of melatonin in patients undergoing TKA and found that melatonin may help patients sleep in the first few days after surgery [2].

• A study that examined how knee replacement surgery affected sleep quality in patients with arthritis found that, although there were sleep disturbances in the perioperative period, knee replacement resulted in improved sleep quality in the late postoperative period [1].