Total Joint Arthroplasty and Sleep: The State of the Evidence.
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Abstract
Background
As the number of total hip and knee arthroplasties (TJA) performed increases, there is heightened interest in perioperative optimization to improve outcomes. Sleep is perhaps one of the least understood perioperative factors that affects TJA outcomes. The purpose of this article is to review the current body of knowledge regarding sleep and TJA and the tools available to optimize sleep perioperatively.Methods
A manual search was performed using PubMed for articles with information about sleep in the perioperative period. Articles were selected that examined: sleep and pain in the perioperative period; the effect of surgery on sleep postoperatively; the relationship between sleep and TJA outcomes; risk factors for perioperative sleep disturbance; the effect of anesthesia on sleep; and the efficacy of interventions to optimize sleep perioperatively.Results
Sleep and pain are intimately associated; poor sleep is associated with increased pain sensitivity. Enhanced sleep is associated with improved surgical outcomes, although transient sleep disturbances are normal postoperatively. Risk factors for perioperative sleep disturbance include increasing age, pre-existing sleep disorders, medical comorbidities, and type of anesthesia used. Interventions to improve sleep include optimizing medical comorbidities preoperatively, increasing sleep time perioperatively, appropriating sleep hygiene, using cognitive behavioral therapy, utilizing meditation and mindfulness interventions, and using pharmacologic sleep aids.Conclusions
Sleep is one of many factors that affect TJA. As we better understand the interplay between sleep, risk factors for suboptimal sleep, and interventions that can be used to optimize sleep, we will be able to provide better care and improved outcomes for patients.Free full text
Total Joint Arthroplasty and Sleep: The State of the Evidence
Associated Data
Abstract
Background
As the number of total hip and knee arthroplasties (TJA) performed increases, there is heightened interest in perioperative optimization to improve outcomes. Sleep is perhaps one of the least understood perioperative factors that affects TJA outcomes. The purpose of this article is to review the current body of knowledge regarding sleep and TJA and the tools available to optimize sleep perioperatively.
Methods
A manual search was performed using PubMed for articles with information about sleep in the perioperative period. Articles were selected that examined: sleep and pain in the perioperative period; the effect of surgery on sleep postoperatively; the relationship between sleep and TJA outcomes; risk factors for perioperative sleep disturbance; the effect of anesthesia on sleep; and the efficacy of interventions to optimize sleep perioperatively.
Results
Sleep and pain are intimately associated; poor sleep is associated with increased pain sensitivity. Enhanced sleep is associated with improved surgical outcomes, although transient sleep disturbances are normal postoperatively. Risk factors for perioperative sleep disturbance include increasing age, pre-existing sleep disorders, medical comorbidities, and type of anesthesia used. Interventions to improve sleep include optimizing medical comorbidities preoperatively, increasing sleep time perioperatively, appropriating sleep hygiene, using cognitive behavioral therapy, utilizing meditation and mindfulness interventions, and using pharmacologic sleep aids.
Conclusions
Sleep is one of many factors that affect TJA. As we better understand the interplay between sleep, risk factors for suboptimal sleep, and interventions that can be used to optimize sleep, we will be able to provide better care and improved outcomes for patients.
Introduction
Total hip and knee arthroplasty (TJA) are among the fastest-growing surgeries in the United States [1,2]. With over one million TJA performed annually and this number projected to quadruple within the next decade, many aspects of patients’ perioperative experience have been explored in depth in the literature. However, perhaps one of the most poorly understood perioperative considerations among TJA patients is sleep.
Sleep affects every aspect of the perioperative patient’s experience. Studies by Sasaki et al. and Parmelee et al. have shown that increased osteoarthritis severity is associated with an increase in nocturnal pain, which impacts sleep duration and quality, mental health, and quality of life [3,4]. Immediately postoperatively, TJA patients describe significantly altered sleep quantity and quality from a variety of etiologies with potentially significant negative consequences, including delirium, poor acute pain control, development of chronic pain, unplanned readmissions, and poorer patient-reported outcomes [[5], [6], [7], [8]]. Finally, some patients continue to suffer from altered sleep up to a year after surgery, risking a lower quality of life [9].
Recognition of the importance of sleep for the body’s health and function is increasing. However, the role sleep plays in the TJA perioperative period remains in its infancy. Here we review the current state of the literature regarding sleep in the perioperative period: importance of sleep, etiologies of sleep disturbance, and preoperative, intraoperative, and postoperative interventions that may improve our patients’ sleep duration and quality after TJA.
Basics of sleep
Sleep plays a vital role in the body’s ability to maintain homeostasis and is essential for the body’s restoration. The 3 basic concepts of sleep and its relationship to our health and well-being are: 1) sleep duration; 2) sleep quality; and 3) circadian rhythm [10]. The recommended amount of sleep per day is 7-9 hours for adults 18-64 years old and 7-8 hours for individuals 65 years and older [11]. Insufficient sleep is associated with a multitude of negative health effects including daytime fatigue, motor vehicle accidents, emotional disturbances, cognitive impairment, weight gain, cardiovascular disease, inflammation, and infection [12].
Good sleep quality is defined by normal sleep architecture without sleep disturbance. Sleep can be broken down into 2 main phases: rapid eye movement (REM) and nonrapid eye movement [13]. Nonrapid eye movement can be divided further into 3 stages: N1, N2, and N3. Each stage is classified by variance in electroencephalography, eye movement, and muscle tone [13]. Normal sleep architecture has a defined pattern of cycling through each of these sleep stages [14,15]. While each stage of sleep is thought to play a particular role, stage N3 (or slow-wave sleep [SWS]) and REM sleep are particularly important for health and restoration [16].
Circadian rhythm refers to the body’s internal clock, which cycles approximately every 24 hours. Not only do sleep-wake cycles run on the circadian rhythm, but cells and organs in the body also function within this framework [17]. Several hormones are also secreted in relation to the circadian rhythm [17]. Disruption of the circadian rhythm has several negative health effects, including mood disorders, metabolic consequences, delirium, and disrupted postsurgical recovery [[17], [18], [19], [20]].
Why does sleep matter in total hip and knee arthroplasty?
Sleep is important for our physical health as well as the well-being of nearly every aspect of our lives. But why should we care about sleep in relation to TJA?
Sleep and postoperative pain
Sleep deprivation and disruption, both preoperatively and postoperatively, are intimately associated with pain perception and are strong predictors of postoperative pain [21]. In otherwise healthy patients, just one night of poor sleep leads to increased pain sensitivity [[22], [23], [24], [25], [26], [27], [28]]. Schuh-Hofer et al. conducted a standardized, quantitative sensory protocol with 14 healthy subjects to assess the role of total sleep deprivation on pain perception. They found a single night of sleep deprivation increased multiple markers of pain perception, including hyperalgesia to heat, cold, blunt pressure, and mechanical pain stimuli [22]. Additionally, Haack et al. assessed the response of 50% sleep restriction from habitual sleep duration over a 12-day period in 40 healthy subjects. They found a significant interindividual increase in bodily discomfort parameters, including generalized body pain, backache, and stomach pain [23]. Moreover, Wright et al. sought to test this phenomenon among surgical patients. They evaluated the preoperative sleep quality and postoperative pain scores of 24 patients undergoing breast-conserving surgical procedures for the treatment of cancer, finding that patients with lower sleep efficiency and increased sleep disruption the night before surgery had greater pain severity despite controlling for age, race, and perioperative analgesics [24]. This occurrence has been repeated in TJA patients as well. In 2020, Bjurström et al. evaluated 52 patients’ preoperative sleep quality and their immediate and long-term pain scores after TJA. They found that preoperative sleep disturbance occurred in 73.1% of patients, and this predicted not only increased opioid utilization during the first 24 hours after surgery but also increased pain severity at 6 months postoperatively [29]. These studies demonstrate that preoperative sleep deprivation, whether experimentally induced or naturally occurring, is associated with hyperalgesia and increased postoperative pain.
The relationship between sleep quality and pain perception acts in a bidirectional fashion; a decline in one adversely affects the other, and vice versa [30]. This effect creates a vicious sleep-pain cycle that can be frustrating for both the patient and physician. Fortunately, an improvement in one aspect of the sleep-pain cycle also has the potential to improve the other. For example, Roehrs et al. studied the effect of extended sleep duration on pain sensitivity. Eighteen healthy volunteers were randomized to either 4 nights of extended sleep time (10 hours or more) or habitual sleep (8 hours or less), and pain sensitivity was significantly reduced in the extended sleep time group [31]. Another study by Roehrs et al. assessed presurgical extended sleep duration in TJA patients and the effects on postoperative pain. Again, 18 patients scheduled to undergo TJA were randomized to 7 nights of either extended sleep duration (habitual sleep time with 2 additional hours) or habitual sleep duration. They found that during inpatient recovery, the extended sleep group reported significantly less average daily pain with fewer daily morphine milligram equivalents [32]. Shen et al. performed a systematic review and meta-analysis to study the impact of enhanced perioperative sleep on pain and analgesic requirements. They concluded that enhanced sleep in the perioperative period significantly reduces acute pain after TJA and decreases the consumption of analgesic medications [33]. Despite the limitations of many of these studies (eg, small sample size), they suggest that heightened pain sensitivity in sleep-deprived individuals can be diminished. The ability to alleviate postoperative pain by improving preoperative and postoperative sleep carries encouraging implications for our TJA patients.
Sleep and postoperative outcomes
Sleep also has important implications for postoperative recovery. Sleep disturbance is associated with the development of a catabolic state in the body, which has been demonstrated to be detrimental to postoperative recovery [34]. Multiple metabolic changes occur in the sleep-deprived patient, including altered glucose metabolism and energy expenditure, elevated levels of catabolic hormones (eg, cortisol, glucagon, and catecholamines), and increased anabolic inhibiting hormones such as insulin and testosterone [35,36]. The effect of sleep disruption on recovery is perhaps most apparent in the intensive care unit (ICU). In the ICU frequent awakening, disrupted circadian rhythms, and decreased time spent in restorative sleep stages have been repeatedly shown to impact patients’ physical and psychological outcomes [37,38].
Despite the push to optimize patients and standardize perioperative and surgical management, TJA patients differ significantly in the speed, quality, and experience of recovery [[39], [40], [41]]. While physical variables (eg, preoperative function) and medical variables (eg, medical comorbidities, psychiatric diagnoses) account for some of the differences in recovery, sleep is also an influential factor [7,8,34,41,42]. For example, Cremeans-Smith et al. prospectively followed 110 patients undergoing primary TJA to determine if sleep disruption after surgery affected pain and functional recovery [8]. Their results indicated that increased pain and sleep disruption at 1 month were significantly associated with decreased function at 3 months. However, despite the presence of pain patients with fewer sleep disruptions at 1 month were correlated with improved function at the 3 month mark, suggesting that sleep disruption may have a greater impact on functional recovery than pain. Another study by Gong et al. suggested that using pharmacologic sleep aids resulted in improved active range of motion at 2 weeks and improved patient-reported quality of life and satisfaction scores [7]. Finally, improving preoperative sleep parameters correlated with improvements in multiple clinical outcomes, including pain, range of motion, function, and length of stay [42]. Since sleep clearly has a significant impact on patient outcomes, it is important to understand what we can do to optimize sleep both preoperatively and postoperatively.
What disrupts sleep before surgery?
Osteoarthritis, nocturnal pain, and sleep
Osteoarthritis (OA) is a multifaceted diagnosis that can create debilitating physical and psychological symptoms, including sleep disturbance [43]. Approximately 71% of patients with symptomatic hip or knee OA have problems with sleep [43]. In a study evaluating knee OA in the geriatric population, 31% of patients were found to have difficulty with sleep initiation on a weekly basis, while 81% had difficulty staying asleep and 51% had frequent early morning awakenings [44]. Disrupted sleep and pain perception are strongly associated, and both are associated with a depressed mood, creating a vicious and complex triad between sleep, depressive symptoms, and pain [4,45].
The presence of nocturnal pain is a key finding in the clinical setting [46]. In fact, most major patient-based clinical scoring systems for knee and/or hip OA include questions about the presence or degree of nocturnal pain, including the Knee Society Rating Scale, the Western Ontario McMaster University Osteoarthritis Index, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and the Japanese Knee Outcome Measurement [[47], [48], [49], [50]]. The progression of knee OA severity has been associated with increasing prevalence of nocturnal pain [3,46]. Similarly, progression of knee OA severity has been correlated with an increasing sleep problems and a significantly lower KOOS quality of life metric [3]. As such, nocturnal pain is considered an indication for TJA, with the potential to significantly improve a patient’s nocturnal pain symptoms and quality of life [[51], [52], [53], [54], [55]].
Altered adult sleep structure after surgery
Major surgery has the potential to cause significant sleep disturbances immediately following the procedure [[56], [57], [58], [59], [60]]. These sleep disturbances are evidenced in sleep studies as fragmentation of sleep and decreased SWS/REM sleep [15]. The clinical manifestations of these changes in sleep patterns are diverse. Many patients will report difficulty initiating sleep, frequent nocturnal awakenings, lower sleep quality, decreased sleep duration, and even frequent nightmares [57,59,61]. The recovery of normal adult sleep architecture occurs gradually, with reports of normalization ranging from postoperative day 4 to 1 week after returning home [57,62]. However, patients have reported clinical manifestations of sleep disturbances for upwards of 10 months to a year postoperatively [9,63].
What disrupts sleep after surgery?
Risk factors
Not all patients enter the postoperative period with the same risk of sleep disturbance. Increased risk has been noted in those with preoperative sleep disorders, the elderly, and those with certain comorbidities, such as obstructive sleep apnea (OSA) [64]. Aging is associated with sleep architecture changes, a higher apnea-hypopnea index (AHI), lower sleep efficiency, and more physiologic difficulty adjusting to anesthesia [64,65]. Patients with sleep-disordered breathing (such as OSA) or obesity have been found to have a higher AHI after surgery, resulting in increased sleep disturbance [58,60]. As OSA affects sleep quality, one would expect that congestive heart failure, pulmonary hypertension, poorly controlled asthma, fluid overload, and any number of other pathologies would affect sleep as well. For example, patients with severe preoperative coronary artery disease, particularly if symptomatic, have been associated with worse sleep after surgery and higher postoperative angina scores [66]. Furthermore, patients with restless leg syndrome (RLS) can experience uncomfortable sensations in their legs that cause significant disruptions in their sleep. RLS can worsen postoperatively, and new-onset RLS has been reported with the use of spinal anesthesia [[67], [68], [69]]. As these findings are common in the TJA population, most patients enter the postoperative period with numerous risk factors.
Postoperative pain
We reviewed above the effects of poor preoperative and postoperative sleep on pain perception and how improving sleep can positively impact pain control after surgery. Poor control of postoperative pain and the associated anxiety are 2 important factors in the sleep-pain cycle [70]. Many studies have demonstrated the effects of increased postoperative pain on sleep [71,72]. In a study of 102 patients undergoing general or orthopedic surgery, pain negatively affected sleep the first postoperative night in 48% of patients [73]. More specific to TJA, other studies have noted impaired postoperative sleep quality as “severe” in up to 50% and “moderate” in up to 40% of patients [7,74]. In 2019, Long et al. surveyed 965 patients with sleep disturbance after total knee arthroplasty (TKA), and 40.1% reported pain and 31.3% reported anxiety as the main disruptors of their sleep [5].
However, addressing postoperative pain comes with challenges. Opioid-induced effects, such as exacerbating or causing sleep-disordered breathing and aggravating depression, delirium, and other psychiatric disorders, are common and disrupt sleep quality [14]. In the absence of other comorbidities, opioids themselves have been shown to reduce sleep efficiency, SWS, and REM sleep, as well as increase stage N2 sleep [[75], [76], [77], [78]]. The relationship between pain and sleep is bidirectional: poor sleep aggravates pain, and pain clearly disrupts sleep.
Types of anesthesia and analgesia
Different modalities of anesthesia during surgery contribute to postoperative sleep disturbance. In 2012, a randomized controlled trial of 162 women undergoing fast-track abdominal hysterectomy were stratified into groups receiving either regional (spinal) anesthesia or general anesthesia [79]. The study group found that patients in the spinal anesthesia group experienced significantly less impaired sleep quality the night after surgery than the general anesthesia group. One explanation for poor sleep quality after general anesthesia is the potential to cause sleep-disordered breathing. A cohort study of 376 patients undergoing surgery demonstrated that general anesthesia was associated with an increase in postoperative central apnea index compared to regional anesthesia [60]. Both Kjolhede and Chung noted that higher consumption of opioids and antiemetics following general anesthesia are potential contributors to suboptimal sleep [60,79]. However, some studies indicate that even patients with opioid-sparing or opioid-avoiding pathways develop sleep disturbance after surgery in the setting of general anesthesia [57,80]. General anesthesia has been postulated to affect sleep by means of medication effects on the hypothalamus and the “master clock” in the suprachiasmatic nuclei, as well as disruptions of the sleep cycle and other aspects of the internal clock including temperature and melatonin secretion [[81], [82], [83], [84], [85]].
In contrast to general anesthesia, neuraxial anesthesia lowers the rates of major complications among patients with OSA [86]. In a study of 376 surgical patients, those who received regional anesthesia had a lower AHI compared to those who received general anesthesia [60]. Regional anesthesia, including spinal blocks, epidural analgesia, and peripheral nerve blocks, helps to limit postoperative opioid use, which negatively affects sleep quality and architecture [77,78,[87], [88], [89]]. Elderly patients are particularly vulnerable to central nervous system effects of anesthesia such as postoperative delirium, which in turn disrupts sleep [90,91]. Between 10% and 60% of this patient population experience postoperative delirium, which is exacerbated by intraoperative medications such as sevoflurane, remifentanil, and fentanyl [90,91].
Furthermore, one must keep in mind that sleep disruption promotes pain and that sleep disruption is linked to opioids [[22], [23], [24], [25], [26], [27], [28], [29],75,76]. Multimodal pain management is now the gold standard for analgesia in TJA, providing enhanced pain control and decreased adverse effects compared to opioid use alone [92]. While there is no one-size-fits-all multimodal regimen, considerations should include optimizing preoperative sleep hygiene, extending preoperative sleep duration, utilizing regional blocks, using local analgesic during surgery, implementing nonpharmacological pain modalities such as cryotherapy, minimizing opioid use, and optimizing nonopioid pharmacotherapy including anti-inflammatories and acetaminophen [[31], [32], [33],77,78,[87], [88], [89],[92], [93], [94], [95], [96], [97]]. Thus, spinal anesthesia and a multimodal approach to pain that reduces opioid consumption are 2 strategies to optimize pain relief while minimizing sleep disruptions.
Physiologic responses
Surgery causes a physiologic insult to the body resulting in an increase in stress, inflammation, and sympathetic response, as well as metabolic and neuroendocrine changes [98]. Each of these processes is connected in a complex manner. Surgical procedures elicit a systemic inflammatory response involving the innate and adaptive immune systems, which causes the release of inflammatory cytokines, neutrophil activation, dysfunction of endothelial cells, glycocalyx injury, and more [99,100]. This response affects the recovering patient in many ways: the surgical site, the organs, the immune system, and even the nervous system [[99], [100], [101]]. Neuroinflammation is thought to contribute to postoperative sleep disturbances among other cognitive impairments [101]. The effects of tumor necrosis factor (TNF) and interleukin-1 (IL-1) have been studied extensively. Injection of exogenous TNF or IL-1 in animal models induces all of the symptoms associated with sleep deprivation, which are weakened by premedication with an IL-1 receptor antagonist [[102], [103], [104]]. Sleep disruption and deprivation have been shown to activate other proinflammatory cytokines, including IL-6 and TNF-alpha. [105,106]. A pro-inflammatory state can adversely affect the hypothalamic-pituitary-adrenal (HPA) axis, resulting in disrupted sleep [107]. Disrupted sleep in turn influences the HPA axis and leads to hyperactivation [108]. Further, afferent nerve input from surgery activates the sympathetic nervous system, resulting in hormonal changes including an increase in catecholamines and cortisol, further feeding into the vicious HPA axis-sleep cycle [[109], [110], [111]]. The inflammatory response after surgery is complex, and although these are only a few of the many modulators involved, this physiologic response clearly contributes to sleep dysfunction in surgical patients.
Environmental conditions
Sleep environment affects sleep quality, and a hospital is not the optimal environment for sleep. Alarms and other noises, lights in patient rooms and hallways, uncomfortable beds, and nighttime awakenings by healthcare staff all contribute to inpatient sleep disruption [73,112]. Noise levels in the ICU can reach up to 85 decibels (dB), and on the general ward, background noise can reach 70 dB compared to an ideal bedroom noise level of <30 dB [113,114]. Furthermore, environmental factors outside of the hospital care team’s control may contribute to sleep disruption, such as departure from the patient’s nighttime routine including deviation from habitual sleeping hours, more frequent toileting needs, anxiety, and fear [112]. In a study of 965 patients who underwent primary TKA, 13.6% experienced postoperative insomnia related to hospital noise, nursing care, medication administration, and room lighting [5]. This percentage is even higher in ICU patients with up to 50% experiencing insomnia [38].
Improving sleep after total hip and knee arthroplasty: modern surgical protocols
Preoperative considerations
Optimizing psychological and medical risk factors preoperatively minimizes the risk and/or severity of postoperative sleep disruption [115,116]. Attention to psychological well-being via patient support, reassurance, and specific relaxation techniques in the perioperative period has been shown to reduce pain and anxiety and improve sleep quality [115,117]. Identifying and managing pre-existing sleep disorders is crucial, as multiple studies have shown improvement in sleep prior to surgery leads to improved patient experience and postoperative outcomes, including sleep [7,[31], [32], [33],42,118]. Patients with OSA or sleep-related hypoventilation should go into surgery with adequate control of sleep-disordered breathing and associated symptoms and should also have a postoperative management plan. Some recommendations include minimizing narcotics and sedatives, not sleeping supine, continuous monitoring of oximetry, and utilizing positive airway pressure when indicated [116,119]. While long-term use of sleep aids for insomnia is not generally recommended, patients who are on medications for insomnia prior to surgery will likely need to continue these medications in the preoperative and postoperative phases to prevent rebound insomnia [120]. However, some sleep aids can worsen sleep-disordered breathing, especially when combined with opiates and other medications that are respiratory depressants [121]. Similarly, continuing or bridging medications for patients with RLS minimizes the risk of symptomatic exacerbations [67,68]. Prior to surgery, it is important to have a discussion with the patient about potential postoperative sleep disruption, with reassurance that this is almost always transient.
Surgical considerations
Surgical efficiency and associated anesthetic duration impact postoperative sleep quality [85]. Shorter surgical time in TJA results in decreased risk of infection, shorter hospital length of stay, lower blood loss, and decreased risk of blood transfusion [[122], [123], [124]]. Minimally invasive, more efficient cholecystectomies are associated with significant reductions in both sleep disturbance and disrupted sleep architecture [61,62]. While the association between shorter TJA operative time and decreased sleep disruption has not been established, a similar result may be expected. Efficient surgery with delicate soft tissue handling will minimize physiologic insult and blunt the surgical stress response [99]. Minimizing blood loss will mitigate the risk of iron deficiency, which contributes to RLS exacerbation postoperatively [67,68]. Minimizing exposure to general anesthesia will mitigate the risk of postoperative nausea and vomiting, delirium, and worsened sleep-disordered breathing, all of which disrupt sleep [90,91,116,119].
Improving sleep after total hip and knee arthroplasty: nonpharmacological interventions
Environment and sleep hygiene
Optimizing sleep habits and sleep environment will decrease potential disruptors of sleep in the postoperative period [125]. For patients who are admitted to the hospital, interventions should focus on decreasing stimulation during the evening and nighttime hours [112,126]. Hospitals may elect to develop sleep care guidelines reflecting current available evidence. Dolan et al. and Celik et al. each emphasized the importance of minimizing nighttime nursing interventions, describing protocols to modify medication dosage timing, arranging for single-bed rooms with more comfortable beds, and allowing patients to set room temperature [73,112]. Cmiel and team implemented a robust plan to reduce the nighttime noise on their unit, describing efforts from minimizing traffic in and out of patient rooms to the use of silent alarms to changing the location of loud towel dispensers and sinks [126]. Even simple interventions such as ear plugs and eye masks are helpful in enhancing sleep in inpatients [127]. While avoiding light during the sleep period is important for sleep, morning sunlight exposure can also improve sleep [128,129]. Therefore, opening hospital room curtains or blinds and having a patient close to a window in the morning may improve nocturnal sleep and decrease the risk of circadian rhythm disruption. Relaxation techniques and music therapy have also been suggested and supported by some, particularly among the elderly at risk for hospital insomnia and delirium [90]. Discharging patients home to a familiar environment as soon as is safely possible may assist in restoring the baseline sleep routine promptly. Although this makes sense intuitively, there is a lack of evidence to support improved postoperative sleep in TJA patients with same-day discharge vs postoperative admission. Nevertheless, patients perceive that same-day discharge after TJA results in improved sleep compared to postoperative admission [130].
Meditation and mindfulness
Meditation and mindfulness, with a directed focus on their applications in improving sleep quality, are increasing in popularity [131]. Meditation represents a broad category of practices in which an individual engages in focused reflection and increased awareness of various areas of attention [132]. Mindfulness is a technique that focuses attention on the present moment by enhancing awareness of where one is and what one is doing while not being overly reactive or feeling overwhelmed [133]. Meditation and mindfulness practices have demonstrated positive impacts on psychological and physical heath [[134], [135], [136]]. Multiple studies have demonstrated the benefits of meditation and mindfulness practices on sleep [131,[137], [138], [139], [140]]. One study compared 2 groups of adults with sleep dysfunction, with one group undergoing mindfulness awareness training and the other sleep hygiene education [137]. While both groups demonstrated improved sleep from baseline, the mindfulness group also demonstrated significant improvements on the Pittsburgh Sleep Quality Index and other validated metrics, as well as improved secondary health outcomes including depression and insomnia. The effectiveness of mindfulness-based strategies appears to be durable. One study found mindfulness positively impacted sleep hygiene in up to 78.6% of patients for up to 6 months [140]. Similarly, a meta-analysis of 18 trials with over 1600 patients found moderate strength evidence to suggest that mindfulness and meditation interventions significantly improve sleep quality with effects persisting for 5 to 12 months [131]. More specifically for TJA, in 2021, Canfield et al. designed a self-guided meditation protocol for their TKA patients. Comparing 189 patients who utilized the protocol and 191 who did not, the protocol group demonstrated increased sleep time by an average of 52 minutes per night with significantly fewer nocturnal awakenings [141].
Delivering meditation and mindfulness programs through digital platforms such as computers and phones facilitates widespread use. Patients are now able to access an extensive number of resources that they can utilize at their convenience. Protocols range from in-person solo or group sessions, online meetings or videos, online learning modules or courses, and phone calls [131,137,138,140,141]. No specific delivery method has been demonstrated to be superior to others, although patient adherence is associated with the convenience of the delivery model [142]. Within the context of numerous perioperative instructions, patient adherence to mindfulness routines can be challenging. Cavanagh et al. utilized an online platform for a 14-day intervention with standardized reminder emails every 3 days [138]. Eighty-seven percent of their participants practiced mindfulness more than once per week, and 26% more than once per day. Canfield et al. created a 9-minute meditation video in collaboration with their Integrative Medicine department with instructions for participants to review twice daily for 2 weeks prior to TJA and 2 weeks afterward [141]. Over 50% of participants utilized the videos, and 47% used them as prescribed throughout the study period. While perioperative meditation and mindfulness practices remain in their infancy, their effectiveness in improving sleep is encouraging. Although significant hurdles exist to achieve patient buy-in and compliance, future studies should continue to investigate their benefits.
Cognitive behavioral therapy
Cognitive behavioral therapy for insomnia (CBT-I) comprises well-established multimodal therapeutic strategies including sleep education, sleep hygiene, stimulus control, sleep restriction, relaxation training, and cognitive therapy [143]. CBT-I seeks to improve behaviors, cognitions, and associations that affect sleep [143]. Its efficacy is well documented as a therapeutic modality in chronic insomnia and is the first-line treatment before pharmacotherapy [143].
Many recommendations for CBT-I that show efficacy for treating chronic insomnia may also be adapted to TJA perioperative care. Good sleep hygiene recommendations include keeping a consistent sleep and rising time to aid in synchronizing the circadian rhythm, limiting heavy meals, avoiding caffeine consumption in the afternoon and evening, avoiding electronic devices within a few hours of bedtime, and avoiding nicotine and alcohol [143]. Modified sleep restriction should be utilized, which curtails time in bed to closely match actual sleep time [144]. Modified stimulus control techniques include using the bedroom for sleep and intimacy only, going to bed only when drowsy, and rising from bed if unable to fall asleep in 20 minutes [144]. Relaxation techniques such as mindfulness and meditation described above are also recommended [144].
Improving sleep after total hip and knee arthroplasty: pharmacologic interventions
Given the many factors that contribute to sleep disruption postoperatively, short-term pharmacotherapy to aid sleep may be needed in some patients. Typically, agents are used for their analgesic, hypnotic, sedative, or anxiolytic properties.
Melatonin and other over-the-counter medications and supplements
Melatonin is secreted by the pineal gland and plays a role in the circadian sleep-wake cycle [145]. Plasma melatonin levels can be decreased after orthopedic surgery and in hospitalized patients [146,147]. In several small studies of patients undergoing prostatectomy or breast cancer surgery, exogenous administration of melatonin improved sleep quality, decreased pain scores, and decreased opioid consumption postoperatively [[148], [149], [150], [151]]. More specific to TJA, Kirksey et al. studied 50 patients undergoing elective TKA under regional anesthesia and a well-described standardized perioperative analgesic regimen [152]. Patients took either 5 mg melatonin or placebo shortly before bedtime for 3 nights prior to surgery and 3 nights after surgery while being monitored via actigraphy wrist bracelets. Though their results did not reach statistical significance, they found an improvement in sleep efficiency and sleep duration with no significant difference in pain medication consumption [152]. In a study of elderly patients undergoing total hip arthroplasty, patients who took melatonin had better sleep quality, overall well-being, and less fatigue compared to those who did not take melatonin [153]. However, an evaluation of 21 randomized trials investigating melatonin in the perioperative period concluded that while melatonin has shown promising results for perioperative use, the quality of studies is heterogeneous with low patient numbers reducing reliability [154].
Melatonin’s potential benefits may be due to its sedative effects, anxiolytic properties, and synergistic analgesia [[148], [149], [150], [151],[155], [156], [157]]. Its weak sedative effects make it safer than most medications used to treat insomnia. Melatonin has a first-pass metabolism of approximately 85% and a half-life of 1 hour, making the likelihood of side effects low and short-lived. [154]. However, adverse effects such as daytime fatigue and dizziness are possible, particularly in older women [148,152].
Despite the wide use of melatonin, a consensus on the dose, duration, and timing of melatonin in the TJA perioperative period has not been established. However, with a well-established safety profile, encouraging results in small-sample studies, and low cost, melatonin remains an attractive option in modern perioperative pathways. Further study on short-term use of melatonin in the perioperative period is warranted. Other over-the-counter medications and supplements such as diphenhydramine, valerian, and L-tryptophan are not currently recommended for the treatment of insomnia due to little to no benefit to sleep and/or potential adverse effects outweighing the limited benefits [158].
Prescription sleep aids
Prescription sleep aids include benzodiazepine receptor agonists (BZRAs), benzodiazepines, orexin receptor antagonist, melatonin agonists, heterocyclic antidepressants, and anticonvulsants. BZRAs, which include zolpidem, eszopiclone, and zaleplon, are among the most commonly used and most widely studied sleep aids. By acting as an agonist at gamma-aminobutyric acid-A receptors found in the central nervous system, these create an increase in chloride channel conductance causing neuroinhibition [159]. BZRAs are reported to maintain overall sleep structure while increasing the proportion of time spent in REM sleep [74,160]. Short-term use of zolpidem has been shown to improve sleep initiation with a low risk of addiction [161]. When used in the total hip arthroplasty perioperative setting, Shakya et al. found that short-term use of zolpidem (10 mg given 2 days preoperatively and 5 mg continued 5 days postoperatively) significantly improved sleep parameters including sleep quality, sleep latency, and sleep duration, as far as 6 weeks postoperatively [162]. Patients reported reduced daytime fatigue and somnolence with improved quality of life and patient-reported outcome measures (PROMs) in the treatment group [162]. Gong et al. in 2015 performed a prospective, double-blinded, randomized controlled study examining the effects of zolpidem use in TKA patients using polysomnography. The treatment group was prescribed 5 mg of zolpidem starting the first night after surgery for 14 days. These patients had significantly improved sleep efficacy, increased active range of motion, and less narcotic consumption compared to the control group [7]. In 2014, Krenk et al. provided 5 mg of zolpidem or placebo to 20 patients undergoing TJA with standardized perioperative protocols. They did not find polysomnographic differences between the 2 groups, but those patients taking zolpidem subjectively reported less fatigue and better sleep quality with reduced number of nighttime arousals [74].
Other perioperative sleep aids have also been evaluated. In a study of 88 patients, use of the orexin receptor antagonist suvorexant 15-20 mg after coronary artery bypass grafting demonstrated reduced postoperative delirium and shorter ICU and hospital stay compared to the patients who did not receive suvorexant [163]. Although trazodone has been found to improve insomnia in nonsurgical patients, the use of trazodone to improve sleep, specifically in postoperative TJA patients, has not been studied [164,165]. Other sleep aids are less promising. For example, several studies have shown that the melatonin receptor agonist ramelteon does not reduce postoperative delirium [166,167].
Although they can be useful in improving sleep, pharmacologic sleep aids can also have adverse effects. The most common adverse effects of BZRAs include daytime drowsiness, dizziness, headache, amnesia, nausea, and vivid dreams [158,168]. As these are sedatives, they may contribute to confusion and delirium, particularly in the elderly [90]. Another significant concern with persistent postoperative use of BZRAs is an increased fall risk [169]. Additional serious effects have also been reported including anaphylaxis, central nervous system depression, parasomnias, which can lead to fatal accidents, changes in mood and behavior, and potential for addiction and withdrawal [168,170]. Additional safety risks are present when sleep aids are combined with opiates and other central nervous system or respiratory depressants. Combined use of BZRAs with opiates increases the risk of overdose and adverse effects including daytime sedation, sleep-disordered breathing, respiratory depression, and even death [[171], [172], [173]].
While it appears that short-term use of some sleep aids such as zolpidem may improve sleep in the perioperative period, this benefit must be balanced with the risks, particularly in the elderly population. If medications are used as sleep aids, patients need to be educated on the potential adverse effects, and clinicians need to monitor for such effects as well. Additionally, long-term use of pharmacologic sleep aids is not recommended. Therefore, in patients with persistent insomnia, referral for CBT-I is recommended. A summary of the authors’ recommendations for improving perioperative sleep in patients undergoing TJA is outlined in Figure 1.
Summary of authors’ recommendations for enhancing sleep perioperatively in patients undergoing TJA. Weeks to months preoperatively, clinicians should focus on sleep hygiene, decreasing narcotic use, and optimizing medical comorbidities in addition to identification and management of pre-existing sleep disorders [32,33,77,78,116,119]. In the days prior to the surgery period, patients should strive to achieve adequate sleep time, consistent bedtime and awakening time, and to continue any sleep medications that were taken preoperatively [32]. On the day of surgery, patients should receive neuraxial and regional anesthesia as opposed to general anesthesia, if feasible [86]. In addition, the surgical procedure should be carried out efficiently, and patients should commence a multimodal pain regimen postoperatively [92,123]. In the days following surgery, the multimodal pain regimen should be continued in addition to any pharmacologic sleep aids the patient was taking preoperatively, and the patient’s sleep environment should be optimized to minimize sleep disruptions [112,126]. In patients who are still experiencing sleep disruptions in the first few days after surgery despite these measures, melatonin and/or zolpidem can be used as backup options to enhance sleep in addition to a mindfulness meditation program [141,153,162]. If the patient continues to have difficulty sleeping for weeks to months postoperatively, meditation and mindfulness programs, referral for cognitive behavioral therapy, and referral to a sleep medicine specialist should be considered [141,143].
Conclusions
While TJA provides life-changing outcomes for many patients, it is pertinent to recognize the impact of the surgical intervention on the body. Each aspect of the perioperative state—from presurgical patient condition to operative intervention to postoperative recovery—contains factors that affect a patient’s sleep. As we understand the importance of sleep with regards to pain control, postoperative cognition, and postoperative outcomes, optimizing patients’ perioperative sleep has the potential to enhance patient experiences and outcomes from their joint replacement. An understanding of both preventative measures and medical interventions (pharmacological and nonpharmacological) will assist surgical and medical teams in providing the best care for our TJA patients.
Conflicts of interest
L. Buller is a paid consultant for LinkBiomedical, OsteoRemedies, and Enovis; receives research support from Enovis and OsteoRemedies; and is a committee member of the AAHKS program committee. S. Stahl serves as Vice Chair of the American Academy of Sleep Medicine’s Education Committee, a volunteer-appointed position not relevant to this manuscript. All other authors declare no potential conflicts of interest.
For full disclosure statements refer to https://doi.org/10.1016/j.artd.2024.101383.
CRediT authorship contribution statement
Robert J. Pettit: Writing – review & editing, Resources, Data curation. Brandon Gregory: Writing – original draft, Conceptualization. Stephanie Stahl: Writing – review & editing, Supervision, Project administration, Conceptualization. Leonard T. Buller: Writing – review & editing, Supervision, Project administration, Conceptualization. Christopher Deans: Writing – review & editing, Writing – original draft, Supervision, Project administration, Conceptualization.
Appendix A. Supplementary Data
References
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