Introduction of an innovative day surgery pathway for unicompartmental knee replacement: no need for early knee flexion

Using orthopaedic health care resources efficiently: A cost analysis of day surgery for unicompartmental knee replacement

BACKGROUND

Day surgery for unicompartmental knee replacement (UKR) could potentially reduce hospital costs. We aimed to measure the impact of introducing a day surgery UKR pathway on mean length of stay (LOS) and costs for the UK NHS, compared to an accelerated inpatient pathway. Secondly, the study aimed to compare the magnitude of costs using three costing approaches: top-down costing; simple micro-costing; and real-world costing.

METHODS

We conducted an observational, before-and-after study of 2,111 UKR patients at one NHS hospital: 1,094 patients followed the day surgery pathway between September 2017 and February 2020; and 1,017 patients followed the accelerated inpatient pathway between September 2013 and February 2016. Top-down costs were estimated using Average NHS Costs. Simple micro-costing used the cost per bed-day. Real-world costs for this centre were estimated by costing actual changes in staffing levels.

RESULTS

532 (48.5%) patients in the day surgery pathway were discharged on the day of surgery compared with 36 (3.5%) patients in the accelerated inpatient pathway. The day surgery pathway reduced the mean LOS by 2.2 (95% CI: 1.81, 2.53) nights and was associated with an 18% decrease in Average NHS Costs (p < 0.001). Mean savings were £1,429 per patient with the Average NHS Costs approach, £905 per patient with the micro-costing approach, and £577 per patient with the "real-world" costing approach. Overall, moving NHS UKR surgeries to a day surgery pathway could save the NHS £8,659,740 per year.

CONCLUSION

Day surgery for UKR could produce substantial cost savings for hospitals and the NHS.

Prehabilitation for Patients Undergoing Orthopedic Surgery: A Systematic Review and Meta-analysis

Importance

Prehabilitation programs for patients undergoing orthopedic surgery have been gaining popularity in recent years. However, the current literature has produced varying results.

Objective

To evaluate whether prehabilitation is associated with improved preoperative and postoperative outcomes compared with usual care for patients undergoing orthopedic surgery.

Data Sources

Bibliographic databases (MEDLINE, CINAHL [Cumulative Index to Nursing and Allied Health Literature], AMED [Allied and Complementary Medicine], Embase, PEDRO [Physiotherapy Evidence Database], and Cochrane Central Register of Controlled Trials) were searched for published trials, and the Institute for Scientific Information Web of Science, System for Information on Grey Literature in Europe, and European clinical trials registry were searched for unpublished trials from January 1, 2000, to June 30, 2022.

Study Selection

Randomized clinical trials (RCTs) comparing prehabilitation with standard care for any orthopedic surgical procedure were included.

Data Extraction and Synthesis

Two independent reviewers screened trials. Data were pooled using a random-effects model. Recommendations were determined using the Grading of Recommendations Assessment, Development and Evaluation system and the study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline.

Main Outcomes and Measures

Pain, function, muscle strength, and health-related quality of life (HRQOL).

Results

Forty-eight unique trials involving 3570 unique participants (2196 women [61.5%]; mean [SD] age, 64.1 [9.1] years) were analyzed. Preoperatively, moderate-certainty evidence favoring prehabilitation was reported for patients undergoing total knee replacement (TKR) for function (standardized mean difference [SMD], -0.70 [95% CI, -1.08 to -0.32]) and muscle strength and flexion (SMD, 1.00 [95% CI, 0.23-1.77]) and for patients undergoing total hip replacement (THR) for HRQOL on the 36-item Short Form Health Survey (weighted mean difference [WMD], 7.35 [95% CI, 3.15-11.54]) and muscle strength and abduction (SMD, 1.03 [95% CI, 0.03-2.02]). High-certainty evidence was reported for patients undergoing lumbar surgery for back pain (WMD, -8.20 [95% CI, -8.85 to -7.55]) and moderate-certainty evidence for HRQOL (SMD, 0.46 [95% CI, 0.13-0.78]). Postoperatively, moderate-certainty evidence favoring prehabilitation was reported for function at 6 weeks in patients undergoing TKR (SMD, -0.51 [95% CI, -0.85 to -0.17]) and at 6 months in those undergoing lumbar surgery (SMD, -2.35 [95% CI, -3.92 to -0.79]). Other differences in outcomes favoring prehabilitation were of low to very low quality of evidence.

Conclusions and Relevance

In this systematic review and meta-analysis of RCTs, moderate-certainty evidence supported prehabilitation over usual care in improving preoperative function and strength in TKR and HRQOL and muscle strength in THR, high-certainty evidence in reducing back pain, and moderate-certainty evidence in improving HRQOL in lumbar surgery. Postoperatively, moderate-certainty evidence supported prehabilitation for function following TKR at 6 weeks and lumbar surgery at 6 months. Prehabilitation showed promising results for other outcomes, although high risk of bias and heterogeneity affected overall quality of evidence. Additional RCTs with a low risk of bias investigating preoperative and postoperative outcomes for all orthopedic surgical procedures are required.

Early post-operative physiotherapy rehabilitation after primary unilateral unicompartmental knee replacement: a systematic review

BACKGROUND

Unicompartmental Knee Replacement (UKR) is an established treatment for end stage arthritis affecting one compartment of the knee. UKR lends itself to rapid recovery and early discharge. The content, type, timing and dose of early post-operative physiotherapy treatment has yet to be reviewed.

OBJECTIVE

To review the content of early physiotherapy in the first eight weeks following unilateral UKR.

DATA SOURCES

A literature search of Medline, CINAHL, AMED and PubMed and the Physiotherapy Evidence Database (PEDRo) plus citation searching.

ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) and observational studies reporting a physiotherapy intervention for UKR involving a form of post-operative exercise/education/advice delivered within the first eight weeks of surgery and commencing as an in-patient. Two reviewers independently performed screening, data extraction and risk of bias assessment.

DATA SYNTHESIS

Narrative syntheses were undertaken due to the heterogeneity of the primary outcomes.

RESULTS

Eleven studies were included (n = 1293 participants), three RCTs and eight observational studies. The dose and content of post-operative physiotherapy was highly variable with a move in recent years to rapid recovery and same day discharge with more self-directed rehabilitation. No studies had a low risk of bias.

LIMITATIONS

Small sample sizes and high heterogeneity limit our findings CONCLUSIONS: This review highlights the range of post-operative physiotherapy provision following UKR with a recent move to minimal physiotherapy input. Further research is required to identify those patients who may need additional physiotherapy above that now routinely provided, along with the most effective timing, type, and dosage of the intervention.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021243238. CONTRIBUTION OF THE PAPER.

Successful same-day discharge in 88% of patients after unicompartmental knee arthroplasty: a systematic review and meta-analysis

PURPOSE

The purpose of this study was to evaluate the effectiveness of day-case unicompartmental knee arthroplasty (UKA) by assessment of successful same-day discharge (SDD), readmission, complication and reoperation rates in the recent literature.

METHODS

For this systematic review and meta-analysis, PubMed, Embase and Cochrane Library were comprehensively searched to identify all eligible studies reporting outcomes of day-case UKA. Studies with intended same-day home discharge after UKA were included. A meta-analysis of proportions, using a random-effects model, was performed to estimate overall rates of successful SDD and adverse events. Subgroup analyses were performed for studies including selected patients (i.e., patients had to meet certain patient-specific criteria to be eligible for day-case UKA) and unselected patients (i.e., no additional criteria for day-case UKA), as well as for clinical and registry-based studies. Additional outcomes included reasons for the failure of SDD and patient satisfaction.

RESULTS

A total of 29 studies and 9694 patients were included with a mean age of 66 ± 9 years and mean follow-up of 59 days (mean range 30-270 days). Based on 24 studies (2733 patients), the overall successful SDD rate was 88% (95% confidence interval [CI] 80-92). These rates were 91% (95% CI 84-95) across studies with selected patients and 76% (95% CI 55-89) across studies with unselected patients. Overall readmission, complication and reoperation rates were 3% (95% CI 1.9-4.4), 4% (95% CI 2.8-5.2) and 1% (95% CI 0.8-1.3), respectively. Inability to mobilize, nausea and uncontrolled pain were frequently reported reasons for failed SDD. The overall patient satisfaction rate was 94%.

CONCLUSION

This systematic review with meta-analysis found an overall successful SDD rate of 88% after UKA in a heterogeneous cohort of selected and unselected patients. Readmission, complication and reoperation rates suggest UKA can be performed safely and effectively as a same-day discharge procedure.

LEVEL OF EVIDENCE

Level IV, systematic review of level III and IV studies.

The compartmental approach to revision of partial knee arthroplasty results in nearer-normal gait and improved patient reported outcomes compared to total knee arthroplasty

PURPOSE

This study investigated the gait and patient reported outcome measures of subjects converted from a partial knee arthroplasty to combined partial knee arthroplasty, using a compartmental approach. Healthy subjects and primary total knee arthroplasty patients were used as control groups.

METHODS

Twenty-three patients converted from partial to combined partial knee arthroplasty were measured on the instrumented treadmill at top walking speeds, using standard gait metrics. Data were compared to healthy controls (n = 22) and primary posterior cruciate-retaining total knee arthroplasty subjects (n = 23) where surgery were performed for one or two-compartment osteoarthritis. Groups were matched for age, sex and body mass index. At the time of gait analysis, combined partial knee arthroplasty subjects were median 17 months post-revision surgery (range 4-81 months) while the total knee arthroplasty group was median 16 months post-surgery (range 6-150 months). Oxford Knee Scores and EuroQol-5D 5L scores were recorded at the time of treadmill assessment, and results analysed by question and domain.

RESULTS

Subjects revised from partial to combined partial knee arthroplasty walked 16% faster than total knee arthroplasty (mean top walking speed 6.4 ± 0.8 km/h, vs. 5.5 ± 0.7 km/h p = 0.003), demonstrating nearer-normal weight-acceptance rate (p < 0.001), maximum weight-acceptance force (p < 0.006), mid-stance force (p < 0.03), contact time (p < 0.02), double support time (p < 0.009), step length (p = 0.003) and stride length (p = 0.051) compared to primary total knee arthroplasty. Combined partial knee arthroplasty subjects had a median Oxford Knee Score of 43 (interquartile range 39-47) vs. 38 (interquartile range 32-41, p < 0.02) and reported a median EQ-5D 0.94 (interquartile range 0.87-1.0) vs. 0.84 (interquartile range 0.80-0.89, p = 0.006).

CONCLUSION

This study finds that a compartmental approach to native compartment degeneration following partial knee arthroplasty results in nearer-normal gait and improved patient satisfaction compared to total knee arthroplasty.

LEVEL OF EVIDENCE

III.

Quality of counselling assessed by patients after total knee arthroplasty: A cross-sectional study

Patient counselling is a key function in nursing. High-quality counselling promotes adherence to treatment and reduces complications. The purpose of the study was to describe the quality of counselling experienced by total knee arthroplasty patients following surgery. The study was a descriptive cross-sectional study. The data were collected from patients following total knee arthroplasty (N = 60) in 2016 with a modified Quality of Counselling Instrument, and analysed using statistical methods. Over half of the patients (58%) were women and the mean age was 68 years (range 49-84). Over a quarter of patients (28.9%) lived alone, and about two-thirds were overweight (42.1%), or obese (31.6%). After surgery, many patients (88%) experienced moderate pain. Half of patients (52.6%) received a good quality of counselling for the disease and its treatment, and counselling for recovery from treatment (81.6%) was good. Most patients (92.1%) received satisfactory counselling about physical activity. There was a correlation between the disease and its treatment counselling and quality of life (r = -0.553, p = 0.003) and pain (r = -0657, p = 0.000). Interaction during counselling was good (97.4%) and it was implemented in a patient-centred way (89.5%). High-quality counselling implemented in a patient-centred manner can play a part in reducing pain and increasing patients' quality of life.

Same-day discharge after early mobilisation and increased frequency of physiotherapy following hip and knee arthroplasty

Background

Advanced rehabilitation pathway (ARP) after hip and knee arthroplasties is popular globally and is gaining ground in South Africa (SA). A multidisciplinary team in Rustenburg, SA, has implemented an ARP with the first same-day discharge (SDD) from hospital. The lack of evidence of physiotherapy protocols within an ARP determined our study.

Objectives

Determine and compare hospital length of stay (LOS) (hours), patient satisfaction (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)), patient safety (30-day re-admission) and cost between the two cohorts.

Method

A quantitative prospective patient (treatment) group receiving early mobilisation with increased frequency of physiotherapy on post-operative day zero (POD0) was compared to a conservatively managed retrospective historical (control) group following post-operative elective hip and knee arthroplasties.

Results

Results for the prospective group which were significantly improved relative to the retrospective group included decreased LOS (median 7.650, p < 0.001), less pain at 6 weeks (mean 16.20, standard deviation [SD] = 2.673, p < 0.001), less stiffness (mean 5.82, SD = 1.214, p = 0.007), higher function (mean 54.87, SD = 8.544, p < 0.001), lower hospital cost (mean R43 340, p < 0.001) and physiotherapy cost (mean R1069, p < 0.001), and total costs compared to the retrospective group (mean R117 062, p < 0.001).

Conclusion

Safe and cost-effective SDD is possible in an ARP with earlier mobilisation and increased frequency of physiotherapy on POD0.

Clinical implications

Achieving safe SDD after hip and knee arthroplasty surgeries saved costs and improved patient satisfaction, with a decrease in LOS being beneficial for medical funders and stakeholders including government aiming to implement National Health Insurance (NHI) in the future.

On the generalizability of same-day partial knee replacement surgery-A non-selective interventional study evaluating efficacy, patient satisfaction, and safety in a public hospital setting

PURPOSE

Programs referred to as Fast-Track/Rapid Recovery/Enhanced Recovery After Surgery have proven both effective and safe in joint replacement surgery, to the degree where same-day discharge (SDD) has been attempted in carefully selected cases at specialized outpatient units. Therefore, the primary aim of this study was to evaluate a same-day surgery protocol regarding safety using the minor partial knee replacement (PKR) procedure by non-selectively recruiting patients at a public hospital for one consecutive year.

METHODS

33 unselected PKR cases were included in this open clinical trial. The inclusion/exclusion criteria were solely based on logistics, as all the procedures were medial PKRs, designated the first morning slots, and performed by one single-surgeon. Strict postoperative criteria based on vital parameters, urinary function, bleeding, and mobilization had to be met before discharge was considered. SDD rate, patient satisfaction, number of outpatient visits, adverse events and readmissions within 90 days were evaluated. A predetermined subgroup analysis was also conducted where patients <80 yrs. and with an American Society of Anesthesiologists (ASA) classification <III was compared with those aged ≥80 yrs. and/or ASA class ≥III.

RESULTS

29 of 33 (88%) successfully achieved SDD. In a univariate comparison, 100% of the patients <80 yrs. and ASA class <III achieved SDD, whereas a corresponding 43% applied for those aged ≥80 yrs. and/or ASA class ≥III (p = 0.001). A 93% overall satisfaction rate was reached. Only 8% extra outpatient visits were required, all occurring within the first 2 weeks (well in line with routine practice.) One plausible transient ischemic attack and one readmission caused by a penetrating trauma not affecting the knee were identified, both of which happened 10 weeks after surgery. No adverse events or readmissions occurred within the first 48 hours of surgery.

CONCLUSION

When following strict criteria for discharge, same-day partial knee replacement surgery may be both feasible and safe, even without preselection of patients.

The patient perspective, experience and satisfaction of day case unicompartmental knee arthroplasty: A short-term mixed-methods study

BACKGROUND

Day case unicompartmental knee arthroplasty (UKA) is increasingly being performed worldwide. When performed in the appropriate patient, day case UKA has been demonstrated to be safe, cost effective and improve resource allocation. Limited evidence highlights increased patient satisfaction of day case UKA when compared with inpatient UKA. A detailed study of the patient perspective, experience and satisfaction following day case UKA has not been described before.

METHODS

A retrospective case series review of 21 consecutive patients (19 unilateral, 2 bilateral) undergoing day case UKA in an elective orthopaedic centre was undertaken. A qualitative and quantitative patient assessment of the day case UKA experience was administered. A five-point Likert scale satisfaction questionnaire, Oxford Knee Score (OKS) and open-ended interview was undertaken. The qualitative responses underwent thematic analysis.

RESULTS

One hundred percent of patients expressed satisfaction (76.2% completely satisfied, 33.8% moderately satisfied) with day case UKA. The majority of patients (90.5%) reported that if they had to undergo UKA again they would prefer a day case over an inpatient procedure. Patients consider surgical outcome, physiotherapy provision, discharge planning, postoperative medications and follow up as key aspects of day case UKA care. One patient was re-admitted following discharge.

CONCLUSIONS

The present study demonstrates a high level of patient satisfaction with day case UKA. The results reported herein are subject to the study limitations of sample size, recall bias and inclusion criteria. We recommend that the themes identified by patients are addressed through a multidisciplinary approach with well-defined clinical pathways for a high-quality patient-centred experience.

Introducing a day-case arthroplasty pathway significantly reduces overall length of stay

Aims

Day-case arthroplasty is gaining popularity in Europe. We report outcomes from the first 12 months following implementation of a day-case pathway for unicompartmental knee arthroplasty (UKA) and total hip arthroplasty (THA) in an NHS hospital.

Methods

A total of 47 total hip arthroplasty (THA) and 24 unicompartmental knee arthroplasty (UKA) patients were selected for the day-case arthroplasty pathway, based on preoperative fitness and agreement to participate. Data were likewise collected for a matched control group (n = 58) who followed the standard pathway three months prior to the implementation of the day-case pathway. We report same-day discharge (SDD) success, reasons for delayed discharge, and patient-reported outcomes. Overall length of stay (LOS) for all lower limb arthroplasty was recorded to determine the wider impact of implementing a day-case pathway.

Results

Patients on the day-case pathway achieved SDD in 47% (22/47) of THAs and 67% (16/24) of UKAs. The most common reasons for failed SDD were nausea, hypotension, and pain, which were strongly associated with the use of fentanyl in the spinal anaesthetic. Complications and patient-reported outcomes were not significantly different between groups. Following the introduction of the day-case pathway, the mean LOS reduced significantly by 0.7, 0.6, and 0.5 days respectively in THA, UKA, and total knee arthroplasty cases (p < 0.001).

Conclusion

Day-case pathways are feasible in an NHS set-up with only small changes required. We do not recommend fentanyl in the spinal anaesthetic for day-case patients. An important benefit seen in our unit is the so-called ‘day-case effect’, with a significant reduction in mean LOS seen across all lower limb arthroplasty.

Cite this article: Bone Jt Open 2021;2(11):900–908.

Physiotherapy in an advanced rehabilitation pathway for patients after hip and knee arthroplasty: A proposal

Background

Accelerated rehabilitation pathway (ARP) decrease patients’ hospital length of stay (LOS). A lack of evidence exists on physiotherapy management and outcome as part of ARP in South Africa (SA). Our study will aim to determine whether early mobilisation and increased frequency of physiotherapy treatments for participants after hip or knee arthroplasty surgery on post-operative day 0 (POD 0) affect outcome.

Methods/design

A quantitative prospective cohort study incorporating ARP on (n = 60) non-randomised elective hip and knee arthroplasty participants will be compared with a more conservatively managed historical control group (n = 60). The physiotherapy protocol includes early mobilisation and exercises 1–3 h post-operatively on POD 0 and a second mobilisation and exercise session, 1–2 h later. Outcomes measures are as follows: hours for LOS, the WOMAC measured pre-operatively, 6 weeks and 3 months post-operatively, 30-day readmission for safety and cost comparison between the prospective and historical cohorts. Descriptive statistics will be undertaken. A paired t-test will be used to analyse each of the outcome measures across the time periods if data are normally distributed. Length of stay, WOMAC score and cost data will be compared between the groups, using a Mann–Whitney U test. The occurrence of adverse events will be compared between the groups using Pearson’s chi-square tests. The confidence interval will be set at 95% and p = 0.05 will be considered statistically significant.

Discussion

Globally, ARP’s are successfully implemented to manage patients presenting with hip and knee osteoarthritis (OA). Research investigating physiotherapy protocols in an ARP is lacking in the literature.

Conclusion

Achieving the same-day discharge after hip and knee arthroplasty surgeries may help elective surgery backlogs and waiting lists in a more cost-effective manner.

Clinical implications

The same day discharge after arthroplasty may be a cost-effective management option in the future.

Protocol identification

Pan African Clinical Trial Registry, PACTR202103637993156.

Outpatient physiotherapy versus home-based rehabilitation for patients at risk of poor outcomes after knee arthroplasty: CORKA RCT

BACKGROUND

Over 100,000 primary knee arthroplasty operations are undertaken annually in the UK. Around 15-30% of patients do not report a good outcome. Better rehabilitation strategies may improve patient-reported outcomes.

OBJECTIVES

To compare the outcomes from a traditional outpatient physiotherapy model with those from a home-based rehabilitation programme for people assessed as being at risk of a poor outcome after knee arthroplasty.

DESIGN

An individually randomised, two-arm controlled trial with a blinded outcome assessment, a parallel health economic evaluation and a nested qualitative study.

SETTING

The trial took place in 14 NHS physiotherapy departments.

PARTICIPANTS

People identified as being at high risk of a poor outcome after knee arthroplasty.

INTERVENTIONS

A multicomponent home-based rehabilitation package delivered by rehabilitation assistants with supervision from qualified therapists compared with usual-care outpatient physiotherapy.

MAIN OUTCOME MEASURES

The primary outcome was the Late Life Function and Disability Instrument at 12 months. Secondary outcomes were the Oxford Knee Score (a disease-specific measure of function); Knee injury and Osteoarthritis Outcome Score; Quality of Life subscale; Physical Activity Scale for the Elderly; EuroQol-5 Dimensions, five-level version; and physical function assessed using the Figure-of-8 Walk Test, 30-Second Chair Stand Test and Single Leg Stance. Data on the use of health-care services, time off work and informal care were collected using participant diaries.

RESULTS

In total, 621 participants were randomised. A total of 309 participants were assigned to the COmmunity based Rehabilitation after Knee Arthroplasty (CORKA) home-based rehabilitation programme, receiving a median of five treatment sessions (interquartile range 4-7 sessions). A total of 312 participants were assigned to usual care, receiving a median of four sessions (interquartile range 2-6 sessions). The primary outcome, Late Life Function and Disability Instrument function total score at 12 months, was collected for 279 participants (89%) in the home-based CORKA group and 287 participants (92%) in the usual-care group. No clinically or statistically significant difference was found between the groups (intention-to-treat adjusted difference 0.49 points, 95% confidence interval -0.89 to 1.88 points; p = 0.48). There were no statistically significant differences between the groups in any of the patient-reported or physical secondary outcome measures at 6 or 12 months post randomisation. The health economic analysis found that the CORKA intervention was cheaper to provide than usual care (£66 less per participant). Total societal costs (combining health-care costs and other costs) were lower for the CORKA intervention than usual care (£316 less per participant). Adopting a societal perspective, CORKA had a 75% probability of being cost-effective at a threshold of £30,000 per quality-adjusted life-year. Adopting the narrower health and social care perspective, CORKA had a 43% probability of being cost-effective at the same threshold.

LIMITATIONS

The interventions were of short duration and were set within current commissioning guidance for UK physiotherapy. Participants and treating therapists could not be blinded.

CONCLUSIONS

This randomised controlled trial found no important differences in outcomes when post-arthroplasty rehabilitation was delivered using a home-based, rehabilitation assistant-delivered rehabilitation package or a traditional outpatient model. However, the health economic evaluation found that when adopting a societal perspective, the CORKA home-based intervention was cost-saving and more effective than, and thus dominant over, usual care, owing to reduced time away from paid employment for this group. Further research could look at identifying the risk of poor outcome and further evaluation of a cost-effective treatment, including the workforce model to deliver it.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13517704.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 65. See the NIHR Journals Library website for further project information.

Why are patients still in hospital after fast-track, unilateral unicompartmental knee arthroplasty

Background and purpose - Previous studies have investigated risk factors related to prolonged length of stay following total knee arthroplasty (TKA), but little is known about specific factors resulting in continued hospitalization within the 1st postoperative days after unicompartmental knee arthroplasty (UKA). We investigated what specific factors prevent patients from being discharged on the day of surgery (DOS) and the first postoperative day (POD-1) following primary UKA in a fast-track setting.Patients and methods - We prospectively collected data on 100 consecutive and unselected medial UKA patients operated from December 2017 to May 2019. All patients were operated in a standardized fast-track setup with functional discharge criteria continuously evaluated from DOS and until discharge.Results - Median length of stay for the entire cohort was 1 day. 22% and 78% of all patients were discharged on DOS and POD-1, respectively. Lack of mobilization and pain separately delayed discharge in respectively 78% and 24% of patients on DOS. The main reasons for lack of mobilization were motor blockade (37%) and logistical factors (26%). For patients placed 1st or 2nd on the operating list, we estimate that the same-day discharge rate would increase to 55% and 40% respectively, assuming that pain and mobilization were successfully managed.Interpretation - One-fifth of unselected UKA patients operated in a standardized fast-track setup were discharged on DOS. Pain and lack of mobilization were the major reasons for continued hospitalization within the initial postoperative 24-48 hours. Strategies aimed at decreasing length of stay after UKA should strive to improve analgesia and postoperative mobilization.

Effectiveness of prehabilitation for patients undergoing orthopaedic surgery: protocol for a systematic review and meta-analysis

INTRODUCTION

Undergoing major surgery can induce physical and functional decline. Prehabilitation programmes aim to improve physical fitness and function preoperatively and could enhance postoperative recovery and outcomes. Prehabilitation interventions have been utilised across a range of orthopaedic populations of all ages and can be multimodal in nature. The aim of this study is to evaluate the effectiveness of prehabilitation for patients undergoing orthopaedic surgery including day surgery procedures. It will also investigate the components of prehabilitation to understand optimum duration and frequency of programmes.

METHODS/DESIGN

Systematic review and meta-analysis designed in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. A comprehensive electronic search will be performed in MEDLINE, CINAHL, AMED, Embase, PEDro and Cochrane CENTRAL databases in order to identify randomised control trials published between January 2000 to 25 March 2019. ISI Web of Science, System for information on grey literature and the European Union clinical trials registry will identify studies that are underway or unpublished. Two independent reviewers will carry out the searches, study selection (title and abstract and full text stages), data extraction, risk of bias assessment (Cochrane Risk of Bias tool 2.0) and evaluation of overall strength of evidence. Meta-analyses will be used for data which demonstrates homogeneity, otherwise a narrative synthesis will be performed for groups of studies of high heterogeneity (I2 >50%). The overall strength of the body of evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation.

ETHICS AND DISSEMINATION

This study raises no ethical issues. This study aims to identify the effectiveness of prehabilitation interventions and may assist clinicians in determining which components, duration, frequency and the method of delivery would form the most effective prehabilitation intervention for patients undergoing an orthopaedic surgical procedure. The findings will be disseminated through publication in a peer-reviewed journal and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42019123268.