Total knee arthroplasty: does ultra-early physical therapy improve functional outcomes and reduce length of stay? A retrospective cohort study

BACKGROUND

The Enhanced Recovery After Surgery (ERAS) Society recommends that after total knee arthroplasty (TKA), patients should be mobilized early. However, there is no consensus on how early physical therapy should be commenced. We aim to investigate whether ultra-early physical therapy (< 12 h postoperatively) leads to better outcomes.

METHODS

This is a retrospective cohort study of 569 patients who underwent primary TKA from August 2017 to December 2019 at our institution. We compared patients who had undergone physical therapy either within 24 h or 24-48 h after TKA. Further subgroup analysis was performed on the < 24 h group, comparing those who had undergone PT within 12 h and within 12-24 h. The outcomes analyzed include the Oxford Knee Scoring System score, Knee Society Scores, range of motion (ROM), length of stay (LOS) and ambulatory distance on discharge. A student's t test, chi-squared test or Fisher's exact test was used where appropriate, to determine statistical significance of our findings.

RESULTS

LOS in the < 24 h group was shorter compared to the 24-48 h group (4.87 vs. 5.34 days, p = 0.002). Subgroup analysis showed that LOS was shorter in the ultra-early PT (< 12 h) group compared to the early PT (12-24 h) group (4.75 vs. 4.96 days, p = 0.009). At 3 months postoperatively, there was no significant difference in ROM, ambulatory distance or functional scores between the < 24 h group and 24-48 h group, or on subgroup analysis of the < 24 h group.

CONCLUSION

Patients who underwent physical therapy within 24 h had a shorter length of stay compared to the 24-48 h group. On subgroup analysis, ultra-early (< 12 h) physical therapy correlated with a shorter length of stay compared to the 12-24 h group (4.75 vs. 4.96 days, p = 0.009) - however, the difference is small and unlikely to be clinically significant. Ultra-early (< 12 h) physical therapy does not confer additional benefit in terms of functional scores, ROM or ambulatory distance. These findings reinforce the importance of early physical therapy after TKA in facilitating earlier patient discharge.

Impact of enhanced recovery pathways on safety and efficacy of hip and knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

Over the past decades, clinical pathways (CPs) for hip and knee arthroplasty have been strongly and continuously evolved based on scientific evidence and innovation.

AIM

The present systematic review, including meta-analysis, aimed to compare the safety and efficacy of enhanced recovery pathways (ERP) with regular pathways for patients with hip and/or knee arthroplasty.

METHODS

A literature search in healthcare databases (Embase, PubMed, Cochrane Library, CINAHL, and Web of Science) was conducted from inception up to June 2018. Relevant randomized controlled trials as well as observational studies comparing ERP, based on novel evidence, with regular or standard pathways, prescribing care as usual for hip and/or knee arthroplasty, were included. The effect of both CPs was assessed for (serious) adverse events [(S)AEs], readmission rate, length of hospital stay (LoS), clinician-derived clinical outcomes, patient reported outcome measures (PROMs), and financial benefits. If possible, a meta-analysis was performed. In case of considerable heterogeneity among studies, a qualitative analysis was performed.

RESULTS

Forty studies were eligible for data extraction, 34 in meta-analysis and 40 in qualitative analysis. The total sample size consisted of more than 2 million patients undergoing hip or knee arthroplasty, with a mean age of 66 years and with 60% of females. The methodological quality of the included studies ranged from average to good. The ERP had lower (S)AEs [relative risk (RR): 0.9, 95% confidence interval (CI): 0.8-1] and readmission rates (RR: 0.8, 95%CI: 0.7-1), and reduced LoS [median days 6.5 (0.3-9.5)], and showed similar or improved outcomes for functional recovery and PROMs compared to regular pathways. The analyses for readmission presented a statistically significant difference in the enhanced recovery pathway in favor of knee arthroplasties (P = 0.01). ERP were reported to be cost effective, and the cost reduction varied largely between studies (€109 and $20573). The overall outcomes of all studies reported using Grading of Recommendation, Assessment, Development and Evaluation, presented moderate or high quality of evidence.

CONCLUSION

This study showed that implementation of ERP resulted in improved clinical and patient related outcomes compared to regular pathways in hip and knee arthroplasty, with a potential reduction of costs.

Ambulation milestones in post-operative physical therapy after total knee arthroplasty: how can we improve short-term outcomes?

Introduction: Post-operative day (POD) 0 physical therapy (PT) after total knee arthroplasty (TKA) has been associated with improved outcomes such as shorter hospital length of stay (LOS), though patient performance is variable. The purpose of this study was to evaluate PT performance and determine whether this affected LOS or discharge to home.Methods: Retrospective review including 412 patients who underwent TKA over 1 year. Specific data assessed included details about demographics, surgery/recovery, PT, LOS, and discharge destination.Results: Overall, 88.8% (366/412) of patients received POD 0 PT. About 73.9% of patients who did not receive POD 0 PT were prevented from doing so by reasons that kept them off of the orthopedic inpatient floor. Patients who walked greater than 10 feet on POD 0 or 100 feet on POD 1 were significantly more likely to have a shorter LOS and more likely to be discharged to home.Discussion: Objective milestones of walking 10 feet on POD 0 and 100 feet on POD 1 were associated with improved short-term outcomes. These performance markers may be useful for stratifying which patients are meeting milestones for early discharge. Late arrival to inpatient floor had the strongest associations with inability to perform PT.

Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review

Background

Elective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.

Objectives

To evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.

Data sources

Seven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.

Review methods

Comparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.

Findings

A total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.

Limitations

Studies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.

Conclusions

Enhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.

Future work

Further studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.

Study registration

This study is registered as PROSPERO CRD42017080637.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Use of an Accelerated Discharge Pathway in Patients With Severe Cerebral Palsy Undergoing Posterior Spinal Fusion for Neuromuscular Scoliosis

BACKGROUND

Implementation of a coordinated multidisciplinary postoperative pathway has been shown to reduce length of stay after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis. This study sought to compare the outcomes of nonambulatory cerebral palsy (CP) patients treated with PSF and cared for using an accelerated discharge (AD) pathway with those using a more traditional discharge (TD) pathway.

METHODS

A total of 74 patients with Gross Motor Function Classification System (GMFCS) class 4/5 CP undergoing PSF were reviewed. Thirty consecutive patients were cared for using a TD pathway, and 44 patients were subsequently treated using an AD pathway. The cohorts were then evaluated for postoperative complications and length of stay.

RESULTS

Length of stay (LOS) was 19% shorter in patients managed with the AD pathway (AD 4.0 days [95% CI 2.5-5.5] vs. TD 4.9 days [95% CI 3.5-6.3], p = .01). There was no difference between groups with respect to age at surgery, GMFCS class, preoperative curve magnitude, pelvic obliquity, kyphosis, postoperative curve correction, fusion to the pelvis, or length of fusion between groups. Length of stay remained significantly shorter in the AD group by 0.9 days when controlling for estimated blood loss (EBL) and length of surgery. Complication rates trended lower in the AD group (33% AD vs. 52% TD, p = .12), including pulmonary complications (21% AD vs. 38% TD, p = .13). There was no significant difference in wound complications, return to the operating room, or medical readmissions between groups.

CONCLUSIONS

Adoption of a standardized postoperative pathway reduced LOS by 19% in nonambulatory CP patients. Overall, complications, including pulmonary, trended lower in the AD group. Early discharge appears to be possible in this challenging patient population. Although the AD pathway may not be appropriate for all patients, the utility of the AD pathway in optimizing care for more routine PSF for this patient subset appears to be worthwhile.

LEVEL OF EVIDENCE

Level III, therapeutic.

Impact of early mobilization on length of stay after primary total knee arthroplasty

Background

Decreasing length of stay (LOS) following primary total knee arthroplasty (TKA) has been an important focus by all the stakeholders involved in the delivery of care. LOS is dictated by both the patient and hospital-related factors. The purpose of this study was to determine if early mobilization on post-operative day 0 (POD 0) following primary TKA has an effect on hospital LOS and discharge to home vs. rehabilitation facilities.

Methods

An analysis was performed of consecutive primary TKAs performed at a single institution over one year. Patients were assigned to two groups: POD 0 or POD 1, based on their day of mobilization. Patients were mobilized following surgery based on time of arrival to the orthopaedic floor and availability of physical therapy (PT) resources. The two groups were compared for LOS and discharge disposition using univariate analysis. A total of 408 consecutive TKAs were evaluated and from this group, a total of 143 patients who were mobilized on POD 0 were then matched to 143 patients mobilized on POD 1. There were no significant differences in age, sex, American Society of Anesthesiologists score, or body mass index (BMI) between POD 0 and POD 1 groups.

Results

There was a significant difference in LOS between POD 0 and POD 1 groups, 2.44 vs. 2.80 days (P=0.002). There were also differences in discharge to home vs. rehabilitation, 70.63% of the POD 0 cohort were discharged home compared to 58.74% in POD 1 (P=0.035).

Conclusions

There was a significant reduction in LOS and there were differences in discharge disposition between patients who mobilized on POD 0 vs. POD 1, with more patients mobilized on POD 0 discharged home. Hospitals should work with their total joint arthroplasty programs to mobilize close to 100% of the patients undergoing primary TKA on POD 0 in order to decrease LOS and healthcare expenditure.

Influence of early mobilization program on pain, self-reported and performance based functional measures following total knee replacement

BACKGROUND

Total knee replacement (TKR) is an optimal treatment for persons with severe knee joint pain and disability, who were unsuccessful with conservative management. Early mobilization can be defined as moving out of bed and/or walking quickly after the surgery for reducing the risks allied with bed rest. There is a paucity of studies on effects of early mobilization on a performance-based measure of timed up and go test (TUG), six-minute walk test (SMWT) and a self-reported disease-specific measure of a knee injury and Osteoarthritis outcome score (KOOS) following TKR.

METHODS

A prospective pre-post-trial was conducted at Manipal Hospital, Bangalore, India. Participants underwent early (POD '0') mobilization on the same postoperative day within 7 h post-TKR surgery. Outcome measures were recorded by an independent blinded observer. The statistical significance level was set at 'p' value < 0.05. The difference between pre-operative and post-operative outcome measure at 1 month and 3 months post-intervention were analyzed using repeated measures of ANOVA.

RESULTS

The study included a total of 78 participants (59 Females; 19 Males) and the mean age of the included participants was 64.1 ± 7 years. Amongst, 78 participants, 53 underwent unilateral TKR, 25 underwent bilateral TKR. There were three dropouts in the study due to post-operative complications. Significant improvements from pre-operative to one month were observed following POD '0' mobilization on NPRS (7.35 ± 1.2 to 4.3 ± 1.7), SMWT (169 ± 70 to 236.7 ± 80.7). KOOS subscales of pain, symptom, and quality of life showed significant changes at one month and 3 months. TUG, Knee strength, Knee ROM and KOOS ADL subscale shown improvements only at 3 months post-intervention.

CONCLUSION

Our study findings suggest that POD '0' (early) mobilization can result in reduced pain and an increase in walking speed at 1 month. Significant changes were observed in pain, Knee strength, Knee ROM, TUG, SMWT and KOOS subscales at 3 months following total knee replacement.

Early mobilisation after total hip or knee arthroplasty: A multicentre prospective observational study

Objective

Early mobilisation is recommended following total hip arthroplasty (THA) or total knee arthroplasty (TKA) to prevent venous thromboembolism (VTE). We sought to determine the proportions of patients that first mobilised on post-operative day 0 (POD 0) and factors associated with earlier time to mobilisation.

Methods

A prospective cohort study was conducted involving patients with hip or knee osteoarthritis who had undergone primary unilateral THA (n = 818) and TKA (n = 989) at 19 Australian hospitals. Patient-related (e.g. age, gender, body mass index), treatment-related (e.g. hospital site, presence of indwelling catheter) and mobilisation-related variables were collected on standardised forms. Time was measured by post-operative days, where POD 0 was defined as the day of surgery ending at midnight. Multivariate Poisson regression analysis identified associations between patient- and treatment-related covariates and time to mobilisation.

Results

Inter-hospital variation was evident, but overall, only 9.4% of THA and 5.6% of TKA patients mobilised on POD 0. For THA patients, earlier time to mobilisation was associated with hospital site and absences of an indwelling catheter and acute complications. For TKA patients, earlier time to mobilisation was associated with hospital site and absence of donor blood transfusion.

Conclusions

Few THA and TKA patients mobilise POD 0, although some hospitals appear more aggressive with their mobilisation attempts than others. Treatment-related factors, not patient-related, are associated with post-operative day of mobilisation, indicating the potentially pivotal role of service providers in promoting early mobilisation to improve health outcomes and reduce rates of VTE.

The Effect of a Rapid Rehabilitation Program on Patients Undergoing Unilateral Total Knee Arthroplasty

BACKGROUND

Few studies have looked at longer term functional outcomes of rapid rehabilitation (physical therapy in the postanesthesia care unit on the day of surgery) for patients undergoing total knee arthroplasty.

PURPOSE

The purpose of this interdisciplinary study (physical therapy and nursing) was to assess the effect of a rapid rehabilitation program on inpatient length of stay (LOS) and functional recovery.

METHODS

Functional outcomes were measured by the Knee Injury Osteoarthritis Outcome Score presurgically and at 4 and 12 weeks postoperatively and by progression along a physical therapy rehabilitation pathway.

RESULTS

Experimental group LOS was significantly shorter than the control group (p = .0261). Multilevel regression modeling showed that KOOS and physical therapy clinical pathway score trajectories did not differ significantly between groups. Patients receiving rapid rehabilitation were 2.5 (95% CI [0.958, 6.53]) times more likely to have a positive physical therapy rehabilitation trajectory than patients in the control group.

CONCLUSION

Findings validated earlier study results in terms of LOS; however, further research is needed to assess the effect of rapid rehabilitation on longer term functional outcomes.

Early commencement of physical therapy in the acute phase following elective lower limb arthroplasty produces favorable outcomes: a systematic review and meta-analysis examining allied health service models

BACKGROUND

Temporal and dose-response relationships between allied health (AH) and recovery in the acute phase following lower limb (LL) arthroplasty are unclear. This systematic review investigates whether early commencement, additional therapy and/or weekend AH affects length of stay (LOS) and patient outcomes in the acute phase following LL arthroplasty.

METHODS

Electronic databases were searched in February 2015. Studies were included if they evaluated any of the following aspects of AH for adults following LL arthroplasty in the acute phase: Early compared to later therapy commencement; Additional therapy; or a 6- or 7-day service compared to a lesser service.

RESULTS

Twenty-four studies met the inclusion criteria, of which 19 investigated effects of physical therapy (PT) alone. Earlier PT reduced LOS (WMD = -1.23 days; 95% CI, -2.16 to -0.30) and resulted in higher probability of discharge directly home (relative risk = 1.45; 95% CI, 1.26-1.67). Addition of weekend PT reduced LOS (WMD = -1.04 days; 95% CI, -1.66 to -0.41) and improved function (SMD = 0.37; 95% CI, 0.02-0.73). Increasing PT from once to twice daily did not affect LOS (WMD = -0.35 days; 95% CI, -0.96-0.26) or function (SMD = 0.31; 95% CI, -0.06-0.71).

DISCUSSION

Early PT commencement and a weekend service may produce favorable outcomes following LL arthroplasty when baseline LOS is 4 days or more. Redistributing PT resources to commence as early as day of surgery regardless of weekday may accelerate postoperative recovery. Current, high quality research is needed to confirm these findings.

Improving value in primary total joint arthroplasty care pathways: changes in inpatient physical therapy staffing

Background

An early physical therapy (PT) care pathway was implemented to provide same-day ambulation after total joint arthroplasty by changing PT staffing hours.

Methods

After receiving an exemption from our institutional review board, we performed a secondary data analysis on a cohort of patients that underwent primary TJA of the hip or knee 6 months before and 12 months after implementation of the change. Data on same-day ambulation rates, length of stay (LOS), and in-hospital costs were reviewed.

Results

Early evaluation and mobilization of patients by PT improved on postoperative day (POD) 0 from 64% to 85% after the change (P ≤ .001). The median LOS before the change was 3.27 days compared to 3.23 days after the change (P = .014). Patients with higher American Society of Anesthesiologists scores were less likely to ambulate on POD 0 (P = .038) and had longer hospital stays (P < .001). Early mobilization in the entire cohort was associated with a greater cost savings (P < .001).

Conclusions

A relatively simple change to staffing hours, using resources currently available to us, and little additional financial or institutional investment resulted in a significant improvement in the number of patients ambulating on POD 0, with a modest reduction in both LOS and inpatient costs.

Outpatient rehabilitation care process factors and clinical outcomes among patients discharged home following unilateral total knee arthroplasty

Research examining care process variables and their relationship to clinical outcomes after total knee arthroplasty has focused primarily on inpatient variables. Care process factors related to outpatient rehabilitation have not been adequately examined. We conducted a retrospective review of 321 patients evaluating outpatient care process variables including use of continuous passive motion, home health physical therapy, number of days from inpatient discharge to beginning outpatient physical therapy, and aspects of outpatient physical therapy (number of visits, length of stay) as possible predictors of pain and disability outcomes of outpatient physical therapy. Only the number of days between inpatient discharge and outpatient physical therapy predicted better outcomes, suggesting that this may be a target for improving outcomes after total knee arthroplasty for patients discharged directly home.

The use of exparel (liposomal bupivacaine) to manage postoperative pain in unilateral total knee arthroplasty patients

Efforts continue to improve pain after total knee arthroplasty (TKA) in order to allow for accelerated rehabilitation. The purpose of this study was to evaluate pain control after TKA. A randomized prospective study of 80 consecutive patients was performed comparing Exparel versus femoral nerve block (FNB). Inpatient pain control was the primary outcome. Secondary outcome measures included ROM (extension and flexion), nausea and vomiting, narcotic consumption, ambulation distance, and length of stay (LOS). There were no statistically significant differences between the groups with regard to pain, nausea and vomiting, and narcotic consumption. The FNB group had greater flexion but the Exparel group had improved early ambulation and decreased LOS. Exparel provided similar pain relief to a FNB after TKA without compromising early rehabilitation.

Gait variability before surgery and at discharge in patients who undergo total knee arthroplasty: a cohort study

This study aimed to determine gait ability at hospital discharge in patients undergoing total knee arthroplasty (TKA) as an indicator of the risk of falling. Fifty-seven patients undergoing primary TKA for knee osteoarthritis participated in this study. Gait variability measured with accelerometers and physical function including knee range of motion (ROM), quadriceps strength, walking speed, and the Timed Up and Go (TUG) test were evaluated preoperatively and at discharge from the hospital (1 month before and 5 days after surgery). All patients were discharged directly home at 5 days after surgery. Knee flexion of ROM, quadriceps strength, walking speed, and the TUG test results were significantly worse at hospital discharge than preoperatively (p < 0.001). However, gait variability was not significantly different before and after TKA. This result indicated that patients following TKA surgery could walk at hospital discharge as stably as preoperatively regardless of the decrease in physical function, including knee ROM, quadriceps strength, and gait speed after surgery.

Impact of peripheral nerve block with low dose local anesthetics on analgesia and functional outcomes following total knee arthroplasty: a retrospective study

OBJECTIVE

While the safety and efficacy of peripheral nerve blocks for postoperative pain management has been established in several well controlled prospective trials, the local anesthetic (LA) concentration and volume used in these studies was associated with a significant increase muscle weakness due to motor nerve block. The purpose of the present retrospective study of patients undergoing total knee arthroplasty was to assess the relative analgesic efficacy and functional outcomes of the low concentration, low volume of LA used in peripheral nerve blocks for postoperative pain management.

METHODS

Twenty-four months of deidentified patient data were extracted from an electronic medical record system. All patients received opioids with or without continuous femoral and sciatic nerve block infusions for postoperative analgesia. Pain (resting and with activity), cumulative opioid and LA use were primary endpoints, participation in physical therapy (PT), muscle strength deficits and length of hospital stay (LOS) were secondary endpoints.

RESULTS

Postoperative pain and opioid use were significantly lower in patients with peripheral nerve blocks (n = 1,329) than those with opioids alone (n = 439). There was no detectable decrease in strength associated with nerve blocks, while a significantly greater proportion of patients with nerve blocks were able to participate in PT on postoperative day 1 (96.4% vs 57.1%). These differences were not due to the impact of the surgeon per se, but whether or not the surgeon used nerve blocks for pain management. There was a small but statistically significant decrease in the average LOS in patients with blocks.

CONCLUSION

This analysis supports the use of low concentration, low volume of LA based peripheral nerve blocks for postoperative pain management.

Continuous Improvements of a Clinical Pathway Increased Its Feasibility and Improved Care Providers' Perception in TKA

Purpose

We aimed to determine 1) whether dropout rate decreased and 2) whether health care providers' perceptions were changed with continued improvements of contents of clinical pathway (CP) for total knee arthroplasty (TKA).

Materials and Methods

This retrospective study included two separate analyses of patients and health care providers. In the analysis of patients, dropout rates and reasons were evaluated in two cohorts of patients who underwent TKA with CP applied at two different time periods (384 patients from 2009 to 2010 and 242 patients from 2012 to 2013). Contents of CP were continuously improved during the 3-year interval. Self-administered questionnaire surveys targeted to health care providers were carried out twice (2010 and 2013) and compared.

Results

Dropout rate decreased from 19.1% in the first time period to 10.4% in the second time period. Although overall satisfaction of care providers was high at both time-points, doctors had more favorable perceptions than nurses; most positive changes of perception were noted in nurses. The health care providers' perceptions for potential concerns of CP were improved while the perceptions for potential benefits and satisfaction were maintained.

Conclusions

Continuously improved CP has increased feasibility for TKA patients and reduced health care providers' concern about its value. We propose that CP can be implemented and actively used to improve the outcomes and efficacy of patient care for TKA, regardless of the rotation of care providers.

Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: a systematic review

OBJECTIVE

To systematically review the effect of early mobilization after hip or knee joint replacement surgery on length of stay in an acute hospital.

METHODS

Randomized controlled trials were selected from electronic databases based on inclusion criterion requiring an experimental group mobilizing (sitting out of bed/walking) earlier than a comparison group post joint replacement surgery of the hip or knee in an acute hospital. Clinically homogeneous data were analyzed with meta-analysis.

RESULTS

Five randomized controlled trials (totaling 622 participants) were included for review. A meta-analysis of 5 trials found a reduced length of stay of 1.8 days (95% confidence interval 1.1 to 2.6) in favor of the experimental group. In 4 of the 5 trials the experimental group first sat out of bed within 24 hours post operatively. In 4 of the 5 trials the experimental group first walked within 48 hours post operatively. Individual trials reported benefits in range of motion, muscle strength and health-related quality of life in favor of the experimental group. There were no differences in discharge destinations, incidence of negative outcomes or adverse events attributable to early mobilization when compared to the comparison groups.

CONCLUSION

Early mobilization post hip or knee joint replacement surgery can result in a reduced length of stay of about 1.8 days. Trials that reported these positive results showed that early mobilization can be achieved within 24 hours of operation. This positive gain was achieved without an increase in negative outcomes.

Fast-track hip and knee arthroplasty: clinical and organizational aspects

Fast-track hip and knee arthroplasty aims at giving the patients the best available treatment at all times, being a dynamic entity. Fast-track combines evidence-based, clinical features with organizational optimization including a revision of traditions resulting in a streamlined pathway from admission till discharge – and beyond. The goal is to reduce morbidity, mortality and functional convalescence with an earlier achievement of functional milestones including functional discharge criteria with subsequent reduced length of stay and high patient satisfaction. Outcomes are traditionally measured as length of stay; safety aspects in the form of morbidity/mortality; patient satisfaction; and – as a secondary parameter – economic savings. Optimization of the clinical aspects include focusing on analgesia; DVT-prophylaxis; mobilization; care principles including functional discharge criteria; patient-characteristics to predict outcome; and traditions which may be barriers in optimizing outcomes. Patients should be informed and motivated to be active participants and their expectations should be modulated in order to improve satisfaction. Also, organizational aspects need to be analyzed and optimized. New logistical approaches should be implemented; the ward ideally (re)structured to only admit arthroplasties; the staff educated to have a uniform approach; extensive preoperative information given including discharge criteria and intended length of stay. This thesis includes 9 papers on clinical and organizational aspects of fast-track hip and knee arthroplasty (I–IX). A detailed description of the fast-track set-up and its components is provided. Major results include identification of patient characteristics to predict length of stay and satisfaction with different aspects of the hospital stay (I); how to optimize analgesia by using a compression bandage in total knee arthroplasty (II); the clinical and organizational set-up facilitating or acting as barriers for early discharge (III); safety aspects following fast-track in the form of few readmissions in general (IV) and few thromboembolic complications in particular (V); feasibility studies showing excellent outcomes following fast-track bilateral simultaneous total knee arthroplasty (VI) and non-septic revision knee arthroplasty (VII); how acute pain relief in total hip arthroplasty is not enhanced by the use of local infiltration analgesia when multi-modal opioid-sparing analgesia is given (VIII); and a detailed description of which clinical and organizational factors detain patients in hospital following fast-track hip and knee arthroplasty (IX). Economic savings following fast-track hip and knee arthroplasty is also documented in studies, reviews, metaanalyses and Cochrane reviews – including the present fast-track (ANORAK). In conclusion, the published results (I–IX) provide substantial, important new knowledge on clinical and organizational aspects of fast-track hip and knee arthroplasty – with concomitant documented high degrees of safety (morbidity/mortality) and patient satisfaction. Future research strategies are multiple and include both research strategies as efforts to implement the fast-track methodology on a wider basis. Research areas include improvements in pain treatment, blood saving strategies, fluid plans, reduction of complications, avoidance of tourniquet and concomitant blood loss, improved early functional recovery and muscle strengthening. Also, improvements in information and motivation of the patients, preoperative identification of patients needing special attention and detailed economic studies of fast- track are warranted.