Early inpatient rehabilitation after elective hip and knee arthroplasty

Patient Frailty is Correlated With Increased Adverse Events and Costs After Revision Total Hip Arthroplasty

BACKGROUND

Frailty has been associated with poor outcomes and higher costs after primary total hip arthroplasty. However, frailty has not been studied in relation to outcomes after revision total hip arthroplasty (rTHA). This study examined the relationship between the Hospital Frailty Risk Score (HFRS), postoperative outcomes, and cost profiles following rTHA.

METHODS

In this retrospective cohort study, we identified patients who underwent rTHA from January 2017 to November 2019 in the Nationwide Readmission Database. The 3 most frequently reported diagnosis codes for rTHA were then selected: dislocation; mechanical loosening; and infection. We calculated the HFRS for each patient to determine frailty status. We compared 30-day readmission rate, length of stay, and hospitalization cost between frail and nonfrail patients, using multivariate logistic and negative binomial regressions to adjust for covariates. We identified 36,243 total patients who underwent rTHA. Overall, 15,448 patients had a revision for dislocation, 11,062 for mechanical loosening, and 9,733 for infection.

RESULTS

Compared to nonfrail patients, frail patients had higher rates of 30-day readmission, longer length of stay, and higher hospitalization cost. Frail patients had significantly higher rates of 30-day complication and 30-day reoperation.

CONCLUSIONS

Frailty, measured using HFRS, is associated with increased postoperative complications and costs after rTHA. The HFRS has the ability to efficiently identify frail patients at-risk for perioperative complications enabling care teams to better focus optimization interventions on this patient cohort.

An analysis of risk factors for venous thromboembolism in primary versus revision total joint arthroplasty

Background

One of the most serious complications after primary or revision lower extremity total joint arthroplasty (TJA) is venous thromboembolism disease (VTE). Identifying patients at high risk for VTE allows tailoring of prophylactic anticoagulation regimens to those most vulnerable. This study aimed to identify risk factors for VTE in primary and revision lower extremity TJA.

Methods

The Electronic Medical Record was queried from a single academic institution for all patients who underwent a lower extremity TJA between 2007 and 2020. Demographics, comorbid conditions, perioperative characteristics, and postoperative complications were identified. An Elastic Net Multiple Logistic Regression Model was used to assess 49 covariates and predict those associated with a significant risk of VTE.

Results

We identified 4900 primary and revision total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients. There was no significant difference between primary and revision THA. Primary TKA had a higher rate of VTE than revision TKA. Significant risk factors identified for VTE in THA patients include histories of deep vein thrombosis (DVT), pulmonary embolism (PE), metastatic tumors, hemiplegia, and Hispanic ethnicity. Risk factors for VTE in TKA patients include histories of DVT, PE, metastatic tumors, and postoperative warfarin and heparin use. In all patients, age was a significant predictor of VTE risk.

Conclusion

Our work identifies many risk factors for VTE following TJA. While the increased rate of VTE in some populations may represent selection bias, it also highlights the incomplete understanding of the etiology and prevention of this complication in the joint arthroplasty population and requires further study.

Guidelines on perioperative optimization protocol for the adult patient 2023

OBJECTIVE

The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs.

DESIGN

A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format.

RESULTS

The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations.

CONCLUSIONS

Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.

Frailty is Associated With Increased Complication, Readmission, and Hospitalization Costs Following Primary Total Knee Arthroplasty

BACKGROUND

Frailty has been associated with poor postoperative outcomes in various medical conditions and surgical procedures. However, the relationship between frailty and outcomes after primary total knee arthroplasty (TKA) has not been well-described. This study investigated the association of the Hospital Frailty Risk Score (HFRS) with postoperative events and hospitalization costs after primary TKA.

METHODS

Using a nationwide readmissions database, we identified 884,479 patients discharged after primary TKA for osteoarthritis between January 2017 and November 2019. HFRS was calculated for each patient to determine frailty status. We used multivariate logistic regressions to evaluate the association of frailty with 30-readmission rate and negative binomial regressions to evaluate lengths of hospital stay and hospitalization costs. The 30-day reoperation and complication rates were compared using chi-square tests.

RESULTS

Frailty was associated with increased odds of 30-day readmissions (odds ratio [OR]: 1.89, 95% confidence interval [CI]: 1.82-1.96), longer lengths of stay (OR: 1.43, 95% CI: 1.43-1.44), and higher hospitalization costs (OR: 1.16, 95% CI: 1.16-1.17). Frail patients also had significantly higher rates of 30-day reoperations (0.6 versus 0.4%), surgical complications (0.6 versus 0.4%), medical complications (3.4 versus 1.3%), and other complications (0.9 versus 0.5%) (P < .01).

CONCLUSIONS

Frailty, as measured using HFRS, was associated with increased adverse events and health care burdens in patients undergoing TKA. The HFRS could be used to swiftly identify high-risk patients undergoing TKA and to potentially help optimize patients prior to elective TKA.

TYPE OF STUDY

Level III retrospective cohort study.

Analysis and Report of the Physical and Rehabilitation Medicine Evaluation Activity in Patients Admitted to Acute Care Setting: An Observational Retrospective Study

BACKGROUND

Disability (both temporary and transitory, or definitive) might occur for the first time in a given patient after an acute clinical event. It is essential, whenever indicated, to undergo a Physical Medicine and Rehabilitation assessment to detect disability and any need for rehabilitation early. Although access to rehabilitation services varies from country to country, it should always be governed by a PRM prescription.

OBJECTIVE

The aim of the present observational retrospective study is to describe consultancy activity performed by PRM specialists in a university hospital in terms of requests' typology, clinical questions, and rehabilitation setting assignment.

METHODS

Multiple parameters were analyzed (clinical condition, patient's socio-family background, and rehabilitation assessment scale scores) and a correlation analysis was performed between the analyzed characteristics and both the different clinical conditions and the assigned rehabilitation setting.

RESULTS

PRM evaluations of 583 patients from 1 May 2021 to 30 June 2022 were examined. Almost half of the total sample (47%) presented disability due to musculoskeletal conditions with a mean age of 76 years. The most frequently prescribed settings were home rehabilitation care, followed by intensive rehabilitation and long-term care rehabilitation.

CONCLUSIONS

Our results suggest the high public health impact of musculoskeletal disorders, followed by neurological disorders. This is, however, without forgetting the importance of early rehabilitation to prevent other types of clinical conditions such as cardiovascular, respiratory, or internal diseases from leading to motor disability and increasing costs.

Patients' Perceptions of Remote Monitoring and App-based Rehabilitation Programs: A Comparison of Total Hip and Knee Arthroplasty

BACKGROUND

Remote monitoring rehabilitation programs are new technologies growing in popularity for patients undergoing lower extremity total joint arthroplasty. The purpose of this study was to assess the patients' perceptions of these technologies.

METHODS

Patients who underwent total hip (THA), knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA) from September 2020 to February 2022 and participated in a clinical study utilizing remote monitoring and an app-based rehabilitation program were given a questionnaire three months postoperatively to assess their perceptions of these technologies. There were 166 patients who completed the survey (42 THA; 106 TKA; 18 UKA).

RESULTS

There were 92% of patients who found the technology easy to use. A majority of patients felt the technologies motivated them. The TKA/UKA patients felt more strongly that these technologies allowed the surgeon to monitor their recovery closely (81.9% v. 65.9%; P=0.009). There were 85% of THA patients and 94.5% of TKA/UKA patients recommended these technologies. The THA patients felt more strongly that digital rehabilitation could completely replace in-person physical therapy compared to TKA/UKA patients (85.4% v. 41.3%; P<0.001). A majority (83%) of patients recommended a combination of inpatient and technology-assisted rehabilitation (THA 90.2%; 84.4% TKA/UKA).

CONCLUSIONS

The THA and TKA/UKA patients found remote monitoring rehabilitation easy to use, increased motivation, and recommend it to other patients undergoing lower extremity arthroplasty. They recommend a combination of technology and in-person rehabilitation postoperatively. The THA patients felt these technologies could replace in-person rehabilitation programs.

Association Between Delayed Discharge From Acute Care and Rehabilitation Outcomes and Length of Stay: A Retrospective Cohort Study

OBJECTIVE

To examine the association between discharge delays from acute to rehabilitation care because of capacity strain in the rehabilitation units, patient length of stay (LOS), and functional outcomes in rehabilitation.

DESIGN

Retrospective cohort study using an instrumental variable to remove potential biases because of unobserved patient characteristics.

SETTING

Two campuses of a hospital network providing inpatient acute and rehabilitation care.

PARTICIPANTS

Patients admitted to and discharged from acute care categories of Medicine and Neurology/Musculoskeletal (Neuro/MSK) and subsequently admitted to and discharged from inpatient rehabilitation between 2013 and 2019 (N=10486).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Rehabilitation LOS, FIM scores at admission and discharge, and rehabilitation efficiency defined as FIM score improvement per day of rehabilitation.

RESULTS

The final cohort contained 3690 records for Medicine and 1733 for Neuro/MSK categories. For Medicine, 1 additional day of delayed discharge was associated with an average 5.1% (95% confidence interval [CI], 3%-7.3%) increase in rehabilitation LOS and 0.08 (95% CI, 0.03-0.13) reduction in rehabilitation efficiency. For Neuro/MSK, 1 additional day of delayed discharge was associated with an average 11.6% (95% CI, 2.8%-20.4%) increase in rehabilitation LOS and 0.08 (95% CI, -0.07 to 0.23) reduction in rehabilitation efficiency.

CONCLUSIONS

Delayed discharge from acute care to rehabilitation because of capacity strain in rehabilitation had a strong association with prolonged LOS in rehabilitation. An important policy implication of this "cascading" effect of delays is that reducing capacity strain in rehabilitation could be highly effective in reducing discharge delays from acute care and improving rehabilitation efficiency.

Earlier Initiation of Postoperative Physical Therapy Decreases Opioid Use after Total Knee Arthroplasty

For patients with advanced osteoarthritis of the knee, total knee arthroplasty (TKA) has been shown to provide significant pain relief and improved function with consistent, reproducible results. Post-operative physical therapy (PT) plays an important role is restoring muscle strength and range of motion (ROM). Yet, the impact of earlier physical therapy initiation after TKA has not been well defined. We assessed 205 patients that underwent primary TKA including 136 patients who started PT on the first post-operative day (POD1) and a second group that started PT 3 days after surgery (POD3), or later. Length of hospital stay (LOS), opioid use during hospital stay, complications, re-admissions, knee ROM and the need for subsequent hospitalized rehabilitation were recorded. LOS was not significantly shorter in the early PT group, compared with the delayed PT group (6.4 ± 2.2 days vs. 6.8 ± 2 days, respectively, P = .217). Patients in the delayed PT group consumed more opioids during their inpatient stay compared with the early PT group on both POD 3 (89% vs 82%, p = 0.013) and POD 4 (81% vs 66%, p = 0.005). There was no significant difference in the incidence of Immediate post-operative complications or final knee ROM between the two groups. While early postoperative PT did not impact hospital LOS or final knee ROM, it was associated with an earlier reduction in postoperative opioid consumption after primary TKA.

Effect of Prehabilitation Before Total Knee Replacement for Knee Osteoarthritis on Functional Outcomes: A Randomized Clinical Trial

IMPORTANCE

Multidisciplinary prehabilitation before total knee replacement (TKR) for osteoarthritis may improve outcomes in the postoperative period.

OBJECTIVE

To compare multidisciplinary prehabilitation with usual care before TKR for osteoarthritis in terms of functional independence and activity limitations after surgery.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, open-label randomized clinical trial recruited participants 50 to 85 years of age with knee osteoarthritis according to the American College of Rheumatology criteria for whom a TKR was scheduled at 3 French tertiary care centers. Recruitment started on October 4, 2012, with follow-up completed on November 29, 2017. Statistical analyses were conducted from March 29, 2018, to March 6, 2019.

INTERVENTIONS

Four supervised sessions of multidisciplinary rehabilitation and education (2 sessions per week, at least 2 months before TKR, delivered to groups of 4-6 participants at each investigating center; session duration was 90 minutes and included 30 minutes of education followed by 60 minutes of exercise therapy) or usual care (information booklet and standard advice by the orthopedic surgeon) before TKR.

MAIN OUTCOMES AND MEASURES

The short-term primary end point was the proportion of participants achieving functional independence a mean (SD) of 4 (1) days after surgery defined as level 3 on the 4 functional tests. The midterm primary end point was activity limitations within 6 months after TKR assessed by the area under the receiver operating characteristic curve of the self-administered Western Ontario Questionnaire and McMaster Universities Osteoarthritis Index function subscale.

RESULTS

A total of 262 patients (mean [SD] age, 68.6 [8.0] years; 178 women [68%]) were randomized (131 to each group). A mean (SD) of 4 (1) days after surgery, 34 of 101 (34%) in the experimental group vs 26 of 95 (27%) in the control group achieved functional independence (risk ratio, 1.4; 97.5% CI, 0.9-2.1; P = .15). At 6 months, the mean (SD) area under the curve for the Western Ontario Questionnaire and McMaster Universities Osteoarthritis Index function subscale was 38.1 (16.5) mm2 in the experimental group vs 40.6 (17.8) mm2 in the control group (absolute difference, -2.8 mm2; 97.5% CI, -7.8 to 2.3; P = .31 after multiple imputation). No differences were found in secondary outcomes.

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found no evidence that multidisciplinary prehabilitation before TKR for osteoarthritis improves short-term functional independence or reduces midterm activity limitations after surgery.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01671917.

Reporting of post-operative rehabilitation interventions for Total knee arthroplasty: a scoping review

Objective

The aim of this study was to evaluate the completeness of reporting of exercise adherence and exercise interventions delivered as part of clinical trials of post-operative total knee replacement (TKA) rehabilitation.

Design: Scoping review

Literature search

A literature search was conducted in PubMed, EMBASE, AMED, CINAHL, SPORTDiscus and Cochrane Library.

Study selection criteria

All randomized controlled trials (RCT) that examined post-operative exercise-based interventions for total knee arthroplasty were eligible for inclusion. Studies that were multifactorial or contained exercise interventions for both hip and knee arthroplasty were also included.

Data synthesis

The definition, type of measurement used and outcome for exercise adherence were collected and analyzed descreptively. Quality of reporting of exercise interventions were assessed using the Consensus for Exercise Reporting Tool (CERT) and the Cochrane Risk of Bias Tool.

Results

There were a total of 112 RCTs included in this review. The majority of RCTs (63%, n = 71) did not report exercise adherence. Only 23% (n = 15) of studies provided a definition of adherence. RCTs were of poor quality, with 85% (n = 95) of studies having high or unclear risk of bias. Reporting of exercise interventions was poor, with only 4 items (of 19) (21%) of the CERT adequately reported (88–99%), with other items not fulfilled on at least 60% of the RCTs. There were no RCTs that had fulfilled all the criteria for the CERT.

Conclusion

The RCTs included in this study poorly reported exercise adherence, as well as description of the post-operative TKA rehabilitation intervention. Future RCTs should use valid and reliable measures of adherence and a proper tool for reporting of exercise interventions (e.g., CERT, TiDER).

Pre-registration

OSF:https://osf.io/9ku8a/

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04460-w.

Hand-Held Dynamometry in the Inpatient Care Setting After Total Knee Arthroplasty: Reliability of Static Knee Strength Measurements

OBJECTIVE

The aim of the study was to determine intrarater and interrater reliabilities for static strength assessment of knee flexors and knee extensors in patients with total knee arthroplasty, during the acute postoperative rehabilitation.

DESIGN

Forty-five total knee arthroplasty patients were included in the study. Two physical therapists performed strength assessments by using hand-held dynamometry. Patients performed three trials and a 30-sec rest was provided between each trial. After this, a 5-min rest was provided, and then, a second investigator performed the same procedure for interrater reliability. Assessments for intrarater reliability were performed 1 hr later.

RESULTS

The intrarater reliability of knee extensors and knee flexors strength measurements were 0.96 and 0.94, respectively. The standard error of measurement and minimal detectable change 95% confidence level were 6.17 and 17.01 Nm for knee extensors and were 8.89 and 24.51 Nm for knee flexors, respectively. The interrater reliability of knee flexors and knee extensors strength measurement was 0.96 for both. The standard error of measurement and minimal detectable change values at 95% confidence level were 6.00 and 16.54 Nm for knee extensors and were 6.32 and 17.42 Nm for knee flexors, respectively.

CONCLUSIONS

Hand-held dynamometry is a reliable method to assess static knee strength. Hand-held dynamometry assessment can be implemented during acute postoperative rehabilitation. Our results may assist the clinicians in determining an accurate postoperative rehabilitation program after total knee arthroplasty surgery.

Early and Direct Rehab Transfer Leads to Significant Cost Savings and Decreased Hospital Length of Stay for Total Joint Arthroplasty in a Veteran Population

BACKGROUND

Total joint arthroplasty is the most common elective orthopedic procedure in the Veterans Affairs hospital system. In 2019, physical medicine and rehabilitation began screening patients before surgery to select candidates for direct transfer to acute rehab after surgery. The primary outcome of this study was to demonstrate that the accelerated program was successful in decreasing inpatient costs and length of stay (LOS). The secondary outcome was to show that there was no increase in complication, reoperation, and readmission rates.

METHODS

A retrospective review of total joint arthroplasty patients was conducted with three cohorts: 1) control (n = 193), 2) transfer to rehab orders on postop day #1 (n = 178), and 3) direct transfers to rehab (n = 173). To assess for demographic disparities between cohorts, multiple analysis of variance tests followed by a Bonferroni P-value correction were used. Differences between test groups regarding primary outcomes were assessed with analysis of variance tests followed by pairwise t-tests with Bonferroni P-value corrections.

RESULTS

There were no significant differences between the cohort demographics or comorbidities. The mean total LOS decreased from 7.0 days in the first cohort, to 6.9 in the second, and 6.0 in the third (P = .00034). The mean decrease in cost per patient was $14,006 between cohorts 1 and 3, equating to over $5.6 million in savings annually. There was no significant change in preintervention and postintervention short-term complications (P = .295).

CONCLUSIONS

Significant cost savings and decrease in total LOS was observed. In the current health care climate focused on value-based care, a similar intervention could be applied nationwide to improve Veterans Affair services.

Blood Flow Restriction Combined with Electrical Stimulation Attenuates Thigh Muscle Disuse Atrophy

PURPOSE

This study aimed to investigate the effects of blood flow restriction (BFR) combined with electrical muscle stimulation (EMS) on skeletal muscle mass and strength during a period of limb disuse.

METHODS

Thirty healthy participants (22 ± 3 yr; 23 ± 3 kg·m-2) were randomly assigned to control (CON; n = 10), BFR alone (BFR; n = 10), or BFR combined with EMS (BFR + EMS; n = 10). All participants completed unloading of a single leg for 14 d, with no treatment (CON), or while treated with either BFR or BFR + EMS (twice daily, 5 d·wk-1). BFR treatment involved arterial three cycles of 5-min occlusion using suprasystolic pressure, each separated by 5 min of reperfusion. EMS (6 s on, 15 s off; 200 μs; 60 Hz; 15% maximal voluntary contraction [MVC]) was applied continuously throughout the three BFR cycles. Quadriceps muscle mass (whole-thigh lean mass via dual-energy x-ray absorptiometry and vastus lateralis [VL] muscle thickness via ultrasound) and strength (via knee extension MVC) were assessed before and after the 14-d unloading period.

RESULTS

After limb unloading, whole-thigh lean mass decreased in the control group (-4% ± 1%, P < 0.001) and BFR group (-3% ± 2%, P = 0.001), but not in the BFR + EMS group (-0.3% ± 3%, P = 0.8). VL muscle thickness decreased in the control group (-4% ± 4%, P = 0.005) and was trending toward a decrease in the BFR group (-8% ± 11%, P = 0.07) and increase in the BFR + EMS group (+5% ± 10%, P = 0.07). Knee extension MVC decreased over time (P < 0.005) in the control group (-18% ± 15%), BFR group (-10% ± 13%), and BFR + EMS group (-18% ± 15%), with no difference between groups (P > 0.5).

CONCLUSION

Unlike BFR performed in isolation, BFR + EMS represents an effective interventional strategy to attenuate the loss of muscle mass during limb disuse, but it does not demonstrate preservation of strength.

Which Patients Require Unexpected Admission to Postacute Care Facilities After Total Hip Arthroplasty?

BACKGROUND

Many surgeons prefer to discharge patients home due to patient preferences, improved outcomes, and decreased costs. Despite an institutional protocol to send total hip arthroplasty (THA) patients home, some patients still required postacute care (PAC) facilities. This study aimed to create two predictive models based on preoperative and postoperative risk factors to identify which patients require PAC facilities.

METHODS

A retrospective review of 2,372 patients undergoing primary unilateral THA at a single institution from 2012 to 2017 was done. An electronic query followed by manual review identified discharge disposition, demographic factors, comorbidities, and other patient factors. Of the 2,372 patients, 6.2% were discharged to skilled nursing facilities or inpatient rehabilitation facilities and 93.8% discharged home. Univariate and multivariate analysis were conducted to create two predictive models for patient discharge: preoperative visit and postoperative hospital course.

RESULTS

Of 45 variables evaluated, 7 were found to be notable predictors for PAC facility discharge. In descending order, these included age 65 years or greater, non-Caucasian race, history of depression, female sex, and greater comorbidities. In addition to preoperative factors, in-hospital complications and surgical duration of 90 minutes or greater led to a higher likelihood of PAC facility discharge. Both models had excellent predictive assessments with area under curve values of 0.77 and 0.80 for the preoperative visit and postoperative models, respectively.

DISCUSSION

This study identifies both preoperative and postoperative risk factors that predispose patients to nonroutine discharges after THA. Orthopaedic surgeons may use these models to better predict which patients are predisposed to discharge to PAC facilities.

A novel early mobility bundle improves length of stay and rates of readmission among hospitalized general medicine patients

Inpatient early mobility initiatives are effective therapeutic interventions for improving patient outcomes and decreasing use of hospital resources among adult ICU and general medicine patients. To establish and demonstrate guidelines for early patient ambulation, we developed and implemented a novel multidisciplinary mobility bundle utilizing the JH-HLM (Johns Hopkins Highest Level of Mobility) scale for mobility classification, on a single adult general medicine unit of a community hospital. Our results show that patients admitted to the unit after implementation of the mobility bundle had improved mobility scores, reduced rates of 30-day hospital readmission, and a shortened length of hospital stay. This study emphasizes the importance of measuring mobility using a systematic method, easing workflow among unit practitioners, and allowing mobility initiatives to be jointly driven by nursing, physical therapy, and physicians.

Occupational advice to help people return to work following lower limb arthroplasty: the OPAL intervention mapping study

BACKGROUND

Hip and knee replacements are regularly carried out for patients who work. There is little evidence about these patients' needs and the factors influencing their return to work. There is a paucity of guidance to help patients return to work after surgery and a need for structured occupational advice to enable them to return to work safely and effectively.

OBJECTIVES

To develop an occupational advice intervention to support early recovery to usual activities including work that is tailored to the requirements of patients undergoing hip or knee replacements. To test the acceptability, practicality and feasibility of this intervention within current care frameworks.

DESIGN

An intervention mapping approach was used to develop the intervention. The research methods employed were rapid evidence synthesis, qualitative interviews with patients and stakeholders, a prospective cohort study, a survey of clinical practice and a modified Delphi consensus process. The developed intervention was implemented and assessed during the final feasibility stage of the intervention mapping process.

SETTING

Orthopaedic departments in NHS secondary care.

PARTICIPANTS

Patients who were in work and intending to return to work following primary elective hip or knee replacement surgery, health-care professionals and employers.

INTERVENTIONS

Occupational advice intervention.

MAIN OUTCOME MEASURES

Development of an occupational advice intervention, fidelity of the developed intervention when delivered in a clinical setting, patient and clinician perspectives of the intervention and preliminary assessments of intervention effectiveness and cost.

RESULTS

A cohort study (154 patients), 110 stakeholder interviews, a survey of practice (152 respondents) and evidence synthesis provided the necessary information to develop the intervention. The intervention included information resources, a personalised return-to-work plan and co-ordination from the health-care team to support the delivery of 13 patient and 20 staff performance objectives. To support delivery, a range of tools (e.g. occupational checklists, patient workbooks and employer information), roles (e.g. return-to-work co-ordinator) and training resources were created. Feasibility was assessed for 21 of the 26 patients recruited from three NHS trusts. Adherence to the defined performance objectives was 75% for patient performance objectives and 74% for staff performance objectives. The intervention was generally well received, although the short time frame available for implementation and concurrent research evaluation led to some confusion among patients and those delivering the intervention regarding its purpose and the roles and responsibilities of key staff.

LIMITATIONS

Implementation and uptake of the intervention was not standardised and was limited by the study time frame. Evaluation of the intervention involved a small number of patients, which limited the ability to assess it.

CONCLUSIONS

The developed occupational advice intervention supports best practice. Evaluation demonstrated good rates of adherence against defined performance objectives. However, a number of operational and implementation issues require further attention.

FUTURE WORK

The intervention warrants a randomised controlled trial to assess its clinical effectiveness and cost-effectiveness to improve rates and timing of sustained return to work after surgery. This research should include the development of a robust implementation strategy to ensure that adoption is sustained.

STUDY REGISTRATION

Current Controlled Trials ISRCTN27426982 and PROSPERO CRD42016045235.

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. 45. See the NIHR Journals Library website for further project information.

Effect of Outpatient Rehabilitation on Functional Mobility After Single Total Knee Arthroplasty: A Randomized Clinical Trial

Importance

Even without evidence, rehabilitation practitioners continue to introduce new interventions to enhance the mobility outcomes for the increasing population with a recent total knee arthroplasty (TKA).

Objective

To compare post-TKA functional mobility outcomes among 3 newly developed physical therapy protocols with a standard-of-care post-TKA rehabilitation protocol.

Design, Setting, and Participants

This randomized clinical trial included 4 study arms implemented in 15 outpatient clinics within a single health system in the Baltimore, Maryland, and Washington, District of Columbia, region from October 2013 to April 2017. Participants included patients who underwent elective unilateral TKA, were aged 40 years and older, and began outpatient physical therapy within 24 days after TKA. A total of 505 patients were screened and 386 participants were enrolled. Patients provided informed consent and were randomly assigned to 1 of 4 groups. Blinding patients and treating therapists was not feasible owing to the nature of the intervention. Analysis was conducted under the modified intent-to-treat principle from October 2017 to May 2019.

Interventions

The control group used a standard recumbent bike for 15 to 20 minutes each session. Interventions used 1 of 3 modalities for 15 to 20 minutes each session: (1) a body weight-adjustable treadmill, (2) a patterned electrical neuromuscular stimulation device, or (3) a combination of the treadmill and electrical neuromuscular stimulation.

Main Outcomes and Measures

Outcomes included the Activity Measure for Post-acute Care basic mobility score, a patient-reported outcome measure, and the 6-minute walk test. Outcomes were measured at baseline, monthly, and on discharge from outpatient therapy.

Results

Data from 363 patients (mean [SD] age, 63.4 [7.9] years; 222 [61.2%] women) were included in the final analysis, including 92 participants randomized to the control group, 91 participants randomized to the treadmill group, 90 participants randomized to the neuromuscular stimulation device group, and 90 participants randomized to the combination intervention group. Activity Measure for Post-acute Care scores at discharge were similar across groups, ranging from 61.1 to 61.3 (P = .99) with at least 9.0 points improvement (P = .80) since baseline. The distances as measured by the 6-minute walking test were not statistically different across groups (range, 382.9-404.5 m; P = .60).

Conclusions and Relevance

This randomized clinical trial found no statistically or clinically significant differences in outcomes across the 4 arms. Because outcomes were similar among arms, clinicians should instead consider relative cost in tailoring TKA rehabilitation.

Trial Registration

ClinicalTrials.gov Identifier: NCT02426190.

Initiating range of motion exercises within 24 hours following total knee arthroplasty affects the reduction of postoperative pain: A randomized controlled trial

Background

Postoperative limitations in the range of motion (ROM) after TKA may occur occasionally and restrict a patient's ADL. Although ROM exercise is a means of increasing the ROM after TKA, the optimal time of initiating ROM exercise is still unclear. The purpose of this study is to examine different initiation timings of postoperative ROM exercises after TKA and to compare the results in terms of postoperative pain, swelling, and ROM improvement to determine the optimal time of initiating ROM exercises following TKA.

Methods

This was a prospective, single-center, single-blinded randomized controlled trial involving 109 patients scheduled for unilateral TKA. All patients underwent the physiotherapist assisted passive and active same rehabilitation program that only differed in the starting time of ROM exercise on postoperative day 1 or day 7. Postoperative assessment was performed with all attending personnel blinded to group assignment. Visual analog scale (VAS) of pain, ROM, thigh swelling, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and adverse outcomes were compared between groups on postoperative days within 2 years after surgery.

Results

VAS scores during the postoperative period from 18 to 72 h were significantly lower in the group with starting time of ROM exercise on postoperative day 1. The ROM, laboratory data, thigh girth, WOMAC and the incidence of complications did not differ between the two groups at any postoperative time-point.

Conclusions

The results of this study suggested that ROM exercises beginning in the early postoperative stage are advantageous in reducing the postoperative pain after TKA.

Intrathecal Morphine and Pulmonary Complications after Arthroplasty in Patients with Obstructive Sleep Apnea

Background

Intrathecal morphine is commonly and effectively used for analgesia after joint arthroplasty, but has been associated with delayed respiratory depression. Patients with obstructive sleep apnea may be at higher risk of postoperative pulmonary complications. However, data is limited regarding the safety of intrathecal morphine in this population undergoing arthroplasty.

Methods

This retrospective cohort study aimed to determine the safety of intrathecal morphine in 1,326 patients with documented or suspected obstructive sleep apnea undergoing hip or knee arthroplasty. Chart review was performed to determine clinical characteristics, perioperative events, and postoperative outcomes. All patients received neuraxial anesthesia with low-dose (100 μg) intrathecal morphine (exposure) or without opioids (control). The primary outcome was any postoperative pulmonary complication including: (1) respiratory depression requiring naloxone; (2) pneumonia; (3) acute respiratory event requiring consultation with the critical care response team; (4) respiratory failure requiring intubation/mechanical ventilation; (5) unplanned admission to the intensive care unit for respiratory support; and (6) death from a respiratory cause. The authors hypothesized that intrathecal morphine would be associated with increased postoperative complications.

Results

In 1,326 patients, 1,042 (78.6%) received intrathecal morphine. The mean age of patients was 65 ± 9 yr and body mass index was 34.7 ± 7.0 kg/m2. Of 1,326 patients, 622 (46.9%) had suspected obstructive sleep apnea (Snoring, Tired, Observed, Pressure, Body Mass Index, Age, Neck size, Gender [STOP-Bang] score greater than 3), while 704 of 1,326 (53.1%) had documented polysomnographic diagnosis. Postoperatively, 20 of 1,322 (1.5%) patients experienced pulmonary complications, including 14 of 1,039 (1.3%) in the exposed and 6 of 283 (2.1%) in the control group (P = 0.345). Overall, there were 6 of 1 322 (0.5%) cases of respiratory depression, 18 of 1,322 (1.4%) respiratory events requiring critical care team consultation, and 4 of 1,322 (0.3%) unplanned intensive care unit admissions; these rates were similar between both groups. After adjustment for confounding, intrathecal morphine was not significantly associated with postoperative pulmonary complication (adjusted odds ratio, 0.60 [95% CI, 0.24 to 1.67]; P = 0.308).

Conclusions

Low-dose intrathecal morphine, in conjunction with multimodal analgesia, was not reliably associated with postoperative pulmonary complications in patients with obstructive sleep apnea undergoing joint arthroplasty.

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What We Already Know about This Topic

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Acute kidney injury is associated with increased healthcare utilization, complications, and mortality after primary total knee arthroplasty

Background:

The objective of this study was to assess healthcare utilization and complications associated with acute kidney injury (AKI) in patients undergoing primary total knee arthroplasty (TKA).

Methods:

We used the 1998–2014 US National Inpatient Sample to assess whether AKI is associated with healthcare utilization or in-hospital postoperative complications post-TKA using multivariable-adjusted logistic regression analyses. We calculated odds ratios (ORs) and a 95% confidence intervals (CIs). Sensitivity analyses additionally adjusted for hospital characteristics (location/teaching status, bed size, and region).

Results:

Of the 8,127,282 people who underwent primary TKA from 1998 to 2014, 104,366 (1.3%) had a diagnosis of AKI. People with AKI had longer unadjusted mean hospital stay, 6.1 versus 3.5 days, higher mean hospital charges, US$71,385 versus US$42,067, and higher rates of all in-hospital postoperative complications, including mortality. Adjusted for age, sex, race, underlying diagnosis, medical comorbidity, income, and insurance payer, AKI was associated with a significantly higher OR (95% CI) of total hospital charges above the median, 2.76 (2.68, 2.85); length of hospital stay > 3 days, 2.21 (2.14, 2.28); and discharge to a rehabilitation facility, 4.68 (4.54, 4.83). AKI was associated with significantly higher OR (95% CI) of in-hospital complications, including infection, 2.60 (1.97, 3.43); transfusion, 2.94 (2.85, 3.03); revision, 2.13 (1.72, 2.64); and mortality, 19.75 (17.39, 22.42). Sensitivity analyses replicated the main study findings, without any attenuation of ORs.

Conclusions:

AKI is associated with a significantly higher risk of increased healthcare utilization, complications, and mortality after primary TKA. Future studies should assess significant factors associated and interventions that can prevent AKI.

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.

Same-Day Physical Therapy Following Total Knee Arthroplasty Leads to Improved Inpatient Physical Therapy Performance and Decreased Inpatient Opioid Consumption

BACKGROUND

Early ambulation with physical therapy (PT) following total knee arthroplasty (TKA) has demonstrated benefits in the literature. However, the impact of early PT on rehabilitation performance and opioid consumption has not been elucidated. We evaluate the effect of same-day PT on inhospital functional outcomes and opioid consumption.

METHODS

We retrospectively identified 2 cohorts of primary TKA patients from July 2016 to December 2017: PT0 (n = 295) received PT on the day of surgery, and PT1 (n = 392) received PT on postoperative day (POD) 1. Outcomes studied included number of feet walked on POD0-3, visual analog scale pain scores, morphine equivalents (ME) consumed, length of stay, and discharge disposition. Analysis was conducted using the Student t-test and Fisher exact test.

RESULTS

In comparison to the PT1 group, the PT0 group walked significantly more steps on POD1 (347.6 vs 167.4 ft, P < .0001), POD2 (342.1 vs 203.5 ft, P < .0001), and POD3 (190.3 vs 128.9 ft, P = .00028). There was no difference between the 2 groups for visual analog scale. The PT0 group also consumed significantly fewer total ME when compared to the PT1 group (149.0 vs 200.3 mg, P = .0002). The PT0 group had a significantly shorter length of stay when compared to the PT1 group (2.7 vs 3.2 days, P = .00075). More patients were discharged home in the PT0 group (81.7% vs 54.8%, P < .0001).

CONCLUSION

We observed that initiation of PT on POD0 led to better PT performance, reduced ME during hospitalization, and more patients discharged home.

LEVEL OF EVIDENCE

III, Retrospective cohort study.

The evolving role of occupational therapists in adult critical care in England

Purpose

A recent paradigm-shift in patient care advocates for long-term recovery and quality of life in survivors of critical illness. Evidence suggests that occupational therapists in critical care can contribute to recovery in areas such as functional outcomes, length of stay and delirium, although poor role understanding can limit service-utilisation. The purpose of this study is to investigate current and future roles and practices of critical care occupational therapists in the UK.

Design/methodology/approach

Occupational therapists with clinical experience in adult critical care were invited to participate in a mixed-methods design using a locally developed online questionnaire and semi-structured interviews, concurrently. Descriptive statistics were generated through SPSS. Qualitative data were analysed using the framework approach.

Findings

Twelve occupational therapists participated in the survey element, with five continuing to interview. Occupational therapists described a multifaceted role in critical care where the majority reported practice in upper limb function, seating/positioning, cognition, psychosocial sequelae and discharge planning. Role and internal characteristics impacted on service delivery. It is envisaged that earlier intervention in a greater percentage of patients, a greater evidence-base, raising awareness and adequate staffing will be features for future development.

Originality/value

This study provides new insight into the current role and practices of adult critical care occupational therapists in England and generates insights into their role in addressing physical and non-physical morbidity for this patient cohort. Findings are preliminary in nature; however, future research is warranted to evaluate the effectiveness of interventions.

Association of Early Postoperative Pain Trajectories With Longer-term Pain Outcome After Primary Total Knee Arthroplasty

IMPORTANCE

Studies to date have not comprehensively examined pain experience after total knee arthroplasty (TKA). Discrete patterns of pain in this period might be associated with pain outcomes at 6 to 12 months after TKA.

OBJECTIVES

To examine patterns of individual post-TKA pain trajectories and to assess their independent associations with longer-term pain outcome after TKA.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study combined data from a national US TKA cohort with ancillary pain severity data at 2 weeks and 8 weeks after the index TKA using a numeric rating scale. All participants received primary, unilateral TKA within the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) national network of community sites in 22 states or at the lead site (University of Massachusetts Medical School). Participants had a date of surgery between May 1, 2013, and December 1, 2014. The data analysis was performed between January 13, 2015, and July 5, 2016.

EXPOSURES

Pain trajectories in the postoperative period (8 weeks).

MAIN OUTCOMES AND MEASURES

Index knee pain at 6 months after TKA using the Knee Injury and Osteoarthritis Outcome Score (KOOS) pain scale. Group-based trajectory methods examined the presence of pain trajectories in the postoperative period (8 weeks) and assessed whether trajectories were independently associated with longer-term pain (6 months).

RESULTS

The cohort included 659 patients who underwent primary TKA with complete data at 4 points (preoperative, 2 weeks, 8 weeks, and 26 weeks). Their mean (SD) age was 67.1 (8.0) years, 64.5% (425 of 659) were female, the mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) was 30.77 (5.66), 94.5% (613 of 649) were white, and the mean (SD) preoperative 36-Item Short Form Health Survey physical component summary and mental component summary scores were 34.1 (8.2) and 53.8 (11.4), respectively. Two pain trajectory subgroups were identified at 8 weeks after TKA: patients who experienced fast pain relief in the first 8 weeks after TKA (fast pain responders, composing 72.4% [477 of 659] of the sample) and patients who did not (slow pain responders, composing 27.6% [182 of 659] of the sample). After adjusting for patient factors, the pain trajectory at 8 weeks after TKA was independently associated with the mean KOOS pain score at 6 months, with a between-trajectory difference of -11.3 (95% CI, -13.9 to -8.7).

CONCLUSIONS AND RELEVANCE

The trajectory among slow pain responders at 8 weeks after surgery was independently associated with improved but greater persistent index knee pain at 6 months after TKA compared with that among fast pain responders. Early identification of patients with a trajectory of slow pain response at 8 weeks after TKA may offer an opportunity for interventions in the perioperative period to potentially improve the long-term pain outcomes after TKA.

Can early rehabilitation after osteoarthritis reduce knee and hip arthroplasty risk?: A national representative cohort study

This retrospective cohort study evaluated the effects of different frequencies of physical therapy intervention on the total knee arthroplasty (TKA) and total hip arthroplasty (THA) risk of osteoarthritis (OA) patients.We sampled 438,833 insurants from Taiwan National Health Insurance Research Database for patients diagnosed as having OA during 2000 to 2013. OA who received physical therapy within in the first year of OA diagnosis were divided based on the number of sessions they received in that first year: >24, 13-23, and <12 sessions.The results revealed that the TKA and THA incidence rates among patients aged 60 to 80 years were respectively 3.5% and 0.9% in the >24 cohort and 4.9% and 1.4% (all P < .001) in the comparison cohort. Moreover, the HRs of TKA and THA in the >24 cohort were 0.77 (0.67-0.87, P < .001) and 0.71 (0.53-0.96, P = .024), respectively. By contrast, no significant differences were noted between the 13-23 and <12 cohorts and their respective comparison cohorts.In conclusion, our study results indicated that elderly patients aged 60 to 80 years who underwent >24 physical therapy sessions within 1 year of receiving an OA diagnosis exhibited reduced of TKA and THA risks.

The necessity of routine postoperative laboratory tests in enhanced recovery after surgery for primary hip and knee arthroplasty: A retrospective cohort study protocol

INTRODUCTION

Over the last few decades, the concepts of minimally invasive surgery and enhanced recovery after surgery (ERAS) protocols have been introduced into the field of total joint arthroplasty (TJA), and tranexamic acid (TXA) has been widely used in TJA. Modern-day surgical techniques and perioperative care pathways of TJA have experienced unexpected improvements. Recently, the necessity of the practice of ordering routine postoperative laboratory tests for patients undergoing primary TJA has been challenged, especially in the context of implementation of ERAS protocols in TJA. These studies have consistently suggested that routine postoperative laboratory tests are not necessary in modern-day primary, unilateral total hip arthroplasty (THA) or total knee arthroplasty (TKA), and laboratory tests after surgery should only be obtained for patients with risk factors. However, it remains unclear whether routine postoperative laboratory tests after THA and TKA remains justified in the Chinese patient population. Therefore, we developed this study to address this issue.

METHODS AND ANALYSIS

This retrospective cohort study will include adult patients who underwent primary unilateral THA or TKA and received multimodal perioperative care pathways according to ERAS protocols. The following patient data will be collected from the electronic medical record system: patients' demographics, preoperative and postoperative laboratory values, operation time, intraoperative blood loss, TXA use, tourniquet use, postoperative length of stay, and any medical intervention directly related to abnormal laboratory values. The main study outcomes are the incidence of acute anemia requiring transfusion and incidence of hypoalbuminemia requiring albumin supplementation. The secondary outcomes are the rates of acute kidney injury, incidence of abnormal serum sodium level, incidence of abnormal serum potassium level, and incidence of abnormal serum calcium level. These clinical data will be analyzed to determine the incidence of abnormal postoperative laboratory values following primary unilateral THA and TKA; to clarify the frequency of any medical intervention directly related to abnormal postoperative laboratory values; and to identify risk factors that predispose patients to have abnormal postoperative laboratory results.

STUDY REGISTRATION

Chinese Clinical Trial Registry (http://www.chictr.org.cn): ChiCTR1900020690.

Immediate Physical Therapy following Total Joint Arthroplasty: Barriers and Impact on Short-Term Outcomes

Background

Recent evidence suggests benefit to receiving physical therapy (PT) the same day as total joint arthroplasty (TJA), but relatively little is known about barriers to providing PT in this constrained time period. We address the following questions: (1) Are there demographic or perioperative variables associated with receiving delayed PT following TJA? (2) Does receiving immediate PT following TJA affect short-term outcomes such as length of stay, discharge disposition, or 30-day readmission? Methods. Primary TJA procedures at a single center were retrospectively reviewed. Immediate PT was defined as within eight hours of surgery. Demographic and perioperative variables were compared between patients who received immediate PT and those who did not. We identified an appropriately matched control group of patients who received immediate PT. Postoperative length of stay, discharge disposition, and 30-day readmissions were compared between matched groups.

Results

In total, 2051 primary TJA procedures were reviewed. Of these, 226 (11.0%) received delayed PT. These patients had a higher rate of general anesthesia (25.2% versus 17.8%, p=0.006), later operative start time (13:26 [11:31-14:38] versus 9:36 [8:24-11:16], p<0.001), longer operative time (1.8 [1.5-2.2] versus 1.6 [1.4-1.8] hours, p=0.002), and higher overall caseload on the day of surgery (6 [4-9] versus 5 [4-8], p=0.002). A matched group of patients who received immediate PT was identified. There were no differences in postoperative length of stay or discharge disposition between matched immediate and delayed PT groups, but delayed PT (OR 4.54; 95% CI 1.61-12.84; p=0.004) was associated with a higher 30-day readmission rate.

Conclusion

Barriers to receiving immediate PT following TJA included general anesthesia, later operative start time, longer operative time, and higher daily caseload. These factors present potential targets for improving the delivery of immediate postoperative PT. Early PT may help reduce 30-day readmissions, but additional research is necessary to further characterize this relationship.

A pragmatic approach to evaluating new techniques in regional anesthesia and acute pain medicine

Anesthesiologists set up regional anesthesia and acute pain medicine programs in order to improve the patient outcomes and experience. Given the increasing frequency and volume of newly described techniques, applying a pragmatic framework can guide clinicians on how to critically review and consider implementing the new techniques into clinical practice. A proposed framework should consider how a technique: increases access; enhances efficiency; decreases disparities and improves outcomes. Quantifying the relative contribution of these four factors using a point system, which will be specific to each practice, can generate an overall scorecard to help clinicians make decisions on whether or not to incorporate a new technique into clinical practice or replace an incumbent technique within a clinical pathway.

Multimodal Clinical Pathway With Adductor Canal Block Decreases Hospital Length of Stay, Improves Pain Control, and Reduces Opioid Consumption in Total Knee Arthroplasty Patients: A Retrospective Review

BACKGROUND

Total knee arthroplasty volume is increasing significantly in the United States. Reducing hospital length of stay may represent the best method for accommodating expanding volume and reducing costs. We hypothesized that tailoring a clinical pathway to facilitate early ambulation would decrease costs and resource utilization.

METHODS

We conducted a sequential before-and-after study of total knee arthroplasty patients after a phased implementation of a clinical pathway that includes multimodal oral analgesic protocols, adductor canal nerve block, and standardized day of surgery ambulation protocols. Primary outcomes measured were hospital length of stay, total opioid consumption, total antiemetic use, and perioperative pain scores.

RESULTS

Two hundred ninety-five patients were divided into 3 sequential cohorts. Cohort 1 received spinal anesthesia, femoral nerve block, and was not placed into postop day 0 ambulation therapy. Cohort 2 received spinal anesthesia, adductor canal block, and postop day 0 ambulation therapy. Cohort 3 received spinal anesthesia, adductor canal block, postop day 0 ambulation therapy, and standardized oral multimodal analgesic protocol. Cohort 3 had significantly reduced hospital length of stay. Cohorts 2 and 3 had significantly less opioid consumption. Cohort 3 had significantly less total ondansetron consumption compared with cohort 1. Cohort 3 had significantly reduced average pain scores compared with cohort 1.

CONCLUSION

The data demonstrate that tailored clinical pathways designed to facilitate early ambulation can reduce hospital length of stay, reduce opioid consumption, reduce antiemetic use, and improve pain control. The results establish that refined clinical pathways can assist in improving care while increasing value to patients, providers, and systems.

Development of a reconditioning program for elderly abdominal surgery patients: the Elder-friendly Approaches to the Surgical Environment-BEdside reconditioning for Functional ImprovemenTs (EASE-BE FIT) pilot study

Background

Elderly individuals who are hospitalized due to emergency abdominal surgery spend over 80% of their recovery time in bed, resulting in early and rapid muscle loss. As these elderly individuals have a lower physiological reserve, the impact of muscle wasting on function may be profound. The objectives of this study are to (1) create an independently led post-surgical reconditioning program and (2) pilot its implementation, while assessing the feasibility and safety of the program.

Methods

The BE FIT program was generated with hospital rehabilitation staff to target lower limb strength, balance, and endurance. This pilot study was assessed using a sequential before and after trial, with a cohort of patients aged ≥ 65 years enrolled in the Elder-friendly Approaches to the Surgical Environment (EASE) study. Change in 30-s sit-to-stand performance between postoperative day 2 and discharge was compared between Usual Care pre- and post-BE FIT participants.

Results

A total of 66 patients participated in the sub-study, 33 Usual Care and 33 BE FIT. Mean (SD) age was 76.2 (8.78); 44 (67%) were female, with 11 (17%) reporting mild/moderate frailty on the CHSA Clinical Frailty Scale. BE FIT participants had a median of three rehab days and self-reported completing an average of 83% of the exercises. The adjusted between group difference showed that the BE FIT patients were able to complete more stands than the Usual Care (1.9 stands (0.94), p = 0.05). There were no reported adverse events.

Conclusion

The reconditioning program was shown to be safe and feasible within the hospital setting for the elderly emergency abdominal surgery patients. More rigorous assessment is needed to confirm this effectiveness and to better assess patient adherence to self-directed exercise.

Trial registration

Registration #NCT02233153 through ClinicalTrials.gov. Registered September 8, 2014.

Who Goes to Inpatient Rehabilitation or Skilled Nursing Facilities Unexpectedly Following Total Knee Arthroplasty?

BACKGROUND

Inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) represent a significant portion of post-operative expenses of bundled payments for total knee arthroplasty (TKA). Although many surgeons no longer routinely send patients to IRFs or SNFs, some patients are unable to be discharged directly home. This study identified patient factors for discharge to post-acute care facilities with an institutional protocol of discharging TKA patients home.

METHODS

A retrospective review of patients undergoing primary unilateral TKA at a single institution from 2012 to 2017 was performed. All surgeons discharged patients home as a routine protocol. An electronic query followed by manual review identified discharge disposition, demographic factors, co-morbidities, and other patient factors. In total, 2281 patients were identified, with 9.6% discharged to SNFs or IRFs and 90.4% discharged home. Univariate and multivariate analyses were conducted to create 2 predictive models for patient discharge: pre-operative visit and hospital course.

RESULTS

Among 43 variables studied, 6 were found to be significant pre-operative risk factors for a discharge disposition other than home. In descending order, age 75 or greater, female, non-Caucasian race, Medicare status, history of depression, and Charlson Comorbidity Index were predictors for patients going to IRFs. In addition, any in-hospital complications led to a higher likelihood of being discharged to IRFs and SNFs. Both models had excellent predictive assessments with area under curve values of 0.79 and 0.80 for pre-operative visit and hospital course.

CONCLUSION

This study identifies pre-operative and in-hospital factors that predispose patients to non-routine discharges, which allow surgeons to better predict patient post-operative disposition.

Intraoperative Infiltration of Liposomal Bupivacaine vs Bupivacaine Hydrochloride for Pain Management in Primary Total Hip Arthroplasty: A Prospective Randomized Trial

BACKGROUND

Pain management after total hip arthroplasty is well studied. Nevertheless, there is no consensus regarding the "cocktail" to use in periarticular infiltration (PAI). Liposomal bupivacaine (LB) is a slow release local anesthetic that can be infiltrated during surgery. In this study, we compared LB to bupivacaine hydrochloride (HCL).

METHODS

Between September 2014 and March 2016, 181 patients were screened for this prospective randomized trial. A total of 107 patients were enrolled and studied. Patients were separated into LB and control groups. LB group (50) received PAI with LB and bupivacaine HCL with epinephrine and the control group (57) received PAI with bupivacaine HCL and epinephrine. Patient morphine equivalent consumption, pain score estimated on visual analog scale, time to first ambulation greater than 20 feet, time to discharge, drug-related side effects, and patient falls were documented. Data were collected up to 72 hours postoperation.

RESULTS

There was no significant difference in morphine equivalent consumption in any of the 12-hour time blocks, up to 72 hours. No patient falls were documented in either group. Time to first ambulation greater than 20 feet, ambulation same day as surgery, time to discharge, and drug-related side effects were not significantly different between groups.

CONLCUSION

Intraoperative PAI with LB did not result in significant differences in postoperative opioid consumption, pain scores, opioid-related side effects, time to first ambulation, and length of stay up to 72 hours following total hip arthroplasty compared to a control group.

Effective exercise intervention period for improving body function or activity in patients with knee osteoarthritis undergoing total knee arthroplasty: a systematic review and meta-analysis

BACKGROUND

Various systematic reviews and/or meta-analyses examining the effects of pre- or postoperative exercise on body function or activity in patients undergoing total knee arthroplasty (TKA) have been published. However, the interventional period needed to at least improve outcomes is unknown.

OBJECTIVE

The aim of this systematic review and meta-analysis was to investigate the exercise intervention period needed to effectively improve body function or activity before and after TKA in patients with knee osteoarthritis (OA).

METHODS

Studies published until July 2017 were included in the review. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was applied to each meta-analysis to determine the quality of the evidence.

RESULTS

Twenty-seven randomized controlled trials were identified. A meta-analysis indicated that exercises performed for 8 weeks after discharge in addition to standard postoperative intervention effectively improved body function as assessed using pain level; physical function, and stiffness on the Western Ontario and McMaster Universities Arthritis Index; extension strength; active knee flexion range of motion; timed up and go test; and gait speed.

CONCLUSION

Overall, we found low- to moderate-quality evidence that an 8-week exercise period was needed after discharge to improve body function and activity in patients with knee OA undergoing TKA.

Assessing the effectiveness of routine use of post-operative in-patient physical therapy services

BACKGROUND

The association between functional decline occurring with prolonged bed rest after surgery is well-known. Immediate in-patient post-operative ambulation with the physical therapy (PT) service has been reported to improve pain and disability, while decreasing the incidence of perioperative complications. Whether formal PT evaluation prior to hospital discharge leads to improved ambulation (number of steps ambulated), shorter duration of hospital stay and lower peri-operative complications compared to nurse-assisted ambulation protocols remain unknown.

METHODS

The medical records of 274 patients (No PT: n=87, PT: n=187) undergoing elective spine surgery at a major academic medical center were reviewed. Patients were categorized based on whether PT services were delivered during the post-operative in-patient stay. Patient demographics, comorbidities, and post-operative complication rates were collected and compared. Ambulation status and the number of steps ambulated were recorded.

RESULTS

Baseline characteristics were similar in both cohorts. Operative variables were similar between both cohorts, with no significant difference in operative time, estimated blood loss (EBL), and number of fusion levels. Peri-operative complication rates were similar between the cohorts. Compared to patients in the nurse-assisted ambulation cohort (No PT), patients in the PT cohort had a longer duration of hospital stay (4.17 vs. 3.39 days, P=0.15). 30-day readmission rates, although higher in the PT cohort, was not statistically significantly different (PT 6.57% vs. No PT: 2.30%, P=0.13).

CONCLUSIONS

Our study suggests that the routine use of the PT services compared to nurse-assisted ambulation programs is associated with a modest increase in the duration of hospital stay without any significant reduction in peri-operative complications profile. In a health conscious healthcare climate, appropriate screening mechanisms and risk stratification should be performed to optimize utilization of post-operative in-patient PT services.

Telerehabilitation Versus Traditional Care Following Total Hip Replacement: A Randomized Controlled Trial Protocol

Background

Total hip replacement (THR) is the gold standard treatment for severe hip osteoarthritis. Effectiveness of physical rehabilitation for THR patients following discharge from hospital is supported by evidence; however, barriers such as geographical location and transport can limit access to appropriate health care. One solution to this issue is using an alternative model of care using telerehabilitation technology to deliver rehabilitation programs directly into patients’ homes. A telerehabilitation model may also have potential health care cost savings for health care providers.

Objective

This study aims to determine if a telerehabilitation model of care delivered remotely is as effective as face-to-face rehabilitation in the THR population and cost effective for health care providers and patients.

Methods

A total of 70 people undergoing THR will be recruited to participate in a randomized, single-blind, controlled noninferiority clinical trial. The trial will compare a technology-based THR rehabilitation program to in-person care. On discharge from hospital, participants randomized to the in-person group will receive usual care, defined as a paper home exercise program (HEP) targeting strengthening exercises for quadriceps, hip abductors, extensors, and flexors; they will be advised to perform their HEP 3 times per day. At 2, 4, and 6 weeks postoperatively, they will receive a 30-minute in-person physiotherapy session with a focus on gait retraining and reviewing and progressing their HEP. The telerehabilitation protocol will involve a program similar in content to the in-person rehabilitation program, except delivery will be directly into the homes of the participants via telerehabilitation technology on an iPad. Outcomes will be evaluated preoperatively, day of discharge from in-patient physiotherapy, 6 weeks and 6 months postoperatively. The primary outcome will be the quality of life subscale of the hip disability and osteoarthritis outcome score, measured at 6 weeks. Both intention-to-treat and per-protocol analyses as recommended in the extension of the Consolidated Standards for Reporting Trials (CONSORT) guideline for noninferiority trials will be performed.

Results

Recruitment commenced in September 2015 and is expected to be completed by June 2017. Data collection will be completed by December 2017. It is anticipated the results from this trial will be published by July 2018.

Conclusions

Previous research investigating telerehabilitation in postoperative orthopedic conditions has yielded promising results. If shown to be as effective as in-person care, telerehabilitation after THR could be helpful in addressing access issues in this population. Furthermore, it may help reduce the cost of health care provision by enabling patients to take a more independent approach to their rehabilitation.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12615000824561; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364010 (Archived by WebCite at http://www.webcitation.org/6oWXweVfI)

Enhanced recovery protocol and hidden blood loss in patients undergoing total knee arthroplasty

BACKGROUND

Perioperative blood loss and postoperative pain following total knee arthroplasty prevent early mobilisation of patients. The Enhanced Recovery Protocol (ERP) followed for patients in our institute aims at reducing post operative pain, blood loss and length of stay.

MATERIALS AND METHODS

50 consecutive patients that underwent ERP following total knee arthroplasty with another group of 70 patients that underwent the same surgery without ERP were compared in terms of hidden blood loss and length of hospital stay. Hidden blood loss was calculated according to previously described method.

RESULTS

Reduction in blood loss was found in both males (305 ml) and females (150 ml) following ERP. Length of stay reduced by 1.5 days in both genders. Regression analysis showed a significant correlation between body weight and blood loss in females.

CONCLUSION

Enhanced recovery protocol could be a useful tool to reduce patient morbidity and reduce length of inpatient stay.

Improving patients’ experience and outcome of total joint replacement: the RESTORE programme

Background

Total hip replacements (THRs) and total knee replacements (TKRs) are common elective procedures. In the REsearch STudies into the ORthopaedic Experience (RESTORE) programme, we explored the care and experiences of patients with osteoarthritis after being listed for THR and TKR up to the time when an optimal outcome should be expected.

Objective

To undertake a programme of research studies to work towards improving patient outcomes after THR and TKR.

Methods

We used methodologies appropriate to research questions: systematic reviews, qualitative studies, randomised controlled trials (RCTs), feasibility studies, cohort studies and a survey. Research was supported by patient and public involvement.

Results

Systematic review of longitudinal studies showed that moderate to severe long-term pain affects about 7–23% of patients after THR and 10–34% after TKR. In our cohort study, 10% of patients with hip replacement and 30% with knee replacement showed no clinically or statistically significant functional improvement. In our review of pain assessment few research studies used measures to capture the incidence, character and impact of long-term pain. Qualitative studies highlighted the importance of support by health and social professionals for patients at different stages of the joint replacement pathway. Our review of longitudinal studies suggested that patients with poorer psychological health, physical function or pain before surgery had poorer long-term outcomes and may benefit from pre-surgical interventions. However, uptake of a pre-operative pain management intervention was low. Although evidence relating to patient outcomes was limited, comorbidities are common and may lead to an increased risk of adverse events, suggesting the possible value of optimising pre-operative management. The evidence base on clinical effectiveness of pre-surgical interventions, occupational therapy and physiotherapy-based rehabilitation relied on small RCTs but suggested short-term benefit. Our feasibility studies showed that definitive trials of occupational therapy before surgery and post-discharge group-based physiotherapy exercise are feasible and acceptable to patients. Randomised trial results and systematic review suggest that patients with THR should receive local anaesthetic infiltration for the management of long-term pain, but in patients receiving TKR it may not provide additional benefit to femoral nerve block. From a NHS and Personal Social Services perspective, local anaesthetic infiltration was a cost-effective treatment in primary THR. In qualitative interviews, patients and health-care professionals recognised the importance of participating in the RCTs. To support future interventions and their evaluation, we conducted a study comparing outcome measures and analysed the RCTs as cohort studies. Analyses highlighted the importance of different methods in treating and assessing hip and knee osteoarthritis. There was an inverse association between radiographic severity of osteoarthritis and pain and function in patients waiting for TKR but no association in THR. Different pain characteristics predicted long-term pain in THR and TKR. Outcomes after joint replacement should be assessed with a patient-reported outcome and a functional test.

Conclusions

The RESTORE programme provides important information to guide the development of interventions to improve long-term outcomes for patients with osteoarthritis receiving THR and TKR. Issues relating to their evaluation and the assessment of patient outcomes are highlighted. Potential interventions at key times in the patient pathway were identified and deserve further study, ultimately in the context of a complex intervention.

Study registration

Current Controlled Trials ISRCTN52305381.

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 12. See the NIHR Journals Library website for further project information.

Factors for Assessing the Effectiveness of Early Rehabilitation after Minimally Invasive Total Knee Arthroplasty: A Prospective Cohort Study

The effectiveness of current rehabilitation programs is supported by high-level evidence from the results of randomized controlled trials, but an increasing number of patients are not discharged from the hospital because of the schedule of the critical path (CP). The present study aimed to determine which factors can be used to assess the effectiveness of early rehabilitation. We enrolled 123 patients with medial knee osteoarthritis (OA) who had undergone unilateral minimally invasive total knee arthroplasty for the first time. The following factors were assessed preoperatively: the maximum isometric muscle strength of the knee extensors and flexors, maximum knee and hip joint angle, pain, 5-m maximum walking speed, sex, age, body mass index, exercise habits, Kellgren-Lawrence grade, femorotibial angle, failure side (bilateral or unilateral knee OA), and functional independence measure. We re-evaluated physical function (i.e., muscle strength, joint angle, and pain) and motor function (5-m maximum walking speed) 14 days postoperatively. Changes in physical function, motor function (5-m maximum walking speed), and number of days to independent walking were used as explanatory variables. The postoperative duration of hospitalization (in days) was used as the dependent variable in multivariate analyses. These analyses were adjusted for sex, age, body mass index, exercise habits, Kellgren-Lawrence grade, femorotibial angle, failure side, and functional independence measure. The duration of hospitalization was significantly affected by the number of days to independent walking (p < 0.001, β = 0.507) and a change in the 5-m maximum walking speed (p = 0.016, β = -0.262). Multiple regression analysis showed that the radiographic knee grade (p = 0.029, β = 0.239) was a significant confounding factor. Independent walking and walking speed recovery were considered to reduce the duration of hospitalization. Therefore, these indices can be used to assess the effectiveness of early rehabilitation.

An ultrasound-guided fascia iliaca catheter technique does not impair ambulatory ability within a clinical pathway for total hip arthroplasty

Background

Both neuraxial and peripheral regional analgesic techniques offer postoperative analgesia for total hip arthroplasty (THA) patients. While no single technique is preferred, quadriceps muscle weakness from peripheral nerve blocks may impede rehabilitation. We designed this study to compare postoperative ambulation outcome in THA patients who were treated with a new ultrasound-guided fascia iliaca catheter (FIC) technique or intrathecal morphine (ITM).

Methods

We reviewed the electronic health records of a sequential series of primary unilateral THA patients who were part of a standardized clinical pathway; apart from differences in regional analgesic technique, all other aspects of the pathway were the same. Our primary outcome was total ambulation distance (meters) combined for postoperative days 1 and 2. Secondary outcomes included daily opioid consumption (morphine milligram equivalents) and analgesic-related side effects. We examined the association between the primary outcome and analgesic technique by performing crude and adjusted ordinary least-squares linear regression. A P value < 0.05 was considered statistically-significant.

Results

The study analyzed the records of 179 patients (fascia iliaca, n = 106; intrathecal, n = 73). The primary outcome (total ambulation distance) did not differ between the groups (P = 0.08). Body mass index (BMI) was the only factor (β = -1.7 [95% CI -0.5 to -2.9], P < 0.01) associated with ambulation distance. Opioid consumption did not differ, while increased pruritus was seen in the intrathecal group (P < 0.01).

Conclusions

BMI affects postoperative ambulation outcome after hip arthroplasty, whereas the type of regional analgesic technique used does not. An ultrasound-guided FIC technique offers similar analgesia with fewer side effects when compared with ITM.

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.

Length of Stay and Achievement of Functional Milestones in a Rural First Nations Population in Northwestern Ontario during Acute-Care Admission after Total Hip Replacement: A Retrospective Chart Review

PURPOSE

To understand the postoperative acute-care physiotherapy course for First Nations people returning after total hip replacement (THR) to remote communities with limited rehabilitation services and to evaluate length of stay and attainment of functional milestones after THR to determine to what extent an urban-based clinical pathway is transferrable to and effective for First Nations patients in a rural setting.

METHODS

Data were collected retrospectively by reviewing charts of patients who underwent THR in the Northwest Ontario catchment area from 2007 through 2012.

RESULTS

For the 36 patient charts reviewed, median length of stay (LOS) at the Sioux Lookout Meno Ya Win Health Centre (SLMHC) was 7.5 days (range 2-335); median LOS from time of surgery at the regional hospital (Thunder Bay Regional Health Centre) to discharge from SLMHC was 13.5 days; and median time for mobilizing and stairs was 9 days (range 1-93).

CONCLUSION

Commonly accepted urban clinical pathways are not a good fit for smaller rural hospitals from which First Nations patients return to remote communities without rehabilitation services. LOS in a rural acute-care facility is similar to LOS in an urban rehabilitation facility.

Can bedside patient-reported numbness predict postoperative ambulation ability for total knee arthroplasty patients with nerve block catheters?

BACKGROUND

Adductor canal catheters offer advantages over femoral nerve catheters for knee replacement patients because they produce less quadriceps muscle weakness; however, applying adductor canal catheters in bedside clinical practice remains challenging. There is currently no patient-reported outcome that accurately predicts patients' physical function after knee replacement. The present study evaluates the validity of a relatively new patient-reported outcome, i.e., a numbness score obtained using a numeric rating scale, and assesses its predictive value on postoperative ambulation.

METHODS

We conducted a retrospective cohort study pooling data from two previously-published clinical trials using identical research methodologies. Both studies recruited patients undergoing knee replacement; one studied adductor canal catheters while the other studied femoral nerve catheters. Our primary outcome was patient-reported numbness scores on postoperative day 1. We also examined postoperative day 1 ambulation distance and its association with postoperative numbness using linear regression, adjusting for age, body mass index, and physical status.

RESULTS

Data from 94 subjects were included (femoral subjects, n = 46; adductor canal subjects, n = 48). Adductor canal patients reported decreased numbness (median [10(th)-90(th) percentiles]) compared to femoral patients (0 [0-5] vs. 4 [0-10], P = 0.001). Adductor canal patients also ambulated seven times further on postoperative day 1 relative to femoral patients. There was a significant association between postoperative day 1 total ambulation distance and numbness (Beta = -2.6; 95% CI: -4.5, -0.8, P = 0.01) with R(2) = 0.1.

CONCLUSIONS

Adductor canal catheters facilitate improved early ambulation and produce less patient-reported numbness after knee replacement, but the correlation between these two variables is weak.

Femoral Nerve Block vs Periarticular Bupivacaine Liposome Injection After Primary Total Knee Arthroplasty: Effect on Patient Outcomes

Context: Patients receiving femoral nerve blocks for total knee arthroplasty (TKA) have been shown to have a high incidence of postoperative falls, which has been attributed to weakening of the quadriceps muscles. Local injection of analgesic medication that allows for full motor function of the quadriceps and, therefore, better progress through inpatient physical therapy and decreased hospital stay, has been suggested as an option for postoperative pain relief.

Objective: To compare the number of inpatient physical therapy sessions and hospital days needed in patients receiving periarticular injection of extended-release bupivacaine liposome vs femoral nerve block after TKA.

Methods: Data were retrospectively reviewed from the records of patients who underwent bilateral primary TKA, in which femoral nerve block was administered at the first operation and periarticular injection of an extended-release bupivacaine liposome mixture at the second operation. An average of 2.3 years had passed between the 2 procedures. The number of inpatient physical therapy sessions and hospital days needed were compared between both procedures for each patient.

Results: Sixteen patients (14 women) were included in the study, with a mean (SD) age of 63.8 (6.7) years. Compared with femoral nerve block, periarticular injection of analgesic medication resulted in fewer inpatient physical therapy sessions (femoral nerve block: mean [SD], 3.5 [1.3] sessions; periarticular injection: mean [SD], 2.3 [1.0] sessions; P=.002) and fewer hospital days (femoral nerve block: mean [SD], 1.9 [0.6] days; periarticular injection: mean [SD], 1.5 [0.6] days; P<.032).

Conclusion: Compared with femoral nerve block, periarticular injection of analgesia was found to quicken postoperative recovery in patients hospitalized for TKA. The use of periarticular injections in patients undergoing TKA could yield substantial cost savings given the high frequency of this procedure.

A Comparison of Single Shot Adductor Canal Block Versus Femoral Nerve Catheter for Total Knee Arthroplasty

The aim of this study was to compare perioperative analgesia provided by single-injection adductor canal block (ACB) to continuous femoral nerve catheter (FNC) when used in a multimodal pain protocol for total knee arthroplasty (TKA). A retrospective cohort study compared outcome data for 148 patients receiving a single-injection ACB to 149 patients receiving an FNC. The mean length of stay (LOS) in the ACB group was 2.67 (±0.56) and 3.01 days (±0.57) in the FNC group (P<0.0001). The median ambulatory distances for the adductor group were further than the femoral group for postoperative days 1 (P<0.0001) and 2 (P=0.01). Single-injection ACB offered similar pain control and earlier discharge compared to continuous FNC in patients undergoing TKA.

Effects of Aquatic Therapy and Land-Based Therapy versus Land-Based Therapy Alone on Range of Motion, Edema, and Function after Hip or Knee Replacement: A Systematic Review and Meta-analysis

PURPOSE

To determine whether aquatic therapy in combination with land-based therapy improves patient outcomes after hip or knee arthroplasty compared with land-based therapy alone.

METHODS

For this systematic review, six online databases (MEDLINE, CINAHL, AMED, EMBASE, Cochrane, and PEDro) were searched from the earliest date available until September 2013. Controlled trials published in English in a peer-reviewed journal that compared aquatic therapy in combination with land-based therapy with land-based therapy alone were included; trial quality was assessed using the PEDro scale. Data were presented as standardized mean differences (SMDs), their associated 95% CIs, and meta-analyses.

RESULTS

Three small trials of moderate quality were included in the qualitative analysis. Meta-analysis of two of these studies found moderate-quality evidence that aquatic therapy in combination with land-based therapy improves functional outcomes (SMD=0.53; 95% CI, 0.03-1.03), knee range of motion (measured in knee or hip arthroplasty; SMD=0.78; 95% CI, 0.27-1.29), and edema (SMD=-0.66; 95% CI, -1.16 to -0.15) compared with land-based therapy alone. The results for improved functional outcomes were not considered clinically significant.

CONCLUSIONS

It is not possible to draw confident conclusions from this review because of the small number of studies of limited quality and the modest differences found. Further studies of sound methodological quality are required to confirm the results. Economic analysis alongside randomized controlled trials is needed to examine the cost-effectiveness of these clinical outcomes.