Accelerated rehabilitation pathway (ARP) decrease patients’ hospital length of stay (LOS). A lack of evidence exists on physiotherapy management and outcome as part of ARP in South Africa (SA). Our study will aim to determine whether early mobilisation and increased frequency of physiotherapy treatments for participants after hip or knee arthroplasty surgery on post-operative day 0 (POD 0) affect outcome.
A quantitative prospective cohort study incorporating ARP on (
Globally, ARP’s are successfully implemented to manage patients presenting with hip and knee osteoarthritis (OA). Research investigating physiotherapy protocols in an ARP is lacking in the literature.
Achieving the same-day discharge after hip and knee arthroplasty surgeries may help elective surgery backlogs and waiting lists in a more cost-effective manner.
The same day discharge after arthroplasty may be a cost-effective management option in the future.
Pan African Clinical Trial Registry, PACTR202103637993156.
Increased life expectancy, lifestyle changes, obesity and non-communicable diseases, trauma and HIV contribute to increased musculoskeletal and orthopaedic diseases such as osteoarthritis (OA) in South Africa (SA) (Plenge et al.
Kurtz et al. (
When considering the increased cost and burden on resources, there has been a national and international shift towards advanced multidisciplinary approaches for hip and knee arthroplasty surgeries. A variety of names are used in the literature for these advanced protocols. Advanced clinical pathway (Plenge et al.
Studies conducted on a fast track or ARP demonstrate that advanced protocols can be implemented safely, effectively and reduce the hospital’s LOS, without increasing complications more than conservative protocols (Lazic et al.
Although advanced pathways have different names, the focus of these protocols is standardised care. The standardised care includes patient education, pain control, thromboprophylaxis (preventing blood clot formation in blood vessels), managing blood loss during surgery and early mobilisation, as the key elements (Lazic et al.
We will now describe the specific core adaptations included in advanced protocols. The pain control is a focussed multi-modal, opioid sparing regime to decrease nausea, dizziness and sleepiness after surgery, thus enabling patients to mobilise within hours of the surgery. Intermittent pneumatic compression pumps (IPCPs) are used post-operatively for thromboprophylaxis. Depending on the patient’s risk profile, aspirin or clexane is prescribed. Blood loss in surgery is restricted by controlled hypotension, no drainage pipes, using a tourniquet at appropriate pressures only during the surgery’s cementation and tranexamic acid. The surgical technique is a minimally invasive, muscle-sparing approach with kinematic alignment and subcutaneous sutures with tissue adhesives that contribute to rapid recovery (Lazic et al.
The advancement in elective total hip and knee arthroplasty has reached a point where decreasing the LOS by using advanced pathways led to outpatient joint arthroplasties in the United States of America and Europe. In 2018, total knee arthroplasties were no longer only in-hospital procedures. According to Yates et al. (
Physiotherapy forms an integral part of the advanced pathways through patient education, management before the surgery, early mobilisation and rehabilitation. Early mobilisation (patient ambulating or walking with an appropriate mobility aid away from the bed), plays an essential role in decreasing post-operative complications, including deep vein thrombosis (DVT), prosthesis-related infections and postural hypotension (Chen et al.
Studies have shown that early mobilisation post-operative day 0 (POD 0) plays a significant role in decreased LOS (Lazic et al.
Despite the advancements in decreased LOS in the hospital for patients who underwent hip and knee arthroplasty surgeries, studies indicate a 10% and 20% patient dissatisfaction percentage for outcomes (Gunaratne et al.
The orthopaedic surgeon at the private hospital where our study is to be carried out has implemented an ARP and early POD 0 mobilisation. For the ARP, the average LOS has decreased from 3.5 to 2.4 days and now is 23 h. When talking about day-surgery, McCulloch et al. (
If early mobilisation (patient ambulating or walking with an appropriate mobility aid away from the bed) and increased frequency of physiotherapy intervention on POD 0 lead to decreased LOS, stakeholders and medical funders will benefit from the cost-saving reduced length of hospital stay in the private and public sectors in SA. Private and public healthcare, the SA government and NHI can accommodate the increased demand for joint arthroplasties by effectively using the available resources and saving on costs. Patients may benefit from a shorter waiting period for their hip or knee arthroplasty leading to a quicker recovery and better quality of life. Good quality healthcare must be provided cost-effectively and improve patient-reported outcomes and satisfaction. The ARP provides a possible improved way of elective total hip and knee arthroplasties.
Appropriate physiotherapy management plays an integral part in the ARP. With a lack of evidence guiding clinical practice in SA, our study thus aims to determine how early mobilisation and increased daily frequency of physiotherapy on POD 0 impact the hospital LOS, safety and patient satisfaction, after hip and knee arthroplasty in a private hospital in SA.
The specific objectives of our study are to:
determine how early mobilisation and the increased frequency of physiotherapy on POD 0 impacts hospital LOS in mean hours, (primary outcome)
determine patient satisfaction (pain, function, stiffness and expectation) 6 weeks and 3 months post-operatively
evaluate the safety of implementing an accelerated rehabilitation pathway on patients after hip and knee arthroplasty, documenting any adverse events and 30-day readmission rate
determine and compare the costs of LOS, in a simple cost comparison between historic cohort and prospective cohort groups.
Our study is a prospective cohort study that includes a purposive convenient, selected sample of patients (
All consecutive elective hip and knee arthroplasty patients cleared pre-surgically by the physician as per ARP will be included. Patients with revision surgery, trauma-related surgeries, bilateral arthroplasty, poor balance and cognitive deficiencies will be excluded from participation.
All patients in both the historical and prospective groups received the same treatment and protocol at the Medicare private hospital in Rustenburg, the difference lying in the time before first mobilisation and the frequency of treatment on POD 0. The historical group received a more conservative protocol that included an educational session in hospital pre-operatively and mobilisation once on POD0-3 hours post-operatively.
The prospective group will receive the new protocol, that is, an educational session the week prior to surgery and before hospital admission; mobilisation 1–3 h post-operatively (Raphael et al.
Information will be provided to all potential participants and informed consent to be included in our study will be obtained. The multidisciplinary team for all surgeries consists of the same group of individuals: orthopaedic surgeons, anaesthetists, physiotherapists and nursing staff. The protocols will be uniform throughout our study except for the differences described here.
The physiotherapy protocol will start with pre-operative education, pre-habilitation (rehabilitation performed by the physiotherapist before the surgery) and include an evaluation session (measurement of hip and knee range of movement (ROM) with a goniometer, hip and knee muscle strength with the Oxford Scale and The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire is also completed in this session). This session emphasises post-operative expectations for the patient and physiotherapist, post-operative exercises, bed mobility, gait re-education, navigating stairs with crutches, preventive measures, early mobilisation and ice programme (Andersen et al.
Post-operatively, patients are routinely monitored in the ward by the nursing staff for nausea, hypotension, tachycardia or desaturation. An ice pack is applied as soon as the patient is back in the ward after surgery. Ice is applied almost continuously during the day through a light compression bandage (Tubigrip). Patients are advised to apply the ice for 8 h per day with short intervals without ice for the first 3 days. Karaduman et al. (
Patients have no catheter or drainage pipes. Patients return to the ward with a short drip in the arm and cardiac monitor electrodes on their chests, which is removed to make mobilisation easier. An intermittent pneumatic compression pump is in place around the patient’s calves to help in preventing DVTs. Patients are mobilised POD 0 as soon as they are fully awake, no nausea or dizziness is observed and with the surgeon’s permission, 1–3 h post-operatively (Raphael et al.
The bed exercise prescription is one set of 10 repetitions, a minimum of five times per day. The patient is then mobilised to sit over the side of the bed. While the patient sits over the side of the bed, a short lever quadriceps extension exercise is prescribed. If the patient has no dizziness, nausea or intense pain and adequate knee proprioception (Jenkins et al.
A second physiotherapy session, 1–2 h after the first physiotherapy session, follows for the prospective group. The second physiotherapy session comprises the same exercises and mobilisation programme as the first session. The physiotherapist will also help the patient to get dressed in their clothes during the second session. In-between the two physiotherapy sessions, the patient, may mobilise with the nursing staff’s assistance to the bathroom if the need arises. Depending on how well and safe the patient is in mobilising, stair climbing might be included in the second session on POD 0 or in the first physiotherapy session on post-operative day 1. Patients will receive physiotherapy sessions twice per day while in hospital.
Before discharge, the patient is expected to demonstrate good independent bed mobility (be able to get in and out of bed by themselves), mobilise 50 m or more with an appropriate assistive device, navigate by climbing five stairs safely with crutches or one step in case of a walking frame (Berger et al.
Upon completing the prospective cohort study, a retrospective comparison with data from our historical control will be conducted including a simple cost comparison.
Length of stay is frequently used as an outcome measure after hip and knee arthroplasty surgeries and will be measured in hours to be more precise and to be able to detect more effectively any small changes in the time period. Length of stay will be measured in hours from when the patient goes to the theatre to when the patient is discharged to be accurate (McCulloch et al.
The WOMAC, a patient-administered questionnaire, is a widely used, valid and reliable outcome measure in patients with hip and knee arthroplasty. It measures pain, stiffness and physical function (Collins et al.
The proposed protocol’s safety will be measured with the 30-day readmission rate. Unplanned readmissions within 30 days after the patient is discharged from the hospital will be documented (Rumball-Smith & Hider
All data obtained will be safely kept electronically on the first author’s password-protected computer for 6 years if not published and 2 years if published. The informed consent and questionnaire hard copies will also be stored securely in the first author’s code-protected office for 6 years.
Descriptive statistics, namely frequencies and percentages for categorical data and mean and standard deviation or median and percentiles for numerical data, will be calculated. Quantitative outcome variables will be tested for normality using the Shapiro–Wilk test. International Business Machines Statistical product and service solutions (IBM SPSS) version 27 will be used to analyse the data. A paired
Validity will be ensured by using consistent, standardised verbal instructions during the protocol. Reliability will be improved by collecting the data in a standardised environment and implementing standardised procedures.
The trial is registered with the Pan African Clinical Trial Registry (PACTR202103637993156). Ethical clearance was obtained from the University of the Witwatersrand Human Research Ethics (Medical) Committee (reference number: M200576), the orthopaedic surgeon and manager of the private hospital in Rustenburg. Permission for data from hospital records for the data collection in the main prospective and historical cohort group will be obtained. Information will be given to prospective participants and written permission to participate in our study will be requested.
Hip and knee pain because of osteoarthritis is one of the leading causes of pain, disability and decreased life quality. Hip and knee arthroplasties have become the answer for optimal function and quality of life. Using an ARP pathway in hip and knee arthroplasty surgeries on patients waiting for elective surgeries may decrease the already long waiting lists (Wainwright
Accelerated rehabilitation protocol has become very popular internationally and is gaining popularity in SA (Immelman et al.
There is a lack of evidence of the physiotherapy protocol in the ARP (Anderson et al.
Our study will determine the LOS, patient satisfaction, safety and cost comparison of early mobilisation and frequency of physiotherapy compared with a historic physiotherapy protocol. The feasibility of a physiotherapy protocol in an ARP will thus be evaluated and may provide a cost-effective rehabilitation method in a resource restraint SA.
The authors would like to express their appreciation to the orthopaedic surgeon, private hospital, staff and the participants for their willingness to be part of this novel approach to hip and knee arthroplasty. They would also like to thank Ms Tonya Esterhuizen for providing statistical support.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
R.P. conceptualised the idea, wrote a physiotherapy protocol and proposed the topic of research. M.M.K. assisted in the refinement of the topic and proposal. R.P. and M.M.K. wrote the first draft of the article. The article was read, elaborated and refined by R.P. and M.M.K.
The authors received no financial support for the research, authorship and/or publication of this article.
The authors confirm that the data supporting the findings of this study are available within the article and/or its supplementary materials. Any future results will be made accessible on the author’s ORCID accounts.
The views expressed in the submitted proposal by the authors are their own and not an official position of the institution or funder.