The rise in the adoption of outpatient arthroplasty has been attributed to its cost-effectiveness, although safety concerns persist. In this meta-analysis, we compare inpatient and outpatient joint arthroplasty with a primary focus on readmission and complication rates, using exclusively high-quality prospective data. Cost-effectiveness was used as a secondary outcome measure.

A literature search was performed in Medline, Embase and Cochrane Library from inception to October 2023. A predefined strategy was used to conduct a systematic review and meta-analysis. Twelve studies were deemed eligible for inclusion. These were critically appraised using RoB analysis and MINORS criteria. Overall readmission rate, readmission rate for THA, readmission rate for TKA, complication rate and cost-analysis were selected as outcomes of interest. Forest plots were extracted using RevMan 5.3.5 software.

The twelve studies included 2470 patients, of which 1052 were outpatients and 1418 inpatient subjects undergoing arthroplasty. Forest plot analysis showed no significant difference in safety outcomes (readmission and complication rates). However, there were significantly lower costs in the outpatient group compared to the inpatient group. The results of the analysis were; overall readmission rate (Odds ratio 0.66; P= 0.29; I2=18%), readmission rate in THA (odds ratio 0.62; P=0.10; I2=51%), readmission rate in TKA (odds ratio 0.67; P=0.56; I2=0%), overall complication rate (odds ratio 0.77; P=0.12; I2=38%) and cost analysis (RR -2.88; P<0.00001; I2= 93%).

This meta-analysis demonstrates that outpatient total joint arthroplasty (TJA) is a safe option, when compared to inpatient surgery. However, it is clear that further prospective studies and long-term randomized clinical data are necessary for a more comprehensive understanding.

 Discharge on day of surgery after hip or knee arthroplasty is increasing, but whether this leads to an increase in the overall number of post-discharge healthcare system contacts is unknown. We aimed to investigate whether day-case surgery leads to increased patient-reported healthcare system contacts compared with non-day-case surgery within the first 30 days postoperatively.

 We performed a prospective multicenter study at seven fast-track centers from September 2022 to August 2023. Candidates for primary total hip arthroplasty (THA), total knee arthroplasty (TKA), or unicompartmental knee arthroplasty (UKA) were evaluated for day-case eligibility using pre-defined criteria. Patients received a survey 30 days postoperatively regarding any healthcare system contacts related to surgery. Planned healthcare visits were excluded. We used day-case eligible patients not discharged on day of surgery (inpatients) as control group.

 Of 2,278 day-case eligible patients, 2,073 (91%) completed the survey, including 1,146 day-case patients (55%) and 927 inpatients (45%). The overall rate of healthcare system contacts was 49% (95% confidence interval [CI] 45-51) in day-case patients compared with 52% (CI 49-56) in inpatients. Specific contacts included visits to a general practitioner (GP) or out-of-hours medical clinic (25% [CI 22-27] vs 32% [CI 29-35]), the emergency department (ED) (6% [CI 4-7] vs 7% [CI 5-8]), and outpatient clinics or wards (35% [CI 33-38] vs 35% [CI 32-38]). The most common reasons for all types of healthcare contacts were wound problems, prescription renewals, and pain management.

 Day-case hip and knee arthroplasties was not associated with increased healthcare system contacts within the first 30 days postoperatively.

The goal of this study is to report our findings on the application of the enhanced recovery after surgery (ERAS) protocol for patients undergoing unicompartmental knee arthroplasty (UKA) and to evaluate the benefits and drawbacks of this approach.

Sixty patients with medial unicompartmental knee osteoarthritis (UKOA) who underwent UKA were the subject of a retrospective investigation. The patients were categorized into 2 groups based on the use of ERAS protocols. Among the metrics that were measured and statistically analyzed were Kellgren-Lawrence grade, femorotibial angle (FTA), Tegner activity score, Lysholm knee score, University of California at Los Angeles (UCLA) activity score, Berg Balance Scale (BBS), numeric pain rating scale (NPRS) score, forgotten joint score, range of motion (ROM), hospital length of stay (LOS), procedure duration, intraoperative bleeding volume, time to ambulation, time to resume normal walking, duration of urinary catheter retention, time to resume a regular diet, and postoperative satisfaction.

The patients allocated to the ERAS cohort showed distinct characteristics compared with the control cohort, including faster resumption of regular dietary intake, ambulation, and gait patterns. The ERAS group showed a decreased FTA and improved BBS scores. On final evaluation, the ERAS group had lower UCLA scores, indicative of superior overall outcomes.

The initial application of ERAS showed promising results in enhancing patient rehabilitation outcomes, reducing the impact of hospitalization, and improving efficient allocation of health care resources. Nevertheless, additional research is necessary to assess the feasibility and effectiveness of widespread implementation for patients undergoing UKA. [Orthopedics. 2025;48(2):87-97.].

Total knee arthroplasty (TKA) is the gold standard for advanced knee osteoarthritis and is increasingly performed on younger, active individuals. While low-impact sports are recommended after TKA, running remains controversial due to concerns about implant loosening. Cemented implants have durability issues at the bone-cement interface, while cementless designs seem to promote better osseointegration. Despite limited research, running after TKA is gaining acceptance. The purpose of this paper is to present a systematic review of the literature and present a novel and specific protocol to guide motivated patients in safely resuming running. We conducted a systematic review of PubMed studies regarding running after TKA and the PRISMA flow diagram shows the inclusion and exclusion criteria adopted. In addition, we present a novel protocol (FAST) specifically designed for TKA patients aiming to return to running which combines surgical techniques, perioperative analgesia, and physical therapy. It has been approved by the Ethics Board, the prospective trial is registered (NCT06383936), and we are currently enrolling participants. After screening according to inclusion and exclusion criteria, six studies were included in the analysis. The FAST protocol combines cementless CR-design implants, minimally invasive surgery, and personalized functional alignment. Local infiltration analgesia reduces pain and enables rehabilitation within 24 h. Rehabilitation progresses with range-of-motion exercises, muscle strengthening, and gradual return to running at 6-8 months. Monitoring activity carefully prevents inflammation, optimizing recovery. Running after TKA, once discouraged, now shows low complication rates. Preoperative fitness and patient-specific factors are key predictors of success. The FAST protocol integrates cementless implants, personalized alignment, and structured rehabilitation. Proper patient selection and communication are essential. Further research is required to validate long-term outcomes.

Patients who undergo major lower extremity amputation (MLEA) have the highest postoperative mortality among orthopedic patient groups. The comorbidity profile for MLEA patients is often extensive and associated with elevated postoperative mortality. This study primarily aimed to investigate the increased short- and long-term mortality following first and subsequent major lower extremity amputation. Secondarily, to examine the mediation role of post-amputation complications.

With data from the Danish National Patient Registry, 11,695 first-time MLEAs in patients aged ≥50 years were identified between January 1, 2010, and December 31, 2021, along with 58,466 unamputated persons matched 1:5 by year of birth, sex, and region of residence. Mediators were identified through diagnosis codes (ICD-10) present in 6 months following MLEA.

The increased mortality following MLEA was highest in the month following MLEA, hazard ratio (HR) 38.7 (95% confidence interval (CI) 30.5-48.9) in women and HR 55.7 (CI 44.3-70.2) in men compared to a matched unamputated cohort. Subsequent amputation resulted in an increased mortality the month after a subsequent amputation (overall HR 3.2 (CI 2.8-3.7) in women and HR 3.2 (CI 2.8-3.6) in men) and almost normalized after the first year. The proportion of the mortality risk that potentially could be reduced by preventing sepsis was 16% (CI 11.7-20.3) for women and 17% (CI 13.4-20.4) for men. For pneumonia, it was 10.5% (CI 7.1-13.9) in women and 14.9% (11.6-18.2) in men.

We observed an increased mortality in the month following MLEA, which remained elevated for years compared to the matched unamputated cohort. A subsequent amputation results in increased mortality in the following year, but declined and normalized after the first year. Sepsis and pneumonia arising after the amputation appeared to be important factors that contributed to the increased postoperative mortality.

Venous thromboembolism (VTE) is a serious complication following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Despite improvements with fast-track treatment protocols, 0.5% of patients still develop a VTE within 90-days postoperatively. Previously, the 5-single nucleotide polymorphism (SNP) genetic risk scores (weighted and simplified) were developed to identify people at a high risk for VTE within the general population.

We aimed to assess whether the 5-SNP scores could be used to identify high-risk patients in a cohort of fast-track THA/TKA patients.

A subset of patients from the Lundbeck Centre for Fast-track Hip and Knee Replacement Database was included based on the availability of genetic information. The 5-SNP scores were calculated for these patients, and their discriminatory performance was determined by c-statistic. Furthermore, the 5-SNP scores were added to a simple logistic prediction model containing clinical predictors to assess the added predictive value.

A total of 7753 THA and TKA procedures (6798 patients) were included in this study. The c-statistics for the weighted and simple 5-SNP scores were 0.50 (95% CI, 0.39-0.61) and 0.48 (95% CI, 0.38-0.58), respectively. For the model with clinical predictors, the c-statistic was 0.67 (95% CI, 0.56-0.77). Addition of either of the 5-SNP scores did not improve discrimination in this model.

These findings do not support genetic risk profiling in fast-track THA/TKA patients to predict VTE. Hence, efforts should be directed at optimizing prediction models with clinical predictors.

Following the implementation of the fast-track protocol in total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA), the median length of stay (LOS) has been significantly reduced without an increase in readmissions. However, it is unclear if the reduction in LOS is at the expense of an increase in nonhome discharge. The aim of this study was to investigate the discharge destination among THA, TKA, and UKA patients.

The prospective multicenter study included 6,856 patients undergoing primary THA, TKA, and UKA in a fast-track setting with an overall median LOS of one day. Outcomes were discharge destination, median LOS in each discharge destination category, and cause of rehabilitation center discharge. Data were gathered using preoperative questionnaires and a review of medical records. Discharge destination and LOS were registered at discharge.

We found that 99% of patients had been discharged to their own homes, of which 21% had been discharged to their own homes with home care. There were 1% who were discharged to a rehabilitation facility and 0.1% who were discharged to a nursing home. The THA (1%, 95% confidence interval [CI] 0.7 to 1) and TKA (1%, 95% CI 0.9 to 2) had a significantly higher rate of discharge to a rehabilitation facility compared to UKA (0.1%, 95% CI 0.0 to 0.5).

Despite a short LOS, 99% of patients were discharged to their own homes. Rehabilitation facility discharge was only 1% and was mostly caused by inadequate postoperative mobilization.

To compare the outcomes and complications of two perioperative protocols for the management of patients who underwent medial unicompartmental knee arthroplasty (UKA): 24 h (1-day surgery [OS]) versus 72 h (enhanced recovery after surgery [ERAS]) of the length of hospital stay (LOS). In our hypothesis, the reduction of the LOS from 3 to 1 day did not influence the outcomes and complications.

A total of 42 patients (21 in each group) with isolated anteromedial knee osteoarthritis and meeting specific criteria were prospectively included in the study. Clinical outcomes included Knee Society Score (KSS) and Forgotten joint score while pain evaluation was performed using a Visual Analogue Scale (VAS). Functional outcomes were assessed measuring the knee range of motion (ROM) while radiographic outcomes were evaluated measuring the amelioration of the varus deformity through the hip-knee-ankle angle (HKA).

Clinical and functional outcomes did not significantly differ between the two groups. Complications occurred in 9.5% of OS and 4.7% of ERAS group patients. Significant improvements in knee ROM, VAS pain, KSS and HKA angle were observed postsurgery, with no significant differences between groups except in KSS expectations and function trends.

The OS protocol is safe and effective and LOS, in a well-defined fast-track protocol, did not significantly impact clinical and functional outcomes. OS may lead to reduced hospitalisation costs and potential reductions in complications associated with prolonged stays, benefiting both patients and healthcare facilities. However, further research with larger sample sizes and longer follow-up periods is needed to confirm these findings. Early mobilisation and rehabilitation protocols are key components of successful patient recovery following UKA procedures.

Level II.

Evidence on how to improve daily physical activity (PA) levels following total knee arthroplasty (TKA) or medial uni-compartmental knee arthroplasty (mUKA) by motivational feedback is lacking. Moreover, it is unknown whether a focus on increased PA after discharge from the hospital improves rehabilitation, physical function, and quality of life. The aim of this randomized controlled trial (RCT) nested in a prospective cohort is (a) to investigate whether PA, physical function, and quality of life following knee replacement can be increased using an activity monitoring device including motivational feedback via a patient app in comparison with activity monitoring without feedback (care-as-usual), and (b) to investigate the potential predictive value of PA level prior to knee replacement for the length of stay, return to work, and quality of life.

The study is designed as a multicenter, parallel-group, superiority RCT with balanced randomization (1:1) and blinded outcome assessments. One hundred and fifty patients scheduled for knee replacement (TKA or mUKA) will be recruited through Odense University Hospital, Denmark, Vejle Hospital, Denmark and Herlev/Gentofte Sygehus, Denmark. Patients will be randomized to either 12 weeks of activity monitoring and motivational feedback via a patient app by gamification or 'care-as-usual,' including activity monitoring without motivational feedback. The primary outcome is the between-group change score from baseline to 12-week follow-up of cumulative daily accelerometer counts, which is a valid proxy for average objectively assessed daily PA.

Improving PA through motivational feedback following knee replacement surgery might improve post-surgical function, health-related quality of life, and participation in everyday life.

ClinicalTrials.gov, ID: NCT06005623. Registered on 2023-08-22.

Recruiting.

Objectives: The aim of this study is to analyse the efficacy of using a combined infiltration between a popliteal artery and knee cap (IPACK) anaesthetic block and a selective saphenous nerve block compared to local infiltration with anaesthetic in knee replacement surgery. Methods: A retrospective observational study was conducted. A total of 312 patients who underwent primary total knee arthroplasty in our hospital between January 2019 and December 2022 were reviewed. Local intra-articular anaesthesia was used in 207 patients and combined nerve block in 105 patients (IPACK group). The mean age in the LIA group was 72.9 years and 70.4 years in the IPACK group. There were 44% men in the LIA group and 53.3% in the IPACK group. The primary outcome was the presence of poorly controlled pain requiring rescue opioid analgesia in the postoperative period. Secondary outcomes included pain scores, range of motion and length of hospital stay. Results: There were no significant differences in the age or gender distribution of patients between the two groups. One patient treated with anaesthetic blocks required rescue analgesia with opioids, while in the LIA group this occurred in 28.5% of cases. There were statistically significant higher VAS scores in the LIA group (p < 0.001). Range of motion was slightly greater in the block group (4.6°, p < 0.05). There were significant differences in hospital stay (2.4 days in the blocks group and 2.8 days in the LIA group (p < 0.05). Conclusions: In our series, patients treated with anaesthetic blocks showed better results with similar postoperative pain control. However, further studies are needed.

Colorectal cancer (CRC) is the third most common cancer in men and the second most common in women globally. CRC is considered a priority public health issue due to its incidence and the high associated costs. Surgery is the predominant therapeutic approach for CRC. Given the involvement of the intestinal tract in the surgical process, there is a significant increase in postoperative morbidity rates, and the average length of hospital stay (LOS) tends to lengthen. In this research, we employed the Lean Six Sigma (LSS) methodology, specifically utilizing the DMAIC cycle, to identify and subsequently examine the effects of fast-track surgery on hospitalization times for interventions related to CRC at the AORN "Antonio Cardarelli" Hospital in Naples (Italy). The process analysis, guided by the DMAIC cycle, facilitated a reduction in the median LOS from 14 days to 12 days. The most notable improvement was observed in the 66-75 age group without comorbidities. The LSS approach provides methodological rigor, as previously recognized, enabling substantial enhancements to the process. This involves standardizing outcomes, minimizing variability, and achieving an overall reduction in the LOS from 14 to 12 days.

Background: The growth of arthroplasty procedures requires innovative strategies to reduce inpatients' hospital length of stay (LOS). This study aims to develop a machine learning prediction model that may aid in predicting LOS after hip or knee arthroplasties. Methods: A collection of all the clinical notes of patients who underwent elective primary or revision arthroplasty from 1 January 2019 to 31 December 2019 was performed. The hospitalization was classified as "short LOS" if it was less than or equal to 6 days and "long LOS" if it was greater than 7 days. Clinical data from pre-operative laboratory analysis, vital parameters, and demographic characteristics of patients were screened. Final data were used to train a logistic regression model with the aim of predicting short or long LOS. Results: The final dataset was composed of 1517 patients (795 "long LOS", 722 "short LOS", p = 0.3196) with a total of 1541 hospital admissions (729 "long LOS", 812 "short LOS", p < 0.001). The complete model had a prediction efficacy of 78.99% (AUC 0.7899). Conclusions: Machine learning may facilitate day-by-day clinical practice determination of which patients are suitable for a shorter LOS and which for a longer LOS, in which a cautious approach could be recommended.

Muscular deficits as part of severe osteoarthritis of the hip may persist for up to two years following total hip arthroplasty (THA). No study has evaluated the mid-term benefit of a modified enhanced-recovery-after-surgery (ERAS) concept on muscular strength of the hip in detail thus far. We (1) investigated if a modified ERAS-concept for primary THA improves the mid-term rehabilitation of muscular strength and (2) compared the clinical outcome using validated clinical scores.

In a prospective, single-blinded, randomized controlled trial we compared patients receiving primary THA with a modified ERAS concept (n = 12, ERAS-group) and such receiving conventional THA (n = 12, non-ERAS) at three months and one year postoperatively. For assessment of isokinetic muscular strength, a Biodex-Dynamometer was used (peak-torque, total-work, power). The clinical outcome was evaluated by using clinical scores (Patient-Related-Outcome-Measures (PROMs), WOMAC-index (Western-Ontario-and-McMaster-Universities-Osteoarthritis-Index), HHS (Harris-Hip-Score) and EQ-5D-3L-score.

Three-months postoperatively, isokinetic strength (peak-torque, total-work, power) and active range of motion was significantly better in the modified ERAS group. One year postoperatively, the total work for flexion was significantly higher than in the Non-ERAS group, whilst peak-torque and power did not show significant differences. Evaluation of clinical scores revealed excellent results at both time points in both groups. However, we could not detect any significant differences between both groups in respect of the clinical outcome.

With regard to muscular strength, this study supports the implementation of an ERAS concept for primary THA. The combination with a modified ERAS concept lead to faster rehabilitation for up to one-year postoperatively, reflected by significant higher muscular strength (peak-torque, total-work, power). Possibly, because common scores are not sensitive enough, the results are not reflected in the clinical outcome. Further larger randomized controlled trials are necessary for long-term evaluation.

Knee arthritis is a destructive disorder that affects the knee joints and causes pain and reduced mobility. Drug treatments, weight loss, and exercise control the symptoms of the disease, but these methods only delay the disease process and eventually, knee joint replacement surgery will be needed. After surgery, with the help of a proper physiotherapy program, full recovery takes an average of 6-12 months. However, currently, there is no similar tool to facilitate this process in Iran.

The purpose of this research is to design and develop the prototype of a rehabilitation system for patients after knee replacement surgery, which provides patients with information and appropriate physiotherapy programs.

This study was development-applied and was done in three stages. In the first stage, the needs and content of education and therapeutic exercises were prepared in the form of a checklist, and then the necessity of each item was checked in the evaluation sessions. In the second stage, the prototype of the system was developed using Adobe XD software and based on the requirements approved from the previous stage. In the third stage, the usability of the program was analyzed from the point of view of experts using the exploratory evaluation method with Nielsen's 13 principles of usability.

At first, the system requirements were extracted and prepared in two checklists of content (51 exercises) and capabilities (60 items). Then after a survey of experts based on the Delphi technique, content information (43 exercises) and functional and non-functional requirements (53 items) were obtained. A survey of experts helped to finalize the information elements, categorize them, and prepare the final version of the checklists. Based on this, the system requirements were classified into 11 categories, and the training content was classified into 3 training periods. Finally, the design and development of the system was done. This system has admin, physician, and patient user interfaces. The result of usability showed that this system is efficient and there are only a few problems in the feature of helping users to detect and recover from errors.

It seems necessary to develop a system based on the principles of usability by therapists and rehabilitation specialists to train and monitor the remote rehabilitation process of patients after knee joint replacement at home. And the importance of involving stakeholders in the design and development of remote rehabilitation systems is not hidden from anyone. Kara system has all of the above.

The frequency of hip and knee arthroplasty surgeries has been rising steadily in recent decades. This trend is attributed to an aging population, leading to increased demands on healthcare systems. Fast Track (FT) surgical protocols, perioperative procedures designed to expedite patient recovery and early mobilization, have demonstrated efficacy in reducing hospital stays, convalescence periods, and associated costs. However, the criteria for selecting patients for FT procedures have not fully capitalized on the available patient data, including patient-reported outcome measures (PROMs).

Our study focused on developing machine learning (ML) models to support decision making in assigning patients to FT procedures, utilizing data from patients' self-reported health status. These models are specifically designed to predict the potential health status improvement in patients initially selected for FT. Our approach focused on techniques inspired by the concept of controllable AI. This includes eXplainable AI (XAI), which aims to make the model's recommendations comprehensible to clinicians, and cautious prediction, a method used to alert clinicians about potential control losses, thereby enhancing the models' trustworthiness and reliability.

Our models were trained and tested using a dataset comprising 899 records from individual patients admitted to the FT program at IRCCS Ospedale Galeazzi-Sant'Ambrogio. After training and selecting hyper-parameters, the models were assessed using a separate internal test set. The interpretable models demonstrated performance on par or even better than the most effective 'black-box' model (Random Forest). These models achieved sensitivity, specificity, and positive predictive value (PPV) exceeding 70%, with an area under the curve (AUC) greater than 80%. The cautious prediction models exhibited enhanced performance while maintaining satisfactory coverage (over 50%). Further, when externally validated on a separate cohort from the same hospital-comprising patients from a subsequent time period-the models showed no pragmatically notable decline in performance.

Our results demonstrate the effectiveness of utilizing PROMs as basis to develop ML models for planning assignments to FT procedures. Notably, the application of controllable AI techniques, particularly those based on XAI and cautious prediction, emerges as a promising approach. These techniques provide reliable and interpretable support, essential for informed decision-making in clinical processes.

Recent advances in total knee arthroplasty (TKA) have been driven by a growing focus on evidence-based medicine. This transition is reflected in the critical appraisal of both, the quality of work and the potential impact on the orthopedic community. The purpose of our study was to (1) identify the top 100 most-cited articles in TKA in the last decade and from all-time, and (2) compare methodological rigor of the most-cited articles in TKA in the last decade to articles all-time by level of evidence.

The top 100 cited articles were recorded for manuscripts from the last decade, January 1, 2012 to December 31, 2022, and manuscripts from all-time for TKA. We collected authors, year of publication, journal of the article, country of origin of authors, article type (basic science article, clinical research article), level of evidence, methodological index for non-randomized studies score, physiotherapy evidence database scale, and citation density (total citations/years published).

The largest number of studies for all-time TKA (53.0%) and decade TKA (42.0%) were Level III. The average methodological index for non-randomized studies score for comparative studies was 18.7 for all-time TKA and 20.7 for decade TKA (P < .001). The average physiotherapy evidence database score was 6.1 for all-time TKA and 8.1 for decade TKA (P > .05). The highest citation density for all-time TKA was 111 and for past decade was 63. The number of level II studies in TKA increased from 19.0% from all time to 38.0% from the last decade (P < .05).

Our findings of improved methodologies over time reflect positive steps toward evidence-based practice in TKA. A continued focus on producing methodologically sound studies may guide evidence-based clinical decision-making.

Early mobilisation after periacetabular osteotomy (PAO) represents an important goal after surgery. The purpose of this study was to determine whether the use of epidural aznalgesia (EA) is associated with prolonged immobility and an increased length of stay (LOS) after PAO surgery.

From January 2022 to July 2023, the study included a cohort of 150 PAO procedures all performed by the same surgeon (SSA). Patients were categorized into two distinct groups: those who received epidural analgesia (EA) (79 PAOs) and those who did not receive EA (71 PAOs). "Ready for discharge" was defined as the ability to ascend and descend a standardized flight of stairs independently. Multivariable linear regression was used to identify additional factors influencing LOS after PAO.

Patients in the EA group were ready for discharge 5.95 ± 2.09 days after surgery which was significantly longer than in the No EA group´s average of 4.18 days ± 2.5, (p < 0.001). While the reduction in the number of patients experiencing pulmonary embolism in the No EA group did not reach statistical significance, it still demonstrated a relevant decrease from two patients within the EA group (2.53%) to 0 (0%) in the No EA group. The active engagement of the surgeon in mobilising patients led to a substantial reduction in LOS, decreasing it from 5.81 ± 2.18 days to 2.2 ± 0.77 days (p < 0.001). Multivariable analysis revealed five independent factors influencing the LOS following PAO which included absence of EA, surgeon-led mobilisation within 24 h after surgery, postoperative hemoglobin levels, BMI, and prior experience with PAO surgery on the contralateral side.

Opting against the use of EA in patients undergoing PAO is advisable, as it will result in extended postoperative immobility and the associated risks. Additionally, the active participation of the surgeon in the mobilisation process is strongly recommended.

The fast-track based on evidence-based medicine, has dramatically reduced the length of stay for patients undergoing total knee arthroplasty (TKA). Therefore, patients must assume the responsibility for self-functional exercise and care as early as possible. Also, higher standards and expectations of care delivery have been set. Studies into patients' experiences when faced with a discharge decision under a fast-track program are lacking.

(1) Increase the knowledge about patients' experiences of discharged from hospital via a fast-track process after TKA. (2) Explore what gaps exist in the current discharge preparation care service for TKA under fast-track and what can be improved.

A qualitative research design was chosen to conduct semi-structured face-to-face interviews with 21 patients from one Chinese hospital who successfully underwent TKA and received discharge orders. Interview data were meticulously analyzed, summarized and thematically distilled using Interpretative Phenomenological Analysis (IPA).

Three themes emerged from the structural analyses: a) Preparing for discharge despite concerns about symptoms-a sense of joy at discharge despite feelings of helplessness, stigmatisation, anxiety about prosthetic function. b) Managing the rehabilitation difficulties-vigilance is needed for medication management, environmental changes, and intimate relationships. c) Creating conditions for safe transition-compassionate bedside manner, listening to patients, and providing a humanized continuing care and referral services are important for safe transitions.

Findings suggest that patients undergoing fast-track TKA report good discharge preparation experiences. However, closer analysis reveals difficulties with this process and important directions in which discharge readiness care services can strive.

Optimization of clinical pathways and logistics led to the introduction of outpatient joint arthroplasty of the hip and knee. Nevertheless, little is known about what these current protocols look like and how they differ from "standard" inpatient protocols. This study aimed to find preoperative, intraoperative, and postoperative differences between outpatient and inpatient pathways.

A questionnaire (ranging between 23 and 37 items) was developed and administered by email to orthopedic surgeons who were a member of the Dutch Hip Society and Dutch Knee Society. Survey response rate was 38% (N = 117).

No significant differences were found in preoperative pathway characteristics. The administration regime for tranexamic acid significantly differed between outpatient and inpatient pathways (P < .001 and P = .002 for hip and knee arthroplasty, respectively), with outpatient pathways using a combined (eg, oral and intravenous) administration regime more frequently. The perioperative antibiotic prophylaxis regime also significantly differed between outpatient and inpatient pathways (P < .001 and P = .014, respectively), with outpatient pathways more frequently incorporating fewer antibiotic doses. Same-day postoperative mobilization significantly less often occurred if surgery took place later that day in inpatient hip arthroplasty pathways (24%; P = .034). Postoperative hemoglobin-check occurred significantly more often on indication in outpatient than in inpatient hip and knee arthroplasty pathways (∼75% vs ∼25%; P = .001).

Few intraoperative and postoperative differences in outpatient and inpatient pathways were found and probably mainly relied on logistical grounds. Nonetheless, findings suggested that outpatient pathways tended to be more up-to-date and innovative than inpatient pathways.

Knee osteoarthritis is a degenerative disorder of the knee, which leads to joint pain, stiffness, and inactivity and significantly affects the quality of life. With an increased prevalence of obesity and greater life expectancies, total knee arthroplasty (TKA) is now one of the major arthroplasty surgeries performed for knee osteoarthritis. When enhanced recovery after surgery (ERAS) was introduced in TKA, clinical outcomes were enhanced and the economic burden on the healthcare system was reduced. ERAS is an evidence-based scientific protocol aimed at ameliorating the surgical stress response. ERAS aims to enhance the recovery phase, which encompasses multidisciplinary strategies at every step of perioperative care, including the rehabilitation phase. Implementation of ERAS in TKA aids in reducing the length of hospital stay, improving pain management, reducing perioperative complications, and enhancing patient satisfaction. Multidisciplinary collaboration, integrating the expertise of anesthesiologists, orthopedic surgeons, nursing personnel, and other healthcare professionals, is the cornerstone of ERAS in patients undergoing TKA.

Total knee arthroplasty (TKA) improves patient-reported function by alleviating joint pain, however the surgical trauma exacerbates already impaired muscle function, which leads to further muscle weakness and disability after surgery. This early postoperative strength loss indicates a massive neural inhibition and is primarily driven by a deficit in quadriceps muscle activation, a process known as arthrogenic muscle inhibition (AMI). To enhance acute recovery of quadriceps muscle function and long-term rehabilitation of individuals after TKA, AMI must be significantly reduced in the early post-operative period. The aim of this narrative review is to review and discuss previous efforts to mitigate AMI after TKA and to suggest new approaches and interventions for future efficacy evaluation. Several strategies have been explored to reduce the degree of post-operative quadriceps AMI and improve strength recovery after TKA by targeting post-operative swelling and inflammation or changing neural discharge. A challenge of this work is the ability to directly measure AMI and relevant contributing factors. For this review we focused on interventions that aimed to reduce post-operative swelling or improve knee extension strength or quadriceps muscle activation measured by twitch interpolation. For individuals undergoing TKA, the use of anti-inflammatory medications, tranexamic acid, cryotherapy, intra-articular drains, torniquets, and minimally invasive surgical techniques for TKA have limited benefit in attenuating quadriceps AMI early after surgery. However, interventions such as inelastic compression garments, voluntary muscle contractions, and neuro-muscular electrical stimulation show promise in mitigating or circumventing AMI and should continue to be refined and explored.

Local infiltration analgesia (LIA) provides postoperative analgesia for total knee arthroplasty (TKA). The purpose of this study was to evaluate the analgesic effect of a cocktail of ropivacaine, morphine, and Diprospan for TKA.

A total of 100 patients from September 2018 to February 2019 were randomized into 2 groups. Group A (control group, 50 patients) received LIA of ropivacaine alone (80 ml, 0.25% ropivacaine). Group B (LIA group, 50 patients) received an LIA cocktail of ropivacaine, morphine, and Diprospan (80 ml, 0.25% ropivacaine, 0.125 mg/ml morphine, and 62.5 μg/ml compound betamethasone). The primary outcomes were the levels of inflammatory markers C-reactive protein (CRP) and interleukin-6 (IL-6), pain visual analog scale (VAS) scores, opioid consumption, range of motion (ROM), functional tests, and sleeping quality. The secondary outcomes were adverse events, satisfaction rates, HSS scores, and SF-12 scores. The longest follow-up was 2 years.

The two groups showed no differences in terms of characteristics (P  >  0.05). Group B had lower resting VAS pain scores (1.54 ± 0.60, 95% CI = 1.37 to 1.70 vs. 2.00 ± 0.63, 95% CI = 2.05 to 2.34) and active VAS pain scores (2.64 ± 0.62, 95% CI = 2.46 to 2.81 vs. 3.16 ± 0.75, 95% CI = 2.95 to 3.36) within 48 h postoperatively than Group A (P < 0.001), while none of the pain differences exceeded the minimal clinically important difference (MCID). Group B had significantly lower CRP levels (59.49 ± 13.01, 95% CI = 55.88 to 63.09 vs. 65.95 ± 14.41, 95% CI = 61.95 to 69.94) and IL-6 levels (44.11 ± 13.67, 95% CI = 40.32 to 47.89 vs. 60.72 ± 15.49, 95% CI = 56.42 to 65.01), lower opioid consumption (7.60 ± 11.10, 95% CI = 4.52 to 10.67 vs. 13.80 ± 14.68, 95% CI = 9.73 to 17.86), better ROM (110.20 ± 10.46, 95% CI = 107.30 to 113.09 vs. 105.30 ± 10.02, 95% CI = 102.52 to 108.07), better sleep quality (3.40 ± 1.03, 95% CI = 3.11 to 3.68 vs. 4.20 ± 1.06, 95% CI = 3.90 to 4.49), and higher satisfaction rates than Group A within 48 h postoperatively (P  <  0.05). Adverse events, HSS scores, and SF-12 scores were not significantly different within 2 years postoperatively.

A cocktail of ropivacaine, morphine, and Diprospan prolongs the analgesic effect up to 48 h postoperatively. Although the small statistical benefit may not result in MCID, the LIA cocktail still reduces opioid consumption, results in better sleeping quality and faster rehabilitation, and does not increase adverse events. Therefore, cocktails of ropivacaine, morphine, and Diprospan have good application value for pain control in TKA. This trial is registered with ChiCTR1800018372.

Essential components of fast-track or enhanced recovery programs in arthroplasty are the optimization of interdisciplinary organizational processes, as well as pre-, intra- and postoperative procedures in everyday clinical practice. The early postoperative mobilization of patients after joint replacement surgery is of central importance, with the aim of avoiding pain and complications. This article provides a detailed overview of fast-track procedures that have already been established in many units. Furthermore, it demonstrates the clinical advantages of FastTrack for total hip arthroplasty (THA) in an evidence-based manner within the framework of a randomized study design.

194 primary THA patients were examined after randomization into two single-blinded groups; Fast-Track (n = 98) or conventional treatment path (n = 96). Mobilization was defined as the primary outcome parameter, measured in seconds using the Timed Up and Go Test (TUG). Secondary parameters were the achievable walking distance in meters and pain using the numerical rating scale (NRS). All parameters were recorded preoperatively and daily until the sixth postoperative day.

No complications or revisions were recorded within the first postoperative week. The fast-track group showed significantly better TUG values and walking distance results compared to the conventional group until the sixth postoperative day (p < 0.05, respectively). There was no significant difference regarding the pain assessment (NRS) (p > 0.05).

The use of Fast-Track in hip arthroplasty can evidently improve short-term postoperative clinical outcomes. This first prospective, single-blinded, randomized controlled study showed very good clinical results with comparable pain after FastTrack THA compared to a conventional treatment path. Fast-Track concepts are highly effective in terms of early mobilization and clinical outcome-without incurring a higher risk of complications in the short term.

Although total hip arthroplasty (THA) is expected to result in a postoperative loss of muscular strength, no study investigated the benefit of an enhanced-recovery-after-surgery (ERAS) concept on the hip muscles in detail. We evaluated if (1) an ERAS-concept for primary THA results in reduced loss of muscular strength five days and four weeks postoperative. We (2) compared the two groups regarding Patient-Related-Outcome-Measures (PROMs), WOMAC-index (Western-Ontario-and-McMaster-Universities-Osteoarthritis-Index), HHS (Harris-Hip-Score) and EQ-5d-3L-score.

In a prospective, single-blinded, randomized controlled trial, we compared isokinetic muscular strength of 24 patients receiving primary THA with an enhanced recovery concept with early mobilization (n = 12, ERAS-group) and such receiving conventional THA (n = 12, non-ERAS). Isokinetic muscular strength was measured with a Biodex-Dynamometer before, as well as five days and four weeks after surgery (peak-torque, total-work, power). Furthermore, WOMAC, HHS, PROMs and EQ-5d-3L were imposed.

The ERAS group revealed significant higher isokinetic strength (peak-torque, total-work, power) at both time points. Both groups showed a significant pain decrease at both time points meeting very high rates of patient satisfaction resembled by good results in PROMs, WOMAC, HHS, EQ-5d. There was no significant difference in any of the scores between both groups.

We proved a significant reduced loss of muscular strength five days and four weeks after primary THA in combination with an ERAS concept. However, the reduced loss of muscular strength is not reflected by patient's functional outcome and quality of life, showing no significant differences in WOMAC, HHS, EQ-5d-3L, PROMs and NRS. Therefore, this study supports the implementation of an ERAS concept for primary THA in terms of isokinetic strength. Further studies are needed to evaluate the development of muscular strength over a long period.

Inertial measurement units (IMUs) are increasingly being used to assess knee function. The aim of the study was to record patients' activity levels and to detect new parameters for knee function in the early postoperative phase after TKA. Twenty patients (n = 20) were prospectively enrolled. Two sensors were attached to the affected leg. The data were recorded from the first day after TKA until discharge. Algorithms were developed for detecting steps, range of motion, horizontal, sitting and standing postures, as well as physical therapy. The mean number of steps increased from day 1 to discharge from 117.4 (SD ± 110.5) to 858.7 (SD ± 320.1), respectively. Patients' percentage of immobilization during daytime (6 a.m. to 8 p.m.) was 91.2% on day one and still 69.9% on the last day. Patients received daily continuous passive motion therapy (CPM) for a mean of 36.4 min (SD ± 8.2). The mean angular velocity at day 1 was 12.2 degrees per second (SD ± 4.4) and increased to 28.7 (SD ± 16.4) at discharge. This study shows that IMUs monitor patients' activity postoperatively well, and a wide range of interindividual motion patterns was observed. These sensors may allow the adjustment of physical exercise programs according to the patient's individual needs.

Enhanced recovery after surgery (ERAS) leads to less morbidity, faster recovery, and, therefore, shorter hospital stays. The expected increment of primary total hip arthroplasty (THA) in the U.S. highlights the need for sufficient pain management. The favorable use of short-lasting spinal anesthesia enables early mobilization but may lead to increased opioid consumption the first 24 h (h) postoperatively.

In a retrospective study design, we compared conventional THA with postoperative immobilization for two days (non-ERAS) and enhanced recovery THA with early mobilization (ERAS group). Data assessment took place as part of the "Quality Improvement in Postoperative Pain Treatment project" (QUIPS). Initially, 2161 patients were enrolled, resulting in 630 after performing a matched pair analysis for sex, age, ASA score (American-Society-of-Anesthesiology) and preoperative pain score. Patient-reported pain scores, objectified by a numerical rating scale (NRS), opioid consumption and side effects were evaluated 24 h postoperatively.

The ERAS group revealed higher activity-related pain (p = 0.002), accompanied by significantly higher opioid consumption (p < 0.001). Maximum and minimum pain as well as side effects did not show significant differences (p > 0.05).

This study is the first to analyze pain scores, opioid consumption, and side effects in a matched pair analyses at this early stage and supports the implementation of an ERAS concept for THA. Taking into consideration the early postoperative mobilization, we were not able to detect a difference regarding postoperative pain. Although opioid consumption appeared to be higher in ERAS group, occurrence of side effects ranged among comparable percentages.

Pharmacological thromboprophylaxis effectively prevents venous thromboembolism (VTE) after total knee (TKA) and total hip arthroplasty (THA). Less is known about the influence of fast-track arthroplasty on VTE risk. We conducted a register-based study to determine the incidence of VTE after fast-track TKA and THA in Finland using long thromboprophylaxis.

All primary TKAs and THAs operated during 2015-2016 in 3 fast-track hospitals were identified from the Finnish Arthroplasty Register. Pulmonary embolism (PE) and deep vein thrombosis (DVT) diagnosed in this patient cohort within 90 days of surgery were identified from the Finnish Hospital Discharge Register. The recommended length of thromboprophylaxis was 10 to 14 days for TKA and 28 days for THA during study period.

During the study period, 3 831 THAs, 4 394 TKAs and 286 bilateral TKAs (BTKAs) were performed. Of all these patients, 60% were females. Venous thromboembolism (VTE) incidence within 90 days of surgery was 0.3% (95% CI 0.2-0.4). These VTEs comprised 10 PEs and 15 DVTs. None of the VTE patients´ died within the 90-day period.

VTE incidence is low in Finnish fast-track TKA and THA patients with long thromboprophylaxis.

Significant progress has been made in recent years in the diagnosis of periprosthetic joint infections (PJI). However, the lack of a gold standard test for the diagnosis of PJI remains a challenge.The aim of this study was to evaluate the diagnostic values of the albumin/fibrinogen ratio (AFR), the C-reactive protein/albumin ratio (CAR), and the levels of fibrinogen (FIB) and albumin (ALB) in the diagnosis of PJI.

The medical records of 158 patients who had undergone hip or knee revisions from January 2018 to May 2022 were retrospectively analyzed. Of these patients, 79 were diagnosed with PJI, while 79 were diagnosed with aseptic loosening (AL). PJI was defined using the Musculoskeletal Infection Society criteria. The plasma levels of C-reactive protein (CRP), ALB, and FIB; the erythrocyte sedimentation rate (ESR); and the AFR and CAR in the two groups were recorded and analyzed. The receiver operating characteristic curve was used to calculate the sensitivity and specificity of each indicator; the diagnostic value for each indicator was calculated as the area under the curve (AUC).

The ESR, CRP, FIB, and CAR values in the PJI group were significantly higher than those in the AL group, and the ALB and AFR values were significantly lower than those in the AL group (p < 0.001). The AUC values of AFR and fibrinogen were 0.851 and 0.848, respectively, which were slightly higher than those of CRP (0.826) and ESR (0.846). The AUC of CAR was 0.831 which was slightly lower than that of CRP (0.846). ALB had an AUC of 0.727. The optimal threshold, sensitivity, and specificity, respectively, were 10.05, 84.81%, and 82.28% for AFR; 4.03 μg/mL, 77.22%, and 86.08% for FIB; 0.23, 72.15%, and 82.28% for CAR; and 37.30 g/L, 65.82%, and 73.42% for ALB.

AFR, CAR, and FIB are good new auxiliary diagnostic indicators of PJI, while ALB is of fair value for the diagnosis of PJI.

There is little evidence proving the concept of partial weight-bearing to be efficient and feasible. Using insole pressure measurement systems, this study aimed to explore the compliance to prescribed weight-bearing restrictions after total knee arthroplasty (TKA).

50 patients after TKA were recruited in a prospective manner. They were advised to limit weight-bearing of the affected limb to 200 N. True load was measured via insole force-sensors on day one after surgery (M1) and before discharge (M2). Compliance to the rehabilitation protocol was the primary outcome parameter.

At M1 and M2 compliance to the rehabilitation protocol was 0% und 2%, respectively. 84% (M1) and 90% (M2) of patients overloaded the affected limb during every step. The affected limb was loaded with 50% ± 14% (M1) and 57% ± 17% (M2) of body weight. Patients older than 65 loaded the affected limb on average 17% (M1) and 34% (M2) more than their younger counterparts did. This difference was even more pronounced when walking stairs up (49% increase on average) and down (53% increase on average).

Surgeons must take into consideration that the ability to maintain partial weight-bearing after TKA is highly dependent on the age of the patient and the achievable load reduction is determined by the patient's body weight.

There is accumulating evidence that deep neuromuscular blockade (NMB) improves intraoperative surgical conditions during laparoscopic surgery. Studies investigating the effects of deep NMB in open surgery are scarce. In theory, by limiting surgical damage through deeper muscle relaxation, postoperative inflammation and concomitant immune suppression can be reduced. Therefore, this study will investigate the effects of deep NMB during total hip arthroplasty, which demands a relatively large exposure of the hip joint through and in between muscles.

This study is a monocentre blinded randomised controlled trial in 100 patients undergoing total hip arthroplasty under general anaesthesia. Patients will be randomised in a 1:1 fashion to an intervention group of intraoperative deep NMB (a post-tetanic count of 1-2) or a control group receiving moderate NMB (a train-of-four count of 1-2). NMB will be achieved by continuous or bolus administration of rocuronium, respectively. The primary endpoint is the quality of recovery at postoperative day 1 measured by the Quality of Recovery-40 Questionnaire, analysed by Analysis of Variance. The secondary endpoint is postoperative innate immune function, measured by ex vivo production capacity of tumour necrosis factor and interleukin-1β on endotoxin stimulation of whole blood.

Ethical approval for this study was granted by the Medical Ethics Committee 'METC Oost-Nederland' (reference number 2022-15754). Informed consent will be obtained prior to study participation. Study results will be published in an international peer-reviewed journal.

ClinicalTrials.gov Registry (NCT05562999) and EudraCT Registry (2022-002451-19).

Recent evidence has led to guidelines to refrain from recommending knee arthroscopy for patients with an osteoarthritis diagnosis. The aim of this study was to evaluate the latest changes in the incidence of arthroscopic surgery for degenerative knee disease, changes in the ages of those patients and the delay between knee arthroscopy and arthroplasty, in Finland between 1998 and 2018.

The data for were collected from the Finnish National Hospital Discharge Register (NHDR). All knee arthroplasties and arthroscopies performed due to osteoarthritis, degenerative meniscal tears, and traumatic meniscal tears were included. Incidence rates (per 100,000 person-years) as well as the median age of patients were calculated.

The incidence of arthroscopy decreased 74% (413 to 106 per 100,000 person-years) and knee arthroplasty increased 179% (94 to 262 per 100,000 person-years) between 1998 and 2018. The incidence of all arthroscopies increased until 2006. Subsequently, the incidence of arthroscopy due to OA decreased by 91% and arthroscopic partial meniscectomy (APM) for degenerative meniscal tears decreased by 77% until 2018. The decrease of traumatic meniscal tears begun later, leading to decrease of 57% between 2011 and 2018. Conversely, the incidence of patients undergoing APM of traumatic meniscal tear increased 375%. The median age of patients who underwent knee arthroscopy decreased from 51 to 46 and from 71 to 69 in knee arthroplasty patients.

Increasing evidence that recommends refraining from knee arthroscopy in OA and degenerative meniscal tears has led to a dramatic decrease in the incidence of arthroscopies. Simultaneously, the median age of the patients who undergo these operations has continued to decrease.

Total hip arthroplasty (THA) is still ranked among the operations with the highest postoperative pain scores. Uncontrolled postsurgical pain leads to prolongated hospital stays, causes more frequent adverse reactions and can induce chronical pain syndromes. In 2014, we implemented a standardized, multidisciplinary pain management concept with continuous benchmarking at our tertiary referral center by using the "Quality Improvement in Postoperative Pain Management" (QUIPS) program with excellent results over a period of two years. The initial study ended in 2016 and we aimed to evaluate if it was possible to obtain the excellent short-term results over a period of six years without any extra effort within the daily clinical routine.

In a retrospective study design, we compared postoperative pain, side effects and functional outcome after primary THA for 2015 and 2021, using validated questionnaires from the QUIPS project. In contrast to the implementation of the pain management concept in 2014, the weekly meetings of the multidisciplinary health care team and special education for nurses were stopped in 2021. Data assessment was performed by an independent pain nurse who was not involved in pain management.

Altogether, 491 patients received primary THA in 2015 and 2021 at our tertiary referral center. Collected data revealed significantly worse maximum and activity-related pain (both p < 0.001) in combination with significantly higher opioid consumption in comparison to implementation in 2015. Though the patients reported to be less involved in pain management (p < 0.001), the worse pain scores were not reflected by patient satisfaction which remained high. While the participation rate in this benchmarking program dropped, we still fell behind in terms of maximum and activity-related pain in comparison to 24 clinics.

Significantly worse pain scores in combination with higher opioid usage and a lower hospital participation rate resemble a reduced awareness in postoperative pain management. The significantly lower patient participation in pain management is in line with the worse pain scores and indirectly highlights the need for special education in pain management. The fact patient satisfaction appeared to remain high and did not differ significantly from 2015, as well as the fact we still achieved an acceptable ranking in comparison to other clinics, highlight the value of the implemented multidisciplinary pain management concept.

In existing studies on fasttrack unicompartmental knee arthroplasty (UKA), the majority of surgeries are medial. There are substantial differences between lateral and medial UKA, which is why outcomes cannot automatically be compared. To gain information on the feasibility and safety of fast-track protocols in lateral UKAs, we investigated length of stay (LOS) and early complications after lateral UKA, performed using a fast-track protocol in well-established fast-track centers.

We retrospectively evaluated prospectively collected data on patients undergoing lateral UKA in a fast-track setup from 2010 to 2018 at 7 Danish fast-track centers. Data on patient characteristics, LOS, complications, reoperations, and revisions was analyzed using descriptive statistics. Safety and feasibility were defined as complication and reoperation rates within 90 days comparable to non-fast track lateral UKA or fast-track medial UKA.

We included 170 of patients with a mean age of 66 (SD 12) years. Median LOS was 1 day (interquartile range 1-1), which was unchanged from 2012-2018. 18% were discharged on the day of surgery. Within 90 days, 7 patients experienced medical complications and 5 patients experienced surgical complications. 3 patients underwent reoperation, 2 were soft tissue revisions and the third was removal of an exostosis due to catching of the patella. 1 patient was revised due to a bearing dislocation.

Our findings suggest that lateral UKA in a fast-track setting is feasible and safe.

Background: Home-based rehabilitation exercise following Total Hip Arthroplasty (THA) shows similar outcomes compared to supervised outpatient rehabilitation exercise. Little is known about patients' experiences with home-based rehabilitation, and this study aimed to investigate how patients perceived home-based rehabilitation exercise and general physical activity after THA, focusing on facilitators and barriers. Methods: Semi-structured interviews of qualitative design were conducted with 22 patients who had undergone THA and who had performed home-based rehabilitation exercise. The study took place in a regional hospital in Denmark between January 2018 and May 2019. Data were analyzed using an interpretive thematic analysis approach, with theoretical underpinning from the concept 'conduct of everyday life'. The study is embedded within the Pragmatic Home-Based Exercise Therapy after Total Hip Arthroplasty-Silkeborg trial (PHETHAS-1). Results: The main theme, 'wishing to return to the well-known everyday life', and four subthemes were identified. Generally, participants found the home-based rehabilitation exercise boring but were motivated by the goal of returning to their well-known everyday life and performing their usual general physical activities, though some lacked contact to physiotherapist. Participants enrolled in the PHETHAS-1 study used the enrollment as part of their motivation for doing the exercises.  Both pain and the absence of pain were identified as barriers for doing home-based rehabilitation exercise. Pain could cause insecurity about possible medical complications, while the absence of pain could lead to the rehabilitation exercise being perceived as pointless. Conclusions: The overall goal of returning to the well-known everyday life served as a facilitator for undertaking home-based rehabilitation exercise after THA along with the flexibility regarding time and place for performing exercises. Boring exercises as well as both pain and no pain were identified as barriers to the performance of home-based rehabilitation exercise. Participants were motivated towards performing general physical activities which were part of their everyday life.

Background: Home-based rehabilitation exercise following Total Hip Arthroplasty (THA) shows similar outcomes compared to supervised outpatient rehabilitation exercise. Little is known about patients' experiences with home-based rehabilitation, and this study aimed to investigate how patients perceived home-based rehabilitation exercise and general physical activity after THA, focusing on facilitators and barriers. Methods: Semi-structured interviews of qualitative design were conducted with 22 patients who had undergone THA and who had performed home-based rehabilitation exercise. The study took place in a regional hospital in Denmark between January 2018 and May 2019. Data were analyzed using an interpretive thematic analysis approach, with theoretical underpinning from the concept 'conduct of everyday life'. The study is embedded within the Pragmatic Home-Based Exercise Therapy after Total Hip Arthroplasty-Silkeborg trial (PHETHAS-1). Results: The main theme, 'wishing to return to the well-known everyday life', and four subthemes were identified. Generally, participants found the home-based rehabilitation exercise boring but were motivated by the goal of returning to their well-known everyday life and performing their usual general physical activities, though some lacked contact to physiotherapist. Participants enrolled in the PHETHAS-1 study used the enrollment as part of their motivation for doing the exercises.  Both pain and the absence of pain were identified as barriers for doing home-based rehabilitation exercise. Pain could cause insecurity about possible medical complications, while the absence of pain could lead to the rehabilitation exercise being perceived as pointless. Conclusions: The overall goal of returning to the well-known everyday life served as a facilitator for undertaking home-based rehabilitation exercise after THA along with the flexibility regarding time and place for performing exercises. Boring exercises as well as both pain and no pain were identified as barriers to the performance of home-based rehabilitation exercise. Participants were motivated towards performing general physical activities which were part of their everyday life.

To explore the impact of a temporary cancellation of elective surgery in winter 2017 on trends in primary hip and knee replacement at a major National Health Service (NHS) Trust, and whether lessons can be learnt about efficient surgery provision.

Observational descriptive study using interrupted time series analysis of hospital records to explore trends in primary hip and knee replacement surgery at a major NHS Trust, as well as patient characteristics, 2016-2019.

A temporary cancellation of elective services for 2 months in winter 2017.

NHS-funded hospital admissions for primary hip or knee replacement, length of stay and bed occupancy. Additionally, we explored the ratio of elective to emergency admissions at the Trust as a measure of elective capacity, and the ratio of public to private provision of NHS-funded hip and knee surgery.

After winter 2017, there was a sustained reduction in the number of knee replacements, a decrease in the proportion of most deprived people having knee replacements and an increase in average age for knee replacement and comorbidity for both types of surgery. The ratio of public to private provision dropped after winter 2017, and elective capacity generally has reduced over time. There was clear seasonality in provision of elective surgery, with less complex patients admitted during winter.

Declining elective capacity and seasonality has a marked effect on the provision of joint replacement, despite efficiency improvements in hospital treatment. The Trust has outsourced less complex patients to independent providers, and/or treated them during winter when capacity is most limited. There is a need to explore whether these are strategies that could be used explicitly to maximise the use of limited elective capacity, provide benefit to patients and value for money for taxpayers.

Total knee arthroplasty (TKA) combined with the concept of enhanced recovery is of continued worldwide interest, as it is reported to improve early functional outcome and treatment quality without increasing complications. The aim of the study was to investigate isokinetic knee muscle strength after cemented TKA in combination with an enhanced recovery after surgery (ERAS) compared to a conventional setup.

In the single blinded prospective randomized study, 52 patients underwent navigated primary cemented TKA within an ERAS (n = 30) or a conventional setup (n = 22). Preoperatively, five days and four weeks after surgery isokinetic knee muscle strength with BIODEX-type measuring device (peak torque in Nm, work in Joules and power in Watt) and subjective patient-related outcome measures (PROMs) were investigated.

The ERAS group showed significantly better outcomes in knee flexion at 180°/s (peak torque (Nm) p = 0.047, work (J) p = 0.040 and power (W) p = 0.016) 5 days postoperatively. The isokinetic measuring at knee extension 60°/s and 180°/s demonstrated no significant difference. The PROMs showed that patients were satisfied with the postoperative results in both groups. After 4 weeks, there was no longer a significant difference in isokinetic measuring at knee extension and flexion between the ERAS and conventional group.

TKA with the concept of ERAS improves excellent isokinetic outcome and patient satisfaction. The isokinetic muscle strength measurement can help patients and surgeons to modify expectations and improve patient satisfaction.

Total hip (THA) and total knee (TKA) arthroplasty procedures have steadily increased over the past few decades, and their use is expected to grow further, mainly due to an increasing number of elderly patients. Cost-containment strategies, supporting a rapid recovery with a positive functional outcomes, high patient satisfaction, and enhanced patient reported outcomes, are needed. A Fast Track surgical procedure (FT) is a coordinated perioperative approach aimed at expediting early mobilization and recovery following surgery and, accordingly, shortening the length of hospital stay (LOS), convalescence and costs. In this view, rapid rehabilitation surgery optimizes traditional rehabilitation methods by integrating evidence-based practices into the procedure. The aim of the present study was to compare the effectiveness of Fast Track versus Care-as-Usual surgical procedures and pathways (including rehabilitation) on a mid-term patient-reported outcome (PROs), the SF12 (with regard both to Physical and Mental Scores), 3 months after hip or knee replacement surgery, with the use of Propensity score-matching (PSM) analysis to address the issue of the comparability of the groups in a non-randomized study. We were interested in the evaluation of the entire pathways, including the postoperative rehabilitation stage, therefore, we only used early home discharge as a surrogate to differentiate between the Fast Track and Care-as-Usual rehabilitation pathways. Our study shows that the entire Fast Track pathway, which includes the post-operative rehabilitation stage, has a significantly positive impact on physical health-related status (SF12 Physical Scores), as perceived by patients 3 months after hip or knee replacement surgery, as opposed to the standardized program, both in terms of the PROs score and the relative improvements observed, as compared with the minimum clinically important difference. This result encourages additional research into the effects of Fast Track rehabilitation on the entire process of care for patients undergoing hip or knee arthroplasty, focusing only on patient-reported outcomes.

Limited data exists on the implementation process and safety of discharge on the day of surgery after primary hip and knee arthroplasty in a multicenter setting. We report our study protocol on the investigation of the feasibility, safety, and socioeconomic aspects following discharge on day of surgery after hip and knee arthroplasty across 8 fast-track centers.

This is a study protocol for a prospective cohort study on discharge on day of surgery from the Center for Fast-track Hip and Knee Replacement. The collaboration includes 8 centers covering 40% of the primary hip and knee arthroplasty procedures undertaken in Denmark. All patients scheduled for surgery are screened for eligibility using well-defined inclusion and exclusion criteria. Eligible patients fulfilling discharge criteria will be discharged on day of surgery. We expect to screen 9,000 patients annually. Duration and outcome: Patients will be enrolled over a 3-year period from September 2022 and reporting of results will run continuously until December 2025. We shall report the proportion of eligible patients and patients discharged on day of surgery as well as limiting factors. Readmissions and complications within 30 days are recorded with real-time follow-up by research staff. Furthermore, patient-reported information on willingness to repeat discharge on day of surgery, contacts with the healthcare system, complications, and workability is registered 30 days postoperatively. EQ-5D, Oxford Knee Score, and Oxford Hip Score are completed preoperatively and after 3 months and 1 year. Finally, outcome data will be used in the development of a prediction model for successful discharge on the day of surgery.

Enhanced recovery after surgery programs, also called fast-track protocols, were developed and successfully applied in the last decade for hip and knee reconstruction. Specific fast-track protocols have not yet been applied to ankle prostheses. The aim of the study was to develop and validate an enhanced recovery protocol for total ankle replacement (TAR) evaluating the clinical and radiographic results. We hypothesize that on the basis of well-defined pre- and postoperative characteristics, the current knowledge on ankle replacement, and referring to hip and knee reconstruction, it is possible to identify a "patient type" to be safely eligible to a Fast-Track Protocol with at least comparable results and without increasing the complications risk.

We identified 8 predictive variables that might affect the outcome of TAR. Those variables were the body mass index, the state of anxiety or depression, the functional preoperative status, ankle equinus, the coronal malalignment, the surgical time, the surgical accessory procedures, and the bone quality. These characteristics were evaluated for each patient with almost validated outcome tools attributing a specific score. Based on the score obtained, the patients were divided into 2 groups: the Standard Protocol group (Control Group) and the Fast-Track Protocol group (Study Group). The main difference between treatment of the 2 groups relates to the use of postoperative plaster casts: in the Fast-Track group the cast was removed the first day after surgery and walking was allowed in sports shoes assisted with crutches, whereas in the Standard Protocol group, the cast was removed after 3 weeks. Clinical and radiographic evaluation was performed for all patients preoperatively and postoperatively every 6 months.

A total of 163 patients received a score between 1 and 5 and were included in the control group (Standard Protocol); 47 patients received a score of 0 and were allocated to the study group (Fast-Track Protocol). Clinically, except for the preoperative American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale score, no statistically significant differences were recorded in the multiple comparisons between the 2 groups. No significant differences were found regarding complications.

In selected patients, it is possible to apply an enhanced recovery protocol of rehabilitation, focused on immediate weightbearing and mobilization without any plaster or boot.

Level II, prospective comparative study.