Comparison of two accelerated clinical pathways--after total knee replacement how fast can we really go?

Abstract

Objective: To evaluate whether a further optimization of an existing accelerated clinical pathway protocol after total knee replacement is feasible and improves postoperative outcome.

Design: Prospective, parallel group design.

Setting: Orthopaedic University Medical Centre.

Patients: A total of 143 patients, scheduled for unilateral primary total knee replacement under perioperative regional analgesia.

Intervention: Sixty-seven patients received an optimized accelerated clinical pathway including patient-controlled regional analgesia pumps, ultra-early/doubled physiotherapy and motor-driven continuous passive motion machine units. Seventy-six patients received a standard accelerated clinical pathway.

Main measures: Feasibility was defined as the proportion of patients successfully completing the assigned pathway. Early postoperative pain on a visual analogue scale, consumption of regional anaesthetics, knee range of motion, time out of bed, non-stop walking distance/stair climbing, circumference measurement and Knee Society Score on the operated leg. Possible discharge according to an own discharge checklist.

Results: All patients assigned to both groups successfully completed this pathway. Patients in the optimized pathway showed significant benefits regarding stair climbing/walking distance/time out of bed/circumference measurements of the thigh/Knee Society function score on the fifth postoperative day and stair climbing/ circumference measurements of the thigh on the eighth postoperative day, and reduction of the consumption of regional anaesthetics. No significant reduction in length of stay was observed.

Conclusions: Early postoperative functional process indicators tended to be higher within the optimized pathway group, but the main effects flattened over the course of the first eight postoperative days.