Pathway-controlled fast-track rehabilitation after total knee arthroplasty: a randomized prospective clinical study evaluating the recovery pattern, drug consumption, and length of stay

Abstract

Purpose: To investigate fast-track rehabilitation concept in terms of a measurable effect on the early recovery after total knee arthroplasty (TKA).

Methods: This was an open, randomized, prospective clinical study, comparing the fast-track rehabilitation--a pathway-controlled early recovery program (Joint Care(®))--with standard postoperative rehabilitation care, after TKA. Overall, 147 patients had TKA (N = 74 fast-track rehabilitation, N = 73 standard rehabilitation). The fast-track rehabilitation patients received a group therapy, early mobilization (same day as surgery) and 1:1 physiotherapy (2 h/day). Patient monitoring occurred over 3 months (1 pre- and 4 post-operative visits). The standard rehabilitation group received individual postoperative care according to the existing protocol, with 1:1 physiotherapy (1 h/day). The cumulative American Knee Society Score (AKSS) was the primary evaluation variable, used to detect changes in joint function and perception of pain. The secondary evaluation variables were WOMAC index score, analgesic drug consumption, length of stay (LOS), and safety.

Results: After TKA, patients in the fast-track rehabilitation group showed enhanced recovery compared with the standard rehabilitation group, as based on the differences between the groups for the cumulative AKSS (p = 0.0003), WOMAC index score (<0.0001), reduced intake of concomitant analgesic drugs, reduced LOS (6.75 vs. 13.20 days, p < 0001), and lower number of adverse events.

Conclusion: For TKA, implementation of pathway-controlled fast-track rehabilitation is achievable and beneficial as based on the AKSS and WOMAC score, reduced intake of analgesic drugs, and reduced LOS.

Fig. 1

Patient disposition. ^#Patients were not treated for the following reasons: violations of the inclusion criteria (N = 4), patient’s request (N = 4), incorrect randomization (N = 2), advanced operation (1), stroke before the operation (N = 2). ^§Patients in each group were withdrawn from the study due to both major and minor protocol deviations and in one case also due to one SAE. AE adverse event, SAE serious adverse event

Fig. 2

Cumulative AKSS score for patients undergoing TKA (per-protocol cohort). Cumulative AKSS score for patients undergoing a TKA in the per-protocol cohort. The data represents men for the AUC values for fast-track rehabilitation group and for the standard rehabilitation group. The data show statistically significant difference in favor of the fast-track rehabilitation group (p = 0.0003, t test and Wilcoxon test). AKSS American Knee Society Score, TKA total knee arthroplasty, AUC area under the curve

Fig. 3

By-visit AKSS score for patients undergoing TKA (per-protocol cohort). Mean and 95 % CI values of American Knee Society Score (AKSS) by visits for patients in the fast-track rehabilitation group and the standard rehabilitation group (per-protocol cohort). The data show statistically significant difference in favor of the fast-track rehabilitation group at visit 1 (p < 0.0001, t test and Wilcoxon test). OP day of surgery. The AKSS is used to evaluate pain and joint function; higher values indicate patients’ better condition (score 0 lowest, score 100 highest). The whole AKSS score (sum of knee and functional score) as primary criterion was used in the analysis. The AKSS (sum of both subscores) was chosen, because it represents an overall criterion for postoperative development and provides the most clinically relevant evidence directly related to the primary objective of the trial

Fig. 4

WOMAC osteoarthritis index score by-visit (per-protocol cohort). By visits mean and standard deviation values for WOMAC index score for patients in the fast-track rehabilitation group and the standard rehabilitation group (per-protocol cohort). OP day of surgery. WOMAC index is a health status instrument used to assess everyday fitness; lower values indicate patients’ better condition (score 0 highest, score 10 lowest) [34]

Fig. 5

Weighted cumulative consumption of analgesic medications (intention-to-treat cohort). Weighed cumulative intake of analgesic medication (in mg), according to the in-house classification (Table 2) for patients in the fast-track rehabilitation group and the standard rehabilitation group. Except for the first 2 days after the surgery, patients in the fast-track rehabilitation group needed a significantly lower amount of analgesic drugs than patients in the standard rehabilitation group (Wilcoxon test p = 0.0019; ITT cohort)

Fig. 6

Patients receiving analgesic medications (intention-to-treat cohort). Number of patients using analgesic drugs for patients in the fast-track rehabilitation group and the standard rehabilitation group (ITT cohort). The horizontal arrow lines indicate 50 % (half of the patients) in each study group and the vertical arrow lines indicate the postoperative day on which half of the patients stopped consuming analgesic drugs. Thus, 50 % of patients in the fast-track rehabilitation group needed 30 days less than in the standard rehabilitation group to stop consuming analgesic drugs (i.e., 71 days after operation standard rehabilitation − 41 days after operation fast-track rehabilitation = 30 days difference)

Fig. 7

Length of stay in hospital after TKA (per-protocol cohort). Mean and standard deviation values for length of stay (LOS) in the hospital for patients showing a significantly shorter LOS in the fast-track rehabilitation group than in the standard rehabilitation group (p < 0.0001, t test and Wilcoxon test, per-protocol cohort)