Enhanced recovery after surgery combined with quantitative rehabilitation training in early rehabilitation after total knee replacement: a randomized controlled trial

Abstract

Background: The number of patients undergoing total knee replacement (TKR) is increasing yearly; however, there is still a relative lack of specific, individualized, and standardized protocols for functional exercise after TKR. Quantitative rehabilitation training was developed to improve the recovery of postoperative joint function, increase patient satisfaction, shorten the length of the hospital stay, improve the quality of life, and promote rapid patient recovery.

Aim: We aimed to compare the effectiveness of quantitative rehabilitation training based on the enhanced recovery after surgery (ERAS) concept with conventional rehabilitation training in the early rehabilitation of patients with TKR.

Design: This was a single-centre, prospective, randomized controlled trial.

Setting: Inpatient department.

Population: Participants were patients who underwent unilateral total knee replacement.

Methods: Based on the ERAS concept, a quantitative rehabilitation training program was developed for the quantitative group, and the control group underwent conventional rehabilitation training. Seventy-eight patients undergoing TKR were randomly divided into two blinded groups: the quantitative rehabilitation group and the conventional rehabilitation group. The analysis was performed according to per-protocol practice. The primary outcome metric was the Hospital for Special Surgery Knee Score (HSS Score), and secondary outcomes included patient satisfaction, Visual Analog Pain Score (VAS), time to get out of bed for the first time after surgery, 6-minute-walk test (6MWT), quality-of-life score (SF-36), and number of days in the hospital. The incidence of postoperative complications was also recorded.

Results: There was no significant difference in HSS scores between the two groups before surgery (P=0.967), but the quantitative rehabilitation training group had significantly higher scores at two weeks (P=0.031), 3 months (P<0.01), and 12 months (P<0.01) after surgery than did the conventional rehabilitation training group, and both groups had higher HSS scores than before surgery. The quantitative training group had significantly higher VAS scores at 24 hours and three days postoperatively than the conventional training group (P<0.01), while there was no statistical significance at any other time points. The quantitative rehabilitation group had an earlier time to get out of bed for the first time after surgery (P<0.01), a longer 6MWT distance (P=0.028), and higher patient satisfaction and quality of life scores (SF-36) (P<0.01) that did the control group. The number of days in the hospital was lower in the quantitative training group than in the control group (P<0.001). There was no significant difference in the incidence of postoperative complications between the two groups.

Conclusions: Compared with conventional rehabilitation training, quantitative rehabilitation training based on the ERAS concept was found to be safe and effective and can accelerate the recovery of joint function after surgery, shorten hospitalization time, improve patient satisfaction, and promote rapid recovery.

Clinical rehabilitation impact: The quantitative rehabilitation training based on the ERAS concept provides a new program for rehabilitation exercises after total knee arthroplasty, which is safe and reliable, accelerates the recovery of joint function, and should be considered for clinical promotion.

Figure 1

—CONSORT inclusion flowchart.

Figure 2

—A) Changes in HSS scores of patients in the quantitative rehabilitation training (QRT) and routine rehabilitation training (RRT) groups before and after surgery. The error bars indicate the standard deviation of the mean. Preop: Preoperative (day of admission); B) HSS scores of patients in the quantitative rehabilitation training (QRT) and routine rehabilitation training (RRT) groups preoperatively and postoperatively. The top and bottom of the boxes indicate the 25th and 75th percentiles, and the horizontal line is the median. The whiskers indicate the minimum and maximum values, and the circles represent outliers. *P value <0.05.

Figure 3

—A) Changes in mean VAS pain scores in patients in the quantitative rehabilitation training (QRT) and routine rehabilitation training (RRT) groups before and after surgery; B) pre- and postoperative VAS pain scores of patients in the quantitative rehabilitation training (QRT) and routine rehabilitation training (RRT) groups.

Figure 4

—SF-36 scores of patients in the quantitative rehabilitation training (QRT) and routine rehabilitation training (RRT) groups at 1 year postoperatively. The SF-36 is divided into two parts: physical component summary (PCS) and mental component summary (MCS).

Figure 5

—Six-minute-walk test (6MWT) for patients in the quantitative rehabilitation training (QRT) and routine rehabilitation training (RRT) groups during hospitalization. The distance is in meters.

Figure 6

—Mean serum concentrations of C-reactive protein (CRP) inflammatory markers (A) and interleukin-6 (IL-6) (B) in the perioperative period. Preo: Preoperative (morning of surgery). POD: postoperative day.