Table 3. Data extracted from the included studies.
| Study | Participants Age, y ± SD, (range) | Interventions in Experimental Group | Interventions in Comparison / Control Group | Summary of Results |
|---|---|---|---|---|
| Chen A et al 2012, [29] USA, Prospective cohort study | Primary elective THA / TKA POD 1 PT (CG) n = 111 43 M, 61 F* 63.2 ± 11.0 POD 0 PT (EG) n = 25 10 M, 14 F* 58.0 ± 9.4 |
Hospitalized DOS, informed of ambulation before DC. POD 0: Patients are transferred to PACU, then inpatient care floor. Patients with TKA began CPM from 0°-90°. Patients are encouraged to get OOB and ambulate. If unable to ambulate, patient was moved from bed to chair. POD 1+: strengthening exercises initiated, progress exercises as appropriate. Exercises included isometric gluteal, quadriceps, hamstring, and hip adductor muscle sets. AAROM / AROM exercises included short-arc quadriceps ROM, long-arc quadriceps ROM, SLR, hip abduction, ankle pumps, and heel slides. Transfers, gait training, and ADLs also included. |
Hospitalized DOS, informed of ambulation before DC. POD 0: Patients are transferred to PACU, then inpatient care floor. Patients with TKA began CPM from 0°-90°. Patients remained in bed or were moved from bed to chair, but did not ambulate. POD 1+: strengthening exercises initiated, progress exercises as appropriate. Exercises included isometric gluteal, quadriceps, hamstring, and hip adductor muscle sets. AAROM / AROM exercises included short-arc quadriceps ROM, long-arc quadriceps ROM, SLR, hip abduction, ankle pumps, and heel slides. Transfers, gait training, and ADLs also included. |
Outcome Measures: LOS Statistically significant between group differences in mean LOS favoring EG. |
| Chen H et al 2012, [30] Taiwan, Retrospective study | TKA No rehabilitation (CoG) n = 5,533 1,497 M, 4,036 F 70.08 ± 8.1 After 2 weeks (CG) n = 1,570 397 M, 1,173 F 69.30 ± 8.5 Within 2 weeks (EG) n = 14,040 3,351 M, 10,689 F 69.56 ± 7.9 |
EG received inpatient or outpatient rehab services within 2 weeks after DC. Treatment protocol included: isometric exercise including ankle pumping, CPM, PROM including knee extension and flexion with heel slides (Range 0–90°), ambulation with walker, WB, and stationary cycling. |
CoG did not receive rehab services after DC. CG received inpatient or outpatient rehab services more than 2 weeks after DC. Treatment protocol included: isometric exercise including ankle pumping, CPM, PROM including knee extension and flexion with heel slides (Range 0–90°), ambulation with walker, WB, and stationary cycling. |
Outcome Measures: Total medical expenses Statistically significant between group differences in total medical expenses with CoG demonstrating the lowest overall costs and CG demonstrating the highest overall costs. |
| den Hertog et al 2012, [44] Germany, RCT | TKA Standard (CG) n = 73 20 M, 53 F 68.25 ±7.91 Fast-track (EG) n = 74 23 M, 51 F 66.58 ± 8.21 |
Joint Care® fast-track rehabilitation implemented, received group therapy on DOS, stayed in three-bed hospital units, improved logistical organization involving case manager, provided with positive messages, informed that early discharge was scheduled for POD 6 as long as discharge criteria was met, competitive care implemented by comparing progress to fellow patients, DOS+: mobilized, 2 hours of standard intensive physiotherapy with focus on ADL, walking exercises, knee PROM flexion-extension up to 90-00-00°, lower limb muscle strengthening, respiratory training, group therapy. 18 day daily exercise program in rehabilitation center following DC from hospital. |
Received standard perioperative care based on the individual’s subjective reports, stayed in three-bed hospital units, medication and discharge planning was discussed when the patient felt ready, not informed about intended LOS. DOS: intravenous fluid program POD 2+: first mobilization, 1 hour of physiotherapy exercises consisting of walking exercises, knee PROM flexion-extension up to 90-00-00°, lower limb muscle strengthening, respiratory training. 18 day daily exercise program in rehabilitation center following DC from hospital. |
Outcome Measures: LOS Statistically significant between group differences in mean LOS favoring EG. |
| Gulotta et al 2011, [46] USA, Prospective cohort study | THA Traditional (CG) n = 134 80 M, 54, F 52.3 ± 8.5 Fast-track (EG) n = 149 98 M, 51 F 50.3 ± 8.9 |
Followed fast-track clinical pathway with a DC goal of 2 days, daily patient goals were outlined, surgery scheduled for first or second case of the day to allow for PT on DOS, educated about fast-track protocol, counseled about pain control and PT regimens, daily goals were outlined. DOS: ambulated x 3 with physical therapist, first time within 6 hours following surgery, progressed to WBAT with walker. POD 1: PT in the morning, attempt to progress to crutches or cane, PT in afternoon, progress to stairs if tolerated. POD 2: PT in the morning, progress to cane, work on stairs/transfers. D/C home if cleared by medical, surgical, and PT teams. Call home day after and 1 week after DC to screen for complications. |
Followed the hospital’s traditional clinical pathway with a DC goal of 4 days. DOS: no ambulation POD 1: ambulated with PT No further information was provided. |
Outcome Measures: LOS Statistically significant between group differences in mean LOS favoring EG. |
| Isaac et al 2005, [47] United Kingdom, Prospective cohort study | TKA Control (CG) n = 80 71.3 ± 8.1, (42–84) Accelerated (EG) n = 50 72.3 ± 9.9, (50–88) |
Attended pre-assessment clinic, educated about rapid rehab and return home. DOS: mobilized using walker 4 hours post-op, SLR exercises, pillow under heel of operated leg to ensure full extension. POD 1: ROM to quadriceps and hamstrings, ambulation with walker. POD 2: ambulation with walker or walking stick. POD 3+: stair negotiation. Home visits 1, 2, 7 days post DC. Outpatient visit at 2, 6 weeks post DC. |
Attended pre-assessment clinic. Rehab approach similar to intervention except, DOS: no PT. No home visits 1, 2, 7 days post DC. |
Outcome Measures: LOS Statistically significant within group reduction in mean LOS for both the EG and CG, with a greater reduction in mean LOS favoring EG. |
| Juliano et al 2011, [31] USA, Retrospective descriptive study | Primary unilateral THA POD 1 (CG) n = 204 106 M, 98 F 60.4, (27–82) DOS (EG) n = 204 109 M, 95 F 60.2, (32–83) |
3 days LOS clinical pathway used. DOS: treatment B/S, evaluation, dangle, stand, or ambulate as tolerated, B/S exercises, instructed on THA precautions. POD 1: treatment B/S, transfer training, progress ambulation distance as tolerated with walker, review exercises and precautions, high chair sitting, bathroom privileges. POD 2: treatment in PT gym, transfer training, attempt gait progression to cane or crutches, stair training, progress exercises. POD 3: treatment in PT gym, transfer training, progress gait, stairs, review HEP and ADL technique, DC if appropriate. |
4 day LOS clinical pathway used. DOS: no PT intervention POD 1: treatment B/S, evaluation, dangle, stand, or ambulate as tolerated, B/S exercises, instruction on THA precautions. POD 2: treatment B/S, transfer training, progress ambulation distance as tolerated with walker, B/S exercises, review exercises and precautions, high chair sitting, bathroom privileges. POD 3: treatment in PT gym, transfer training, attempt gait progression to cane or crutches, stair training, progress exercises, review precautions, high chair sitting, bathroom privileges. POD 4: treatment in PT gym, transfer training, progress gait, stairs, review HEP and ADL technique, DC if appropriate. |
Outcome Measures: LOS Statistically significant between group differences in mean LOS favoring EG. |
| Labraca et al 2011, [32] Spain, RCT | Primary TKA for OA Control (CG) n = 135 25 M, 110 F 66.36 ± 5.03 Intervention (EG) n = 138 37 M, 101 F 65.48 ± 4.83 |
POD 1: patient and family educated on rehab plan, PROM and AAROM knee flexion-extension from 0°-40°, isometric quadriceps and hamstring exercises with alternating 5-sec contract-relax, ankle flexion-extension for 10 minutes, active assisted anterior flexion of leg in extension, diaphragmatic breathing, education on posture. POD 2: same as day 1, in-bed sitting posture, transfer from bed to chair, standing, short-distance ambulation, management of AD, learning seated flexion-extension exercises, isotonic muscle work. POD 3: same as day 2, intensified exercises with AD, increased ambulation distance, ADLs. POD 4+: active-resisted quadriceps exercises, gait re-education, increased ambulation distance, stair negotiation with simulator, intensified muscle work, increased adaptation to ADLs |
POD 1: no treatment, remained at rest in bed or chair POD 2: patient and family educated on rehab plan, PROM and AAROM knee flexion-extension from 0°-40°, isometric quadriceps and hamstring exercises with alternating 5-sec contract-relax, ankle flexion-extension for 10 minutes, active assisted anterior flexion of leg in extension, diaphragmatic breathing, education on posture. POD 3: same as day 1, in-bed sitting posture, transfer from bed to chair, standing, short-distance ambulation, management of AD, learning seated flexion-extension exercises, isotonic muscle work. POD 4: same as day 2, intensified exercises with AD, increased ambulation distance, ADLs. POD 5+: active-resisted quadriceps exercises, gait re-education, increased ambulation distance, stair negotiation with simulator, intensified muscle work, and increased adaptation to ADLs. |
Outcome Measures: LOS Statistically significant between group differences in mean LOS favoring EG. |
| Larsen et al 2008, [33] Denmark, Quasi-experimental study | Primary elective THA Control (CG) n = 48 27 M, 23 F† 67 ± 9.8 Intervention (EG) n = 50 28 M, 27 F† 65 ± 9.6 |
Educated with 1 relative in groups about surgery and accelerated procedure at information day Friday before surgery, individual consults, hospitalized in new accelerated unit DOS, patient’s own clothes to be worn for LOS. DOS: mobilization. POD 1: goal of 4 hours OOB, training with PT and OT. POD 2+: goal 8+ hours mobilization. Outpatient follow-up 3 months post DC. |
Hospitalized day before surgery, placed in general orthopedic ward, hospital clothes to be worn for LOS, educated individually day before surgery. POD 1: mobilized OOB, began training. POD 2+: mobilization increased to reach DC criteria, rehab adjusted to meet patient’s immediate state, care given to meet patient’s actual needs. Outpatient follow-up 3 months post DC. |
Outcome Measures: LOS |
| Larsen et al 2009, [34] Denmark, Cost-effectiveness study based on RCT (Larsen, 2008) | Primary elective THA / TKA / UKA Standard (CG) n = 42 23 M, 19 F 66 ± 9.2 Accelerated (EG) n = 45 20 M, 25 F 64 ± 10.8 |
Educated in groups at outpatient clinic visit prior to hospitalization, hospitalized day of DOS, placed together with patients involved in study on separate part of ward, one nurse in charge of multidisciplinary team of nurses, OTs, and PTs, nutrition screening and focus on daily consumption of 1.5L of fluid, including two protein beverages. DOS: began mobilization and exercise. POD 1+: intensive mobilization of patients in teams following preset daily goals, 8 hours of mobilization daily. |
Educated individually on day of admission, hospitalized day before surgery, placed randomly in general ward among other patients who were not part of study, various nurses in charge of care, various OTs and PTs responsible for mobilization, nutrition screening. POD 1: began mobilization and exercise. POD 2+: individual and gradual mobilization according to patient’s tolerance, 4 hours of mobilization daily. |
Outcome Measures: Total cost Statistically significant between group differences in mean cost savings favoring the EG in patients with THA and TKA. |
| Larsen et al 2008, [35] Denmark, Prospective before-after trial | Primary elective THA / Primary elective TKA Control (CG) n = 105 53 M, 52 F 65 ± 11.0 Intervention (EG) n = 142 68 M, 74 F 65 ± 11.0 |
Educated with 1 relative in groups about procedure and plan for DC at information day week before surgery, individual consults, hospitalized in separate male and female beds in new accelerated unit DOS, patient’s own clothes to be worn for LOS. DOS: mobilization. POD 1: goal 4 hours OOB, training with PT and OT. POD 2+: goal 8+ hours mobilization. OOB activity (70% of mob time), gait training (15% of mob time), and exercises (15% of mob time). Exercises included hip and knee muscle strengthening, avoiding restricted motions; increased intensity, repetitions, and progression of acceleration as compared to CG. |
Hospitalized day before surgery, placed in orthopedic ward, hospital clothes to be worn for LOS, educated about plan and procedure. POD 1: training in bed before lunch, mobilized OOB by PT after lunch. POD 2+: mobilized avg. 4 hours, mobilization increased to reach DC criteria, OOB activity (50% of mob time), gait training (25% of mob time), and exercises (25% of mob time). Exercises included hip and knee muscle strengthening, avoiding restricted motions. |
Outcome Measures: LOS Statistically significant between group differences in mean LOS favoring EG. |
| Larsen et al 2008, [36] Denmark, RCT | THA / TKA / UKA Control (CG) n = 42 23 M, 19 F 66 ± 9.2 Intervention (EG) n = 45 20 M, 25 F 64 ± 10.8 |
Educated with 1 relative in groups about surgery and accelerated procedure at information day Friday before surgery, individual consults, hospitalized in new accelerated unit DOS, patient’s own clothes to be worn for LOS. DOS: mobilization. POD 1: goal of 4 hours OOB, training with PT and OT. POD 2+: goal 8+ hours mobilization. Outpatient follow-up 3 months post DC. |
Hospitalized day before surgery, placed in general orthopedic ward, educated individually day before surgery, hospital clothes to be worn for LOS. POD 1: training in bed before lunch, mobilized OOB after lunch. POD 2+: mobilization increased to reach DC criteria, rehab adjusted to meet patient’s immediate state, care given to meet patient’s actual needs. Outpatient follow-up 3 months post DC. |
Outcome Measures: LOS Statistically significant between group differences in mean LOS favoring EG. |
| Pua & Ong 2014, [37] Singapore, Retrospective cohort study | Primary elective unilateral TKA for OA Late ambulation on POD 2 (CG) n = 701 123 M, 578 F 66.8 ± 8.1 Early ambulation on POD 1 (EG) n = 803 183 M, 620 F 66.1 ± 7.6 |
Managed using coordinate clinical pathway. POD 1: began standard PT intervention including knee ROM, muscle strengthening exercises, began ambulation. |
Managed using a coordinated clinical pathway. POD 1: began standard PT intervention including knee ROM, muscle strengthening. POD 2: began ambulation. |
Outcome Measures: LOS, Total hospitalization costs on DC Statistically significant between group differences in mean LOS favoring EG. Statistically significant between group differences in mean costs favoring EG. |
| Raphael et al 2011, [50] Canada, Retrospective cohort study | THA / TKA Standard (CG) n = 100 47 M, 53 F 69 ± 8 Fast-track (EG) n = 100 52 M, 48 F 65 ± 9 |
Educated about fast-track program and expected plan for DC on POD 2, attended pre-surgical clinic several week prior to surgery. Following surgery patients were transferred to PACU and then SSU when they met PACU DC criteria. DOS: began physiotherapy in SSU 2–4 hours following surgery, 1–2 sessions of physiotherapy, bed transfers, sit to stand transfers, progressing to 5–10 minute ambulation with assistance from two staff members and AD, deep breathing, ankle pumps, static quadriceps, buttock exercises. Patients discharged to home or tertiary care facility when they met DC criteria. Contacted by nurse practitioner 2–3 days after DC to assess symptoms and recovery. |
All surgery performed at tertiary care hospital, limited in preoperative education, no predetermined LOS plan, minimal DC planning prior to admission. DOS: no PT intervention POD 1: physiotherapy initiated if tolerated No further information was provided. |
Outcome Measures: LOS Mean LOS was shorter in the EG than in the CG. |
| Reilly et al 2005, [45] UK, RCT | UKA Standard (CG) n = 20 63 Accelerated (EG) n = 21 63 24 M, 17 F total‡ |
Facilitated DC and DC support provided, goal of DC 24 hours following surgery. DOS: mobilized using walking frame two hours after surgery given the patient was alert and sufficiently pain free, progressed to ambulation using elbow crutches, stair negotiation, use of pain diary, Patients instructed on home use of pain diary, rehabilitation instructions, and potential problems. Patients educated to rest limb in extension, flex knee within limits of bandage, and use extension splint for ambulation for the first 5 days. Patients attended outpatient session with physiotherapist 5 days following DC for wound check and ROM assessment. Sutures removed, ROM assessed, and progression to one or two sticks occurred at appointment with physiotherapist 10–14 days following surgery. ROM assessed and observation by physiotherapist at 6 weeks post surgery. |
Standard preparation for DC, urgency for deadlines not emphasized as it was with EG. Patient provided with pain diary and postoperative rehabilitation instructions. No further information was provided. |
Outcome Measures: LOS, total cost Mean LOS was shorter for EG than CG. Average total cost was greater for CG than EG. |
| Robbins et al 2014, [38] USA, Retrospective cohort study | THA Control (CG) n = 400 188 M, 212 F Accelerated (EG) n = 190 99 M, 91 F 58.6, (31–87) |
Patient and healthcare team education emphasized anticipated 24–48 hour LOS and DC to home, patients transferred from PACU to patient care unit by stretcher, unit staff received special education and instruction on post-op care of this patient cohort, mobilization and gait training implemented DOS for transfer from stretcher to hospital bed with walker or crutches, stand pivot transfer or slide transfer used for patients unable to begin gait training upon admission to hospital unit. | Patients transferred from PACU to patient care unit by hospital bed, mobilization initiated POD 1. |
Outcome Measures: LOS Statistically significant between group difference in mean LOS favoring the EG. |
| Tayrose et al 2013, [39] USA, Prospective cohort study | THA / TKA Standard rehab (CG) n = 569 216 M, 353 F 64.3 Rapid rehab (EG) n = 331 125 M, 206 F 63.7 |
DOS: mobilized in recovery room, progress standard rehab protocol throughout LOS. Protocol includes progression of hang legs over side of bed, transfer to chair, ambulation, and climbing stairs. | POD 1: progress standard rehab protocol throughout LOS. Protocol includes progression of hang legs over side of bed, transfer to chair, ambulation, and climbing stairs. |
Outcome Measures: LOS Statistically significant between group differences in mean LOS favoring EG. |
| Wellman et al 2011, [40] USA, Prospective cohort study | THA Control (CG) n = 209 Accelerated (EG) n = 218 97 M, 121 F 57.3, (23.5–79.9) |
DOS: Patients are transferred from OR to PACU, then to hospital floor on stretcher, not hospital bed. Upon arrival, patients stand in hallway and walk to hospital bed with bilateral assistance, mobilized by PT or nursing staff. More senior or frail patients stand and pivot B/S instead of ambulation. Patients are encouraged to get up with PT or nursing staff one to several times daily and to walk to bathroom. | DOS: Patients are transferred from OR to PACU, then to hospital bed. Patients remain in bed to following morning. |
Outcome Measures: LOS Mean LOS was shorter in the EG and resulted in faster DC to home. |
Abbreviations: AAROM, active-assistive range of motion; AROM, active range of motion; ADL, activities of daily living; AD, assistive device; AVG, average; BOS, base of support; B/S, bed side CG, comparison group; CPM, continuous passive motion; CoG, control group; DOS, day of surgery; DC, discharge; EG, experimental group; F, females; HRQOL, health-related quality of life; HEP, home exercise program; LOS, length of stay; M, males; OT, occupational therapy; OR, operating room; OA, osteoarthritis; OOB, out of bed; PROM, passive range of motion; PT, physical therapy; PACU, post-anesthesia care unit; POD, post-operative day; RCT, randomized clinical trial; ROM, range of motion; SSU, short stay unit; SLR, straight leg raise; THA, total hip arthroplasty; TKA, total knee arthroplasty: TKR, total knee replacement; UKA, unicompartmental knee arthroplasty; WB, weight-bearing; WBAT, weight-bearing as tolerated
* The number of male and female participants is not reflective of the sample size (n = 111, n = 25) as n represents the total number of joints replaced.
† The number of male and female participants is not reflective of the sample size (n = 48, n = 50) because in this study the authors reported total sample size after losses to follow-up were taken into account. The exact number of male and female drop-outs were not reported in the study.
‡ The number of male and female participants was not reported for each group; only the total ratio was provided.