Factors associated with early functional recovery following primary unilateral total hip and knee arthroplasty.

  • Nicola Hewlett-Smith

Student thesis: Master's Thesis


The prevalence of osteoarthritis is growing in many countries including Australia, and accounts for the vast majority of primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) surgeries performed. In Australia, demand for these elective procedures has increased substantially over the last 15 years, adding further burden to healthcare costs and resources. Hence, efficient delivery of quality patient care is paramount to accelerate early post-operative recovery and reduce the length of hospital stay and, ultimately, the
costs associated with these surgeries. To this end some healthcare organisations have implemented Enhanced Recovery Pathways (ERP) whereby each step of the patient surgical journey has been rationalised and optimised.

The introduction of ERP for THA and TKA has demonstrated both patient and organisational benefits. However, ERP are complex in nature and comprise multiple components for which there are currently no standardised guidelines. Thus, ERP vary between healthcare organisations, as do their measures of success, particularly inpatient functional outcomes. Despite inpatient functional recovery being essential for safe and timely hospital discharge following THA and TKA, research undertaken to establish prognostic factors for inpatient
functional recovery is limited, and therefore forms the topic of this thesis.

An initial literature review (Chapter 2) identified only a single systematic review which investigated patient-related predictors of inpatient recovery and length of stay (LOS) following THA. Thus, evidence regarding associations between individual surgical factors and inpatient recovery, which could inform ERP, had not been considered. Importantly, there is currently no gold standard tool by which to assess inpatient functional recovery.

A systematic review (Chapter 3) was therefore conducted to examine the available evidence for both patient and surgical factors associated with early post-operative function (assessed using validated measures) following THA and TKA. Strong level evidence supported preoperative Timed Up and Go time and American Society of Anesthesiologists grade as factors significantly associated with inpatient functional recovery following TKA. However, studies of early functional recovery were found to be heterogenous in nature. Variance in
methodological quality, variables examined, outcome measures, and the time points at which they were assessed, impeded synthesis of results. Furthermore, recent surgical advances including muscle-sparing approaches and robot-assisted surgery had not been assessed.

A prospective cohort study (Chapter 4) was undertaken to explore the potential prognostic relationship between patient and surgical factors and inpatient functional recovery following THA and TKA. Secondary outcome measures were acute hospital LOS, and longer-term patient-reported functional outcomes assessed at six months post-operatively. Inpatient functional recovery was assessed on the afternoon of the second post-operative day using objective performance measures relevant to the early post-operative time points and
reflective of the tasks required for safe discharge from acute orthopaedic wards. Patient-related factors significantly prognostic for inpatient functional recovery in the study population included age, sex, pre-operative function, general health, and Risk Assessment and Prediction Tool score. Significant surgical prognostic factors in the study population included techniques for administering analgesia and anaesthesia, arthroplasty site, and surgical approach (for THA).

This program of research has demonstrated that several patient-related factors assessed pre-operatively, as well as surgical and post-operative factors were associated with inpatient functional outcomes, and with LOS in patients following THA and TKA. In addition, longer-term functional outcomes for these patients reflected their inpatient functional outcomes. Standardised functional outcome measures are needed to evaluate patient-centred ERP outcomes, and to facilitate benchmarking, auditing and improving ERP.
Date of Award3 Feb 2021
Original languageEnglish
SupervisorWayne Hing (Supervisor), Rodney Pope (Supervisor) & James Furness (Supervisor)

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