Does rapid mobilisation as part of an enhanced recovery pathway improve length of stay, return to function and patient experience post primary total hip replacement? A randomised controlled trial

Abstract

Demand for total hip replacement (THR) surgery has increased over the last twelve years and continues to increase. Day zero ambulation may enable patients to recover and leave hospital quicker post-operatively, increasing efficiency and allowing services to cope with increasing demand. This thesis investigated the effectiveness of day-zero ambulation as a physiotherapeutic intervention within a UK hospital. Investigation of this topic started with a systematic review of the existing literature using a narrative synthesis. This showed that day-zero-ambulation may reduce length of stay (LOS) with resultant cost savings and speed functional recovery, without increasing incidence of post-operative complications. However, methodological limitations such as concomitant interventions mean that changes may not be confidently attributed to day-zero ambulation. Following on from this, a feasibility study was conducted which established the scientific and practical implications of conducting a randomised controlled trial.

Finally, this research included a fully-powered, single-centered, non-blinded randomised controlled trial involving 176 participants who underwent primary uncomplicated THR. Participants were randomly allocated into two groups; the intervention group attempted ambulation on the same day as surgery (n =87) and the control group attempted ambulation the day after surgery (n = 89). Apart from time of ambulation, both groups received the same post-operative management. The primary outcome was LOS, with secondary outcomes for time to physiotherapy ready for discharge, post-operative numerical pain scores, consumption of opioid and antiemetic medications, incidence of post-operative complications, time to reach functional milestones and functional independence and participant experience.

Median LOS was 3 days both in the control group (IQR 2-4) and intervention group (IQR 2-3) however, this study observed reduced LOS variation in the interquartile range between groups meaning groups were statistically significantly different (p=0.02). Intervention group participants were physiotherapy ready to leave hospital 19.5 hours earlier than control group participants (p=0.00006), achieved functional milestones significantly quicker than those in the control group, and were 2.06 (CI 1.55 to 2.74) times more likely to be functionally independent at any given time point than the control group (p<0.0001). There were no significant differences in the incidence of post-operative complications, post-operative pain, opioid and anti-emetic consumption and participant experience between groups. Day zero ambulation appears to improve efficiency of recovery and speed return to functional independence without adversely affecting the incidence of post-operative complications, pain experience or overall patient experience.

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Identifiers

ORCID for Christopher Matthew Efford: orcid.org/0000-0002-0730-8310

ORCID for Dinesh Samuel: orcid.org/0000-0003-3610-8032

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