Translate this page into:
What is the multifactorial efficacy of day-zero ambulation post-total hip replacement surgery: A systematic review
∗Corresponding author: Christopher Efford. christopher.efford@uhd.nhs.uk
-
Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
To examine the multi-factorial efficacy of day-zero ambulation following primary total hip arthroplasty.
MEDLINE, CINAHL, AMED, EMBASE and APA PsychInfo in accordance with PRISMA guidelines.
Studies were classified for study design and ranked in a hierarchy of evidence. Studies ranked excellent or good who followed a treatment pathway inclusive of day-zero ambulation were appraised using the appropriate content checklist (PRISMA, CONSORT, STROBE), CASP checklist and where possible for risk of bias using the appropriate tool (RoB 2.0, ROBINS-1). Results were produced using a narrative synthesis.
A total of 8 studies met inclusion criteria. Studies reported a consensus of a reduced length of hospital stay in pathways where day-zero ambulation was included, but with varying effect sizes. Findings suggested that day-zero ambulation may speed up return to function following THR. There was not enough evidence to provide synthesised results on financial efficiency, post-operative pain, or safety of day-zero ambulation via post-operative complications.
This systematic review reveals limitations within the literature base on day zero-ambulation. There are problems of concomitant interventions, methodological heterogeneity, and an abundance of research low in the evidence hierarchy. Day zero-ambulation shows promise in reducing length of hospital stay and there is suggestion that it accelerates functional recovery. However, to establish this with rigor, there is further need for high quality, prospective studies such as RCTs to examine the multi-factorial effect of day-zero ambulation, challenge existing theories and contribute to confident synthesised findings more useful to clinical decision makers.
Keywords
Arthroplasty
Hip replacement
Efficacy
1 Introduction
Elective orthopaedic services face increasing demand, limitations in resources and finite healthcare budgets.1 Consequently, healthcare providers require pathway efficiency changes in order to maintain public value. Day-zero ambulation following lower limb joint arthroplasty means the initiation of walking or weight-bearing activities on the day of the surgery itself, typically within hours after the procedure. The aim of this is to promote faster recovery, reduce the length of hospital stay (LOS), and enhance postoperative outcomes. Day-zero ambulation may be an important low-cost physiotherapeutic pathway option for improving service efficiency. Much of the research in this field focuses on LOS.1,2 While this is an important metric of service efficiency, clinical decisions also need to account for factors such as incidence of post-operative complications, patient pain experience, functional recovery and patient lived experience, which feasibly could all be influenced by day-zero ambulation.
This systematic review aimed to investigate the current knowledge base of day-zero ambulation following total hip arthroplasty (THA) as an intervention; focussed on answering the following research questions:
What effect does day-zero ambulation have on patient recovery in terms of?Length of hospital stay (LOS)?Financial efficiency?Functional recovery?Post-operative pain?
Is day-zero ambulation safe, when considering post-operative complications and mortality?
This review was registered with PROSPERO (i.e. THE International Prospective Register of Systematic Reviews) under the reference ID 247796.
Protocol available online at:
https://www.crd.york.ac.uk/PROSPEROFILES/247796_PROTOCOL_20210408.pdf.
This study was conducted and is reported using PRISMA checklist guidance.3
2 Methods
A systematic search of the online databases of MEDLINE, CINAHL, AMED, EMBASE and APA PsychInfo from 2005 to 2022 was conducted to identify eligible studies. PICO criteria guidance4 was used in the development of the search strategy and used medical subject headings and text words relating to the research questions. Day-zero ambulation was defined as the patient ambulating for the first time on the same calendar day as their arthroplasty was completed. The final search strategy was reviewed by both reviewers and an independent university librarian for completeness (Included in supplementary study information).
2.1 Study selection
Two reviewers independently reviewed abstracts against the inclusion and exclusion criteria shown in Table 1, and full texts were obtained for all potentially relevant studies.
| Inclusion Criteria |
| •Published since 2005 |
| •Full text available in English language |
| •Participants treated with day-zero ambulation following THA |
| •Presented empirical findings relating to day-zero ambulation post THA |
| •Ranked as excellent or good study design in the hierarchy of evidence(56) |
| Exclusion Criteria |
| •No outcome measures relevant to THA |
Study type was identified using the NICE 2012 algorithm for classifying quantitative study designs.5,6 Studies were ranked for hierarchy in evaluating efficacy of healthcare intervention according to the guidance shown in Fig. 1.
Studies that employed a design ranked as fair or poor in the effectiveness column of Fig. 1 were excluded. Any exclusions were discussed and agreed between reviewers. Disagreements underwent full text methodology review and inclusion/exclusion discussion before agreement between reviewers.
2.2 Methodological quality assessment
Following ranking, studies were individually assessed via full text review for methodological quality by the two reviewers independently. Content assessment was guided by the appropriate PRISMA,3 CONSORT7 or STROBE8 checklist. In addition, overall study quality was appraised using the CASP analysis tool.9 Research findings and critical appraisal comments were summarised in a meta-summary table to enable structured comparison. Although meta-analysis is the gold standard for the synthesis of quantitative study findings, a previous attempt by the author at meta-analysis following this intervention indicated considerable heterogeneity making narrative synthesis the most appropriate method for combining results.
2.3 Risk of bias assessment
Where possible, all included studies were assessed for risk of bias in line with the Cochrane handbook10 guidance. RCTs were assessed using the RoB 2.0 tool.11,12 Studies which did not employ randomisation were assessed using the ROBINS-1 tool.13 Risk of bias assessments were completed independently by both reviewers. Outcomes were then discussed and agreed. Risk of bias across studies was summarised using traffic light plots and weighted bar plots using the ROBvis tool.14
3 Results
3.1 Study selection
Literature search identified 163 individual articles for abstract review. 151 articles were excluded in total with reasons detailed within the PRISMA flow diagram (Fig. 2).
One paper15 was excluded following risk-of-bias assessment due to critical risk of bias in the confounding domain, the detail of this risk of bias assessment is shown within the supplementary study information. This left 8 papers for inclusion shown in Table 2.
3.2 Hierarchy of evidence rankings
Of the 8 papers included in this literature review, 2 ranked within an excellent study design, and the remaining 6 as good. Studies judged of excellent methodological design consisted of one systematic review and one multi-centre RCT. The remaining 6 studies consisted of two single centre RCTs, 2 cohort studies, one case-control study and one cost-utility study.
Study findings and appraisal of strengths and weaknesses are included in a meta-summary table in Table 2. All included studies performed satisfactorily for the expected elements of reporting via CONSORT, STROBE and PRISMA checklists.
3.3 Risk of bias assessment
Six of the included studies used designs amenable to risk of bias assessment. Two studies were not assessed16,17 as the tools available were unsuitable for use with cost-utility studies or systematic reviews respectively. All RCTs were judged overall as having low risk of bias (Fig. 3).
Within the non-randomised studies, one was excluded due to scoring as a critical risk of bias.15 Of the remaining included studies two were determined as having a serious risk of bias and one with a moderate risk of bias. This is summarised in Fig. 4.
3.4 Length of stay (LOS)
Five of the included studies presented empirical findings about LOS,18–21 this included three RCTs and two cohort studies. Findings were mixed, with the two earlier studies reporting a statistically significant reduction in LOS, but the other studies conducted in 2016 reported no statistically significant differences. While the largest effect was observed in Larsen, Sørensen et al., 2008, with an LOS reduction of 3 days, the other four included studies showed much more modest or statistically insignificant reductions in LOS. Two studies did not directly measure LOS as an outcome.22 One instead examined characteristics associated with patients staying more than a single day in hospital following THA. In this study, not ambulating on day zero was strongly associated with an increased LOS (odds ratio 3.93, p < 0.001), supporting the inference of a true LOS reduction with day-zero ambulation. Oberfeld et al., 2021 examined time to readiness for discharge and found this to be 0.74 days quicker in their intervention group.
Three studies isolated day-zero ambulation as the sole intervention, had high participant numbers, were specifically examining patients undergoing hip arthroplasty and had well representative inclusion and exclusion criteria to ensure generalisability to UK orthopaedic practice.(19,20,22) These studies saw a modest reduction in LOS in the fast-track group of 0.21 days (p = 0.014) and 0.41 days (p = 0.11) respectively. While this is at odds with larger effect sizes seen in other studies, this may be more reliable as a representative effect size for day-zero ambulation on LOS following THA.
3.5 Financial efficiency
Only one of the included studies examined the financial effect of a pathway that included day-zero ambulation,16 comparing 45 patients treated under an accelerated rehabilitation programme, with 42 treated under standard care. Over the entire care-episode and subsequent 12-month recovery, this study observed significant reductions in the average cost-per-patient.
3.6 Safety of day-zero mobilisation
Two included papers commented on the safety of day-zero ambulation (17,22). One systematic review reported no differences in complications, revision surgeries or readmission rates in participants who underwent day-zero ambulation as part of an outpatient arthroplasty programme. This review did not breakdown these adverse events complications into types. One RCT reported no differences in day-of-surgery adverse events but did not examine complications beyond the day of surgery.
3.7 Functional recovery
Two studies examined outcomes relating to post-operative function or health related quality of life(HRQoL).18,19 One examined proportions of participants who achieved functional milestones in recovery (independence in negotiating stairs and walking with a cane). In this study, there were no significant differences in the attainment of these milestones despite a slightly shortened LOS within the intervention group – indicating a faster functional recovery). The second reported improved EQ (5D) scores23 in patients who had undergone day-zero ambulation, which did reach statistical significance. One study(22) showed no differences in 12 month follow-up functional scores using the WOMAC(24).
This suggests benefits of day-zero ambulation in speed of functional recovery and HRQoL. However, as all papers examined very different outcomes, this review cannot build more confidence in these findings beyond that which is presented within the original research papers.
3.8 Pain
Of the studies that reached the level of evidence to be included within this review, none examined the post-operative pain experience as part of their study aims.
4 Discussion
4.1 Summary of findings
In the systematic review, studies on LOS revealed mixed findings, with two studies in 2016 showing no significant differences. One study associated non-ambulation on day zero with increased LOS, supporting the idea of a true LOS reduction with day-zero ambulation. Financial efficiency was only assessed in one study but indicated significant cost-per-patient reductions. Safety analysis found no differences in complications with day-zero ambulation. Two studies suggested benefits in functional recovery and health-related quality of life, but varying outcomes limit inter-study comparison. Post-operative pain was not examined in any included studies.
4.2 Length of stay
There are indications that day-zero ambulation may reduce LOS18–21 and there is consistency in the direction of effect within the wider literature beyond that included within this systematic review, with a further 16 papers showing a relative reduction in LOS.15,24–37
Across included studies, there was either a comparative reduction in LOS or a lower LOS than would be normally expected in standard UK care which has been evidenced at a mean of 12.3 days when examined across 151 UK hospitals.38 However, different studies showed large variation in LOS reductions following day-zero ambulation, with reductions ranging from 0.21 19 to 3 days.18 Within the wider literature an even greater variation exists, with one study reporting a LOS reduction of 6.45 days.24 This leaves clinicians with poor confidence in the number of bed days which could be saved by employing day-zero ambulation. Due to limitations in methodological heterogeneity and minimal studies isolating day-zero ambulation as the sole intervention, attributing any change directly to day-zero ambulation as an intervention is flawed.
4.3 Financial efficiency
Only one of the included studies specifically examined the financial effect of a pathway that included day-zero ambulation16 and observed significant reductions in the average cost-per-patient. Andreasen et al.39 also claimed a reduction in the cost of providing THR. Their comparison, however, was made using costs from a previous 2016 publication and without a direct comparison group and without accounting for the prosthetic implant costs. While these studies indicate there could be significant financial savings by using day-zero ambulation, currently these studies are in isolation and were carried out in healthcare systems very different to UK practice. While Larsen (2009) has a strong methodology as a fully-blown cost-utility study, it was based on data from another included study,18 which illustrated the greatest reduction in LOS. Cost saving on bed days is expected to be the main source of cost saving. If identical economic evaluations were carried out on the studies which saw more modest reductions in LOS, the cost-per-patient savings would also likely be much more modest.
As financial efficiency is strongly linked with LOS, financial efficiency findings based on studies examining LOS are inherently subject to the same limitations affecting LOS findings.
4.4 Safety, when considering post-operative complications and mortality
Judgement on the safety of day-zero ambulation within this review is limited to one included systematic review, which ultimately was not examining day-zero ambulation as an isolated intervention as it was exploring outpatient arthroplasty pathways. Despite this, other studies in the wider literature although not reaching the inclusion criteria of this review, present encouragingly positive findings. Seven different published studies have found no difference in post-operative complication rates between their intervention and control groups.17,25,28,32,34,36,40
For complications directly associated with THA, multiple studies report no significant differences in incidence of DVT/PE,28,40–42 dislocation rates40,43,44 and risk of falls.45 Other individual studies also report positives such as benefits in preserving post-operative cognitive abilities,46,47 reduced post-operative blood transfusion rate and 30-day incidence of myocardial infarction.25
However Amlie et al. reported a significant increase in the incidence of revision surgery within 3 months post-op due to deep infection48 and one study also saw an increase in the incidence rates of post-operative nausea and vomiting.27
When looking at readmissions, the majority of studies supported the results of Pollock et al.17 in finding no significant differences in readmission rates between groups.25,27,40,43,45,49,50 However, Pitter et al.,51 who specifically examined participants over 85 years observed a 20 % increase in readmissions within a 90 day follow-up; suggesting that age is likely to be a confounding factor in readmission rates.
Overall, there may be some potentially important safety benefits observed in the wider literature, with some benefits appearing to have lasting post-discharge advantages in reducing risks of morbidity. However, while in comparison relatively few; there were some negative findings within the wider literature. While some complications such as PONV are relatively minor, findings of an increased requirement of revision surgery48 and increased readmission rates in cohorts over 85 years51 are concerning as more serious potential implications.
4.5 Functional recovery
Potential benefits of using day-zero ambulation as an intervention include a faster functional recovery and improved HRQoL.18,19 Several studies within the wider literature support the findings of a faster functional recovery, but lacked the scientific rigor to meet the inclusion criteria of this systematic review.24,34,52–54 None of these papers contradict the claims of the included studies of there being functional benefit to day-zero ambulation, particularly in the early post-operative phase.
5 Limitations
This systematic review had strict inclusion and exclusion criteria. Consequently, only a small number of studies reached the standards set for inclusion. While this approach limited this review to the highest quality evidence available, it meant there was limited information across several of the research questions set at the outset of this review, in particular in the domains of functional recovery and post-operative pain. Also as we reviewed only the published research base, limitations and biases within the publication process, must also apply to the findings of systematic reviews.
Of the papers included, four studies were inclusive of THA and TKA with results presented as one finding. Grouping THA and TKA together when considering the efficacy of day-zero ambulation appears non-scientific, given the significant differences in surgical procedure with likely different pain experiences, trauma, functional challenges and rehabilitation aims.
This problem is inherent in the wider published literature, where it appears that presenting conjoined findings for different types of arthroplasty is widely accepted. This approach is questionable as it may not provide specific enough findings to make robust clinical decisions for a particular arthroplasty group.
Within five of the seven included studies, there were concomitant interventions or changes to the experimental group pathways. These changes varied between studies but included interventions likely to have been significant confounding factors such as changes in surgical technique, anaesthetic protocol, post-operative analgesia and patient education. In these cases, the reported results cannot be confidently attributed solely to day-zero ambulation. Most studies published on this topic were not designed to isolate the efficacy of day-zero ambulation.
There was high heterogeneity in post-operative management across included studies. The Cochrane Handbook10 breaks down heterogeneity into clinical diversity or methodological diversity, of which there is evidence of both when examining this review's literature. Evidence is visible through the significant variability in control group outcomes. Using LOS as an example, one study reported a control group LOS of 7.8 days18 compared with 3.48 days in another.19 Indeed, this control group outperformed the intervention group LOS of 4.9 days.18 This suggests a significant difference in either the population examined or the methods of control group care delivery. In addition, amalgamating both THR and TKR results, and the use of concomitant interventions are clear potential causes of clinical diversity and methodological diversity respectively.
Much of the published research about day-zero ambulation following THR comes from studies using a fair or poor research design.5 Cross-sectional studies constituted 58 % of the identified literature; as such, this proportion of evidence did not provide any experimental comparison with standard care. This review only identified three empirical RCTs relevant to this topic, one of which was excluded for only examining TKA. Currently, there is a lack of studies using high-end methodologies that would be most visible and meaningful to front-line clinicians.
All the studies included within this systematic review reported LOS in terms of the mean. However, the mean is vulnerable to skewing from small numbers of patients with long hospital stays, something frequently seen in orthopaedic LOS data. This makes it a poor measure of central tendency in skewed datasets and violates the assumption of normal distribution associated with the parametric comparative testing used in these publications. McCulloch et al. recognised this problem and recommends using the median for reporting LOS for the above reasons.55
6 Conclusions
While studies included within this review claim positive effects of pathways including day-zero ambulation, limitations within the published literature lower confidence in attributing these effects directly to day-zero ambulation and in what effect sizes clinical services may expect if delivering day-zero ambulation to patient populations. In addition, there is a lack of evidence focused on how day-zero ambulation may affect post-operative pain.
From the findings synthesised within this systematic review, adopting day-zero ambulation in wider practice shows potential to reduce LOS, reduce costs and promote faster functional recovery. The literature suggests that this may be achievable without raising the risk of serious post-operative complications. However, included studies did not provide enough strength of evidence to allay fears of increasing the risk of periprosthetic infection and readmissions in older populations which have been reported in the wider literature.
Implementing day-zero ambulation with all patients would require service redesign and staffing investment. As such service leaders and decision-making clinicians need future high-quality research which focusses on THA only and gives greater confidence in the effect size to justify change.
Clinical messages
This literature base has problems of concomitant interventions, and an abundance of low-level research. There is further need for high quality prospective studies. This author recommends using a multi-centre RCT methodology inclusive of only THA participants to produce gold-standard empirical research on this topic.
Day-zero ambulation may reduce LOS and accelerate functional recovery however, heterogeneity across studies mean the size of the effect is unclear.
Further research is required on the effect of day-zero ambulation on the incidence of post-operative complications and pain.
Ethical approval
The study was approved by the Hampshire B research ethics committee and hospital research and development prior to commencement.
Funding
This research received no grant from any funding agency in the public, commercial or not-for-profit sectors.
Patient consent
Not applicable.
Conflicts of interest
The authors have no conflicts of interest in relation to this research to disclose.
CRediT authorship contribution statement
Christopher Efford: Conceptualization. Catherine Holdsworth: Acted as a reviewer within the systematic review. Margaret Donovan-Hall: Acted as an academic supervisor and reviewed the manuscript for intellectual content. Dinesh Samuel: Acted and an academic supervisor and reviewed and edited the manuscript for submission.
References
- A national review of adult elective orthopaedic services in England: getting it right first time. Br Orthop Assoc [Internet]. 2015 March:68.
- [Google Scholar]
- Getting it Right in Orthopaedics: REflecting on Success and Reinforcing Improvement - a follow-up report on the GIRFT national specialty report on orthopaedics. 2020
- [Google Scholar]
- Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6
- [Google Scholar]
- Evidence-based nursing practice: 7 steps to the perfect PICO search. EBSCO Heal CINAHL Comp.. 2004;35(3):309.
- [Google Scholar]
- CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. BMC Med. 2010;8(18)
- [Google Scholar]
- Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344-349.
- [Google Scholar]
- The Cochrane Collaboration. 2008;5:297-334.
- [Google Scholar]
- RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366
- [Google Scholar]
- The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011;343(7829)
- [Google Scholar]
- ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355(i4919)
- [Google Scholar]
- Risk-of-bias VISualization (robvis): an R package and Shiny web app for visualizing risk-of-bias assessments. 2021:55-61.
- [Google Scholar]
- A multidisciplinary total hip arthroplasty protocol with accelerated postoperative rehabilitation: does the patient benefit? Am J Orthop (Belle Mead NJ) [Internet]. 2014;43(4):178-181.
- [Google Scholar]
- Cost-effectiveness of accelerated perioperative care and rehabilitation after total hip and knee arthroplasty. J Bone Jt Surg. 2009 Apr 1;91(4):761.
- [Google Scholar]
- Outpatient total hip arthroplasty, total knee arthroplasty, and unicompartmental knee arthroplasty. JBJS Rev [Internet]. 2016;4(12):1.
- [Google Scholar]
- Accelerated perioperative care and rehabilitation intervention for hip and knee replacement is effective: a randomized clinical trial involving 87 patients with 3 months of follow-up. Acta Orthop [Internet]. 2008;79(2):149-159.
- [Google Scholar]
- Initiating physical therapy on the day of surgery decreases length of stay without compromising functional outcomes following total hip arthroplasty. Arch Orthop Trauma Surg. 2011;7(1):16-20.
- [Google Scholar]
- Day-of-Surgery mobilization reduces the length of stay after elective hip arthroplasty. J Arthroplasty [Internet]. 2016;31(10):2227-2230.
- [Google Scholar]
- Does accelerated physical therapy after elective primary hip and knee arthroplasty facilitate early discharge? Am J Orthoped. 2016;45(6)
- [Google Scholar]
- Predictors of hospital length of stay in an enhanced recovery after surgery program for primary total hip arthroplasty. J Arthroplasty. 2016 Oct 1;31(10)
- [Google Scholar]
- Effect of mobilization on the day of surgery after total hip arthroplasty in elderly, obese, and severely diseased patients. J Arthroplasty [Internet]. 2021;36(11):3686-3691.
- [Google Scholar]
- EuroQol - a new facility for the measurement of health-related quality of life. Health Policy (New York) [Internet]. 1990;16(3):199-208.
- [Google Scholar]
- The western ontario and McMaster universities osteoarthritis index (WOMAC): a review of its utility and measurement properties. Arthritis Rheum. 2001;45(5):453-461.
- [Google Scholar]
- Pathway-controlled fast-track rehabilitation after total knee arthroplasty: a randomized prospective clinical study evaluating the recovery pattern, drug consumption, and length of stay. Arch Orthop Trauma Surg [Internet]. 2012;132(8):1153-1163.
- [Google Scholar]
- Reduced short-term complications and mortality following Enhanced Recovery primary hip and knee arthroplasty: results from 6,000 consecutive procedures. Acta Orthop [Internet]. 2014;85(1):26-31.
- [Google Scholar]
- Enhanced recovery program for hip and knee replacement reduces death rate. Acta Orthop. 2011;82(5):577-581.
- [Google Scholar]
- Easily adoptable total joint arthroplasty program allows discharge home in two days. Can J Anaesth [Internet]. 2011;58(10):902-910.
- [Google Scholar]
- Newer anesthesia and rehabilitation protocols enable outpatient hip replacement in selected patients. Clin Orthop Relat Res. 2009;467(6):1424-1430.
- [Google Scholar]
- Fast-track hip and knee arthroplasty: clinical and organizational aspects. Acta Orthop Suppl [Internet]. 2012;83(346):1-39.
- [Google Scholar]
- A rapid recovery program after total hip arthroplasty. Curr Orthop Pract. 2010;21(4):381-384.
- [Google Scholar]
- Rapid mobilization decreases length-of-stay in joint replacement patients. Bull NYU Hosp Jt Dis.. 2013;71(3):222-226.
- [Google Scholar]
- Implementation of an accelerated mobilization protocol following primary total hip arthroplasty: impact on length of stay and disposition. Curr Rev Musculoskelet Med [Internet]. 2011;4(3):84-90.
- [Google Scholar]
- Why still in hospital after fast-track hip and knee arthroplasty? Acta Orthop. 2011;82:679-684.
- [Google Scholar]
- The efficacy of multimodal high-volume wound infiltration in primary total knee replacement in facilitating immediate post-operative pain relief and attainment of early rehabilitation milestones. Eur J Orthop Surg Traumatol. 2014;24(4):571-577.
- [Google Scholar]
- Effect of immediate postoperative physical therapy on length of stay for total joint arthroplasty patients. J Arthroplasty [Internet]. 2012;27(6):851-856.
- [Google Scholar]
- Fast track THR: one hospital's experience with a 2-day length of stay protocol for total hip replacement. HSS J. 2011;7(3):223-228.
- [Google Scholar]
- English Hospitals Can Improve Their Use of Resources: An Analysis of Costs and Length of Stay for Ten Treatments. 2012;78:44-48.
- [Google Scholar]
- Time-driven activity-based cost of fast-track total hip and knee arthroplasty. J Arthroplasty [Internet]. 2017;32(6):1747-1755.
- [Google Scholar]
- Same day total hip arthroplasty performed at an ambulatory surgical center: 90-day complication rate on 549 patients. J Arthroplasty [Internet]. 2017;32(4):1103-1106.
- [Google Scholar]
- Low risk of thromboembolic complications after fast-track hip and knee arthroplasty. Acta Orthop. 2010;81(5):599-605.
- [Google Scholar]
- Preoperative prediction of potentially preventable morbidity after fast-track hip and knee arthroplasty: a detailed descriptive cohort study. BMJ Open. 2016;6(1)
- [Google Scholar]
- Readmissions after fast-track hip and knee arthroplasty. Arch Orthop Trauma Surg. 2010;130(9):1185-1191.
- [Google Scholar]
- Subacute pain and function after fast-track hip and knee arthroplasty. Anaesthesia. 2009;64:508-513.
- [Google Scholar]
- Role of patient characteristics for fast-track hip and knee arthroplasty. Br J Anaesth [Internet]. 2013;110(6):972-980.
- [Google Scholar]
- Delirium in the fast-track surgery setting. Best Pract Res Clin Anaesthesiol [Internet]. 2012;26(3):345-353.
- [Google Scholar]
- Cognitive dysfunction after fast-track hip and knee replacement. Anesth Analg. 2014;118(5):1034-1040.
- [Google Scholar]
- A trend for increased risk of revision surgery due to deep infection following fast-track hip arthroplasty. Adv Orthop. 2016;2016
- [Google Scholar]
- Rapid recovery protocols for primary total hip arthroplasty can safely reduce length of stay without increasing readmissions. J Arthroplast [Internet]. 2015;30(4):521-526.
- [Google Scholar]
- Postoperative morbidity and discharge destinations after fast-track hip and knee arthroplasty in patients older than 85 years. Anesth Analg. 2016;122(6):1807-1815.
- [Google Scholar]
- The first 6 weeks of recovery after primary total hip arthroplasty with fast track: a diary study of 94 patients. Acta Orthop. 2017;88(2):140-144.
- [Google Scholar]
- Rehabilitation implications during the development of the Norwich Enhanced Recovery Programme (NERP) for patients following total knee and total hip arthroplasty. Orthop Traumatol Surg Res [Internet]. 2012;98(5):499-505.
- [Google Scholar]
- Does walking the day of total hip arthroplasty speed up functional independence? A non-randomized controlled study. Arch Physiother. 2020;10(1)
- [Google Scholar]
- Hierarchy of evidence: a framework for ranking evidence evaluating healthcare interventions. J Clin Nurs [Internet]. 2003 Jan 1;12(1):77-84.
- [Google Scholar]