PURPOSE: The purpose of this project was to study the length of the hospital stay (LOS) in relation to a new multimodal pain strategy for patients undergoing elective hip and knee arthroplasty. Usual discharge criteria were used: independence in ambulation and transfers, independence in toileting and dressing, and pain medication with only oral analgesics.

RELEVANCE: Current efforts focus to shorten the LOS and improve pain management. However, a decreased LOS has to ensure restoration of functional ability to the same level achieved with traditional LOS. Accordingly a description of the content and amount of physiotherapy is required. This study is the first step towards developing guidelines for future physiotherapy for patients with hip or knee arthroplasty.
DESCRIPTION: Material: Sixteen patients with unilateral, total hip arthroplasty (THA) and sixteen patients with unilateral, total knee arthroplasty (TKA) were consecutively included from an orthopaedic department, specialized in arthroplasty operations. Age (years), mean (min-max) THA: 64(40-77), TKA: 66(28-86), sex (male/female), THA: 8/8, TKA: 2/14, weight (kg) mean (min-max) THA: 78.3(78.1-101), TKA: 79.9(44-125).
Method: Preoperatively all patients attended a multidisciplinary information meeting. They were operated in spinal anaesthesia supplemented with local wound analgesic injections used peri- and postoperatively for 24 hours, subsequently gabapentin, paracetamol and a COX-2 inhibitor, followed by standardized oral medication.
Patients started mobilisation on the day of the operation with further physiotherapy the following days, including transfer and ambulation training, and specific joint and muscle exercises. In connection with all activities, pain scores were assessed, using a Visual Analog Scale (VAS). All patients underwent the "Timed Up & Go" test, a test for functional mobility. Patients were discharged according to criteria mentioned above and were asked to evaluate the quality of the hospital stay.

EVALUATION: LOS was decreased for the THA patients from an already accelerated track of 3.8 days to 3.1 days, and for TKA patients from 3.9 to 3.5 days. At day one (day of operation) 28 of the 32 patients were able to walk with a walking aid. At the day of discharge patients used crutches as walking aids.
Pain registered with VAS in connection with transfer showed a mean score of 3.2 at day one, reduced at discharge to 2.5 for THA, and for TKA from 5.0 to 3.6. Gait VAS mean score for THA was 2.8 at day one, reduced to 1.9 at discharge, and for TKA from 5.2 to 2.4.
The TUG test for THA showed a mean value of 27.4 sec. at day two, reduced at discharge to 21.0 sec. For TKA from 31.3 to 22.0 sec.
At discharge patients scored mean nine out of possible ten points regarding their satisfaction with the entire stay including LOS.
CONCLUSIONS: These results demonstrate, that LOS can be shortened without reducing the quality of the hospital stay. Further studies conducted as randomized controlled trials, including follow-up after rehabilitation are needed.

IMPLICATIONS: Due to the short LOS goals and guidelines for outpatients physiotherapy treatment including functional tests and outcome measurements are needed.