Assessing early postoperative recovery following lower limb joint replacement

Improving perioperative recovery is critical to enhance patient care, ensure timely discharge from the patient, clinician and hospital perspective and improve short and long-term outcomes after surgery. A systematic review was performed examining tools for early post-operative recovery after elective lower limb joint replacement. It showed that no fully-validated, patient-reported tools existed. Currently used measures included pain scores, opioid usage, length of stay and surgical satisfaction. In order to address this need, a patient-reported outcome measure (PROM) and change measure for use in the first six weeks following surgery have been developed. A five-phased, best practice, iterative approach was used. Planning Phase - Qualitative interviews (n=22) were performed with orthopaedic healthcare professionals, ascertaining if and how clinicians would use such a PROM. These helped determine the views of potential users, and guide structure and layout. Phase One - Qualitative patient-interviews (n=30) from the day of surgery to nine weeks postoperatively were completed. Analysis of these interviews identified important patient-reported factors in early recovery. Phase Two - The factors provided from Phase One interviews were used to find questionnaire themes. Items were then generated and pilot questionnaires developed. Items were tested and refined in the context of cognitive debrief interviews (n=34) for potential inclusion in the final tools. Phase Three - Final testing of questionnaire properties with item reduction (n=168). The Oxford Arthroplasty Early Recovery Score (OARS) is a 14-item PROM measuring health status at the time of testing. The Oxford Arthroplasty Early Change Score (OACS) is a 14-item measure to assess change. Phase Four - Validation: The OARS and OACS were administered to consecutive patients (n=155) in an independent cohort. Validity and reliability were assessed. Psychometric testing showed positive results, good validity and sensitivity to change. The OARS and OACS were then utilised in a pilot study to assess the feasibility of day case treatment. Inpatient (n=29) and day-case (n=26) unicompartmental knee arthroplasty (UKA) patients completed the two measures, and the results confirmed that day case treatment and discharge is a valid option. The work completed in this thesis will now enable these newly developed scores to be used to define and assess an optimal-recovery protocol for lower limb joint replacement.