Setting, Clinical Pathways, Fast-Track and Rehabilitation FollowingPrimary Knee Arthroplasty: A Literature Review

In view of the high incidence of total knee replacements, it is important to identify the most efficient yet cost- effective rehabilitation program, in order to optimize patient care within the constraints of the National Healthcare System. This paper aimed at reviewing the literature on post-acute Total Knee Replacement (TKR) rehabilitation discharge setting, and on the strategies for early discharge of TKR patients from orthopedic wards. Research studies on the effectiveness of rehabilitation in intensive rehabilitation care, skilled nursing facilities, home rehabilitation, fast-tracks, enhanced recovery and clinical pathways in total knee replacement patients have been reviewed. Length of stay following knee arthroplasty is influenced by the following factors: age, sex, marital status, co-morbidity, preoperative use of walking aids, pre and postoperative hemoglobin levels, the need for blood transfusion, ASA (American Society of Anesthesiologists) score and time between surgery and mobilization. Clinical pathways and fast tracks seem to be effective in reducing length of stay without increasing clinical complications. However, despite the vast quantity of literature available, results remain inconclusive. There is no clear evidence supporting an algorithm for the optimal rehabilitation management after total knee replacement. Beside the question of which setting or path is preferable in terms of organization, the review enlightens that it is relevant also gaining a deeper understanding of the most important predictors of the best outcomes. There is a need to review criteria for admitting total knee arthroplasty patients to intensive rehabilitation, to start a "fast- track" protocol, to build "Clinical Pathways" and to discharge patients to home rehabilitation.