Enhanced Recovery in Hip and Knee Arthroplasty: Findings from a Swiss Quasi-Experimental Orthopaedic Study

Enhanced Recovery in Hip and Knee Arthroplasty: Findings from a Swiss Quasi-Experimental Orthopaedic Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Enhanced Recovery in Hip and Knee Arthroplasty: Findings from a Swiss Quasi-Experimental Orthopaedic Study Paulo Sousa, Muriel Nirina Maeder, Andrei Zaporojanu, Daniel Castro Reina, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7955804/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Enhanced recovery protocols (ERPs) are designed to accelerate postoperative recovery and reduce hospital length of stay (LoS). Among ERP components, early mobilization plays a pivotal role in improving functional outcomes, reducing complications, and enhancing patient satisfaction. However, most evidence originates from large tertiary centers, leaving uncertainty about the feasibility and impact of such interventions in smaller hospitals with more limited resources. This study aimed to evaluate whether implementing a structured early mobilization protocol could reduce LoS and improve functional recovery after total knee (TKA) and total hip arthroplasty (THA) in a Swiss peripherical hospital. Methods A quasi-experimental pre/post study was conducted at a single orthopedic unit as a retrospective analysis of a practice change. Adults undergoing elective unilateral TKA or THA were included. Exclusion criteria were bilateral procedures, major postoperative complications or impairing mobilization. Patients operated before April 2021 received standard postoperative care, while those treated from November 2021 onwards followed the ERP. The ERP emphasized early mobilization and optimized perioperative analgesia, including preoperative education, physiotherapy, minimally invasive techniques, periarticular local infiltration, and replacement of femoral nerve blocks with adductor canal blocks. Physiotherapist-led mobilization began within 4–6 hours postoperatively, with walking and stair climbing on day one. The primary outcome was hospital LoS. Secondary outcomes were time to cane use, unaided ambulation, stair climbing, knee flexion at discharge (for TKA), and reported pain. Statistical analyses included non-parametric tests and chi-square comparisons, as appropriate. Additionally, linear multivariable regression and linear mixed-effects models were applied to examine associations between the intervention and key outcomes, adjusting for potential confounders and repeated measures. Results Patients in the intervention group had a significantly shorter median LoS compared to the control group (4 vs. 5.5 days, P < 0.01). The enhanced protocol was significantly associated (P < 0.01) with earlier achievement of functional milestones, including cane use, stair climbing, and attainment of adequate knee flexion. Improvements among THA patients were more modest. Multivariable modeling identified sex, age, and body mass index as significant predictors of recovery outcomes. No significant reduction in pain was observed. Conclusions ERP implementation was associated with shorter hospitalization and faster functional recovery, particularly after TKA. These findings support integrating structured early mobilization pathways to improve outcomes and efficiency, especially in smaller hospitals where reduced LoS can optimize bed occupancy and resource use. Rehabilitation Arthroplasty Replacement Hip Arthroplasty Replacement Knee Figures Figure 1 Figure 2 Background Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are considered the standard surgical interventions for advanced osteoarthritis of the knee and hip, respectively, particularly when conservative treatments fail and patients experience significant functional limitations. These procedures are among the most effective and well-established in orthopaedic practice, with substantial evidence supporting their ability to restore joint function and improve quality of life [ 2 , 13 , 16 , 17 ] Concerning THA, a meta-analysis encompassing 20 studies (n > 1,000 patients; mean follow-up 7 years) demonstrated significant improvements in the Harris Hip Score, as well as in the pain and function domains of the Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) ( P < 0.01), with additional gains reported in Short Form-36 Health Survey (SF-36) scores ( P < 0.01) [ 17 ]. For TKA, a meta-analysis of 72 high-quality studies with follow-up periods extending up to 5 years revealed early and sustained functional improvements, with substantial gains observed as early as 3 to 6 months postoperatively and maintained through five years [ 14 ]. Furthermore, the frequency of these procedures is notable: in high income countries, the average rate of THA reached 191.5 per 100,000 population in 2018 [ 7 ], and 150 per 100,000 for TKA in 2011 [ 15 ]. This high utilization has driven continuous technical and scientific progress. From a surgical perspective, navigation-assisted arthroplasty has been shown to significantly reduce prosthetic malalignment [ 24 ]. Advances in anaesthesia, such as periarticular local infiltration combined with adductor canal blocks (ACB) in TKA [ 10 ], have improved postoperative analgesia and facilitated earlier mobilization. Similarly, in THA, periarticular infiltration has been associated with reduced postoperative pain and decreased opioid consumption [ 12 ]. These advancements have contributed to the development of Enhanced Recovery After Surgery (ERAS) protocols, which aim to accelerate functional recovery and shorten hospital stays [ 21 – 23 ]. Reducing postoperative length of stay (LoS) is clinically relevant, as prolonged immobilization increases the risk of thromboembolic events [ 4 ], and extended hospitalization is associated with a higher risk of nosocomial infections [ 8 ]. Additionally, shorter LoS may contribute to substantial cost savings. We developed an Enhanced Recovery Protocol (ERP) inspired by existing ERAS framework, focusing on early mobilization, optimized perioperative analgesia, and reduced LoS. The protocol was structured around key components supported by the literature, including preoperative therapeutic education and physiotherapy when needed, advances in surgical techniques such as navigation-assisted knee arthroplasty and minimally invasive anterior approaches for hip replacement, and the use of periarticular local infiltration for both procedures. Additionally, we replaced femoral nerve blocks (FNB) with ACB to preserve motor function and facilitate early rehabilitation. A central feature of the protocol was early mobilization by physiotherapists, beginning with assisted standing 4 to 6 hours after surgery and progressing to walking and stair climbing by postoperative day one. Reducing LoS is particularly relevant for peripherical hospitals, where optimizing postoperative recovery has direct implications for both care quality and resource management. A shorter hospital stay after joint arthroplasty can translate into substantial cost savings and more efficient bed utilization, reducing strain on inpatient capacity. At the same time, earlier discharge allows patients to resume daily activities and work sooner, improving perceived quality of care and overall satisfaction. However, most evidence on enhanced recovery protocols originates from large tertiary centers, where dedicated multidisciplinary teams and high patient volumes facilitate protocol implementation. Therefore, the primary objective of this study was to evaluate whether the implementation of the ERP reduced the LoS following TKA or THA compared with the standard protocol in a peripherical hospital in Switzerland. Secondary objectives were to assess recovery trajectories in terms of mobility and postoperative pain, and to compare outcomes between the two protocols. Methods We conducted a retrospective analysis of a practice change, designed as a quasi-experimental pre/post intervention study, at the single orthopaedic unit of St-Imier hospital involving patients undergoing elective total knee arthroplasty (TKA) or total hip arthroplasty (THA). Participants were allocated to either a control group, consisting of patients who underwent surgery prior to April 2021 and received standard postoperative care, or an intervention group, comprising patients who underwent surgery from November 2021 onwards and were managed according to the newly implemented ERP. Our research was granted an exemption from full ethical review by the local Ethics Committee (Canton of Bern, Switzerland) and conforms to Helsinki Declaration. Sample size The sample size was estimated for the primary outcome, hospital length of stay (LoS). Assuming a two-sided α = 0.05, 80% power, an allocation ratio of approximately 2.6:1 (control:intervention), and a common standard deviation (SD) of 2.5 days, detecting a 1.5-day difference in LoS between groups would require approximately 110 patients (79 in the control group and 31 in the intervention group). To detect a smaller difference of 1.0 day, approximately 246 patients (178 control and 68 intervention) would be required. Selection Criteria Eligible patients were aged 18 years or older and scheduled for elective unilateral TKA or THA. Patients undergoing bilateral joint arthroplasties or those who experienced major postoperative complications affecting mobilization – such as revision surgery or surgical site infection – were excluded. Intervention The ERP group followed a structured program that differed from conventional care in several ways. In the month preceding surgery, patients were required to attend a multidisciplinary group session led by the case manager and a physiotherapist, focusing on preoperative education and therapeutic preparation. On the day of surgery ( Day 0 ), patients were admitted directly to the orthopaedic ward. Anaesthesia protocols were tailored to the type of arthroplasty. TKA patients received either general or spinal anaesthesia, supplemented with an ACB and periarticular local infiltration. For THA, general anaesthesia was recommended, although spinal anaesthesia was also permitted; in both cases, local infiltration was applied. Postoperatively, patients were provided with a printed rehabilitation plan at discharge. Physiotherapists initiated early mobilization, beginning with the first mobilization (sitting or standing) 4 to 6 hours after surgery. Ambulation was encouraged either later the same day or the following morning. Stair climbing was targeted for the first postoperative day, depending on the patient's condition. A schema of the ERP program is summarized in Fig. 1 . All surgeries were performed by fellowship-trained arthroplasty surgeons. Outcome Measures The primary outcomes of interest included postoperative LoS in days, time to use of a cane (TCU, in days), time to time to first unaided ambulation (TFUA, in days), time to stair climbing (TSC, in days), and, for TKA patients, knee flexion at discharge (KFD, in days). As secondary outcomes, we assessed the degree of knee flexion achieved at discharge, categorized into four ranges: 60–69°, 70–79°, 80–89°, and 90° and pain levels, assessed twice a day (morning and afternoon) during hospitalization using a 0–10 numeric rating scale. To ensure that observed differences were attributable to the ERP rather than to unrelated practice changes, we reviewed perioperative procedures, anaesthesia techniques, and discharge criteria across the study period. Data Analyses Continuous variables were summarized as medians with interquartile ranges (IQR) or as means with standard deviations (SD), depending on their distribution (non-parametric or parametric), and compared using the Wilcoxon rank-sum test or the independent t-test, respectively. Categorical variables were compared using the chi - square test or Fisher’s exact test, as appropriate. A two-sided P -value < 0.05 was considered statistically significant. Furthermore, for the main outcomes (length of stay, time to first ambulation, cane use, stair climbing, and knee flexion) we conducted multivariable linear regression analyses adjusted for age, sex, body mass index (BMI), comorbidities (Charlson Comorbidity Index, CCI), and the American Society of Anesthesiologists Physical Status Classification System (ASA-PSCS). Model assumptions, including linearity, normality of residuals, and homoscedasticity, were verified through residual plots and statistical tests. Model fit was evaluated using the adjusted R² and Akaike Information Criterion (AIC), with lower AIC and higher adjusted R² values indicating better fit. Competing models were compared following the principle of parsimony, retaining the model with the best explanatory power and clinical plausibility. Pain trajectories were analyzed separately for THA and TKA patients using linear mixed-effects models with fixed effects for group (intervention vs control), day, and their interaction, and random intercepts for individual patients to account for repeated measures. Model adequacy was assessed by examining residual distributions, Q–Q plots, and conditional and marginal R² values. Model fit and parsimony were compared using the AIC, with lower values indicating a better fit. Estimated marginal means and between-group contrasts at each time point were computed using the emmeans package [ 9 ]. All statistical analyses were performed using R statistical software [ 9 ]. Results Demographics A total of 196 patients underwent 206 surgical operations. 149 (72.3%) were managed under the previous protocol (considered here as the “control group”), and 57 (27.7%) under the newly implemented ERP (considered here as the “intervention group”). In the control group (December 2019 to March 2021), 77 patients (51.7%) underwent THA and 72 (48.3%) TKA. In the intervention group (November 2021 to March 2023), 27 patients (47.4%) underwent THA and 30 (52.6%) TKA. Ten patients underwent two procedures, typically one knee followed by the second after approximately one year. Table 1 summarizes the characteristics of the sample, highlighting differences in sex, age, body mass index, and CII. Table 1 Patients’ characteristic Intervention Control P -value Women, n (%) 31 (54.4) 63 (42.3) 0.16 THA 27 (47.4) 77 (51.7) 0.69 TKA 30 (52.6) 72 (48.3) 0.71 Age (per year), median (IQR) 70 (62–77) 69 (61–76) 0.78 BMI (kg/m²), median (IQR) 30.1 (26-33.5) 30 (24.4–33.1) 0.43 ASA-PSCS, n (%) 0.97 1 5 (8.8) 13 (8.7) 2 38 (66.6) 97 (65.1) 3 14 (24.6) 35 (23.5) Unknown 0 (0) 4 (2.7) CII, n (%) 0.83 0 28 (49.0) 76 (51.0) 1 16 (28.0) 35 (23.0) 2 5 (8.8) 16 (11.0) 3 4 (7.0) 9 (6.0) > 3 4 (7.0) 13 (8.7) ASA-PSCS = American Society of Anesthesiologists Physical Status Classification System BMI = Body Mass Index CII = Charlson comorbidity index IQR = Interquartile range THA = Total Hip Arthroplasty TKA = Total Knee Arthroplasty Length of Stay (LoS) Median LoS was significantly shorter in the intervention group (4 days, IQR: 3–5.5) compared to the control group (5.5 days, IQR: 4–7.5; P < 0.01). However, when analyzed by type of arthroplasty, the difference was statistically significant only for TKA, with the intervention group showing a markedly shorter stay (4 vs. 7.5 days; P < 0.01). The final model (Adj. R² = 0.22) included sex, BMI, age, and intervention. Male patients and those in the intervention group had significantly shorter stays, while increasing age and BMI were associated with longer hospitalizations. Time to Cane Use (TCU) Time to assisted walking with canes was significantly shorter in the intervention group (0.5 days, IQR: 0.5–1.5) vs. control (1.5 days, IQR: 1–3; P < 0.01) for both THA and TKA patients. The model (Adj. R² = 0.25) included the same predictors as for LoS. Again, male sex and intervention predicted faster use of a cane, while older age and higher BMI were associated with delays. Time to First Unaided Ambulation (TFUA) First postoperative ambulation occurred slightly earlier in the intervention group (0.5 days, IQR: 0–0.5) than in the control group (0.5 days, IQR: 0.5–1; P < 0.01). However, among THA patients, this difference was not statistically significant ( P = 0.4). The final model (Adj. R² = 0.09) retained sex, BMI, and intervention, but age was not included. Intervention and male sex were significantly associated with earlier ambulation, while BMI predicted delays. However, the association with intervention did not reach statistical significance ( P = 0.13). Time to stair climbing (TSC) Time to stair climbing was significantly shorter in the intervention group (1 day, IQR: 1–2) vs. control (3 days, IQR: 1.5–4; P < 0.01). For THA, the intervention group climbed stairs earlier (1 day, IQR: 0.75–1.25) than the control group (1.75 days, IQR: 1.1–3; P < 0.01). For TKA, stair climbing occurred at 2 days (IQR: 1.5–3) vs. 4 days (IQR: 3.4–4.5; P < 0.01). The best-fitting model (Adj. R² = 0.33) included intervention, sex, BMI, and age, all of which were significant predictors. Intervention and male sex were associated with faster stair climbing; older age and higher BMI predicted delays. Knee Flexion at Discharge (KFD) Among TKA patients, time to achieve acceptable passive knee flexion was significantly shorter in the intervention group (1.5 days, IQR: 1.5–3) vs. control (4.5 days, IQR: 4–5.5; P < 0.01). At discharge, 90° of knee flexion was reached by 75% of control patients (54/72) and 57% of intervention patients (17/29) ( P = 0.16). Although the distribution across angle categories was slightly different between groups, there was reasonable no evidence of a real effect ( P = 0.21) (Table 2 ). Table 2 Knee flexion milestones at discharge in total knee arthroplasty patients Arm 60–69° 70–79° 80–89° 90° P -value Control (n = 72) 2 (2.8%) 4 (5.6%) 12 (16.7%) 54 (75.0%) 0.21 Intervention (n = 29) 2 (6.9%) 1 (3.4%) 9 (31.0%) 17 (58.6%) Total n = 101 4 (4.0%) 5 (5.0%) 21 (20.8%) 71 (70.3%) A parsimonious model (Adj. R² = 0.32) with only sex and intervention was sufficient to explain variation in flexion degree. Neither BMI nor age contributed significantly and were excluded from the final model. Table 3 provides a summary of the bivariate analysis for the main outcomes Table 3 Summary of the bivariate analysis for the main outcomes Outcome Arm n Day Day P -value Test Min-Max Median (IQR) LoS Control 149 2–14 5.5 (4-7.5) < 0.01 Wilcoxon rank sum test Intervention 57 2.5–11.5 4 (3-5.5) THA Control 77 2-13.5 4 (3–6) 0.13 Wilcoxon rank sum test THA Intervention 27 2.5–11.5 3.5 (3–5) TKA Control 72 2.5–14 7.5 (5–8) < 0.01 Wilcoxon rank sum test TKA Intervention 30 2.5–10.5 4 (3.5-6) TCU Control 142 0.5–12.5 1.5 (1–3) < 0.01 Wilcoxon rank sum test Intervention 22 0.5–3.5 0.5 (0.5–1.5) THA Control 75 0.5–12.5 1 (0.5-2) < 0.01 Wilcoxon rank sum test THA Intervention 12 0.5-2 0.5 (0.5–0.5) TKA Control 67 1–7 2.5 (1.5-4) < 0.01 Wilcoxon rank sum test TKA Intervention 10 0.5–3.5 1.25 (0.6–1.5) TFUA Control 147 0-5.5 0.5 (0.5-1) < 0.01 Wilcoxon rank sum test Intervention 57 0-2.5 0.5 (0-0.5) THA Control 76 0–2 0.5 (0-0.5) 0.4 Wilcoxon rank sum test THA Intervention 27 0-0.5 0.5 (0-0.5) TKA Control 71 0-5.5 0.5 (0.5-1) < 0.01 Wilcoxon rank sum test TKA Intervention 30 0-2.5 0.5 (0-0.5) TSC Control 138 0.5-9 3 (1.5-4) < 0.01 Wilcoxon rank sum test Intervention 21 0.5–3.5 1 (1–2) THA Control 70 0.5-8 1.75 (1.1-3) < 0.01 Wilcoxon rank sum test THA Intervention 11 0.5-2 1 (0.75–1.25) TKA Control 64 1–9 4 (3.4–4.5) < 0.01 Wilcoxon rank sum test TKA Intervention 9 1-3.5 2 (1.5-3) KFD (TKA) Control 64 1.5-8 4.5 (4-5.5) < 0.01 Wilcoxon rank sum test Intervention 9 1.5-4 1.5 (1.5-3) KFD = Knee Flexion at Discharge LoS = Length of Stay TCU = Time to Cane Use TFUA = Time to First Unaided Ambulation THA = Total Hip Arthroplasty TKA = Total Knee Arthroplasty TSC = Time to Stair Climbing Across all models, male sex and participation in the intervention were consistently associated with faster recovery, whereas higher BMI and older age were generally associated with delayed recovery. Neither ASA-PSCS nor CII emerged as significant predictors in any model. A summary of the linear regression models (Best Subset/Stepwise) for each outcome is presented in Table 4 . Table 4 Summary of Linear Regression Models (Best Subset/Stepwise) for Each Outcome Predictors Length of Stay (LoS) Time to Cane Use (TCU) Time to First Unaided Ambulation (TFUA) Time to Stair Climbing (TSC) Knee Flexion at Discharge (KFD) Adjusted R² 0.22 0.25 0.09 0.33 0.32 Treatment Arm Control Reference Reference Reference Reference Reference Intervention –1.70 ** –2.57 *** –0.41 (p = 0.13) –3.64 *** –5.71 *** Sex Women Reference Reference Reference Reference Reference Men –1.09 ** –1.60 *** –0.57 ** –1.80 *** –2.30 *** Age (per year) 0.08 *** 0.06 ** Not in model 0.08 *** Not in model BMI (kg/m²) 0.14 *** 0.17 *** 0.05 ** 0.23 *** Not in model *P < 0.05; **P < 0.01; *** P < 0.001; BMI = Body Mass Index Pain levels at discharge Patients in the intervention group reported lower pain scores at discharge (median 0.78, IQR: 0.31–1.27) compared to the control group (1.0, IQR: 0.48–1.63; P = 0.07). Among THA patients, scores were 0.62 (IQR: 0.20–1.12) vs. 0.71 (IQR: 0.38–1.57; P = 0.13), and for TKA, 1.0 (IQR: 0.6–1.31) vs. 1.21 (IQR: 0.8–1.8; P = 0.19) (Table 4 ). Table 5 Pain levels at discharge in total hip arthroplasty and total knee arthroplasty patients Arm Operation n (%) Median (IQR) P -value Control 149 (72.3) 1.0 (0.48–1.63) 0.07 Intervention 57 (27.7) 0.78 (0.31–1.27) Control THA 77 (80.1) 0.71 (0.38–1.57) 0.13 Intervention THA 27 (19.9) 0.62 (0.2–1.12) Control TKA 72 (70.6) 1.21 (0.8–1.8) 0.19 Intervention TKA 30 (29.4) 1.0 (0.6–1.31) THA = Total Hip Arthroplasty TKA = Total Knee Arthroplasty Pain evolution was analyzed separately for THA and TKA patients. For THA patients (n = 1,006 observations, 99 patients), pain varied significantly over time ( P < 0.01), peaking on postoperative day 1 and declining thereafter. Age was negatively associated with pain (β = − 0.02, P = 0.02). No significant main effect of group or consistent group × day interaction was observed. However, on day 0 afternoon, the intervention group reported significantly lower pain (estimate = − 1.45; P = 0.03), with non-significant trends favoring the intervention group at other time points. For TKA patients (n = 803 observations, 99 patients), pain also declined over time, with no significant group effect (β = 0.10, P = 0.79) or consistent interactions. Still, pain was significantly lower in the intervention group on day 2 afternoon (estimate = − 3.07; P < 0.01), and a trend was noted on day 5 afternoon (estimate = − 2.58; P = 0.07). The evolution of pain over time in THA and TKA patients is graphically illustrated in Fig. 2 . Discussion This study evaluated the impact of an ERP on key postoperative outcomes among patients undergoing TKA and THA. Our results suggest that this intervention was associated with earlier discharge, faster recovery milestones, and reduced use of assistive devices, especially among TKA patients. Surgical staffing, implant types, and rehabilitation resources remained consistent throughout the study. Patients managed under the ERP had a significantly shorter hospital length of stay (LoS) compared with controls (β = − 1.70, p < 0.01), corresponding to a median reduction from 7.5 to 4 days after TKA. This reduction may be attributed to the change in the anaesthesia protocol from FNB to ACB, combined with periarticular local infiltration. ACB provides effective pain relief while preserving quadriceps strength, thus facilitating earlier mobilization and reducing the need for extended hospital stays. This finding is consistent with the study by Li et al. [ 10 ] which demonstrates that ACB combined with periarticular injections can accelerate recovery following TKA by improving early postoperative ambulation and reducing the need for opioid-based pain management. This shift in anaesthesia techniques likely played a significant role in the enhanced recovery outcomes observed in the intervention group. Improvements were also observed in the time to first use of canes, and stair climbing, with consistent and statistically significant advantages for the intervention group. These findings might be justified not only by the changes in the anaesthesia protocol and surgical procedure, but also by the introduction of a preoperative education session on ambulation, use of walking aids and stair climbing conducted by the physiotherapist. This is supported by the findings of Vasileiadis et al. [ 20 ] who conducted a systematic review on this subject and found that several trials demonstrate that preoperative physiotherapy interventions improve functional performance for patients shortly after TKA. While ambulation time and pain scores did not differ significantly, a favorable trend for lower pain and earlier mobilization was consistently observed in the intervention group. The linear regression analyses confirmed the beneficial effect of the intervention, independently of sex, BMI, and age. In all models, participation in the ERP group was associated with improved outcomes, particularly regarding discharge timing, cane use, stair climbing, and passive knee flexion. These findings agree with similar protocols overall. Meta-analyses have found that patients on ERAS pathways go home 2 days earlier on average than those on standard protocols [ 3 ]. A randomized clinical trial suggests that ERAS patients achieve mobility milestones sooner than those under standard care [ 5 ]. On this study, ERAS group showed significantly better Timed Up-and-Go test times, longer walking distances, and more stairs climbed in the first week after surgery. Men were generally associated with better recovery across indicators, while higher BMI and older age tended to predict longer recovery durations. These findings are in line with those obtained by other authors [ 11 ], suggesting that women experience worse knee function preoperatively but with greater improvement in pain relief and physical function at 3 and 6 months after standard TKA. Concerning BMI, Järvenpää et al. [ 6 ] found that obese patients had a worse postoperative range of motion (averaging 110° flexion vs. 118° in non-obese, P < 0.01) as well as a higher rate of complications (e.g. wound issues) at a 3 month follow up of TKA patients. In THA populations, obesity has similarly been linked to slower inpatient recovery and rehab progress. A study found that in the acute postoperative period, morbidly obese patients trended towards increased hospital LoS [ 1 ]. Advanced age has been found to be associated with a slower recovery in other studies as well. Data from a rehabilitation study on hip replacements [ 22 ] showed that patients ≥ 85 years old had significantly lower gains in functional independence compared to younger patients. These octogenarian patients had longer hospital stays, lower improvement in functional independence measures and were less likely to regain independence to the point of returning home directly after surgery. Together, these findings highlight the effectiveness of the ERP in accelerating recovery without compromising safety. The improvements were especially notable in patients undergoing TKA, suggesting that this subgroup may benefit the most from structured early recovery protocols. Furthermore, although this study does not aim to provide a detailed cost-benefit analysis, by estimating the average cost of hospitalization in Switzerland at approximately USD 2,300–2,900 per day [ 18 ], we estimate that the new rehabilitative approach led to an average savings of around USD 1,150–1,450 per patient for THA and USD 8,000–10,000 per patient for TKA. Study Limitations A notable strength of the present study is the inclusion of multiple objectives and clinically meaningful indicators of postoperative functional recovery, such as time to ambulation, stair climbing, and attainment of adequate knee flexion. This multidimensional assessment offers a more comprehensive evaluation of early rehabilitation outcomes beyond the sole measure of hospital length of stay. Nevertheless, several limitations warrant consideration. The quasi-experimental, non-randomized design entails a risk of selection bias and residual confounding, which may limit the strength of causal inferences. We attempted to mitigate these risks through statistical adjustments, including multivariable modeling for observed confounders. While the overall sample provided > 95% power to detect the observed 1.5-day reduction in length of stay (primary outcome), the THA subgroup had ~ 80% power only for differences ≥ 1.3 days, leaving it underpowered for the smaller effect observed. The temporal separation of control and intervention groups may also have introduced bias; however, all outcomes were assessed by the same clinical staff, and no institutional policy changes occurred during the study period, which likely minimized this risk. Moreover, our analysis was limited to early postoperative outcomes and did not address longer-term recovery, complications, or readmissions. Finally, the single-center design restricts external validity, and further studies in diverse clinical settings are needed to confirm generalizability. Conclusions This study demonstrates that early mobilization significantly enhances postoperative recovery following total knee arthroplasty, with patients reaching key rehabilitation milestones and discharge readiness earlier. Although effects were less pronounced in THA, similar trends were observed. Despite limitations, including a non-randomized design and small sample size, the findings support the feasibility and clinical value of structured early mobilization. These protocols may reduce hospital stay, optimize resource use, and improve functional outcomes. Additionally, substantial cost savings require further investigation through cost-effectiveness analyses in larger, controlled studies. Further randomized studies are warranted to confirm these results and explore long-term benefits. Abbreviations ACB Adductor Canal Blocks ASA-PSCS American Society of Anesthesiologists Physical Status Classification System BMI Body Mass Index CII Charlson Comorbidity Index ERP Enhanced Recovery Protocol ERAS Enhanced Recovery After Surgery FNB Femoral Nerve Block KFD Knee Flexion at Discharge LoS Length of Stay TCU Time to Use of a Cane TFUA Time to First Unaided Ambulation THA Total Hip Arthroplasty TKA Total Knee Arthroplasty TSC Time to Stair Climbing WOMAC Western Ontario and McMaster Universities Osteoarthritis index Declarations Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki and approved by the local Ethics Committee (Canton of Bern, Switzerland; reference number Reg-2025-00732). This study does not qualify as a clinical trial. It is a pre/post quasi-experimental study conducted to compare two perioperative protocols implemented sequentially as part of routine clinical practice for all eligible patients at the hospital of St-Imier. As such, the study was exempted from ethical review by the Cantonal Ethics Committee of Bern. Thus, Clinical trial number is not applicable. Moreover, given the retrospective nature of the analysis and the use of anonymized data from routine clinical practice, the requirement for individual informed consent was waived by the Ethics Committee. Consent for publication Not applicable, as the manuscript does not contain any individual person’s data in any form (including images, videos, or case details). Availability of data and materials The datasets generated and/or analyzed during the current study are publicly available in the Zenodo repository at https://doi.org/10.5281/zenodo.17453408 Competing interests The authors declare that they have no competing interests related to this work. Acknowledgements The authors deeply thank all patients, physiotherapists and medical staff who participated in this project. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The research was supported by internal funds of the hospital. Conflict of Interest The authors declare that they do not have any conflicts of interests. Author Contributions PS: conceptualization, methodology, investigation, writing – original draft AB: writing – original draft, data curation, formal analysis, validation (final approval of the published version) MNM: writing – review and editing, validation (final approval of the published version) AK: funding acquisition, validation (final approval of the published version) AZ: methodology, investigation, validation (final approval of the published version) DCR: methodology, investigation, validation (final approval of the published version) References Cochrane N, Ryan S, Kim B, Wu M, O’donnell J, Seyler T. Total Hip Arthroplasty in Morbidly Obese: Does a Strict Body Mass Index Cutoff Yield Meaningful Change? Hip Pelvis. 2022;34(3):161–71. Da Silva RR, Santos AAM, De Sampaio Carvalho Júnior J, Matos MA. Quality of life after total knee arthroplasty: Systematic review. Rev Bras Ortop. 2014;49(5):520–7. Deng QF, Gu HY, Peng WY, Zhang Q, Huang ZD, Zhang C, et al. Impact of enhanced recovery after surgery on postoperative recovery after joint arthroplasty: Results from a systematic review and meta-analysis. Postgrad Med J. 2018;94(1118):678–93. Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S et al. Prevention of VTE in orthopedic surgery patients. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 SUPPL.):e278S-e325S. Götz J, Maderbacher G, Leiss F, Zeman F, Meyer M, Reinhard J, et al. Better early outcome with enhanced recovery total hip arthroplasty (ERAS-THA) versus conventional setup in randomized clinical trial (RCT). Arch Orthop Trauma Surg. 2024;144(1):439–50. Järvenpää J, Kettunen J, Kröger H, Miettinen H. Obesity may impair the early outcome of total knee arthroplasty. A prospective study of 100 patients. Scand J Surg. 2010;99(1):45–9. Jennison T, MacGregor A, Goldberg A. Hip arthroplasty practice across the Organisation for Economic Co-operation and Development (OECD) over the last decade. Ann R Coll Surg Engl. 2023;105(7):645–52. Kurtz SM, Lau E, Schmier J, Ong KL, Zhao K, Parvizi J. Infection Burden for Hip and Knee Arthroplasty in the United States. J Arthroplasty. 2008;23(7):984–91. Lenth R. Emmeans: estimated marginal means [Internet]. Aka Least-Squares Means. 2019. p. https://cran.r-project.org/package=emmeans . Available from: https://cran.r-project.org/package=emmeans Li Y, Li A, Zhang Y. The efficacy of combined adductor canal block with local infiltration analgesia for pain control after total knee arthroplasty: A meta-analysis. Med (United States). 2018;97(49). Liebs TR, Herzberg W, Roth-Kroeger AM, Rüther W, Hassenpflug J. Women recover faster than men after standard knee arthroplasty. Clin Orthop Relat Res. 2011;469(10):2855–65. Ma HH, Chou TFA, Tsai SW, Chen CF, Wu PK, Chen WM. The efficacy of intraoperative periarticular injection in Total hip arthroplasty: A systematic review and meta-analysis. BMC Musculoskelet Disord. 2019;20(1). Mariconda M, Galasso O, Costa GG, Recano P, Cerbasi S. Quality of life and functionality after total hip arthroplasty: A long-term follow-up study. BMC Musculoskelet Disord. 2011;12. Orange GM, Hince DA, Travers MJ, Stanton TR, Jones M, Sharma S et al. Physical Function Following Total Knee Arthroplasty for Osteoarthritis: A Longitudinal Systematic Review With Meta-analysis. J Orthop Sports Phys Ther. 2025;55(1). Pabinger C, Lothaller H, Geissler A. Utilization rates of knee-arthroplasty in OECD countries. Osteoarthr Cartil. 2015;23(10):1664–73. Palazzuolo M, Antoniadis A, Mahlouly J, Wegrzyn J. Total knee arthroplasty improves the quality-adjusted life years in patients who exceeded their estimated life expectancy. Int Orthop. 2021;45(3):635–41. Shan L, Shan B, Graham D, Saxena A. Total hip replacement: A systematic review and meta-analysis on mid-term quality of life. Osteoarthr Cartil. 2014;22(3):389–406. Stucki M. Factors related to the change in Swiss inpatient costs by disease: a 6-factor decomposition. Eur J Heal Econ. 2021;22(2):195–221. Team RC. A Language and Environment for Statistical Computing. [Internet]. R Foundation for Statistical Computing. Vienna; 2018. Available from: https://www.r-project.org/ Vasileiadis D, Drosos G, Charitoudis G, Dontas I, Vlamis J. Does preoperative physiotherapy improve outcomes in patients undergoing total knee arthroplasty? A systematic review. Musculoskelet Care. 2022;20(3):487–502. Vendittoli PA, Pellei K, Desmeules F, Massé V, Loubert C, Lavigne M, et al. Enhanced recovery short-stay hip and knee joint replacement program improves patients outcomes while reducing hospital costs. Orthop Traumatol Surg Res. 2019;105(7):1237–43. Vincent HK, Alfano AP, Lee L, Vincent KR. Sex and age effects on outcomes of total hip arthroplasty after inpatient rehabilitation. Arch Phys Med Rehabil. 2006;87(4):461–7. Wainwright TW, Gill M, McDonald DA, Middleton RG, Reed M, Sahota O, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Acta Orthop. 2020;91(1):3–19. Xu K, Li Y, min, Zhang H feng, Wang Cguang, Xu Y, qiang, Li Z. jun. Computer navigation in total hip arthroplasty: A meta-analysis ofrandomized controlled trials. Int J Surg. 2014;12(5):528–33. Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":175644,"visible":true,"origin":"","legend":"\u003cp\u003eSchema of the ERP program\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7955804/v1/a9b091cc8993c87382ba81f2.png"},{"id":97136584,"identity":"5da290a6-b5c3-4106-9ca4-6e7703737599","added_by":"auto","created_at":"2025-12-01 09:56:48","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":237886,"visible":true,"origin":"","legend":"\u003cp\u003ePain evolution over time in THA and TKA patients\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7955804/v1/f28102206a7e784590905f8b.png"},{"id":97144666,"identity":"f1800379-92d2-423d-8cd6-e6bbe4e24bf0","added_by":"auto","created_at":"2025-12-01 10:11:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1333799,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7955804/v1/c05ae600-6c14-4389-89a6-2ecd4c45d18d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Enhanced Recovery in Hip and Knee Arthroplasty: Findings from a Swiss Quasi-Experimental Orthopaedic Study","fulltext":[{"header":"Background","content":"\u003cp\u003eTotal knee arthroplasty (TKA) and total hip arthroplasty (THA) are considered the standard surgical interventions for advanced osteoarthritis of the knee and hip, respectively, particularly when conservative treatments fail and patients experience significant functional limitations. These procedures are among the most effective and well-established in orthopaedic practice, with substantial evidence supporting their ability to restore joint function and improve quality of life [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eConcerning THA, a meta-analysis encompassing 20 studies (n\u0026thinsp;\u0026gt;\u0026thinsp;1,000 patients; mean follow-up 7 years) demonstrated significant improvements in the Harris Hip Score, as well as in the pain and function domains of the Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), with additional gains reported in Short Form-36 Health Survey (SF-36) scores (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. For TKA, a meta-analysis of 72 high-quality studies with follow-up periods extending up to 5 years revealed early and sustained functional improvements, with substantial gains observed as early as 3 to 6 months postoperatively and maintained through five years [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Furthermore, the frequency of these procedures is notable: in high income countries, the average rate of THA reached 191.5 per 100,000 population in 2018 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and 150 per 100,000 for TKA in 2011 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This high utilization has driven continuous technical and scientific progress. From a surgical perspective, navigation-assisted arthroplasty has been shown to significantly reduce prosthetic malalignment [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Advances in anaesthesia, such as periarticular local infiltration combined with adductor canal blocks (ACB) in TKA [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], have improved postoperative analgesia and facilitated earlier mobilization. Similarly, in THA, periarticular infiltration has been associated with reduced postoperative pain and decreased opioid consumption [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese advancements have contributed to the development of Enhanced Recovery After Surgery (ERAS) protocols, which aim to accelerate functional recovery and shorten hospital stays [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Reducing postoperative length of stay (LoS) is clinically relevant, as prolonged immobilization increases the risk of thromboembolic events [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], and extended hospitalization is associated with a higher risk of nosocomial infections [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Additionally, shorter LoS may contribute to substantial cost savings.\u003c/p\u003e\u003cp\u003eWe developed an Enhanced Recovery Protocol (ERP) inspired by existing ERAS framework, focusing on early mobilization, optimized perioperative analgesia, and reduced LoS. The protocol was structured around key components supported by the literature, including preoperative therapeutic education and physiotherapy when needed, advances in surgical techniques such as navigation-assisted knee arthroplasty and minimally invasive anterior approaches for hip replacement, and the use of periarticular local infiltration for both procedures. Additionally, we replaced femoral nerve blocks (FNB) with ACB to preserve motor function and facilitate early rehabilitation. A central feature of the protocol was early mobilization by physiotherapists, beginning with assisted standing 4 to 6 hours after surgery and progressing to walking and stair climbing by postoperative day one.\u003c/p\u003e\u003cp\u003eReducing LoS is particularly relevant for peripherical hospitals, where optimizing postoperative recovery has direct implications for both care quality and resource management. A shorter hospital stay after joint arthroplasty can translate into substantial cost savings and more efficient bed utilization, reducing strain on inpatient capacity. At the same time, earlier discharge allows patients to resume daily activities and work sooner, improving perceived quality of care and overall satisfaction. However, most evidence on enhanced recovery protocols originates from large tertiary centers, where dedicated multidisciplinary teams and high patient volumes facilitate protocol implementation.\u003c/p\u003e\u003cp\u003eTherefore, the primary objective of this study was to evaluate whether the implementation of the ERP reduced the LoS following TKA or THA compared with the standard protocol in a peripherical hospital in Switzerland. Secondary objectives were to assess recovery trajectories in terms of mobility and postoperative pain, and to compare outcomes between the two protocols.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe conducted a retrospective analysis of a practice change, designed as a quasi-experimental pre/post intervention study, at the single orthopaedic unit of St-Imier hospital involving patients undergoing elective total knee arthroplasty (TKA) or total hip arthroplasty (THA). Participants were allocated to either a control group, consisting of patients who underwent surgery prior to April 2021 and received standard postoperative care, or an intervention group, comprising patients who underwent surgery from November 2021 onwards and were managed according to the newly implemented ERP.\u003c/p\u003e\u003cp\u003e Our research was granted an exemption from full ethical review by the local Ethics Committee (Canton of Bern, Switzerland) and conforms to Helsinki Declaration.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSample size\u003c/h2\u003e\u003cp\u003eThe sample size was estimated for the primary outcome, hospital length of stay (LoS). Assuming a two-sided α\u0026thinsp;=\u0026thinsp;0.05, 80% power, an allocation ratio of approximately 2.6:1 (control:intervention), and a common standard deviation (SD) of 2.5 days, detecting a 1.5-day difference in LoS between groups would require approximately 110 patients (79 in the control group and 31 in the intervention group). To detect a smaller difference of 1.0 day, approximately 246 patients (178 control and 68 intervention) would be required.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSelection Criteria\u003c/h3\u003e\n\u003cp\u003eEligible patients were aged 18 years or older and scheduled for elective unilateral TKA or THA. Patients undergoing bilateral joint arthroplasties or those who experienced major postoperative complications affecting mobilization \u0026ndash; such as revision surgery or surgical site infection \u0026ndash; were excluded.\u003c/p\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003eThe ERP group followed a structured program that differed from conventional care in several ways. In the month preceding surgery, patients were required to attend a multidisciplinary group session led by the case manager and a physiotherapist, focusing on preoperative education and therapeutic preparation. On the day of surgery (\u003cem\u003eDay 0\u003c/em\u003e), patients were admitted directly to the orthopaedic ward.\u003c/p\u003e\u003cp\u003eAnaesthesia protocols were tailored to the type of arthroplasty. TKA patients received either general or spinal anaesthesia, supplemented with an ACB and periarticular local infiltration. For THA, general anaesthesia was recommended, although spinal anaesthesia was also permitted; in both cases, local infiltration was applied.\u003c/p\u003e\u003cp\u003ePostoperatively, patients were provided with a printed rehabilitation plan at discharge. Physiotherapists initiated early mobilization, beginning with the first mobilization (sitting or standing) 4 to 6 hours after surgery. Ambulation was encouraged either later the same day or the following morning. Stair climbing was targeted for the first postoperative day, depending on the patient's condition. A schema of the ERP program is summarized in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eAll surgeries were performed by fellowship-trained arthroplasty surgeons.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eOutcome Measures\u003c/h3\u003e\n\u003cp\u003eThe primary outcomes of interest included postoperative LoS in days, time to use of a cane (TCU, in days), time to time to first unaided ambulation (TFUA, in days), time to stair climbing (TSC, in days), and, for TKA patients, knee flexion at discharge (KFD, in days). As secondary outcomes, we assessed the degree of knee flexion achieved at discharge, categorized into four ranges: 60\u0026ndash;69\u0026deg;, 70\u0026ndash;79\u0026deg;, 80\u0026ndash;89\u0026deg;, and 90\u0026deg; and pain levels, assessed twice a day (morning and afternoon) during hospitalization using a 0\u0026ndash;10 numeric rating scale.\u003c/p\u003e\u003cp\u003e To ensure that observed differences were attributable to the ERP rather than to unrelated practice changes, we reviewed perioperative procedures, anaesthesia techniques, and discharge criteria across the study period.\u003c/p\u003e\n\u003ch3\u003eData Analyses\u003c/h3\u003e\n\u003cp\u003eContinuous variables were summarized as medians with interquartile ranges (IQR) or as means with standard deviations (SD), depending on their distribution (non-parametric or parametric), and compared using the Wilcoxon rank-sum test or the independent t-test, respectively. Categorical variables were compared using the \u003cem\u003echi\u003c/em\u003e-\u003cem\u003esquare\u003c/em\u003e test or Fisher\u0026rsquo;s exact test, as appropriate. A two-sided \u003cem\u003eP\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003cp\u003eFurthermore, for the main outcomes (length of stay, time to first ambulation, cane use, stair climbing, and knee flexion) we conducted multivariable linear regression analyses adjusted for age, sex, body mass index (BMI), comorbidities (Charlson Comorbidity Index, CCI), and the American Society of Anesthesiologists Physical Status Classification System (ASA-PSCS). Model assumptions, including linearity, normality of residuals, and homoscedasticity, were verified through residual plots and statistical tests. Model fit was evaluated using the adjusted R\u0026sup2; and Akaike Information Criterion (AIC), with lower AIC and higher adjusted R\u0026sup2; values indicating better fit. Competing models were compared following the principle of parsimony, retaining the model with the best explanatory power and clinical plausibility.\u003c/p\u003e\u003cp\u003ePain trajectories were analyzed separately for THA and TKA patients using linear mixed-effects models with fixed effects for group (intervention vs control), day, and their interaction, and random intercepts for individual patients to account for repeated measures. Model adequacy was assessed by examining residual distributions, Q\u0026ndash;Q plots, and conditional and marginal R\u0026sup2; values. Model fit and parsimony were compared using the AIC, with lower values indicating a better fit. Estimated marginal means and between-group contrasts at each time point were computed using the \u003cem\u003eemmeans\u003c/em\u003e package [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. All statistical analyses were performed using R statistical software [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eDemographics\u003c/h2\u003e\u003cp\u003eA total of 196 patients underwent 206 surgical operations. 149 (72.3%) were managed under the previous protocol (considered here as the “control group”), and 57 (27.7%) under the newly implemented ERP (considered here as the “intervention group”). In the control group (December 2019 to March 2021), 77 patients (51.7%) underwent THA and 72 (48.3%) TKA. In the intervention group (November 2021 to March 2023), 27 patients (47.4%) underwent THA and 30 (52.6%) TKA. Ten patients underwent two procedures, typically one knee followed by the second after approximately one year.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the characteristics of the sample, highlighting differences in sex, age, body mass index, and CII.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatients’ characteristic\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWomen, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31 (54.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63 (42.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTHA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27 (47.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e77 (51.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTKA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30 (52.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72 (48.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (per year), median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70 (62–77)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69 (61–76)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI (kg/m²), median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30.1 (26-33.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30 (24.4–33.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eASA-PSCS, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (8.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38 (66.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e97 (65.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (24.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (23.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnknown\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (2.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCII, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28 (49.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76 (51.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16 (28.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (23.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (8.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (11.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (7.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (6.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt; 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (7.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eASA-PSCS = American Society of Anesthesiologists Physical Status Classification System\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eBMI = Body Mass Index\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eCII = Charlson comorbidity index\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eIQR = Interquartile range\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eTHA = Total Hip Arthroplasty\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eTKA = Total Knee Arthroplasty\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eLength of Stay (LoS)\u003c/h3\u003e\n\u003cp\u003eMedian LoS was significantly shorter in the intervention group (4 days, IQR: 3–5.5) compared to the control group (5.5 days, IQR: 4–7.5; \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01). However, when analyzed by type of arthroplasty, the difference was statistically significant only for TKA, with the intervention group showing a markedly shorter stay (4 vs. 7.5 days; \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01).\u003c/p\u003e\u003cp\u003eThe final model (Adj. R² = 0.22) included sex, BMI, age, and intervention. Male patients and those in the intervention group had significantly shorter stays, while increasing age and BMI were associated with longer hospitalizations.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eTime to Cane Use (TCU)\u003c/h2\u003e\u003cp\u003eTime to assisted walking with canes was significantly shorter in the intervention group (0.5 days, IQR: 0.5–1.5) vs. control (1.5 days, IQR: 1–3; \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01) for both THA and TKA patients.\u003c/p\u003e\u003cp\u003eThe model (Adj. R² = 0.25) included the same predictors as for LoS. Again, male sex and intervention predicted faster use of a cane, while older age and higher BMI were associated with delays.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eTime to First Unaided Ambulation (TFUA)\u003c/h2\u003e\u003cp\u003eFirst postoperative ambulation occurred slightly earlier in the intervention group (0.5 days, IQR: 0–0.5) than in the control group (0.5 days, IQR: 0.5–1; \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01). However, among THA patients, this difference was not statistically significant (\u003cem\u003eP\u003c/em\u003e = 0.4).\u003c/p\u003e\u003cp\u003eThe final model (Adj. R² = 0.09) retained sex, BMI, and intervention, but age was not included. Intervention and male sex were significantly associated with earlier ambulation, while BMI predicted delays. However, the association with intervention did not reach statistical significance (\u003cem\u003eP\u003c/em\u003e = 0.13).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eTime to stair climbing (TSC)\u003c/h2\u003e\u003cp\u003eTime to stair climbing was significantly shorter in the intervention group (1 day, IQR: 1–2) vs. control (3 days, IQR: 1.5–4; \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01). For THA, the intervention group climbed stairs earlier (1 day, IQR: 0.75–1.25) than the control group (1.75 days, IQR: 1.1–3; \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01). For TKA, stair climbing occurred at 2 days (IQR: 1.5–3) vs. 4 days (IQR: 3.4–4.5; \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01).\u003c/p\u003e\u003cp\u003eThe best-fitting model (Adj. R² = 0.33) included intervention, sex, BMI, and age, all of which were significant predictors. Intervention and male sex were associated with faster stair climbing; older age and higher BMI predicted delays.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eKnee Flexion at Discharge (KFD)\u003c/h2\u003e\u003cp\u003eAmong TKA patients, time to achieve acceptable passive knee flexion was significantly shorter in the intervention group (1.5 days, IQR: 1.5–3) vs. control (4.5 days, IQR: 4–5.5; \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01).\u003c/p\u003e\u003cp\u003eAt discharge, 90° of knee flexion was reached by 75% of control patients (54/72) and 57% of intervention patients (17/29) (\u003cem\u003eP\u003c/em\u003e = 0.16). Although the distribution across angle categories was slightly different between groups, there was reasonable no evidence of a real effect (\u003cem\u003eP\u003c/em\u003e = 0.21) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eKnee flexion milestones at discharge in total knee arthroplasty patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eArm\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60–69°\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70–79°\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e80–89°\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e90°\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eControl (n = 72)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (2.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (5.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12 (16.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e54 (75.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntervention (n = 29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (6.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (3.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (31.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17 (58.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal n = 101\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (4.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (5.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21 (20.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e71 (70.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eA parsimonious model (Adj. R² = 0.32) with only sex and intervention was sufficient to explain variation in flexion degree. Neither BMI nor age contributed significantly and were excluded from the final model. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e provides a summary of the bivariate analysis for the main outcomes\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSummary of the bivariate analysis for the main outcomes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eArm\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDay\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDay\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eTest\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMin-Max\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMedian (IQR)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLoS\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e149\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2–14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.5 (4-7.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u0026lt; 0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWilcoxon rank sum test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.5–11.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 (3-5.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTHA\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2-13.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 (3–6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWilcoxon rank sum test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTHA\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.5–11.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.5 (3–5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTKA\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.5–14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.5 (5–8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u0026lt; 0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWilcoxon rank sum test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTKA\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.5–10.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 (3.5-6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTCU\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e142\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5–12.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.5 (1–3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u0026lt; 0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWilcoxon rank sum test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5–3.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.5 (0.5–1.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTHA\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5–12.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (0.5-2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u0026lt; 0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWilcoxon rank sum test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTHA\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5-2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.5 (0.5–0.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTKA\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1–7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.5 (1.5-4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u0026lt; 0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWilcoxon rank sum test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTKA\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5–3.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.25 (0.6–1.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTFUA\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e147\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0-5.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.5 (0.5-1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u0026lt; 0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWilcoxon rank sum test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0-2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.5 (0-0.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTHA\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0–2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.5 (0-0.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWilcoxon rank sum test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTHA\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0-0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.5 (0-0.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTKA\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0-5.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.5 (0.5-1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u0026lt; 0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWilcoxon rank sum test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTKA\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0-2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.5 (0-0.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTSC\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e138\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5-9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3 (1.5-4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u0026lt; 0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWilcoxon rank sum test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5–3.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (1–2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTHA\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5-8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.75 (1.1-3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u0026lt; 0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWilcoxon rank sum test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTHA\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5-2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (0.75–1.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTKA\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1–9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 (3.4–4.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u0026lt; 0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWilcoxon rank sum test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTKA\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1-3.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (1.5-3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eKFD (TKA)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.5-8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.5 (4-5.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u0026lt; 0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWilcoxon rank sum test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.5-4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.5 (1.5-3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eKFD = Knee Flexion at Discharge\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eLoS = Length of Stay\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eTCU = Time to Cane Use\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eTFUA = Time to First Unaided Ambulation\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eTHA = Total Hip Arthroplasty\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eTKA = Total Knee Arthroplasty\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eTSC = Time to Stair Climbing\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAcross all models, male sex and participation in the intervention were consistently associated with faster recovery, whereas higher BMI and older age were generally associated with delayed recovery. Neither ASA-PSCS nor CII emerged as significant predictors in any model. A summary of the linear regression models (Best Subset/Stepwise) for each outcome is presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSummary of Linear Regression Models (Best Subset/Stepwise) for Each Outcome\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePredictors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLength of Stay (LoS)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTime to Cane Use (TCU)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTime to First Unaided Ambulation (TFUA)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTime to Stair Climbing (TSC)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eKnee Flexion at Discharge (KFD)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAdjusted R²\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTreatment Arm\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e–1.70 **\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e–2.57 ***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e–0.41 (p = 0.13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e–3.64 ***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e–5.71 ***\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWomen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eReference\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e–1.09 **\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e–1.60 ***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e–0.57 **\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e–1.80 ***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e–2.30 ***\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge (per year)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.08 ***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.06 **\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNot in model\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.08 ***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNot in model\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBMI (kg/m²)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.14 ***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.17 ***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.05 **\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.23 ***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNot in model\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e*P \u0026lt; 0.05; **P \u0026lt; 0.01; *** P \u0026lt; 0.001; \u003cem\u003eBMI = Body Mass Index\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003ePain levels at discharge\u003c/h2\u003e\u003cp\u003ePatients in the intervention group reported lower pain scores at discharge (median 0.78, IQR: 0.31–1.27) compared to the control group (1.0, IQR: 0.48–1.63; \u003cem\u003eP\u003c/em\u003e = 0.07). Among THA patients, scores were 0.62 (IQR: 0.20–1.12) vs. 0.71 (IQR: 0.38–1.57; \u003cem\u003eP\u003c/em\u003e = 0.13), and for TKA, 1.0 (IQR: 0.6–1.31) vs. 1.21 (IQR: 0.8–1.8; \u003cem\u003eP\u003c/em\u003e = 0.19) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePain levels at discharge in total hip arthroplasty and total knee arthroplasty patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eArm\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eOperation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMedian (IQR)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e149 (72.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.0 (0.48–1.63)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e57 (27.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.78 (0.31–1.27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eTHA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e77 (80.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.71 (0.38–1.57)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eTHA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27 (19.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.62 (0.2–1.12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eTKA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e72 (70.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.21 (0.8–1.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eTKA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30 (29.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.0 (0.6–1.31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTHA = Total Hip Arthroplasty\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eTKA = Total Knee Arthroplasty\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003ePain evolution was analyzed separately for THA and TKA patients.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFor THA patients (n = 1,006 observations, 99 patients), pain varied significantly over time (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01), peaking on postoperative day 1 and declining thereafter. Age was negatively associated with pain (β = − 0.02, \u003cem\u003eP\u003c/em\u003e = 0.02). No significant main effect of group or consistent group × day interaction was observed. However, on day 0 afternoon, the intervention group reported significantly lower pain (estimate = − 1.45; \u003cem\u003eP\u003c/em\u003e = 0.03), with non-significant trends favoring the intervention group at other time points.\u003c/p\u003e\u003cp\u003eFor TKA patients (n = 803 observations, 99 patients), pain also declined over time, with no significant group effect (β = 0.10, \u003cem\u003eP\u003c/em\u003e = 0.79) or consistent interactions. Still, pain was significantly lower in the intervention group on day 2 afternoon (estimate = − 3.07; \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01), and a trend was noted on day 5 afternoon (estimate = − 2.58; \u003cem\u003eP\u003c/em\u003e = 0.07).\u003c/p\u003e\u003cp\u003eThe evolution of pain over time in THA and TKA patients is graphically illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study evaluated the impact of an ERP on key postoperative outcomes among patients undergoing TKA and THA. Our results suggest that this intervention was associated with earlier discharge, faster recovery milestones, and reduced use of assistive devices, especially among TKA patients. Surgical staffing, implant types, and rehabilitation resources remained consistent throughout the study.\u003c/p\u003e\u003cp\u003ePatients managed under the ERP had a significantly shorter hospital length of stay (LoS) compared with controls (β = − 1.70, p \u0026lt; 0.01), corresponding to a median reduction from 7.5 to 4 days after TKA. This reduction may be attributed to the change in the anaesthesia protocol from FNB to ACB, combined with periarticular local infiltration. ACB provides effective pain relief while preserving quadriceps strength, thus facilitating earlier mobilization and reducing the need for extended hospital stays. This finding is consistent with the study by Li et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] which demonstrates that ACB combined with periarticular injections can accelerate recovery following TKA by improving early postoperative ambulation and reducing the need for opioid-based pain management. This shift in anaesthesia techniques likely played a significant role in the enhanced recovery outcomes observed in the intervention group.\u003c/p\u003e\u003cp\u003eImprovements were also observed in the time to first use of canes, and stair climbing, with consistent and statistically significant advantages for the intervention group. These findings might be justified not only by the changes in the anaesthesia protocol and surgical procedure, but also by the introduction of a preoperative education session on ambulation, use of walking aids and stair climbing conducted by the physiotherapist. This is supported by the findings of Vasileiadis et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] who conducted a systematic review on this subject and found that several trials demonstrate that preoperative physiotherapy interventions improve functional performance for patients shortly after TKA.\u003c/p\u003e\u003cp\u003eWhile ambulation time and pain scores did not differ significantly, a favorable trend for lower pain and earlier mobilization was consistently observed in the intervention group.\u003c/p\u003e\u003cp\u003eThe linear regression analyses confirmed the beneficial effect of the intervention, independently of sex, BMI, and age. In all models, participation in the ERP group was associated with improved outcomes, particularly regarding discharge timing, cane use, stair climbing, and passive knee flexion. These findings agree with similar protocols overall. Meta-analyses have found that patients on ERAS pathways go home 2 days earlier on average than those on standard protocols [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. A randomized clinical trial suggests that ERAS patients achieve mobility milestones sooner than those under standard care [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. On this study, ERAS group showed significantly better Timed Up-and-Go test times, longer walking distances, and more stairs climbed in the first week after surgery.\u003c/p\u003e\u003cp\u003eMen were generally associated with better recovery across indicators, while higher BMI and older age tended to predict longer recovery durations. These findings are in line with those obtained by other authors [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], suggesting that women experience worse knee function preoperatively but with greater improvement in pain relief and physical function at 3 and 6 months after standard TKA. Concerning BMI, Järvenpää et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] found that obese patients had a worse postoperative range of motion (averaging 110° flexion vs. 118° in non-obese, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01) as well as a higher rate of complications (e.g. wound issues) at a 3 month follow up of TKA patients. In THA populations, obesity has similarly been linked to slower inpatient recovery and rehab progress. A study found that in the acute postoperative period, morbidly obese patients trended towards increased hospital LoS [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Advanced age has been found to be associated with a slower recovery in other studies as well. Data from a rehabilitation study on hip replacements [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] showed that patients ≥ 85 years old had significantly lower gains in functional independence compared to younger patients. These octogenarian patients had longer hospital stays, lower improvement in functional independence measures and were less likely to regain independence to the point of returning home directly after surgery.\u003c/p\u003e\u003cp\u003eTogether, these findings highlight the effectiveness of the ERP in accelerating recovery without compromising safety. The improvements were especially notable in patients undergoing TKA, suggesting that this subgroup may benefit the most from structured early recovery protocols. Furthermore, although this study does not aim to provide a detailed cost-benefit analysis, by estimating the average cost of hospitalization in Switzerland at approximately USD 2,300–2,900 per day [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], we estimate that the new rehabilitative approach led to an average savings of around USD 1,150–1,450 per patient for THA and USD 8,000–10,000 per patient for TKA.\u003c/p\u003e\u003cp\u003eStudy Limitations\u003c/p\u003e\u003cp\u003eA notable strength of the present study is the inclusion of multiple objectives and clinically meaningful indicators of postoperative functional recovery, such as time to ambulation, stair climbing, and attainment of adequate knee flexion. This multidimensional assessment offers a more comprehensive evaluation of early rehabilitation outcomes beyond the sole measure of hospital length of stay. Nevertheless, several limitations warrant consideration. The quasi-experimental, non-randomized design entails a risk of selection bias and residual confounding, which may limit the strength of causal inferences. We attempted to mitigate these risks through statistical adjustments, including multivariable modeling for observed confounders. While the overall sample provided \u0026gt; 95% power to detect the observed 1.5-day reduction in length of stay (primary outcome), the THA subgroup had ~ 80% power only for differences ≥ 1.3 days, leaving it underpowered for the smaller effect observed. The temporal separation of control and intervention groups may also have introduced bias; however, all outcomes were assessed by the same clinical staff, and no institutional policy changes occurred during the study period, which likely minimized this risk. Moreover, our analysis was limited to early postoperative outcomes and did not address longer-term recovery, complications, or readmissions. Finally, the single-center design restricts external validity, and further studies in diverse clinical settings are needed to confirm generalizability.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study demonstrates that early mobilization significantly enhances postoperative recovery following total knee arthroplasty, with patients reaching key rehabilitation milestones and discharge readiness earlier. Although effects were less pronounced in THA, similar trends were observed. Despite limitations, including a non-randomized design and small sample size, the findings support the feasibility and clinical value of structured early mobilization. These protocols may reduce hospital stay, optimize resource use, and improve functional outcomes. Additionally, substantial cost savings require further investigation through cost-effectiveness analyses in larger, controlled studies.\u003c/p\u003e\u003cp\u003eFurther randomized studies are warranted to confirm these results and explore long-term benefits.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eACB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAdductor Canal Blocks\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eASA-PSCS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAmerican Society of Anesthesiologists Physical Status Classification System\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBody Mass Index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCII\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCharlson Comorbidity Index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eERP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEnhanced Recovery Protocol\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eERAS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEnhanced Recovery After Surgery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFNB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFemoral Nerve Block\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eKFD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eKnee Flexion at Discharge\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLoS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLength of Stay\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTCU\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTime to Use of a Cane\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTFUA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTime to First Unaided Ambulation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTHA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTotal Hip Arthroplasty\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTKA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTotal Knee Arthroplasty\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTSC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTime to Stair Climbing\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWOMAC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWestern Ontario and McMaster Universities Osteoarthritis index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki and approved by the local Ethics Committee (Canton of Bern, Switzerland; reference number Reg-2025-00732).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study does not qualify as a clinical trial. It is a pre/post quasi-experimental study conducted to compare two perioperative protocols implemented sequentially as part of routine clinical practice for all eligible patients at the hospital of St-Imier. As such, the study was exempted from ethical review by the Cantonal Ethics Committee of Bern. Thus, Clinical trial number is not applicable.\u003c/p\u003e\n\u003cp\u003eMoreover, given the retrospective nature of the analysis and the use of anonymized data from routine clinical practice, the requirement for individual informed consent was waived by the Ethics Committee.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable, as the manuscript does not contain any individual person’s data in any form (including images, videos, or case details).\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are publicly available in the Zenodo repository at https://doi.org/10.5281/zenodo.17453408\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests related to this work.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe authors deeply thank all patients, physiotherapists and medical staff who participated in this project.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The research was supported by internal funds of the hospital.\u003c/p\u003e\n\u003ch2\u003eConflict of Interest\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they do not have any conflicts of interests.\u003c/p\u003e\n\u003ch2\u003eAuthor Contributions\u003c/h2\u003e\n\u003cp\u003ePS: conceptualization, methodology, investigation, writing – original draft AB: writing – original draft, data curation, formal analysis, validation (final approval of the published version) MNM: writing – review and editing, validation (final approval of the published version) AK: funding acquisition, validation (final approval of the published version) AZ: methodology, investigation, validation (final approval of the published version) DCR: methodology, investigation, validation (final approval of the published version)\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCochrane N, Ryan S, Kim B, Wu M, O\u0026rsquo;donnell J, Seyler T. Total Hip Arthroplasty in Morbidly Obese: Does a Strict Body Mass Index Cutoff Yield Meaningful Change? Hip Pelvis. 2022;34(3):161\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDa Silva RR, Santos AAM, De Sampaio Carvalho J\u0026uacute;nior J, Matos MA. Quality of life after total knee arthroplasty: Systematic review. Rev Bras Ortop. 2014;49(5):520\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDeng QF, Gu HY, Peng WY, Zhang Q, Huang ZD, Zhang C, et al. Impact of enhanced recovery after surgery on postoperative recovery after joint arthroplasty: Results from a systematic review and meta-analysis. Postgrad Med J. 2018;94(1118):678\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFalck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S et al. Prevention of VTE in orthopedic surgery patients. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 SUPPL.):e278S-e325S.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eG\u0026ouml;tz J, Maderbacher G, Leiss F, Zeman F, Meyer M, Reinhard J, et al. Better early outcome with enhanced recovery total hip arthroplasty (ERAS-THA) versus conventional setup in randomized clinical trial (RCT). Arch Orthop Trauma Surg. 2024;144(1):439\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJ\u0026auml;rvenp\u0026auml;\u0026auml; J, Kettunen J, Kr\u0026ouml;ger H, Miettinen H. Obesity may impair the early outcome of total knee arthroplasty. A prospective study of 100 patients. Scand J Surg. 2010;99(1):45\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJennison T, MacGregor A, Goldberg A. 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The efficacy of combined adductor canal block with local infiltration analgesia for pain control after total knee arthroplasty: A meta-analysis. Med (United States). 2018;97(49).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiebs TR, Herzberg W, Roth-Kroeger AM, R\u0026uuml;ther W, Hassenpflug J. Women recover faster than men after standard knee arthroplasty. Clin Orthop Relat Res. 2011;469(10):2855\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMa HH, Chou TFA, Tsai SW, Chen CF, Wu PK, Chen WM. The efficacy of intraoperative periarticular injection in Total hip arthroplasty: A systematic review and meta-analysis. BMC Musculoskelet Disord. 2019;20(1).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMariconda M, Galasso O, Costa GG, Recano P, Cerbasi S. Quality of life and functionality after total hip arthroplasty: A long-term follow-up study. BMC Musculoskelet Disord. 2011;12.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOrange GM, Hince DA, Travers MJ, Stanton TR, Jones M, Sharma S et al. Physical Function Following Total Knee Arthroplasty for Osteoarthritis: A Longitudinal Systematic Review With Meta-analysis. J Orthop Sports Phys Ther. 2025;55(1).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePabinger C, Lothaller H, Geissler A. Utilization rates of knee-arthroplasty in OECD countries. Osteoarthr Cartil. 2015;23(10):1664\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePalazzuolo M, Antoniadis A, Mahlouly J, Wegrzyn J. Total knee arthroplasty improves the quality-adjusted life years in patients who exceeded their estimated life expectancy. Int Orthop. 2021;45(3):635\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShan L, Shan B, Graham D, Saxena A. Total hip replacement: A systematic review and meta-analysis on mid-term quality of life. Osteoarthr Cartil. 2014;22(3):389\u0026ndash;406.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStucki M. Factors related to the change in Swiss inpatient costs by disease: a 6-factor decomposition. Eur J Heal Econ. 2021;22(2):195\u0026ndash;221.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTeam RC. A Language and Environment for Statistical Computing. [Internet]. R Foundation for Statistical Computing. Vienna; 2018. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.r-project.org/\u003c/span\u003e\u003cspan address=\"https://www.r-project.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVasileiadis D, Drosos G, Charitoudis G, Dontas I, Vlamis J. Does preoperative physiotherapy improve outcomes in patients undergoing total knee arthroplasty? A systematic review. Musculoskelet Care. 2022;20(3):487\u0026ndash;502.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVendittoli PA, Pellei K, Desmeules F, Mass\u0026eacute; V, Loubert C, Lavigne M, et al. Enhanced recovery short-stay hip and knee joint replacement program improves patients outcomes while reducing hospital costs. Orthop Traumatol Surg Res. 2019;105(7):1237\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVincent HK, Alfano AP, Lee L, Vincent KR. Sex and age effects on outcomes of total hip arthroplasty after inpatient rehabilitation. Arch Phys Med Rehabil. 2006;87(4):461\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWainwright TW, Gill M, McDonald DA, Middleton RG, Reed M, Sahota O, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS\u0026reg;) Society recommendations. Acta Orthop. 2020;91(1):3\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXu K, Li Y, min, Zhang H feng, Wang Cguang, Xu Y, qiang, Li Z. jun. Computer navigation in total hip arthroplasty: A meta-analysis ofrandomized controlled trials. Int J Surg. 2014;12(5):528\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Rehabilitation; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee","lastPublishedDoi":"10.21203/rs.3.rs-7955804/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7955804/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eEnhanced recovery protocols (ERPs) are designed to accelerate postoperative recovery and reduce hospital length of stay (LoS). Among ERP components, early mobilization plays a pivotal role in improving functional outcomes, reducing complications, and enhancing patient satisfaction. However, most evidence originates from large tertiary centers, leaving uncertainty about the feasibility and impact of such interventions in smaller hospitals with more limited resources. This study aimed to evaluate whether implementing a structured early mobilization protocol could reduce LoS and improve functional recovery after total knee (TKA) and total hip arthroplasty (THA) in a Swiss peripherical hospital.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA quasi-experimental pre/post study was conducted at a single orthopedic unit as a retrospective analysis of a practice change. Adults undergoing elective unilateral TKA or THA were included. Exclusion criteria were bilateral procedures, major postoperative complications or impairing mobilization. Patients operated before April 2021 received standard postoperative care, while those treated from November 2021 onwards followed the ERP. The ERP emphasized early mobilization and optimized perioperative analgesia, including preoperative education, physiotherapy, minimally invasive techniques, periarticular local infiltration, and replacement of femoral nerve blocks with adductor canal blocks. Physiotherapist-led mobilization began within 4\u0026ndash;6 hours postoperatively, with walking and stair climbing on day one. The primary outcome was hospital LoS. Secondary outcomes were time to cane use, unaided ambulation, stair climbing, knee flexion at discharge (for TKA), and reported pain. Statistical analyses included non-parametric tests and chi-square comparisons, as appropriate. Additionally, linear multivariable regression and linear mixed-effects models were applied to examine associations between the intervention and key outcomes, adjusting for potential confounders and repeated measures.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003ePatients in the intervention group had a significantly shorter median LoS compared to the control group (4 vs. 5.5 days, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The enhanced protocol was significantly associated (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) with earlier achievement of functional milestones, including cane use, stair climbing, and attainment of adequate knee flexion. Improvements among THA patients were more modest. Multivariable modeling identified sex, age, and body mass index as significant predictors of recovery outcomes. No significant reduction in pain was observed.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eERP implementation was associated with shorter hospitalization and faster functional recovery, particularly after TKA. These findings support integrating structured early mobilization pathways to improve outcomes and efficiency, especially in smaller hospitals where reduced LoS can optimize bed occupancy and resource use.\u003c/p\u003e","manuscriptTitle":"Enhanced Recovery in Hip and Knee Arthroplasty: Findings from a Swiss Quasi-Experimental Orthopaedic Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-28 06:55:46","doi":"10.21203/rs.3.rs-7955804/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-01-04T09:13:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"200432087835015487318302135314490027586","date":"2026-01-04T08:51:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-17T12:37:36+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-01T06:48:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-30T05:37:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-30T05:36:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2025-10-27T09:42:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"42b32657-d648-421a-93f5-8e229ba54ae8","owner":[],"postedDate":"November 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-28T06:55:46+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-28 06:55:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7955804","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7955804","identity":"rs-7955804","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}