i Patients’ perspectives, pain, and health-related quality of life in same-day discharge hip and knee arthroplasty Martin Harry van Heerden A Dissertation submitted to the Faculty of Healthcare Sciences, The University of the Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree of Masters in Physiotherapy. Johannesburg, 27th May 2024. ii Declaration I, Martin Harry van Heerden, declare that this Dissertation is my unaided work. It is being submitted for the Masters in Physiotherapy at the University of the Witwatersrand, Johannesburg. It has not been submitted before for any degree or examination at any other University. Martin Harry van Heerden _______________________________ Name of candidate Signature of candidate On the 27th day of May 2024 in Pretoria. iii Dedication A work such as this is not possible without support from those closest to me. My children, Adam, Juliet and Zachary, thank you for your patience and understanding, while I spent hours in front of the computer. Chad, thank you for your patience, for blowing wind into my sails and supporting me throughout the process. I am grateful too for your Microsoft Word skills, grammar tips and for always being willing to listen to my frustrations. Thank you to my team at Van Heerden Physiotherapy for their patience and support. Without you, it would not have been possible to complete this dissertation. iv Presentations arising from this Study Poster Presentation – South African Society of Physiotherapy Congress, Stellenbosch, 16-18 September 2022. Poster Presentation – World Physiotherapy Congress, Dubai, 2-4 June 2023 Platform Presentation – World Physiotherapy Africa Region Congress, 12-15 September 2024 Publications arising from this Study No publications yet. v Abstract Background International protocols for same-day discharge (SDD) following total hip (THA) and total knee arthroplasty (TKA) have recently been introduced in South Africa. Comparisons between recovery trajectories of THA and TKA patients in traditional length-of-stay models and SDD are limited. The impact of SDD related to pain, health-related quality of life and the patient perspective has yet to be studied in the South African context. Aim This study aimed to explore, evaluate, and compare patients' perspectives, experiences, pain, and health-related quality of life (HRQOL) following SDD after THA and TKA. Method A mixed-methods design was implemented with a collection of patient-reported outcome measures (PROMs) over six weeks (n=109: 55 THA and 54 TKA) and concluded with semi-structured interviews (n=24: 14 THA and 10 TKA). Participants scheduled for SDD THA and TKA who met the study criteria were selected through convenience sampling. Descriptive and inferential statistics were used, and a thematic analysis of interview data was conducted. Results There were significant improvements in PROMs by six weeks postoperatively in both groups. Significant between-group differences revealed persistent neuropathic pain (P=0.536) and worse health-related quality of life scores (p=0.102) in the TKA group. The themes identified highlight positive perspectives of SDD, emphasising unique challenges in the SDD TKA group. Findings indicate that patients undergoing SDD THA and TKA in South Africa produce results comparable to those in international studies. Conclusion This research advocates for a holistic approach in SDD THA and TKA, emphasising patient-centric care, effective communication, and preparation. The study contributes insights into this evolving clinical pathway and encourages further research. vi Acknowledgements Study supervisors, Dr Monique M Keller and Mrs Sandy Lord. Dr Duwayne Vermaak, Dr Toni Monni and Dr Faf Labuschagne of Surge Orthopaedics. Mr Stephen Barnsley, Ms Kelsi Greenwood and Mrs Noelle Turnbull for assisting with data collection. Prof Tonya Esterhuizen for assistance with statistics. Dr Jaques van Heerden for initial assistance with protocol development and editing. vii Table of Contents Declaration .................................................................................................................. ii Dedication ................................................................................................................... iii Presentations arising from this Study........................................................................ iv Publications arising from this Study .......................................................................... iv Abstract ....................................................................................................................... v Background ..................................................................................................................... v Method ............................................................................................................................ v Results ............................................................................................................................ v Chapter 1 Conclusion ................................................................................................ v Acknowledgements .................................................................................................... vi List of Tables ............................................................................................................. xiii List of Figures............................................................................................................xiv List of Appendices..................................................................................................... xv List of Abbreviations .................................................................................................xvi Chapter 2 Introduction ............................................................................................... 1 2.1 Background .......................................................................................................... 1 2.2 Problem Statement .............................................................................................. 3 2.3 Aims and Objectives ............................................................................................ 4 2.3.1 To evaluate reported pain and HRQOL in the acute and subacute postoperative phases following SDD in the THA and TKA groups. ........ 4 2.3.2 To compare the reported pain and HRQOL between SDD THA and TKA from the day of discharge to six weeks postoperatively at scheduled intervals after completion of the care pathway. ....................................... 4 2.3.3 To explore patient perceptions and experiences related to patient- reported pain and SDD after THA and TKA. ........................................... 4 2.3.4 To compare patient perceptions and experiences related to patient- reported pain and the SDD process between THA and TKA.................. 4 2.4 Significance ......................................................................................................... 4 viii 2.5 Outline of this Dissertation .................................................................................. 5 Chapter 3 Literature Review ..................................................................................... 6 3.1 Introduction .......................................................................................................... 6 3.2 Search Strategy ................................................................................................... 6 3.3 Arthroplasty .......................................................................................................... 6 3.3.1 Same-day Discharge Arthroplasty ........................................................... 7 3.4 Pain .................................................................................................................... 14 3.4.1 Pain after Arthroplasty ............................................................................ 15 3.5 The Patient Perspective .................................................................................... 17 3.6 Health-Related Quality of Life Measures .......................................................... 22 3.7 Conclusion ......................................................................................................... 22 Chapter 4 Methods .................................................................................................. 24 4.1 Introduction ........................................................................................................ 24 4.2 Study Design ..................................................................................................... 24 4.3 Study Setting ..................................................................................................... 24 4.4 Participants ........................................................................................................ 24 4.4.1 Source of Participants ............................................................................ 24 4.4.2 Sample Size............................................................................................ 25 4.4.3 Sample Selection ................................................................................... 25 4.5 Instrumentation and Outcome Measures ......................................................... 26 4.5.1 Quantitative Data .................................................................................... 26 4.5.1.1 Numerical Rating Scale (NRS) of Pain .......................................... 26 4.5.1.2 The Short-form McGill Pain Questionnaire-2 (SF-MPQ-2) ............ 26 4.5.1.3 The EuroQol 5-Dimension 5-Level and EuroQol Visual Analogue Scale ................................................................................................ 27 4.5.2 Qualitative Data ...................................................................................... 27 4.5.2.1 Semi-structured Interviews ............................................................. 27 4.6 Procedure .......................................................................................................... 28 4.6.1 Pilot Testing ............................................................................................ 28 ix 4.6.1.1 Quantitative Pilot Testing ................................................................ 28 4.6.1.2 Qualitative Pilot Testing .................................................................. 28 4.6.2 Main Study .............................................................................................. 29 4.6.2.1 Same-day Discharge Care Pathway .............................................. 29 4.6.3 Quantitative Data Collection .................................................................. 33 4.6.3.1 Postoperative Numeric Rating Scale of pain intensity on the day of surgery............................................................................................. 33 4.6.3.2 Numeric Rating Scale of pain Intensity .......................................... 33 4.6.3.3 Short-form McGill Pain Questionaire-2, EuroQol 5-Dimension 5- Level and EuroQol Visual Analogue Scale of overall health ......... 34 4.6.4 Qualitative Data Collection ..................................................................... 34 4.7 Ethical Considerations....................................................................................... 34 4.8 Data Reduction .................................................................................................. 35 4.9 Data Analyses.................................................................................................... 36 4.9.1 Quantitative Data Analysis ..................................................................... 36 4.9.2 Qualitative Data Analysis ....................................................................... 36 4.9.3 Merging of Quantitative and Qualitative Data........................................ 37 Chapter 5 Results .................................................................................................... 38 5.1 Introduction ........................................................................................................ 38 5.2 Quantitative Results .......................................................................................... 38 5.2.1 Introduction ............................................................................................. 38 5.2.2 Demographics ........................................................................................ 42 5.2.3 Comparison of baseline preoperative scores between THA and TKA groups ..................................................................................................... 42 5.2.3.1 Comparison of baseline preoperative scores of EQ-VAS; NRS pain and SF-MPQ-2 ................................................................................ 42 5.2.3.2 Comparison of baseline preoperative scores of EuroQol-5D-5L ... 42 5.2.4 Numeric Rating Scale of pain on the day of surgery ............................. 43 x 5.2.4.1 Numeric Rating Scale of pain pre-mobilising and post-mobilising on the day of surgery ........................................................................... 43 5.2.4.2 Comparison between THA and TKA groups of Numeric Rating Scale of pain pre-mobilising and post-mobilising on the day of surgery . 44 5.2.5 Numeric Rating Scale of pain over time ................................................ 45 5.2.6 Short-form McGill Pain Questionaire-2 .................................................. 47 5.2.6.1 Short-form McGill Pain Questionaire-2: Total Score, Continuous Pain, and Intermittent Pain ............................................................. 47 5.2.6.2 Short-form McGill Pain Questionaire-2: Between-group comparison of Total Score, Continuous Pain, and Intermittent Pain ................. 49 5.2.6.3 Short-form McGill Pain Questionaire-2: Neuropathic Pain ............ 50 5.2.6.4 Short-form McGill Pain Questionaire-2: Affective Pain Descriptors ......................................................................................................... 52 5.2.7 EuroQol – Visual Analogue Scale of overall health............................... 53 5.2.8 EuroQol 5-Dimension 5-Level ................................................................ 55 5.2.8.1 EuroQol Dimension 1: Mobility ....................................................... 55 5.2.8.2 EuroQol Dimension 2: Self-care ..................................................... 56 5.2.8.3 EuroQol Dimension 3 Usual Activities ............................................ 58 5.2.8.4 EuroQol Dimension 4 Pain/Discomfort ........................................... 59 5.2.8.5 EuroQol Dimension 5 Anxiety/Depression ..................................... 60 5.2.9 Conclusion of Quantitative Results ........................................................ 61 5.3 Qualitative Results............................................................................................. 61 5.3.1 Introduction ............................................................................................. 61 5.3.2 Demographics ........................................................................................ 62 5.3.3 Total Hip Arthroplasty Thematic Analysis Results ................................ 63 5.3.3.1 Theme 1: Factors Affecting Recovery after SDD THA .................. 63 5.3.3.2 Theme 2: Predominantly Positive Perception of SDD THA ........... 70 5.3.3.3 Theme 3: Perceptions of Pain and Pain Management Strategies 74 xi 5.3.3.4 Summary of the same-day discharge total hip arthroplasty thematic analysis results ................................................................................ 76 5.3.4 Total Knee Arthroplasty Thematic Analysis Results ............................. 77 5.3.4.1 Theme 1: Primarily Positive Perspectives of SDD TKA ................. 78 5.3.4.2 Theme 2: Factors Promoting Recovery in SDD TKA..................... 84 5.3.4.3 Summary of the same-day discharge total knee arthroplasty thematic analysis results ................................................................. 90 5.3.5 Summary of the Qualitative Results ...................................................... 90 5.4 Conclusion of the Quantitative and Qualitative Results ................................... 91 Chapter 6 Discussion .............................................................................................. 92 6.1 Introduction ........................................................................................................ 92 6.2 Quantitative Results Discussion ....................................................................... 92 6.2.1 Introduction ............................................................................................. 92 6.2.2 Quantitative Discussion .......................................................................... 92 6.2.3 Quantitative Discussion Conclusion ...................................................... 98 6.3 Qualitative Results Discussion .......................................................................... 99 6.3.1 Introduction ............................................................................................. 99 6.3.2 Total Hip Arthroplasty Themes .............................................................. 99 6.3.2.1 Theme 1: Factors Affecting Recovery After Same-day Discharge Total Hip Arthroplasty ..................................................................... 99 6.3.2.2 Theme 2: Predominantly Positive Perception of Same-day Discharge Total Hip Arthroplasty .................................................. 101 6.3.2.3 Theme 3: Perceptions of Pain and Pain Management Strategies ....................................................................................................... 103 6.3.2.4 Summary of the Total Hip Arthroplasty Discussion ..................... 104 6.3.3 Total Knee Arthroplasty Themes ......................................................... 106 6.3.3.1 Theme 1: Primarily Positive Perspectives of Same-day Discharge Total Knee Arthroplasty ................................................................ 106 6.3.3.2 Theme 2: Factors Promoting Recovery in Same-day Discharge Total Knee Arthroplasty ......................................................................... 108 xii 6.3.3.3 Summary of the Total Knee Arthroplasty Discussion .................. 109 6.3.4 Comparison of Total Hip Arthroplasty and Total Knee Arthroplasty Themes ................................................................................................. 111 6.3.4.1 Patient-centric Approaches........................................................... 111 6.3.4.2 Collaboration of Stakeholders ...................................................... 111 6.3.4.3 Positive Perception and Efficient Processes ................................ 111 6.3.4.4 Negative Experiences ................................................................... 111 6.3.4.5 Pain Management Strategies ....................................................... 112 6.3.4.6 Participant Collaboration and Responsibility ................................ 112 6.3.4.7 Distinct Recovery Factors ............................................................. 112 6.3.4.8 The Role of Carers ........................................................................ 112 6.4 Integration of Quantitative and Qualitative Discussions ................................. 113 Chapter 7 Conclusion and Recommendations ..................................................... 116 7.1 Introduction ...................................................................................................... 116 7.2 Clinical/Practical Recommendations .............................................................. 116 7.3 Recommendations for Future Research ......................................................... 116 7.4 Strengths and Limitations ................................................................................ 117 7.5 Summary.......................................................................................................... 118 Reference List ............................................................................................................. 119 Appendix ..................................................................................................................... 127 xiii List of Tables Table 2.1 Categories reported in the systematic review conducted by Makimoto et al. (2020) ............................................................................................................................ 21 Table 3.1 Inclusion and exclusion criteria of the participants...................................... 25 Table 3.2 Quantitative Data Collection Schedule ........................................................ 33 Table 4.1 Descriptive stats and sample sizes at each time point for EQ-VAS, NRS of pain and SF-MPQ-2...................................................................................................... 40 Table 4.2 Descriptive statistics and sample sizes at each time point for EuroQol 5- Dimension 5-Level ........................................................................................................ 41 Table 4.3 Comparison of baseline preoperative scores between THA and TKA groups ...................................................................................................................................... 42 Table 4.4 Comparison of baseline preoperative EuroQol Dimension 2-Self-care between THA and TKA groups .................................................................................... 43 Table 4.5 Pre- and post-mobilising Numeric Rating Scale of pain on the day of surgery. ...................................................................................................................................... 44 Table 4.6 Comparing THA and TKA groups pre- and post-mobilising Numeric Rating Scale of pain on the day of surgery ............................................................................. 44 Table 4.7 Numeric Rating Scale of pain over time ...................................................... 46 Table 4.8 Short-form McGill Pain Questionaire-2: Total Score, Continuous Pain, and Intermittent Pain ........................................................................................................... 48 Table 4.9 Comparison of THA and TKA Group's Short-form McGill Pain Questionaire- 2: Total Score, Continuous Pain, and Intermittent Pain .............................................. 50 Table 4.10 Short-form McGill Pain Questionaire-2 Neuropathic Pain ........................ 51 Table 4.11 SF-MPQ-2: Affective Pain Descriptors THA and TKA .............................. 53 Table 4.12 EuroQol-VAS: THA and TKA ..................................................................... 54 Table 4.13 EuroQol Dimension 1: Mobility .................................................................. 56 Table 4.14 EuroQol Dimension 2: Self-care ................................................................ 57 Table 4.15 EuroQol Dimension 3: Usual Activities ...................................................... 59 Table 4.16 EuroQol Dimension 4: Pain/Discomfort ..................................................... 60 Table 4.17 EuroQol Dimension 5: Anxiety/Depression ............................................... 61 xiv List of Figures Figure 1.1 Outline of the dissertation ............................................................................. 5 Figure 3.1 Overview of the Qualitative Data Analysis Process ................................... 37 Figure 4.1 Overview of quantitative results presentation ............................................ 39 Figure 4.2 Sex distribution of quantitative study participants ...................................... 42 Figure 4.3 Comparison of mean NRS of pain pre- and post-mobilising on the day of surgery .......................................................................................................................... 45 Figure 4.4 Comparison of THA and TKA NRS of pain over time ................................ 47 Figure 4.5 Comparison of THA and TKA Neuropathic Pain over time ....................... 52 Figure 4.6 EuroQol-VAS comparison of THA and TKA groups .................................. 55 Figure 4.7 EQ2 – Self-care Comparison of THA and TKA Groups ............................ 58 Figure 4.8 Sex distribution of qualitative study participants ........................................ 62 Figure 4.9 Same-Day Discharge THA Thematic Analysis .......................................... 63 Figure 4.10 Sub-theme 1 of same-day discharge total hip arthroplasty ..................... 64 Figure 4.11 Theme 2 of same-day discharge total hip arthroplasty ........................... 71 Figure 4.12 Overview of same-day discharge total knee arthroplasty thematic analysis ...................................................................................................................................... 77 Figure 4.13 Percentage of positive and negative comments regarding the experience of same-day discharge total knee arthroplasty ............................................................ 78 Figure 5.1 Theme 2: Predominantly positive perception of same-day discharge total hip arthroplasty ........................................................................................................... 102 Figure 5.2 Relationships between themes in same-day discharge total hip arthroplasty .................................................................................................................................... 106 Figure 5.3 Perspectives of same-day discharge total knee arthroplasty .................. 107 Figure 5.4 The relationship between themes in same-day discharge total knee arthroplasty ................................................................................................................. 110 Figure 5.5 Integrating qualitative and quantitative results ......................................... 114 Figure 5.6 Unique considerations for same-day discharge total knee arthroplasty . 115 xv List of Appendices Appendix A Numeric Rating Scale of pain ................................................................. 127 Appendix B Short-form McGill Pain Questionnaire-2 ................................................ 128 Appendix C EuroQol 5-Dimension 5-Level and Visual Analogue Scale of overall health .................................................................................................................................... 129 Appendix D Semi-structured Interview Guide............................................................ 133 Appendix E Participant Information Sheet and Informed Consent Document ......... 135 Appendix F Same-day Discharge Care Pathway ...................................................... 138 Appendix G Ethics Approval Certificate ..................................................................... 139 Appendix H Reflective Journal Total Hip Arthroplasty .............................................. 140 Appendix I Reflective Journal Total Knee Arthroplasty ............................................. 163 Appendix J Baseline preoperative scores for EQ-VAS, NRS of Pain and ................ 177 Appendix K Interview Transcript H38 ........................................................................ 181 Appendix L Turnitin Report ........................................................................................ 189 Appendix M Quantitative Data Analysis……………………………………………….. 190 xvi List of Abbreviations ADL Activities of daily living ARP Advanced rehabilitation pathways ASC Ambulatory Surgical Centre DVT Deep vein thrombosis ERAS Enhanced recovery after surgery EQ-5D-5L EuroQol 5-Dimension 5-Level EQ-VAS EuroQol Visual analogue scale of overall health GEE Generalised estimating equation HADS Hospital and Anxiety Depression Scale HOOS-PS Hip Injury and Osteoarthritis Score Physical Function Short Form HRQOL Health-related quality of life IASP International Association for the Study of Pain IDT Interdisciplinary team KOOS Knee Injury and Osteoarthritis Outcome Score KSS Knee Society Score LLA Lower limb arthroplasty LOS Length of stay MCID minimal clinically important difference NRS Numeric Rating Scale OA Osteoarthritis OKS Oxford Knee Score PASS patient-acceptable symptomatic state PROM Patient-reported outcome measure RSA Republic of South Africa SDD Same-Day Discharge SF-MPQ-2 Short-form McGill Pain Questionnaire-2 SPSS Statistical Package for Social Sciences TKA Total knee arthroplasty THA Total hip arthroplasty UKA Unicompartmental knee replacement VAS Visual Analogue Scales VRS Verbal Rating Scales xvii USA United States of America WOMAC Western Ontario and McMaster Universities Osteoarthritis Index 1 Chapter 1 Introduction 1.1 Background The development of specific protocols has made it possible to shorten the length of stay after lower limb arthroplasty. Healthcare providers focusing on patient selection, education, and preparation can reduce length of stay (LOS), and discharge can occur within 24 hours of admission. Same calendar day discharge (SDD) following lower limb arthroplasty (LLA) is defined as discharge on the date of surgery incurring no overnight stay (Scully et al., 2020; Gromov et al., 2019). The discharge of selected patients from hospitals, day hospitals, and ambulatory surgical centre (ASC) settings has grown in popularity internationally (Scully et al., 2020; Hoeffel et al., 2019). However, total knee arthroplasty (TKA) and total hip arthroplasty (THA) as SDD are novel concepts that were recently introduced in the Republic of South Africa (RSA) in 2020. The traditional length of stay after LLA has a wide reported range in the literature (one – 21 days); in South Africa, traditional length of stay protocols range from four to seven days (Immelman et al., 2018). The essential elements of an SDD LLA care pathway, according to the American Association of Hip and Knee Surgeons and the American Academy of Orthopaedic Surgeons, include patient selection, patient education and expectation management, good social support, clinical and surgical team experience and expertise, conducive facility environment to optimise surgical outcomes, and evidence-based pathways for pain management, blood conservation, wound management, mobilisation, and venous thromboembolism prophylaxis (Scully et al., 2020). Hoeffel et al. (2019) echoed these elements, particularly for SDD LLA conducted in ASCs. Researchers abroad have conducted numerous quantitative studies on SDD LLA. There appears, however, to be limited research on SDD following LLA in South Africa. International studies have addressed the safety, complications, patient-reported outcomes, and efficacy of SDD TKA and THA (Jaibaji et al., 2020; Rosinsky et al., 2020; Xu et al., 2020; Gromov et al., 2019; Pollock et al., 2016; Hawker et al., 2011). SDD LLA is a safe alternative to traditional LOS (Jaibaji et al., 2020; Rosinsky et al., 2020; Gromov et al., 2019). Studies of patient-reported outcome measures (PROM) 2 have shown an improvement in SDD compared to inpatient or traditional LOS THA (Rosinsky et al., 2020). SDD and inpatient LLA complications were comparable (Gromov et al., 2019; Pollock et al., 2016). Comparative studies between SDD and lengthier stays following LLA have proven SDD after THA and TKA feasible and successful (Scully et al., 2020; Goyal et al., 2017). Few qualitative studies have explored SDD LLA. In Canada, Churchill et al. (2018) investigated the experiences and perspectives of patients and their primary caregivers after either SDD or inpatient THA. They reported high patient and caregiver satisfaction after the implementation of SDD THA. The authors highlight concerns and challenges regarding patient expectations for recovery, medications and their impact on mobility, timing of postoperative education, availability of formal care, self-care, caregiver support, and pain. The adverse effects of acute pain related to LLA, as listed by Pinto et al. (2017) includes increased hospital stay and cost, the possibility of developing chronic pain, and the detrimental effects on both physiological and psychological states. A study on the early recovery phase in patients after THA and TKA revealed pain as one of several prominent themes (Strickland et al., 2018). Similarly, Husted et al. (2011) identified pain as one of the leading clinical reasons for an increased LOS after THA and TKA. Pain is one of the most common reasons for failed SDD after THA (Fraser et al., 2018). Goyal et al. (2017) found more significant pain on the first day after surgery in a SDD THA group when compared to an inpatient group. The reason for this pain was attributed to the increased activity levels required for SDD. The authors suggest that patients may require more counselling regarding pain management and their expectations. Pinto et al. (2017) noted that most published evidence comparing THA and TKA postoperative pain is related to chronic postoperative pain, indicating a need for more research in the acute postoperative phase. This highlights the rationale for addressing acute postoperative pain in patients following SDD LLA. Hoeffel et al. (2019) described increased pain immediately postoperatively and 48 hours later in both SDD THA and TKA, the latter reporting greater pain intensity. Similarly, when comparing the differences between THA and TKA, Pinto et al. (2017) reported increased pain after TKA. Using postoperative morphine usage as a parameter, Pang et al. (2000) found that TKA patients required more morphine than 3 THA patients in traditional LOS following LLA. The current SDD care pathway related to this protocol prescribes identical postoperative analgesia for THA and TKA. However, Pinto et al. (2017) argued that THA and TKA should at least be approached separately regarding the management of acute postoperative pain. Investigating the differences between the two surgeries concerning acute postoperative pain will shed further light on this subject. 1.2 Problem Statement International studies have compared SDD with inpatient THA and TKA and have demonstrated that SDD can be performed safely with similar outcomes (Bodrogi et al., 2020). Researchers have conducted few qualitative or mixed-method studies to establish the patient's perspective of SDD LLA and link these to numerous quantitative findings. Pain experienced after SDD in THA and TKA is a frequently identified topic (Churchill et al., 2018; Fraser et al., 2018; Strickland et al., 2018; Goyal et al., 2017; Husted et al., 2011). However, only a few studies have focused on acute postoperative pain after THA and TKA. Furthermore, researchers primarily conducted pain studies on standard LOS LLA but not SDD. Few studies have compared pain experienced after THA and TKA (Pinto et al., 2017). This difference suggests that TKA is more painful during the initial stages of recovery (Hoeffel et al., 2019; Pinto et al., 2017; Pang et al., 2000). There is limited published research on SDD hip and knee arthroplasty in the RSA. The pertinence of SDD THA and TKA in the South African context can be established with reproducible local research using outcome measures, such as those used in international studies. 4 1.3 Aims and Objectives This study aimed to explore, evaluate, and compare patients' perspectives, experiences, pain, and health-related quality of life (HRQOL) following SDD after THA and TKA. The objectives of the study were: 1.3.1 To describe reported pain and HRQOL in the acute and subacute postoperative phases following SDD in the THA and TKA groups. 1.3.2 To compare the reported pain and HRQOL between SDD THA and TKA from the day of discharge to six weeks postoperatively at scheduled intervals after completion of the care pathway. 1.3.3 To explore patient perspectives and experiences related to patient-reported pain and SDD after THA and TKA. 1.3.4 To compare patient perspectives and experiences related to patient-reported pain and the SDD process between THA and TKA. 1.4 Significance Same-day discharge LLA is a new concept and clinical pathway introduced in the RSA in 2020 (Prinsloo and Keller 2021). It challenges the status quo in the private sector regarding traditional LOS following LLA. The global trend toward universal health coverage continues to gain ground as a major health priority. The transformation of the healthcare system, particularly in the South African context, is being called for to change how healthcare is financed and organised (Michel et al., 2019). This study will potentially add to the knowledge base specifically in the South African setting, providing a basis for future research, potentially informing healthcare transformation, and encouraging alignment with evidence-based international trends in LLA. 5 Outline of this Dissertation Figure 1.1 provides an overview of the sections and the structure of this dissertation Figure 1.1 Outline of the dissertation 6 Chapter 2 Literature Review 2.1 Introduction Chapter Two reviews the concepts related to this study's research aim and objectives. The focus is on hip and knee arthroplasty and the shift toward SDD following arthroplasty. Additionally, the literature regarding pain, the patient's perspective, and health-related quality of life following arthroplasty is explored. 2.2 Search Strategy Evidence was sourced from online databases, including PubMed, CINAHL, PEDro, Science Direct, and Google Scholar. English articles published between January 2000 and January 2024 were filtered. Given the recent dramatic increase in the occurrence of SDD LLA (Clouette et al., 2020), emphasis was placed on more recent publications from 2010 onwards. Keywords and terms used in the search were “arthroplasty”, "same day discharge," "same calendar day discharge," "day surgery," "outpatient surgery," "ambulatory surgery," "enhanced recovery after surgery," "pain", "acute pain," "orthopaedic surgery", "health-related quality of life," "knee arthroplasty", "hip arthroplasty", "postsurgical complications" and "patient perspective." The search terms were supplemented with relevant free text terms. Database searches were complemented by sourcing additional articles by manually reviewing the reference lists of the relevant articles. 2.3 Arthroplasty Studies have confirmed the safety and efficacy of THA and TKA as the gold standard and definitive treatment for end-stage osteoarthritis (OA) of the hip and knee (Mandl 2013). An ageing population is projected to cause a dramatic increase in the volume of total joint arthroplasty in the United States of America (USA) by 2030. By 2030, projections indicate a 71% increase to 635 000 procedures per year for THA and an 85% increase to 1.26 million procedures per year by 2030 (Sloan et al., 2018). Unfortunately, no projections are available for the RSA as relevant registry data have not been recorded since 2015 (mandatory reporting of arthroplasties in SA is not required (Ashforth & Dymond 2023)). However, an ageing population has increased the demand for arthroplasty in keeping with global trends. The RSA public health sector provides healthcare to 84% of the population, and there is increasing pressure on 7 arthroplasty waiting lists (Sekeitto and Aden 2021). The media has reported waiting lists of up to seven years for total joint arthroplasty (Rahlaga 2016). Sekeitto and Aden (2021) noted the economic burden of traditional LOS arthroplasty and a strained public healthcare budget, indicating the need to reduce costs by shortening LOS. Inpatient admissions were reported to contribute 18,47% of the total costs of primary THA in the public health sector. The expected increase in LLA due to a growing need in younger, healthier, and more active patient populations, as well as the rising burden on healthcare systems, are driving the shift toward earlier discharge, including SDD options (Sloan et al., 2018; Klein et al., 2017; Kurtz et al., 2007; Kurtz et al., 2009). Advances in surgical techniques, prostheses, anaesthetics, and postoperative care have led to the possibility of shorter LOS following THA and TKA (Stambough et al., 2015). 2.3.1 Same-day Discharge Arthroplasty In this study, SDD refers to patients discharged home on the same calendar day as the procedure. Distinguishing SDD is necessary, as researchers often label discharge within 23 hours after surgery as "outpatient" arthroplasty despite incurring an overnight stay (Bodrogi et al., 2020). Inpatient LLA refers to THA or TKA that requires at least one overnight hospital stay (Bovonratwet et al., 2017). The essential elements of an SDD LLA care pathway, according to the American Association of Hip and Knee Surgeons and the American Academy of Orthopaedic Surgeons, include patient selection, education, social support, clinical expertise, facility optimisation, and evidence-based pain management (Scully et al., 2020). A clinical care pathway is an operational tool used to ensure best practice. A local and specific interdisciplinary team usually designs the clinical guidelines within a care pathway, ensuring consistent care delivery for a specific condition (Hipp et al., 2016). Same-day discharge in LLA has shown promise in terms of safety and efficacy, with multiple studies demonstrating comparable complication rates, improved PROMs, improved patient satisfaction, similar readmission rates, and reduced costs compared to inpatient LLA (Almand et al., 2022; Lan et al., 2021; Jaibaji et al., 2020; Rosinsky et al., 2020; Scully et al., 2020; Darrith et al., 2019; Gogineni et al., 2019; Gromov et al., 2019; Sershon et al., 2019; Hoffmann et al., 2018; Shah et al., 2018; Toy et al., 2018; 8 Goyal et al., 2017; Parcells et al., 2016; Pollock et al., 2016). These studies indicated favourable and similar outcomes to traditional LOS; however, one must be aware of their retrospective nature, small study populations, and the potential for researcher bias. In the last five years, researchers have conducted six systematic reviews and meta- analyses regarding SDD LLA, which will now be discussed chronologically. Xu et al. (2020) compared the postoperative complication rates in outpatients and inpatients following LLA. Subgroup analyses of the THA and TKA groups were also performed. Seven studies were included, including 176 179 inpatients and 1613 outpatients. Overall, outpatient LLA had complication rates comparable to inpatient LLA. The researchers recommended the careful preoperative selection of patients to optimise outcomes. The Bordoni et al. (2020) systematic review and meta-analysis aimed to quantitatively evaluate and compare outpatient TKA complications and readmission rates with inpatient TKAs. Eight studies with 212 632 patients were included. Their findings indicated that outpatient TKAs led to a slightly higher number of complications than inpatient TKA and no difference in readmission rates. The systematic review and meta-analysis by Bemelmans et al. (2022) included 41 studies (totalling 40 758 patients undergoing outpatient LLA) conducted in the USA, Europe, Denmark, and Canada. This study aimed to compare the safety and efficacy of SDD LLA with inpatient LLA pathways. Seven of these studies reported on PROMs which included the Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Knee Score (OKS), EuroQoL 5-Dimension 5-Level (EQ-5D-5L), Visual Analogue Scale (VAS) for pain, and various patient satisfaction questionnaires. The review reported similar PROM results when comparing SDD and inpatient LLA. A meta-analysis of outpatient TKA conducted by Migliorini et al. (2021a) aimed to compare inpatient versus outpatient TKA PROMs, infection rates, revision rates, deep vein thrombosis (DVT) incidence, and mortality rates. Ten studies with a total of 159 219 patients were included. Their findings indicated greater rates of revision, mortality, 9 and DVT in inpatients than in outpatients. The inpatient and outpatient groups had similar OKS, readmission, and infection rates. The same authors conducted a meta-analysis of outpatient THA (Migliorini et al., 2021b). The authors aimed to investigate the potential advantages of outpatient THA. This study included 16 studies with a total of 102 839 patients. The authors found no differences in pain, infections, mortality, revision rates, rates of dislocation, and hospital readmissions. However, the outpatient group had a significantly higher DVT rate. Li et al. (2022) conducted the final systematic review and meta-analysis. The authors aimed to compare mortality, readmission, and complications between SDD LLA and inpatient LLA. Fourteen studies, including 222 766 patients, were included (10 062 SDD and 212 704 inpatients). The results indicated similar mortality and complication rates between the SDD and traditional inpatient LOS groups; however, there was a significantly higher risk of complications in SDD when comparing SDD to enhanced recovery after surgery (ERAS) LLA. Same-day discharge had a lower risk of infection but a higher risk of DVT and renal complications in the comparison. Further systematic reviews comparing SDD and inpatient LLA studies conducted over the past ten years will be explored below. A systematic review conducted by Pollock et al. (2016) examined the evidence regarding the safety and feasibility of performing LLA on an outpatient basis. Their review included 17 studies with 79 500 patients. Their findings revealed low and comparable complication rates to traditional LOS LLA, no difference in readmission rates, and improved Harris Hip Scores (HHS). Hoffman et al. (2018) included ten publications with 1009 patients. Their review refuted their hypothesis that SDD LLA would lead to increased readmission rates and complications compared with inpatient LLA. Functional assessment scores (PROMs) revealed mixed results, with no differences or significant improvements. The scores used included the KSS, HHS, and VAS for pain. 10 Bodrogi et al. (2020) reviewed observational and interventional research on the effectiveness of SDD LLA. The number of included studies was not reported in their paper. They reported that the safety of SDD LLA, PROM scores, pain scores, and patient satisfaction were equal to those of inpatient LLA. PROMs included KOOS, KSS, WOMAC, OKS, VAS for pain, and HHS. However, the authors highlighted that these findings are relevant to a subset of carefully selected patients. The systematic review by Jaibaji et al. (2020) included 19 studies with 6519 surgeries—the review aimed to assess the complication and reoperation rates of outpatient arthroplasty. Despite the consistently low readmission and reoperation rates, the authors indicate that it is difficult to draw firm conclusions regarding the safety of outpatient LLA from the available data. This is due to the reviewed studies having small study samples and poor methodological designs. Furthermore, studies that were used to compare outpatient arthroplasty with traditional LOS had significant differences in the age and activity levels of participants (outpatient studies had younger and more active participants). Shapira et al. (2021) conducted a systematic review focusing on the analysis of the outcomes of SDD THA and included nine studies with a total population of 683. This review reported significant improvements in pain scores in the SDD THA cohort. At the latest follow-up, on average, HHS achieved a minimal clinically important difference (MCID) and patient-acceptable symptomatic state (PASS). In their systematic review, Pollock et al. (2016) reported that HHS was significantly higher, with low complication rates and no difference in long-term complications between SDD and inpatient groups after surgery. Furthermore, no differences in the readmission rates were observed. Their review included 17 articles with approximately 79,500 patients and focused on the safety and feasibility of SDD for LLA. A comparison of the findings from these systematic reviews, meta-analyses, and additional literature follows. When considering readmission rates, most systematic reviews have found similar or equal readmission rates (Bemelmans et al., 2022; Shapira et al., 2021; Migliorini et al., 2021a; Migliorini et al., 2021b; Bordoni et al., 2020; Bodrogi et al., 2020; Li et al., 2019; 11 Hoffmann et al., 2018; Pollock et al., 2016). Jaibaji et al. (2020) reported low readmission rates following SDD LLA. Migliorini et al. (2021b) reported increased revision surgery in inpatient TKA compared to SDD TKA (p=0.03). Conversely, Xu et al. (2019) reported increased reoperation rates following SDD LLA (THA and TKA). Low, equal, and no differences between SDD and inpatient reoperation rates have also been reported (Bodrogi et al., 2020; Jaibaji et al., 2020; Hoffmann et al., 2018). Major and minor complications following SDD LLA were reported to be equal or similar to inpatient LLA (Bemelmans et al., 2022; Bodrogi et al., 2020; Xu et al., 2020; Hoffmann et al., 2018; Pollock et al., 2016). Li et al. (2021) report increased complications after SDD compared to ERAS LLA, listing increased risk of DVT, renal impairment and renal failure. However, they reported a decreased risk of postoperative infections in SDD LLA. Contradictory findings were reported, specifically in SDD TKA regarding complications, with a significantly higher risk of complications during SDD (Bordoni et al., 2020). Conversely, Migliorini et al. (2021b) reported a greater risk of mortality (p=0.003) and DVT (p=0.005) after inpatient TKA. There was no significant difference in the occurrence of serious adverse events between the SDD and inpatient LLA groups. Contradictions in the available literature related to complications following SDD LLA are varied and evident, indicating a need for further research. Equal or similar outcomes for PROMs have been reported when comparing SDD and inpatient LLA (Bemelmans et al., 2022; Bodrogi et al., 2020; Hoffmann et al., 2018). Migliorini et al. (2021b) reported greater Oxford Knee Scores (p=0.01) in SDD participants compared to inpatient TKA. Systematic reviews that included patient satisfaction reported patient satisfaction rates of 96% with an SDD LLA (Hoffmann et al., 2018). Bodrogi et al. (2020) reported that 80–96% of patients with SDD LLA would undergo SDD again if they had to. An interesting thread revealed in most of these systematic reviews and meta-analyses is the importance of patient selection to ensure safety and favourable outcomes in SDD LLA. Many authors specify that their results apply to select patient populations and patients with no significant comorbidities (Bemelmans et al., 2022; Shapira et al., 2021; Bodrogi et al., 2020; Xu et al., 2020; Pollock et al., 2016). 12 Although these systematic reviews and meta-analyses are considered Level 1 evidence, they have similar limitations. A significant limitation of all the studies was the heterogeneity of the included study samples regarding inclusion and exclusion criteria, study settings, healthcare systems, discharge criteria, implants, surgical techniques, selection criteria, standardised protocols, and outcome measures used (Li et al., 2022; Bemelmans et al., 2022; Shapira et al., 2021; Migliorini et al., 2021a; Migliorini et al., 2021b; Xu et al., 2020; Jaibaji et al., 2020; Bordoni et al., 2020; Bodrogi et al., 2020; Hoffmann et al., 2018; Pollock et al., 2016). The generalisability of the results is thereby limited, which often leads to inconclusive findings as evidenced above. Other limitations highlighted in the systematic reviews were the retrospective observational nature and poor study design (Bemelmans et al., 2022; Li et al., 2022; Migliorini et al., 2021a; Migliorini et al., 2021b; Bordoni et al., 2020; Jaibaji et al., 2020; Hoffmann et al., 2018; Pollock et al., 2016), small sample sizes (Migliorini et al., 2021a; Migliorini et al., 2021b; Bordoni et al., 2020; Jaibaji et al., 2020), moderate to high levels of bias (Bemelmans et al., 2022; Migliorini et al., 2021a; Migliorini et al., 2021b; Bordoni et al., 2020; Jaibaji et al., 2020; Hoffmann et al., 2018; Pollock et al., 2016), and lack of long term follow up of discharged patients (Bemelmans et al., 2022; Shapira et al., 2021; Xu et al., 2020). Studies that indicated increased complications associated with SDD, especially cardiac and pulmonary complications, were found for TKA but not THA. Nowak and Schemitsch (2019) indicated reduced major and minor complications after TKA when discharged on day one or two after surgery, as opposed to SDD and more extended hospital stays. The Liu et al. (2019) and Nowak & Schemitsch (2019) studies both had limitations in that they were population-based retrospective studies, limited by accurateness and completeness of data collection. The studies only looked at readmission rates, not emergency department visits, and only included the 30 days after surgery. The Liu et al. (2019) study investigated both THA and TKA, whereas Nowak and Schemitsch (2019), like Bordoni et al. (2020) only considered TKA cohorts. The systematic review by Bordoni et al. (2020), which indicated a slightly higher number of complications in outpatient TKA patients, included a low level of comparative studies and was affected by a moderate risk of bias, affecting the quality of evidence. The authors also indicated low proof levels for complications and readmissions. Bovonratwet et al. (2017) suggested that TKA SDD should be 13 considered in select patients; however, higher surveillance of these patients post- discharge is warranted. Despite the mixed findings regarding complications in SDD LLA, Clouette et al. (2020) indicated dramatic increases in the number of SDD LLAs in the USA before the COVID- 19 pandemic, with increases of 0.95% to 20.5% from 2011 to 2016 (Clouette et al., 2020). The COVID-19 pandemic has further accelerated the use of SDD pathways to decrease the inpatient burden in the USA. Despite these increases, Mitchell et al. (2023) recently found no difference in emergency department visits, readmissions, or reoperations in patients with SDD. In summary, SDD LLA has equal or improved outcomes in terms of reoperation rates, readmissions, mortality, and PROMs (including pain scores). There is however evidence of higher complication rates, which tend to be associated with TKA. The limitations of the current literature (as mentioned earlier) make it difficult to draw firm conclusions from the available data. Prospective randomised and multicentre studies with larger sample sizes would increase the current evidence regarding SDD LLA internationally (Migliorini et al., 2021b; Bordoni et al., 2020). Few local studies on SDD have been published in the RSA. A recent study by Prinsloo and Keller (2022), on implementing advanced rehabilitation pathways (ARP) in TKA and THA, was conducted in a private healthcare setting in the RSA. In the prospective group of elective THA and TKA patients, 66% of the participants achieved SDD safely. The implementation of ARP resulted in statistically significant: less pain at six weeks, less stiffness, and higher function, with 98% patient satisfaction and lower total costs compared to a retrospective group that followed traditional LOS and rehabilitation pathways (Prinsloo & Keller 2022). To our knowledge, this is the first published local study to record SDD in LLA. According to Bosch (2023), the presentation of the first SDD arthroplasty cases at a local congress caused a stir in the South African arthroplasty community. These congress presentations have not yet been published; however, they indicate safety and excellent clinical outcomes at six-month follow-ups in 602 patients within the South African context. 14 It is important to note that although we now have published research on local SDD in LLA, we cannot yet draw firm conclusions to compare the South African research findings with international findings. The small sample size, retrospective component, single centre, and single surgeon study population of the Prinsloo and Keller (2022) research has limitations similar to those found in international studies. As mentioned earlier, the same principles apply to national studies regarding SDD LLA; prospective, randomised, multicentre studies with larger study populations are required (Migliorini et al., 2021a; Bordoni et al., 2020). Other local studies have focused on ERAS protocols. A study reviewing a retrospective cohort of elective TKA patients following ERAS protocols found significantly reduced LOS without compromising patient safety or functional outcomes compared to a traditional length of stay cohort (Beukes et al., 2022). A similar study on ERAS in THA had the same outcomes (Immelman et al., 2018). Although this was not a study specifically on SDD, it indicates a trend in SA toward reducing LOS without compromising safety. These local studies were conducted in the private healthcare sector, which provides optimal resources. A study by Plenge et al. (2020), looking at the quality of recovery in THA and TKA performed in the public health sector (with limited resources), suggested that the quality of patient care and postoperative recovery may improve with the implementation of ERAS principles. 2.4 Pain In 2020, The International Association for the Study of Pain (IASP) revised its definition of pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage (Raja et al., 2020). Pain is often categorised temporally into acute, sub-acute, and chronic stages. The classification of acute and sub-acute pain varies in the literature; the overlapping periods for these stages of pain create the impression that subacute pain typically occurs between one and two months or six–12 weeks after the commencement of acute pain (Banerjee & Argáez 2019). Acute pain, as defined by Carr and Goudas (1999), is a normal physiological response to adverse stimuli such as surgery, trauma, or critical illness. Acute pain is commonly measured using unidimensional, validated tools that do not consider the complexity of the biopsychosocial factors of an individual (Gordon 2015). The importance of understanding the complexity, prevalence, and effective treatment of acute pain has 15 become more evident in recent years. The global prevalence of acute pain as the primary reason for emergency department visits has been reported to range from 43% (Wu et al., 2022) to 74% (Daoust et al., 2019; Keating & Smith 2011). Local research is limited in this field; however, Lourens et al. (2020) alluded to a similar prevalence of acute pain with limited evidence of adequate pain assessment and ineffective management in South African prehospital settings. Acute postsurgical pain is a form of acute pain which can be severe and occurs in about 80% of surgery patients (Coley et al., 2002). Effective and early management of acute pain may lead to a decreased potential for chronic pain by preventing the transition of the underlying pain mechanisms. Gan (2017) listed the negative consequences of suboptimal acute pain management in surgery patients as increased morbidity, impaired physical function and quality of life, slow recovery, prolonged opioid use, and increased cost of care. 2.4.1 Pain after Arthroplasty Orthopaedic patients often experience moderate to severe postoperative pain, making it a frequent research subject. The severity of pain after arthroplasty, particularly TKA, is a significant concern. Acute postoperative pain, particularly in TKA, is often poorly managed pharmacologically and is reported to be more severe than in THA (Gerbershagen et al., 2013; Wylde et al., 2011). Li et al. (2019) reported that 60% of TKA patients experience severe postoperative knee pain, with 30% experiencing moderate pain. Acute postoperative pain can hinder early ambulation and range of motion, potentially leading to complications such as thromboembolism and affecting overall rehabilitation and patient satisfaction. Acute pain in lower-limb arthroplasty has further adverse effects, including increased length of hospital stay and cost, potential development of chronic pain, and detrimental effects on physiological and psychological states (Pinto et al., 2017). Pain is often identified as one of the main reasons for increased hospital stays following THA and TKA (Husted et al., 2011). Hoeffel et al. (2019) described increased pain immediately postoperatively and 48 hours later in both SDD THA and TKA, the latter reporting greater pain intensity. Similarly, when comparing the differences between THA and TKA, Pinto et al. (2017) 16 reported increased pain after TKA. Using postoperative morphine usage as a parameter, Pang et al. (2000) found that TKA patients required more morphine than THA patients in traditional LOS. Similarly, Andersen et al. (2009) found insufficient analgesia in the subacute phase after TKA compared with THA participants. They called for improvements and additional components of their multimodal pain regimen for TKA (Andersen et al., 2009). Salmon et al. (2001) found that pain and function improved significantly less in TKA than in THA six months following surgery. Pinto et al. (2017) argued that THA and TKA pain management should be addressed separately to optimally manage acute pain. Neuropathic pain is defined as "pain arising as a direct consequence of a lesion or disease affecting the somatosensory nervous system “ (Treede et al., 2008). It is characterised by burning, stabbing, and electric shock-like warning sensations. These may present as sharp, dull, painful, pressurised, or deep neuropathic itching (Şahin et al., 2021). The rates of neuropathic pain following TKA are reported to be between 5% as early as six months postoperatively (Phillips et al., 2014) and 6% at three to four years postoperatively (Wylde et al., 2011). The neuropathic pain experienced after TKA is most likely due to local peripheral nerve trauma caused by mechanical forces which are applied intraoperatively as well as potentially being caused by immune- mediated inflammation (Speelziek et al., 2019). Pain caused by OA involves both peripheral and central sensitisation, modulated by environmental, psychological, genetic, and neurochemical factors (Ohashi et al., 2023). The degree of nociplastic pain before TKA may relate to the risk of persistent pain after TKA (Lundblad et al., 2008). The combination of nociplastic pain, peripheral sensitisation and the acute nociceptive stimulation experienced following TKA may contribute to postoperative neuropathic pain and the development of chronic postoperative pain in TKA (Vergne-Salle 2016). The introduction of multimodal analgesia as the preferred method of pain management following orthopaedic surgery has been effective in addressing the concerns and adverse effects of acute postsurgical pain (Hartman et al., 2022). This includes the principle of combining multiple modes of pain management. By using analgesics with different mechanisms of action (opioid and non-opioid medications) (Hartman et al., 2022), psychotherapy, physiotherapy, regional anaesthesia, local injections, non- 17 opioid medications, and multidisciplinary collaboration, superior pain control is achieved with accelerated recovery and overall increased patient satisfaction (Chunduri & Aggarwal 2022; Hsu et al., & the Orthopaedic Trauma Association Musculoskeletal Pain Task Force 2019). Prinsloo and Keller (2021) reported increased physiotherapy frequency on the day of surgery, the use of regional nerve blocks, and multidisciplinary team involvement in their protocol for SDD THA and TKA in SA. Their findings revealed significantly less pain, stiffness, and function and increased total WOMAC scores at six-week and three-month follow-ups. This finding supports combining multiple pain management modes, as Hartman et al. (2022) suggested. 2.5 The Patient Perspective The patient's perspective is crucial in healthcare research, as it encourages a patient- centred approach. Turner and Archer (2020) reported that improved relationships between healthcare providers and their patients improved health outcomes and reduced costs. Investigating patients' perspectives in emerging fields such as SDD LLA will potentially lead to improved health outcomes. Quantitative studies on SDD LLA outnumber qualitative studies (Scully et al., 2020; Churchill et al., 2018). Two qualitative studies were found, including SDD-THA. These were the Churchill et al. (2018) and the recent Boogmans et al. (2023) studies. No qualitative studies including SDD TKA alone, have been conducted. Qualitative studies of ERAS LLA are more prevalent and will be explored further. Churchill et al. (2018) conducted in-depth semi-structured interviews with patient and primary carer dyads. Twenty-eight patients who underwent THA were included, with 16 undergoing the SDD care pathway and 12 receiving standard LOS care. Thematic and content analyses were applied to the interview data. Three themes were developed: "Supporting the transition home," "Challenges for transitioning home," and "Unique considerations for SDD." The latter included sub-themes including satisfaction with SDD, having higher expectations for recovery following SDD, optimal timing of education for the patient and caregiver to reduce stress and confusion, adjusting expectations for recovery due to increased pain, and the benefit of being at home despite minimal issues with anaesthesia side-effects. The Churchill et al. (2017) study was limited in that the results were only generalisable to a few specific centres providing SDD THA, and interviews were conducted in English, which was not necessarily in a participant's home language. 18 Boogmans et al. (2023) conducted 15 interviews with open-ended questions regarding the pre-, peri-, and postoperative experience following the SDD THA care pathway. Four main themes were identified, "Multimodal preoperative education is essential for reducing stress and increasing self-confidence in SDD-THA", "The day of surgery was not experienced as stressful," "Uncertainty of SDD due to fear of the unknown," "Inadequate postoperative pain management was a frequent problem." The need for a "(para)medical and social safety net" was vital for a successful SDD (Boogmans et al., 2023). Three qualitative studies were found that explored ERAS LLA, including both THA and TKA (Jansson et al., 2020; Specht et al., 2018; Strickland et al., 2018), one looking at ERAS TKA (Høvik et al., 2018) and, one systematic review of ERAS THA and TKA (Makimoto et al., 2020). These will be explored further in chronological order. A Danish study (Specht et al., 2018) observed eight patients throughout a fast-track (ERAS) care pathway and concluded with semi-structured interviews. The authors aimed to explore the lived experiences of patients in fast-track primary THA and TKA care pathways by following a phenomenological-hermeneutic approach. Three main themes emerged: pain, feelings of confidence or uncertainty, and, the meaning of information and readiness for discharge. In general, patients were resistant to taking strong analgesics (morphine) and were uncertain when to take supplementary analgesics. Confidence was boosted by receiving information about fast track surgery, meeting the team beforehand, and involving relatives in preoperative information sharing. In contrast, they found that uncertainty was caused by incorrect or conflicting information. Optimal use of time during hospitalisation, sufficient pain management, and feeling well-rested were identified as crucial factors allowing for early discharge. The limitations of this study include the fact that it was conducted at a single centre with a small study population. A British study (Strickland et al., 2018) conducted 30 open, semi-structured interviews in the perioperative period following ERAS LLA (16 THA, 11 TKA, 2 unicompartmental knee arthroplasty(UKA)). This study aimed to understand the patient's perspective better when undergoing ERAS THA and TKA. The interview data underwent in-depth narrative and thematic analysis. Seven main themes were identified: "improving function and mobility," "pain," "experiences of healthcare," "support for others," 19 "involvement and understanding of care decisions," "behaviour and coping", and "fatigue and sleeping." Improving function and mobility was important for all respondents during recovery. Pain was seen as an inevitable part of recovery following surgery, reported as significantly reduced after surgery, and was often compared to preoperative pain caused by osteoarthritic conditions. Mixed responses were received regarding healthcare experiences; negative experiences were often related to fear of the unknown, but overall, patients were happy with the care and attention they received. Support from family, friends, and formal caregivers was identified as vital in perioperative recovery. Support in the form of preoperative "joint schools" was well- received and was a source of multidisciplinary information. Comfort was experienced in knowing there was support after discharge via telephone calls if required. Mixed feelings regarding the patient’s involvement in, and understanding of care received were also reported. Some patients wanted more of an active role, whereas others preferred being looked after. Relief and autonomy during recovery after discharge were also reported. Physical aids, medications, activity and participation modifications, and participant attitudes played a role in recovery. Finally, sleep disturbance due to pain and the inability to find comfortable positions lead to fatigue, which initially affected recovery. The study's limitations relate to a very homogenous patient population lacking cultural variability, and the findings are only generalisable to the National Health System of the United Kingdom. A qualitative study in Norway investigated patients' experiences with early discharge after TKA and focussed on the first two weeks of recovery (Høvik et al., 2018). Three focus group interviews were conducted with 13 patients. Interview data were analysed using Malteruds' method of systematic text condensation (a descriptive and exploratory method of thematic cross-case analysis). The main finding was the patients' determination and ability to cope at home. Education, knowledge, and predictability strengthened patients' coping capacity. Four main themes emerged after discharge: taking responsibility for rehabilitation once home, a prerequisite for feeling safe once home, empowerment through sharing experiences with others, and postoperative pain. Limitations in this study relate to not having access to patients who were not as well and perhaps had a troublesome 2-week recovery period, creating bias. The results can only be generalised to ERAS TKA. However, the study included two centres, which ensured a variety of experiences. 20 Qualitative semi-structured interviews were conducted in Finland (Jansson et al., 2020) to explore patient satisfaction and to identify experiences during fast-track (ERAS) LLA. Twenty patients (nine THA and 11 TKA) were included, and interview data were analysed using inductive content analysis. Overall satisfaction was measured using Numeric Rating Scales (NRSs); high satisfaction rates of 9.0 on a scale of 0-10 (SD 1.1) were reported. Eight main categories were derived: "patient selection," "meeting the Health Care Guarantee," "patient flow," "post-discharge care," "patient counselling," "transparency of the journey," "communication," and "feedback." The first two categories and components of the "patient flow" category are related to the Finnish healthcare system and irrelevant to this study. Logistical issues were frequent, and patients suggested more information regarding the discharge criteria and daily targets for recovery. Aspects highlighted regarding post-discharge care included coordination and continuity of care and required comprehensive and clear communication and information. Patients were satisfied with the quality of counselling; however, inconsistency and a lack of patient-centred counselling were highlighted. Written information was well received but lacked detailed guidance and clarity. Required refinements were identified regarding the transparency of the ERAS journey. These included logistical information and more details about pain management and recovery. Communication between stakeholders and patients was lacking, and there was confusion regarding who could be contacted once discharged. Finally, aspects of feedback highlighted a disconnect between patients and external stakeholders, with patients not knowing how to receive or provide feedback regarding the ERAS journey. This study highlighted logistical and operational issues in the Finnish LLA ERAS care pathway, limiting the generalisation of results to this organisation. A systematic review and synthesis of patient experiences following decreased LOS after THA and TKA was conducted by Makimoto et al. (2020). Sixteen qualitative studies (THA (n=5) TKA, (n =6); THA/TKA (n=5)) including 253 participants were analysed for content analysis. Six categories were generated, as presented in Table 2.1. 21 Table 2.1 Categories reported in the systematic review conducted by Makimoto et al. (2020) Category Elaboration I. Postoperative pain and medication Variability in pain experience. Variable views on pain medication. II. Difficulty in performing activities of daily living (ADL) Performing ADL is difficult. Patients should be assessed for appropriate assistive devices to cope. Patients should be encouraged to prepare in advance for reduced mobility. III. Appreciation for support and difficulties associated with receiving support Most patients received sufficient support from family and friends. Some had no one to depend on. Patients should be assessed for care requirements, and local resources should be identified for those in need. IV. Variability in the recovery process and information-seeking Substantial variability in recovery rate (from frustration over slow recovery to a sense of daily recovery). Patients are anxious to know if their recovery is within the expected range. There is a need for patient support groups to share experiences regarding recovery. V. Lack of patient- centred care Poorly coordinated care. Poor discharge planning. Inadequate care plan for physiotherapy. VI. Transportation problems and social isolation Driving restrictions lead to social isolation. Limitations regarding this review are related to only including English publications; most studies were conducted at single institutions with small sample sizes. Furthermore, LOS is not always provided, and the substantial variability in medical care systems among countries decreases the transferability of the findings. In conclusion, studies reporting specifically on qualitative aspects of SDD indicate that SDD is well accepted by patients, increases patient satisfaction, and produces a lower perception of disease (Bordoni et al., 2020; Churchill et al., 2018; Kelly et al., 2017). The absence of qualitative SDD studies necessitates relying on insights from research on fast-track or ERAS care pathways. This highlights the need for further qualitative exploration and understanding of the SDD care pathways. 22 2.6 Health-Related Quality of Life Measures Lower limb arthroplasty is performed to improve function, decrease pain and burden of disease, and improve the quality of life. Therefore, patient-reported outcome measures addressing health-related quality of life are apt to measure outcomes following LLA. According to Wilson et al. (2019), data collection from PROMs has the potential to inform many important decisions related to value-based care, quality assurance and improvement, and refinement of surgical indications, to name a few. The authors further indicate the importance of PROMs that patients invest in, such as pain relief, health-related quality of life, and improved function. According to Ethgen et al. (2004), health-related quality-of-life measures are valuable in providing relevant health status information to healthcare professionals, which informs the most adequate standards of care. 2.7 Conclusion In conclusion, this literature review addressed diverse perspectives in the evolving field of SDD LLA and the challenges associated with the acute and subacute postoperative recovery periods. Promising outcomes have been highlighted and supported by comparable or improved reoperation rates, readmissions, mortality, and PROMs. However, study limitations, such as heterogeneity, small sample sizes, and potential biases, necessitate larger, prospective, and multicentre trials to strengthen the current evidence. Regarding acute postoperative pain, the revised definition by the International Association for the Study of Pain emphasises the interaction between the sensory and emotional components of pain. The acknowledgement of neuropathic pain in TKA deepens the pain management paradigm, emphasising the need for revision of the current approaches and encouraging comprehensive and multidimensional approaches. As favourable outcomes in studies such as Prinsloo and Keller (2022) demonstrate, multimodal analgesia is a promising strategy that encourages ongoing research to refine and improve protocols and tailor interventions in SDD LLA. Furthermore, this literature review underscores the crucial role of patient's perspectives and experiences in shaping healthcare research, as evidenced in qualitative studies of SDD LLA. These studies reveal insights into pain management, mobility expectations, and the crucial role of support for the patient and primary caregiver. Gaps in our 23 understanding do exist, particularly in SDD TKA, which warrant further qualitative research. Patient experiences in ERAS LLA provide valuable insights into acute and sub-acute recovery following THA and TKA. Limitations, such as small sample sizes and single-centre and region-specific studies, are acknowledged. Continued research is required, particularly regarding SDD arthroplasty care pathways and patient perspectives. This will enhance our understanding and develop improved patient-centred healthcare clinical pathways. By addressing these gaps in the body of available evidence, contributions can be made to improve outcomes for both patients and healthcare systems, as well as the establishment of more precise guidelines for implementing emerging practices, such as SDD in THA and TKA . 24 Chapter 3 Methods 3.1 Introduction This chapter presents a research methodology that employs a mixed-method approach to investigate SDD THA and TKA. Combining quantitative and qualitative methods allows for a more complex and robust investigation of the SDD process. This integration of methodologies provides a holistic view that enhances the validity and depth of the findings. This section describes the research design, outlines the methods employed, and clarifies how they converge to address the research objectives. A mixed-method methodology aims to comprehensively understand SDD for THA and TKA, offering insights into theory and practice. 3.2 Study Design A mixed methods convergent design was used with a concurrent collection of quantitative (NRS of pain; Short-form McGill Pain Questionnaire2 (SF-MPQ-2); EQ- 5D-5L and EuroQol Visual Analogue Scale of overall health(EQ-VAS)) and qualitative (semi-structured interviews) data. Equal weighting was applied to the quantitative and qualitative data and handled independently for analysis. The findings were then merged for further analysis, which will be elaborated on later in this chapter (3.9.3)(p.38). 3.3 Study Setting The study was conducted at a private hospital and day clinic (ASC) in Pretoria, RSA. Same-day discharge is a novel concept recently introduced in the RSA private sector and has not been performed in public health institutions. 3.4 Participants Male and female participants diagnosed with hip or knee OA by an orthopaedic surgeon and scheduled for SDD LLA were invited to participate in the study. 3.4.1 Source of Participants The participants were recruited from an SDD LLA program overseen by three orthopaedic surgeons in Pretoria, RSA. The orthopaedic surgeons identified patients 25 who would be potential candidates for SDD LLA. These patients then entered the SDD LLA care pathway as described in 3.6.2.1. 3.4.2 Sample Size 3.4.2.1 Quantitative Selection The sample size for the quantitative phase was determined based on a study that compared acute postoperative pain following THA and TKA. Aarons et al. (1996) found a mean pain intensity of 5.53 (SD 3.00) for the THA group (n = 40) and 6.91 (SD = 2.00) for the TKA group (n= 23). Assuming a 95% confidence level with a power of 80%, an estimated minimum sample size of 110 participants was calculated to detect differences between the two groups (n = 55 per group). 3.4.2.2 Qualitative Selection Consecutive participants who underwent SDD THA or TKA were invited to participate in the interviews. Iterative sampling was implemented to ensure equal THA and TKA participants. Coding of broad thematic issues was applied, and participants were recruited until coding saturation was met. The researcher applied data saturation once no new codes emerged from the transcripts, as described by Saunders et al. (2018). 3.4.3 Sample Selection Convenience sampling was used due to the limited number of available participants. Table 3.1 displays the criteria for this study's quantitative and qualitative portions. Table 3.1 Inclusion and exclusion criteria of the participants Inclusion Criteria Exclusion Criteria Successful discharge on the same calendar day of surgery following LLA from a private healthcare setting. Discharge to any other facility, step down or frail care where there are professional or trained carers. Primary THA or TKA because of OA. THA or TKA due to trauma, avascular necrosis, or infection. Adults between 40 and 80 years of age. Unicompartmental or partial knee arthroplasty. Male and female participants. 26 3.5 Instrumentation and Outcome Measures This section introduces the key components of the mixed-methods study's outcome measures and instrumentation. The four quantitative outcome measures used to gather data are outlined, followed by an introduction of the qualitative aspect and semi- structured interviews. 3.5.1 Quantitative Data 3.5.1.1 Numerical Rating Scale (NRS) of Pain An NRS was used to gather information regarding pain intensity (Appendix A). Numeric Rating Scales were selected as they are easily administered verbally and ideally suited for telephone interviews. Numeric Rating Scales of Pain have shown good compliance and a high correlation with other pain assessment tools (Haefeli & Elfering 2006). However, the authors pointed out that NRSs were not as effective in detecting changes in pain over time, but their studies were related to assessing more complex long-term back pain. A systematic review comparing NRSs, Verbal Rating Scales (VRS), and VAS for assessing unidimensional pain intensity found that using NRS was applicable in most settings. Furthermore, the NRS was recommended based on higher compliance rates, better responsiveness, ease of use, and good applicability relative to the VAS or VRS (Hjermstad et al., 2011). In their study on outpatient unicompartmental knee arthroplasty, Hoorntje et al. (2017) used the NRS for pain intensity. Numeric Rating Scales for pain intensity were found to better identify differences in pain intensity between sexes. They were also the most responsive between VAS, VRS and the Faces Pain Scale-Revised in clinical and research settings (Ferreira-Valente et al., 2011) The NRS for pain intensity is a valid measure less influenced by non-pain intensity factors (pain interference and unpleasantness) than the VRS and Faces Pain Scale-Revised (Thong et al., 2018) and has shown good test-retest reliability (r=0.79- 0.96) (Cheatham, Stull & Kolber 2018). 3.5.1.2 The Short-form McGill Pain Questionnaire-2 (SF-MPQ-2) The SF-MPQ-2 (Appendix B) provides a valid, responsive, and efficient pain assessment in clinical research that applies to various acute and chronic pain conditions (Dworkin et al., 2015). The SF-MPQ-2 measures both the sensory and 27 affective components of pain. It has demonstrated sensitivity to clinical changes following various interventions and is effective across multiple age groups (Iohom 2006). The test-retest reliability in patients with musculoskeletal pain is adequate (r>70) (Hawker et al., 2011), and Dworkin et al. (2009) found excellent reliability and validity for the SF-MPQ-2. The SF-MPQ-2 was selected as it is a multidimensional pain measurement tool including both the quality and intensity of pain and differentiates between neuropathic and non-neuropathic pain. It is considered an efficient pain assessment tool for clinical research (Dworkin et al., 2015). The SF-MPQ-2 has a total score and four subscale scores that 22 pain descriptors are divided into namely Continuous (throbbing pain, cramping pain, gnawing pain, aching pain, heavy pain and tenderness), Neuropathic (hot-burning pain, cold-freezing pain, pain caused by light touch, itching, tingling or “pins and needles” and numbness), Intermittent (shooting, stabbing, sharp, splitting, electric-shock and piercing) and Affective pain descriptors (tiring-exhausting, sickening, fearful and punishing-cruel) (Kachooei et al., 2015). Using the SF-MPQ-2 will contribute to exploring pain after SDD THA and TKA. 3.5.1.3 The EuroQol 5-Dimension 5-Level and EuroQol Visual Analogue Scale The EQ-5D-5L is broadly separated into two parts. The first part measured five dimensions of HRQOL (mobility, self-care, usual activities, pain/discomfort, anxiety/depression). The second part of the EQ-5D-5L is the EQ-VAS, which measures overall health from 0 (worst health imaginable) to 100 (best health imaginable) (Appendix C). The EQ-5D-5L and EQ-VAS scores were found to be valid (0.782), reliable (Cronbach’s Alpha was 0.86), and responsive outcome measures for hip and knee OA, specifically for the pain/discomfort, mobility, and usual activity dimensions (Bilbao et al., 2018; Conner-Spady et al., 2015). The availability of a validated phone version contributed to the selection of this instrument. The EQ-5D-5L use in longitudinal studies involving THA and TKA is recommended because of their responsiveness to the HRQOL (Jin et al., 2019), informing the objective of measuring and describing HRQOL. 3.5.2 Qualitative Data 3.5.2.1 Semi-structured Interviews Semi-structured interviews explored participants' perceptions and experiences following SDD LLA at six weeks postoperatively. The interviews were conducted using 28 an interview guide administered by Churchill et al. (2018). An additional question was added to assess the value of the physiotherapy services. A question about the Canadian healthcare system was removed as it was irrelevant to the South African private healthcare system (Appendix D). Together, these quantitative and qualitative measures form a methodologically robust approach, ensuring a thorough exploration of the research objectives. 3.6 Procedure 3.6.1 Pilot Testing After ethical approval was attained, a pilot test was conducted to enhance the reliability and validity of the data collection processes and procedures for the quantitative and qualitative components of the study. This pilot test served as a preparatory phase, allowing the identification of potential logistical and methodological challenges that could affect the quality of the main study data. The insights gained are described below and contribute to the reliability and validity of the study's findings. 3.6.1.1 Quantitative Pilot Testing This part of the pilot test included 10% of the sample (11 participants). The data collection process was refined, and no significant procedural changes were made. Minor changes related to refining the data recording in a spreadsheet were made. Therefore, the data from the pilot test were used in the main study. The data were collected as described in the main study (Table 3.2). The results of the PROMs from the pilot testing provided valid data that addressed the research questions. 3.6.1.2 Qualitative Pilot Testing Three participants were used to pilot the interview process described in the main study. A minor modification related to using a superior software application (Otter AI) for recording interviews was made, enhancing the recorded data's quality. The test data were still of sufficient quality, rendering it suitable for the main study. The data collected was screened to determine if sufficient content was present to address the research questions. All three interviews provided substantial data that deemed the questionnaire a valid tool for the study design 29 3.6.2 Main Study During the initial preoperative assessment, the participants who agreed to participate were provided with an information sheet regarding the nature of the study and informed consent documents (Appendix E). Participants were informed that individual interviews would be conducted with some participants who completed the study and that they would potentially be asked to participate. The signed consent documents were obtained and stored in a filing cabinet, which is kept locked, and only the researcher has access. The study procedures were further explained, and the initial PROM, namely the EQ-5D-5L, EQ-VAS, NRS of pain intensity, and SF-MPQ-2 were collected. Data was collected by the researcher and research assistants trained regarding the study protocol. 3.6.2.1 Same-day Discharge Care Pathway An overview of the SDD clinical care pathway used in this study is provided in Appendix F. The elaboration of each component follows. Anaesthetic Clinic: Potential participants identified by their orthopaedic surgeon and eager to follow the SDD THA or TKA care pathway attended the preoperative clinic, also called the "Anaesthetic Clinic." The primary caregiver was encouraged to accompany and attend the clinic with the participant. The participants completed detailed medical history forms before being seen by the registered nurse. Participants were then assessed individually by each interdisciplinary team member (IDT) consisting of a registered nursing practitioner, anaesthetist, physiotherapist, clinical coordinator, and primary healthcare physician (general practitioner). The registered nurse performed initial observations of vital signs (blood pressure, pulse rate, pulse oximetry, and body temperature) and additional side-room investigations (resting electrocardiogram and random blood glucose concentration tests). An anaesthetist then assessed the participant's medical suitability for opioid-sparing anaesthetic as well as spinal and peripheral nerve blocks. An extensive explanation of the anaesthetic protocols is provided to participants. A physiotherapist assessed all participants. The assessment included gathering relevant physiotherapy history and information, including functional level during ADL, assistive device use, pain, home environment, discharge plan, and information 30 regarding the planned primary caregiver. Objective measurements of joint range of movement, muscle strength, gait analysis, and general function were recorded. The rehabilitation protocol was discussed in detail, providing candidates and their primary caregivers insight into what to expect during each step, from the day of surgery to the six-week follow-up. Information was provided regarding preparing a safe home environment, the safety of movement postoperatively (specifically, no traditional posterolateral THA precautions and weight bearing as tolerated), and discussions on what to expect regarding postoperative pain in the first six weeks. Pain management strategies were discussed, including reinforcing information disseminated by the anaesthetist, primary care physician, and clinical coordinator. The candidate was then given a home exercise program, and each exercise was demonstrated. Candidates were shown how to use assistive ambulatory devices such as elbow crutches or walking frames. The clinical coordinator (a registered nursing practitioner) then provided a detailed education session with the participant and their primary caregiver, providing an overview of the SDD process. The clinical coordinator was the candidate's first port of call during the recovery process if there were any queries or concerns postoperatively. In such cases, the appropriate team member is contacted, and decisions are made regarding managing the questions or concerns. The information session included information related to contact details, the role of the clinical coordinator, the SDD process, the medication schedule, and general advice to the participant and primary caregiver. The primary care physician assessment followed with a revision of the medical history, provision, and explanation of the postoperative medication prescription. Any medical concerns were addressed, and referral was made to appropriate specialists or further medical testing was performed (only if required) before the candidate could enter the SDD care pathway. Referrals could have been to a specialist physician or for further clinical testing if the primary care physician had raised any concerns. Once all IDT members assessed candidates, informal discussions took place regarding the medical, social, and psychological impressions that the team had made. The entire team had to agree that the candidate was suitable, and the candidate had to be committed to the SDD process before entering the SDD care pathway. 31 Day of surgery: Per each institution's protocol, participants were admitted to the hospital or the ASC. The nursing staff, orthopaedic surgeon, anaesthetist, and physiotherapist assessed the participants for their suitability to undergo surgery on the day. The protocols were revised and reinforced, and appropriate team members addressed queries from participants. Arthroplasty was performed according to the orthopaedic surgeon's specific protocols (posterolateral surgical approach for THA). Following the procedure, the anaesthetist informed the rest of the IDT when the participant was awake in recovery. The physiotherapist would see the participant between two- and three hours after surgery. There was constant communication between the IDT members regarding the participants' progress. Once the participant had eaten, the physiotherapist assessed the participant's recorded vital signs, motor and sensory function following spinal and peripheral nerve blocks, pain levels, and alertness. Any postoperative symptoms that were not conducive to safe mobilisation were reported to the appropriate team members. When the participant was stable and considered safe to mobilise, the physiotherapist proceeded with the initial bed mobility and postoperative exercises, then assisted the participant in mobilising with an assistive device. The home exercise program was revised, SDD protocol information was reviewed, and any queries were addressed. The participant had to complete bed transfers with minimal assistance, mobilise safely with assistive devices for 20m or more, and safely negotiate stairs with stand-by supervision before they were deemed safe for discharge from a functional perspective. The IDT and participants were involved in deciding when the participant was ready for discharge. The clinical coordinator contacted the participants a few hours after discharge to confirm they arrived home safely. The clinical coordinator was available 24 hours a day for telephone queries. Daily "check-ins" were scheduled for at least three days following surgery at 18:00 and one week later. Post Discharge Physiotherapy The timing of contac