The present study demonstrated that the early short-term inpatient rehabilitation provided by therapist significantly improved patient satisfaction, and increased knee flexion ROM, compared with usual surgeon guided rehabilitation. What’s more, the improvement of flexion ROM is an important factor associated with satisfaction. Consequently, we concluded that therapist led short-term postoperative rehabilitation may raise patient satisfaction though increasing the flexion ROM. In addition, we verified this conclusion by adjusting for baseline differences between the two groups with PSM scores.
Commonly, function and mobility are limited after TKA, burdening patients of worries about the future active daily life or return to sports. Therefore, a good outcome in the short period before discharge would relieve the anxiety, which is indeed important to the long-term effects of TKA. The core idea of enhanced recovery after surgery (ERAS) is to reduce surgical stress response, alleviate pain during perioperative period, reduce the incidence of complications, accelerate functional recovery, and improve patient satisfaction. Early inpatient rehabilitation was conducted to improve pain, mobility and range of motion and facilitate ERAS.
Patient PROM satisfaction is an increasing focus to assess the outcomes of TKA. Regarding the satisfaction in the prior studies was either from the comparation between different physical therapy started timings  or from the assessment of treatment . As we acknowledge that patient satisfaction may relate to many factors, which is possible to be far from the satisfaction evaluated from functional data by surgeons. That is why many surgeons confused by the dissatisfaction from a patient with a very good function recovery and pain relief. We used the patient subjective feeling for the overall inpatient treatment and his present situation to generate a satisfaction score, avoiding the misunderstanding gap. Therefore, focus on the patient subjective satisfaction may improve the medical care better.
Our study found that the satisfaction was obviously improved in patients received therapist led rehabilitation compared to the usual therapy led by surgeons. The short-term overall satisfaction was lower than previous reported results obtained by a long postoperative follow-up (69% vs 80%) . This is most likely due to the limited function, muscle strength and flexibility of the knee in the short term, especially regarding the swelling and pain of the affected limb, which doesn’t meet the patient's expectations at that time.
ROM is considered as a measure to determine the success of TKA surgery, as well as an indicator of postoperative physiotherapy. It was identified of an improved active knee ROM on discharge in the intervention group, which may reflect the increased level of postoperative mobilization and strengthening exercises these patients received . Our results showed a nearly 8° increase in active ROM in the therapist rehabilitation group compare favorably with a prospective trial incorporating additional passive ROM exercises in addition to standard postoperative rehabilitation.
There are few reports on the relationship between ROM and satisfaction, and the relationship remains unclear. Ha et al first reported that patient satisfaction did not correlate with postoperative flexion but correlated with an improvement in the flexion angle . Recently, Kubo et al showed a similar result, stating that the postoperative flexion angle had a significant effect on knee function and improvement in the flexion angle had a significant effect on patient satisfaction.  Consistently, the flexion degree improvement was favorable in terms of satisfaction in the multivariable analysis in this study.
Although several studies have suggested that early rehabilitation reduced opioid use during hospitalization , we didn’t observe a difference of pain scores between the two groups. In addition, short-term postoperative inpatient rehabilitation didn’t influence WOMAC scores, IDKC scores and Lysholm knee score scale at 3-week follow up. Our study only collected these data at three- and six-week follow up. No data were collected at hospital discharge because the recovery period was short during hospital stay leading to patient active daily life was influenced much.
The present study has several strengths in the context of the previous literature. First, we identified that the early therapist rehabilitation did enhance the patient satisfaction. Second, we found a subgroup of patients, aged over 65 years, may benefit more from an early therapist rehabilitation program. Considering this founding, we recommend surgeons should try their bests to arrange the therapist rehabilitation for patients aged over 65.
A primary limitation of this study is that it was conducted at a single site. We will include more cases in the future study. Secondly, although there are many studies confirmed the relationship between met satisfaction and patient satisfaction , , expectation scores were not prospectively collected in the retrospective study. Nevertheless, knee joint swelling, pain, limited mobility and other complications were informed by the surgeons during the preoperative education, when patient knew that there was no way to achieve the expectation in the short hospitalization, indicating the expectation was not a determinant of short-term satisfaction. Thirdly, the enhanced communication between doctors and patients may improve the patient subjective satisfaction. In this case, the therapists’ accompany and interaction with the patient during the bedside rehabilitation would increase the communication. But in this retrospective study, the communication was not collected in advance. Finally, it is important to acknowledge that statistical significance on a patient reported outcome measure does not always imply clinical significance , . The mid- and long-term effects need further research in larger patient cohorts with a longer follow-up.