Background and purpose — Essential for safe and timely hospital discharge, inpatient functional recovery following lower limb arthroplasty is also variable. A previous systematic review reported moderate and conflicting levels of evidence regarding patient-related predictors of inpatient recovery for primary total hip arthroplasty (THA). A systematic review of surgical prognostic factors for inpatient recovery following THA or total knee arthroplasty (TKA) is yet to be undertaken. We identified patient and surgical prognostic factors for inpatient functional recovery following THA and TKA; determined whether inpatient functional recovery varies between these procedures; and established whether validated outcome measures relevant to the patient’s functional requirements for hospital discharge are routinely assessed. Patients and methods — Critical Appraisal Skills Programme checklists assessed methodological quality, and a best-evidence synthesis approach determined the levels of evidence supporting individual prognostic factors. PubMed, CINAHL, Embase, Scopus, and PEDro databases were searched from inception to May 2019. Included studies examined patient or surgical prognostic factors and a validated measure of post-operative function within 2 weeks of primary, unilateral THA or TKA. Results — Comorbidity status and preoperative function are supported by a strong level of evidence for TKA. For THA, no strong level of evidence was found for patient-related prognostic factors, and no surgical factors were independently prognostic for either arthroplasty site. Limited evidence supports fast-track protocols in the TKA population. Interpretation — Preoperative screening and optimization is recommended. Assessment of Enhanced Recovery Pathways using validated outcome measures appropriate for the early postoperative period is warranted.

Background: The introduction of enhanced recovery pathways has demonstrated both patient and organisational benefits. However, enhanced recovery pathways implemented for total hip arthroplasty (THA) and total knee arthroplasty (TKA) vary between health-care organisations, as do their measures of success, particularly patientrelated outcomes. Despite inpatient functional recovery being essential for safe and timely hospital discharge, there is currently no gold standard method for its assessment, and the research undertaken to establish prognostic factors is limited. This study aimed to identify prognostic factors and subsequently develop prognostic models for inpatient functional recovery following primary, unilateral THA and TKA; identify factors associated with acute length of stay; and assess the relationships between inpatient function and longer-term functional outcomes. Methods: Correlation and multiple regression analyses were used to determine prognostic factors for functional recovery (assessed using the modified Iowa Level of Assistance Scale on day 2 post-operatively) in a prospective cohort study of 354 patients following primary, unilateral THA or TKA. Results: For the overall cohort and TKA group, significant prognostic factors included age, sex, pre-operative general health, pre-operative function, and use of general anaesthesia, local infiltration analgesia, and patient-controlled analgesia. In addition, arthroplasty site was a prognostic factor for the overall cohort, and surgery duration was prognostic for the TKA group. For the THA group, significant prognostic factors included pre-operative function, Risk Assessment and Prediction Tool score, and surgical approach. Several factors were associated with acute hospital length of stay. Inpatient function was positively correlated with functional outcomes assessed at 6 months post-operatively. Conclusions: Prognostic models may facilitate the prediction of inpatient flow thus optimising organisational efficiency. Surgical prognostic factors warrant consideration as potential key elements in enhanced recovery pathways, associated with early post-operative functional recovery. Standardised measures of inpatient function serve to evaluate patientcentred outcomes and facilitate the benchmarking and improvement of enhanced recovery pathways.