Introduction of Clinical Pathways in Orthopedic Surgical Care: The Experience of the Hospital for Special Surgery

  • Susan Flics
  • Shivi Duggal
  • Katarzyna Kujawa
  • Charles N. CornellEmail author


Clinical pathways are structured multidisciplinary care plans that address specific clinical scenarios. Their purpose is to standardize and coordinate care. Elective orthopedic surgical procedures are particularly suited to application of these pathways. Clinical pathways must address the entire episode of care including pre-hospital preparation, in-hospital care, and post-hospital discharge. Clinical pathways must be multidisciplinary involving all members of the healthcare team. Each hospital should design these pathways based on their unique environment and culture. Adoption of clinical pathways standardizes care resulting in greater patient safety, reduced perioperative complications, shorter length of stay, and higher patient satisfaction with their experience. Following implementation all clinical pathways should be continuously reassessed to provide for continuous process improvement.


Total joint replacement Clinical pathways 


  1. 1.
    Pennington JM, Jones DP, McIntyre S. Clinical pathways in total knee arthroplasty: a New Zealand experience. J Orthop Surg (Hong Kong). 2003;11(2):166–73.CrossRefGoogle Scholar
  2. 2.
    Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89:780–5.CrossRefGoogle Scholar
  3. 3.
    Ayalon O, Liu S, Flics S, Cahill J, Juliano K, Cornell CN. A Multimodal clinical pathway can reduce length of stay after total knee arthroplasty. HSS J. 2011;7(1):9–15.CrossRefGoogle Scholar
  4. 4.
    Iorio R. Strategies and tactics for successful implementation of bundled payments: bundled payment for care improvement at a large urban medical center. J Arthroplasty. 2015;30:349–50.CrossRefGoogle Scholar
  5. 5.
    Kim K, Iorio R. The 5 clinical pillars of value for total joint arthroplasty in a bundled payment paradigm. J Arthroplasty. 2017;32:1712–6.CrossRefGoogle Scholar
  6. 6.
    Walter FL, Bass N, Bock G, Markel D. Success of clinical pathways for total joint arthroplasty in a community hospital. Clin Orthop Relat Res. 2007;457:133–7.PubMedGoogle Scholar
  7. 7.
    Husted H, Holm G. Fast track in total hip and knee arthroplasty – experiences from Hvidovre University Hospital, Denmark. Injury. 2006;37S:S31–5.CrossRefGoogle Scholar
  8. 8.
    Healy WL, Iorio R, Ko J, Appleby D, Lemos DW. Impact of cost reduction programs on short-term patient outcome and hospital cost of total knee arthroplasty. J Bone Joint Surg. 2002;84:348–53.CrossRefGoogle Scholar
  9. 9.
    Pilot P, Bogie R, Draijer WF, Verburg AD, van Os JJ, Kuipers H. Experience in the first four years of rapid recovery; is it safe? Injury. 2006;37S:S37–40.CrossRefGoogle Scholar
  10. 10.
    Pinzur MS, Gurza E, Kristopaitis T, Monson R, Wall MJ, Porter A, et al. Hospitalist-orthopedic co-management of high-risk patients undergoing lower extremity reconstruction surgery. Orthopedics. 2009;32(7):495.CrossRefGoogle Scholar
  11. 11.
    Larsen K, Hvass KE, Hansen TB, Thomsen PB, Soballe K. Effectiveness of accelerated perioperative care and rehabilitation intervention compared to current intervention after hip and knee arthroplasty. A before-after trial of 247 patients with a 3-month follow-up. BMC Musculoskelet Disord. 2008;9:59.CrossRefGoogle Scholar
  12. 12.
    Teeny SM, York SC, Benson C, Perdue ST. Does shortened length of hospital stay affect total knee arthroplasty rehabilitation outcomes? J Arthroplasty. 2005;20:7.CrossRefGoogle Scholar
  13. 13.
    Peterson MGE, Ciopa-Mosca J, Finerty E, Graziano S, King S, Sculco TP. Effectiveness of best practice implementation in reducing hip arthroplasty length of stay. J Arthroplasty. 2008;23(1):69.CrossRefGoogle Scholar
  14. 14.
    Ganz SB, Wilson PD Jr, Cioppa-Mosca J, Peterson MGE. The day of discharge after total hip arthroplasty and the achievement of rehabilitation functional milestones. J Arthroplasty. 2003;18(4):453.CrossRefGoogle Scholar
  15. 15.
    Husted H, Holm G, Jacobsen S. Predictors of length of stay and patient satisfaction after hip and knee replacement surgery. Acta Orthop. 2008;79:168–73.CrossRefGoogle Scholar
  16. 16.
    McDonald S, Hetrick S, Green S. Pre-operative education for hip or knee replacement. Cochrane Database Syst Rev. 2004;(1):CD003526.Google Scholar
  17. 17.
    Yoon RS, Nellans KW, Geller JA, Kim AD, Jacobs MR, Macaulay W. Patient education before hip or knee arthroplasty lowers length of stay. J Arthroplasty. 2010;25:547–51.CrossRefGoogle Scholar
  18. 18.
    Hebl JR, Dilger JA, Byer DE, Kopp SL, Stevens SR, Pagnano MW, et al. A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. Reg Anesth Pain Med. 2008;33:510–7.CrossRefGoogle Scholar
  19. 19.
    Choi PT, Bhandari M, Scott J, Doukitis J. Epidural analgesia for pain relief following hip or knee replacement. Cochrane Database Syst Rev. 2003;(3):CD003071.Google Scholar
  20. 20.
    Andersen KV, Pfeiffer-Jensen M, Haraldsted V, Soballe K. Reduced hospital stay and narcotic consumption and improved mobilization with local and intraarticular infiltration after hip arthroplasty. Acta Orthop. 2007;78(2):180–6.CrossRefGoogle Scholar
  21. 21.
    Ekman EF, Koman LA. Acute pain following musculoskeletal injuries and orthopedic surgery: mechanisms and management. Instr Course Lect. 2005;54:21–33.PubMedGoogle Scholar
  22. 22.
    Gómez-Cardero P, Rodríguez-Merchán EC. Postoperative analgesia in TKA: ropivacaine continuous intraarticular infusion. Clin Orthop Relat Res. 2010;468:1242–7.CrossRefGoogle Scholar
  23. 23.
    Larsen K, Hansen TB, Thomsen PB, Christiansen T, Soballe K. Cost-effectiveness of accelerated perioperative care and rehabilitation after total hip and knee arthroplasty. J Bone Joint Surg Am. 2009;91(4):761–72.CrossRefGoogle Scholar
  24. 24.
    den Hertog A, Gliesche K, Timm J, Muhlbauer B, Zebrowski S. Pathway controlled fast track rehabilitation after total knee arthroplasty: a randomized prospective clinical study evaluating recovery, drug consumption and length of stay. Arch Orthop Trauma Surg. 2012;132(8):1153–63.CrossRefGoogle Scholar
  25. 25.
    Rapheal M, Jaeger M, van Vlymen J. Easily adoptable total joint arthroplasty program allows discharge home in two days. Can J Anesth. 2011;58:902–10.CrossRefGoogle Scholar
  26. 26.
    Rotter T, Kinsman L, James E, Machotta A, Goethe H, Willis J, et al. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Sys Rev. 2010;(3):CD006632.Google Scholar
  27. 27.
    Kehlet H, Thienpont E. Fast track knee arthroplasty- status and future challenges. Knee. 2013;20 Suppl 1:529–33.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Susan Flics
    • 1
  • Shivi Duggal
    • 2
  • Katarzyna Kujawa
    • 3
  • Charles N. Cornell
    • 4
    Email author
  1. 1.Hospital for Special Surgery, Executive OfficesNew YorkUSA
  2. 2.SUNY Albany School of Public HealthRensselaerUSA
  3. 3.Department of OperationsHospital for Special SurgeryNew YorkUSA
  4. 4.Department of Orthopedics the Hospital for Special Surgery Weill Cornell MedicineNew YorkUSA

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