In recent years, valuable thought processes have been invested in shaping targeted patient care and awareness to elevate the quality of the healthcare system. Compliance with the treatment plan is both the result and indicator of the quality of care experi enced by the patients. This study demonstrates the sociodemographic factors pivotal in understanding compliance patterns with post-operative rehabilitation protocols (Table 1.). The importance of effective rehabilitation is understood with the enhanced recovery after surgery protocol, demonstrating less post-operative pain and complications, decreased mortality, and hospital readmission rates [16].
Medication adherence was highest in our cohort (91.7%). This is consistent with Kattan et al. (2023), who reported medication adherence above 85% among orthopaedic patients in Saudi Arabia [1]. Similarly, Bender et al. (2024) observed high adherence to prescribed medications among U.S. orthopaedic surgery patients [6].
Exercise adherence in our study was 78.3%, aligning with Campbell et al. (2001), who found compliance with physiotherapy exercises in knee osteoarthritis to be around 70% [17]. Comparable rates of 65–75% have also been reported in systematic reviews of adherence to physical therapy [3]. Weight-bearing adherence was lowest in our study (75.4%), a similar finding noted by Zelle et al. (2015), who documented significant loss to follow-up and non- compliance with mobility restrictions in orthopaedic trauma patients [5]. Jester et al. (2021) also noted that nearly one-third of orthopaedic trauma patients deviated from prescribed mobility instructions [7]. These findings confirm that active rehabilitation tasks, such as exercises and weight-bearing, are more challenging for patients than passive tasks like medication intake.
In this study, younger patients (59.1% in 18–40 years) and patients with higher education (postgraduates- 70.6%) directly correlate with better compliance postoperatively. It can be due to social norms of older people becoming more dependent on caretakers, and mobility issues due to poor geriatric care and health maintenance. Kattan et al. observed that younger individuals and educated patients were less compliant and had higher chances of missing appointments, attributed to more responsibilities, busier lifestyle, and poorer work- life balance [1]. Mathes et al. and Bender et al. observed that higher education correlated with more employment and contributed to better compliance, like in this study [3, 6]. However, a relationship between marital status and compliance was not found [3]. On the contrary, our research observed that married patients showed higher compliance (58.3%) than unmarried (52.6%) and widowed patients(29.6%), possibly due to a lack of social support and psychosocial factors (Fig. 3).
Cash-paying patients had the highest compliance (63.9%), while government-funded patients were least compliant (45.4%), possibly due to the lack of accessibility to health care facilities for routine follow-ups and financial constraints among the underprivileged, while patients paying cash, perhaps, could have the motivation to put in maximum effort to aid in betterment. Zelle et al. (2015) reported similar findings, with patients on public assistance more likely to be lost to follow-up. However, the same research could not find significant observations on the mechanism of injury and compliance [5]. In contrast, in this study, patients involved in road traffic accidents (64.8%) and sports injuries (63.0%) showed higher compliance than patients involved in slip and fall injuries (42.6%), possibly due to the perceived severity of injury among patients involved in high-velocity injuries. The age groups involved in the mechanism are also important, as sports injuries are common among the younger population, who have adequate social independence to undergo recommended rehabilitation protocols. At the same time, slip and fall is more common among older adults, who are socially dependent on day-to-day activities.
Higher compliance was observed among males (58.2%) compared to females (44%), indicating the sex-based differences between both genders in seeking health care in their respective societies and support systems. Zester et al. and Bender et al. demonstrated that males showed patterns of non-compliance and developed the feeling to get better post- surgery [6, 7].
In our study, the patient’s comorbidities at discharge did not show significant variation in compliance (No comorbidities- 55.6% vs. Comorbid at discharge- 50.0%).
Campbell et al. suggested that initial compliance with treatment was high in patients with comorbidities, due to the presumed severity of symptoms [17].
Geographic location influenced compliance: rural and metropolitan patients (42.9% each) were least compliant. Subjects at both ends of the spectrum demonstrated low compliance, possibly due to the accessibility to health care centres and financial constraints while residing in rural areas. In contrast, in urban towns, patients are exposed to a busier lifestyle, where postoperative rehabilitation could seem challenging. Casp et al. (2017) reported that 12% of patients cited distance and geographic barriers as reasons for poor follow-up in orthopaedic trauma [4].
In most cases, patients undergoing arthroscopic surgery exhibited poor compliance, possibly due to the underestimation of the surgery performed with the smaller incision and the elective nature (Fig. 1). A high majority of patients (70.5%) in arthroscopy surgery, who are government-funded, could be the reason for the increased non-compliance. Focused improvement in terms of rehabilitation for patients undergoing arthroscopy surgeries with educational support and awareness could be measures that enhance surgery outcomes. Females undergoing arthroplasty (70%) were less compliant than males, requiring close monitoring and frequent follow-ups (Fig. 2). Married patients undergoing “other surgeries” were the most compliant (76.2%), highlighting the protective role of social support.
The study highlights the multifactorial inter-relationship of factors influencing patients’ compliance after orthopaedic lower limb surgeries, suggesting that no variable alone correlates with the outcome, as reflected in the multivariate regression analysis (Table 2). Addressing accessibility to healthcare among the underprivileged population and programming patient-specific, focused intervention plans into the management protocols adds to healthcare quality and helps the physician treat the patient with the disease, not just the disease itself.
Future scope of standardising health-care should focus on integrating these variables into providing community programmed rehabilitation support, a multidisciplinary approach for post-operative care, digital care tools for structured follow-up, and specific group-based rehabilitation sessions.
The study proves to have many strengths, such as its prospective design, uniform unit-based counselling, and subgroup analysis.
However, the study has limitations as well, such as categorical scoring (not capturing frequency or quality of rehabilitation), single-assessor bias, and a short one-month follow- up. Categorisation of continuous variables such as age and BMI may have reduced statistical power. Furthermore, although associations were observed, multivariate regression did not identify independent predictors, indicating that compliance is multifactorial. This should be considered a hypothesis for future research.
Clinical messages
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Active parameters of rehabilitation (exercises advised and weight-bearing status) show lower compliance than passive parameters (medication intake).
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It’s an interplay between various factors after surgery, determining patients’ compliance with rehabilitation protocols post-surgery, accounting for physical, mental, and social dimensions.
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Identifying these factors during the perioperative period and incorporating a patient- specific treatment plan is essential for the surgeon to achieve optimum post-surgery results during rehabilitation.
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