Post-Acute Rehabilitation After Total Knee Replacement: A Multicenter Randomized Clinical Trial Comparing Long-Term Outcomes

Robotic exoskeletons and total knee arthroplasty: The future of knee rehabilitation and replacement - A meta-analysis

OBJECTIVE

Exoskeletons can play a crucial role in post-TKA rehabilitation by accelerating recovery, improving mobility, and reducing further injury risk. This meta-analysis evaluated the effectiveness of exoskeletons in post-total knee replacement (TKR) rehabilitation.

DESIGN

Comprehensive searches were conducted on PubMed, OVID Medline, Cochrane Collaboration Library, and Embase (period: database inception to March 2023). Randomized controlled trials enrolling patients who underwent TKR and studies examining the effect of robot-assisted rehabilitation on physical function and pain outcomes were eligible for inclusion. Eight studies (302 patients) were thus included.

RESULTS

Exoskeletons significantly improved active range of motion (ROM) (SMD: 10.98, 95% confidence interval (CI): 7.81-14.16, P < .001), passive ROM (SMD: 4.11, 95% CI: 1.02-7.20, P = .009), Hospital for Special Surgery scores (SMD: 7.78, 95% CI: 5.87-9.68, P < .00001), and hospital stay length (SMD: -3.19, 95% CI: -4 to -2.38, P < .00001) compared with conventional rehabilitation. Active and passive ROM improvements suggest that exoskeletons aid knee function restoration and mobility post-TKR, whereas Hospital for Special Surgery score improvements support exoskeleton use in TKR rehabilitation. A shorter hospital stay was an important finding which could potentially reduce healthcare costs and improve outcomes.

CONCLUSION

Despite the inclusion of a limited number of studies, our findings suggest that exoskeletons can enhance post-TKR rehabilitation outcomes and improve quality of life. Robot-assisted rehabilitation may be effective following TKR. Further research should confirm these findings.

Rehabilitation for Total Knee Arthroplasty: A Systematic Review

ABSTRACT

We sought to determine the comparative benefit and harm of rehabilitation interventions for patients who have undergone elective, unilateral total knee arthroplasty for the treatment of primary osteoarthritis. We searched PubMed, Embase, The Cochrane Register of Clinical Trials, CINAHL, PsycINFO, Scopus, and ClinicalTrials.gov from January 1, 2005, through May 3, 2021. We included randomized controlled trials and adequately adjusted nonrandomized comparative studies of rehabilitation programs reporting performance-based, patient-reported, or healthcare utilization outcomes. Three researchers extracted study data and assessed risk of bias, verified by an independent researcher. The team assessed strength of evidence. Evidence from 53 studies randomized controlled trials suggests that various rehabilitation programs after total knee arthroplasty may lead to comparable improvements in pain, range of motion, and activities of daily living. Rehabilitation in the acute phase may lead to increased strength but result in similar strength when delivered in the postacute phase. No studies reported evidence of risk of harms due to rehabilitation delivered in the acute period after total knee arthroplasty; risk of harms among various postacute rehabilitation programs seems comparable. All findings were of low strength of evidence. Evaluation of rehabilitation after total knee arthroplasty needs a systematic overhaul to sufficiently guide future practice or research including the use of standardized intervention components and core outcomes.

Prevalence and determinants of physical activity, sedentary behaviour and fatigue five years after total knee replacement

OBJECTIVE

To determine the prevalence and predictors of physical activity, sedentary behaviour and fatigue five years after total knee replacement surgery.

DESIGN

A longitudinal cohort study.

SETTING

Community-dwelling adults who had previously undergone total knee replacement.

METHODS

Five-year follow-up questionnaire data were obtained from participants previously enrolled in a randomised controlled trial examining rehabilitation after total knee replacement. Main study outcomes at one year did not differ between randomisation groups, hence data were pooled for the present longitudinal analysis. Before and one and five years after surgery, participants completed questionnaires (Active Australia Survey, WOMAC, SF12 v2, demographics and fatigue).

RESULTS

272/422 community-dwelling adults (45-74 years) completed the questionnaires at five years. Excessive sedentary behaviour was evident in 91% of the cohort, predicted by excessive sedentary behaviour and lack of energy at one year. Inadequate physical activity at five years was evident for 59% of the cohort, predicted by higher fatigue and comorbidity scores pre-surgery and inadequate physical activity at one year. Just under half (47%) of the cohort experienced clinically-important fatigue at five years, predicted by clinically-important fatigue before and one year after surgery, lack of sleep before surgery and physical activity one year after surgery.

CONCLUSION

Documenting physical activity, sedentary behaviour and fatigue before and one year after knee replacement is important to identify those at risk of longer-term inadequate physical activity, excessive sedentary behaviour and clinically-important fatigue. Interventions to maintain activity and reduce sedentary behaviour are needed to reap the potential health benefits of total knee replacement surgery.

Utilisation of outpatient physiotherapy in patients following total knee arthroplasty - a systematic review

OBJECTIVE

Data on the utilisation of outpatient physiotherapy (PT) in patients following total knee arthroplasty (TKA) are scarce, and available studies have not been systematically synthesised. This study aims to summarise the existing literature on outpatient PT following TKA as well as to identify factors associated with its use.

METHODS

A systematic literature search in MEDLINE (via PubMed), CINAHL, Scopus and PEDro was conducted in July 2020 without language restrictions. Two authors independently selected studies, extracted data and assessed study quality. The primary outcome was the proportion being treated with at least one session of outpatient PT (land- or water-based treatments supervised/provided by a qualified physiotherapist) during any defined period within 12 months following TKA. Furthermore, predictors for the use of PT were assessed. Studies including only revision surgeries or bilateral TKA were excluded.

RESULTS

After screening 1934 titles/abstracts and 56 full text articles, 5 studies were included. Proportions of PT utilisation ranged from 16.7 to 84.5%. There were large variations in the time periods after hospital discharge (4 weeks to 12 months) and in the reporting of PT definitions. Female sex was associated with higher PT utilisation, and compared to patients after total hip arthroplasty, utilisation was higher among those following TKA.

CONCLUSION

Despite using a broad search strategy, we found only 5 studies assessing the utilisation of PT after hospital discharge in patients with TKA. These studies showed large heterogeneity in PT utilisation, assessed time periods and PT definitions. Clearly, more studies from different countries with uniform PT definitions are needed to address this relevant public health question.

Reporting of post-operative rehabilitation interventions for Total knee arthroplasty: a scoping review

Objective

The aim of this study was to evaluate the completeness of reporting of exercise adherence and exercise interventions delivered as part of clinical trials of post-operative total knee replacement (TKA) rehabilitation.

Design: Scoping review

Literature search

A literature search was conducted in PubMed, EMBASE, AMED, CINAHL, SPORTDiscus and Cochrane Library.

Study selection criteria

All randomized controlled trials (RCT) that examined post-operative exercise-based interventions for total knee arthroplasty were eligible for inclusion. Studies that were multifactorial or contained exercise interventions for both hip and knee arthroplasty were also included.

Data synthesis

The definition, type of measurement used and outcome for exercise adherence were collected and analyzed descreptively. Quality of reporting of exercise interventions were assessed using the Consensus for Exercise Reporting Tool (CERT) and the Cochrane Risk of Bias Tool.

Results

There were a total of 112 RCTs included in this review. The majority of RCTs (63%, n = 71) did not report exercise adherence. Only 23% (n = 15) of studies provided a definition of adherence. RCTs were of poor quality, with 85% (n = 95) of studies having high or unclear risk of bias. Reporting of exercise interventions was poor, with only 4 items (of 19) (21%) of the CERT adequately reported (88–99%), with other items not fulfilled on at least 60% of the RCTs. There were no RCTs that had fulfilled all the criteria for the CERT.

Conclusion

The RCTs included in this study poorly reported exercise adherence, as well as description of the post-operative TKA rehabilitation intervention. Future RCTs should use valid and reliable measures of adherence and a proper tool for reporting of exercise interventions (e.g., CERT, TiDER).

Pre-registration

OSF:https://osf.io/9ku8a/

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04460-w.

Quadriceps muscle group function and after total knee arthroplasty-asystematic narrative update

BACKGROUND

This article systematically summarizes the present evidences, published in the last 20 years, regarding the pre- and post-operative factors, which may influence recovery of the function of the quadriceps muscle group following total knee arthroplasty (TKA). We following the PRISMA methodology, including meta-analyses and high-level evidence studies (prospective trials, and, when unavailable, retrospective studies).

SOURCES OF DATA

Pubmed and Cochrane databases: 582 articles were identified and 54 of them were selected.

AREAS OF AGREEMENT

Tourniquets inflated at high pressure exert a detrimental effect on the quadriceps muscle group. Faster quadriceps recovery takes place using mini-invasive approaches, an eight-week rehabilitation period including balance training and the use of nutraceuticals.

AREAS OF DISAGREEMENT

Pre-habilitation and pre-operative factors, analgesic methods and different TKA implants.

GROWING POINTS AND AREAS TIMELY FOR DEVELOPING RESEARCH

Telerehabilitation seems a cost-effective tool for rehabilitation after TKA. Patients' optimization protocols before TKA should include standardized nutraceuticals intake.

Deep Learning in Gait Parameter Prediction for OA and TKA Patients Wearing IMU Sensors

Quantitative assessments of patient movement quality in osteoarthritis (OA), specifically spatiotemporal gait parameters (STGPs), can provide in-depth insight into gait patterns, activity types, and changes in mobility after total knee arthroplasty (TKA). A study was conducted to benchmark the ability of multiple deep neural network (DNN) architectures to predict 12 STGPs from inertial measurement unit (IMU) data and to identify an optimal sensor combination, which has yet to be studied for OA and TKA subjects. DNNs were trained using movement data from 29 subjects, walking at slow, normal, and fast paces and evaluated with cross-fold validation over the subjects. Optimal sensor locations were determined by comparing prediction accuracy with 15 IMU configurations (pelvis, thigh, shank, and feet). Percent error across the 12 STGPs ranged from 2.1% (stride time) to 73.7% (toe-out angle) and overall was more accurate in temporal parameters than spatial parameters. The most and least accurate sensor combinations were feet-thighs and singular pelvis, respectively. DNNs showed promising results in predicting STGPs for OA and TKA subjects based on signals from IMU sensors and overcomes the dependency on sensor locations that can hinder the design of patient monitoring systems for clinical application.

Pain, sensitization and physical performances in patients with chronic painful knee osteoarthritis or chronic pain following total knee arthroplasty: An explorative study

BACKGROUND

The aim of this study was to assess clinical pain, pain sensitization and physical performances to profile patients with chronic painful knee osteoarthritis (OA) or pain after total knee arthroplasty (TKA). Examining the interactions between pain mechanisms and physical performances would enable us to investigate the underlying explanatory relationships between these parameters.

METHODS

In this explorative study, 70 patients with chronic painful knee OA (N = 46) or chronic pain after TKA (N = 24) were assessed for clinical pain, quantitative sensory profiling (mechanical pinprick pain sensitivity, temporal summation (TS) and conditioned pain modulation), physical performances (chair stand, walk and stair climb tests) and self-reported outcomes. Between-group comparisons were made using ANCOVA tests and associations between outcomes were analysed using multivariate linear regression models.

RESULTS

Overall, no differences between groups regarding clinical pain and quantitative sensory profiling outcomes were observed. Physical performances were lower in the TKA group compared with the OA group with moderate-to-large effect sizes, and a tendency towards better scores in self-reported outcomes for the OA group was observed with small-to-moderate effect sizes. Self-reported function seems to be associated with physical performances in the TKA group. Sensitization (TS) appears to be associated with poorer physical performances in the OA group.

CONCLUSIONS

Similar profiles for pain intensity, signs of sensitization and conditioned pain modulation were observed. Patients with TKA seems to have impaired physical performances compared with the OA group, underlining the importance of targeting physical performances. Only the OA patients showed an association between sensitization (TS) and physical performance.

SIGNIFICANCE

Quantitative pain profiling assessment was used to assess pain intensities and pain mechanisms. We observed associations between physical performances and temporal summation in the OA group underlining the importance of assessing motor functions and pain mechanisms in the same trial. We observed lower levels of physical performances in the TKA group compared with the OA group, suggesting that examination and rehabilitation of physical performances is essential for TKA patients with chronic pain.

Effect of Outpatient Rehabilitation on Functional Mobility After Single Total Knee Arthroplasty: A Randomized Clinical Trial

Importance

Even without evidence, rehabilitation practitioners continue to introduce new interventions to enhance the mobility outcomes for the increasing population with a recent total knee arthroplasty (TKA).

Objective

To compare post-TKA functional mobility outcomes among 3 newly developed physical therapy protocols with a standard-of-care post-TKA rehabilitation protocol.

Design, Setting, and Participants

This randomized clinical trial included 4 study arms implemented in 15 outpatient clinics within a single health system in the Baltimore, Maryland, and Washington, District of Columbia, region from October 2013 to April 2017. Participants included patients who underwent elective unilateral TKA, were aged 40 years and older, and began outpatient physical therapy within 24 days after TKA. A total of 505 patients were screened and 386 participants were enrolled. Patients provided informed consent and were randomly assigned to 1 of 4 groups. Blinding patients and treating therapists was not feasible owing to the nature of the intervention. Analysis was conducted under the modified intent-to-treat principle from October 2017 to May 2019.

Interventions

The control group used a standard recumbent bike for 15 to 20 minutes each session. Interventions used 1 of 3 modalities for 15 to 20 minutes each session: (1) a body weight-adjustable treadmill, (2) a patterned electrical neuromuscular stimulation device, or (3) a combination of the treadmill and electrical neuromuscular stimulation.

Main Outcomes and Measures

Outcomes included the Activity Measure for Post-acute Care basic mobility score, a patient-reported outcome measure, and the 6-minute walk test. Outcomes were measured at baseline, monthly, and on discharge from outpatient therapy.

Results

Data from 363 patients (mean [SD] age, 63.4 [7.9] years; 222 [61.2%] women) were included in the final analysis, including 92 participants randomized to the control group, 91 participants randomized to the treadmill group, 90 participants randomized to the neuromuscular stimulation device group, and 90 participants randomized to the combination intervention group. Activity Measure for Post-acute Care scores at discharge were similar across groups, ranging from 61.1 to 61.3 (P = .99) with at least 9.0 points improvement (P = .80) since baseline. The distances as measured by the 6-minute walking test were not statistically different across groups (range, 382.9-404.5 m; P = .60).

Conclusions and Relevance

This randomized clinical trial found no statistically or clinically significant differences in outcomes across the 4 arms. Because outcomes were similar among arms, clinicians should instead consider relative cost in tailoring TKA rehabilitation.

Trial Registration

ClinicalTrials.gov Identifier: NCT02426190.

Physical Therapist Management of Total Knee Arthroplasty

A clinical practice guideline on total knee arthroplasty was developed by an American Physical Therapy (APTA) volunteer guideline development group that consisted of physical therapists, an orthopedic surgeon, a nurse, and a consumer. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches to management of total knee arthroplasty.

Effect of Group-Based Outpatient Physical Therapy on Function After Total Knee Replacement: Results From a Multicenter Randomized Controlled Trial

Objective

To evaluate the long‐term clinical effectiveness of a novel group‐based outpatient physical therapy (PT) following total knee replacement (TKR).

Methods

In this 2‐center, unblinded, superiority, randomized controlled trial, 180 patients on a waiting list for primary TKR due to osteoarthritis were randomized to a 6 session group‐based outpatient PT intervention and usual care (n = 89) or usual care alone (n = 91). The primary outcome was patient‐reported functional ability measured by the Lower Extremity Functional Scale at 12 months postoperative. Secondary outcomes included knee symptoms, depression, anxiety, and satisfaction. Questionnaires were completed preoperatively and at 3, 6, and 12 months postoperatively.

Results

The mean difference in function between groups was 4.47 (95% confidence interval [95% CI] 0.20, 8.75; P = 0.04) at 12 months postoperative, favoring the intervention. The mean difference in function between groups decreased over time, from 8.1 points at 3 months (95% CI 3.8, 12.4; P < 0.001) to 5.4 (95% CI 1.1, 9.8; P = 0.015) at 6 months postoperative. There were no clinically relevant differences in any secondary outcomes between groups, although patients in the intervention group were more likely to be satisfied with their PT. No serious adverse events related to the intervention were reported.

Conclusion

Supplementing usual care with this group‐based outpatient PT intervention led to improvements in function at 12 months after TKR, although the magnitude of the difference was below the minimum clinically important difference of 9 points. However, patient satisfaction was higher in the intervention group, and there was some evidence of clinically relevant improvements in function at 3 months.

Intensive, personalized multimodal rehabilitation in patients with primary or revision total knee arthroplasty: a retrospective cohort study

Background

Recent evidence has shown that many patients suffer from persistent pain and impaired function after primary or revision total knee arthroplasty (TKA). Post-surgical complications may in addition decrease physical performances and lead to more pain and impacted quality of life.

The purpose of the study was to assess the changes in pain intensity and functional capacity among patients with post-surgical complications after TKA three weeks of intensive, personalized multimodal rehabilitation.

Methods

A retrospective cohort study consisting of 217 patient of which 166 had primary TKA and 51 had revision TKA was conducted. On average, primary TKA patients and revision TKA patients were 3.7 and 2.7 months post-surgical, respectively. All patients have had post-surgical complications and were referred to an inpatient rehabilitation department, where they received a personalized three-week intensive, multimodal rehabilitation protocol. The rehabilitation consisted of sessions targeting neuromuscular function, postural control, and flexibility, sessions focusing on improving muscle strength and cardiovascular function and sessions with focus on gait retraining. The frequency of training was 2–4 sessions/day. The primary outcome was the Knee injury and Osteoarthritis Outcome Score (KOOS) and secondary outcomes were pain intensities measured using numerical rating scale, 6 min. walking test, stair-climbing test and range of motion for knee flexion and extension. Outcome measures were assessed at baseline upon referral and at follow-up before discharge.

Results

All outcomes, except pain at rest in the revision group, improved significantly. KOOS subscales, improved 8.5 to 14.2 in the primary TKA group (p < 0.001) and 6.9 to 10.8 in the revision group (p < 0.001). For the TKA group, effect sizes were medium-to-large for all KOOS subscales, 6 min. walking test, stair-climbing test, and pain intensity during activity. For the revision group, effect sizes were medium-to-large for KOOS subscales symptoms and activity of daily living, 6 min. walking test, stair-climbing test, and knee flexion.

Conclusion

Patients with post-surgical complications after primary or revision TKA experienced clinical relevant improvement in self-reported outcomes, pain relief, and improved physical performances after three weeks of personalized multimodal rehabilitation. The results suggest that an intensive, multimodal approach might be useful to obtain clinically relevant improvements.

Incorporating hip abductor strengthening exercises into a rehabilitation program did not improve outcomes in people following total knee arthroplasty: a randomised trial

QUESTION

In adults following primary total knee arthroplasty, does the incorporation of hip abductor strengthening exercises into a 6-week rehabilitation program improve muscle strength, functional performance and patient-reported outcomes at the end of rehabilitation and at 26 weeks?

DESIGN

Randomised controlled trial with concealed allocation, blinded assessors and intention-to-treat analysis.

PARTICIPANTS

One hundred and five adults admitted to an inpatient rehabilitation facility immediately following total knee arthroplasty.

INTERVENTION

Participants in both groups attended 12 days of inpatient physiotherapy followed by 6 weeks of outpatient physiotherapy, which aimed to improve knee range of movement, strength and mobility. The experimental group completed a standard rehabilitation protocol with the addition of hip abductor strengthening. The control group completed the same standard rehabilitation protocol, with the addition of 15 minutes of general functional exercises.

OUTCOME MEASURES

Primary outcomes were the Knee Injury and Osteoarthritis Outcome Score (KOOS) and isometric hip abductor muscle strength normalised to body mass index. Secondary outcome measures included the stair climb test, 6-minute walk test, Timed Up and Go test, 40-m fast-paced walk test, 30-second chair stand test, step test, isometric quadriceps muscle strength, Lower Extremity Functional Scale, and Short Form-12.

RESULTS

The experimental intervention did not result in significantly greater improvements in hip strength, KOOS or any of the secondary outcome measures than the control intervention at 6 weeks or 26 weeks.

CONCLUSION

Similar improvements in muscle strength, functional performance and patient-reported outcomes were observed whether specific hip-strengthening exercises were incorporated or general functional exercises were continued instead as part of a postoperative rehabilitation program for participants after total knee arthroplasty.

REGISTRATION

ANZCTR 12615000863538.

Physical activity levels after hip and knee joint replacement surgery: an observational study

Usual care after hip or knee joint replacement does not adequately address the problem of low physical activity levels. We aimed to determine whether exercise delivered in a group setting in the early stage of outpatient rehabilitation influenced self-reported physical activity levels after hip or knee joint replacement. A case series of 79 participants referred to a 6-week outpatient orthopaedic exercise group after total hip or knee replacement were evaluated using the International Physical Activity Questionnaire (IPAQ) short form. Physical function was evaluated using Osteoarthritis Research Society International (OARSI) recommended performance-based tests (30 s Chair Stand Test, 40 m Fast Pace Walk Test, Stair Climb Test, Timed Up and Go Test, 6 Minute Walk Test). Measures were assessed at admission, discharge and 6 weeks after group discharge. Non-parametric analysis was conducted for IPAQ scores. Analysis of functional measures was conducted with linear mixed models with time modelled as a repeated measure. Standard multiple regression and correlation analysis were conducted. Fifty-four participants completed the study. Self-reported activity levels improved significantly at program discharge but not at 6-week follow-up. All performance-based measures improved significantly at program discharge. Fast-paced walking and 6 Minute Walk Test measures continued to improve at 6-week follow-up. Group dynamics present in an outpatient rehabilitation exercise program may increase physical activity levels during group participation but not after group cessation. Performance in all functional measures improved at group discharge.

Prevalence and determinants of physical activity and sedentary behaviour before and up to 12 months after total knee replacement: a longitudinal cohort study

OBJECTIVE

This study aims to evaluate the prevalence and determinants of inadequate physical activity and excessive sedentary behaviour before and after total knee replacement.

DESIGN, SETTING AND SUBJECTS

Secondary analysis was performed on data from a cohort of 422 adults (45-74 years), drawn from 12 public or private hospitals, undergoing primary unilateral or bilateral total knee replacement surgery.

MAIN MEASURES

Questionnaires were used to determine the presence of inadequate physical activity and excessive sedentary behaviour before and 6  and 12 months after total knee replacement surgery. Knee pain, activity limitations, comorbidities, muscle strength, psychological well-being, fatigue, sleep and body mass index were measured/assessed as possible determinants of physical activity or sedentary behaviour.

RESULTS

Before surgery, 77% ( n = 326) of the cohort participated in inadequate physical activity according to World Health Organization guidelines, and 60% ( n = 253) engaged in excessive sedentary behaviour. Twelve months after surgery, 53% ( n = 185) of the cohort engaged in inadequate physical activity and 45% ( n = 157) in excessive sedentary behaviour. Inadequate physical activity before surgery ( P = 0.02), obesity ( P = 0.07) and comorbidity score >6 ( P = 0.04) predicted inadequate physical activity 12 months after surgery. Excessive sedentary behaviour and activity limitations before surgery predicted excessive sedentary behaviour 12 months after surgery.

CONCLUSION

Although there were improvements after total knee replacement, 12 months after surgery about half the cohort did not meet World Health Organization recommendations for activity. Pre-surgery assessment of physical activity, activity limitations, sedentary behaviour and body mass index is essential to identify patients at risk for long-term inactivity.

Effectiveness of postdischarge interventions for reducing the severity of chronic pain after total knee replacement: systematic review of randomised controlled trials

OBJECTIVE

Approximately 20% of patients experience chronic pain after total knee replacement (TKR). The aim of this systematic review was to evaluate the effectiveness of postdischarge interventions commenced in the first 3 months after surgery in reducing the severity of chronic pain after TKR.

DESIGN

The protocol for this systematic review was registered on PROSPERO (registration number: CRD42017041382). MEDLINE, Embase, CINAHL, PsycINFO and The Cochrane Library were searched from inception to November 2016. Randomised controlled trials of postdischarge intervention which commenced in the first 3 months after TKR surgery were included. The primary outcome of the review was self-reported pain severity at 12 months or longer after TKR. Risk of bias was assessed using the Cochrane risk-of-bias tool.

RESULTS

Seventeen trials with data from 2485 randomised participants were included. The majority of trials evaluated physiotherapy interventions (n=13); other interventions included nurse-led interventions (n=2), neuromuscular electrical stimulation (n=1) and a multidisciplinary intervention (n=1). Opportunities for meta-analysis were limited by heterogeneity. No study found a difference in long-term pain severity between trial arms, with the exception of one trial which found home-based functional exercises aimed at managing kinesiophobia resulted in lower pain severity scores at 12 months postoperatively compared with advice to stay active.

CONCLUSION

This systematic review and narrative synthesis found no evidence that one type of physiotherapy intervention is more effective than another at reducing the severity of chronic pain after TKR. Further research is needed to evaluate non-physiotherapy interventions, including the provision of care as part of a stratified and multidisciplinary care package.

PROSPERO REGISTRATION NUMBER

CRD42017041382.

Total knee arthroplasty: improving outcomes with a multidisciplinary approach

Total knee arthroplasty (TKA) is the most commonly performed inpatient surgical procedure within the USA and is estimated to reach 3.48 million procedures annually by 2030. As value-based care initiatives continue to focus on hospital readmission rates and patient satisfaction, it has become essential for health care providers to develop and implement a multidisciplinary approach to enhance TKA outcomes while minimizing unnecessary expenditures. Through this necessity, clinical care pathways have been developed to standardize, organize, and improve the quality and efficiency of patient care while simultaneously encouraging the collaboration among various medical care providers. Here, we review several systems based programs and specialty care practices that can be adopted into the standard orthopedic practice.

Effective exercise intervention period for improving body function or activity in patients with knee osteoarthritis undergoing total knee arthroplasty: a systematic review and meta-analysis

BACKGROUND

Various systematic reviews and/or meta-analyses examining the effects of pre- or postoperative exercise on body function or activity in patients undergoing total knee arthroplasty (TKA) have been published. However, the interventional period needed to at least improve outcomes is unknown.

OBJECTIVE

The aim of this systematic review and meta-analysis was to investigate the exercise intervention period needed to effectively improve body function or activity before and after TKA in patients with knee osteoarthritis (OA).

METHODS

Studies published until July 2017 were included in the review. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was applied to each meta-analysis to determine the quality of the evidence.

RESULTS

Twenty-seven randomized controlled trials were identified. A meta-analysis indicated that exercises performed for 8 weeks after discharge in addition to standard postoperative intervention effectively improved body function as assessed using pain level; physical function, and stiffness on the Western Ontario and McMaster Universities Arthritis Index; extension strength; active knee flexion range of motion; timed up and go test; and gait speed.

CONCLUSION

Overall, we found low- to moderate-quality evidence that an 8-week exercise period was needed after discharge to improve body function and activity in patients with knee OA undergoing TKA.

Post-operative patient-related risk factors for chronic pain after total knee replacement: a systematic review

OBJECTIVE

To identify postoperative patient-related risk factors for chronic pain after total knee replacement (TKR).

DESIGN

The systematic review protocol was registered on the International Prospective Register of Systematic Reviews (CRD42016041374). MEDLINE, Embase and PsycINFO were searched from inception to October 2016 with no language restrictions. Key articles were also tracked in the Institute for Scientific Information (ISI) Web of Science. Cohort studies evaluating the association between patient-related factors in the first 3 months postoperatively and pain at 6 months or longer after primary TKR surgery were included. Screening, data extraction and assessment of methodological quality were undertaken by two reviewers. The primary outcome was pain severity in the replaced knee measured with a patient-reported outcome measure at 6 months or longer after TKR. Secondary outcomes included adverse events and other aspects of pain recommended by the core outcome set for chronic pain after TKR.

RESULTS

After removal of duplicates, 16 430 articles were screened, of which 805 were considered potentially relevant. After detailed evaluation of full-text articles, 14 studies with data from 1168 participants were included. Postoperative patient-related factors included acute pain (eight studies), function (five studies) and psychosocial factors (four studies). The included studies had diverse methods for assessment of potential risk factors and outcomes, and therefore narrative synthesis was conducted. For all postoperative factors, there was insufficient evidence to draw firm conclusions about the association with chronic pain after TKR. Selection bias was a potential risk for all studies, as none were reported to be conducted at multiple centres.

CONCLUSION

This systematic review found insufficient evidence to draw firm conclusions about the association between any postoperative patient-related factors and chronic pain after TKR. Further high-quality research is required to provide a robust evidence base on postoperative risk factors, and inform the development and evaluation of targeted interventions to optimise patients' outcomes after TKR.