Monitoring Patient Recovery After THA or TKA Using Mobile Technology

Completion of Patient-Reported Outcome Measures Improved With Use of a Mobile Application in Arthroplasty Patients: Results From a Randomized Controlled Trial

BACKGROUND

The collection of patient-reported outcome measures (PROMs) has historically been reported as costly and time-consuming, with low compliance rates that may impact reimbursement. Little research has reported the effects of mobile applications to support PROMs collection following arthroplasty.

METHODS

Secondary analysis of data from a multicenter randomized controlled trial was performed. Patients undergoing knee and hip arthroplasty were randomized to utilize a smartphone-based care management platform (app) for self-directed rehabilitation and completed joint-specific PROMs (Hip Dysfunction and Osteoarthritis Outcome Score, Joint Replacement or Knee Injury and Osteoarthritis Score, Joint Replacement) via the application at prescribed intervals or on paper during clinic visits. Control patients received practice standard of care, and completed PROMs via emailed hyperlink or during clinic visits following lower limb arthroplasty. Overall, 455 patients underwent knee arthroplasty procedures (245 control, 210 app group) and 380 underwent total hip arthroplasty (206 control, 174 app group). Compliance with expected PROMs completion was calculated through one year postoperatively.

RESULTS

Compliance was higher in the app group preoperatively in both knee (98.1 versus 86.9%, P < .0001) and hip cohorts (96.0 versus 88.4%, P = .008), and postoperatively, including at one year (knees, 72.2 versus 53.7%, P < .0001; hips, 71.1 versus 49.2%, P < .0001). On log-binomial regressions, intervention arm was the strongest predictor of completion of all PROMs, where app users undergoing knee (Relative Risk 2.039, 95% confidence interval (CI) 1.595 to 2.607, P < .000) and hip arthroplasty (2.268 95% CI 1.742 to 2.953, P < .0001) were more likely to be compliant at all timepoints. The majority of patients in the app group, including those over 65 years of age, completed PROMs using the application as opposed to paper methods.

CONCLUSIONS

A smartphone mobile application that engages patients during recovery after knee and hip joint arthroplasty improved compliance with completion of preoperative and postoperative PROMs compared to other electronic and paper methods.

Comparison of Early Postoperative Step and Stair Counts With the Direct Anterior Approach Versus the Posterior Approach for Total Hip Arthroplasty

BACKGROUND

The purpose of this study was to evaluate the impact of direct anterior approach (DAA) or posterior approach (PA) on step and stair counts after total hip arthroplasty using a remotely monitored mobile application with a smartwatch while controlling for baseline characteristics.

METHODS

This is a secondary data analysis from a prospective cohort study of patients utilizing a smartphone-based care management platform. The primary outcomes were step and stair counts and changes from baseline through one year. Step and stair counts were available for 1,501 and 847 patients, respectively. Longitudinal regression models were created to control for baseline characteristics.

RESULTS

Patients in the DAA group had significantly lower body mass index (P = .049) and comorbidities (P = .028), but there were no significant differences in age (P = .225) or sex (P = .315). The DAA patients had a higher average and improvement from baseline in step count at 2 and 3 weeks postoperatively after controlling for patient characteristics (P = .028 and P = .044, respectively). The average stair counts were higher for DAA patients at one month postoperatively (P = .035), but this difference was not significant after controlling for patient demographics. Average stair ascending speeds and changes from baseline were not different between DAA and PA patients. Descending stair speed was higher at 2 weeks postoperatively for DAA patients, but was no longer higher after controlling for baseline demographics.

CONCLUSIONS

After controlling for baseline characteristics, DAA patients demonstrate earlier improvement in step count than PA patients after total hip arthroplasty. However, patient selection and surgeon training may continue to influence outcomes through a surgical approach.

Characterization of the Relative Change in Objective and Subjective Metrics by Baselining Patients Who Have Wearable Technology Before Total Knee Arthroplasty

BACKGROUND

Wearable sensors and associated supporting technologies (ie, patient applications) can provide both objective (joint position, step counts, etc.) and subjective data (ie, pain scores and patient-reported outcome measures) to track a patient's episode of care. Establishing a subjective and objective baseline of a patient's experience may arguably be beneficial for multiple reasons, including setting recovery expectations for the patient and demonstrating the effectiveness or success of the intervention.

METHODS

In this pilot study, we characterized a subset of patients (n = 82 from 7 surgeons) using a wearable sensor system at least 6 days before total knee arthroplasty and provided postsurgical data up to 50 days postintervention. The 5-day average before surgery for total step counts (activity), achieved flexion and extension on a progress test (functional limit) and visual analog scale daily pain score were calculated. The difference from baseline was then calculated for each patient for each day postsurgery and reported as averages.

RESULTS

On average, a patient will experience a relative deficit of 4,000 steps immediately following surgery that will return to near-baseline levels 50 days postintervention. A 30° deficit in flexion and a 10° deficit in extension will return at a similar rate as steps. Relative pain scores will worsen with an increase of approximately 3 points immediately following surgery. However, pain will decrease by 2 points relative to baseline between 40 and 50 days.

CONCLUSIONS

The results of this pilot study demonstrate a method to baseline a patient's presurgical subjective and objective data and to provide a reference for postsurgical recovery expectations. Applications for these data include benchmarking for evaluating intervention success as well as setting patient expectations.

A Retrospective Study on the Feasibility of Using Low-burden Patient-reported Pain Scores to Track Recovery and Outcomes After Total Joint Replacement

Background

Patients undergo total joint arthroplasty to improve function and resolve pain. Patient-reported outcome measures (PROMs) are often sought to determine the success of total joint arthroplasty but are time-consuming and patient response rates are often low. This study sought to determine whether pain numeric rating scores (NRSs) were associated with PROMs and objective mobility outcomes.

Methods

This is a retrospective review of data in patients who utilized a smartphone-based care management application prior to and following total joint arthroplasty. NRS, Hip Disability and Osteoarthritis Outcome Score, Joint Replacement and Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, and objective mobility data (step counts, gait speed, and gait asymmetry) were collected preoperatively and at 30 and 90 days postoperatively. Quantile regression was performed to evaluate the correlations between NRS and PROMs.

Results

Total knee arthroplasty patients reported higher NRS than total hip arthroplasty patients postoperatively. NRS was significantly correlated with gait speed preoperatively and at 30 and 90 days postoperatively on quantile regression. Gait asymmetry was significantly associated with NRS at 30 days postoperatively. Regression results suggested significant correlations between NRS and PROMs scores; Hip Disability and Osteoarthritis Outcome Score, Joint Replacement, -0.46 (95% confidence interval: -0.48 to -0.44, P < .001) and Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, -0.38 (95% confidence interval: -0.40 to -0.36, P < .001).

Conclusions

NRS is correlated with both objective and subjective measures of function in patients undergoing arthroplasty. Simple pain ratings may be a valid measurement to help predict functional outcomes when collection of traditional PROMs is not feasible.

How Active Are Our Patients in the First 6 Weeks Following Total Knee Arthroplasty?

BACKGROUND

Patient activity after total knee arthroplasty (TKA) surgery has been estimated through patient- reported outcome measures. The use of data from an implanted sensor that transmits daily gait activity provides a more objective, complete recovery trajectory.

METHODS

In this retrospective analysis of 794 patients who received a TKA with sensors in the tibial extension between October 4, 2021, and January 13, 2023, the average age of the patients was 64 years, and the cohort was 54.9% women. During the 6-week postoperative period, 90.3% of patients transmitted data. Patient activity in terms of qualified step count, cadence, walking speed, stride length, functional tibial range of motion, and functional knee range of motion were compared at 1 week, 3 weeks, and 6 weeks postoperatively.

RESULTS

All gait parameters increased in the first six weeks post-surgery: qualified step count increased 733%, cadence increased 22%, walking speed increased 50%, stride length increased 17%, tibial range of motion (ROM) increased 19%, and functional knee ROM increased 14%. There were statistically significant differences at both postoperative periods (P = 0.029, P < 0.001, and P < 0.001 at 3 and 6 weeks, respectively) in step counts for different body mass index (BMI) categories, with qualified step counts decreasing with increasing BMI. Patients under 65 years tended to have a higher qualified step count than those 65 and older at all time points, but these differences were not statistically significant. Men had significantly higher step counts than women (P < 0.001 at 1, 3, and 6 weeks).

CONCLUSIONS

Initial results with an implanted sensor that collects data during activities of daily living confirm that 90% of patients transmit objective gait metrics daily after TKA surgery. Those results differ by sex and BMI.

Impact of Chronic Opioid Use on Postoperative Mobility Recovery and Patient-Reported Outcomes: A Propensity-Matched Study

BACKGROUND

Opioid use prior to total joint arthroplasty may be associated with poorer postoperative outcomes. However, few studies have reported the impact on postoperative recovery of mobility. We hypothesized that chronic opioid users would demonstrate impaired objective and subjective mobility recovery compared to nonusers.

METHODS

A secondary data analysis of a multicenter, prospective observational cohort study in which patients used a smartphone-based care management platform with a smartwatch for self-directed rehabilitation following hip or knee arthroplasty was performed. Patients were matched 2:1 based on age, body mass index, sex, procedure, Charnley class, ambulatory status, orthopedic procedure history, and anxiety. Postoperative mobility outcomes were measured by patient-reported ability to walk unassisted at 90 days, step counts, and responses to the 5-level EuroQol-5 dimension 5-level, compared by Chi-square and student's t-tests. Unmatched cohorts were also compared to investigate the impact of matching.

RESULTS

A total of 153 preoperative chronic opioid users were matched to 306 opioid-naïve patients. Age (61.9 ± 10.5 versus 62.1 ± 10.3, P = .90) and sex (53.6 versus 53.3% women, P = .95) were similar between groups. The proportion of people who reported walking unassisted for 90 days did not vary in the matched cohort (87.8 versus 90.7%, P = .26). Step counts were similar preoperatively and 1-month postoperatively but were lower in opioid users at 3 and 6 months postoperatively (4,823 versus 5,848, P = .03). More opioid users reported moderate to extreme problems with ambulation preoperatively on the 5-level EuroQol-5 dimension 5-level (80.6 versus 69.0%, P = .02), and at 6 months (19.2 versus 9.3%, P = .01).

CONCLUSIONS

Subjective and objective measures of postoperative mobility were significantly reduced in patients who chronically used opioid medications preoperatively. Even after considering baseline factors that may affect ambulation, objective mobility metrics following arthroplasty were negatively impacted by preoperative chronic opioid use.

Incorporating Wearable Technology for Enhanced Rehabilitation Monitoring after Hip and Knee Replacement

Osteoarthritis (OA) poses a growing challenge for the aging population, especially in the hip and knee joints, contributing significantly to disability and societal costs. Exploring the integration of wearable technology, this study addresses the limitations of traditional rehabilitation assessments in capturing real-world experiences and dynamic variations. Specifically, it focuses on continuously monitoring physical activity in hip and knee OA patients using automated unsupervised evaluations within the rehabilitation process. We analyzed data from 1144 patients who used a mobile health application after surgery; the activity data were collected using the Garmin Vivofit 4. Several parameters, such as the total number of steps per day, the peak 6-minute consecutive cadence (P6MC) and peak 1-minute cadence (P1M), were computed and analyzed on a daily basis. The results indicated that cadence-based measurements can effectively, and earlier, differ among patients with hip and knee conditions, as well as in the recovery process. Comparisons based on recovery status and type of surgery reveal distinctive trajectories, emphasizing the effectiveness of P6MC and P1M in detecting variations earlier than total steps per day. Furthermore, cadence-based measurements showed a lower inter-day variability (40%) compared to the total number of steps per day (80%). Automated assessments, including P1M and P6MC, offer nuanced insights into the patients' dynamic activity profiles.

Patient-reported outcomes the first thirty days after fast-track primary total hip arthroplasty. A prospective cohort study using a web-based registration tool for postoperative follow-up

INTRODUCTION

The documentation on patient reported outcomes the first weeks at home following total hip arthroplasty (THA) is sparse. Length of hospital stay after THA is substantially reduced. Therefore, knowledge on whether patients are managing their own postoperative rehabilitation early after discharge is important, in order to give the patients realistic preoperative information, to modify expectations and enable patients to monitor their own rehabilitation process.

METHODS

Eighty-two THA patients were included in a prospective cohort study. Patient-reported outcomes were collected twice a week thirty days postoperatively using a web-based registration tool. Numeric rating scales (0-10) for pain, function, and quality of life, EQ-5D, and the use of opioids were registered. Four weeks postoperatively a telephone interview were conducted. Pain, EQ5D and hip specific physical function score (HOOS-PS) were recorded preoperatively, at three- and twelve-months follow-up.

RESULTS

Pain was maintained the first days after hospital discharge. From day 0 to day 30, pain decreased from 4.0 (SD 2.23) to 2.3 (SD 1.75), function improved from 4.4 (SD 2.06) to 7 (SD 1.57), quality of life improved from 6.3 (SD 2.69) to 7.8 (SD 1.47), and EQ-5D improved from 0.4 to (SD 0.27) to 0.7 (SD 0.14). After 30 days, 32% still used opioids. All patients completed the web-registration. Pain, EQ-5D and HOOS-PS improved substantially from preoperatively to twelve months follow-up.

CONCLUSION

Fast-track THA patients can expect continued postoperative pain and impaired quality of life the first week at home, before gradually improvement. After thirty days, 32 % of the patients still used opioids.

Early post-operative walking bouts are associated with improved gait speed and symmetry at 90 days

INTRODUCTION

There is a paucity of literature on optimal patterns of daily walking following joint arthroplasty, which are now evaluated with consumer technologies like smartphones, and can enhance our understanding of post-operative mobility. When smartphone-recorded, daily walking patterns are captured, qualities of gait-recovery such as gait speed or symmetry can be analyzed in real-world environments.

RESEARCH QUESTION

Are the daily distribution of walking bouts in the early post-operative period associated with 90-day gait quality measures following hip and knee arthroplasty?

METHODS

Gait data was collected passively using a smartphone-based care management platform in patients undergoing hip and knee arthroplasty. As recorded via subjects' free-living smartphone-collected gait bouts, data were investigated as a function of the walking session length and were used to create a ratio to the total time logging bouts, representing the fraction of walking performed during a single session per day (aggregation score). Quantile regression was performed to evaluate the association between early walking session lengths or aggregation score at 30 days post-operatively and the gait-sampled speed and asymmetry of walking at 90 days.

RESULTS

In total, 2255 patients provided evaluable data. The walking session length at 30 days was positively associated with 90-day mean gait speed across procedure types where quantile regression coefficients ranged from 0.11 to 0.17. In contrast, aggregation score was negatively associated with gait speed at 90 days, with coefficients ranging from -0.18 to -0.12.

SIGNIFICANCE

The duration and frequency of walking bouts was associated with recovery of gait speed and symmetry following lower limb arthroplasty. The findings may help clinicians design walking protocols that are associated with improved gait metrics at 3 months.

Young or Old Age and Non-White Race Are Associated With Poor Patient-Reported Outcome Measure Response Compliance After Orthopaedic Surgery

Purpose

To investigate orthopaedic patient compliance with patient-reported outcome measures (PROMs) and identify factors that improve response rates.

Methods

Our search strategy comprised a combination of key words and database-specific subject headings for the concepts of orthopaedic surgical procedures, compliance, and PROMs from several research databases from inception to October 11, 2022. Duplicates were removed. A total of 97 studies were included. A table was created for the remaining articles to be appraised and analyzed. The collected data included study characteristics, follow-up/compliance rate, factors that increase/decrease compliance, and type of PROM. Follow-up/compliance rate was determined to be any reported response rate. The range and average used for analysis was based on the highest or lowest number reported in the specific article.

Results

The range of compliance reported was 11.3% to 100%. The overall response rate was 68.6%. The average baseline (preoperative/previsit) response rate was 76.6%. Most studies (77%) had greater than 50% compliance. Intervention/reminder of any type (most commonly phone call or mail) resulted in improved compliance from 44.6% to 70.6%. Young and elderly non-White male patients had the lowest compliance rate. When directly compared, phone call (71.5%) resulted in a greater compliance rate than electronic-based (53.2%) or paper-based (57.6%) surveys.

Conclusions

The response rates for PROMs vary across the orthopaedic literature. Patient-specific factors, such as age (young or old) and race (non-White), may contribute to poor PROM response rate. Reminders and interventions significantly improve PROM response rates.

Clinical Relevance

PROMs are important tools in many aspects of medicine. The data generated from these tools not only provide information about individual patient outcomes but also make hypothesis-driven comparisons possible. Understanding the factors that affect patient compliance with PROMs is vital to our accurate understanding of patient outcomes and the overall advancement of medical care.

Patient Perceptions of Wearable and Smartphone Technologies for Remote Outcome Monitoring in Total Knee Arthroplasties

While there is enthusiasm for wearables and smartphone technologies in evaluating clinical outcomes among clinicians, less is known about the willingness of patients who have osteoarthritis (OA) to consent for remote outcome monitoring. We developed an Institutional Review Board-approved questionnaire to assess patient perceptions of remote monitoring technologies in a high-volume orthopaedic clinical center. Fifty total knee arthroplasty (TKA) patients (56% female; mean age: 61 years, range: 23-89) and fifty nonoperative OA knee patients (54% female; mean age: 58 years, range: 25-89) routinely consulted in the clinic as part of their OA treatment and consented to participate in the study. Patient perceptions were compared using Pearson's chi-square analyses with a significance threshold of p < 0.05. We found that TKA patients were more receptive to the use of smartphone apps (84 vs. 60%, p = 0.008) and wearable sensors (80 vs. 48%, p < 0.001) and learning to use custom wearables (72 vs. 38%, p = 0.002) than nonoperative OA knee patients as part of their treatment. Likewise, the majority of TKA patients were willing to use the global positioning system in their postoperative technology (54 vs. 18%, p < 0.001), especially if they were only active during certain circumstances (62 vs. 24%, p < 0.001). TKA patients also expressed willingness to have their body movement (68%), balance (70%), sleep (76%), and cardiac output (80%) tracked using remote technologies. Overall, we found that TKA patients were highly receptive to using wearable technology in their treatments, whereas nonoperative OA knee patients were generally unreceptive. Our study challenges the concept that current wearable technology approaches will be generally effective as a tool to remotely monitor all patients across the OA severity landscape.

Stepping Beyond Counts in Recovery of Total Hip Arthroplasty: A Prospective Study on Passively Collected Gait Metrics

Gait quality parameters have been used to measure recovery from total hip arthroplasty (THA) but are time-intensive and previously could only be performed in a lab. Smartphone sensor data and algorithmic advances presently allow for the passive collection of qualitative gait metrics. The purpose of this prospective study was to observe the recovery of physical function following THA by assessing passively collected pre- and post-operative gait quality metrics. This was a multicenter, prospective cohort study. From six weeks pre-operative through to a minimum 24 weeks post-operative, 612 patients used a digital care management application that collected gait metrics. Average weekly walking speed, step length, timing asymmetry, and double limb support percentage pre- and post-operative values were compared with a paired-sample t-test. Recovery was defined as the post-operative week when the respective gait metric was no longer statistically inferior to the pre-operative value. To control for multiple comparison error, significance was set at p < 0.002. Walking speeds and step length were lowest, and timing asymmetry and double support percentage were greatest at week two post-post-operative (p < 0.001). Walking speed (1.00 ± 0.14 m/s, p = 0.04), step length (0.58 ± 0.06 m/s, p = 0.02), asymmetry (14.5 ± 19.4%, p = 0.046), and double support percentage (31.6 ± 1.5%, p = 0.0089) recovered at 9, 8, 7, and 10 weeks post-operative, respectively. Walking speed, step length, asymmetry, and double support all recovered beyond pre-operative values at 13, 17, 10, and 18 weeks, respectively (p < 0.002). Functional recovery following THA can be measured via passively collected gait quality metrics using a digital care management platform. The data suggest that metrics of gait quality are most negatively affected two weeks post-operative; recovery to pre-operative levels occurs at approximately 10 weeks following primary THA, and follows a slower trajectory compared to previously reported step count recovery trajectories.

Inertial-Sensor-Based Monitoring of Sample Entropy and Peak Frequency Changes in Treadmill Walking during Recovery after Total Knee Arthroplasty

This study aimed to investigate whether sample entropy (SEn) and peak frequency values observed in treadmill walking could provide physical therapists valuable insights into gait rehabilitation following total knee arthroplasty (TKA). It was recognized that identifying movement strategies that during rehabilitation are initially adaptive but later start to hamper full recovery is critical to meet the clinical goals and minimize the risk of contralateral TKA. Eleven TKA patients were asked to perform clinical walking tests and a treadmill walking task at four different points in time (pre-TKA, 3, 6, and 12 months post-TKA). Eleven healthy peers served as the reference group. The movements of the legs were digitized with inertial sensors and SEn and peak frequency of the recorded rotational velocity-time functions were analyzed in the sagittal plane. SEn displayed a systematic increase during recovery in TKA patients (p < 0.001). Furthermore, lower peak frequency (p = 0.01) and sample entropy (p = 0.028) were found during recovery for the TKA leg. Movement strategies that initially are adaptive, and later hamper recovery, tend to diminish after 12 months post-TKA. It is concluded that inertial-sensor-based SEn and peak frequency analyses of treadmill walking enrich the assessment of movement rehabilitation after TKA.

Novel Use of an Accelerometer to Assess Load Asymmetry Over Time After Hip Resurfacing Arthroplasty

INTRODUCTION

There is limited knowledge regarding usage of wearable technology to guide return to sport after hip resurfacing arthroplasty (HRA). This study evaluated the use of accelerometers to identify when symmetry is restored between operative and non-operative limbs.

METHODS

A total of 26 primary HRA patients performed five validated physical tests before, 3 and 6 months after HRA: broad jump, double leg vertical jump (DLVJ), hop test, lateral single leg jump (LSLJ), and vertical single leg jump (VSLJ). Impact load and average intensity data (g-force units) were collected using accelerometers. Strength data (pounds (lbs.)) for internal and external rotation was collected with a dynamometer. Univariate and correlation analyses analyzed interlimb asymmetries.

RESULTS

At pre-operation, there were significant impact load asymmetries for DLVJ (P=.008), hop test (P=.021), and LSLJ (P=.003), and intensity asymmetry for DLVJ (P=.010) and LSLJ (P=.003). At 3 months, there was impact load asymmetry for DLVJ (P=.005) and LSLJ (P=.005), and intensity asymmetry for broad jump (P=.020), hop test (P=.042), and LSLJ (P=.005). There were significant strength asymmetries at pre- and 3 months post-operation for internal (P=.013) and external rotation (P=.037). All significant asymmetries indicated the non-operative leg had greater output. No significant asymmetries were found for any exercises at 6 months post-operation. An increase in Harris Hip Score was significantly associated with a decrease in impact asymmetry (r_s = -0.269, P=.006).

DISCUSSION AND CONCLUSION

Impact loads and strength reach interlimb symmetry at 6 months post-HRA. Wearable accelerometers provide useful metrics to distinguish limb asymmetries for recovery monitoring.

Remote Patient Monitoring Following Total Joint Arthroplasty

This review article presents the current state of remote patient monitoring (RPM) in total joint arthroplasty. RPM refers to the use of telecommunication with wearable and implantable technology to assess and treat patients. Several forms of RPM are discussed including telemedicine, patient engagement platforms, wearable devices, and implantable devices. The benefits to patients and physicians are discussed in the context of postoperative monitoring. Insurance coverage and reimbursement of these technologies are reviewed.

Use of a Recovery Messaging Application in Outpatient Total Joint Replacement

Total joint replacement (TJR) is performed in an outpatient setting for cost containment and reimbursement changes. However, outpatient readmission to the hospital within 30-90 days postoperatively can be costly. Increases in readmission to the hospital less than 30 days postoperatively increase healthcare expenditure and can leave surgical centers without reimbursement. The purpose of the integrative review was to examine 30-day readmission rates for adults post-outpatient TJR within a 12- to 14-week time frame using the recovery messaging application following discharge. A literature search was conducted, and articles were included if they were peer-reviewed academic journals written in English between 2017 and 2022. Fifteen articles were included and evaluated using the John Hopkins evidence summary table to assess the evidence level. The literature analysis identified three themes after using the smartphone application: (a) reducing hospital 30- day readmissions, (b) increasing patient engagement and early mobility, and (c) improving patient outcomes and satisfaction. The findings of this integrative review indicate that using an evidence-based intervention, such as the smartphone application for recovery messaging, can reduce less than 30-day hospital readmissions after outpatient TJR, thus reducing healthcare costs. Future studies should evaluate specific smartphone applications after other general surgical procedures.

The role of commercially available smartphone apps and wearable devices in monitoring patients after total knee arthroplasty: a systematic review

Purpose

Commercially available smartphone apps and wearable devices have proven valuable in a variety of clinical settings, yet their utility in measuring physical activity and monitoring patient status following total knee arthroplasty (TKA) remains unclear.

Methods

A systematic review was performed to assess the evidence supporting the use of smartphone apps and wearable devices to assist rehabilitation interventions following TKA. A search was conducted in the PubMed, Cochrane, Medline, and Web of Science databases in September 2021.

Results

One hundred and seventy-six studies were retrieved, of which 15 met inclusion criteria, including 6 randomized control trials. Four of these studies utilized smartphone apps, seven utilized wearable devices, and four utilized a combination of both. A total of 1607 TKA patients participated in the included studies. For primary outcomes, three reported on device accuracy, three on recovery prediction, two on functional recovery, two on physical activity promotion, two on patient compliance, two on pain control, and one on healthcare utilization.

Conclusion

Commercially available smartphone apps and wearable devices were shown to capably monitor physical activity and improve patient engagement following TKA, making them potentially viable adjuncts or replacements to traditional rehabilitation programs. Components of interventions such as step goals, app-based patient engagement platforms, and patient-specific benchmarks for recovery may improve effectiveness. However, future research should focus on the economics of implementation, long-term outcomes, and optimization of compliance and accuracy when using these devices.

Patient Perceptions of Wearable and Smartphone Technologies for Remote Outcome Monitoring in Patients Who Have Hip Osteoarthritis or Arthroplasties

BACKGROUND

Although there is interest in wearables and smartphone technologies for remote outcome monitoring, little is known regarding the willingness of hip osteoarthritis (OA) and/or total hip arthroplasty (THA) patients to authorize and adhere to such treatment.

METHODS

We developed an Institutional Review Board-approved questionnaire to evaluate patient perceptions of remote monitoring technologies in a high-volume orthopedic center. Forty-seven THA patients (60% female; mean age: 66 years) and 50 nonoperative OA hip patients (52% female; mean age: 63 years) participated. Patient perceptions were compared using Pearson's chi-squared analyses.

RESULTS

THA patients were similarly interested in the use of smartphone apps (91% vs 94%, P = .695) in comparison to nonoperative hip OA patients. THA patients were more receptive to using wearable sensors (94% vs 44%, P < .001) relative to their nonoperative counterparts. THA patients also expressed stronger interest in learning to use custom wearables (87% vs 32%, P < .001) vs nonoperative patients. Likewise, the majority of THA patients were willing to use Global Positioning System technology (74% vs 26%, P < .001). THA patients also expressed willingness to have their body movement (89%), balance (89%), sleep (87%), and cardiac output (91%) tracked using remote technology.

CONCLUSION

Overall, we found that THA patients were highly receptive to using wearable technology in their treatments. Nonoperative OA hip patients were generally unreceptive to using smart technologies, with the exception of smartphone applications. This information may be useful as utilization of these technologies for patient care continues to evolve.

Has modern human immunodeficiency virus therapy decreased complications following total knee arthroplasty?

BACKGROUND

Anti-retroviral therapy (ART) remains the cornerstone of decreasing morbidity and mortality in human immunodeficiency virus (HIV) patients. However, a large study comparing HIV patients taking ART prior to total knee arthroplasty (TKA) is lacking. We sought to examine: (1) readmissions; (2) post-operative complications; and (3) revisions in ART-treated or untreated HIV patients compared with a non-HIV population.

METHODS

We queried a national, all-payer database to identify TKA patients from 2010-2020 (n = 1,393,357). The presence or absence of ART was identified and matched with non-HIV patients based on age, sex, diabetes, obesity, and tobacco status resulting in 889 patients in each cohort. Readmissions, post-operative complications, and revisions were assessed.

RESULTS

Readmissions were higher among all HIV patients and even higher in those not taking ART, as compared to the matching cohort (4.8 versus 1.6%, p < 0.01). Prosthetic joint infections (PJIs) at 1-year were higher among HIV patients who were either taking ART (4.0%; OR, 1.41 [0.82-2.45]) or not taking ART (5.1%; OR, 2.44 [1.42-4.21]) as compared to non-HIV patients (2.1%, all p < 0.03). Revision rates at 1-year trended higher in HIV patients who were taking ART (2.6%; Odds Ratio (OR), 1.94 [0.96-3.93]) and who did not take ART (3.1%; OR, 2.38 [1.20-4.70]), compared to non-HIV patients (1.3%, all p < 0.09).

CONCLUSIONS

ART-treated HIV patients are associated with lower readmissions, post-operative complications, and revisions when compared to HIV patients not taking ART. The findings of this study underscore the utility of ART and patient optimization to reduce risk in HIV patients.

A web-based communication tool for postoperative follow-up and pain assessment at home after primary knee arthroplasty: Feasibility and Usability Study (Preprint)

Background

Objective

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Trial Registration

Designing the Optimal Digital Health Intervention for Patients' Use Before and After Elective Orthopedic Surgery: Qualitative Study

Background

Health behavior changes made by patients during the perioperative period can impact the outcomes and success of elective surgeries. However, there remains a limited understanding of how best to support patients during this time, particularly through the use of digital health interventions. Recognizing and understanding the potential unmet needs of elective orthopedic surgery patients is central to motivating healthier behavior change, improving recovery, and optimizing overall surgical success in the short and long term.

Objective

The aim of this study is to explore patient perspectives on technology features that would help support them to change their lifestyle behaviors during the pre- and postoperative periods, and that could potentially maintain long-term healthy lifestyles following recovery.

Methods

Semistructured interviews with pre- and postoperative elective orthopedic patients were conducted between May and June 2020 using telephone and video call–based software. Patient perspectives on the use of digital technologies to complement current surgical care and support with lifestyle behavior changes were discussed. Interviews were audio recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes from the data, with QSR NVivo software (version 12) facilitating data management. Ethical approval was obtained from the National Health Service Health Research Authority.

Results

A total of 18 participants were interviewed. Four themes were developed from the data regarding the design and functionality of digital technologies to best support the perioperative journey. These center around an intervention’s ability to incorporate interactive, user-centered features; direct a descriptive and structured recovery; enable customizable, patient-controlled settings; and deliver both general and specific surgical advice in a timely manner. Interventions that are initiated preoperatively and continued postoperatively were perceived as beneficial. Interventions designed with personalized milestones were found to better guide patients through a structured recovery. Individualized tailoring of preparatory and recovery information was desired by patients with previously high levels of physical activity before surgery. The use of personalized progression-based exercises further encouraged physical recovery; game-like rewards and incentives were regarded as motivational for making and sustaining health behavior change. In-built video calling and messaging features offered connectivity with peers and clinicians for supported care delivery.

Conclusions

Specific intervention design and functionality features can provide better, structured support for elective orthopedic patients across the entire surgical journey and beyond. This study provides much-needed evidence relating to the optimal design and timing of digital interventions for elective orthopedic surgical patients. Findings from this study suggest a desire for personalized perioperative care, in turn, supporting patients to make health behavior changes to optimize surgical success. These findings should be used to influence future co-design projects to enable the design and implementation of patient-focused, tailored, and targeted digital health technologies within modern health care settings.