The importance of informational, clinical and personal support in patient experience with total knee replacement: a qualitative investigation

Educational needs and preferences of adult patients with acute pain: a mixed-methods systematic review

ABSTRACT

Many patients experience acute pain, which has been associated with numerous negative consequences. Pain education has been proposed as a strategy to improve acute pain management. However, studies report limited effects with educational interventions for acute pain in adults, which can be explained by the underuse of the person-centered approach. Thus, we aimed to systematically review and synthetize current evidence from quantitative, qualitative and mixed-methods studies describing patients' needs and preferences for acute pain education in adults. We searched original studies and gray literature in 7 databases, from January 1990 to October 2023. Methodological quality was assessed with the Mixed Methods Appraisal Tool. A total of 32 studies were included (n = 1847 patients), two-thirds of which were qualitative studies of high methodological quality. Most of the studies were conducted over the last 15 years in patients with postsurgical and posttraumatic pain, identified as White, with a low level of education. Patients expressed the greatest need for education when it came to what to expect in pain intensity and duration, as well how to take the medication and its associated adverse effects. The most frequently reported educational preferences were for in-person education while involving caregivers and to obtain information first from physicians, then by other professionals. This review has highlighted the needs and preferences to be considered in pain education interventions, which should be embedded in an approach cultivating communication and partnership with patients and their caregivers. The results still need to be confirmed with different patient populations.

Challenges in rehabilitation and continuum of care provision after knee replacement: a mixed-methods study from a low- and middle-income country

PURPOSE

Continuum-of-care is crucial following knee replacement. This is an understudied area in the context of low- and middle-income countries. We report findings of a mixed-methods study conducted to understand patient's postoperative experiences in following unsupervised home-based physiotherapy protocols and healthcare provider's experiences in providing rehabilitation care.

METHODS

Consecutive adults (n = 79) scheduled or had undergone knee replacement, attending an urban tertiary care hospital in India completed a 22-item questionnaire to gauge attitude towards physical rehabilitation. We conducted in-depth interviews with nine patients, ten physiotherapists, and three surgeons using a phenomenology approach. Data were interpreted using the capability, opportunity, and motivation-behaviour (COM-B) framework.

RESULTS

Patients were motivated to do exercises and valued family support during the recovery period. However, they desired physiotherapy support, especially during the early recovery period due to post-operative pain. Healthcare providers reported poor adherence with the exercise regimen and desired a mechanism to monitor patient progress after discharge. Patients and health care providers identified accessibility to rehabilitation centre as a major barrier in availing affordable and reliable physiotherapy services.

CONCLUSION

There is a need for a continuum of care to improve patient experience during recovery and for health care providers to monitor progress and provide personalised progressive exercise therapy.

Mobile and Computer-Based Applications for Rehabilitation Monitoring and Self-Management After Knee Arthroplasty: Scoping Review

BACKGROUND

Successful post-knee replacement rehabilitation requires adequate access to health information, social support, and periodic monitoring by a health professional. Mobile health (mHealth) and computer-based technologies are used for rehabilitation and remote monitoring. The extent of technology use and its function in post-knee replacement rehabilitation care in low and middle-income settings are unknown.

OBJECTIVE

To inform future mHealth intervention development, we conducted a scoping review to map the features and functionality of existing technologies and determine users' perspectives on telerehabilitation and technology for self-management.

METHODS

We followed the Joanna Briggs Institute methodology for scoping reviews. We searched the Embase, Medline, PsycINFO via OVID, and Cochrane Central Register of Controlled Trials databases for manuscripts published from 2001 onward. We included original research articles reporting the use of mobile or computer-based technologies by patients, health care providers, researchers, or family members. Studies were divided into the following 3 categories based on the purpose: validation studies, clinical evaluation, and end user feedback. We extracted general information on study design, technology features, proposed function, and perspectives of health care providers and patients. The protocol for this review is accessible in the Open Science Framework.

RESULTS

Of the 5960 articles, 158 that reported from high-income settings contributed to the qualitative summary (64 studies on mHealth or telerehabilitation programs, 28 validation studies, 38 studies describing users' perceptions). The highest numbers of studies were from Europe or the United Kingdom and North America regarding the use of a mobile app with or without wearables and reported mainly in the last decade. No studies were from low and middle-income settings. The primary functions of technology for remote rehabilitation were education to aid recovery and enable regular, appropriate exercises; monitoring progress of pain (n=19), activity (n=20), and exercise adherence (n=30); 1 or 2-way communication with health care professionals to facilitate the continuum of care (n=51); and goal setting (n=23). Assessment of range of motion (n=16) and gait analysis (n=10) were the commonly validated technologies developed to incorporate into a future rehabilitation program. Few studies (n=14) reported end user involvement during the development stage. We summarized the reasons for satisfaction and dissatisfaction among users across various technologies.

CONCLUSIONS

Several existing mobile and computer-based technologies facilitate post-knee replacement rehabilitation care for patients and health care providers. However, they are limited to high-income settings and may not be extrapolated to low-income settings. A systematic needs assessment of patients undergoing knee replacement and health care providers involved in rehabilitation, involving end users at all stages of development and evaluation, with clear reporting of the development and clinical evaluation can make post-knee replacement rehabilitation care in resource-poor settings accessible and cost-effective.

Assessing perceived participation among older adults total hip arthroplasty and total knee arthroplasty patients six months post-surgery: a cross-sectional study

Aims

This research sought to assess the perceived levels of participation and autonomy in senior patients who had received total hip arthroplasty (THA) or total knee arthroplasty (TKA) in Hangzhou, China. Furthermore, the study aimed to identify the factors linked to these outcomes.

Study design

This investigation will utilize a cross-sectional study design to assess perceived participation and autonomy among older adults total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients. The research was conducted in Hangzhou, China, at a tertiary hospital.

Methods

Convenient sampling was utilized to select 139 patients who underwent THA or TKA between March 2022 and March 2023 and met the inclusion criteria at a tertiary hospital in Hangzhou. The Impact on Participation and Autonomy Questionnaire, Hip/Knee Injury and Osteoarthritis Outcome Score (HOOS/KOOS), 5-Item Geriatric Depression Scale, Multidimensional Scale of Perceived Social Support, and Elders Health Empowerment Scale were used to assess perceived participation, hip/knee-related symptoms and functional restrictions, depression symptoms, social support, and health empowerment.

Results

The mean score for perceived participation and autonomy was 22.554 (SD: 13.042). The mean scores for participation in indoor autonomy, outdoor autonomy, family roles, and social relations were 0.654 (SD: 0.608), 1.324 (SD: 0.792), 1.053 (SD: 0.657), and 0.664 (SD: 0.542), respectively. Negative correlations were observed between perceived participation/autonomy scores and HOOS/KOOS, social support, and health empowerment scores. Conversely, a positive correlation was found between perceived participation/autonomy scores and depression scores. The detrimental effect of HOOS/KOOS, social support, and health empowerment scores on perceived participation and autonomy was notable, while the impact of depressive symptoms was comparatively minor.

Conclusion

Older Chinese patients, at first six months post THA/TKA surgery, reported higher levels of perceived participation compared to individuals with other conditions, such as stroke patients. Functional limitations resulting from hip/knee-related symptoms, as well as social support and health empowerment, emerged as significant influencing factors for perceived participation and autonomy. This research enhances our comprehension of the elements influencing perceived participation among older adults individuals who have undergone THA/TKA procedures.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Substance Use

Substance use is one of the most common risk factors contributing to complications following total joint arthroplasty. Preoperative optimization programs can help patients modify or stop substance use. The purpose of this study was to provide recommendations and resources that will help nurse navigators standardize and improve preoperative optimization protocols regarding substance use. In a semistructured format, we asked nurse navigators how smoking, alcohol use, and opioid use were addressed. We conducted a literature review and combined findings with nurse navigator reports to create practice recommendations. We recommend consistently referring patients who smoke to smoking cessation programs; using validated screening tools to evaluate alcohol use and involving internists in caring for patients at risk for withdrawal; and involving pain specialists and local resources to assist patients who use opioids. There is a breadth of resources for managing substance use that nurse navigators can utilize to support stronger and more consistent preoperative optimization protocols.

Preoperative education on realistic expectations improves the satisfaction of patients with central sensitization after total knee arthroplasty: a randomized-controlled trial

PURPOSE

The aim of this study was to investigate whether an additional module on realistic expectations following total knee arthroplasty (TKA) would lead to a higher proportion of satisfied patients compared to existing preoperative education.

METHODS

This was a single-center, randomized-controlled trial. A total of 172 patients who were scheduled for TKA between September 2020 and October 2021 were enrolled. Patients were randomized to receive either only standard preoperative education, or an additional module on realistic expectations following TKA. The primary outcome was patient satisfaction. Secondary outcomes were Short Form-36, Western Ontario and McMaster Universities Osteoarthritis Index, crepitus score, and range of motion. Subgroup analysis was performed based on central sensitization inventory (CSI) score stratification. Assessment was performed at the 3-month, 6-month, and > 1-year follow-up.

RESULTS

At more than 1 year, 65/78 (83.3%) patients in the intervention group and 52/80 (65.0%) patients in the control group were satisfied (P = 0.03). The mean satisfaction score was measured as 4.2 ± 0.9 in the intervention and 3.9 ± 0.9 in the control at > 1 year (P = 0.01). There were significant differences in Short Form-36 physical and mental component summary scores and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and stiffness scores at 6 months (P = 0.02, P = 0.02, P = 0.04, P = 0.04). The frequency of satisfaction and mean satisfaction score in the top 25 percentile CSI group were 15/16 (93.8%) and 4.6 ± 0.6 in those who received intervention and 12/19 (63.2%) and 3.8 ± 0.8 in those who did not (P = 0.01, P = 0.01).

CONCLUSIONS

Thorough preoperative education on realistic expectations following TKA showed effects on WOMAC pain and satisfaction at > 1 year after surgery. It was more prominent in the group with a higher CSI score at > 1-year follow-up.

LEVEL OF EVIDENCE

Level I.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Improving Patient Access to Musculoskeletal Care

Preoperative optimization programs for total joint arthroplasty identify and address risk factors to reduce postoperative complications, thereby improving patients' ability to be safe surgical candidates. This article introduces preoperative optimization programs and describes the role of orthopaedic nurse navigators. This foundation will be used to produce an article series with recommendations for optimization of several modifiable biopsychosocial factors. We consulted orthopaedic nurse navigators across the United States and conducted a literature review regarding preoperative optimization to establish the importance of nurse navigation in preoperative optimization. The responsibilities of nurse navigators, cited resources, and structure of preoperative optimization programs varied among institutions. Optimization programs relying on nurse navigators frequently demonstrated improved outcomes. Our discussions and literature review demonstrated the integral role of nurse navigators in preoperative optimization. We will discuss specific risk factors and how nurse navigators can manage them throughout this article series.

'Maze' not pathway: focus group exploration of patients' and public experiences of the UK NHS elective total joint arthroplasty pathway

OBJECTIVE

To explore patient and public perceptions of planned improvements to the National Health Service (NHS) total joint arthroplasty (TJA) pathway.

DESIGN

Three qualitative focus groups undertaken March-May 2018, as part of a mixed-methods evaluation of Getting It Right First Time. Transcripts were subject to framework analysis to identify thematic content between October 2018 and October 2021.

SETTING

Elective TJA surgery in the English NHS.

PARTICIPANTS

Two focus groups including patients who had undergone TJA in the previous 2 years (group 1: n=5; group 2: n=4) and the other individuals who had not but were aged 60+ (group 3: n=5). Participants were recruited via community groups and patient panels.

RESULTS

Fourteen individuals took part in the focus groups; all were aged over 60; seven (50%) were female and nine (64%) had undergone TJA surgery. Participants' perspectives were categorised into themes and mapped onto stages of the TJA pathway. Although perioperative care is often the focus of improvement efforts, participants argued that the patient journey begins before individuals present to primary care. Participants had concerns about other aspects of the pathway, such as obtaining a surgical referral, with prereferral interventions aimed at potentially avoiding the need for surgery (ie, physiotherapy) being perceived as a mechanism to restrict access to secondary care. Patient experience was also conceptualised as a 'maze', rather than the logical, sequential process set out in clinical guidelines; exacerbated by a lack of information, knowledge and power imbalances.

CONCLUSION

The linear conceptualisation of the TJA pathway is at odds with patient experience. Improvement programmes focused on perioperative care fail to consider patient concerns and priorities. Patients should be directly involved in improvement programmes, to ensure that patient experience is optimised, as well as informing related processes and important outcomes of care.

Patient Perspectives on Transitions from Acute to Community-Based Physiotherapy Care Following Total Knee Replacement Surgery Within the Context of a Bundled Care Model

Purpose

Research on fiscal implications of the bundled care (BC) model exist; however, patient-perceived experiences are less well known. As BC expands in Ontario, this study aims to examine these experiences with physiotherapy care within the total knee replacement (TKR) BC programme.

Methods

Qualitative cross-sectional study design. Semi-structured one-on-one telephone interviews were conducted with eight patients four to six weeks post-TKR. Thematic analysis was used.

Results

This exploratory study identified three themes across the care journey that patients perceived as influencing their physiotherapy experiences: timely access to physiotherapy care, quality of physiotherapy care, and patient outcomes. Communication, clinical support, and social support were sub-themes.

Conclusions

Patients' overall experiences with BC physiotherapy were positive. Areas for improvement included coordination of postoperative physiotherapy and return-to-work support. Patients valued group settings and were interested in meeting previous TKR patients. Health system planners are advised to consider incorporating patient experiences when evaluating and developing BC programmes to achieve patient-centred outcomes.

Scoping review of the preferences of older adults for patient education materials

OBJECTIVE

To provide an overview of studies that describe the preferred mode and format of delivery of patient education materials to older adults.

METHODS

A scoping review was used to identify relevant literature published between January 2010 and June 2021, with specific attention given to studies conducted in high income countries with similar health systems.

RESULTS

A total of 3245 titles were identified, and 20 met the inclusion criteria and were included in this scoping review. Older adults preferred written information that could be accessed via health professionals or downloaded online. Other key features were identified including logical layout, signposted information, larger text size, labelled visual aids, and use of images appropriate and relevant to the target group were preferred. Audio visual resources were also considered valuable when well designed. Formats for patient education such as apps, group classes and online courses were less popular with older adults.

CONCLUSIONS

Patient education materials for older adults should be carefully designed, with attention to layout and content. Older adults indicated a preference for hard copy handouts or in a format that can be downloaded.

PRACTICE IMPLICATIONS

Regular engagement with older consumers about their preferences is important as technology for delivery of patient education materials evolve. Key features for specific attention during the design process include a logical layout (tested with consumers), signposted information, text size, labelled visual aids and appropriate images. The perspectives of other key groups of older adults such as those from minority populations or other disadvantaged groups are largely unexplored.

The Effect of a Multidimensional Home Rehabilitation Program for Post-Total Knee Arthroplasty Elderly Patients

Patients with total knee arthroplasty (TKA) experience pain, decreased muscle strength, and decreased knee function, resulting in increases in depression and decreased subjective well-being. A multidimensional home program may prevent these adverse events. The aim of this study was to test the effect of a home rehabilitation program that included education, exercise, aroma massage, and phone counseling for post-TKA patients. We used a randomized control group pretest/posttest design. Fifty-nine patients participated, with 29 in the experimental group and 30 in the control group. Pain, knee joint range of motion (ROM), quadriceps strength, depression, and subjective well-being were measured as outcome variables. Data were analyzed using repeated-measures analysis of variance and generalized estimating equations. The experimental group showed significant improvement in knee pain, active ROM, muscle strength, depression, and subjective well-being with no significant between-groups difference in passive ROM. The multidimensional home rehabilitation program can be an effective nursing intervention for physical and emotional recovery of patients with TKA.

"I could have a proper ankle" - a qualitative study of patients' perceptions of total ankle replacement and ankle fusion surgery

BACKGROUND

End-stage ankle osteoarthritis typically causes severe pain and impaired function. Surgical treatment involves total ankle replacement (TAR) or ankle fusion. Definitive evidence about which procedure is optimal is lacking. No previous studies have thoroughly explored patients' experiences across the entire TAR/ankle fusion pathway. This study aimed to address this gap by exploring perceptions of surgery, education, rehabilitation and outcomes among patients who had undergone TAR or ankle fusion.

METHODS

Seven participants were purposively selected from an orthopaedic centre in northern England (3 females, 4 males). Participants had undergone primary TAR without revision (n = 2), TAR requiring revision (n = 3) or ankle fusion (n = 2). Each participant completed a single semi-structured interview. Interviews were digitally recorded, transcribed verbatim and analysed thematically.

RESULTS

Three themes, each with two subthemes, were identified: decision-making (seeking help; surgical options), perceptions of support (information/education; clinical support) and impact on the individual (personal circumstances and beliefs; post-operative outcomes). Pain affecting participants' valued activities was key to their decision to seek help. Participants' decision between TAR and ankle fusion was influenced by multiple factors. Concerns regarding the lack of joint flexibility following fusion were highlighted, with some participants perceiving TAR as a "proper ankle" that would enable them to avoid limping. Participants obtained information from various sources, with most feeling that the education from their care team was inadequate. Participants' individual circumstances and beliefs influenced their decision-making and perceptions of their post-operative outcomes. Finally, whilst most participants were pleased with their outcomes, some experienced substantial ongoing problems such as difficulty walking and chronic pain.

CONCLUSIONS

This study demonstrates the importance of providing adequate education about TAR and ankle fusion to enable patients to make informed decisions. Most participants felt that the education and clinical support they received did not fully meet their needs. Participants' personal circumstances and beliefs had a strong influence on their decision-making and perceptions of their post-operative outcomes, highlighting the need to personally tailor education and clinical support. Future work with a larger sample of patients and other key stakeholders is required to develop consensus-based guidelines on pre- and post-operative support for patients undergoing TAR/ankle fusion.

Importance of Patient Involvement in Creating Content for eHealth Interventions: Qualitative Case Report in Orthopedics

Background

In many industries, collaboration with end users is a standard practice when developing or improving a product or service. This process aims for a much better understanding of who the end user is and how the product or service could be of added value to them. Although patient (end user) involvement in the development of eHealth apps is increasing, this involvement has mainly focused on the design, functionalities, usability, and readability of its content thus far. Although this is very important, it does not ensure that the content provided aligns with patients’ priorities.

Objective

In this study, we aimed to explore the added value of patient involvement in developing the content for an eHealth app. By comparing the findings from this study with the existing app, we aimed to identify the additional informational needs of patients. In addition, we aimed to help improve the content of apps that are already available for patients with knee replacements, including the app our group studied in 2019.

Methods

Patients from a large Dutch orthopedic clinic participated in semistructured one-on-one interviews and a focus group session. All the patients had undergone knee replacement surgery in the months before the interviews, had used the app, and were therefore capable of discussing what information they missed or wished for before and after the surgery. The output was inductively organized into larger themes and an overview of suggestions for improvement.

Results

The interviews and focus group session with 11 patients identified 6 major themes and 30 suggestions for improvement, ranging from information for better management of expectations to various practical needs during each stage of the treatment. The outcomes were discussed with the medical staff for learning purposes and properly translated into an improved version of the app’s content.

Conclusions

In this study, patients identified many suggestions for improvement, demonstrating the added value of involving patients when creating the content of eHealth interventions. In addition, our study demonstrates that a relatively small group of patients can contribute to improving an app’s content from the patient’s perspective. Given the growing emphasis on patients’ self-management, it is crucial that the information they receive is not only relevant from a health care provider’s perspective but also aligns with what really matters to patients.

Trial Registration

Netherlands Trial Register NL8295; https://trialsearch.who.int/Trial2.aspx?TrialID=NL8295

Postoperative Outcomes of a Digital Rehabilitation Program After Total Knee Arthroplasty: Retrospective, Observational Feasibility Study

Background

Surgery can sometimes be the best solution for chronic musculoskeletal pain, but presurgical preparation and postsurgical rehabilitation are often required to achieve the maximum benefits. A digital musculoskeletal surgical care program was developed to support the population of patients undergoing total knee arthroplasty.

Objective

We aimed to demonstrate safety, engagement, and acceptability and explore clinical outcomes, health care use, and satisfaction among participants of a digital musculoskeletal surgical care program who were undergoing total knee arthroplasty.

Methods

A retrospective, observational feasibility study comparing digital musculoskeletal surgical care program participants to a comparison group was conducted. The intervention group registered for a digital musculoskeletal surgical care program, which included health coaches, physical therapists, and tailored exercises and educational articles to provide preoperative and postoperative support to patients who had recently undergone total knee arthroplasty. Comparison group members received standard-of-care treatment. Engagement (number of exercise therapy sessions and educational articles accessed per week) and acceptability (Net Promoter Score) were examined among intervention group participants. Descriptive statistics for postoperative outcomes, including safety (postoperative complications), clinical improvement (pain, function, anxiety, and depression), and health care use and experiences (length of hospital stay, surgery satisfaction, and physical therapy adherence), were reported for both groups. Differences among postoperative results were compared by using the independent samples 2-tailed t test or Mann-Whitney test for continuous outcomes and the Fisher exact test or chi-square test for categorical outcomes.

Results

Of the 53 participants (intervention group: n=22; comparison group: n=31) who were included in this study, 35 (66%) were female and 25 (47%) were aged from 45 to 60 years. On average, the intervention group completed 23 exercise sessions, read 2.7 educational articles, sent 45.5 texts to their health coaches, and were actively engaged for 6 weeks after their operation. Among 21 participants, 14 (67%) self-reported as promoters on the Net Promoter Score scale. Intervention group members reported fewer postoperative complications (6/22, 27%) than the comparison group (15/31, 48%), and they experienced better outcomes with regard to function (Knee Injury and Osteoarthritis Outcome Score–Physical Function Short Form—intervention group: mean 23.0; comparison group: mean 32.5), depression (Patient Health Questionnaire 2-Item—intervention group: mean 0.4; comparison group: mean 1.6), anxiety (General Anxiety Disorder 2-Item—intervention group: mean 0.6; comparison group: mean 1.5), and impressions of change (Patient Global Impression of Change—intervention group: median 7.0; comparison group: median 6.0). Intervention group participants also reported less health care use, better adherence to their physical therapy exercises, and higher surgery satisfaction.

Conclusions

Our digital musculoskeletal surgical care program shows promising levels of engagement and acceptability among those who recently underwent total knee arthroplasty. The surgical care program may also help with improving postsurgical complications and clinical outcomes and lowering health care use.

What matters to patients following total knee arthroplasty? A grounded theory of adapting to a knee replacement

Background

Globally the volume of total knee arthroplasty (TKA) is on the rise, reflecting aging populations, an associated increase in treatment of osteoarthritis, and a desire for improved quality of life. There is evidence that as high as 15 to 20% of patients are not satisfied with their TKA results and efforts need to be made to improve these rates. This study set out to identify what patients consider important when reflecting on TKA satisfaction, to pave the way to identifying service transformation opportunities that will enhance patient-centred care and satisfaction with this procedure.

Methods

Twenty-seven TKA recipients were recruited in the province of British Columbia, Canada. Semi-structured interviews were conducted about participants’ experience and satisfaction with TKA, three to four years post-surgery. Grounded theory was employed to analyze participants’ stories about what was front of mind when they reflected on satisfaction with their new knee.

Results

Participants described their post-TKA knee in terms its adequacy: how it felt and worked, and how it matched their pre-surgical expectations. The central element of their stories was the process of adapting, which gave rise to their perceptions of adequacy. Adapting comprises the patient experience of physically integrating and cognitively accepting their new knee. Patterns of adapting reflect the level of the new knee’s achieved adequacy and the straightforwardness of the adapting process.

Discussion

The conceptualization of adequacy and the process of adapting allow a patient-centred understanding of what patients experience following TKA. For participants who did not readily achieve the adequacy they had anticipated, the challenges they experienced during adapting dominated their stories. Participants’ adapting stories afford key insights into how the health care system could adjust to better support TKA patients, and improve rates of satisfaction with this procedure.

Conclusions

The process of adapting lends itself to system intervention in support of enhanced post-TKA outcomes and satisfaction. These interventions could include the development of a care model including long-term clinical support for patients whose knees do not achieve desired results on schedule, and collaborating with patients to set and manage reasonable expectations about how their post-TKA knee will feel and function.

Content and delivery of pre-operative interventions for patients undergoing total knee replacement: a rapid review

BACKGROUND

Total knee replacement (TKR) is a common operation typically performed for end-stage knee osteoarthritis. Patients awaiting TKR often have poor health-related quality of life. Approximately 20% of patients experience persistent pain post-TKR. Pre-operative TKR interventions could improve pre- and post-operative outcomes, but future research is required to inform their design. This review aimed to identify and synthesize recent literature on the content and delivery of pre-operative TKR interventions to help guide future research and clinical practice.

METHODS

This rapid review included randomized trials of pre-operative TKR interventions ("outcomes studies") and primary studies exploring patients' and/or health professionals' views of pre-operative TKR interventions ("views studies"). Medline, Embase, PsycINFO, CINAHL and the Cochrane Central Register of Controlled Trials were searched for English language studies published between January 2009 and December 2020. Eligible studies' reference lists were screened. Studies were appraised using the Mixed Methods Appraisal Tool. The findings were narratively synthesized using a convergent segregated approach.

RESULTS

From 3263 records identified, 52 studies were included (29 outcomes studies, 21 views studies, two outcomes/views studies). The studies' methodological quality varied but was generally highest in qualitative studies. The outcomes studies investigated education (n=5), exercise (n=20), psychological (n=2), lifestyle (n=1), and/or other interventions (n=5). The views studies addressed education (n=20), exercise (n=3), psychological (n=1), lifestyle (n=4), and/or other interventions (n=1). Only three outcomes studies (two randomized controlled trials (RCTs) and a pilot study) compared the effectiveness of intervention components/delivery approaches. The two RCTs' results suggest that pre-operative TKR exercise interventions are equally effective regardless of whether they include strength or strength plus balance training and whether they are hospital- or home-based. Personal tailoring and using more than one delivery format were associated with improved outcomes and/or perceived as beneficial for multiple intervention types.

CONCLUSIONS

Definitive evidence on the optimal design of pre-operative TKR interventions is lacking. Personal tailoring and employing multiple delivery formats appear to be valuable design elements. Preliminary evidence suggests that including balance training and hospital versus home delivery may not be critical design elements for pre-operative TKR exercise interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019143248 FUNDER: National Institute for Health and Care Research (ICA-CDRF-2018-04-ST2-006).

Patient perspectives of pain and function after knee replacement: a systematic review and meta-synthesis of qualitative studies

Introduction

Joint replacement surgery typically results in good clinical outcome, although some people experience suboptimal pain relief and functional improvement. Predicting surgical outcome is difficult.

Objectives

There is merit in better understanding patients' perspectives of pain and function to identify avoidable problems perceived to contribute to their outcome, to inform prognostic expectations, and to identify potential cointerventions to sit alongside surgery that might mitigate pain/functional problems. Here, we aimed to synthesise the available literature exploring perspectives of people with knee osteoarthritis about their pain and function following joint replacement.

Methods

Six electronic databases and 2 websites were searched. Two independent reviewers completed study inclusion, quality assessment, and data extraction. Data were iteratively synthesised using first-, second-, and third-order analyses.

Results

Twenty-eight studies were included. Four themes were identified; perceptions of pain and function were inseparable. Theme 1 addressed experiences of recovery after surgery, which often differed from expectations. Theme 2 described the challenges of the pain experience and its functional impact, including the difficulty navigating medication use in context of personal beliefs and perceived stigma. Theme 3 articulated the toll of ongoing problems spanning pain-function-mood, necessitating the need to "endure." Theme 4 encompassed the importance of clinical/social interactions on mood and pain, with reports of concerns dismissed and practical support missing.

Conclusions

Together, these findings show that numerous individual considerations beyond the technical aspects of surgery influence experiences of pain and function. A tailored approach addressing these considerations from the patient perspective could provide a basis for improved success of knee replacement surgery.

Hip and Knee Replacement Patients' Experiences With an Orthopaedic Patient Navigator: A Qualitative Study

Hip and knee replacement surgery is common, yet more than 10% of patients who undergo total hip replacement (THR) and total knee replacement (TKR) report postsurgery dissatisfaction. Recommendations for improving patient experience after total joint replacement surgery include increasing support to patients, including having a patient navigator available to patients before and after surgery. This article reports on THR and TKR patients' experiences of using an orthopaedic patient navigator. We employed qualitative description to understand THR and TKR patients' experiences of interacting with an orthopaedic patient navigator in a community teaching hospital. Telephone interviews were conducted with 15 purposefully selected total joint replacement patients (TKR: n = 11; THR: n = 4) who had at least one contact with the navigator. Interview transcripts were analyzed using thematic analysis. Patients described receiving physical support services, emotional support services, informational support services, and care coordination services from the patient navigator. All interactions with the patient navigator were positive. Knowing the patient navigator was available for any future concerns also provided indirect benefits of reassurance, comfort, and security. Patients described these direct and indirect benefits as potentially having long-lasting and resilient positive effects. An orthopaedic patient navigator can have a positive impact on patients' THR and TKR experience and fill gaps in support identified in earlier studies. Addressing patients' complex and varied care needs is well suited to a clinical nurse specialist in the role. Investing in an orthopaedic patient navigator provides reassurance to patients that their needs are a priority and will be addressed in a timely manner.

Exploring the Role of Social Support between Discharge Teaching and Readiness for Discharge in Ocular Fundus Disease Patients: A Cross-Sectional Study

Background

This study aims to evaluate the quality of discharge teaching and readiness for discharge of fundus disease patients treated with day surgery and understand the role of social support between them.

Methods

This was a cross-sectional descriptive correlational survey. Through convenient sampling, fundus disease patients treated with day surgery from Zhongshan Ophthalmic Center, China, were recruited. Data were collected using demographic and disease-related information, quality of discharge teaching scale, readiness for hospital discharge scale, and social support scale.

Results

255 fundus disease patients treated with day surgery were recruited at last. The mean total score of readiness for discharge, quality of discharge teaching, and social support in patients with fundus disease were 157.91 (SD = 26.68), 122.97 (SD = 21.55), and 36.32 (SD = 7.60), respectively. Participants with stronger social support had better discharge teaching and then had higher readiness for discharge. Social support played a partial mediator role in the relationship between discharge teaching and readiness for discharge. The mediation effect ratio was 5.5%.

Conclusions

The quality of discharge teaching and social support among fundus disease patients who underwent day surgery was relatively high, and readiness for discharge was good. Social support is essential for the quality of discharge teaching and the improvement of discharge readiness. Clinical nurses need to provide appropriate guidelines to help patients seek effective support and improve quality of discharge teaching to enhance the readiness for discharge of fundus disease patients treated with day surgery.

Consensus on pre-operative total knee replacement education and prehabilitation recommendations: a UK-based modified Delphi study

BACKGROUND

Over 90,000 total knee replacement (TKR) procedures are performed annually in the United Kingdom (UK). Patients awaiting TKR face long delays whilst enduring severe pain and functional limitations. Almost 20% of patients who undergo TKR are not satisfied post-operatively. Optimising pre-operative TKR education and prehabilitation could help improve patient outcomes pre- and post-operatively; however, current pre-operative TKR care varies widely. Definitive evidence on the optimal content and delivery of pre-operative TKR care is lacking. This study aimed to develop evidence- and consensus-based recommendations on pre-operative TKR education and prehabilitation.

METHODS

A UK-based, three-round, online modified Delphi study was conducted with a 60-member expert panel. All panellists had experience of TKR services as patients (n = 30) or professionals (n = 30). Round 1 included initial recommendations developed from a mixed methods rapid review. Panellists rated the importance of each item on a five-point Likert scale. Panellists could also suggest additional items in Round 1. Rounds 2 and 3 included all items from Round 1, new items suggested in Round 1 and charts summarising panellists' importance ratings from the preceding round. Free-text responses were analysed using content analysis. Quantitative data were analysed descriptively. All items rated as 'Important' or 'Very important' by at least 70% of all respondents in Round 3 were included in the final set of recommendations.

RESULTS

Fifty-five panellists (92%) (patients n = 26; professionals n = 29) completed Round 3. Eighty-six recommendation items were included in Round 1. Fifteen new items were added in Round 2. Rounds 2 and 3 therefore included 101 items. Seventy-seven of these reached consensus in Round 3. Six items reached consensus amongst patient or professional panellists only in Round 3. The final set of recommendations comprises 34 education topics, 18 education delivery approaches, 10 exercise types, 13 exercise delivery approaches and two other treatments.

CONCLUSIONS

This modified Delphi study developed a comprehensive set of recommendations that represent a useful resource for guiding decision-making on the content and delivery of pre-operative TKR education and prehabilitation. The recommendations will need to be interpreted and reviewed periodically in light of emerging evidence.

Education, engagement and provision of empathy by trained counselor enhances the patient satisfaction after Total Knee Arthroplasty

BACKGROUND

One of the major concerns following Total Knee Arthroplasty (TKA) surgery is patient satisfaction. Hence, this study sought to assess the effect of patient education, engagement and provision of empathy delivered by trained counselor on patient satisfaction.

METHODS

All the patients included in the study were randomly allocated to two groups: Patients who received counseling from trained personnel during pre-, peri- and post-TKA phase constituted group-A (n = 100) whereas patients who were advised by the surgeon before the procedure constituted group-B (n = 100). All the patients who were counseled by trained personnel continued to receive counseling up to six months following TKA surgery. Patients belonging to group-A were provided counseling pertaining to education related to TKA procedure, the modalities of pain management and post-TKA ambulation regimen. Patient satisfaction was measured with Forgotten Joint Score-12 (FJS-12) and consumer gap (defined as the difference between patient perception and expectation) was recorded by an independent observer after 52-week of the TKA procedure.

RESULTS

Patients belong to group-A had higher satisfaction as compared to those in group-B as evident by statistically higher FJS-12 score (64.5 ± 16.4 vs. 59.4 ± 17.9; p = 0.0369). There was statistically significant difference observed in consumer gap between group-A (6%) and group-B (16%) (p = 0.0242).

CONCLUSIONS

The results of the study are encouraging to employ counseling by trained personnel during pre-, peri- and post-TKA phases as to improve patient satisfaction and reduce consumer gap.

'I Accelerate' model: A grounded theory on conceptual framework of patient experience with nursing care in China

AIM

To develop a conceptual framework of patient experience with nursing care.

BACKGROUND

Patient experience includes several aspects of health care delivery that patients value highly when they seek and receive care and is now increasingly used to evaluate the quality of care. Nurses are the backbone of the health care system, and patient experience with nursing care significantly influences the overall patient satisfaction and hospital performance. However, the conceptual framework of patient experience with nursing care is not clear.

METHOD

This grounded theory study employed in-depth interviews with 37 inpatients between March and May 2020.

RESULTS

An explanatory theoretical framework of the patient experience with nursing care emerged and was termed the 'I Accelerate' model; 'I Accelerate' stands for information and interpretation, appropriate attitude, close monitoring of progress, continuity of care, education, linking of the medical team, emotional support, responding to requests promptly, admission and discharge coordination, technical skills, and environment management, highlighting professional, emotional and coordinating functions of nurses.

CONCLUSIONS

This study resulted in a holistic nursing care model based on patients' views, values and preferences.

IMPLICATIONS FOR NURSING MANAGEMENT

To create a more therapeutic nurse-patient relationship and a more patient-centred health care system, hospital administrators, nursing managers and nursing practitioners should understand what patients desire and expect. Efforts should be made to explore the barriers and facilitators of using patient experience for quality improvement and to further determine how these patient-perceived attributes of nursing care can be rooted in the daily practice through organisational changes, culture shaping and staff education. There should be recognition of the potential need for psychological and emotional support, as well as of the importance of meeting communication and information needs.

A Qualitative Descriptive Study of Patient Experiences of Pain Before and After Spine Surgery

OBJECTIVE

The purpose of this study was to describe the preoperative and postoperative experiences of spine surgery from the patient's perspective to help inform behavioral health services provided before, during, and after hospitalization.

SETTING

Single urban academic tertiary care hospital.

METHODS

Semistructured interviews with 14 adults who underwent spine surgery. Interview transcriptions were analyzed using content analysis by three investigators to identify emergent themes.

RESULTS

Three broad domains with associated themes emerged from the analysis: 1) preoperative experience-preparation, worries, and expectations; 2) recovery process-activity and pain management strategies; and 3) postoperative support in recovery-family and social support.

CONCLUSIONS

The results of this qualitative descriptive study can be used to guide future perioperative behavioral health services for patients undergoing spinal surgery. Establishing realistic expectations of spine surgery and a comprehensive pain management plan are essential for adequate preoperative preparation. Furthermore, family involvement in the preoperative preparation for surgery is important for support of the patient during the recovery process.

Identifying patient decisions and related information needs during decision making related to total knee arthroplasty

Aim: Research regarding decisions patients make about total knee arthroplasty, apart from having the procedure or not, are limited. Understanding patient decision making and related information needs is essential for shared decision making. Methods: Focus groups with an online community-based sample identified decisions about total knee arthroplasty beyond the decision to have the surgery itself. An online survey was used to determine relative importance of five major decisions and evaluate related information available. Results: Patients did not feel they have enough information to make important decisions of surgeon, device type, surgical approach, facility, or timing, for their total knee arthroplasty. Conclusion: Although further research is needed to generalize these findings, physicians should consider these questions during shared decision making with patients considering total knee arthroplasty.

Review and synthesis of the experience of patients following total hip or knee arthroplasty in the era of rapidly decreasing hospital length of stay

AIM

The hospital length of stay for orthopedic surgery has been decreasing during the last couple of decades. Therefore, this study was performed to explore the postoperative experiences of adult/older patients (age ≥20 years) with osteoarthritis who underwent total hip or knee arthroplasty, focusing on the first 6 weeks following discharge.

METHODS

A systematic literature search on qualitative studies was conducted using six databases, such as Medline, CINAHL and Mednar. Verbatim interview data and themes or subthemes related to the patients' experience after discharge were extracted. Content analysis was used to code interview data. Codes similar in meaning were grouped, and subcategories were formed. These subcategories were then grouped into categories.

RESULTS

Sixteen qualitative studies with 253 participants were analyzed. In total, 136 codes were generated and formed 29 subcategories. Six categories were generated: (a) postoperative pain and medication; (b) difficulty in performing activities of daily living; (c) appreciation for support and difficulties associated with receiving support; (d) variability in recovery process and information-seeking; (e) lack of patient-centered care; and (f) transportation problems and social isolation.

CONCLUSION

Our review suggests that prospective patients and their caregivers need individually tailored presurgical education and advanced planning for postsurgical reduced mobility.

Outpatient, Home-Based Physical Therapy Promotes Decreased Length of Stay and Post-Acute Resource Utilization After Total Joint Arthroplasty

BACKGROUND

Patients and healthcare systems are increasingly focused on evaluating interventions that increase the value of care delivered. Our objective of this study is to evaluate early post-operative outcomes among those patients who underwent total joint arthroplasty with and without the participation in our piloted Outpatient Physical Therapy Home Visits (OPTHV) program.

METHODS

A retrospective analysis of patients undergoing total hip arthroplasty and total knee arthroplasty at a single institution from July 2016 to September 2017 was performed. Matched cohorts were compared according to OPTHV enrollment status.

RESULTS

In total, 1729 patients were included in this study. Two hundred ninety-three patients were enrolled in OPTHV, while 1436 patients received institutional standard care. Patients were matched by gender (56.7% vs 57.7% female, P = .751), age (67.75 vs 66.95 years, P = .167), body mass index (30.18 vs 30.12 kg/m², P = .859), and average American Society of Anesthesiologists score (2.31 vs 2.36, P = .131). OPTHV patients had a shorter length of stay (1.39 vs 1.64 days, P < .001) and were more likely to discharge to home (89.8% vs 74.7%, P < .001). Ninety-day re-admissions (2.7% vs 2.6%, P = .880) and emergency room visits (4.1% vs 4.3%, P = .864) were equivalent.

CONCLUSION

OPTHV is a novel program that facilitates discharge home and decreased length of stay after total joint arthroplasty without increasing re-admissions or emergency room visits. Utilization of OPTHV may contribute toward reducing the episode of care costs by reducing utilization of skilled nursing facility and home health services. Further prospective studies are needed to evaluate the effect of OPTHV on the total cost of care and functional outcomes.

Changes in actual daily physical activity and patient-reported outcomes up to 2 years after total knee arthroplasty with arthritis

The current study aimed 1) to describe changes in patient-reported outcomes and physical activity measured with an accelerometer preoperatively, 6 months and 2 years postoperatively in older patients undergoing total knee arthroplasty (TKA) for arthritis, and 2) to examine the predictors of the changes in physical activity (PA). This study included 58 patients (mean age 72.6 years, 84.5% women) who completed the Oxford Knee Score (OKS) and the 8-item Short Form Health Survey. Physical activity measured mean steps per day, duration of light physical activity and moderate-to-vigorous physical activity (MVPA) per week. All PA indicators and patient-reported outcomes improved 6 months postoperatively. After 6 months, knee-related pain and function gradually improved, and MVPA increased. The OKS was a sole predictor of improvement in PA during the 2-year study period, suggesting the importance of disease-specific quality of life.

Orthopaedic Nurses' Perceptions of Preoperative Education for Total Knee Replacement

BACKGROUND

Limited descriptions of preoperative education programs for total knee replacement (TKR) surgery are provided in the literature, and the most effective program design is currently unknown.

PURPOSE

The purpose of this qualitative study is to describe orthopaedic nurses' perceptions of preoperative education prior to TKR surgery.

METHODS

Ten participants completed phone interviews and transcripts were analyzed qualitatively for themes among participants.

RESULTS

Participants believed that preoperative education was a significant component impacting patient outcomes following surgery. Interprofessional preoperative education was valued, but pragmatic factors were identified as barriers to the inclusion of other disciplines within these programs. Education programs were constantly evolving on the basis of evidence-based practice and changes to orthopaedic protocols. Pragmatic factors influenced all aspects of program design, such as the timing and length of education sessions.

CONCLUSIONS

Results from this study provide descriptions of factors that influence program design and can be used to restructure education programs for improved patient outcomes.

Misconceived expectations: Patient reflections on the total knee replacement journey

INTRODUCTION

Fifty per cent of patients consent for total knee replacement (TKR) with unrealistic expectations about what it involves and can achieve. A framework is needed to help surgeons identify key knowledge gaps and misconceptions that can be targeted during the informed consent process. In this qualitative study, we explored knowledge gaps and misconceptions by asking patients to reflect on their expectations along the TKR journey.

METHODS

Eligible adults were ≥18 years, 12-month post-TKR and had completed a validated expectations questionnaire pre-TKR as part of a joint replacement registry. To capture a variety of perspectives, people with a range of pre-TKR expectation scores were invited. In interviews, participants reflected on anticipated and actual experiences and unexpected experiences they had along the way. Transcripts were analysed through inductive thematic analysis. Recruitment ceased when thematic saturation was reached.

ETHICS APPROVAL

Ethical approval for this study was granted by the St Vincent's Hospital Melbourne Ethics Committee (LRR 077/18).

RESULTS

In the final sample (n = 20; 50% female; median age = 72 years; contralateral TKR = 11), all participants described instances where their anticipated and actual experiences diverged, including high expectations of improvements in pain/function (pre-surgical optimism), lacking awareness about anaesthetic procedures (perioperative misunderstandings), feeling unprepared for the length of the recovery period (post-operative misestimations) and trying to make sense of ongoing functional limitations (long-term misattributions).

DISCUSSION AND CONCLUSION

These findings are captured in a preliminary framework of therapeutic misconception. Although future research is needed to test this framework prospectively in larger, more generalisable samples, surgeons can consider these key knowledge gaps and misconceptions when consenting for TKR.

Preoperative Education for Total Knee Replacement: A National Survey of Orthopaedic Nurses

BACKGROUND

Preoperative education aids in reducing the incidence of poor outcomes after total knee replacement (TKR) and increasing patient readiness for discharge home but is not well described in the literature.

PURPOSE

The purpose of the study is to describe the current design of preoperative education for TKR across the United States.

METHODS

A large, national sample of orthopaedic nurses completed an online survey to describe preoperative education at their facilities.

RESULTS

Most participants provided preoperative education as part of interprofessional teams in either a group format or combined group and individual education. Verbal instruction was the most common educational delivery method, followed by written instruction. Education typically lasted between 1 and 1.5 hours, was delivered in a single session, and included a variety of topics.

CONCLUSION

Results of this study describe preoperative educational practices and can support future research to improve patient outcomes following TKR surgery.

Effects of presurgical interventions on chronic pain after total knee replacement: a systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

Nearly 100 000 primary total knee replacements (TKR) are performed in the UK annually. The primary aim of TKR is pain relief, but 10%-34% of patients report chronic pain. The aim of this systematic review was to evaluate the effectiveness of presurgical interventions in preventing chronic pain after TKR.

DESIGN

MEDLINE, Embase, CINAHL, The Cochrane Library and PsycINFO were searched from inception to December 2018. Screening and data extraction were performed by two authors. Meta-analysis was conducted using a random effects model. Risk of bias was assessed using the Cochrane tool and quality of evidence was assessed by Grading of Recommendations Assessment, Development and Evaluation.

PRIMARY AND SECONDARY OUTCOMES

Pain at 6 months or longer; adverse events.

INTERVENTIONS

Presurgical interventions aimed at improving TKR outcomes.

RESULTS

Eight randomised controlled trials (RCTs) with data from 960 participants were included. The studies involved nine eligible comparisons. We found moderate-quality evidence of no effect of exercise programmes on chronic pain after TKR, based on a meta-analysis of 6 interventions with 229 participants (standardised mean difference 0.20, 95% CI -0.06 to 0.47, I²=0%). Sensitivity analysis restricted to studies at overall low risk of bias confirmed findings. Another RCT of exercise with no data available for meta-analysis showed no benefit. Studies evaluating combined exercise and education intervention (n=1) and education alone (n=1) suggested similar findings. Adverse event data were reported by most studies, but events were too few to draw conclusions.

CONCLUSIONS

We found low to moderate-quality evidence to suggest that neither preoperative exercise, education nor a combination of both is effective in preventing chronic pain after TKR. This review also identified a lack of evaluations of other preoperative interventions, such as multimodal pain management, which may improve long-term pain outcomes after TKR.

PROSPERO REGISTRATION NUMBER

CRD42017041382.

A research agenda to improve patients' experience of knee replacement surgery: a patient-oriented modified Delphi study of patients of South Asian origin in British Columbia

BACKGROUND

Up to 1 in 5 patients who undergo total knee arthroplasty (TKA) express dissatisfaction with their surgery. Our goal was to understand the experiences of patients of South Asian origin who undergo TKA and to identify a research agenda for this patient population.

METHODS

We undertook a modified Delphi study in British Columbia to generate and prioritize potential research topics. An initial list of topics was generated using 3 focus groups with patients of South Asian origin who underwent TKA and their caregivers. Focus group sessions were audiotaped and transcribed, and the data were analyzed using thematic analysis. The resulting Delphi question-naire was administered over 2 rounds to patients, caregivers and health professionals. The second-round questionnaire included only topics that were strongly supported in the first round. A patient-oriented approach was adopted, with 3 patient partners as full research team members, who contributed to scoping, design, data collection, analysis and interpretation.

RESULTS

Twenty-one patients who had undergone TKA and 6 caregivers attended the focus groups. Our analyses resulted in 6 broad themes and 25 research topics, all of which were presented in the first round of the Delphi survey. The survey was completed by 27 patients and 5 caregivers (54% combined response rate) and by 25 clinicians (76% response rate). Top priorities both for patients and caregivers and for clinicians were promoting exercise following surgery and self-management after hospital discharge. One of the highest ranked topics for patients and caregivers was improving knee implants; this was supported by only 60% of clinicians.

INTERPRETATION

The patients and caregivers in our study prioritized research on promotion of exercise and self-management following surgery and improvement in knee implants. Future patient-oriented research efforts in Canada should emphasize these topics for this patient population.

[Predictors for persistent pain and dissatisfaction after total knee arthroplasty]

BACKGROUND

A substantial number of patients patients suffer from persistent pain or are unsatisfied after total knee arthroplasty (TKA).

OBJECTIVES

This work aims to present the frequency of postoperative persistent pain and/or dissatisfaction as well as known causes and predictors.

MATERIALS AND METHODS

The current literature is studied regarding the subject and is reviewed narratively.

RESULTS

Most postoperative problems did not arise from operation details, but from patient-related criteria, a lack of patient education and selection. The satisfaction correlates most strongly with the reduction of preoperative pain.

CONCLUSION

For a successful TKA, care should be taken that the following aspects are met preoperatively: clinically and radiologically advanced osteoarthritis, a patient age preferably older than 60 years, sufficient psychosocial resources to cope with postoperative stress, no opioid medication and realistic expectations after TKA. Postoperatively, patients with persistent pain or dissatisfaction should be checked for any prosthesis-related problems. If no prosthesis-related problems could be detected, the patients should be referred for interdisciplinary therapies.

Experiences of pre- and postoperative information among patients undergoing knee arthroplasty: a systematic review and narrative synthesis

Purpose: The aim of this review was to identify and synthesize knowledge of how patients undergoing knee arthroplasty experience pre- and postoperative information provided by healthcare professionals.Materials and methods: A systematic review and narrative synthesis was conducted in accordance with Popay et al.'s guidelines which involve 1) developing a preliminary synthesis; 2) exploring relationships; and 3) assessing the robustness of the synthesis. Qualitative and quantitative studies were considered for inclusion, and a systematic, extensive search was conducted in scientific databases.Results: A total of 31 studies were included in this review. The analysis resulted in five synthesized themes: 1) Support in the decision to undergo surgery; 2) Confidence versus uncertainty in the preparation for surgery; 3) Prerequisites for feeling secure before discharge; 4) Struggling through rehabilitation at home; and 5) Unmet expectations and endeavoring to accept realities.Conclusions: The findings illustrate the complexities of patients' experiences of information from healthcare professionals and its significance for how they manage challenges throughout the surgical care pathway. Information from healthcare professionals influences patients' knowledge, skills and confidence in the journey through knee arthroplasty. Therefore, it is important that healthcare professionals recognize patients' support requirements and adapt information to their individual needs.Implications for rehabilitationHealthcare professionals should encourage more dialog with patients and adapt information to their individual circumstances and needs throughout the surgical care pathway.It is important that healthcare professionals provide ongoing information and repeat information throughout the entire surgical care pathway in order to facilitate predictability and improve patients' ability to comprehend and assimilate information.Improved access to information and advice from healthcare professionals following knee arthroplasty will offer patients reassurance and increase their confidence in managing postoperatively at home.Patients who require enhanced information and guidance from healthcare professionals need to be identified in order to support their progress and achieve the best possible postoperative outcomes.

Factors Influencing Discharge Readiness After Total Knee Replacement

Total knee replacement (TKR) surgery has been found to achieve positive outcomes for many patients such as reduced pain and increased function. However, some patients experience suboptimal outcomes including falls, readmission to hospital, and reduced functional performance. Preparation for discharge after TKR surgery is often defined related to pain control, walking, knee function, and ability to climb stairs. These measures may not fully encompass aspects of recovery that impact patients' readiness for discharge after surgery. The purpose of this article is to review discharge readiness following TKR surgery and discuss factors that are known to impact preparedness for discharge.

Revisiting patient satisfaction following total knee arthroplasty: a longitudinal observational study

Background

Total knee arthroplasty (TKA) is the most common joint replacement surgery in Canada. Earlier Canadian work reported 1 in 5 TKA patients expressing dissatisfaction following surgery. A better understanding of satisfaction could guide program improvement. We investigated patient satisfaction post-TKA in British Columbia (BC).

Methods

A cohort of 515 adult TKA patients was recruited from across BC. Survey data were collected preoperatively and at 6 and 12 months, supplemented by administrative health data. The primary outcome measure was patient satisfaction with outcomes. Potential satisfaction drivers included demographics, patient-reported health, quality of life, social support, comorbidities, and insurance status. Multivariable growth modeling was used to predict satisfaction at 6 months and change in satisfaction (6 to 12 months).

Results

We found dissatisfaction rates (“very dissatisfied”, “dissatisfied” or “neutral”) of 15% (6 months) and 16% (12 months). Across all health measures, improvements were seen post-surgery. The multivariable model suggests satisfaction at 6 months is predicted by: pre-operative pain, mental health and physical health (odds ratios (ORs) 2.65, 3.25 and 3.16), and change in pain level, baseline to 6 months (OR 2.31). Also, improvements in pain, mental health and physical health from 6 to 12 months predicted improvements in satisfaction (ORs 1.24, 1.30 and 1.55).

Conclusions

TKA is an effective intervention for many patients and most report high levels of satisfaction. However, if the TKA does not deliver improvements in pain and physical health, we see a less satisfied patient. In addition, dissatisfied TKA patients typically see limited improvements in mental health.

How do orthopaedic surgeons inform their patients before knee arthroplasty surgery? A cross-sectional study

Background

Total knee arthroplasty (TKA) is a successful and common procedure. However, 6–28% of patients are dissatisfied postoperatively. The provision of preoperative patient information, inquiring about patients’ expectations, and taking a psychiatric history are essential parts of both preoperative evaluation and postoperative outcome. The aim of this study was to investigate how orthopaedic knee surgeons in Sweden inform their patients before surgery.

Methods

A questionnaire was distributed to all knee surgeons performing TKA in Sweden. Responses were received from 60 of the 65 orthopaedic departments performing TKA in Sweden (92%), covering 219 of the approximately 311 knee surgeons at the 65 departments (70%). The answers were analysed with descriptive statistics. A content analysis of the surgeons’ opinions was also performed using a thematic method.

Results

In terms of information provision, 58% of the surgeons always gave written information while 92% informed orally. Only 44% always asked about the patient’s expectations, and only 42% always informed patients about the 20% dissatisfaction rate after TKA. Additionally, 24% never operated on mild indication of arthrosis, 20% always took a psychiatric history, and half never or seldom consulted a psychiatrist. However, all the knee surgeons believed in a psychiatric impact on TKA outcome. Qualitative analysis revealed five common causes of patient dissatisfaction, which in descending frequency were: patients’ expectations, choice of patients to operate on, surgical factors, combinations of factors, and insufficient information provision to patients.

Conclusions

Knee surgeons in Sweden have considerable awareness of the importance of preoperative patient information, the impact of patient expectations, and psychiatric illness. However, they need to improve their preoperative routines when it comes to providing written information, asking about the patient’s expectations, and psychiatric assessment.

Clinician perceptions of a prototype wearable exercise biofeedback system for orthopaedic rehabilitation: a qualitative exploration

OBJECTIVES

This study explores the opinions of orthopaedic healthcare professionals regarding the opportunities and challenges of using wearable technology in rehabilitation. It continues to assess the perceived impact of an exemplar exercise biofeedback system that incorporates wearable sensing, involving the clinician in the user-centred design process, a valuable step in ensuring ease of implementation, sustained engagement and clinical relevance.

DESIGN

This is a qualitative study consisting of one-to-one semi-structured interviews, including a demonstration of a prototype wearable exercise biofeedback system. Interviews were audio-recorded and transcribed, with thematic analysis conducted of all transcripts.

SETTING

The study was conducted in the orthopaedic department of an acute private hospital.

PARTICIPANTS

Ten clinicians from a multidisciplinary team of healthcare professionals involved in the orthopaedic rehabilitation pathway participated in the study.

RESULTS

Participants reported that there is currently a challenge in gathering timely and objective data for the monitoring of patients in orthopaedic rehabilitation. While there are challenges in ensuring reliability and engagement of biofeedback systems, clinicians perceive significant value in the use of wearable biofeedback systems such as the exemplar demonstrated for use following total knee replacement.

CONCLUSIONS

Clinicians see an opportunity for wearable technology to continuously track data in real-time, and feel that feedback provided to users regarding exercise technique and adherence can further support the patient at home, although there are clear design and implementation challenges relating to ensuring technical accuracy and tailoring rehabilitation to the individual. There was perceived value in the prototype system demonstrated to participants which supports the ongoing development of such exercise biofeedback platforms.

Holding It Together-Patients' Perspectives on Postoperative Recovery When Using an e-Assessed Follow-Up: Qualitative Study

Background

There is an emerging trend to perform surgeries as day surgery. After a day surgery, most of the recovery period takes place at home, and patients are responsible for their own recovery. It has been suggested that electronic health (eHealth) technologies can support patients in this process. A mobile app has recently been developed to assess and follow up on postoperative recovery after a day surgery.

Objective

The aim of this study was to explore experiences associated with postoperative recovery after a day surgery in patients using a mobile app to assess the quality of their recovery.

Methods

This is a qualitative interview study with an explorative and descriptive design. Participants were recruited from 4 different day surgery units in different parts of Sweden. The study included 18 participants aged >17 years who had undergone day surgery and used the Recovery Assessment by Phone Points, a mobile app for follow-up on postoperative recovery after day surgery. Participants were purposively selected to ensure maximum variation. Semistructured individual interviews were conducted. Data were analyzed using thematic analysis.

Results

A total of two themes and six subthemes emerged from the data: (1) the theme Give it all you’ve got with the subthemes Believing in own capacity, Being prepared, and Taking action, where participants described their possibilities of participating and themselves contributing to improving their postoperative recovery; and (2) the theme The importance of feeling safe and sound with the subthemes Feeling safe and reassured, Not being acknowledged, and Not being left alone, which describe the importance of support from health care professionals and next of kin.

Conclusions

It is important that patients feel safe, reassured, and acknowledged during their postoperative recovery. They can achieve this themselves with sufficient support and information from the health care organization and their next of kin. Using a mobile app, both for assessment and to enable contact with the day surgery unit during the postoperative recovery period, can improve care and create a feeling of not being alone after surgery. We propose that postoperative recovery starts in the prerecovery phase when patients prepare for their recovery to get the best possible outcome from their surgery.

Does a Program Based on Cognitive Behavioral Therapy Affect Kinesiophobia in Patients Following Total Knee Arthroplasty? A Randomized, Controlled Trial With a 6-Month Follow-Up

BACKGROUND

To evaluate the effects of a cognitive behavioral therapy (CBT) program on kinesiophobia, knee function, pain and pain catastrophizing in patients following total knee arthroplasty (TKA).

METHODS

This was a parallel-group, randomized, controlled pilot study in which 100 patients who exhibited kinesiophobia after TKA were randomly assigned to participate in a CBT (experimental group) or standard care (control group) program. Each group included 50 patients. Before intervention (preintervention), 4 weeks after intervention (postintervention), and 6 months after the end of intervention (follow-up), patients were assessed via the Tampa Scale for Kinesiophobia, the Pain Catastrophizing Scale, a numerical rating scale, and the Hospital for Special Surgery knee rating scale. Repeated-measures analysis of variance was used to test the significance of each outcome measure.

RESULTS

The CBT program had significant group (P < .001), time (P < .001), and group-by-time interaction (P < .001) effects on kinesiophobia, pain catastrophizing, and knee function, and these effects lasted for at least 6 months after the end of the intervention. Pain was reduced in both groups after the intervention, but there were significant time and group effects (P = .003) in favor of the experimental group.

CONCLUSION

The CBT program was superior to standard care in reducing kinesiophobia, pain catastrophizing, and knee pain and in enhancing knee function in patients who have a high level of kinesiophobia following TKA. The treatment effect was clinically significant and lasted for at least 6 months after the end of the intervention.