One-to-one therapy is not superior to group or home-based therapy after total knee arthroplasty: a randomized, superiority trial

Stratification of Outpatient Physical Therapy Following Total Knee Arthroplasty: Knee Arthroplasty Physical Therapy Pathways (KAPPA) Nonrandomized Controlled Trial

BACKGROUND

Outpatient physical therapy following total knee arthroplasty (TKA) is often considered crucial for an effective recovery. However, recent evidence suggests that a self-directed pathway may yield similar benefits to supervised care. Despite this, there appear to be no established criteria to determine who can successfully self-direct their rehabilitation versus those who would benefit from outpatient physical therapy. This study aimed to determine if early postoperative criteria can stratify TKA patients into a self-directed or supervised physical therapy pathway without compromising outcomes.

METHODS

Overall, 60 TKA patients were initially allocated to a self-directed, unsupervised protocol for their postoperative rehabilitation. Baseline demographics, along with functional and self-reported outcomes, were assessed preoperatively and at 2 weeks, 6 weeks, and 4 months following surgery. Patients were referred to supervised outpatient physical therapy if they met any of the following Knee Arthroplasty Physical Therapy Pathways (KAPPA) criteria: (1) knee flexion range of motion <90 degrees; (2) knee extension range of motion lacking >10 degrees; or (3) dissatisfaction with the progress of their rehabilitation.

RESULTS

At 2 weeks post-TKA, 28 participants met the KAPPA criteria for supervised physical therapy for reasons of knee flexion <90 degrees (61%), a lack of knee extension >10 degrees (36%), or not being satisfied with the progress of their recovery (3%). The remaining 32 participants continued with a self-directed rehabilitation pathway. All outcomes assessed favored the self-directed group at 2 weeks, however, after an average of 4 supervised physical therapy sessions at 4 months there were no longer any differences between the 2 groups.

CONCLUSIONS

Over half of the included participants could self-direct their rehabilitation following TKA without supervised physical therapy while also maintaining excellent clinical outcomes. For those who met KAPPA criteria at 2 weeks post-TKA, 4 supervised physical therapy sessions appeared to be beneficial when outcomes were reassessed at 4 months.

Similar Recovery Rate for Patients Aged between 50 and 89 Years That Go Home on the Surgery Day and Self-Administer Their Rehabilitation after Kinematically Aligned Total Knee Arthroplasty

BACKGROUND

for kinematic alignment (KA) total knee arthroplasty (TKA), it was unknown whether 'the pace of recovery' at six weeks was different for patients with ages ranging between 50-59, 60-69, 70-79, and 80-89 years who were discharged on the surgery day and self-administered their rehabilitation.

METHODS

a single surgeon treated 206 consecutive patients with a KA-designed femoral component and an insert with a medial ball-in-socket, lateral flat articulation, and PCL retention. Each filled out preoperative and six-week Oxford Knee Score (OKS), Knee Society Score (KSS), Knee Function Score (KFS), and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) questionnaires. The six-week minus preoperative value indicated improvement.

RESULTS

between age cohorts, the improvement was not different (p = 0.2319 to 0.9888). The mean improvement/six-week postoperative value was 6°/-2° for knee extension, 0°/119° for knee flexion, 7/31 for the OKS, 39/96 for the KSS, 7/64 for the KFS, and 13/62 for the KOOS. The 30-day hospital readmission rate was 1%.

CONCLUSION

surgeons who perform KA TKA can counsel 50 to 89-year-old patients that they can be safely discharged home on the surgery day with a low risk of readmission and can achieve better function at six weeks than preoperatively when performing exercises without a physical therapist.

Cost and outcomes of Hospital-based Usual cAre versus Tele-monitor self-directed Rehabilitation (HUATR) in patients with total knee arthroplasty: A randomized, controlled, non-inferiority trial

OBJECTIVE

To evaluate the clinical efficacy and cost-effectiveness of telemonitored self-directed rehabilitation (TR) compared with hospital-based rehabilitation (HBR) for patients with total knee arthroplasty (TKA).

DESIGN

In this randomized, non-inferiority clinical trial, 114 patients with primary TKA who were able to walk independently preoperatively were randomized to receive HBR (n = 58) or TR (n = 56). HBR comprised at least five physical therapy sessions over 10 weeks. TR comprised a therapist-led onboarding session, followed by a 10-week unsupervised home-based exercise program, with asynchronous monitoring of rehabilitation outcomes using a telemonitoring system. The primary outcome was fast-paced gait speed at 12 weeks, with a non-inferiority margin of 0.10 m/s. For economic analysis, quality-adjusted-life-years (QALY) was the primary economic outcome (non-inferiority margin, 0.027 points).

RESULTS

In Bayesian analyses, TR had >95% posterior probability of being non-inferior to HBR in gait speed (week-12 adjusted TR-HBR difference, 0.02 m/s; 95%CrI, -0.05 to 0.10 m/s; week-24 difference, 0.01 m/s; 95%CrI, -0.07 to 0.10 m/s) and QALY (0.006 points; 95%CrI, -0.006 to 0.018 points). When evaluated from a societal perspective, TR was associated with lower mean intervention cost (adjusted TR-HBR difference, -S$227; 95%CrI, -112 to -330) after 24 weeks, with 82% probability of being cost-effective compared with HBR at a willingness to pay of S$0/unit of effect for the QALYs.

CONCLUSIONS

In patients with uncomplicated TKAs and relatively good preoperative physical function, home-based, self-directed TR was non-inferior to and more cost-effective than HBR over a 24-week follow-up period. TR should be considered for this patient subgroup.

A Smartphone Application-Based Remote Rehabilitation System for Post-Total Knee Arthroplasty Rehabilitation: A Randomized Controlled Trial

BACKGROUND

Remote rehabilitation after total knee arthroplasty has gradually gained popularity in recent years. This study aimed to determine whether smartphone application-based remote rehabilitation could outperform home-based rehabilitation and outpatient guidance in terms of 12-week outcomes following primary unilateral total knee arthroplasty.

METHODS

Patients who underwent primary unilateral total knee arthroplasty were recruited and randomly divided into a telerehabilitation group and a control group. A total of 100 patients were examined, with 50 each assigned to the telerehabilitation and control groups. In the telerehabilitation group, a telerehabilitation application was installed on the smartphones of the participants to allow postdischarge guidance. The primary outcomes were knee range of motion (ROM) at 12 weeks postoperatively. Secondary outcomes included the Western Ontario and McMaster Universities Osteoarthritis Index, Knee Society Score, The Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), Five Times Sit-to-Stand Test (5xSST), Single-Leg Stance Test (SLST), satisfaction, rehabilitation costs, complication rate, and 90-day readmission rate. All outcomes were collected at 2, 6, and 12 weeks after surgery.

RESULTS

At 12 weeks postoperatively, the telerehabilitation patients significantly outperformed the controls in terms of knee ROM (124 ± 8.7 versus 119 ± 5.5 P = .01), SF-36 (physiological function) (61.5 ± 20.3 versus 45.5 ± 18.1 P = .000), SF-36 (role-physical) (49.3 ± 41.5 versus 27.7 ± 28.9 P = .012), SLST (13.0 ± 9.1 versus 9.1 ± 5.9 P = .026), and 5xSST (17.7 ± 4.3 versus 19.4 ± 3.5 P = .043). No significant differences were found between groups in the Western Ontario and McMaster Universities Osteoarthritis Index score, Knee Society Score, rehabilitation costs, 90-day readmission rate, or incidence of adverse events.

CONCLUSION

Our study showed that smartphone app-based remote rehabilitation worked better than home-based rehabilitation with outpatient guidance in terms of short-term results in ROM, SLST, and 5xSST.

Association Between Patient and Facility Characteristics and Rehabilitation Outcomes After Joint Replacement Surgery in Different Rehabilitation Settings for Older Adults: A Systematic Review

BACKGROUND AND PURPOSE

In the United States, an exponential increase in total hip arthroplasty (THA) and total knee arthroplasty (TKA) demand has occurred over the last 2 decades. Evidence suggesting patients receiving inpatient rehabilitation following a TKA or THA experience similar outcomes as those with rehabilitation in other settings led to dramatic shifts in postsurgical care settings owing to Centers for Medicare & Medicaid Services (CMS) payment reforms. A contemporary synthesis of evidence about the association between patient and facility factors and outcomes from older adults undergoing THA or TKA in the United States is needed.

METHODS

To identify eligible studies, we searched PubMed, Scopus, and CINAHL. We followed PRISMA guidelines to identify articles evaluating either patient or facility factors associated with outcomes after THA or TKA for older adults who may have been cared for in inpatient settings (ie, inpatient rehabilitation or skilled nursing facility [SNF]). Eligible articles were conducted in the United States and were published between January 1, 2000, and December 31, 2021.

RESULTS

We included 8 articles focused on patient factors and 9 focused on facility factors. Most included older adults and the majority were White (in those reporting race/ethnicity). Most studies evaluated outcomes at discharge and showed that patients admitted to inpatient rehabilitation facilities had either similar or better functional outcomes (mobility, self-care, and functional independence measure (FIM) score) and lower length of stay compared with those in SNFs. Few studies focused on home health care.

CONCLUSIONS

The systematic review focused on older adults showed that findings in these patients are consistent with previous research. Older adults undergoing THA/TKA had acceptable outcomes regardless of postsurgical, inpatient setting of care. Research conducted after CMS payment reforms, in home health care settings, and in more diverse samples is needed. Given the known racial/ethnic disparities in THA/TKA and the shifts to postsurgical home health care with little regulatory oversight of care quality, contemporary research on outcomes of postsurgical THA/TKA outcomes is warranted.

Characteristics of Early Interventions for Pain and Function Following Lower Extremity Joint Replacement: Systematic Review

Occupational therapy is beneficial among adults with chronic pain; however, occupational therapy interventions addressing earlier phases of pain have not been clearly explicated. This systematic review characterized acute and subacute interventions billable by occupational therapy after hip or knee replacement to improve pain and function. Seven articles met inclusion criteria. Six articles had a low risk of bias. Three intervention types were found: task-oriented exercise, water-based, and modalities. Only task-oriented interventions improved both pain and function one-year after surgery. There are long-term benefits to early task-oriented exercise. Further research is needed to contextualize occupational therapy's role in early pain interventions.

Effectiveness and safety of outpatient rehabilitation versus home-based rehabilitation after knee arthroplasty: a systematic review and meta-analysis

BACKGROUND

Rehabilitation post-knee arthroplasty is integral to regaining knee function and ensuring patients' overall well-being. The debate over the relative effectiveness and safety of outpatient versus home-based rehabilitation persists.

METHODS

A thorough literature review was conducted adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines across four databases. Two researchers independently identified eligible studies centering on knee arthroplasty patients undergoing either outpatient or home-based rehabilitation. Study quality was assessed using the Cochrane Collaboration's risk of bias tool, while continuous outcomes were subject to meta-analyses using Stata 17 software.

RESULTS

Our analysis identified no significant differences in primary outcomes, including Range of Motion, Western Ontario and McMaster Universities Arthritis Index, Knee Injury and Osteoarthritis Outcome Score, Oxford Knee Score, and the Knee Society Score, between home-based and outpatient rehabilitation across different follow-up points. Adverse reactions, readmission rates, the need for manipulation under anesthesia, reoperation rate, and post-surgery complications were also similar between both groups. Home-based rehabilitation demonstrated cost-effectiveness, resulting in substantial annual savings. Furthermore, quality of life and patient satisfaction were found to be comparable in both rehabilitation methods.

CONCLUSIONS

Home-based rehabilitation post-knee arthroplasty appears as an effective, safe, and cost-efficient alternative to outpatient rehabilitation. Despite these findings, further multicenter, long-term randomized controlled trials are required to validate these findings and provide robust evidence to inform early rehabilitation choices post-knee arthroplasty.

Physical therapy for sleep apnea: a smartphone application for home-based physical therapy for patients with obstructive sleep apnea

Purpose

In this study, we described "PT for Sleep Apnea", a smartphone application for home-based physical therapy of patients with Obstructive Sleep Apnea (OSA).

Methods

The application was created in a joint program between the University of Medicine and Pharmacy at Ho Chi Minh City (UMP), Vietnam, and National Cheng Kung University (NCKU), Taiwan. Exercises maneuvers were derived from the exercise program previously published by the partner group at National Cheng Kung University. They included exercises for upper airway and respiratory muscle training and general endurance training.

Results

The application provides video and in-text tutorials for users to follow at home and a schedule function to assist the user in organizing the training program, which may improve the efficacy of home-based physical therapy in patients with Obstructive Sleep Apnea.

Conclusion

In the future, our group plans to conduct a user study and randomized-controlled trials to investigate whether our application can benefit patients with OSA.

A Home-Based, Remote-Clinician-Controlled, Physical Therapy Device Leads to Superior Outcomes When Compared to Standard Physical Therapy for Rehabilitation After Total Knee Arthroplasty

BACKGROUND

The optimal postoperative rehabilitation regimen following total knee arthroplasty (TKA) is not clearly defined. The advent of telerehabilitation offers potential for increased patient convenience and decreased cost, while maintaining similar outcomes to traditional physical therapy (PT). Therefore, we evaluated a novel, home-based, clinician-controlled, multi-modal evaluation and therapy device with telerehabilitation functionality for TKA.

METHODS

A total of 135 consecutive TKA patients receiving standard therapy protocol (STP) were compared to 135 consecutive patients receiving a home-based clinician-controlled therapy system (HCTS). Outcomes were assessed at 2, 6, and 12 weeks, including visual analog scale (VAS) for pain, knee injury and osteoarthritis outcome score JR (KOOS JR), and knee range of motion (ROM) measured by the same certified physical therapists.

RESULTS

Postoperative knee ROM was greater in the HCTS group at all time points throughout the study period (P < .001 at 2, 6, and 12 weeks). VAS and the KOOS JR functional scores were statistically better (P < .001) in the HCTS group at all time points and exceeded the threshold for minimal clinically important difference (MCID) for both VAS and KOOS JR. There were significantly fewer cases of arthrofibrosis requiring manipulation under anesthesia (MUA) in the HCTS group (1.48 versus 4.44%).

CONCLUSION

Following TKA, a novel, home-based, clinician-controlled, multi-modal therapy device was superior to standard PTduring the first 12 weeks postoperatively for ROM, KOOS JR, and VAS (with all scores exceeding the MCID) and had substantially fewer manipulations for arthrofibrosis.

Not All Patients Need Supervised Physical Therapy After Primary Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

Although postoperative physical therapy (PT) has long been considered essential to successful total knee arthroplasty (TKA) recovery, recent literature has suggested that unsupervised home exercise regimens may offer similar benefits to formal supervised sessions. We aimed to compare objectively measured physical function and subjective patient-reported outcomes (PROs) between primary TKA patients who received formal supervised physical therapy sessions and those who received unsupervised home exercise regimens after discharge. Six electronic databases were queried to identify randomized controlled trials comparing supervised physical therapy to unsupervised home exercise regimens in primary TKA patients after discharge. Outcomes of interest included change from baseline in objective measures (knee flexion range of motion (ROM), lower extremity strength, and aerobic capacity) and PROs (physical function and quality of life scores). These outcomes were subdivided into short-term (<6 months from surgery; closest data point to three months is used if multiple measurements were made in this time period) and long-term (≥6 months from surgery; closest data point to 12 months is used if multiple measurements were made in this time period) assessments. A total of 1,884 cases performed in 11 studies were included in this review. There were no significant differences between cohorts with regard to short-term knee flexion ROM (p = 0.7), lower extremity strength (p = 0.6), or patient-reported quality of life (p = 0.5), as well as long-term knee flexion ROM (p = 0.7), patient-reported quality of life (p = 0.2), or patient-reported physical outcome scores (p = 0.3). A small difference in short-term patient-reported physical outcomes was observed in favor of the supervised cohort (standardized mean difference (SMD): 0.3 (95% confidence interval (CI): 0.01, 0.6); I2 = 82%; p = 0.04). Formal supervised physical therapy regimens do not confer clinically significant benefits over unsupervised home exercise regimens following primary TKA. The routine use of supervised physical therapy after discharge may not be warranted. Further study is needed to determine the subset of patients that may benefit from supervised care.

Supervised versus unsupervised rehabilitation following total knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

Outcomes after total knee arthroplasty (TKA) are strongly influenced by the adequacy of rehabilitation and the consequent functional recovery. The economic impact of rehabilitation it is not negligible. Inpatient rehabilitation can be 5 to 26 times more expensive than the home-based rehabilitation. This topic is extremely relevant as the COVID-19 pandemic has highlighted the importance of unsupervised rehabilitation in orthopedic surgery. The aim of this review and meta-analysis is to investigate the scientific evidence regarding the comparison between supervised and unsupervised rehabilitation following TKA.

MATERIALS AND METHODS

Following PRISMA guideline, a comprehensive search of PubMed, Cochrane and Scopus databases using combinations of keywords and MeSH descriptors: "total "Knee replacement," "Arthroplasty", "Rehabilitation" was performed from inception to December 2021. All relevant articles were retrieved, and their bibliographies were searched for further relevant references. Only English written randomized controlled trials comparing supervised and unsupervised rehabilitation following TKA were included in this systematic review. The outcomes considered were long-term pain, physical function, knee flexion and extension ROM, 6 minute walking test (6MWT) and timed up and go test (TUG).

RESULTS

11 studies (2.181 patients in total) were included in this systematic review. The long-term pain outcome showed no significant differences (Std. Mean Difference [SMD] = 0.00, 95 % confidence interval [CI] -0.16, 0.017) between the supervised (n = 397) and unsupervised (n = 255). Physical function showed no significant differences among the two groups (mean difference [MD] = 0.84, 95 % CI = -1.82, 3.50). Non-significant differences were also found for knee ROM flexion (mean difference [MD] = -0.46, 95 % CI = -2.95, 2.04) and for knee extension (mean difference [MD] = 0.54, 95 % CI = -0.89, 1.97). At the 52-week follow-up, the unsupervised group showed significant better results in 6MWT (mean difference [MD] = -26.10, 95 % CI = -47.62, -4.59) and in Timed up and go test (mean difference [MD] = 1.33, 95 % CI = 0.50, 2.15).

CONCLUSION

This systematic review did not show a significant clinical difference in improving pain, function, and mobility outcomes after TKA between supervised PT and unsupervised PT. Therefore, it would appear that supervised rehabilitation did not had additional benefits compared to unsupervised rehabilitation.

Is group-based physical therapy superior to individual rehabilitation in elderly adults after total knee arthroplasty? A prospective observational study

Knee osteoarthritis (OA) is the most prevalent joint disease and one of the leading causes of disability, poor physical activity levels (PAL), and quality of life (Qol) of elderly people worldwide. The purpose of this study was to evaluate the superiority of a novel group-based physical therapy (GBPT) intervention compared to a more traditional one-to-one individual physical therapy (IPT) among elderly Bulgarian subjects underwent total knee arthroplasty (TKA). One hundred and thirty elderly TKA recipients of both genders with mean age=72.69±0.44 were randomly assigned to GBPT or to one-to-one IPT. Elderly participants were assessed at baseline and at 3 and 6 months after both rehabilitation interventions, with the use of the following evaluation tools: Physical Activity Scale for the Elderly (PASE), Six-Minute Walk Test (6MWT), and Short Form Health Survey questionnaire (SF-36v2). At 6 months elderly TKA recipients who received GBPT achieved 7.36 points more in the PASE questionnaire when compared with the IPT group. Elderly participants of the GBPT group walked significantly longer distance during the 6MWT than TKA recipients attended IPT, respectively 421.56 m vs. 398.62 m, (p< 0.001). Furthermore, significantly greater improvement in health-related quality of life (HRQoL) was obtained from the elderly participants of the GBPT arm compared with the participants of the IPT arm, respectively 70, 7% vs. 60, 8% at 6 months follow up. We conclude that our results suggest the superiority of the GBPT in terms of PAL (PASE score, 6MWT) and HRQoL among elderly TKA recipients across the first 6 months.

Group-based exercice training programs for military members presenting musculoskeletal disorders - protocol for a pragmatic randomized controlled trial

BACKGROUND

Musculoskeletal disorders are a leading cause of morbidity and the most prevalent source of disability among soldiers. Their high prevalence in armed forces and limited ressources have led to problems related to access to physical rehabilitation care. To increase access, supervised group-based exercise programs for the most prevalent musculoskeletal disorders (low back pain, patellofemoral pain, rotator cuff-related shoulder pain or lateral ankle sprain) have been developed at a Canadian Armed forces (CAF) base, but their effectiveness has not been evaluated. The primary objective of this randomized controlled trial is to evaluate the mid- and long-term effects of these group-based training programs on pain severity and functional limitations, in comparison with usual individual physiotherapy care. Secondary objectives include comparing both interventions in terms of health-related quality of life, pain-related fear, and patients' satisfaction.

METHODS

One hundred and twenty soldiers with a new medical referral for physiotherapy services for one of the four targeted musculoskeletal disorders will be consecutively recruited. They will be randomly assigned to either group-based training program or usual individual physiotherapy care, and will take part in the assigned 12-week intervention. There will be four evaluation sessions over 26 weeks (baseline, week 6, 12 and 26). At each follow-up, functional limitations, pain severity, health-related quality of life and pain-related fears will be assessed. Patients satisfaction with treatment will also be evaluated at the end of the intervention period. Either two-way repeated measures ANOVA will be used to analyse and compare the effects of the interventions.

DISCUSSION

This RCT will determine the effectiveness of group-based training programs compared to usual individual physiotherapy care. This new intervention model could represent an efficient, and more pro-active approach to manage a higher number of soldiers with musculoskeletal disorders. It could improve access to physical rehabilitation care and improve the health of soldiers.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT05235152 ), February 11th 2022.

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

Objective

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

Design: Scoping review

Literature search

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

Study selection criteria

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

Data synthesis

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

Results

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

Conclusion

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

Pre-registration

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

Supplementary Information

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

Discharge Disposition and Clinical Outcomes After Spine Surgery

OBJECTIVE

Spinal decompression with or without fusion is one of the most commonly performed procedures in spine surgery. However, there is limited evidence on the effect of discharge environment on outcomes after surgery. The purpose of this study is to identify the effects of discharge disposition setting on clinical outcomes after spine surgery.

METHODS

Patients who underwent lumbar decompression, lumbar decompression and fusion, or posterior cervical decompression and fusion surgery were retrospectively identified. All clinical and demographic data were obtained from electronic health records. Surgical outcomes included wound complications, revision surgery, "30-day" readmission (0-30 d), and "90-day" readmission (31-90 d). Discharge disposition was stratified into home/self-care, acute inpatient rehabilitation, and subacute rehabilitation. Patient-reported outcome measures including VAS Back, VAS Leg, VAS Neck, VAS Arm, PCS-12 and MCS-12, ODI, and NDI were compared between patient discharge disposition settings using the Mann-Whitney U test. Pearson's chi-square analysis was used to assess for differences in wound complications, revision surgery, 30-day readmission, or 90-day readmission rates. Multivariate logistic regression incorporating age, sex, body mass index (BMI), Charlson Comorbidity Index (CCI), and discharge disposition was used to determine independent predictors of wound complications.

RESULTS

A total of 637 patients were included in the study. A significant difference (P = 0.03) was found in wound complication based on discharge disposition, with subacute disposition having the highest proportion of wound complications (6.1%) and home disposition having the lowest (1.5%). There were no significant differences in the rates of revision surgery, 30-day readmission, or 90-day readmission between groups. Subacute rehabilitation (odds ratio: 3.67, P = 0.047) and CCI (odds ratio 1.49, P = 0.01) were independent predictors of wound complications. Significant improvement in PROMs was seen across all postacute discharge dispositions. Baseline (P = 0.02) and postoperative (P = 0.02) ODI were significantly higher among patients discharged to an acute facility (49.4 and 32.0, respectively) compared to home (42.2 and 20.0) or subacute (47.4 and 28.4) environments.

CONCLUSION

Subacute rehabilitation disposition and CCI are independent predictors of wound complications after spinal decompression surgery. Patients undergoing spine surgery have similar readmission and revision rates and experience similar clinical improvement across all postacute discharge dispositions.

2021 Mark Coventry Award: Use of a smartphone-based care platform after primary partial and total knee arthroplasty: a prospective randomized controlled trial

AIMS

The purpose is to determine the non-inferiority of a smartphone-based exercise educational care management system after primary knee arthroplasty compared with a traditional in-person physiotherapy rehabilitation model.

METHODS

A multicentre prospective randomized controlled trial was conducted evaluating the use of a smartphone-based care management system for primary total knee arthroplasty (TKA) and partial knee arthroplasty (PKA). Patients in the control group (n = 244) received the respective institution's standard of care with formal physiotherapy. The treatment group (n = 208) were provided a smartwatch and smartphone application. Early outcomes assessed included 90-day knee range of movement, EuroQoL five-dimension five-level score, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) score, 30-day single leg stance (SLS) time, Time up and Go (TUG) time, and need for manipulation under anaesthesia (MUA).

RESULTS

Overall, 90-day mean flexion was not significantly different between the control (121° (SD 11.7°)) and treatment groups (121^o; p = 0.559); 90-day mean SLS was 22.7 seconds (SD 9.8) in controls and 24.3 seconds (SD 20.8) in treatment (p = 0.519); 90-day mean TUG times were 10.1 seconds (SD 4.8) in control and 9.3 seconds (SD 3.3) in treatment (p = 0.139). Mean KOOS JR scores were significantly different between control group (73.6 (SD 13.4)) and treatment group (70.4 (SD 12.6); p = 0.026). MUAs were performed in nine (3.7%) patients in the control group and four (1.9%) in the treatment group (p = 0.398). Physiotherapy was performed by 230 (94.4%) of control group and 123 (59.3%) of treatment group (p < 0.001). There were no significant differences between groups in postoperative urgent care visits, or readmissions within 90 days, with significantly fewer emergency department visits in the treatment group (16 (8.2%) vs five (2.5%), p = 0.014).

CONCLUSION

The use of the smartwatch/smartphone care platform demonstrated non-inferiority of clinically significant outcomes to traditional care models, while requiring significantly less postoperative physiotherapy and fewer emergency department visits. This platform could aid in decreasing postoperative costs, while improving patient engagement and communication with the healthcare team. Cite this article: Bone Joint J 2021;103-B(6 Supple A):3-12.

Activity Recommendations After Total Hip and Total Knee Arthroplasty

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A formal unsupervised activity program should be recommended to all patients recovering from total knee arthroplasty (TKA) and total hip arthroplasty (THA).

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In a subset of all patients undergoing TKA or THA, studies have found that an unsupervised activity program may be as efficacious as supervised physical therapy (PT) after surgery. Certain patients with inadequate independent function may continue to benefit from supervised PT.

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For TKA, supervised telerehabilitation has also been proven to be an effective modality, with studies suggesting equivalent efficacy compared with supervised in-person PT.

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Following TKA, there is no benefit to the use of continuous passive motion or cryotherapy devices, but there are promising benefits from the use of pedaling exercises, weight training, and balance and/or sensorimotor training as adjuncts to a multidisciplinary program after TKA.

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No standardized postoperative limitations exist following TKA, and the return to preoperative activities should be dictated by an individual's competency and should consist of methods to minimize high impact stress on the joint.

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Despite traditional postoperative protocols recommending range-of-motion restrictions after THA, it is reasonable to recommend that hip precautions may not be needed routinely following elective primary THA.

An Assessment of Randomized Controlled Trial Quality in The Journal of Bone & Joint Surgery: Update from 2001 to 2013

BACKGROUND

The quality of reporting of randomized controlled trials (RCTs) published in The Journal of Bone & Joint Surgery (JBJS) from 1988 to 2000 was previously analyzed. The purpose of this current study was to analyze the quality of reporting of RCTs published in JBJS from 2001 to 2013 to identify trends over time and potential areas of improvement for future clinical trials.

METHODS

A manual search of the JBJS database identified RCTs published between January 2001 and December 2013. Quality assessments, using the Detsky quality-of-reporting index (Detsky score), a modified Cochrane risk-of-bias tool, and abstraction of relevant data identifying predictors of quality, were conducted.

RESULTS

A total of 5,780 publications were identified in JBJS from 2001 to 2013, with 285 RCTs (4.9%), representing an increase from the prior 13-year period. The overall mean transformed Detsky score (and standard error) increased significantly (p < 0.001) from 68.1% ± 1.67% to 76.24% ± 0.72%. The percentage of multicenter RCTs decreased from 67% to 31%. The percentage of positive trials also decreased from 80% to 50.5%, as did the mean sample size (212 to 166). Regression analysis indicated that trials with an epidemiologist as the first author and nonsurgical trials were significantly associated (p = 0.001) with a higher overall trial quality score. The categories of the lowest mean methodology scores were randomization and concealment, eligibility criteria, and reasons for patient exclusion, as identified with the Detsky score, and patient and assessor blinding, as identified with the risk-of-bias assessment.

CONCLUSIONS

The quantity and quality of published RCTs in JBJS have increased in the 2001 to 2013 time period compared with the previous time period. Although these improvements are encouraging, trends to smaller, single-center trials were also observed. To efficiently determine the efficacy of orthopaedic treatments and limit bias, high-quality randomized trials of appropriate sample size and rigorous design are needed.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Interventions

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Trial Registration

ClinicalTrials.gov Identifier: NCT02426190.

Web-Based Self-Directed Exercise Program Is Cost-Effective Compared to Formal Physical Therapy After Primary Total Knee Arthroplasty

BACKGROUND

Web-based physical therapy (WBPT) is a potential means to reduce costs following total knee arthroplasty (TKA). Although outcomes data support the use of self-directed therapy after TKA, there is a paucity of literature evaluating its cost-effectiveness. This study aimed to determine utilization trends of either outpatient physical therapy (OPPT) or WBPT after TKA, assess the outcomes of patients based on their use of WBPT, OPPT, or both, and evaluate OPPT costs based on the amount of WBPT used.

METHODS

A retrospective review of 701 patients (731 TKAs) was performed. Patients were given a prescription for OPPT and access to a self-directed WBPT program. Functional scores were obtained preoperatively and 6 months postoperatively, and the rate of manipulation under anesthesia (MUA), range of motion, and PT costs were recorded.

RESULTS

About 49.8% of patients utilized WBPT, 34.7% of patients utilized WBPT and OPPT, and 23% of patients utilized neither source of therapy. Patients that utilized both WBPT and OPPT demonstrated the lowest rates of MUA. There were no differences in postoperative outcomes based on the number of WBPT logins. Overall, PT cost was 3.4× higher for those that underwent MUA. Subgroup analysis of patients that utilized WBPT revealed that the cost and number of PT visits decreased as the number of logins increased. Patients younger than 65 utilized more WBPT and OPPT while demonstrating worse outcomes (lower Knee Injury and Osteoarthritis Outcome Score for Joint Replacement postoperative scores and more MUAs).

CONCLUSION

WBPT can be an effective option to offset costs associated with OPPT, without compromising outcomes.

Goal Attainment Scaling Rehabilitation Improves Satisfaction with Work Activities for Younger Working Patients After Knee Arthroplasty: Results from the Randomized Controlled ACTION Trial

BACKGROUND

Knee arthroplasty (KA) is increasingly performed in relatively young, active patients. This heterogeneous patient population often has high expectations, including work resumption and performance of knee-demanding leisure-time activities. Goal attainment scaling (GAS) may personalize rehabilitation by using patient-specific, activity-oriented rehabilitation goals. Since unmet expectations are a leading cause of dissatisfaction after KA, personalized rehabilitation may improve patient satisfaction. We hypothesized that, compared with standard rehabilitation, GAS-based rehabilitation would result in younger, active patients having higher satisfaction regarding activities after KA.

METHODS

We performed a single-center randomized controlled trial. Eligible patients were <65 years of age, working outside the home, and scheduled to undergo unicompartmental or total KA. The required sample size was 120 patients. Using GAS, patients developed personal activity goals with a physiotherapist preoperatively. These goals were used to monitor patients' goal attainment and provide goal-specific feedback during postoperative outpatient rehabilitation. Standard rehabilitation consisted of regular outpatient physiotherapy visits. The primary outcome measures were visual analogue scale (VAS) scores (scale of 0 to 100) for satisfaction regarding activities of daily living and work and leisure-time activities 1 year postoperatively, which were analyzed using generalized estimating equation models.

RESULTS

Patient satisfaction with work activities was significantly higher in the GAS group (β = 10.7 points, 98% confidence interval [CI] = 2.0 to 19.4 points) than in the control group. Patient satisfaction with activities of daily living and leisure-time activities did not differ between groups. We found no differences in VAS satisfaction scores between unicompartmental KA and total KA.

CONCLUSIONS

Personalized, goal-specific rehabilitation using GAS resulted in higher patient satisfaction with work activities, compared with standard rehabilitation, 1 year after KA.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Rehabilitation protocols following total knee arthroplasty: a review of study designs and outcome measures

Total knee arthroplasty (TKA) is among the most common elective procedures performed worldwide. Recent efforts have been made to significantly improve patient outcomes, specifically with postoperative rehabilitation. Despite the many rehabilitation modalities available, the optimal rehabilitation strategy has yet to be determined. Therefore, this systematic review focuses on evaluating existing postoperative rehabilitation protocols. Specifically, this review analyses the study designs, rehabilitation methods, and outcome measures of postoperative rehabilitation protocols for TKA recipients in the past five years. The PubMed, EMBASE, and Cochrane Library databases were queried for studies evaluating rehabilitation protocols following primary TKA. Of the 11,013 studies identified within the last five years, 70 met the inclusion and exclusion criteria. After assessing for relevance and removing duplicates, a final count of 20 studies remained for analysis. Level-of-evidence was determined by the American Academy of Orthopaedic Surgeons (AAOS) classification system. Our findings demonstrated that continuous passive motion and inpatient rehabilitation may not provide additional benefit to the patient or healthcare system. However, early rehabilitation, telerehabilitation, outpatient therapy, high intensity, and high velocity exercise may be successful forms of rehabilitation. Additionally, weight-bearing biofeedback, neuromuscular electrical stimulation, and balance control appear to be beneficial adjuncts to conventional rehabilitation. Postoperative rehabilitation following TKA facilitates patient recovery and improves quality of life. This systematic review analyzed the existing rehabilitation protocols from the past five years. Some studies did not accurately describe the conventional rehabilitation protocols, the duration of therapy sessions, and the timing of these sessions. As such, future studies should explicitly describe their methodology. This will allow high-quality assessments and the conception of standardized protocols.

Self-Directed Home Exercises vs Outpatient Physical Therapy After Total Knee Arthroplasty: Value and Outcomes Following a Protocol Change

BACKGROUND

The need for outpatient physical therapy (OPPT) has been questioned following primary total knee arthroplasty (TKA). Recent studies have suggested that similar outcomes may be possible with self-directed home exercise programs (HEP) compared to OPPT, which can be costly to both the patient and healthcare system. The aim of the present study is to compare the safety, efficacy, and health economics of formal OPPT with self-directed home exercises after TKA following a protocol change.

METHODS

A single-surgeon, retrospective study of 520 consecutive patients undergoing primary unilateral TKA from 2016 to 2018 was performed. All 251 TKAs performed in 2016 were routinely prescribed OPPT, while all 269 TKAs in 2017 completed a self-directed HEP alone for 2 weeks. At their 2-week visit, OPPT was prescribed if patients had less than 90° range of motion or per patient request. Financial data of postdischarge costs were collected for all patients. Multivariate logistic regression evaluated for variables associated with failure of the HEP program.

RESULTS

Overall, 65.8% (177/269) of patients in the HEP group did not require OPPT. There was no significant difference in percentage of patients whose range of motion was less than 90° at 2-week follow-up between OPPT and HEP (14% vs 11.9%, P = .467). Between OPPT and HEP, there were no differences in manipulation under anesthesia (3.2% vs 3%, P = .883). On average, patients who received OPPT incurred an increase in average cost of $1340.87 and $1893.42 for Medicare and private insurer patients, respectively. We did not identify any significant risk factors for failing HEP.

CONCLUSION

Comparable outcomes were demonstrated between patients receiving HEP compared to OPPT with a substantial cost saving. While a portion of patients still require formal OPPT, the majority do not. Surgeons should consider an initial trial of HEP with close follow-up in order to limit unnecessary costs associated with OPPT.

Quadriceps muscle activity during commonly used strength training exercises shortly after total knee arthroplasty: implications for home-based exercise-selection

Background

In the early phase after a total knee arthroplasty (TKA), patients experience multi-level weakness in the operated leg, which is caused primarily by reduced central nervous system (CNS) activation failure of the muscles - especially the knee extensors (quadriceps muscle). Whether similar levels of neuromuscular activity of the muscles in the operated leg, elicited during strength training exercises in machines, can be reached during strength training exercises in more simple forms is unknown. Many clinicians are faced with the problem of not having strength training equipment at their institution or having to prescribe simple strength training exercises for home-based training. Therefore, the purpose of this study was to determine which strength training exercises that activated the muscles in the operated leg the most after TKA. The hypothesis was that strength training exercises performed in machines would elicit higher levels of voluntary peak quadriceps and hamstring muscle activity than strength training exercises performed in more simple forms, using elastic bands or the patients’ own body weight.

Methods

A cross-sectional electromyographic study investigated voluntary peak muscle activity in the operated leg during 6 different strength training exercises. Twenty-four patients, who received a TKA 4 to 8 weeks earlier, performed the exercises in a randomized order, using a pre-determined loading of 10 RM (repetition maximum). Voluntary peak muscle activity (%EMGmax) was calculated for the quadriceps and hamstring muscles for each exercise.

Results

Knee extensions with elastic band showed significantly higher voluntary peak quadriceps muscle activity than knee extensions in machine (93.3 vs. 74.9; mean difference, 18.3 %EMGmax [95% confidence interval (CI), 11.7 to 24.9]; P < 0.0001). Similarly, one-legged squat (and sit to stand) elicited higher voluntary peak quadriceps muscle activity than leg press in machine (86.7 vs. 66.8; mean difference, 19.9 %EMGmax [95% CI, 14.8 to 25.0]; P < 0.0001).

Conclusions

Strength training exercises in more simple forms elicited higher voluntary peak quadriceps muscle activity than strength training exercises in machines early after TKA. Consequently, simple home-based strength training exercises using e.g. elastic bands or the patients’ own bodyweight should be considered to alleviate muscle strength losses early after TKA.

Trial registration

ClinicalTrials.gov identifier: NCT01708980.

Electronic supplementary material

The online version of this article (10.1186/s40634-019-0193-5) contains supplementary material, which is available to authorized users.

Web-Based, Self-Directed Physical Therapy After Total Knee Arthroplasty Is Safe and Effective for Most, but Not All, Patients

BACKGROUND

Recently, self-directed physical therapy (SDPT) programs have gained popularity following total knee arthroplasty (TKA). This study evaluated the safety and efficacy of the routine use of an SDPT program in a nonselect patient population.

METHODS

This is a single-surgeon, retrospective study of 296 consecutive patients from August 2016 to October 2017 discharged home after primary, unilateral TKA and enrolled in a web-based SDPT program. Patients were seen 2 weeks after surgery and outpatient physical therapy (OPPT) was prescribed if flexion was less than 90°, upon patient request, or inability to use the web-based platform.

RESULTS

Overall, 195 of 296 (65.9%) patients did not require OPPT (SDPT-only) while 101 of 296 were prescribed OPPT (34.1%, SDPT + OPPT). In SDPT + OPPT, 66.3% were for flexion <90°, 27.7% by patient request, 5.0% received a prescription but did not attend OPPT, and 1.0% due to inability to use the web-based platform. The rate of manipulation under anesthesia was 2.36% overall (SDPT + OPPT, 6.93%; SDPT-only, 0.0%). Multivariate analysis identified elevated Charlson comorbidity index, elevated body mass index, higher preoperative SF12 mental score, and loss of flexion at 2 weeks as independent predictors associated with the need for OPPT.

CONCLUSION

Web-based SDPT is safe and effective for most patients eligible for home discharge after TKA. It is difficult to preoperatively predict those patients who will require OPPT; therefore, we recommend close follow-up. It is critical to preserve these services for patients who require them after TKA as up to a third of patients required OPPT.

Does formal vs home-based physical therapy predict outcomes after ankle fracture or ankle fracture-dislocation?

Background

Ankle fractures are among the most common injuries treated by orthopaedic surgeons. Various postoperative rehabilitation strategies have been promoted, but the ability to improve patient-reported functional outcome has not been clearly demonstrated. We aim to evaluate outcomes associated with clinic-based, physical therapist-supervised rehabilitation (Formal-PT) compared to surgeon-directed rehabilitation (Home-PT).

Methods

This prospective observational study included patients with operative bimalleolar or trimalleolar ankle fractures with or without dislocation (n = 80) at a Level I trauma center. Patients were prescribed PT per the surgeon's practice pattern. Patient-reported functional outcomes at 6 months and complication rates were compared between groups.

Results

Of the 80 patients, 38 (47.5%) patients received Formal-PT; the remaining received Home-PT. Thirty-four patients (89.5%) attended ≥1 PT session. Number of sessions attended ranged from 1 to 36 (mean = 16). Receipt of Formal-PT did not differ by injury characteristics or demographics. Of patients with private insurance, 57% were prescribed Formal-PT vs 7% of uninsured patients (P = .033). FAAM and Combination SMFA scores at 6 months were similar between groups (Formal-PT: 69.7, 20.1; Home-PT: 70.9, 24.4; P = .868, .454, respectively). Postoperative complications were rare and equivalent between groups.

Conclusions

Comparison of outcomes between patients with operatively treated displaced ankle fractures/dislocations with Formal-PT vs Home-PT showed no difference in SMFA and FAAM scores. These findings suggest patients receiving supervised PT produced a similar outcome to those under routine physician-directed rehabilitation at 6 months. The cost for therapy averaged $2012.96 per patient receiving Formal-PT.

Variation in rehabilitation setting after uncomplicated total knee or hip arthroplasty: a call for evidence-based guidelines

Background

High-level evidence consistently indicates that resource-intensive facility-based rehabilitation does not provide better recovery compared to home programs for uncomplicated knee or hip arthroplasty patients and, therefore, could be reserved for those most impaired. This study aimed to determine if rehabilitation setting aligns with evidence regardless of insurance status.

Methods

Sub-study within a national, prospective study involving 19 Australian high-volume public and private arthroplasty centres. Individuals undergoing primary arthroplasty for osteoarthritis participated. The main outcome was the proportion participating in each rehabilitation setting, obtained via chart review and participant telephone follow-up at 35 and 90 days post-surgery, categorised as ‘facility-based’ (inpatient rehabilitation and/or ≥ four outpatient-based sessions, including day-hospital) or ‘home-based’ (domiciliary, monitored or unmonitored home program only). We compared characteristics of the study cohort and rehabilitation setting by insurance status (public or private) using parametric and non-parametric tests, analysing the knee and hip cohorts separately.

Results

After excluding ineligible participants (bilateral surgeries, self-funded insurance, participation in a concurrent rehabilitation trial, experience of a major acute complication potentially affecting their rehabilitation pathway), 1334 eligible participants remained. Complete data were available for 1302 (97%) [Knee: n = 610, mean age 68.7 (8.5) yr., 51.1% female; Hip: n = 692, mean age 65.5 (10.4) yr., 48.9% female]; 26% (158/610) of knee and 61% (423/692) of hip participants participated predominantly in home-based programs. A greater proportion of public recipients were obese and had greater pre-operative joint impairment, but participated more commonly in home programs [(Knee: 32.9% (79/240) vs 21.4% (79/370) (P = 0.001); Hip: 71.0% (176/248) vs 55.6% (247/444) (P <  0.001)], less commonly in inpatient rehabilitation [Knee: 7.5% (18/240) vs 56.0% (207/370) P (< 0.001); Hip: 4.4% (11/248) vs 33.1% (147/444) (P <  0.001], and had fewer outpatient treatments [Knee: median (IQR) 6 (3) vs 8 (6) (P < 0.001); Hip: 6 (4) vs 8 (6) (P < 0.001)].

Conclusions

Facility-based programs remain the norm for most knee and many hip arthroplasty recipients with insurance status being a major determinant of care. Development and implementation of evidence-based guidelines may help resolve the evidence-practice gap, addressing unwarranted practice variation across the insurance sectors.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2570-8) contains supplementary material, which is available to authorized users.

Assessment of Outcomes of Inpatient or Clinic-Based vs Home-Based Rehabilitation After Total Knee Arthroplasty: A Systematic Review and Meta-analysis

IMPORTANCE

Recent publication of the largest trials to date investigating rehabilitation after total knee arthroplasty (TKA) necessitate an updated evidence review.

OBJECTIVE

To determine whether inpatient or clinic-based rehabilitation is associated with superior function and pain outcomes after TKA compared with any home-based program.

DATA SOURCES

MEDLINE, Embase, CINAHL, and PubMed were searched from inception to November 5, 2018. Search terms included knee arthroplasty, randomized controlled trial, physiotherapy, and rehabilitation.

STUDY SELECTION

Published randomized clinical trials of adults who underwent primary unilateral TKA and commenced rehabilitation within 6 postoperative weeks in which those receiving postacute inpatient or clinic-based rehabilitation were compared with those receiving a home-based program.

DATA EXTRACTION AND SYNTHESIS

Two reviewers extracted data independently and assessed data quality and validity according to the PRISMA guidelines. Data were pooled using a random-effects model. Data were analyzed from June 1, 2015, through June 4, 2018.

MAIN OUTCOMES AND MEASURES

Primary outcomes were mobility (6-minute walk test [6MWT]) and patient-reported pain and function (Oxford knee score [OKS] or Western Ontario and McMaster Universities Osteoarthritis Index) reported at 10 to 12 postoperative weeks. The GRADE assessment (Grading of Recommendations, Assessment, Development, and Evaluation) was applied to the primary outcomes.

RESULTS

Five unique studies involving 752 unique participants (451 [60%] female; mean [SD] age, 68.3 [8.5] years) compared clinic- and home-based rehabilitation, and 1 study involving 165 participants (112 [68%] female; mean [SD] age, 66.9 [8.0] years) compared inpatient and home-based rehabilitation. Low-quality evidence showed no clinically important difference between clinic- and home-based programs for mobility at 10 weeks (6MWT favoring home program; mean difference [MD], -11.89 m [95% CI, -35.94 to 12.16 m]) and 52 weeks (6MWT favoring home program; MD, -25.37 m [95% CI, -47.41 to -3.32 m]). Moderate-quality evidence showed no clinically important difference between clinic- and home-based programs for patient-reported pain and function at 10 weeks (OKS MD, -0.15 [95% CI, -0.35 to 0.05]) and 52 weeks (OKS MD, 0.10 [95% CI, -0.14 to 0.34]).

CONCLUSIONS AND RELEVANCE

Based on low- to moderate-quality evidence, no superiority of clinic-based or inpatient programs compared with home-based programs was found in the early subacute period after TKA. This evidence suggests that home-based rehabilitation is an appropriate first line of therapy after uncomplicated TKA for patients with adequate social supports.

The benefits to functional ambulation and physical activity of group-based rehabilitation in frail elderly Bulgarians undergoing total knee arthroplasty. Preliminary results

OBJECTIVES

Frailty is a geriatric syndrome associated with increased vulnerability of older adults. Knee osteoarthritis (OA) is the most prevalent joint disease and one of the leading causes of disability and poor physical activity (PA) of elderly individuals worldwide. Total knee arthroplasty TKA has been recognized as an effective surgical treatment in end-stage of knee OA. There is a lack of consensus regarding the universally accepted rehabilitation protocol for frail elderly subjects after TKA.

AIM

to evaluate the potential benefits in functional ambulation (FA) and PA among frail elderly Bulgarian subjects underwent TKA, a novel group-based rehabilitation protocol was performed from the subjects.

MATERIALS AND METHODS

A total of 130 frail elderly Bulgarian TKA recipients (67 women and 63 men aged 72, 69 ± 0.44,) were included. FA was assessed by the six-minute walking distance (6MWD). PA was evaluated by the PASE questionnaire. Participants were evaluated one week before TKA, as well as 3 and 6 months after the group-based rehabilitation.

RESULTS

Significant increase in FA was observed at the third and sixth month after the group-based intervention (p< 0.001). PASE score, was increased at the third and sixth month after the group-based intervention (p<0.001, r2=0.74).

CONCLUSIONS

Our results suggest that the applied group-based intervention led to a significant improvement in FA as well as in PA of frail elderly subjects over the first six months after the group-based intervention.

The safety, efficacy and cost-effectiveness of the Maxm Skate, a lower limb rehabilitation device for use following total knee arthroplasty: study protocol for a randomised controlled trial

BACKGROUND

Physical rehabilitation is required to enhance functional outcomes and overall recovery following total knee arthroplasty (TKA). However, there are no universally accepted clinical guidelines available to consistently structure rehabilitation for TKA patients. A common method is rehabilitation provided in an outpatient setting, on a one-to-one treatment basis. This method is resource-intensive and outcomes must be compared to less costly alternatives such as home-based rehabilitation. The current study will analyse a novel home-based rehabilitation program. The Maxm skate is a portable, lower-limb, postoperative, rehabilitation exercise device for individual use in a hospital or home-based setting. This study was developed to compare the safety, efficacy and cost-effectiveness of the Maxm Skate rehabilitation program to standard rehabilitative care following TKA. The primary outcome is the range of motion (ROM) achieved by patients who received the Maxm Skate program compared to standard care at three months post TKA. Secondary outcomes include patient-reported outcomes, costs and functional evaluations which will be collected at multiple time-points up to 12 months after TKA.

METHODS

This is a single-blinded, randomised controlled trial (RCT) in which 116 eligible participants consented for primary TKA will be randomly allocated to receive either the Maxm Skate rehabilitation program or standard rehabilitative care. Fifty-eight participants per group will provide 90% power (α = 0.05) to detect 10° of difference in ROM between groups at three months after TKA, assuming a within-group standard deviation of 16° and allowing for 5% loss to follow-up. Participants randomised to the Maxm Skate group will use the skate device and accompanying iOS App and sensors to complete rehabilitation exercises, as outlined in the Maxm Skate Rehabilitation Guide. Outcomes will be compared to those receiving standard rehabilitative care. A blinded physiotherapist will evaluate functional outcomes preoperatively and at 2, 4, 6, 12, 26 and 52 weeks after TKA. The functional assessment will include measures of knee ROM, pain, isometric knee strength, balance and knee/thigh circumference. Limited measures will also be assessed at day 2 postoperatively by an alternate, unblinded physiotherapist. Clinical outcome measures will be administered preoperatively and at 6, 12 and 52 weeks postoperatively. An economic evaluation will be conducted and participants will be screened for adverse event occurrences from the time of consent to 12 months postoperatively.

DISCUSSION

This RCT will be the first to investigate the safety, efficacy and cost-effectiveness of the home-based Maxm Skate Rehabilitation program, in comparison to standard rehabilitative care following primary TKA.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12616001081404p . Registered on 11 August 2016.

Benefits of direct patient discharge to outpatient physical therapy after total knee arthroplasty

Purpose: To investigate the effectiveness of home health physical therapy followed by outpatient physical therapy as compared to patients discharged directly to outpatient physical therapy in improving functional performance, strength/activation and residual knee pain outcomes among patients who received a total knee arthroplasty.Materials and methods: A secondary analysis of longitudinal data in which patients with total knee arthroplasty underwent home health physical therapy or were discharged directly to outpatient physical therapy. Main outcome measures included the stair climb test, timed up and go, 6-min walk test, quadriceps and hamstring strength, quadriceps activation and residual knee pain.Results: Patients referred to home health physical therapy prior to outpatient physical therapy demonstrated significantly greater declines in stair climb test (10.3; 95% CI [6.5, 14.1]; t = 5.41; p < 0.0001), timed up and go (2.0; 95% CI [1.0, 3.0]; t = 4.10; p < 0.0001), 6-min walk (53.8; 95% CI [29.4, 78.2]; t = 4.35; p < 0.0001), quadriceps strength (21.7%; 95% CI [19.3%, 24.9%]; t = 2.53; p = 0.01), hamstring strength (44.7%; 95% CI [43.4%, 45.7%], t = 3.17; p = 0.002) and higher residual knee pain (0.53; 95% CI [0.04, 1.03]; t = 2.17; p = 0.03) 1 month after total knee arthroplasty compared to those referred directly to outpatient physical therapy.Conclusions: These findings suggest that patients discharged directly to outpatient physical therapy had a more rapid recovery 1 month after total knee arthroplasty. Additional research is needed to investigate the potential causal relation between care pathways and clinical outcomes following total knee arthroplasty.Implications for rehabilitationTotal knee arthroplasty, typically performed to alleviate end-stage knee osteoarthritis, is the most commonly performed elective surgery in the United States.Despite improvement in pain, objective measurements of functional performance and strength often remain at preoperative levels one year after total knee arthroplasty.Patients discharged directly to higher intensity outpatient physical therapy have a more rapid recovery after total knee arthroplasty compared with those patients who received two weeks of home health prior to undergoing outpatient physical therapy.

2018 John N. Insall Award: Recovery of Knee Flexion With Unsupervised Home Exercise Is Not Inferior to Outpatient Physical Therapy After TKA: A Randomized Trial

BACKGROUND

Concerns about the cost and convenience of postsurgical physical therapy (PT) have sparked interest in unsupervised, home-based rehabilitation. However, the effectiveness of unsupervised home exercise after primary TKA has not been previously evaluated.

QUESTIONS/PURPOSES

(1) Can unsupervised home exercise after surgery provide noninferior recovery of passive knee flexion compared with formal outpatient PT? (2) Does a web-based platform for home-based exercise provide an advantage compared with a printed PT manual?

METHODS

We conducted a randomized, noninferiority trial involving 290 patients (20% of the 1464 eligible patients who could be contacted) who underwent primary TKA from March 2016 to April 2018. We included patients > 18 years old who were undergoing primary, unilateral TKA and provided written consent. We excluded patients with preoperative knee flexion < 90°, patients considering surgical intervention in a hip or the contralateral knee, patients discharged to an extended care facility, and revision or conversion TKA. We randomized patients to one of three groups: outpatient PT, unsupervised home exercise using a web-based platform (web PT), or unsupervised home exercise using a printed paper manual (paper PT). We also implemented a "delayed recovery intervention" within the home exercise program, in which patients were obliged to begin outpatient PT if knee flexion was < 70° at 2 weeks or < 90° at 4 weeks. The primary outcome was change in knee flexion from preoperative baseline after 4 to 6 weeks and 6 months. Secondary outcomes included Knee Injury and Osteoarthritis Outcome Score (KOOS), time back to activities of daily living, and time off narcotics. All analyses were intention to treat, and the noninferiority margin was 5% with maximum flexion as the outcome of interest for this parameter.

RESULTS

Adjusted differences in change in passive flexion for web PT +3° (95% confidence interval [CI], -1.2° to 6.4°) and paper PT +5° (95% CI, 0.99°-8.6°) were not inferior to outpatient PT based on a predefined 5° margin. Change in knee flexion from baseline was 0° for outpatient PT, -2° for web PT, and -1° for paper PT after 4 to 6 weeks and 8°, 8°, and 12° for the three groups, respectively, after 6 months. Additionally, there was no difference in the change in KOOS from baseline at 4 to 6 weeks or 6 months postoperatively as well as time back to work, driving, and walking without an assistive device.

CONCLUSIONS

Unsupervised home exercise is an effective rehabilitation strategy after primary TKA and was noninferior to formal outpatient PT in selected patients. It is worthwhile to reconsider the current practice of automatically designating patients for outpatient PT after primary TKA, because appropriately selected patients with adequate clinical support can achieve similar results at home.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Goal Setting and Achievement in Individualized Rehabilitation of Younger Total and Unicondylar Knee Arthroplasty Patients: A Cohort Study

OBJECTIVE

To investigate activity goals, intensity and achievement of these activity goals in younger knee arthroplasty (KA) patients, and to identify the differences between total knee arthroplasty (TKA) and unicondylar knee arthroplasty (UKA) patients.

DESIGN

Prospective cohort study.

SETTING

Department of orthopedic surgery and physical therapy practices.

PARTICIPANTS

Patients (N=48) aged 65 years or younger who underwent KA.

INTERVENTION

Rehabilitation with goal attainment scaling (GAS).

MAIN OUTCOME MEASURES

GAS goals for daily life activity, work and leisure time, corresponding metabolic equivalent of task (MET) values, corrected MET values, and GAS scores at 3 and 6 months.

RESULTS

The intensity levels of all 144 formulated activity goals were light in 16% of cases, moderate in 63%, and vigorous in 21%. Intensity levels did not differ between TKA and UKA patients. Following rehabilitation using GAS, 54% of daily life activity goals, 65% of work activity goals, and 46% of leisure time activity goals were attained after 3 months. After 6 months, 91% of daily life activity goals, 93% of work activity goals, and 89% of leisure time activity goals were attained. Goal attainment did not differ between MET intensity levels. Higher goal attainment was achieved in the UKA group (100%) compared with the TKA patients (82%) after 6 months (P<.001).

CONCLUSIONS

Younger patients aim to perform many different activities of varying metabolic intensity levels following KA. After 6 months of rehabilitation using GAS, in these patients attain 91% of their preoperatively formulated activity goals, independent of the MET intensity level. After 6 months, UKA patients attain significantly more activity goals than TKA patients. GAS might be a useful objective outcome measure in evaluating clinical outcomes of individual KA patients.

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

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

The effectiveness of inpatient rehabilitation after uncomplicated total hip arthroplasty: a propensity score matched cohort

Background

Inpatient rehabilitation is an expensive option following total hip arthroplasty (THA). We aimed to determine if THA patients who receive inpatient rehabilitation report better hip and quality of life scores post-surgery compared to those discharged directly home.

Methods

Prospective, propensity score matched cohort involving 12 private hospitals across five Australian States. Patients undergoing THA secondary to osteoarthritis were included. Those receiving inpatient rehabilitation for reasons other than choice or who experienced significant health events within 90-days post-surgery were excluded. Comparisons were made between those who did and did not receive inpatient rehabilitation for patient-reported hip pain and function (Oxford Hip Score, OHS) and ‘today’ health rating (EuroQol 0–100 scale). Rehabilitation provider charges were also estimated and compared.

Results

Two hundred forty-six patients (123 pairs, mean age 67 (10) yr., 66% female) were matched on 19 covariates for their propensity to receive inpatient rehabilitation. No statistically nor clinically significant between-group differences were observed [OHS median difference (IQR): 0 (− 3, 3), P = 0.60; 0 (− 1 to 1), P = 0.91, at 90 and 365-days, respectively; EuroQol scale median difference 0 (− 10, 12), P = 0.24; 0 (− 10, 10), P = 0.49; 5 (− 10, 15), P = 0.09, at 35-, 90- and 365-days, respectively]. Median rehabilitation provider charges were 10-fold higher for those who received inpatient rehabilitation [median difference $7582 (5649, 10,249), P <  0.001]. Sensitivity analyses corroborated the results of the primary analyses.

Conclusion

Utilization of inpatient rehabilitation pathways following THA appears to be low value healthcare. Sustainability of inpatient rehabilitation models may be enhanced if inpatient rehabilitation is reserved for those most impaired or who have limited social supports.

Trial registration

ClinicalTrials.gov Identifier: NCT01899443.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2134-3) contains supplementary material, which is available to authorized users.

Formal Physical Therapy May Not Be Necessary After Unicompartmental Knee Arthroplasty: A Randomized Clinical Trial

BACKGROUND

The purpose of this randomized clinical trial was to compare formal outpatient physical therapy (PT) and unsupervised home exercises after unicompartmental knee arthroplasty (UKA).

METHODS

Fifty-two patients were randomized to 6 weeks of outpatient PT or an unsupervised home exercise program after UKA. The primary outcome was change in range of motion at 6 weeks with secondary outcomes including total arc of motion, Knee Society Score, Knee Injury and Osteoarthritis Outcome Score Jr, Lower Extremity Functional Scale, and Veterans Rands-12 score.

RESULTS

Twenty-five patients received outpatient PT, 22 patients the self-directed exercise program, while 3 patients deviated from the protocol, 1 patient withdrew, and 1 patient was lost to follow-up. There was no difference in the change of range of motion (P = .43) or total arc of motion at 6 weeks (P = .17) between the groups and likewise no significant differences were found in any of the secondary outcomes. Two patients who crossed over from the unsupervised home exercise program to formal outpatient PT within the first 2 weeks postoperatively required a manipulation under anesthesia.

CONCLUSIONS

Our results suggest self-directed exercises may be appropriate for most patients following UKA. However, there is a subset of patients who may benefit from formal PT.

Participation in Regular Physical Activity After Total Knee or Hip Arthroplasty for Osteoarthritis: Prevalence, Associated Factors, and Type

OBJECTIVE

To describe the rates of participation in regular physical activity presurgery and at 3 years follow-up after knee or hip arthroplasty, and to describe factors associated with participation postsurgery and types of activity undertaken.

METHODS

A previously acquired multicenter, prospective cohort of knee or hip arthroplasty recipients was followed up for 3 years postsurgery. Regular participation in physical activity was defined as participation in physical activity ≥1 time/week, excluding incidental activities. Participants were interviewed about current participation as well as participation in the year presurgery. Joint-specific and health-related quality-of-life scores and information on experience of major complications were obtained. Information about comorbidity and body weight were updated. Factors associated with 3-year physical activity participation were determined using multivariable logistic regression modeling.

RESULTS

In total, 73.4% of the eligible cohort (1,289 of 1,757) were followed up (718 patients with total knee arthroplasty, and 571 patients with total hip arthroplasty). Participation profiles were similar regardless of the joint replaced. Participation in physical activity increased postsurgery in the combined cohort (from 45.2% to 63.5%; P < 0.001). Participation at 3 years was associated with participation presurgery (P < 0.0001), better 3-year quality of life (P < 0.001), younger age (P = 0.002), better 3-year joint scores (P = 0.01), >1 lifetime arthroplasty (P = 0.02), and higher education level (P = 0.04). Low-impact and nonambulatory activities significantly increased postsurgery with no change in high-impact activities.

CONCLUSION

Participation rates increased postsurgery when recovery was stable, but approximately one-third of arthroplasty recipients did not engage in physical activity at least once per week. Because participation is associated with habitual activity presurgery, a potential role for behavior change interventions is suggested. The increase in nonambulatory activities indicates that current devices measuring ambulatory activity alone are inadequate for capturing physical activity.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSION

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

PROSPERO REGISTRATION NUMBER

CRD42017041382.

Outpatient Total Knee Arthroplasty: Are We There Yet? (Part 2)

The method by which surgeons conduct outpatient total knee procedures has yet to be fully elucidated. Literature demonstrates different experiences from various care protocols in place across the nation. This article reviews current recommendations for implementing successful total knee arthroplasty (TKA) and unicompartmental knee arthroplasty outpatient protocols. Specifically, information regarding anesthesia and analgesia modalities, perioperative care, operative technique, and postoperative care within outpatient TKA pathways is discussed.

Total knee arthroplasty status and patient-reported, knee-related quality of life over a 4-year follow-up period: data from the osteoarthritis initiative

PURPOSE

To examine the relationship between baseline total knee arthroplasty (TKA) status and patient-reported, knee-related quality of life (QoL) over a 4-year follow-up relative to no knee osteoarthritis (OA).

PATIENTS AND METHODS

Data from the Osteoarthritis Initiative were included, comprising 4,674 adults aged 45-79 years at baseline. Patients were categorized into four groups: no knee OA (n=3,711), non-TKA (n=902), pre-TKA (n=36), and post-TKA (n=25). QoL was measured using the Knee Injury Osteoarthritis Outcome Score-QoL subscale. General linear mixed models were used for the relationship between TKA and QoL.

RESULTS

After adjusting for covariates, a reduced QoL was noted for patients in the non-TKA (mean [standard error], -13.97 [0.73]; P<0.0001), pre-TKA (-21.34 [3.57]; P<0.0001), and post-TKA (-9.68 [3.94]; P=0.0143) groups compared with the no knee OA group. QoL in the non-TKA group also decreased over time (-0.16 [0.07]; P=0.226).

CONCLUSION

Non-, pre-, and post-TKA status is associated with a lower QoL.

Efficacy and safety of home-based exercises versus individualized supervised outpatient physical therapy programs after total knee arthroplasty: a systematic review and meta-analysis

PURPOSE

The aim of the present study was to evaluate the efficacy and safety of non-supervised home-based exercise versus individualized and supervised programs delivered in clinic-based settings for the functional recovery immediately after discharge from a primary TKA.

METHODS

Medline, Embase, Cochrane, and PEDro databases were screened, from inception to April 2015, in search for randomized clinical trials (RCT) of home-based exercise interventions versus individualized and supervised outpatient physical therapy after primary TKA. Target outcomes were: knee range of motion (ROM), patient-reported pain and function, functional performance, and safety. Risk of bias was assessed with the PEDro scale. After assessing homogeneity, data were combined using random effects meta-analysis and reported as standardized mean differences or mean differences. We set a non-inferiority margin of four points in mean differences.

RESULTS

The search and selection process identified 11 RCT of moderate quality and small sample sizes. ROM active extension data suitable for meta-analysis was available from seven studies with 707 patients, and ROM active flexion from nine studies with 983 patients. Most studies showed no difference between groups. Pooled differences were within the non-inferiority margin. Most meta-analyses showed significant statistical heterogeneity.

CONCLUSION

Short-term improvements in physical function and knee ROM do not clearly differ between outpatient physiotherapy and home-based exercise regimes in patients after primary TKA; however, this conclusion is based on a meta-analysis with high heterogeneity.

LEVEL OF EVIDENCE

I.

The value of inpatient rehabilitation after uncomplicated knee arthroplasty: a propensity score analysis

OBJECTIVE

To compare the effectiveness of rehabilitation after total knee arthroplasty (TKA) in models with or without an inpatient rehabilitation component.

DESIGN, SETTING AND PARTICIPANTS

A propensity score-matched cohort of privately insured patients with osteoarthritis who underwent primary, unilateral TKA in one of 12 Australian hospitals between August 2013 and January 2015 were included. Those discharged to an inpatient facility because of poor progress or who experienced significant complications within 90 days of surgery were excluded.

INTERVENTION

Discharge after surgery to an inpatient rehabilitation facility or home.

MAIN OUTCOME MEASURES

Patient-reported knee pain and function (Oxford Knee Score; at 90 and 365 days after surgery) and health rating (EuroQol "today" health scale; at 35, 90 and 365 days). Inpatient and community-based rehabilitation provider charges were also assessed.

RESULTS

258 patients (129 pairs) from a sample of 332 were matched according to their propensity scores for receiving inpatient rehabilitation; covariates used in the matching included age, sex, body mass index, and markers of health and impairment. The only significant difference in outcomes was that EuroQol health scores were better on Day 35 for patients not undergoing inpatient rehabilitation (median difference, 5; IQR, -10 to 19; P = 0.01). Median rehabilitation provider charges were significantly higher for those discharged to inpatient therapy (total costs: median difference, $9500; IQR, $7000-11 497; P < 0.001; community therapy costs: median difference, $749; IQR, $0-1980; P < 0.001).

CONCLUSIONS

Rehabilitation pathways incorporating inpatient rehabilitation did not achieve better joint-specific outcomes or health scores than alternatives not including inpatient rehabilitation. Given the substantial cost differences, better value alternatives should be considered for patients after uncomplicated TKA.

Perioperative Physiotherapy in Total Knee Arthroplasty

Total knee arthroplasty has a high success rate. In the interest of enhancing patient outcomes, numerous perioperative interventions have been studied, including preoperative education, preoperative rehabilitation, postoperative inpatient rehabilitation, continuous passive motion, postoperative outpatient rehabilitation, unsupervised in-home exercises, telerehabilitation, and various combinations of these. This comprehensive review analyzes the existing body of evidence on these perioperative interventions and examines some burgeoning opportunities in rehabilitation after total knee arthroplasty in the interest of improving patient outcomes and ensuring sustainable health care utilization for the future of total knee arthroplasty. [Orthopedics. 2017; 40(5):e765-e773.].

Single-stage total knee arthroplasty and osteotomy as treatment of secondary osteoarthritis with severe coronal deviation of joint surface due to extra-articular deformity

PURPOSE

Severe extra-articular deformities can be treated with single-stage total knee replacement (TKA) and osteotomy. Aim of this study was to examine the patient-reported outcome measures (PROMs) and the complications after single-stage TKA and osteotomy. We hypothesized patients achieve good outcome after single-stage TKA and osteotomy, which is comparable to outcome after primary TKA without deformity.

METHODS

Twenty-one patients with severe extra-articular deformity who underwent single-stage TKA and deformity-correcting osteotomy were reviewed and invited to fill in PROMs including the Oxford Knee Score, the Short Form-12, a Visual Analogue Scale for pain, and questions about satisfaction and quality of life.

RESULTS

The mean follow-up period was 64 months. Ten patients were treated with TKA and supracondylar femoral osteotomy. Although PROMs showed good results (mean quality of life score was 85 out of 100), two patients had a revision of the osteotomy due to non-union. Eleven patients were treated with TKA and high tibial osteotomy. Patients were satisfied with the results (mean quality of life score was 81 out of 100). Two patients developed infection requiring debridement, resulting in one arthrodesis and one gastrocnemius transfer for wound closure.

CONCLUSION

In general, patients were satisfied with the postoperative result. Outcome was comparable to patients after primary TKA in the literature. However, serious complications need to be taken into account.

LEVEL OF EVIDENCE

III.

GEDOS-SECOT consensus on the care process of patients with knee osteoarthritis and arthoplasty

OBJECTIVE

To develop recommendations on the evaluation and management procedure in patients undergoing total knee replacement based on best evidence and the experience of a panel of experts.

METHODS

A multidisciplinary group of 12 experts was selected that defined the scope, users and the document parts. Three systematic reviews were performed in patients undergoing knee replacement: (i)efficacy and safety of fast-tracks; (ii)efficacy and safety of cognitive interventions in patients with catastrophic pain, and (iii) efficacy and safety of acute post-surgical pain management on post-surgical outcomes. A narrative review was conducted on the evaluation and management of pain sensitization, and about the efficacy and safety of pre-surgical physiotherapy. The experts generated the recommendations and explicative text. The level of agreement was evaluated in a multidisciplinary group of 85 experts with the Delphi technique. The level of evidence was established as well for each recommendation.

RESULTS

A total of 20 recommendations were produced. An agreement higher than 80% was reached in all of them. We found the highest agreement on the need for a full discharge report, on providing proper information about the process and on following available guidelines.

CONCLUSIONS

There is consensus among professionals involved in the management of patients undergoing total knee replacement, in that it is important to protocolize the replacement process, performing a proper, integrated and coordinated patient evaluation and follow-up, paying special attention to the surgical procedure and postoperative period.

The effectiveness of the use of a digital activity coaching system in addition to a two-week home-based exercise program in patients after total knee arthroplasty: study protocol for a randomized controlled trial

BACKGROUND

There is consistent evidence that supervised programs are not superior to home-based programs after total knee arthroplasty (TKA), especially in patients without complications. Home-based exercise programs are effective, but we hypothesize that their effectiveness can be improved by increasing the adherence to physical therapy advice to reach an adequate exercise level during the program and thereafter. Our hypothesis is that an activity coaching system (accelerometer-based activity sensor), alongside a home-based exercise program, will increase adherence to exercises and the activity level, thereby improving physical functioning and recovery. The objective of this study is to determine the effectiveness of an activity coaching system in addition to a home-based exercise program after a TKA compared to only the home-based exercise program with physical functioning as outcome.

METHODS

This study is a single-blind randomized controlled trial. Both the intervention (n = 55) and the control group (n = 55) receive a two-week home-based exercise program, and the intervention group receives an additional activity coaching system. This is a hand-held electronic device together with an app on a smartphone providing information and advice on exercise behavior during the day. The primary outcome is physical functioning, measured with the Timed Up and Go test (TUG) after two weeks, six weeks and three months. Secondary outcomes are 1) adherence to the activity level (activity diary); 2) physical functioning, measured with the 2-Minute Walk Test (2MWT) and the Knee Osteoarthritis Outcome Score; 3) quality of life (SF-36); 4) healthcare use up to one year postoperatively and 5) cost-effectiveness. Data are collected preoperatively, three days, two and six weeks, three months and one year postoperatively.

DISCUSSION

The strengths of the study are the use of both performance-based tests and self-reported questionnaires and the personalized tailored program after TKA given by specialized physical therapists. Its weakness is the lack of blinding of the participants to treatment allocation. Outcomes are generalizable to uncomplicated patients as defined in the inclusion criteria.

TRIAL REGISTRATION

The trial is registered in the Dutch Trial Register ( www.trialregister.nl , NTR 5109) (March 22, 2015).

Association between rehabilitation attendance and physical function following discharge after total knee arthroplasty: prospective cohort study

BACKGROUND

Rehabilitation is widely advocated and provided as a standard of care for patients with total knee arthroplasty (TKA) but its effects on intermediate- to longer-term physical function is unclear. Also unknown is the relationship between the number of rehabilitation sessions attended and functional outcomes.

METHODS

We conducted a prospective cohort study of 1540 patients who had undergone TKA and were referred for rehabilitation. Physical function was indexed by the Short-Form 36 (SF-36) physical function score at 6 months post-TKA. We used multivariable linear regression to assess the association between rehabilitation attendance and Month-6 physical function. Among patients who attended rehabilitation, multivariable linear regression was used to examine the dose-response association between the number of sessions attended and Month-6 physical function.

RESULTS

Of the 1540 patients, 68 patients did not attend rehabilitation, 86 patients attended one session, and 1386 patients attended two or more sessions. Adjusted for the propensity to attend rehabilitation, rehabilitation attendance was independently associated with better Month-6 SF-36 physical function (point estimate, 5.0 points; 95% CI, 0.5-9.5; P = 0.028 compared with patients with no rehabilitation). Among patients who attended rehabilitation, attending five sessions was associated with a 3.6-point increase in SF-36 scores (95% CI, 0.8-6.5; P = 0.01) relative to patients who attended one session.

CONCLUSIONS

Rehabilitation attendance post-TKA is associated with an increase in self-report physical function. Among patients who attended rehabilitation, a modest dose-response relationship was observed between the number of sessions and functional outcomes.