Abstract
Recent publication of the largest trials to date investigating rehabilitation after total knee arthroplasty (TKA) necessitate an updated evidence review. To determine whether inpatient or clinic-based rehabilitation is associated with superior function and pain outcomes after TKA compared with any home-based program. MEDLINE, Embase, CINAHL, and PubMed were searched from inception to November 5, 2018. Search terms included knee arthroplasty, randomized controlled trial, physiotherapy, and rehabilitation. 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. 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. 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. 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]). 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.
Highlights
This evidence suggests that home-based rehabilitation is an appropriate first line of therapy after uncomplicated Total knee arthroplasty (TKA) for patients with adequate social supports
Total knee arthroplasty (TKA) was the most frequently performed inpatient operating room procedure in the United States in 2012.1 From 2003 to 2012, the incidence of TKA increased from 145.4 to 223.0 per 100 000 population (a 4.9% mean annual increase), with the total number performed in the United States projected to increase from 711 000 in 2011 to 3.48 million by 2030.2 in Australia, the incidence increased from 108.3 per 100 000 population in 2003 to 222.3 per 100 000 population in 2017, with more than 54 000 TKAs performed in 2017.3
Six eligible randomized clinical trials were included in the review (Table 1),[16,17,37,38,39,40 5] of which were included in the meta-analysis (Figure 1).[17,37,38,39,40]
Summary
Total knee arthroplasty (TKA) was the most frequently performed inpatient operating room procedure in the United States in 2012.1 From 2003 to 2012, the incidence of TKA increased from 145.4 to 223.0 per 100 000 population (a 4.9% mean annual increase), with the total number performed in the United States projected to increase from 711 000 in 2011 to 3.48 million by 2030.2 in Australia, the incidence increased from 108.3 per 100 000 population in 2003 to 222.3 per 100 000 population in 2017, with more than 54 000 TKAs performed in 2017.3The increased volume of surgery constitutes a significant burden on the acute health care budget, but because the surgery is typically followed by a protracted rehabilitation period, the latter can add significantly to the cost of care. The setting, cost, and modes of provision vary greatly when rehabilitation is delivered in the community.[6,9] Available options include one-to-one or group-based interventions (land or water) and various iterations of home-based care, including domiciliary programs (physiotherapy visits in the home), telerehabilitation, or more simple monitored (via occasional clinic visits or telephone contact) or unmonitored home programs.[9,10,11,12,13] Previous systematic reviews of randomized clinical trials[14,15] have concluded that no single setting—clinic- or homebased, in water or on land—appears to be associated with better recovery across a range of outcomes Despite this finding, to date, no evidence-based clinical practice guideline exists to promote the use of home-based programs after uncomplicated TKA. A more contemporary review is warranted, potentially as a precursor to development of a much-needed clinical practice guideline
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