Abstract
BackgroundApproximately 20% of patients are not satisfied with the outcome of total knee replacement, great volumes of which are carried out yearly. Physiotherapy is often provided by the NHS to address dysfunction following knee replacement; however the efficacy of this is unknown. Although clinically it is accepted that therapy is useful, provision of physiotherapy to all patients post-operatively does not enhance outcomes at one year. No study has previously assessed the effect of targeting therapy to individuals struggling to recover in the early post-operative phase.The aim of the TRIO study is to determine whether stratifying care by targeting physiotherapy to those individuals performing poorly following knee replacement is effective in improving the one year outcomes. We are also investigating whether the structure of the physiotherapy provision itself influences outcomes.Methods/DesignThe study is a multi-centre prospective randomised controlled trial (RCT) of patients undergoing primary total knee replacement, with treatment targeted at those deemed most susceptible to gain from it. Use of the national PROMS programme for pre-operative data collection allows us to screen all patients at initial post-operative clinical review, and recruit only those deemed to be recovering slowly.We aim to recruit 440 patients through various NHS orthopaedic centres who will undergo six weeks of physiotherapy. The intervention will be either ‘intensive’ involving both hospital and home-based functional exercise rehabilitation, or ‘standard of care’ consisting of home exercises. Patients will be randomised to either group using a web-based system. Both groups will receive pre and post-intervention physiotherapy review. Patients will be followed-up to one year post-operation. The primary outcome measure is the Oxford Knee Score. Secondary outcomes are patient satisfaction, functional ability, pain scores and cost-effectiveness.Trial registrationCurrent Controlled Trials ISRCTN23357609. ClinicalTrials.gov NCT01849445.
Highlights
20% of patients are not satisfied with the outcome of total knee replacement, great volumes of which are carried out yearly
A previous study suggested that postoperative physiotherapy was not effective at improving the patients’ one year outcome, when applied uniformly to all patients after knee replacement [7]
Mitchell et al (2005) found the cost of physiotherapy to be small at only £136.50 per patient, as such, only a comparatively small change in patient quality of life is required for the treatment to fall comfortably below the threshold of £30,000 per quality adjusted life year (QALY) implied by National Institute for health and Care Excellence (NICE) [11] as being cost-effective
Summary
Knee osteoarthritis is an extremely common and extremely disabling condition, often requiring surgical intervention. A previous study suggested that postoperative physiotherapy was not effective at improving the patients’ one year outcome, when applied uniformly to all. Unspecified post-operative physiotherapy applied to a whole cohort of patients who had undergone knee replacement did not find a significant improvement over the control group one year following surgery [7]. A previous UK economic analysis of a different physiotherapy treatment than is proposed in this trial showed no significant effects, when such physiotherapy is applied universally to all total knee arthroplasty (TKA) patients [9]. It is entirely possible that subgroups of patients may be cost-effective to treat when the total population is not [10]. Mitchell et al (2005) found the cost of physiotherapy to be small at only £136.50 per patient (95% CI £113 to £160), as such, only a comparatively small change in patient quality of life is required for the treatment to fall comfortably below the threshold of £30,000 per quality adjusted life year (QALY) implied by NICE [11] as being cost-effective
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