Factors Correlated With Physical Function 1 Year After Total Knee Arthroplasty in Patients With Knee Osteoarthritis: A Systematic Review and Meta-analysis

Exercise therapy, education, and cognitive behavioral therapy alone, or in combination with total knee arthroplasty, in patients with knee osteoarthritis: a randomized feasibility study

BACKGROUND

One in five patients experience chronic pain 1 year after total knee arthroplasty (TKA), highlighting the need for enhanced treatment strategies to improve outcomes. This feasibility trial aimed to optimize the content and delivery of a complex intervention tailored to osteoarthritis (OA) patients at risk of poor outcome after TKA and assess the feasibility of initiating a full-scale multicenter randomized controlled trial (RCT).

METHODS

Patients scheduled for TKA were included between August 2019 and June 2020 and block-randomized into one of three groups: (a) 12-week exercise therapy and education (ExE) and 10-module internet-delivered cognitive behavioral therapy (iCBT), (b) TKA followed by ExE and iCBT and (c) TKA and standard postoperative care. Outcomes were (i) recruitment and retention rate, (ii) compliance to the intervention and follow-up, (iii) crossover, and (iv) adverse events, reported by descriptive statistics.

RESULTS

Fifteen patients were included in the study. Only 1 out of 146 patients screened for eligibility was included during the first 4 months. During the next 3 months, 117 patients were not included since they lived too far from the hospital. To increase the recruitment rate, we made three amendments to the inclusion criteria; (1) at-risk screening of poor TKA outcome was removed as an eligibility criterion, (2) patients across the country could be included in the study and (3) physiotherapists without specific certification were included, receiving thorough information and support. No patients withdrew from the study or crossed over to surgery during the first year. Nine out of 10 patients completed the ExE program and six out of 10 completed the iCBT program. Fourteen out of 15 patients completed the 1-year follow-up. One minor adverse event was registered.

CONCLUSIONS

Except for recruitment and compliance to iCBT, feasibility was demonstrated. The initial recruitment process was challenging, and necessary changes were made to increase the recruitment rate. The findings informed how a definitive RCT should be undertaken to test the effectiveness of the complex intervention.

TRIAL REGISTRATION

The MultiKnee RCT, including the feasibility study, is pre-registered at ClinicalTrials.gov: NCT03771430 11/12/2018.

Previous cartilage surgery is associated with inferior patient-reported outcomes after knee arthroplasty

PURPOSE

The hypothesis of the present study assumed that a history of focal cartilage lesions would not affect Knee Injury and Osteoarthritis Outcome scores (KOOSs) following knee arthroplasty compared to a matched national cohort of knee arthroplasty patients.

METHODS

Fifty-eight knee arthroplasty patients with previous surgery for focal cartilage lesions (cartilage cohort) were compared to a matched cohort of 116 knee arthroplasty patients from the Norwegian Arthroplasty Register (control group). Age, sex, primary or revision arthroplasty, type of arthroplasty (total, unicondylar or patellofemoral), year of arthroplasty surgery and arthroplasty brand were used as matching criteria. Demographic data and KOOS were obtained through questionnaires. Regression models were employed to adjust for confounding factors.

RESULTS

Mean follow-up post knee arthroplasty surgery was 7.6 years (range 1.2-20.3) in the cartilage cohort and 8.1 (range 1.0-20.9) in the control group. The responding patients were at the time of surgery 54.3 versus 59.0 years in the cartilage and control group, respectively. At follow-up the control group demonstrated higher adjusted Knee Injury and Osteoarthritis Outcome subscores than the previous focal cartilage patients with a mean adjusted difference (95% confidence interval in parentheses): Symptoms 8.4 (0.3, 16.4), Pain 11.8 (2.2, 21.4), Activities of daily living (ADL) 9.3 (-1.2, 18.6), Sport and recreation 8.9 (-1.6, 19.4) and Quality of Life (QoL) 10.6 (0.2, 21.1). The control group also demonstrated higher odds of reaching the patient-acceptable symptom state threshold for the Knee Injury and Osteoarthritis Outcome subscores with odds ratio: Symptoms 2.7 (1.2, 6.4), Pain 3.0 (1.3, 7.0), ADL 2.1 (0.9, 4.6) and QoL 2.4 (1.0, 5.5).

CONCLUSION

Previous cartilage surgery was associated with inferior patient-reported outcomes after knee arthroplasty. These patients also exhibited significantly lower odds of reaching the patient-acceptable symptom state threshold for the Knee Injury and Osteoarthritis Outcome subscores.

LEVEL OF EVIDENCE

Level III.

Exercise- and education-based prehabilitation before total knee arthroplasty: a pilot study

OBJECTIVE

To determine the feasibility and estimates of effects of a supervised exercise- and education-based prehabilitation programme aiming to improve knee functioning compared with usual care in patients awaiting total knee arthroplasty.

DESIGN

A randomized controlled pilot study.

SUBJECTS

Patients receiving primary, unilateral total knee arthroplasty.

METHODS

Patients randomized to the intervention group participated in a personalized 4-8-week prehabilitation programme before surgery. Feasibility of the intervention and self-reported knee functioning, pain, physical performance and hospital stay were assessed at baseline, immediately preoperatively, 6 and 12 weeks after surgery.

RESULTS

Twenty patients (mean age 72.7±5.95 years) were enrolled in this study. The personalized prehabilitation programme was found to be feasible and safe, with an exercise adherence of 90%. Significant medium interaction effects between groups and over time favouring prehabilitation were reported for the sport subscale of the Knee Osteoarthritis Outcome Score (F(3/54) = 2.895, p = 0.043, η² = 0.139) and Tegner Activity Scale (F(2.2/39.1) = 3.20, p = 0.048, η² = 0.151).

CONCLUSION

The absence of adverse events and high adherence to the programme, coupled with beneficial changes shown in the intervention group, support the conduct of a full-scale trial investigating the effectiveness of prehabilitation.

Factors associated with pain and functional impairment five years after total knee arthroplasty: a prospective observational study

BACKGROUND

Few studies have evaluated the associations between preoperative factors and pain and physical function outcomes after total knee arthroplasty (TKA) from a mid-term perspective. Identification of such factors is important for optimizing outcomes following surgery. Thus, we examined the associations between selected preoperative factors and moderate to severe pain and pain-related functional impairment as measured using the Brief Pain Inventory (BPI), five years after TKA in patients with knee osteoarthritis.

METHODS

In this prospective observational study, all patients scheduled for primary unilateral TKA for osteoarthritis were consecutively recruited. Preoperative factors identified from previous meta-analyses were included to assess their associations with pain severity and pain-related functional impairment five years after TKA. Pain severity was the primary outcome, while pain-related functional impairment was the secondary outcome. The BPI was used to evaluate outcomes five years post-TKA. Statistically significant factors from univariate regressions were entered into a multiple logistic regression model to identify those with the strongest associations with pain severity or pain-related functional impairment five years after TKA.

RESULTS

A total of 136 patients were included, with a mean age of 67.7 years (SD 9.2) and a majority being female (68%). More severe preoperative pain (OR = 1.34, 95% CI [1.03 to 1.74]), more painful sites (OR = 1.28., 95% CI [1.01 to 1.63]), and more severe anxiety symptoms (OR = 1.14., 95% CI [1.01 to 1.28]) were associated with increased likelihood of moderate to severe pain five years after TKA surgery, while more severe osteoarthritis (OR = 0.13, 95% CI [0.03 to 0.61]) was associated with reduced likelihood of moderate to severe pain five years after TKA. More severe anxiety symptoms (OR = 1.25, 95% CI [1.08 to 1.46]) were also associated with increased likelihood of moderate to severe pain-related functional impairment five years after surgery, while male sex (OR = 0.23, 95% CI [0.05 to 0.98]) was associated with reduced likelihood of pain-related functional impairment five years after surgery.

CONCLUSION

The identified preoperative factors should be included in larger prognostic studies evaluating the associations between preoperative factors and mid-term pain severity and physical function outcomes after TKA surgery.

Construction and Validation of Machine Learning Algorithms to Predict Chronic Post-Surgical Pain Among Patients Undergoing Total Knee Arthroplasty

BACKGROUND

Chronic post-surgical pain (CPSP) is a common but undertreated condition with a high prevalence among patients undergoing total knee arthroplasty (TKA). An effective model for CPSP prediction has not been established yet.

AIMS

To construct and validate machine learning models for the early prediction of CPSP among patients undergoing TKA.

DESIGN

A prospective cohort study.

PARTICIPANTS/SUBJECTS

A total of 320 patients in the modeling group and 150 patients in the validation group were recruited from two independent hospitals between December 2021 and July 2022. They were followed up for 6 months to determine the outcomes of CPSP through telephone interviews.

METHODS

Four machine learning algorithms were developed through 10-fold cross-validation for five times. In the validation group, the discrimination and calibration of the machine learning algorithms were compared by the logistic regression model. The importance of the variables in the best model identified was ranked.

RESULTS

The incidence of CPSP in the modeling group was 25.3%, and that in the validation group was 27.6%. Compared with other models, the random forest model achieved the best performance with the highest C-statistic of 0.897 and the lowest Brier score of 0.119 in the validation group. The top three important factors for predicting CPSP were knee joint function, fear of movement, and pain at rest in the baseline.

CONCLUSIONS

The random forest model demonstrated good discrimination and calibration capacity for identifying patients undergoing TKA at high risk for CPSP. Clinical nurses would screen out high-risk patients for CPSP by using the risk factors identified in the random forest model, and efficiently distribute preventive strategy.

The efficacy and safety of telerehabilitation for patients following total knee arthroplasty: a overviews of systematic reviews

BACKGROUND

Studies evaluating the effectiveness and safety of telerehabilitation in patients undergoing total knee arthroplasty (TKA) have increased. However, the study quality and results differ, systematic reviews are limited. We aimed to synthesise systematic reviews and meta-analyses to assess the effects of telerehabilitation in patients post-TKA.

MATERIALS AND METHODS

Systematic reviews and meta-analyses regarding the effectiveness and safety of TKA telerehabilitation were retrieved from eight databases from establishment to 18 December 2022. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2), Risk of Bias in Systematic Reviews (ROBIS) and GRADE system were used to evaluate results, methods, bias and evidence quality.

RESULTS

Thirteen systematic reviews and meta-analyses were analysed. The AMSTAR 2 showed low methodological quality in seven studies and very low quality in six. Among the key items, item 2 had been registered on website before systematic review in four reviews. Concerning item 4, did not provide a comprehensive search strategy in 4 reviews. For item 7, none of the reviews provided a list of reasons for excluding an article. For item 9, regarding whether appropriate tools were used to assess the risk of bias of each included study, one review was assessed as 'partially yes', one review only included RCTs, and the remainder were assessed as 'yes'. For item 11, one review did not specify the statistical methods used, and three reviews did not conduct a meta-analysis. For item 13, four reviews considered the risk of bias when interpreting or discussing the study results. For item 15, seven reviews did not evaluate publication bias. The PRISMA scores of the 13 reviews ranged from 17.5 to 26.0. The PRISMA indicated that 69.2% had no protocol registration, 38.5% did not provide other materials and evidence certainty, 23.1% did not provide certainty assessment, 30.8% did not report study bias. According to the ROBIS scale, diferrent domains have diferrent risks in all the reviews.

CONCLUSION

Telerehabilitation positively affects walking ability, knee extension and patient costs post-TKA surgery. Regarding the quality of life, patient satisfaction and the WOMAC, telerehabilitation had similar effects to conventional rehabilitation. Owing to the low quality of the studies, these conclusions should be interpreted cautiously, high-quality studies are needed in the future.

Only 1% of Total Knee Arthroplasty Clinical Trials Report Patient Opioid Use Before or After Surgery: A Systematic Review

OBJECTIVES

Many clinical trials report significant improvements in osteoarthritis-related pain and function after total knee arthroplasty (TKA). Opioids are commonly prescribed for pain management of knee osteoarthritis and also perioperative pain after surgery. The extent of persistent opioid use after TKA is unknown. Because up to 20% of individuals have poor outcomes after TKA and prior opioid use is a risk factor for future opioid use, treatment effects from TKA clinical trials would be better understood by assessing opioid use data from trial participants. The purpose of this review was to determine the proportion of participants in TKA trials with opioid use before surgery and persistent use after surgery and how well clinical trials capture and report these variables.

MATERIALS AND METHODS

A systematic review of the literature (5 databases: CINAHL Cochrane CENTRAL, Embase, PubMed, and Web of Science) was conducted to assess the reporting of opioid use in TKA clinical trials. All opioid use was extracted, both prior and postoperatively. Long-term opioid use was determined using 4 different contemporary definitions to increase the sensitivity of the assessment.

RESULTS

The search produced 24,252 titles and abstracts, and 324 met the final inclusion criteria. Only 4 of the 324 trials (1.2%) reported any type of opioid use; 1 identified prior opioid use, and none reported long-term opioid use after surgery. Only 1% of TKA clinical trials in the past 15 years reported any opioid use.

DISCUSSION

Based on available research, it is not possible to determine if TKA is effective in reducing reliance on opioids for pain management. It also highlights the need to better track and report prior and long-term opioid use as a core outcome in future TKA trials.

What can we expect from patellar denervation in knee arthroplasty? An updated systematic review and meta-analysis

Denervation by electrocauterization was proposed to be efficient in preventing anterior knee pain (AKP) following arthroplasty. The purpose of this study was to evaluate the effects of patellar denervation (PD) in primary knee arthroplasty. Systematic search was performed in PubMed, ScienceDirect, Cochrane Library, and ClinicalKey databases until July 2022 for published articles. The quantitative analyses were carried out by Review Manager 5.4 software. Twenty-one studies were included. Overall incidence of AKP, visual analog scale (VAS), and knee society score were significantly superior in PD group. Denervation also showed better outcomes in incidence of AKP at each follow-up time point, and in VAS and range of motion (ROM) at ≤3 months. Subanalyses based on depth of electrocautery showed statistically better results with 2–3 mm depth in VAS and PS compared to ≤1 mm. This study concluded that PD might contribute to lower incidence of knee pain. Patients who expect quicker recovery in pain and ROM may benefit from this procedure.

Professional continuous glucose monitoring in patients with diabetes mellitus: A systematic review and meta-analysis

AIM

To evaluate the effect on glucose control of professional continuous glucose monitoring (p-CGM)-based care as compared with standard care in the management of patients with type 1 and type 2 diabetes.

MATERIALS AND METHODS

The PubMed database was searched comprehensively to identify prospective or retrospective studies evaluating p-CGM as a diagnostic tool for subsequent implementation of lifestyle and/or medication changes and reporting glycated haemoglobin (HbA1c) as an outcome measure.

RESULTS

We found 872 articles, 22 of which were included in the meta-analysis. Overall, the use of p-CGM was associated with greater HbA1c reduction from baseline (-0.28%, 95% confidence interval [CI] -0.36% to -0.21%, I²  = 0%, P < 0.00001) than usual care, irrespective of type of diabetes, length of follow-up, frequency of continuous glucose monitoring (CGM) use and duration of CGM recording. In the few studies describing CGM-derived glucose metrics, p-CGM showed a beneficial effect on change in time in range from baseline (5.59%, 95% CI 0.12 to 11.06, I²  = 0%, P = 0.05) and a neutral effect on change in time below the target range from baseline (-0.11%, 95% CI -1.76% to 1.55%, I²  = 33%, P = 0.90).

CONCLUSIONS

In patients with type 1 and type 2 diabetes, p-CGM-driven care is superior to usual care in improving glucose control without increasing hypoglycaemia.

Effects of psychological distress on the general health to self-reported pain and function outcome relationship in knee arthroplasty: A causal mediation study

Objectives

We examined two potential causal pathways that could be intervention targets to enhance knee arthroplasty outcomes. Data from a no-effect trial of persons with moderate to high pain catastrophizing were used to determined whether pain catastrophizing, depressive symptoms causally mediate the effect of preoperative general health on postoperative knee pain and functional difficulty.

Methods

We used natural-effects models to conduct causal mediation analyses using the preoperative dichotomized EQ-5D-5L general health measure as the exposure, 2-month postoperative pain catastrophizing, depressive symptoms, and localized knee pain as potential mediators, and 12-month dichotomized Western Ontario and McMaster's University Osteoarthritis Index (WOMAC) Pain and Function scores reflecting good versus poor outcome as the outcomes.

Results

Estimates of the indirect (mediating) effect suggested that pain catastrophizing mediated the effect of preoperative general health on 12-month WOMAC pain score by increasing odds of a good outcome by 8% (natural indirect effect odds ratio ​= ​1.08, 95% CI: 0.88, 1.29). The direction of mediating effects and their magnitude were similar for depressive symptoms; Sensitivity analyses suggested similar magnitudes and mediating effects to those reported for the main analyses.

Conclusions

Our findings suggested that pain catastrophizing and depressive symptoms have a mediating role on the effect of baseline general health on self-reported pain and function outcomes. These findings support the continued treatment of pain catastrophizing and depressive symptoms as viable targets for interventions to potentially enhance pain and function outcomes for patients with moderate to high levels of psychological distress prior to surgery.