The past and future of peri-operative interventions to reduce arthrogenic quadriceps muscle inhibition after total knee arthroplasty: A narrative review.

Total knee arthroplasty (TKA) improves patient-reported function by alleviating joint pain, however the surgical trauma exacerbates already impaired muscle function, which leads to further muscle weakness and disability after surgery. This early postoperative strength loss indicates a massive neural inhibition and is primarily driven by a deficit in quadriceps muscle activation, a process known as arthrogenic muscle inhibition (AMI). To enhance acute recovery of quadriceps muscle function and long-term rehabilitation of individuals after TKA, AMI must be significantly reduced in the early post-operative period. The aim of this narrative review is to review and discuss previous efforts to mitigate AMI after TKA and to suggest new approaches and interventions for future efficacy evaluation. Several strategies have been explored to reduce the degree of post-operative quadriceps AMI and improve strength recovery after TKA by targeting post-operative swelling and inflammation or changing neural discharge. A challenge of this work is the ability to directly measure AMI and relevant contributing factors. For this review we focused on interventions that aimed to reduce post-operative swelling or improve knee extension strength or quadriceps muscle activation measured by twitch interpolation. For individuals undergoing TKA, the use of anti-inflammatory medications, tranexamic acid, cryotherapy, intra-articular drains, torniquets, and minimally invasive surgical techniques for TKA have limited benefit in attenuating quadriceps AMI early after surgery. However, interventions such as inelastic compression garments, voluntary muscle contractions, and neuro-muscular electrical stimulation show promise in mitigating or circumventing AMI and should continue to be refined and explored.

Expert Consensus for the Use of Outpatient Rehabilitation Visits After Total Knee Arthroplasty: A Delphi Study.

OBJECTIVE: There is no consensus for how to use rehabilitation visits after total knee arthroplasty (TKA). We sought to develop expert recommendations for outpatient rehabilitation visit usage after TKA. DESIGN: Delphi study. METHODS: First, we developed a broad list of preliminary visit usage recommendations, which were specific to patients' recovery status (ie, slow, typical, or fast recovery) and time since surgery. We then invited 49 TKA experts to participate on a Delphi panel. During round 1, we surveyed panelists regarding their level of agreement with each preliminary recommendation. We conducted additional Delphi rounds as needed to build consensus, which we defined using the RAND/UCLA method. We updated the survey each round based on panelist feedback and responses from the previous round. RESULTS: Thirty panelists agreed to participate, and 29 panelists completed 2 Delphi rounds. The panel reached consensus on recommendations related to visit frequency, visit timing, and the use of telerehabilitation. The panel recommended that outpatient rehabilitation should begin within 1 week after surgery at a frequency of 2 times per week for the first postoperative month regardless of recovery status. The panel recommended different visit frequencies depending on the patient's recovery status for postoperative months 2 to 3. The panel agreed that telerehabilitation can be recommended for most patients after TKA, but not for patients recovering slowly. CONCLUSION: We used the Delphi process to develop expert recommendations for the use of outpatient rehabilitation visits after TKA. We envision these recommendations could help patients decide how to use visits based on their own preferences. J Orthop Sports Phys Ther 2023;53(9):1-9. Epub: 10 July 2023. doi:10.2519/jospt.2023.11840.

A scoping review of postoperative return to sport criteria and protocols for patients with femoroacetabular impingement syndrome.

PURPOSE: To identify the objective criteria and guidelines utilized to determine if patients diagnosed with FAIS can safely return to sport following hip arthroscopy. METHODS: The electronic databases MEDLINE Ovid, EMBASE Ovid, and CINAHL were searched to identify eligible studies. Details of study design, sample size, primary diagnosis, and return to sport protocol, duration, and rate were collected by two reviewers, independently. RESULTS: Sixty-two studies were selected for full text review of which 14 were included in the final analysis. Of these, nine were clinical commentaries and five were retrospective cohort studies. Three types of rehabilitation guidelines are currently utilized postoperatively: 4-phase, 5-phase, and 6-phase protocols. Although all 14 studies recommend using various types of outcome measures to evaluate a patient's ability to return to sport, only eleven outlined the specific outcome criteria they must achieve to do so. The most utilized outcome measures are the hip outcome score, active and passive range of motion tests, gait analysis, single- and double-leg squat tests, and the Vail hip sports test. Criteria across all three types of protocols was variable, but they all evaluated the same international classification of disability and function constructs described by the World Health Organization: body function, body structure limitations, and activity capacity limitations. CONCLUSIONS: There is no consensus on the optimal methods of evaluating a patient's readiness to return to sport after undergoing hip arthroscopy, with most criteria focused on expert opinion. Performance-based return to sport outcome criteria is not clearly defined, and validated outcome measures are not being used for FAIS patients post hip arthroscopy. Lastly, well-conducted prospective cohort studies using validated outcome measures and objective definitions of return to sport are needed to consistently identify signs that are prognostic of safe return to sport.

Cost and safety of inpatient versus outpatient open reduction internal fixation of isolated ankle fractures.

BACKGROUND: As health care shifts to value-based models, one strategy within orthopedics has been to transition appropriate cases to outpatient or ambulatory settings to reduce costs; however, there are limited data on the efficacy and safety of this practice for isolated ankle fractures. The purpose of this study was to compare the cost and safety associated with inpatient versus outpatient ankle open reduction internal fixation (ORIF). METHODS: All patients who underwent ORIF of isolated closed ankle fractures at 2 affiliated hospitals between April 2016 and March 2017 were identified retrospectively. Demographic characteristics, including age, gender, comorbidities and injuryspecific variables, were collected. We grouped patients based on whether they underwent ankle ORIF as an inpatient or outpatient. We determined case costing for all patients and analyzed it using multivariate regression analysis. RESULTS: A total of 196 patients (125 inpatient, 71 outpatient) were included for analysis. Inpatients had a significantly longer mean length of stay than outpatients (54.3 h [standard deviation (SD) 36.3 h] v. 7.5 h [SD 1.7 h], p < 0.001). The average cost was significantly higher for the inpatient cohort than the outpatient cohort ($4137 [SD $2285] v. $1834 [SD $421], p < 0.001). There were more unimalleolar ankle fractures in the outpatient group than in the inpatient group (42 [59.2%] v. 41 [32.8%], p < 0.001). Outpatients waited longer for surgery than inpatients (9.6 d [SD 5.6 d] v. 2.0 d [SD 3.3 d], p < 0.001). Fourteen patients (11.2%) in the inpatient group presented to the emergency department or were readmitted to hospital within 30 days of discharge, compared to 5 (7.0%) in the outpatient group (p = 0.3). CONCLUSION: In the treatment of isolated closed ankle fractures, outpatient surgery was associated with a significant reduction in length of hospital stay and overall case cost compared to inpatient surgery, with no significant difference in readmission or reoperation rates. In medically appropriate patients, isolated ankle ORIF can be performed safely in an ambulatory setting and is associated with significant cost savings.

A qualitative dominant mixed methods exploration of novel educational material for patients considering total knee arthroplasty.

PURPOSE: To optimize non-operative management and decision making surrounding TKR we created educational whiteboard videos for patients with knee OA. The purpose of this study was to pilot our educational videos with end-users (patients) to determine patients' experiences and perspectives regarding the content and clarity of videos and to better understand their potential impact on patient's health behaviour. MATERIALS AND METHODS: This was a mixed methods evaluation, using a qualitative descriptive approach, of patients attending their first consultation with an arthroplasty surgeon for TKR. We conducted in-depth semi-structured interviews with patients. Three members of the research team coded data independently, implementing a thematic analysis. RESULTS: Thirteen participants were included. Participants indicated that the videos enhanced their confidence and clarity surrounding their decision to undergo TKR. The videos also addressed several knowledge gaps in their understanding of OA management. Barriers to uptake of the education were identified including limited access to PTs and the challenge of weight loss. Conclusions: The current educational intervention was valued by patients with knee OA. Implementation of these videos may have important implications for patients, providers, and our health care system.IMPLICATIONS FOR REHABILITATIONPatients with knee OA referred by primary care physicians to arthroplasty surgeons have knowledge gaps that may influence their self-management and decision making surrounding their condition.Educational materials can address these gaps and support patients in their understanding and management of their condition, which may have important downstream implications.Barriers to accessing non-operative care including physiotherapy must be pre-emptively addressed to ensure that enhanced knowledge is met with improved access for patients.

Wait times, resource use and health-related quality of life across the continuum of care for patients referred for total knee replacement surgery.

Background: The escalating socioeconomic burden of knee osteoarthritis (OA) underscores the need for innovative strategies to reduce wait times for total knee arthroplasty (TKA). The purpose of this study was to evaluate resource use, costs and health-related quality of life (HRQoL) across the continuum of care for patients with knee OA. Methods: This was a prospective study of 383 patients recruited from a high-volume teaching hospital at different stages of care (referral, consultation and presurgery). Outcomes included health care resource use; costs captured from the health care payer, private sector and societal perspectives; HRQoL measured using the Western Ontario and McMaster Universities Osteoarthritis Index, the 12-Item Short Form Health Survey, and EuroQoL 5-Dimension 5-Level tool; wait times; and the proportion of referrals deemed suitable candidates for surgery. Results: The most commonly used conservative treatments were pharmacotherapy, exercise and lifestyle modification. Forty percent of patients referred for TKA were deemed not to be suitable candidates for surgery. The greatest proportion of costs was borne by the patient or private insurer; a small proportion was borne by the public payer. Across all stages of care, more than 60% of the total costs was attributed to productivity losses. HRQoL remained relatively stable throughout the waiting period (mean wait time from referral to TKA 13.2 mo) but improved postoperatively. Conclusion: The suboptimal primary care management of knee OA calls for the development of innovative models of care. This study may provide valuable guidance on the design and implementation of a new online educational platform to improve referral efficiency and expedite wait times for TKA.

Contexte: Le fardeau socioéconomique croissant de l'arthrose du genou rappelle que nous avons besoin de stratégies novatrices afin de réduire les temps d'attente pour l'arthroplastie totale du genou (ATG). Le but de cette étude est d'évaluer l'utilisation des ressources, les coûts et la qualité de vie liée à la santé (QVLS) dans tout le continuum des soins pour les patients souffrant d'arthrose du genou. Méthodes: Cette étude prospective a porté sur 383 patients recrutés dans un établissement d'enseignement fort achalandé, qui en étaient à différentes étapes du continuum de soins (demande de consultation, consultation et préchirurgie). Les paramètres incluaient l'utilisation des ressources en santé, les coûts du point de vue sociétal et des régimes d'assurance maladie publics et privés, la QVLS mesurée au moyen de l'indice WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), du questionnaire Short Form Health Survey en 12 points et de l'outil EuroQoL appliqué à 5 dimensions et à 5 niveaux, les temps d'attente, et la proportion de demandes de consultation concernant des patients considérés comme de bons candidats à la chirurgie. Résultats: Les traitements conservateurs les plus utilisés étaient la pharmacothérapie, l'exercice et les modifications à l'hygiène de vie. Quarante pour cent des patients adressés en consultation pour ATG ont été considérés comme de bons candidats à la chirurgie. La plus grande part des coûts a été assumée par le patient ou un assureur privé; une faible part des coûts a été assumée par le régime public. À toutes les étapes du continuum, plus de 60 % des coûts totaux ont été attribués à des pertes de productivité. La QVLS est demeurée relativement stable tout au long de la période d'attente (temps d'attente moyen entre la consultation et l'ATG, 13,2 mois) mais s'est améliorée après la chirurgie. Conclusion: La prise en charge sous-optimale de l'arthrose du genou en soins primaires rappelle qu'il est nécessaire d'établir des modèles de soins novateurs. Cette étude pourrait faciliter la mise au point et l'application d'une nouvelle plateforme éducative en ligne pour améliorer l'efficience des demandes de consultation et abréger les temps d'attente pour l'ATG.

Optimizing outpatient total hip arthroplasty: perspectives of key stakeholders.

BACKGROUND: Advances in surgical techniques combined with multimodal analgesia and early rehabilitation have potentiated early mobilization in patients undergoing total hip arthroplasty (THA). Given an increasing push from patients to accelerate recovery and health care budgetary limitations, there has been growing interest in the implementation of outpatient THA in selected patients. Understanding the patient and primary caregiver experience of outpatient THA is important to optimize care. We aimed to gain insight into patient and caregiver perspectives regarding the perceived advantages and disadvantages of same-day discharge to identify areas of care that can be improved. METHOD: Using a qualitative descriptive approach, we conducted in-depth semistructured interviews with patient-primary caregiver dyads who experienced same-day discharge or standard care after primary THA with the direct anterior approach in 2016-2017. Two members of the research team coded the data independently, implementing a thematic and content analysis. RESULTS: Twenty-eight participants (16 same-day discharge, 12 standard care) were included. Both groups experienced high levels of satisfaction with their care pathway. Concerns and challenges identified in both groups pertained to mobility, pain, self-care and caregiver support. Challenges and concerns unique to same-day discharge were identified regarding expectations for recovery, medications and their impact on mobility, the timing of postoperative education and the availability of formal care. CONCLUSION: Outpatient THA can be implemented with high patient and caregiver satisfaction. Preoperative education, clarification of recovery processes and expectations, and proactively addressing concerns related to caregiving are important.

CONTEXTE: Les progrès des techniques chirurgicales, alliés à l'analgésie multimodale et à la réadaptation hâtive, ont potentialisé la mobilisation précoce des patients soumis à une intervention pour prothèse totale de la hanche (PTH). Compte tenu de la pression croissante venant des patients pour accélérer leur rétablissement et des contraintes budgétaires en santé, on s'intéresse de plus en plus à la PTH effectuée en externe chez certains patients. Pour optimiser les soins, il est important de comprendre l'expérience des patients et de leurs proches aidants relativement à la PTH effectuée en externe. Nous avons voulu cerner les points de vue des patients et des proches aidants au sujet des avantages et inconvénients perçus du congé le jour même, afin de déterminer quels éléments des soins gagneraient à être améliorés. MÉTHODES: À l'aide d'une approche qualitative descriptive, nous avons procédé à des entrevues semi-structurées approfondies avec des paires patients-proches aidants à qui on a offert soit le congé le jour même, soit les soins standards après une PTH primaire par approche antérieure directe en 2016-2017. Deux membres de l'équipe de recherche ont codé les données indépendamment, en procédant à une analyse par thèmes et par contenu. RÉSULTATS: Vingt-huit participants (16 ayant reçu leur congé le jour même et 12 soumis aux soins standards) ont été inclus. Les 2 groupes ont exprimé un degré élevé de satisfaction à l'endroit du déroulement de leurs soins. Les problèmes et les difficultés identifiés dans les 2 groupes concernaient la mobilité, la douleur, les soins personnels et le soutien aux proches aidants. Les difficultés ou problèmes particuliers aux cas de congé le jour même ont été associés aux attentes concernant le rétablissement, les médicaments et leur impact sur la mobilité, le moment de l'enseignement postopératoire et la disponibilité des soins standards. CONCLUSION: La PTH en externe peut être offerte et générer beaucoup de satisfaction chez les patients et leurs aidants. Il est important d'offrir un enseignement préopératoire, de clarifier le processus de rétablissement et les attentes et de répondre de manière proactive aux préoccupations exprimées relativement aux soins.

The development and validation of a multivariable model to predict whether patients referred for total knee replacement are suitable surgical candidates at the time of initial consultation.

BACKGROUND: In previous studies, 50%-70% of patients referred to orthopedic surgeons for total knee replacement (TKR) were not surgical candidates at the time of initial assessment. The purpose of our study was to identify and cross-validate patient self-reported predictors of suitability for TKR and to determine the clinical utility of a predictive model to guide the timing and appropriateness of referral to a surgeon. METHODS: We assessed pre-consultation patient data as well as the surgeon's findings and post-consultation recommendations. We used multivariate logistic regression to detect self-reported items that could identify suitable surgical candidates. RESULTS: Patients' willingness to undergo surgery, higher rating of pain, greater physical function, previous intra-articular injections and patient age were the factors predictive of patients being offered and electing to undergo TKR. CONCLUSION: The application of the model developed in our study would effectively reduce the proportion of nonsurgical referrals by 25%, while identifying the vast majority of surgical candidates (> 90%). Using patient-reported information, we can correctly predict the outcome of specialist consultation for TKR in 70% of cases. To reduce long waits for first consultation with a surgeon, it may be possible to use these items to educate and guide referring clinicians and patients to understand when specialist consultation is the next step in managing the patient with severe osteoarthritis of the knee.

CONTEXTE: Dans des études précédentes, de 50 % à 70 % des patients dirigés vers des chirurgiens orthopédistes pour une arthroplastie totale du genou (ATG) n'étaient pas des candidats à la chirurgie au moment de l'évaluation initiale. Notre étude visait à recenser et à contrevalider les facteurs prédictifs de l'opportunité d'une ATG fondés sur des renseignements fournis par les patients, ainsi qu'à déterminer l'utilité clinique d'un modèle de prévision qui évaluerait le moment et la pertinence de diriger un patient vers un chirurgien. MÉTHODES: Nous avons évalué les données des patients préconsultation ainsi que les conclusions du chirurgien et ses recommandations postconsultation. Nous avons mené une analyse de régression logistique multivariée pour détecter les éléments autodéclarés qui permettraient de reconnaître les candidats pour la chirurgie. RÉSULTATS: Les facteurs permettant de prédire si un patient se ferait offrir une ATG et choisirait de subir l'intervention étaient la disposition favorable du patient à se faire opérer, une douleur d'intensité élevée, des capacités physiques fonctionnelles supérieures, des antécédents d'injections intra-articulaires et l'âge. CONCLUSION: Concrètement, l'application du modèle élaboré durant notre étude réduirait le nombre de patients dirigés vers un chirurgien sans motif valable dans une proportion de 25 %, tout en permettant de reconnaître la vaste majorité des candidats à la chirurgie (> 90 %). À partir des renseignements fournis par les patients, nous pouvons prédire correctement le résultat d'une consultation avec un spécialiste pour une ATG dans 70 % des cas. Les conclusions de notre étude pourraient servir à réduire les longs délais d'attente pour une première consultation avec un chirurgien en aidant les professionnels de la santé et les patients à déterminer quand il convient de consulter un spécialiste pour la prise en charge d'une gonarthrose grave.