knee replacement surgery evaluating rehabilitation management strategies dr marlene fransen
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Knee Replacement SurgeryEvaluating Rehabilitation Management Strategies
Dr Marlene Fransen
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The George Institute
Mission Burden of non-communicable diseases and injury
Expertise Large scale clinical trials and observational
studies Track record in osteoarthritis and orthopaedic
surgery clinical research
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Outline of Presentation
> Epidemiology> Outcomes> Current rehabilitation regimes > Implications for private health insurance> Research proposal
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Epidemiology: arthritis
> No.1 health problem older Australians
> Aging population> Obese population> No cure> Main diagnosis for TKR
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Epidemiology: knee replacements
Year 2003-2004
> Total: 29,899> Private hospital: 20,022
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Epidemiology: knee replacements
Private hospitals
> 1998-1999: 9,957> 2003-2004: 20,022> 2008-2009: ?
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Epidemiology: aging population
2001
2031
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Epidemiology
> Increasing surgeon confidence in technology
> Emerging ‘baby boomer’ cohort > < 65 years at surgery
> 2000: 25%> 2003: 30%> 2006: ?
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Outcomes
Most patients benefit from TKR.
Younger patients…> Greater proportion dissatisfied with results> Revision rates markedly higher > Implant survival particularly poor in obese,
males
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Outcomes
Why the difference in outcome?> Continued shortfall in lower limb muscle
strength.> Reduced ligamentous constraints. > Higher physical demands.> Longer risk exposure.
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Current rehabilitation practice
Diversity> Inpatient, outpatient, home visits
Consistency> Routine ongoing referral> Mostly 1:1 provision> Mostly completed within 8 weeks of surgery
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Effectiveness of rehabilitation?
> Few randomised clinical trials (5)> Small studies (n<100)> Short term outcomes (3-6 months)> Inappropriate outcomes (ROM)> Most conclude no evidence of benefit
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Implications for private health insurance
Supporting costly programs
with no evidence of:> benefit> need for 1:1 treatments> usefulness of early treatment
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Research Aim
Determine effectiveness and
cost-effectiveness of ‘shifting’
outpatient rehabilitation
following TKR.
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Proposed ResearchManagement
Committee
Ranndomisation Data Management
Orthopaedic CentreTKR
Standard acute care
Orthopaedic CentreTKR
Standard acute care
Class-based Rehabilitation
2 months
Orthopaedic CentreTKR
Standard acute care
Orthopaedic CentreTKR
Standard acute care
Standard careClass-based Rehabilitation
2 months
Standard careClass-based Rehabilitation
2 months
Standard careClass-based Rehabilitation
2 months
Standard care
6 monthsPain
FunctionHealth services
6 monthsPain
FunctionHealth services
6 monthsPain
FunctionHealth services
6 monthsPain
FunctionHealth services
6 monthsPain
FunctionHealth services
6 monthsPain
FunctionHealth services
6 monthsPain
FunctionHealth services
6 monthsPain
FunctionHealth services
12 monthsPain
FunctionHealth services
12 monthsPain
FunctionHealth services
12 monthsPain
FunctionHealth services
12 monthsPain
FunctionHealth services
12 monthsPain
FunctionHealth services
12 monthsPain
FunctionHealth services
12 monthsPain
FunctionHealth services
12 monthsPain
FunctionHealth services
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Collaborators
Orthopaedic surgeons
Physiotherapists
Rheumatologists
Clinical trials
Epidemiologists
Health economist
Biostatisticians
Randomisation centre
Data management
Project management
Patient advocate
12 large hospitals
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Current Research
Prevention of chronic ectopic bone-related pain and disability after total hip replacementwith peri-operative NSAIDs
RCT conducted amongst 902 patients in 20orthopaedic centres in Australia and NZ .
Funded: NH&MRC and MBF
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Current Research
Risk of EBF
Clinical outcomes 6-12 months after surgery
Bleeding events during admission period andprolonged hospitalisation
Recommendations
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Current ResearchGlucosamine studyRCT900 patients Early OA knee 1500mg GS/placeboTwo yearsMain outcomes
> Pain, function> Joint space
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Conclusion
There is no convincing evidence for the
effectiveness of rehabilitation after TKR. The costs for post-acute care are likely to
be substantial and will increase rapidly. Research is urgently required to develop
cost-effective rehabilitation regimes.
www.thegeorgeinstitute.org