Knee Replacement Surgery Evaluating Rehabilitation Management Strategies Dr Marlene Fransen

Knee Replacement SurgeryEvaluating Rehabilitation Management Strategies

Dr Marlene Fransen

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

Outline of Presentation

> Epidemiology> Outcomes> Current rehabilitation regimes > Implications for private health insurance> Research proposal

Epidemiology: arthritis

> No.1 health problem older Australians

> Aging population> Obese population> No cure> Main diagnosis for TKR

Epidemiology: knee replacements

Year 2003-2004

> Total: 29,899> Private hospital: 20,022

Epidemiology: knee replacements

Private hospitals

> 1998-1999: 9,957> 2003-2004: 20,022> 2008-2009: ?

Epidemiology: aging population

2001

2031

Epidemiology

> Increasing surgeon confidence in technology

> Emerging ‘baby boomer’ cohort > < 65 years at surgery

> 2000: 25%> 2003: 30%> 2006: ?

Outcomes

Most patients benefit from TKR.

Younger patients…> Greater proportion dissatisfied with results> Revision rates markedly higher > Implant survival particularly poor in obese,

males

Outcomes

Why the difference in outcome?> Continued shortfall in lower limb muscle

strength.> Reduced ligamentous constraints. > Higher physical demands.> Longer risk exposure.

Current rehabilitation practice

Diversity> Inpatient, outpatient, home visits

Consistency> Routine ongoing referral> Mostly 1:1 provision> Mostly completed within 8 weeks of surgery

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

Implications for private health insurance

Supporting costly programs

with no evidence of:> benefit> need for 1:1 treatments> usefulness of early treatment

Research Aim

Determine effectiveness and

cost-effectiveness of ‘shifting’

outpatient rehabilitation

following TKR.

Proposed ResearchManagement

Committee

Ranndomisation Data Management

Orthopaedic CentreTKR

Standard acute care


Standard acute care

Class-based Rehabilitation

2 months


Standard acute care


Standard acute care

Standard careClass-based Rehabilitation

2 months


2 months


2 months

Standard care

6 monthsPain

FunctionHealth services

6 monthsPain


6 monthsPain


6 monthsPain


6 monthsPain


6 monthsPain


6 monthsPain


6 monthsPain


12 monthsPain


12 monthsPain


12 monthsPain


12 monthsPain


12 monthsPain


12 monthsPain


12 monthsPain


12 monthsPain


Collaborators

Orthopaedic surgeons

Physiotherapists

Rheumatologists

Clinical trials

Epidemiologists

Health economist

Biostatisticians

Randomisation centre

Data management

Project management

Patient advocate

12 large hospitals

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

Current Research

Risk of EBF

Clinical outcomes 6-12 months after surgery

Bleeding events during admission period andprolonged hospitalisation

Recommendations

Current ResearchGlucosamine studyRCT900 patients Early OA knee 1500mg GS/placeboTwo yearsMain outcomes

> Pain, function> Joint space

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

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Knee Replacement Surgery Evaluating Rehabilitation Management Strategies Dr Marlene Fransen