Knee Replacement Surgery Evaluating 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 >Total: 29,899 >Private hospital: 20,022

Epidemiology: knee replacements Private hospitals > : 9,957 > : 20,022 > : ?

Epidemiology: aging population

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 Research Management Committee Ranndomisation Data Management Orthopaedic Centre TKR Standard acute care Class-based Rehabilitation 2 months 6 months Pain Function Health services 12 months Pain Function Health services Standard care 6 months Pain Function Health services 12 months Pain Function Health services Orthopaedic Centre TKR Standard acute care Class-based Rehabilitation 2 months 6 months Pain Function Health services 12 months Pain Function Health services Standard care 6 months Pain Function Health services 12 months Pain Function Health services Orthopaedic Centre TKR Standard acute care Class-based Rehabilitation 2 months 6 months Pain Function Health services 12 months Pain Function Health services Standard care 6 months Pain Function Health services 12 months Pain Function Health services Orthopaedic Centre TKR Standard acute care Class-based Rehabilitation 2 months 6 months Pain Function Health services 12 months Pain Function Health services Standard care 6 months Pain Function Health services 12 months Pain Function Health services

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 replacement with peri-operative NSAIDs RCT conducted amongst 902 patients in 20 orthopaedic 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 and prolonged hospitalisation Recommendations

Current Research Glucosamine study RCT 900 patients Early OA knee 1500mg GS/placebo Two years Main 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.