OBJECTIVE: To explore and gain more insight into the usual preoperative and postoperative physical therapy (PT) treatment of patients with a total knee arthroplasty (TKA) among Dutch physical therapists experienced with TKA rehabilitation. Secondly, to evaluate physical therapists\' adherence to guideline recommendations for postoperative rehabilitation.
METHODS: In this cross-sectional study, physical therapists working in primary care within a designated Dutch hospital\'s catchment area were surveyed online. The survey queried PT treatment approaches before surgery, during hospitalisation, and after surgery. All data were analysed descriptively. When both education and all recommended exercise modalities were used postoperatively, therapists were considered fully adherent with the Dutch clinical practice guideline.
RESULTS: One hundred and three therapists participated, representing a response rate of 58%. Postoperative PT treatment was applied by all therapists, of which 65 (63.1%) were fully adherent to the guideline. Partial adherence was mainly due to not using the aerobic exercise modality. Furthermore, beyond the modalities recommended in the guideline, a range of PT interventions were used. Preoperative treatment was applied by 73 therapists (70.9%). These 73 indicated that only a median of 20% (IQR 10%-40%) of their patients received preoperative PT.
CONCLUSIONS: This study revealed satisfactory adherence to guideline recommendations on postoperative management of patients with a TKA among experienced physical therapists. Aerobic exercises were utilised less often or with inappropriate intensity. Correct adherence to guideline recommendations on aerobic exercise training can result in more physically active individuals and important general health benefits.

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.

In 2013, the American Association of Hip and Knee Surgeons tasked a workgroup to provide obesity-related recommendations in total joint arthroplasty and determined that patients who had body mass index (BMI) ≥ 40 seeking hip/knee arthroplasty were at increased perioperative risk and recommended preoperative weight reduction. Few studies have shown the actual results of instituting this; therefore, we reported the effect of instituting a BMI < 40 threshold in 2014 on our elective, primary total knee arthroplasties (TKAs).
We queried an institutional database to select all TKAs conducted from January 2010 to May 2020. There were 2,514 TKA pre-2014 and 5,545 TKA post-2014 that were identified. The 90-day emergency department (ED) visits, readmissions, and returns-to-operating room (OR) outcomes were identified. Patients were propensity score weight-matched as per comorbidities, age, initial surgical consultation (consult) BMI, and sex. We conducted 3 outcome comparisons: (1) pre-2014 patients who had a consult and surgical BMI ≥ 40 against post-2014 patients who had a consult BMI ≥ 40 and surgical BMI < 40; (2) pre-2014 patients against post-2014 patients who had a consult and surgical BMI < 40; (3) post-2014 patients who had a consult BMI ≥ 40 and surgical BMI < 40 against post-2014 patients who had a consult BMI ≥ 40 and surgical BMI ≥ 40.
Pre-2014 patients who had a consult and surgical BMI ≥ 40 had more ED visits (12.5% versus 6%, P = .002) but similar readmissions and returns-to-OR than post-2014 patients who had a consult BMI ≥ 40 and surgical BMI < 40. Pre-2014 patients who had a consult and surgical BMI < 40 had more readmissions (8.8% versus 6%, P < .0001) but similar ED visits and returns-to-OR when compared to their post-2014 counterparts. Post-2014 patients who had a consult BMI ≥ 40 and surgical BMI < 40 had fewer ED visits (5.8% versus 10.6%) but similar readmissions and returns-to-OR than patients who had a consult BMI ≥ 40 and surgical BMI ≥ 40.
Patient optimization prior to total joint arthroplasty is essential. Enacting BMI reduction pathways prior to total knee arthroplasty seems to afford morbidly obese patients major risk mitigation. We must continue to ethically balance the pathology, expected improvement after surgery, and the overall risks of complications for each patient.
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Recent guidelines have produced a consensus statement for perioperative care in hip and knee replacement. However, there is still a need for reanalysis of the evidence and recommendations. Therefore, we retrieved and reanalyzed the evidence of each recommended components of enhanced recovery after surgery (ERAS) based on the guidelines of total joint arthroplasty. For each one, we included for the highest levels of evidence and those systematic reviews and meta-analyses were preferred. The full texts were analyzed and the evidence of all components were summarized. We found that most of the recommended components of ERAS are supported by evidence, however, the implementation details of each recommended components need to be further optimized. Therefore, implementation of a full ERAS program may maximize the benefits of our clinical practice but this combined effect still needs to be further determined.

OBJECTIVE: To describe the application and examine the influence of a continuous quality improvement intervention, which had a goal of standardizing care to reduce the proportion of patients who do not have a meaningful improvement in patient-reported outcomes following total knee arthroplasty (TKA). DESIGN: Continuous quality improvement. METHODS: A physical therapy (PT) care guideline was initiated in 2013 for patients following TKA. The Knee Outcome Survey - Activities of Daily Living (KOS-ADL) was measured at every visit, and scores were extracted from a clinical outcomes database to calculate the proportion of patients who did not achieve a minimal clinically important difference. Based on logistic regression analysis, we compared the proportion of patients who did not progress on the KOS-ADL in a non-care guideline group (2008-2012) to a care guideline (CG) group (2014-2019). RESULTS: This study included 12 355 patients (aged 18-92 years) following TKA incurring at least 3 PT visits from 2008 to 2019. The percentage of patients who did not progress in the non-care guideline group was 25.8% and in the care guideline group 14.3% (P<0.001). The relationship between care guideline adherence and lack of progression on the KOS-ADL was statistically significant, X2 (df = 1) = 148.7, P<.001. CONCLUSION: The percentage of patients who did not achieve meaningful progress on the KOS-ADL declined significantly in the 6 years after implementing a TKA care guideline without an increase in the number of clinical visits. The standardized care guideline was associated with meaningful improvements for patients following TKA when applied in conjunction with PT access to outcome data, feedback through audits, performance goals, and financial incentives. J Orthop Sports Phys Ther 2023;53(3):143-150. Epub: 12 December 2022. doi:10.2519/jospt.2022.11369.

BACKGROUND: Surgical site infection (SSI) and venous thromboembolism (VTE) are associated with high burden and cost and are considered largely preventable following total knee or hip arthroplasty (TKA, THA). The risk of developing VTE and SSI is reduced when prophylaxis is compliant with evidence-based clinical guidelines. However, the association between VTE and antibiotic prophylaxis clinical guideline compliance and patient-reported outcome measures (PROMs) after THA/TKA is unknown. This study aims to explore whether care that is non-compliant with VTE and antibiotic guideline recommendations is associated with PROMs (Oxford Hip/Knee Score and EQ-5D Index scores) at 90- and 365-days after surgery.
METHODS: This prospective observational study included high-volume arthroplasty public and private sites and consenting eligible participants undergoing elective primary THA/TKA. We conducted multiple linear regression and linear mixed-effects modelling to explore the associations between non-compliance with VTE and antibiotic guidelines, and PROMs.
RESULTS: The sample included 1838 participants. Compliance with VTE and antibiotic guidelines was 35% and 13.2% respectively. In adjusted modelling, non-compliance with VTE guidelines was not associated with 90-day Oxford score (β = - 0.54, standard error [SE] = 0.34, p = 0.112) but was significantly associated with lower (worse) 365-day Oxford score (β = - 0.76, SE = 0.29, p = 0.009), lower EQ-5D Index scores at 90- (β = - 0.02 SE = 0.008, p = 0.011) and 365-days (β = - 0.03, SE = 0.008, p = 0.002).. The changes in Oxford and EQ-5D Index scores were not clinically important. Noncompliance with antibiotic guidelines was not associated with either PROM at 90- (Oxford: β = - 0.45, standard error [SE] = 0.47, p = 0.341; EQ-5D: β = - 0.001, SE = 0.011, p = 0.891) or 365-days (Oxford score: β = - 0.06, SE = 0.41, p = 0.880 EQ-5D: β = - 0.010, SE = 0.012, p = 0.383). Results were consistent when complications were included in the model and in linear mixed-effects modelling with the insurance sector as a random effect.
CONCLUSIONS: Non-compliance with VTE prophylaxis guidelines, but not antibiotic guidelines, is associated with statistically significant but not clinically meaningful differences in Oxford scores and EQ-5D Index scores at 365 days.

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Guidelines are increasingly being used for clinical decision-making. Such guidelines are usually based on meta-analyses, which are generally derived from RCTs. However, their interpretations are often hindered as they do not always consider current clinical relevance. Analyses of RCTs assessing analgesic efficacy of advanced regional analgesic techniques in knee arthroplasty show that the majority of trials do not include a package of basic analgesics such as paracetamol, NSAIDs or cyclooxygenase-2 specific inhibitors, dexamethasone, and local infiltration analgesia in the comparator group. Consequently, the current approach to analyse meta-analyses of pain interventions is not optimal, and may lead to inadequate or inappropriate conclusions and clinical guidance.