Currently, five core clinical centers and 26 community sites comprising 114 surgeons and 8,100 patients across 22 states are participating in the registry. According to Dr. Franklin, preliminary data show an improvement in pain relief in up to 86% of patients at the centers participating in the registry, but noted that she and her colleagues still want to understand the 14% reporting suboptimal results.
She emphasized the need to use TKR outcome measures that are appropriate to measuring TKR (i.e., pain, physical function, and joint stiffness) as well as ones that are accessible to clinicians and patients. The outcome measures must be reliable, valid, and responsive to change.
To this end, Dr. Franklin and her colleagues use both the SF-36 and Knee Injury Osteoarthritis Outcome Score and an estimated Western Ontario and McMaster OA Index, along with imaging to provide a more comprehensive picture of the severity of knee osteoarthritis.
Variability of Post-TKR Rehabilitation
Along with a greater understanding and assessment of the contribution of patient factors on TKR outcomes is the need to consider the variability in post-TKR rehabilitation on outcomes. Carol A. Oatis, PT, PhD, professor of physical therapy at Arcadia University in Glenside, Pa., presented data that show considerable variability in the timing and duration of rehabilitation following TKR. She noted that rehabilitation, including acute care followed by institutional or home care rehabilitation, typically lasts from nine to 18 days, depending on the site of care, with little data on further rehabilitation beyond this. She cited data showing the typical recovery trajectory following TKR, which show that men and women typically report improvement in physical function at 12 weeks that plateaus at four months. Based on this, Dr. Oatis posed the question that perhaps providing more or more standardized intervention between three weeks and four months after TKR may improve TKR outcomes.
Overall, Dr. Oatis said that, despite its prevalence, TKR lacks accepted clinical benchmarks or treatment strategies to direct interventions and that more research is needed to determine if a more standardized and evidence-based rehabilitation approach improves functional outcomes.
Recommendations for Best Practice
Marie D. Westby, PT, a postdoctoral fellow at the School of Public Health at the University of Alberta, and an Arthritis Research Centre of Canada trainee in Richmond, British Columbia, presented efforts to develop a more standardized approach to postacute TKR rehabilitation care. One effort was a systematic review of TKR she and colleagues undertook to assess postacute care. Based on seven studies published between 2003 and 2009 that included a total of 779 patients, the review showed that the quality of evidence is not sufficiently high or consistent enough to suggest that any one rehabilitation approach is superior. The review also showed key evidence gaps, including gaps in rehab parameters for optimal outcomes, outcome measures to routinely use in clinical practice and research, how adherence impacts outcomes, and which contextual factors have the strongest influence on outcomes and patient satisfaction.
