An exercise and education program before knee and hip surgery
leads to better outcomes for patients

The rate of these surgeries is rapidly increasing
Osteoarthritis (OA) is a condition in which cartilage that normally protects the ends of bones gradually wears away, which leads to pain and disability in that joint. OA can occur in just about any of the body's joints, but it's most common in the knees and hips since they are responsible for handling a great deal of body weight. Although non-surgical treatment is recommended first for hip and knee OA, many patients go on to have surgery when their condition does not improve, which is called total hip or knee arthroplasty. Between an aging population and the number of obese individuals growing, the rates for these surgeries are also increasing, and are only expected to keep going up in the future. This is why it's so important to develop strategies to increase the chances of a successful outcome after surgery. One way to accomplish this is to have patients undergo a pre-surgery rehabilitation program - sometimes called "prehabilitation" - led by a physical therapist. These programs typically include a variety of stretching and strengthening exercises, as well as education on what to expect after surgery. The evidence to support these types of programs for total hip or knee arthroplasty are limited, so researchers decided to conduct a powerful pair of studies called a systematic review and meta-analysis to determine if prehabilitation can improve outcomes after surgery.

10 medical databases searched for relevant studies
Researchers performed a search of 10 major medical databases for relevant studies that investigated the effects of prehabilitation before total hip or knee arthroplasty on outcomes like pain, function, and length of hospital stay. This search produced 160 studies that were screened in greater detail, and a total of 35 randomized-controlled trials (RCTs) fit the necessary criteria and were accepted into the studies. RCTs are high-quality individual studies that are considered the gold standard for evaluating the effectiveness of a treatment, and the accepted RCTs consisted of data on 2,959 patients who underwent knee or hip surgery. A total of 25 of these RCTs used exercise alone, 9 used education alone, and 11 used a combination of exercise and education before surgery, and the programs typically lasted for 4-8 weeks with 1-5 sessions per week. Once collected, the findings of these studies were analyzed and compared to one another, and their quality was assessed to gauge their reliability.

Prehabilitation leads to several improvements in patient outcomes
Results showed that on the whole, the prehabilitation programs led to a number of improvements in patient outcomes following surgery.  In particular, there was a small but significant difference favoring prehabilitation for improving pain identified in 25 studies, and a moderate, significant difference favoring prehabilitation for improving function found in 23 studies. There was also a moderate and significant difference favoring prehab for muscle strength identified in eight studies, and a small-to-moderate but significant difference favoring prehab for decreasing hospital length of stay in 19 studies. When divided by the type of surgery, significant improvements were found in pain, function and length of stay for patients undergoing total hip arthroplasty, and for function, muscle strength and length of stay for patients undergoing total knee arthroplasty. Taken together, these findings suggest that prehabilitation can help patients undergoing surgery for hip or knee OA recover faster by leading to less pain and better function. Although more research is now needed to confirm these results, patients who are planning to have a total hip or knee arthroplasty surgery should take note and strongly consider seeing a physical therapist for a prehabilitation program before their procedure to increase their chances of a successful outcome.

-Summarized by Greg Gargiulo
-As reported in the December '17 issue of JBJS Reviews