Do pre-operative therapeutic interventions affect outcome in people undergoing hip and knee joint replacement? A systematic analysis of systematic reviews

BackgroundTHR and TKR patients represent one of the largest groups of surgical patients globally, yet we do not know how to optimise pre-operative care to improve post-operative outcomes.ObjectiveTo clarify the effect of pre-operative prehabilitation interventions such as exercise, neuromuscular stimulation, and psychological therapies on outcomes for hip (THR) and knee (TKR) replacement patients.MethodsWe used PRISMA guidelines and guidelines by Smith and colleagues on conducting reviews of reviews. Searches were conducted on Medline, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects (DARE). Additional hand searches were also conducted. Articles were selected based on inclusion criteria and we report meta-analyses of data by outcome measures.Major Findings6848 articles were screened and the full text of 33 reviews were obtained. Twenty systematic reviews were included, containing 67 unique randomised controlled trials. In 70% of the reviews (14/20), intervention fidelity was not reported. The components of prehabilitation that were tested were: exercise, education, nutrition, acupuncture and neuromuscular stimulation. Exercise alone did not affect functional outcome for TKR patients, but it did affect activity levels prior to THR, and pain prior to THR and TKR. Exercise alone may reduce Length of Stay (by between 0.8 and 4 days). Education when combined with exercise can reduce Length of Stay for TKR patients. Relaxation did not affect function or length of stay but gave a modest reduction of pain.ConclusionsProviding education alongside exercise as a pre-operative intervention may reduce Length of Stay. One small RCT combined all three elements of exercise, education and dietary advice and there is no robust evidence to determine whether combining these elements can influence functional outcome.