0. Total Knee Replacement
Patient Population and Physiotherapy Management Review
Greater Newcastle Acute Hospital Network– Physiotherapy
National Allied Health Benchmarking Consortium- Health Round Table
October 2009

1. BACKGROUND
376 TKR patients were seen by RNC Physiotherapy as an outpatient during 2006/2007
Number of TKR procedures in Australia has increased by 152.3% over past 12 years
33,737 performed in Australia in 2005/6 FY
Public hospital growth rate far greater than private (14.5% vs 1.6%)
Increasing demands upon public hospital Physiotherapy services
Evidence base for PT management of TKR is quite limited (Naylor et al 2006)
No clinical guidelines exist for post-operative Physiotherapy
Considerable variation in Physiotherapy practice (Roos 2003)
Australian Orthopaedic Association National Joint Replacement Registry, 2007

2. AIMS
To review the TKR patient population receiving physiotherapy services at the RNC
To review current outcome measure utilisation throughout the clinical pathway
To review current physiotherapy management strategies and resource consumption
To analyse clinical outcomes

3. METHODOLGY Cross-Sectional Retrospective Analysis
TKR patients identified via PiMS and AHMIS
Random sample of 50 records
Received pre-operative, in-patient and out-patient physiotherapy services at the RNC for primary TKR
No post-operative complication

4. POPULATION CHARACTERISTICS
The RNC TKR population is similar to other reported TKR populations in regards to age, gender and reason for arthroplasty
Perhaps interestingly, the mean BMI in our data was found to be higher than all other reported TKR populations (by around 4 points)
Previous research has identified that patient’s with higher BMI’s typically obtain poorer ROM (Anouchi et al 1996, Lizaur et al 1997)
There is strong evidence that the primary patient factor influencing post-operative range of motion is pre-operative range of motion (Dennis et al 2007, Lizaur et al 1997, Parsley et al 1992, Ritter et al 2003)
Considerable variance in the pre-operative flexion range of movement has been reported in the literature
However the pre-operative flexion ROM in patients at the RNC approximates the central tendency of these reported figures (104.2°)

5. RESOURCE CONSUMPTION
Standard practice at the RNC involves all patients attending a pre- operative individual consultation with a physiotherapist
50% of Hospitals in Sydney South West Area Health Service provide a similar pre-operative service
Mean in-patient LOS was 7.46 days (95%CI 6.82 to 8.1 days)
The last outpatient appointment was a mean of 6.86 weeks (95%CI to7.85) from the date of surgery
Comparable to the previously published figures for TKR patients in other Australian hospitals (Naylor et al 2006)
A low correlation was discovered between age and duration of physiotherapy management, with younger patients attending for greater durations (r = -0.36, 95%CI –0.58 to –0.09)
Age, Sex and BMI had no influence on any other measures of resource consumption.

6. USE OF OUTCOME ASSESSMENT

7. OUTCOME ASSESSMENT & PT MANAGEMENT
A review of literature and analysis of the data identified an opportunity to include further outcome assessment measures
Patient Perceived Function
Eg. Lower Extremity Functional Scale
Measures of Patient-Important Function
Eg. Timed Up and Go
Patient Satisfaction with Care/Outcome
The nature and frequency of the interventions used at the RNC appear consistent with those reported in other sites within Australia (Naylor et al 2006, Sydney South West Area Health Service)

8. PHYSIOTHERAPY MANAGEMENT

9. PHYSIOTHERAPY MANAGEMENT

10. KNEE ROM OUTCOMES KNEE FLEXION KNEE EXTENSION
A small correlation existed between pre-operative flexion ROM and final flexion ROM at the last OP appt (r=0.34)
For each 4 increase in pre-operative flexion, the predicted flexion range at the final physiotherapy appointment increases by 1
Final flexion ROM had no relationship to the number of physiotherapy OOS (r=0.1)
Those with poorer flexion ROM at their last appointment tended to have poorer extension ROM (r=0.29)
KNEE EXTENSION
No influence by age, sex or prosthesis type
Interestingly, a small positive correlation was identified between BMI and pre-operative extension ROM (r=0.37)
for every increase in BMI by 5 points, the predicted pre-operative extension improves by 2
No influence by mobility tolerance or mobility aid utilisation
No relationship with the number of physiotherapy OOS

11. KNEE ROM OUTCOMES KNEE FLEXION
Paired t-test statistical analysis identified the differences in flexion range of movement scores between all of the five time periods to be significantly different (p < 0.05)

12. KNEE ROM OUTCOMES KNEE FLEXION
No influence by age, sex or BMI at any time point
No influence by prosthesis type at any time point

13. KNEE ROM OUTCOMES KNEE EXTENSION
No significant difference between extension ROM pre-operatively and at the final appointment (difference = 1, p=0.42)

14. MOBILITY AID UTILISATION OUTCOMES

15. Key Findings & Opportunities
Fairly consistent with other populations reported in the literature
Would seem reasonable to make comparisons
Our sample had a higher BMI than other reported populations
Similar Physiotherapy resource consumption and management strategies to comparable services
Similar physical outcome measures to previously published reports
Outcome Assessment
Consistency throughout the clinical pathway
Patient Perceived Functional Status
Patient-Important Function
Patient Satisfaction with Care/Outcome
Investigation of opportunities for benchmarking
Collaborative research initiatives

16. Project Team Judith Henderson Damien Smith Chris Barnett Kieren Brown
Area Professional Director, Physiotherapy
Damien Smith
Team Leader, Royal Newcastle Centre
Chris Barnett
Team Leader, Outpatient Physiotherapy, Royal Newcastle Centre
Kieren Brown
Team Leader, Inpatient Physiotherapy, Royal Newcastle Centre
Veronica Parraga
Physiotherapist, Royal Newcastle Centre
Robin Haskins
Tim Lee