Definition of a “True” Periprosthetic Shoulder Infection Still Eludes Us

Commentary Moffet et al. present a very well done, prospective, randomized, single-blinded, noninferiority study with excellent methodology comparing in-home telerehabilitation and in-home face-to-face physical therapy following total knee arthroplasty. The results of this study are important, given the increasing frequency of knee replacement surgery, shrinking health-care resources, and increasing expectations of patients for a quicker and optimal recovery, as well as the increased scrutiny and public reporting by various payers with regard to patient satisfaction and outcomes of knee replacement surgery. In the United States, depending on the type of care after discharge, over one-third of the overall cost of total knee arthroplasty occurs following discharge from the acute care facility1. Much of this cost is for postoperative rehabilitation in either an inpatient setting (e.g., an acute care rehabilitation or skilled nursing facility) or an outpatient setting (e.g., in-home or outpatient physical therapy). The frequency of total knee arthroplasties is expected to increase, with an earlier estimate of nearly 3.5 million procedures annually by 20302, although more recent data have suggested the rise in the frequency of total knee arthroplasties may be leveling off3,4. Nevertheless, one must question whether we can sustain the same level and cost of care after discharge. Less costly methods that are equally effective must be developed. Two hundred and five patients were randomized to receive either in-home standard physical therapy (the STD group) or in-home telerehabilitation (the TELE group). In-home telerehabilitation was performed by a physical therapist via a two-way Internet-based video and audio connection. Both groups received sixteen sessions over a two-month period following discharge. The sessions included supervised exercises and instructions on home exercises to be done between sessions. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at four months postoperatively. A number of secondary outcomes (Knee Injury and Osteoarthritis Outcome Score [KOOS], six-minute walk test, timed stair test, range of motion, and static strength) were also assessed. The two groups were comparable preoperatively with the exception of the greater number of patients who experienced depression, lived alone, or had asthma in the TELE group. (The increased number of patients with depression and living alone would intuitively make one think that the TELE group would be at risk for a poorer outcome). The timed stair test was also longer in the TELE group prior to surgery. Data on 100 patients in the STD group and ninety-eight in the TELE group underwent analysis. There was no difference between the groups with respect to the mean WOMAC scores in both the per-protocol and the intention-to-treat analysis. The two groups also had similar results for all secondary outcomes. The mean flexion in both groups at four months was 112°. A similar number in both groups required manipulation (one in the STD group and three in the TELE group) and received additional therapy after the planned intervention therapy (six in the STD group and nine in the TELE group). While this study adds to the evidence that telerehabilitation is an effective alternative to standard face-to-face encounters, there are a few points noteworthy of emphasis. Of the patients assessed for eligibility in this study (1754), about half (839) did not meet inclusion criteria (which were not overly restrictive) and just over a third (657) declined to participate. Only 258 (15%) of the 1754 potential patients underwent baseline evaluation in the study. Hence, the results of this study may not be as applicable to a broad population. Patients who were ultimately enrolled into the study may have been “more engaged” in their postoperative and postdischarge rehabilitation. Patients who are less motivated or less computer savvy or are technologically adverse may not be able to navigate this type of system and hence may not have similar results. Further to the point that widespread use of telerehabilitation may not yet be mainstream is that nearly one-fifth (twenty-two) of the patients in the TELE group also received face-to-face encounters. Eighteen of these were because of delayed installation of the technology or technical problems. Only three in-home visits were for abnormal knee recovery. Lastly, it is also of interest to note the difference in the start of the first therapy session (a mean [and standard deviation] of 3.7 ± 2.1 days after discharge for the STD group and 6.1 ± 4.2 days for the TELE group), yet the two groups had similar findings at both two and four months. This point should also help to dispel the notions that therapy needs to start immediately after discharge and that delaying therapy a few days has a detrimental effect. The selection of treatment arms (in-home telerehabilitation versus in-home therapy) is understandable as both are “in-home” techniques of rehabilitation. However, the authors also missed the opportunity to compare in-home telerehabilitation and outpatient therapy or no formal therapy after discharge (a home exercise program alone). Some studies have concluded that a self-directed home exercise program is as effective as formal outpatient therapy5,6. Other forms of telerehabilitation have shown effectiveness and are being incorporated into day-to-day clinical practice7. The authors should be commended for advancing the knowledge in this field specific to knee replacement. As the authors pointed out in the discussion, this technology may be applied to the routine follow-up of patients after joint replacement, avoiding the need for patients to travel lengthy distances for short routine follow-up appointments. The authors demonstrated that there is no inferiority of telerehabilitation compared with in-home face-to-face physical therapy. They have also analyzed the costs of in-home telerehabilitation versus in-home face-to-face encounters in another study and have determined the circumstances under which telerehabilitation may be more cost-effective8.

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