Title: Development of an optimal physiotherapy intervention for arthrofibrosis following total knee replacement
Funder: Department of Health and Social Care

Abstract: Background Arthrofibrosis is a complication following Total knee Replacement (TKR) that results in severely restricted range of movement, pain and loss of function. Physiotherapy is the first-line treatment but there are no guidelines as to what this should include and there is wide variation in what is delivered. Patients who fail to respond usually undergo manipulation under anaesthetic to break the adhesions and improve range of movement. However, this incurs a five-fold increased risk of revision TKR representing poorer long term outcomes for patients and higher NHS costs. The wider impact of arthrofibrosis on patients outcomes is unknown. Aims and Objectives The study aims to develop an optimal physiotherapy intervention to improve outcomes for people with arthrofibrosis and reduce the need for MUA and further surgery. Four work-packages (WP) will be undertaken, guided by the MRC framework for intervention development. We will ensure the voices of patients are evident throughout the studies by adding the patient perspective to the analysis of all WPs. Methods WP1. A systematic review of non-surgical interventions for arthrofibrosis following TKR to identify (i) potential components of an optimal intervention; (iii) the effectiveness of existing interventions and (iii) reported outcome measures for patients. WP2. Qualitative interviews with patients to explore (i) the impact of arthrofibrosis and their experiences of care, identify important outcomes and unmet needs; and with health care professionals (HCPs) to understand (ii) their experiences, perceptions and context of managing arthrofibrosis and (iii) their opinions on the intervention components identified in WP1. WP3. A Delphi exercise with HCPs and patients to achieve consensus agree on components of an optimal intervention. WP4. Intervention Workshop with HCPs and patients to refine the intervention protocol. Timelines for delivery: Total time is 18 months. WP1 and 2 will be completed in year 1. WP3 and 4 will be completed in year 2. Anticipated Impact and Dissemination The primary output of this research will be the production of an evidence-based, consensus-agreed intervention protocol that can be tested in a feasibility trial prior to full evaluation. We will apply to the NIHR to fund a future feasibility study (RfPB) and a subsequent definitive trial (HTA). It is anticipated this will have a direct impact on patient care, improve outcomes for patients and save money for the NHS through reduced need for MUA and revision TKR. Findings will be disseminated widely using lay summaries for participants, patient forums, magazines and websites; academic outputs will be disseminated through open access journals, conferences, professional networks and social media.

Lay abstract: Aim. This research aims to develop an optimal physiotherapy intervention for people with arthrofibrosis (stiffness due to scar tissue) after total knee replacement (TKR). Background. Arthrofibrosis is the second most common reason for hospital re-admission following TKR. It limits knee movement, causes pain and interferes with everyday activities. There are no guidelines as to how best to treat this complication. Most people will have additional physiotherapy but it is not clear exactly what this should involve. People who don t improve will usually undergo manipulation under anaesthetic (MUA), a procedure where the knee is forcefully flexed to release the stiff joint. People who have a MUA are more likely to have poorer outcomes and long-term are more likely to need a repeat knee replacement which is distressing for patients and costly to the NHS. An optimal physiotherapy intervention could result in better outcomes for patients and reduce the need for MUA and further surgery. Methods. We will develop an optimal intervention by conducting: A review of the evidence to identify what components could be included in the intervention, how effective they are and what outcomes have been measured by the research. Interviews with patients with arthrofibrosis to understand the impact it has on their life and what outcomes are important to them and interviews with healthcare professionals (HCPs) to understand their experiences of treating patients with arthrofibrosis. A Delphi study with a larger group of HCPs and patients to reach a consensus on what the optimal intervention should include. This involves a series of anonymous voting on a range of items that have been generated by the group and the results of the evidence review. A workshop with patients, HCPs and health-care commissioners to finalise the intervention. During the workshop we will present our findings and work in small groups to agree the intervention. At the end of this study, we will have an intervention that has been agreed by patients and HCPs that can then be tested to see if it can work in practice and if a larger trial can be conducted. Patient and Public Involvement (PPI). Patients who have had knee arthrofibrosis after TKR have told us this is an important topic to research. They experienced variations in their care and felt that improving treatment for arthrofibrosis would benefit patients and the NHS, particularly if MUA could be prevented. Our PPI members will be actively involved throughout the project to ensure the study remains patient-focussed. Dissemination. We will share the findings of this study with patients, healthcare professionals and healthcare commissioners locally through meetings and magazine/ internet articles and more widely by presenting at conferences, publishing in academic journals and on social media.

Research activity codes: 5.7 PHYSICAL
Health categories: MUSCULOSKELETAL