[Physio Explained] What makes hip and knee surgery successful? with Dr Michael Mansfield

0:05SPEAKER_00:Pre-HAD seems to be better at proving, I suppose, the preparedness for surgery and then how that can influence those short-term outcomes moving towards the long-term outcomes following surgery. And that distinction is important, and that is recognised by some of our nice guidelines as well.

0:25SPEAKER_01:Is prehabilitation before a total hip or knee replacement really as effective as we might think? And what actually determines whether a patient has a good outcome after surgery? We explore this and much more in today's episode of Physio Explained with Dr. Michael Mansfield. Mike is an assistant professor in musculoskeletal physiotherapy at the University of Birmingham. His research focuses on improving outcomes in musculoskeletal and orthopedic care, rehabilitation and health inequalities.

0:53SPEAKER_01:He also leads the Align Network, an interdisciplinary program working with the Royal Orthopedic Hospital NHS Trust to understand how orthopaedic care pathways can better meet patients' needs. In this episode, we explore the difference between technically successful operations and a successful outcome for the patient. An implant may well be positioned and the X-ray may well look excellent, but the person may still be experiencing pain, weakness, difficulty walking, or an inability to return to the life that they expected.

1:24SPEAKER_01:We discuss why good outcomes need to be considered across several dimensions, including pain, physical function, activity, participation, quality of life, and crucially the patient's own goals and expectations. Michael also explains why the period before surgery is not simply a neutral waiting phase. We examine the role of prehabilitation, including why it may improve strength, function, and pain around the time of surgery, but doesn't necessarily guarantee better long-term postoperative outcomes.

1:54SPEAKER_01:Most importantly, we discuss why better care is not simply about providing more rehabilitation, but about selecting the right strategies for the individual and understanding what a successful recovery actually looks like for them. As you can see, there is an awful lot in this episode for you today. I'm James Armstrong and this is Physio Explained. Mike, great to have you on the Physio Explained podcast. Excellent. Thanks, James. Thanks so much for the invite.

2:24SPEAKER_01:Really looking forward to our conversation. Definitely, and I'm sure our listeners are too. So today we're talking about outcomes of hip and or knee orthopedic rehabilitation. And probably something that I think every listener is either dealing with on a regular basis or has done in the past, either postoperatively, pre-operatively, whether patients are avoiding surgery or post-surgery, particularly for our conversations today. What do we mean by a good outcome after hip and knee replacement?

2:54SPEAKER_00:So thanks, James. Yeah, a really poignant question. And this may change depending on what person that you speak to, be that a surgeon, be that a physiotherapist, an occupational therapist, but most importantly, perhaps the person, the patient that's sitting in front of us. So I think for me, looking at some of the research that we are completing with the Royal Orthopedic Hospital in HS Trust and the University of Birmingham through the Align Research Network, we're beginning to untangle and build upon the evidence as to start to separate perhaps a technically successful operation from a successful outcome for the person, the patient.

3:32SPEAKER_00:So the implant may be well positioned, there may not be any surgical complications, the x-ray looks excellent, but the patient may still have pain, weakness, perhaps difficulty walking, or maybe they feel they haven't quite returned to their own life as they expected. So for me, we mustn't lose sight that people improve significantly and substantially following a hip or knee replacement. That's important not to lose sight. Of course, that is the case.

3:57SPEAKER_00:But particularly after knee replacements, what we tend to see that there's a meaningful group who continue to experience pain or report less than good outcomes. So success, I suppose, can't simply be defined as the joint has been replaced. Now, for physiotherapists or rehabilitation specialists, you know, I think that these outcomes for a good, a good outcome following a joint arthroplasty probably has several dimensions. Of course, we have pain, physical function, perhaps activity, participation in everyday activities, quality of life.

4:33SPEAKER_00:But what's also important here is the person, the patient's own goals. Can they walk to the shops again? Can they walk up the stairs? Can they return to work? Can they get back into gardening again? These are the things that are perhaps what will define and enhance much more for an individual than perhaps their number of degrees of flexion at the knee. Absolutely.

4:54SPEAKER_01:And you touched on a few things there. Do you think in terms of their expectations? I know we're going to talk a little probably about this in a minute, but expectation prior to surgery is quite important in terms of their expectations after. And then what is a success to that patient?

5:09SPEAKER_00:I think that's a really important point there, James. And I think from my perspective, it's not a philosophical argument around what's a good outcome or what are the expectations. And we're seeing here more and more research around establishing expectations and how that influences patient and clinical outcomes. And importantly, perhaps how those expectations or pre-operative measures can be measured and how that then shapes the postoperative outcome.

5:38SPEAKER_00:So I suppose what it means is that we perhaps shouldn't entirely rely on patient-reported outcomes or physical tests in silos. Expectations, as you've mentioned, clearly comes into play here. And often patients may feel significantly better, but may have strength deficits, or actually they may be very strong, if you like, but perhaps not have the outcome that they wish to have or expected to have before the operation. So I think that clinical conversation needs to move towards or continuing to move towards what does successful recovery look like for you, the person, the individual, and how that then feeds into expectation setting and meeting some of those expectations too.

6:22SPEAKER_01:And flipping that the other way around, would you potentially see some patients who don't have necessarily a meaningful conversation prior to surgery, that they may be sitting on some quite significant anxieties and worries, maybe it their experiences with a family member who's had a poor outcome. So then their expectations might actually be the other way around and that might influence their success.

6:45SPEAKER_00:Yeah, absolutely. I think what we are very much aware of now with the contemporary evidence that's published and the work that our surgical colleagues, our rehabilitation colleagues are very much on that front line is we're not operating in silos here. Physical health, mental health interacts with one another and how that then influences major surgery, like joint arthroplasty. And for us as healthcare professionals, working alongside and ensuring that that person, patient, is at the center of those conversations will continue to drive more positive outcomes for that person going forward.

7:24SPEAKER_01:Indeed. So then we talked about what happens before, and why does that matter? We say we touched on it there already, but talk us a bit more through that, Mike.

7:33SPEAKER_00:Yeah, I think it's a good point, and I mould over this a little bit, and we still do with our aligned research network at the university and with the Royal Orthopedic Hospital, is that I think perhaps historically we have a have a little tendency to conceptualize joint replacement around the operation itself. So a clocal timeline may be a person deteriorates, they're listed for surgery, they have their surgery, and then rehabilitation begins. And of course, that largely speaking still happens.

8:02SPEAKER_00:But increasingly we see it as one continuous pathway or one continuous sort of entity that before surgery throughout the operation and throughout recovery. So I suppose that first important point is that the waiting pre-op isn't a neutral period. We're seeing some quite interesting studies that are published with tens of thousands of people, patients that have been on waiting lists or waiting for surgery and found clinically significant deterioration in quality of life and how that then impacts joint function and the aspects you brought up earlier, James: the anxiety, depression, and well-being, and how that then feeds into patient-reported outcome measures.

8:41SPEAKER_00:So interesting, we're seeing perhaps the evidence that a longer wait necessarily produces poorer postoperative outcomes, it's becoming a little bit murky and a little bit less clear as it could be or should be. So I want to be really careful here is that not that we're saying that everyone is deteriorating on a waiting list. That's not what I'm saying, not what the evidence is saying or jeopardizing surgical results. That's not what we're saying.

9:07SPEAKER_00:But what we can say is we're much more confident is that if people patients can spend many months living with increasing disability and poor quality of life during that pre-op waiting period, then perhaps we're beginning to see a trend to poorer outcomes in the future. To build on that a little bit further in some of the work that we're beginning to complete in our research network is that prehabilitation can improve some outcomes, particularly strength, function, pain at the time of surgery.

9:39SPEAKER_00:But importantly, the evidence of where it sits at the moment is in that early stage post-op as well. So we do see that NICE recommends that people are waiting for hip or knee replacements to engage in exercise, lifestyle factor amendments, perhaps maximising functional independence as well. But where we are at the moment with evidence is that we might not see that perhaps long-term post-op. So we are seeing something, and perhaps what we're coming on to here, maybe the third point of discussion of what it looks like for the individual in front of us, too.

10:12SPEAKER_01:Are you struggling to keep up to date with new research? Let our research reviews do the hard work for you. Our team of experts summarise the latest and most clinically relevant research for instant application in your clinic. So you can save time and effort keeping up to date. Click the link in the show notes to try Physio Network's research reviews for free today. Definitely. So so am I right in thinking is there a limited amount that someone on a waiting list then for surgery can do to help them after surgery?

10:43SPEAKER_01:Is it more are you are we now about to start saying that actually it's what we do immediately after surgery, it's more important, or have I misunderstood that?

10:49SPEAKER_00:No, I think I think it's both aspects, if I'm being quite honest, James. I think what we can see here is that if we can engage in meaningful prehabilitation, the expectation setting, the engagement in physical health strategies, mental health strategies, we are seeing a trend towards more enhanced outcomes post-operative as well. But those outcomes post-op tend to be quite short-lived. So that's where the rehabilitation in this pathway after the operation, where we need to continue the good work that perhaps is done pre-operatively.

11:21SPEAKER_01:Great. So what we could say there, we can't rely on good pre-habilitation to get us through a total knee replacement. That needs to be coupled with very good rehabilitation as well.

11:32SPEAKER_00:Yeah, absolutely. You know, and I think what's important here is it's not more. It's not well, if I have more physiotherapy before operational, I'll have much better outcomes. It's ensuring that we are selecting, stratify, and understanding that person in front of us to understand, well, it may not be more, it may be just more targeted at to the various health domains that I've mentioned earlier around the physical aspects, mental health aspects, which are very much intertwined.

11:56SPEAKER_01:And sticking on sort of quite a physical aspect, does the research stand up in terms of that someone who can maintain good, say, good range of movement will then see better range of movement post-operatively, better strength prior to surgery, will have better outcomes afterwards or recovery afterwards? Are there still those elements that we can still have those discussions with patients when we're trying to sort of I say sell that element of physical prehabilitation?

12:25SPEAKER_00:Yeah, I mean it's a really interesting point. And perhaps some of these systematic reviews, the meta-analysis have found probably mild to moderate certainty of evidence that prehabilitation and some of those domains that you've scratched on there will maintain and improve post-operation as well. So although we do see that six-week window is post-stop, if that people do engage in prehabilitation will tend to have more enhanced outcomes, but that's not always significant.

12:56SPEAKER_00:So I think what we're saying here is that, or what we're not saying is that everyone should do prehabilitation. Everyone should engage in range of motion muscle strength because they will have improved outcomes post-op. Although that may be the case for the majority, it might not be a blanket across that. So I perhaps rather reframe and say that pre-CAD seems to be better at proving, I suppose, the preparedness for surgery and then how that can influence those short-term outcomes moving towards the long-term outcomes following surgery.

13:29SPEAKER_00:And that distinction is important and that is recognised by some of our nice guidelines as well. Absolutely.

13:35SPEAKER_01:Okay, no, that's that's great. So that one size fits all doesn't work for everyone. Talk us more through that.

13:43SPEAKER_00:Yeah, sadly not. That seems like life in general, doesn't it? You know, on the shelf is perhaps not the phrase we want to. So I think this is perhaps where we need to maybe distinguish between standardization and equity. There are obviously good reasons to standardise aspects of care, and I'm not disputing that. We want evidence-based, evidence-informed information, early mobilization, clear rehab pathways. But if we're giving every person the same pathway, it doesn't necessarily always mean that every person has the same opportunity to benefit from that same pathway.

14:17SPEAKER_00:So if I took two very clocal examples, two patients that are leaving hospital with the same exercise program, one might have a supportive family network, a car, good health literacy, come from a supportive, adaptable home environment, access to digital resources, and six weeks away from work compared to someone who perhaps lives alone, relies on public transport, multiple comorbidities, has caring responsibilities, social economic aspects, and perhaps even that English isn't their first language.

14:49SPEAKER_00:So despite having the same joint replacement, the same exercise program that's come off the shelf, we're likely to see two very different outcomes. And I know that's not going to be shock horror to some of your audience members, and that will affirm what they see clinically day to day. The point here is the ability to engage in with what intervention is tailored, perhaps more so, to the requirements, expectations, needs for that person in order to succeed post-op as well.

15:17SPEAKER_00:Brilliant, Mike.

15:18SPEAKER_01:Brilliant. So, as always, these episodes go very quickly. What can our listeners take away? What would be your sort of top tips when managing and supporting a patient through this journey from pre to during to post? What's some of the top tips?

15:35SPEAKER_00:Yeah, I think for me, I've got perhaps some headlines to think about here. Ask asking about participation, not just impairments. And lots of our excellent physiotherapists, many, many of us do this day in, day out. So alongside pain, range of motion, strength, ask the patient, engage with the family members around what that person wants to get back to and whether they're actually able to do that and how that can be adapted. Perhaps treat the waiting list as maybe the active clinical phase, not just the wait-in period before an operation.

16:05SPEAKER_00:So reviewing mobility, function, falls, analgesia, sleep, psychological well-being, and other aspects there that potentially could be engaged with before the operation in order to set expectations and enhance the outcomes post-op as well. I think use prehabilitation honestly, and what I mean by that is helping people to maintain or improve strength, function, confidence is important, but perhaps not overpromising that prehabilitation will necessarily produce the superior long-term outcomes following an operation.

16:41SPEAKER_00:So just be mindful of that. It's not negating that. And perhaps the final point as we come towards the conclusion is personalise where able and where the healthcare system enables that physiotherapist as well. And physiotherapy perhaps is most valuable when it moves beyond the procedure-driven delivery towards that focus, that individual focus of recovery, and how we can reason our strategies around that too. So I think it's three or four key things that we're beginning to see as part of our align network at the university and at the Royal Orthopedic Hospital too.

17:13SPEAKER_01:Mike, that's brilliant, brilliant. And I think our listeners will take a couple of things away from there, and hopefully some of them will be thinking, great, I'm already doing that. That's good. That's a tick in the box, I'm still doing the right thing. But I think certainly some of those areas around, I like the honesty around prehabilitation, being not too high promising to the patients and saying, do this, and you will be a lot better off actually being mindful around how much of a promise you make there.

17:40SPEAKER_01:I think that's probably a very, very good takeaway. And making this person-centered, it's a phrase we use all of the time on this podcast. Mike, thank you so much for your time. It's been an absolute pleasure to have you join us, and no doubt we'll have you back on the show again at some other point in the future.

17:56SPEAKER_00:No, it's been a pleasure, James. Thanks so much for the invite and uh look forward to staying connected. Thank you. Thanks, Mike.