Does inpatient and / or outpatient rehabilitation lead to better recovery after arthroscopic meniscectomy compared to home rehabilitation?
Despite the fact that arthroscopic meniscectomy is a primary risk factor for knee osteoarthritis and there is a body of evidence to support its effectiveness, it is still one of the most widely used surgical procedures for a number of indications.
Arthroscopic menisectomy is a procedure that partially or completely removes a damaged meniscus. Since it is trauma to the knee, post-operative rehab is required to restore function and relieve pain, and numerous studies have examined and compared rehab programs at home and in the hospital, but a definitive recommendation for the superior approach became not submitted.
Which guidelines work according to TKR?
The aim of a new systematic review published in JAMA aims to compare the outcomes of home rehab with standard inpatient / outpatient rehab after arthroscopic menisectomy and to come to a firm conclusion as to which approach is best .
Methods
This system was registered on PROSPERO and adhered to the PRISMA instructions. Four databases; PubMed, CENTRAL, WoS and Scopus with the search in March 2021. The database research was supplemented by a manual search for the references of the articles contained. The search string used was as follows:
("Physiotherapy" OR Physiotherapy OR Rehabilitation OR Exercise OR "Exercise Therapy" OR "Home Exercise Program" OR "Home Exercise Therapy" OR "Home Exercise") AND Meniscectomy
Studies were excluded if they were non-comparative, non-randomized or observational studies in data and preclinical studies. Only comparative RCTs were included, and the selection of the studies was carried out by two authors independently, the disagreement being resolved by consensus with a third.
The main result examined in this systematic review was the functional recovery of the knee, measured with the Lysholm knee score in the short- and medium-term follow-up care. Secondary target parameters include self-reported pain, IKDC score, vertical jump test in cm, force measurement with isokinetic test, knee ROM and thigh circumference in cm.
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The risk of bias of the included studies was assessed using the Chochrane tool for the risk of bias (2.0) and the overall quality of the evidence for each outcome was assessed using the GRADE guidelines. Statistical analysis used the inverse variance method for continuous variables to measure the difference between the outcome measures, with the results expressed as mean differences (MD).
Heterogeneity was tested with the I2 metric and considered significant if I2> 25%. Originally, the authors wanted to use a random effect model for the meta-analysis, but the results were less heterogeneous than expected, so a fixed model with a p-value of 0.05 was used instead. The Hartung-Knapp correction was used to analyze the results of some articles, but this is not without concern.
Clinical Take-Home – Which rehab method is the best?
A total of 8 studies from a first 1914 that were retrived were included. There were 434 people, 209 of them in the home rehab group and 225 in the inpatient / outpatient group. The age of the participants ranged from 21 to 74 years with a gender distribution of 332 men and 104 women. Follow-up ranged from 28 days to six months.
The inpatient / outpatient rehab approach differed between the studies, but all contained what the majority of clinicians would consider standard care – 1: 1 strengthening / rehab sessions, EMG biofeedback training, neuromuscular work , manual therapy and soft tissue techniques.
The home-based rehabilitation approach of the studies was less diverse and was characterized by oral and written exercise instructions, some of which were illustrated. In a study that consisted exclusively of an abstract with result-related data in tabular form, HBP was delivered via internet-based rehabilitation.
Brief summary of the rehabilitation setting after meniscectomy
There was no overall significant difference in the short- or medium-term results between inpatient, outpatient or home rehabilitation
Rehabilitation at home resulted in a larger thigh circumference compared to inpatient / outpatient rehabilitation with a difference of 1.38 cm in men
Inpatient / outpatient rehab have marginal improvements in single & vertical hop after 3 months compared to home rehab
The home rehab group returned to work earlier than the inpatient / outpatient group
Looking at the results reported by patients, there does not seem to be any clinical or statistical difference between the two groups in the Lysholm or IKDC scores. It should be noted that only a few studies were included in the meta-analysis for the Lysholm score, as well as major concerns about the bias, which classify the GRADE level as low to very low.
The physical results showed a very similar picture with no real difference in knee flexion (MD -7.40 °) or knee extension (MD -0.55 °), with only the thigh circumference making a significant difference in favor of rehab Home. with a mean difference of 1.38 cm. The clinical benefit of this is probably negligible.
From a functional point of view, there was no significant statistical difference in the single or vertical hop tests, but those in the inpatient / outpatient group slightly outperformed the home group in both tests. However, this slight improvement in the hop test does not result in a faster return to work, since the home group returned to work more quickly (MD 4.5 days).
Given these results and the fact that none are superior to the others, home rehab should be a commonly used method of knee arthroscopy rehab, especially given the COVID-19 pandemic and the cost savings implications. This study is not without its limitations, therefore caution is advised when applying the results to your clinical setting.
