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Surgery can sometimes be the best solution for chronic musculoskeletal pain, but presurgical preparation and postsurgical rehabilitation are often required to achieve the maximum benefits. A digital musculoskeletal surgical care program was developed to support the population of patients undergoing total knee arthroplasty.
We aimed to demonstrate safety, engagement, and acceptability and explore clinical outcomes, health care use, and satisfaction among participants of a digital musculoskeletal surgical care program who were undergoing total knee arthroplasty.
A retrospective, observational feasibility study comparing digital musculoskeletal surgical care program participants to a comparison group was conducted. The intervention group registered for a digital musculoskeletal surgical care program, which included health coaches, physical therapists, and tailored exercises and educational articles to provide preoperative and postoperative support to patients who had recently undergone total knee arthroplasty. Comparison group members received standard-of-care treatment. Engagement (number of exercise therapy sessions and educational articles accessed per week) and acceptability (Net Promoter Score) were examined among intervention group participants. Descriptive statistics for postoperative outcomes, including safety (postoperative complications), clinical improvement (pain, function, anxiety, and depression), and health care use and experiences (length of hospital stay, surgery satisfaction, and physical therapy adherence), were reported for both groups. Differences among postoperative results were compared by using the independent samples 2-tailed
Of the 53 participants (intervention group: n=22; comparison group: n=31) who were included in this study, 35 (66%) were female and 25 (47%) were aged from 45 to 60 years. On average, the intervention group completed 23 exercise sessions, read 2.7 educational articles, sent 45.5 texts to their health coaches, and were actively engaged for 6 weeks after their operation. Among 21 participants, 14 (67%) self-reported as
Our digital musculoskeletal surgical care program shows promising levels of engagement and acceptability among those who recently underwent total knee arthroplasty. The surgical care program may also help with improving postsurgical complications and clinical outcomes and lowering health care use.
Chronic musculoskeletal pain is a leading cause of disability and increased health care costs in the United States, affecting over 50 million people and resulting in an estimated total lost productivity cost of US $296 million per year [
For surgery outcomes to be successful, it is important for patients to adhere to both preoperative rehabilitation and postoperative rehabilitation [
In order to address care gaps and their subsequent impacts on both care quality and clinical outcomes, we developed a digital surgical care program consisting of medical, social, and educational support (
The preoperative phase of the surgical care program started up to 8 weeks prior to surgery. Participants worked with health coaches to achieve goals that supported the best surgical outcomes, such as reducing presurgery anxiety or creating healthier eating habits for recovery. Participants also worked with physical therapists to strengthen muscles that supported their new joints to allow for optimal recovery. The postoperative phase lasted for 12 weeks after surgery. During this time, participants received support and accountability training for achieving their recovery goals, as per their rehabilitation plans.
The digital musculoskeletal surgical care program provides users with a tailored program containing medical, social, and educational support. PT: physical therapist.
The program was complemented by the plans that were recommended and directed by participants’ surgeons. As such, participants still attended their recommended in-person physical therapy sessions. Participants informed their care program health coaches of their in-person physical therapy exercises, and information on these exercises was loaded into the app to assist with tracking progress.
The goal of this study was to determine the feasibility of our novel surgical care program. The primary objective was to demonstrate safety, engagement, and acceptability among the participants of the surgical care program. The secondary objectives included exploring postoperative clinical improvement and comparing the health care use and experiences of surgical care program participants against those of a comparison group.
Patients who need orthopedic surgery typically benefit from the social support provided through caregivers or family members, but not everyone is able to receive assistance. Therefore, our digital surgical care program aims to provide the needed social support and improve care quality and clinical outcomes both before and after the surgery process. The results from this study will contribute to developing larger-scale studies that will provide evidence that this digital surgical care program effectively addresses care gaps.
A retrospective, observational feasibility study comparing digital musculoskeletal surgical care program participants (herein, the
Participants who were eligible for the intervention were identified based on our inclusion and exclusion criteria and the information they provided in the app. The inclusion criteria were patients who had a smartphone, patients who created an account for the digital musculoskeletal surgical care program, patients who completed the app questionnaire at least 4 weeks prior to starting the surgical care program, patients who enrolled in the knee surgical care program, patients who underwent knee replacement surgery 6 or more weeks before survey data collection, and English-speaking patients.
Comparison group participants were recruited through a proprietary research panel maintained by Momentive. The panel includes over 100 million people who are invited to take part in surveys. We screened panelists by age and included those who had not previously participated in Hinge Health programs and underwent knee replacement surgery between June and December 2021.
This study (reference number: 20160949) was reviewed and approved by the WIRB-Copernicus Group Institutional Review Board (Office for Human Research Protections and Food and Drug Administration Institutional Review Board registration number: IRB00000533). Intervention group participants acknowledged and provided research consent. The institutional review board deemed the comparison group participants exempt from providing informed consent.
For the primary objective of this feasibility study, we examined engagement, acceptability, and safety outcomes to demonstrate that it was possible to implement the program and this study
To assess the intervention group’s engagement, data on the number of app-based exercise therapy sessions and educational articles accessed per week were collected through the app. Acceptability was measured through the Net Promoter Scores (NPSs) that participants provided for the following question: “On a scale of 0-10, how likely is it that you would recommend the surgical program to a friend or colleague” (0=not likely; 10=very likely)? NPSs ranging from 0 to 6 were labeled as
Safety was based on self-reported postsurgical complications, which included wound infections requiring antibiotics or surgery, blood clots or deep vein thrombosis, stiffness requiring manipulation under anesthesia, falls, surgery on the same knee for other reasons, and general soreness.
The clinical outcomes included pain improvement, function, anxiety, and depression. Patient Global Impression of Change (PGIC) scores were measured for both groups through the following question: “Compared to before the surgery, how would you rate your knee pain now” (1=much worse; 7=much improved)? Function was measured through the Knee Injury and Osteoarthritis Outcome Score–Physical Function Short Form (KOOS-PS; 0=no difficulty; 100=extreme difficulty). Anxiety and depression were measured through the General Anxiety Disorder 2-Item (GAD-2) and Patient Health Questionnaire 2-Item (PHQ-2), respectively.
We measured the length of stay in the hospital after surgery based on the following question: “How many nights did you spend in the hospital or surgery facility after your surgery?” Surgery satisfaction was measured based on the following question: “Overall, how satisfied were you with the results of your knee replacement surgery” (0=very dissatisfied; 3=very satisfied)? Physical therapy adherence was measured through the following question: “How often did you perform home exercise sessions as recommended by your in-person physical therapist” (0=never; 5=always)?
The web-based program registration process provided baseline demographic data for the intervention group. Surveys that evaluated postoperative outcomes were emailed to both the intervention group and the comparison group. Intervention group respondents received gift cards worth US $30 upon the completion of the survey.
Because this was a feasibility study, no formal sample size calculations were conducted. Summary statistics were estimated for the baseline demographic characteristics of the intervention group. Descriptive statistics for the postoperative outcomes of both the intervention group and the comparison group were reported, including means with SDs and medians with IQRs. Differences between the postoperative results of the two groups were compared by using the independent samples 2-tailed
Altogether, 53 participants completed the study (intervention group: n=22; comparison group: n=31).
Study participant characteristics.
Characteristics | Intervention group (n=22), n (%) | Comparison group (n=31), n (%) | All participants (N=53), n (%) | |||||||
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<.001a | |||||||||
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30-44 | 0 (0) | 4 (13) | 4 (8) |
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45-60 | 5 (23) | 20 (65) | 25 (47) |
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>60 | 17 (77) | 7 (23) | 24 (45) |
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.57b | |||||||||
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Male | 6 (27) | 12 (39) | 18 (34) |
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Female | 16 (73) | 19 (61) | 35 (66) |
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.99a | |||||||||
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June | 1 (5) | 2 (7) | 3 (6) |
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July | 3 (14) | 5 (16) | 8 (15) |
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August | 2 (9) | 4 (13) | 6 (11) |
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September | 4 (18) | 7 (23) | 11 (21) |
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October | 5 (23) | 6 (19) | 11 (21) |
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November | 4 (18) | 3 (10) | 7 (13) |
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December | 3 (14) | 4 (13) | 7 (13) |
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aFisher exact test.
bChi-square test with continuity correction.
cMonths of surgery are from 2021.
On average, intervention group participants completed 23 (SD 34.8) exercise therapy sessions, read 2.7 (SD 5.3) educational articles, sent 45.5 (SD 51.7) text messages to their health coaches, and were actively engaged for 6 (SD 6.7) weeks after their operation. Among 21 program participants, 14 (67%) were promoters on the NPS.
The percentage of participants who reported postsurgical complications was higher in the comparison group versus the intervention group by 21%. The reported complications among comparison group members were stiffness (4/15, 27%), surgery on the same knee for other reasons (4/15, 27%), blood clots or deep vein thrombosis (4/15, 27%), wound infections requiring antibiotics (2/15, 13%), general soreness (2/15, 13%), infections requiring surgery (1/15, 7%), and falls (1/15, 7%). The complications among the intervention group were stiffness (4/6, 67%) and vasculitis (ie, a latex allergy; 1/6, 17%). Manipulation for addressing stiffness was recommended for a patient, but the treatment was deferred (1/6, 17%).
The intervention group reported better knee pain after their surgery compared to that reported by the comparison group (PGIC score: mean 7.0 vs mean 6.0;
The median length of hospital stay was 1 (IQR 0) night for the intervention group and 1 (IQR 1) night for the comparison group. There was a significant difference (W=275;
Postoperative outcomes.
Outcomes | Intervention group (n=22) | Comparison group (n=31) | All participants (N=53) | |||
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.12a | |||||
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No complications | 16 (73) | 16 (52) | 32 (60) |
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Complications | 6 (27) | 15 (48) | 21 (40) |
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Patient Global Impression of Change score, median (IQR) | 7.0 (1.0) | 6.0 (2.0) | 7.0 (1.0) | .06b | |
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Knee Injury and Osteoarthritis Outcome Score–Physical Function Short Form, mean (SD) | 23.0 (17.4) | 32.5 (15.9) | 28.6 (17.0) | .049c | |
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General Anxiety Disorder 2-Item score, mean (SD) | 0.6 (1.3) | 1.5 (1.6) | 1.1 (1.5) | .01b | |
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Patient Health Questionnaire 2-Item score, mean (SD) | 0.4 (1.1) | 1.6 (1.8) | 1.1 (1.7) | .004b | |
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Length of hospital stay (number of nights), median (IQR) | 1.0 (0) | 1.0 (1.0) | 1.0 (0) | .009b | |
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Physical therapy adherence score, median (IQR) | 4.0 (2.0) | 3.0 (2.5) | 3.0 (3.0) | .06b | |
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Surgery satisfaction score, median (IQR) | 3.0 (1.0) | 2.0 (1.0) | 2.0 (1.0) | .06b |
aChi-square test.
bMann-Whitney
cIndependent samples
This study aimed to assess the feasibility of a novel, digital surgical care program for total knee arthroplasty by (1) examining patient engagement, acceptability, and safety and (2) exploring clinical improvements as well as health care use and experiences. First, we posit that a program that offers clinical, educational, and social support is viable and that it would be well received by persons planning to undergo a total knee arthroplasty. We found that on average, the intervention group remained active in the program by engaging in 23 exercise sessions, reading 2.7 educational articles, and sending 45.5 text messages to their coaches. Satisfaction among the intervention group was high, as two-thirds of participants (14/21, 67%) were NPS promoters.
We also demonstrated that the intervention was safe. The most frequently reported complication from the intervention group was stiffness, which can be expected postoperatively. Manipulation under anesthesia for stiffness was recommended for a patient by the surgeon but was deferred by the patient. The remaining complication (a latex allergy) was unrelated to the surgery itself. The intervention group also experienced fewer adverse events and complications than those experienced by the comparison group. One possible explanation is that the intervention helped participants adhere to postsurgical exercise regimens and avoid complications. Another explanation is the presence of unmeasured confounding variables. For example, intervention group members may have received a higher quality of in-person care compared to the care that the comparison group received.
The results of this study will be used in two formative projects. In the first project, we will use the lessons learned in this study to refine and improve the program. For example, we learned more about the nature of the complications experienced by both the intervention group and the comparison group. We may prepare additional tools and resources for participants about how to identify complications, when to contact providers for help, and how to best recover from complications. In the second project, we will use the estimates from this preliminary study to develop a larger observational study that is powered to detect statistically significant differences between an intervention group and comparison group. Furthermore, implementing the surgical care program at scale will allow us to further evaluate intervention effectiveness in a more generalizable setting.
We provide preliminary evidence that an intervention that offers clinical and social support is associated with better clinical outcomes, including better impressions of change, function, anxiety, and depression scores after surgery. These results are consistent with those of a qualitative study that found that patients who had a positive total knee arthroplasty experience often reported having adequate social and clinical support [
The strengths of this study include evaluating multiple outcomes to demonstrate program feasibility, including engagement, acceptability, safety, clinical, and health care use and experience outcomes. This study also included a comparison group for comparing postoperative outcomes.
This study however also presents limitations. As with most retrospective studies, there is a risk of bias associated with data that are collected prior to the start of a study. This study compared the postoperative outcomes of the intervention and comparison groups. A future, larger-scale observational study that compares both preoperative outcomes and postoperative outcomes with those of a comparison group, as well as surgeries in other pathways (eg, total hip arthroplasty), can provide more insight into the effectiveness of a digital musculoskeletal surgical care program. Lastly, this study was designed to demonstrate feasibility with a small set of early surgical care program members and a convenience sample comparison group. As such, there are differences between the two groups that may have influenced our exploratory clinical outcomes. The preliminary findings of this study are encouraging, and they will be used as the basis for the next steps in program development, that is, in research where we will adjust for potential confounding factors.
Our digital musculoskeletal surgical care program, which provides social support, medical advice, and education to those who have recently undergone total knee arthroplasty, is feasible and acceptable. We demonstrated engagement, satisfaction, and safety among the participants of the program. Additionally, compared to the comparison group, this study showed preliminary evidence of improved clinical outcomes, lower health care use, and higher satisfaction among intervention group participants. Based on the results of this feasibility study, a larger-scale observational study can build on the findings of this study to further evaluate the effectiveness of the surgical care program.
General Anxiety Disorder 2-Item
Knee Injury and Osteoarthritis Outcome Score–Physical Function Short Form
Net Promoter Score
Patient Global Impression of Change
Patient Health Questionnaire 2-Item
Hinge Health, Inc, provided the digital musculoskeletal surgical care program to participants.
MH, MY and JFB designed the study. MH and MY analyzed the data. MH, JL, MY, and JFB interpreted the data and were major contributors in writing the manuscript. MH, JL, MY, and JFB read and approved the final manuscript.
MH and JL are Hinge Health, Inc, employees and have equity interest in Hinge Health, Inc.