Developing a new intervention to improving kneeling after knee replacement

Motif

Supervisors

  • Dr Vikki Wylde – Associate Professor in Musculoskeletal Health, Bristol Medical School with expertise in health services research
  • Dr Katie Whale – Research Fellow in Qualitative Health Research, Bristol Medical School with expertise in health psychology, intervention development and qualitative methods
  • Professor Mike Whitehouse – Professor of Trauma and Orthopaedics, Bristol Medical School with expertise in developing and piloting early-stage orthopaedic interventions

Theme

Surgical and orthopaedic innovation  

Keywords

Kneeling, knee replacement, intervention development, qualitative, quantitative

Background

Approximately 100,000 total knee replacement (TKR) operations are performed annually in the NHS. Kneeling ability is consistently one of the poorest outcomes after TKR, with 60–80% of patients reporting difficulty kneeling or an inability to kneel. Problems with kneeling impacts on many areas of life, including activities of daily living, self-care, social activities, religious activities, employment and getting up after a fall. Given the wide range of activities that involve kneeling, and the expectation that this will be improved with surgery, problems kneeling after TKR are a source of dissatisfaction and disappointment for many patients.

Research suggests that patients can physically kneel after TKR but elect not to. Reasons for this are multifactorial, including knee pain/discomfort, numbness, fear of harming the prosthesis, co-morbidities and recommendations from health professionals. There is currently no evidence that there is any clinical reason why patients should not kneel on their replaced knee, and reasons for not kneeling could be addressed through education and rehabilitation.

To date, there has been little research to evaluate the provision of healthcare services and interventions for patients who find kneeling problematic after TKR. Research to inform the provision of services is needed to improve patient care and allow patients to return to this important activity.

Aims and objectives

The aim of this project is to design a new intervention to support patients with kneeling after TKR. Specific objectives include:

  1. Evaluate the existing evidence and current service provision, to understand the context in which a new intervention would be implemented
  2. Explore the needs and preferences of patients who experience difficulty kneeling after TKR and the views of healthcare professionals who provide care for these patients
  3. Gain consensus from patients and healthcare professionals on the design of the intervention, including the content, format and mode of delivery

Methods

This project will involve a series of quantitative and qualitative studies to inform the design of a new intervention to improve kneeling after TKR. These include:

  1. Systematic review of the literature to identify randomised and non-randomised studies that have evaluated interventions to improve kneeling after TKR
  2. National online survey of approximately 50 NHS orthopaedic centres to understand current service provision in relation to supporting kneeling after TKR and identify potential barriers and facilitators to implementing a new intervention
  3. Qualitative interviews or focus groups with patients who have undergone TKR surgery to explore their experiences, needs and preferences in relation to kneeling
  4. Qualitative interviews or focus groups with healthcare professionals to understand how to design an intervention that could be implemented within the NHS
  5. Co-work with patient representatives to develop a preliminary intervention design, using relevant theory e.g. health psychology, behaviour change, sociology, and implementation science.
  6. Consensus study, such as a Delphi survey, with patients and healthcare professionals to finalise the intervention design.

The project will involve working closely with a patient and public involvement (PPI) group to ensure that the intervention is acceptable and addresses the needs of patients.

Expected knowledge, skills and attitudes to be gained

This project provides the opportunity to gain a strong multifaceted skillset in qualitative and quantitative methods applied to healthcare intervention development. The student will gain knowledge and experience of protocol writing, preparation of study documents, and gaining relevant governance approvals.

Quantitative skills will be developed in evidence synthesis through the conduct of a systematic review, including designing literature searches, screening records, extracting data from articles and performing narrative synthesis or meta-analysis.

The national survey and consensus survey will provide the opportunity to develop skills in questionnaire design, data cleaning and descriptive quantitative data analysis. Qualitative research methodology skills that will be gained include designing and conducting in-depth interviews and/or focus groups with different stakeholder groups, coding and analysing data, and applying the findings to inform intervention design.

The student will develop knowledge of how to apply theory to intervention design and support behaviour change.

This project would suit students with a social science or health science undergraduate degree and/or some experience of qualitative research.

Project references

  1. Amin RM, Vasan V, Oni JK. Kneeling after Total Knee Arthroplasty. J Knee Surg. 2020 Feb;33(2):138-143
  2. Fletcher D, Moore AJ, Blom AW, Wylde V. An exploratory study of the long-term impact of difficulty kneeling after total knee replacement. Disabil Rehabil. 2019 Apr;41(7):820-825
  3. Sabeh KG, Hernandez VH, Cohen-Levy WB, Ong A, Orozco F, Bennett V, Post Z. The Effects of Patient Occupation, Hobbies, and Body Mass Index on Kneeling after Total Knee Arthroplasty. J Knee Surg. 2021 Jun;34(7):772-776
  4. Smith JRA, Mathews JA, Osborne L, Bakewell Z, Williams JL. Why do patients not kneel after total knee replacement? Is neuropathic pain a contributing factor? Knee. 2019 Mar;26(2):427-434
  5. Wylde V, Artz N, Howells N, Blom AW. Kneeling ability after total knee replacement. EFORT Open Rev. 2019 Jul 7;4(7):460-467