How do patients, physiotherapists and orthopedic surgeons perceive delayed recovery during total knee arthroplasty rehabilitation? A qualitative study

How do patients, physiotherapists and orthopedic surgeons perceive delayed recovery during total knee arthroplasty rehabilitation? 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A qualitative study Anke van den Broek, J. Bart Staal, Maaike G.J. Gademan, Thea Vliet Vlieland, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9291961/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background. Although total knee arthroplasty (TKA) and its physiotherapeutic rehabilitation process are among the most frequently performed medical interventions, a substantial proportion (10-30%) of patients is not satisfied with their recovery. Early identification of delayed recovery would enable timely adjustments of the rehabilitation process. This study aimed to explore and compare the perceptions of patients, physiotherapists, and orthopedic surgeons regarding delayed recovery during TKA rehabilitation. Methods. Three focus group meetings were organized: patients (n=6), physiotherapists (n=6), and orthopedic surgeons (n=5). Focus group meetings were structured around three predefined topics regarding delayed recovery during TKA rehabilitation: (i) most important outcome domains, (ii) how and when delayed recovery can be identified, and (iii) most important prognostic factors of (delayed) recovery. To facilitate the discussion of the third topic, a rapid review of reviews was performed prior to the focus group meetings, to compile a list of prognostic factors consistently associated with TKA rehabilitation recovery, as reported in recent systematic reviews. Results. The focus group meetings showed that patients prioritized pain relief as most important outcome domain of TKA rehabilitation recovery, whereas physiotherapists prioritized physical function, and orthopedic surgeons patient satisfaction. According to the physiotherapists, delayed recovery can already be identified within the first six weeks after TKA, while orthopedic surgeons mentioned much longer periods before delayed recovery can be determined. All three stakeholder groups perceived patient expectations as an important prognostic factor of TKA rehabilitation recovery. Besides this factor, physiotherapists and orthopedic surgeons mostly prioritized other patient-related factors, whereas patients considered predominantly external factors as important prognostic factors of recovery during TKA rehabilitation. Conclusion. This study found similarities but mostly differences in how patients, physiotherapists and orthopedic surgeons perceive delayed recovery during TKA rehabilitation, and which prognostic factors they consider to be most important in this recovery. Our findings suggest that consensus is needed among clinicians on how and when TKA recovery should be considered as delayed. Future research should confirm that patient expectations are an important prognostic factor as well as a potential treatment target in TKA rehabilitation that could result in optimization of TKA rehabilitation outcomes. Total knee arthroplasty Rehabilitation Physiotherapy Orthopedics Recovery Outcome domains Prognostic factors. Introduction Total knee arthroplasty (TKA) is one of the most frequently performed surgical procedures worldwide, and its incidence is still increasing (Kurtz et al., 2011 ; van Veghel et al., 2025 ). This procedure is widely regarded as a successful and cost-effective intervention for managing advanced symptomatic knee osteoarthritis (OA) (Kamaruzaman et al., 2017 ). After TKA, postoperative physiotherapy in primary care for a period of 3 to 6 months is standard practice (Groot et al., 2022 ; Jette et al, 2020 ). While many patients recover well during TKA rehabilitation, a substantial proportion (10–30%) is not satisfied with their recovery (Beswick et al., 2012 ; Bourne et al., 2010 ; DeFrance et al., 2023; Gunaratne et al., 2017 ; Halawi et al., 2019 ). Apart from the impact on the individual patients, unsuccessful TKAs lead to a significant societal and economic burden, including increased costs due to prolonged work absenteeism and at-work productivity loss (Hylkema et al., 2019 ; Marsh et al., 2022 ; Tilbury et al., 2015). Currently, it is challenging to predict recovery during TKA rehabilitation (Halvorson et al., 2024 ). This may be due to previous prognostic research (Dowsey et al., 2016 ; Duan et al., 2023 ; Gokhale et al., 2023 ; Halvorson et al., 2024 ; Harmelink et al., 2017 ; Pua et al., 2019; Sanchez-Santos et al., 2018; Santaguida et al., 2008; Waheeb et al., 2015) predominantly focusing on acute (e.g., first week after surgery) rather than long-term outcomes, and on preoperative rather than postoperative) predictors, as well as a lack of consensus regarding the definition of delayed or unsuccessful recovery. As a result, international guidelines (e.g., Jette et al., 2022) provide limited guidance on how to predict and optimize this recovery, leading to suboptimal TKA rehabilitation. Potentially, early prediction of recovery could enable timely treatment adjustments and improve outcomes (George et al., 2020 ; Sinnige et al., 2022 ; Van der Groen et al., 2024). Considering the enormous and even further increasing number of TKA procedures performed annually and the substantial proportion of TKAs failing to achieve the desired outcome, it is important to gain new insights into the prediction of delayed recovery during TKA rehabilitation. Recent qualitative studies explored patients’ (Singh et al, 2021 ; Te Molder et al., 2024a ; Te Molder et al., 2024b ) and professionals’ perceptions of TKA outcomes (Te Molder et al., 2024a ; Te Molder et al., 2024b ), with a primary focus on negative outcomes such as adverse consequences. Thus, there remains limited understanding of how (differently) patients, physiotherapists, and orthopedic surgeons perceive delayed recovery during the TKA rehabilitation process, and which prognostic factors play a role in this (delayed) recovery. Addressing these gaps would be a next step towards early prediction and optimization of TKA rehabilitation outcomes. The overall objective of this study is to explore and compare the perceptions of patients, physiotherapists, and orthopedic surgeons regarding delayed recovery during TKA rehabilitation. Specifically, the study focused on three predefined topics: (i) most important (positive and negative) outcome domains for TKA rehabilitation, (ii) how and when delayed recovery can be identified during the TKA rehabilitation process, and (iii) most important prognostic factors of (delayed) recovery during TKA rehabilitation. To facilitate the discussion of the third topic, a rapid review of reviews was performed prior to the focus group meetings, to compile a list of prognostic factors consistently associated with TKA rehabilitation recovery, as reported in recent systematic reviews. Methods Study Design A qualitative study design, to gain insight into the perceptions of patients, physiotherapists, and orthopedic surgeons regarding aspects of delayed recovery during TKA rehabilitation. Reporting of the qualitative study was done according to the Consolidated Criteria for REporting Qualitative Research (COREQ) (Tong et al., 2007 ). Focus groups Three online focus groups were conducted, each with a distinct stakeholder group: patients, physiotherapists, and orthopedic surgeons. Each focus group was intentionally designed to be homogenous in terms of participant type (i.e., patients, physiotherapists, or orthopedic surgeons), to create a comfortable environment where participants can speak more freely and to ensure focused discussions (Krueger, 2014 ). A maximum of six participants per focus group was chosen to ensure in-depth discussions, individual input and richer exchanges of perspectives (Smith et al., 2009). We chose online meetings to enable participation from different locations without the need for travel (Jones et al., 2022 ; Lee et al., 2024). We applied a deductive approach (i.e., use of semi-structured interview guide with predefined topics) in combination with elements of nominal group technique to facilitate structured discussion, enhance participant engagement and achieve consensus within each stakeholder group (McMillan et al., 2016 ; Rankin et al., 2016; Harvey et al., 2012). Recruitment and selection Purposive sampling was used to recruit participants who met the predefined inclusion criteria (Appendix 1). Patients were recruited from an ongoing multi-center, prospective cohort study (Longitudinal Leiden Orthopedics Outcomes of Osteoarthritis Study (LOAS) (Tilbury et al., 2020; Groot et al., 2022 )). Since 2012, that study includes patients scheduled for primary TKA or total hip arthroplasty as a result of osteoarthritis. A research assistant from the LOAS study contacted potentially eligible participants for the current qualitative study via phone, but only if they had previously given consent for being contacted for future research. If this would not be sufficient, patients were additionally recruited from the network of the project group or via the participating physiotherapists or surgeons. Physiotherapists and orthopedic were recruited from six primary care physiotherapy practices and five hospitals, respectively, with one person per site allowed. If this would not be sufficient, additional candidates were recruited from the network of the project group. For the focus group with patients, we aimed for diversity in terms of age, gender, educational level, and whether they were satisfied or dissatisfied with their perceived recovery after TKA. For the focus group with physiotherapists and with orthopedic surgeons, diversity was sought in age, gender, and working experience in TKA rehabilitation/procedures. Study procedure All potentially eligible participants received an information letter, outlining the study background, aims, and design, and a consent form to sign. After having provided informed consent, three focus groups were scheduled between June and September 2024. One week before the focus group meeting, participants were asked to complete a brief online questionnaire via Microsoft Forms (Microsoft Corporation, Redmond, WA). Next to collecting general characteristics (for patients; age, gender, time since TKA, duration (in months and number of sessions) of physiotherapy rehabilitation, and whether they were satisfied (yes/no) with their recovery); for physiotherapists and surgeons: age, gender, profession, education, work experience, TKA rehabilitation/surgery experience), the questionnaire allowed participants to independently reflect on the three main topics by filling in four open-ended questions. This would ensure that each participant had time to carefully consider the topics before engaging in the focus group discussion. A semi-structured interview guide with open-ended questions was constructed, as shown in Appendix 2. The focus groups were structured into three parts, each dedicated to one of the three main topics: most important (positive and negative) outcome domains of recovery during TKA rehabilitation; how and when delayed recovery during the TKA rehabilitation process can be identified; most important prognostic factors of (delayed) recovery during TKA rehabilitation. To facilitate the discussion of the third topic, a rapid review of reviews was performed prior to the focus group meetings. Aim of this review was to pragmatically compile a list of prognostic factors consistently associated with TKA rehabilitation recovery, as reported in the most recent systematic reviews (i.e., published since the review of Harmelink et al 2017 ). We included systematic (umbrella) reviews reporting associations between prognostic factors and outcome domains pain and/or physical functioning, with follow-up points exceeding 6 months post-TKA. Reviews were identified through a PubMed search strategy (see Appendix 3). From the selected reviews, prognostic factors were derived if reported in at least two individual studies with consistent evidence which we defined as ≥ 75% of these studies reporting a statistically significant association in the same direction). This definition is in line with the Cochrane Collaboration Back Review Group (Van Tulder et al., 2013) and used by for example Van der Worp et al., 2015 . The focus group meetings followed the subsequent stages of the nominal group technique: round robin, clarification, and voting (McMillan et al., 2016 ). The ‘round robin stage’ involved participants sharing their ideas one at a time, with each response being recorded for further discussion. The summarized responses from the questionnaire served as the foundation for the group discussion (‘silent generation of ideas’). The ‘clarification stage’ allowed participants to expand on their responses, ask for clarification, and evaluate the importance of the ideas in the context of the study. In the ‘voting stage’, participants collaboratively discussed the ideas generated and came to a consensus on which answers, ideas, or themes were the most important for each main topic. When applicable, insights from previous focus group(s) were incorporated into subsequent ones. All three online focus group meetings were conducted using Microsoft Teams (Microsoft Corporation, Redmond, WA). Each focus group was led by a moderator (AvdB) and supported by an observer (JK). The moderator followed the semi-structured interview guide, encouraged active participation from all patients, and facilitated interaction among participants. Meanwhile, the observer took notes, ensured the continuity of the recordings, and assisted the moderator when needed. With permission from participants, focus group meetings were audio recorded. Data analysis The questionnaire was analyzed descriptively, using numbers and percentages (for categorical variables) and median, minimum and maximum (for continuous variables). The focus group meetings were transcribed, coded and interpreted qualitatively, using elements of thematic analysis (Braun and Clarke, 2006 ; Braun and Clarke, 2021 ). After each group meeting, one researcher (AvdB) analyzed the audio recordings, cross-referenced them with the notes and verified the completeness of the data analysis. The detailed minutes of the focus group were sent to participants via email to check whether this reflected the views of participants (Morse et al., 2002 ). Results Literature review For the rapid review of reviews facilitating the discussion of the third topic, from a total of 18 eligible reviews published since 2017, the three most recent reviews focusing on the outcomes pain and physical function were selected. These were an umbrella review of reviews by Fernandez-de-las-Penas et al. (2023) (outcome: pain), and two systematic reviews by Olsen et al.: Olsen et al. (2022) (outcome: physical function) and Olsen et al. (2023) (outcome: pain). From these three reviews, 11 prognostic factors with consistent evidence were derived (see Table 1 ). Factors consistently associated with more pain during/after TKA-rehabilitation were more preoperative pain (Fernandez-de-las-Penas et al. (2023); Olsen et al. (2023)), presence of chronic pain (Fernandez-de-las-Penas et al. (2023); Olsen et al. (2023)), central sensitization (Fernandez-de-las-Penas et al. (2023)), anxiety (Fernandez-de-las-Penas et al. (2023); Olsen et al. (2023)), and pain catastrophizing (Fernandez-de-las-Penas et al. (2023); Olsen et al. (2023)); factors consistently associated with less pain were higher radiological severity of knee OA (Kellgren-Lawrence (KL) grade) (Olsen et al. (2023)) and more social support (Fernandez-de-las-Penas et al. (2023); Olsen et al. (2023)). Factors consistently associated with worse physical functioning during/after TKA-rehabilitation were BMI and walking aid use; factors consistently associated with better physical functioning were better preoperative physical functioning, higher radiological severity of knee OA (KL grade), and more knee joint mobility (all reported in Olsen et al. (2022)). Table 1 Prognostic factors identified in rapid review of reviews Pain Physical function • Preoperative pain • Severity of osteoarthritis (KL grade) • Chronic (knee) pain • Central sensitization • Anxiety • Pain catastrophizing • Social support • Preoperative physical function • Preoperative knee joint mobility • BMI • Walking aid use BMI: Body Mass Index; KL: Kellgren Lawrence. Focus group meetings Participant characteristics Twelve patients were approached, of whom six participated: three from the LOAS cohort study and three via one of the researchers’ (AvdB) own network. From nine invited physiotherapists, six participated. One physiotherapist did not fully meet the requirement of two years of experience, but was deemed eligible due to his/her amount of supervised TKA-rehabilitation trajectories. From ten invited orthopedic surgeons, five participated. One orthopedic surgeon did not fully meet the requirement of performing 30 TKA procedures a year, but was included for his/her extensive prior experience. Characteristics of focus group participants are presented in Table 2 . The focus group meetings were conducted in the following order: physiotherapists (duration 86 minutes), orthopedic surgeons (68 minutes), and patients (85 minutes). Thematic analysis The consensus-based results for each of the three topics are presented separately for each stakeholder group below, and summarized in Table 3 . Table 2 Characteristics of focus group participants*. Female Patients (n = 6) Physiotherapists (n = 6) Orthopedic surgeons (n = 5) 4 (66.7) 3 (50) 1 (20) Age (years) 66 (50–76) 43 (23–60) 47 (41–66) Highest level of education High school Vocational or technical school University or college 3 (50.0) 2 (33.3) 1 (16.7) --- --- --- --- --- --- Time elapsed since TKA (years) 2.25 (1–5) --- --- TKA rehabilitation Duration (months) Number of PT-sessions 3–12 sessions 25–36 sessions 6 (3–10) 2 (33.3) 4 (66.7) --- --- --- --- --- --- Satisfied with recovery after TKA rehabilitation (yes) 4 (66.7) --- --- Working experience with TKA patients (years) --- 18 (2–30) 14 (10–35) Number of TKA patients per year --- 13 (10–25) 150 (15–160) *Values are numbers (percentage) or median (range; i.e., min-max); PT = physiotherapy; TKA = total knee arthroplasty. Table 3 Consensus-based results on the three topics by stakeholder group. Topic Patients Physiotherapists Orthopedic surgeons Most relevant outcome domains during TKA rehabilitation • Being pain-free, allowing the return to activities important for the patient, such as ADL, work, hobbies, and sports • Physical functioning in ADL, work, and sports, for which outcomes at the impairment level (e.g., pain, ROM, stability) are prerequisite • Meeting patient expectations and patient satisfaction • Pain and its related physical functioning in ADL, work, and sports • Technically well-performed surgery, with no infection occurring How and when to identify delayed recovery during TKA rehabilitation • If there is no improvement in recovery after 6–8 months and it is still not possible to perform certain activities that are important to the patient and should be possible according to the physiotherapist • A lack of progress in comparison to expected outcomes based on preoperative status and exercise frequency, with no improvement despite modifications to the treatment plan • Delayed recovery could generally be identified within 6 weeks post-TKA: reduced ROM, in particular knee flexion (4–6 weeks), persistent pain that does not decrease (6 weeks), wound healing (1 week), stiff gait pattern with a non-relaxed swing phase (6 weeks) • 6 weeks to 3 months post-TKA: functional impairment in the knee, with extension deficits being considered more significant than flexion deficits • 9 to 12 months post-TKA: pain and ADL outcomes do not reach the expected level for the patient Most important prognostic factors for (delayed) recovery during TKA-rehabilitation* • Positive, realistic patient expectations, managed by preoperative patient education • Physiotherapist’s guidance during rehabilitation • Social support and well-prepared home environment • Post-TKA pain medication • Obesity • Positive, realistic patient expectations • Psychological factors (e.g., fear of movement, pain perception, coping strategies, confidence in movement, illness/pain perceptions) • Preoperative status (particularly limited knee extension and history of chronic (knee) pain/central pain mechanisms) • Active rehabilitation approach • Positive, realistic patient expectations • Psychological factors (e.g., pain catastrophizing, fear of movement, coping strategies, motivation, anxiety, depression) • Preoperative status (particularly better physical functioning) • Work conflict ADL: activities of daily living; ROM: range of motion; TKA: total knee arthroplasty. *consensus for a top 3–5 was attempted to reach within each focus group Topic 1: Most relevant (positive and negative) outcome domains Patients All six patients mentioned pain as the most relevant outcome domain during TKA rehabilitation. Pain relief was considered to enable better sleep, regain activities of daily living (ADL), and return to hobbies, sport, or work, and longer walking and cycling distances. Both two patients who were not satisfied with their recovery after TKA mentioned persistent pain hindering their activities as most important outcome domain. Physiotherapists The majority of the participating physiotherapists identified physical functioning as a key outcome domain during TKA rehabilitation. They emphasized the importance of patients regaining independence in ADL and achieving functional use of the knee, including activities such as walking and cycling. Additionally, the ability to participate in sports and return to occupational activities, when applicable, was regarded as important. Outcomes such as pain reduction, knee range of motion (ROM), knee stability, and gait pattern were viewed as prerequisites for achieving the patient-specific goals. Orthopedic surgeons Orthopedic surgeons emphasized that patient satisfaction (by meeting the patient’s expectations) is the most relevant outcome domains during TKA rehabilitation. Orthopedic surgeons described patient satisfaction as multifaceted and sometimes unpredictable, referring to it as a black box. While a technically well-executed surgery without complications was considered a prerequisite for success, it was mentioned that a well-executed TKA was not always decisive for patient satisfaction. Pain and physical functioning, particularly in ADL, work, or sports, were also identified as important outcome domains, despite difficulties regarding their subjective nature. Topic 2: How and when to identify delayed recovery Patients Most patients indicated that they would be concerned if there was no improvement and they were unable to perform important activities after on average 6–8 months post-TKA. Two patients emphasized that understanding what to expect, especially during the first months after TKA, helped them manage their recovery process more effectively. Patients considered physical complaints during this first period (3 months) challenging but normal. Physiotherapists Most physiotherapists stated that delayed recovery could generally be identified already within 6 weeks post-TKA. They mentioned reduced knee mobility (in particular knee flexion) at 4–6 weeks as a first sign of delayed recovery, and that in such cases an orthopedic surgeon or hospital-based physiotherapist may need to be consulted. While pain alone was not considered a definitive indicator of delayed recovery, physiotherapists considered pain accompanied with other issues like reduced mobility to be concerning, within the first 6 weeks. Also wound complications, such as poor closure or leakage, were flagged as signs of delayed recovery. Physiotherapists stressed the importance of prompt referral to the orthopedic surgeon within one week to prevent infection. Additionally, abnormal gait patterns, such as a stiff walk without a relaxed swing phase, were noted as contributing to delayed recovery, as they could exacerbate pain and hinder progress. Orthopedic surgeons Orthopedic surgeons generally believed that the 6-week period that was mentioned by the physiotherapists is too early to determine delayed recovery. They recognized that patients are often referred to them by worried physiotherapists within this early stage. Such cases usually do not require intervention rather than reassurance, as symptoms often improve over time, according to the orthopedic surgeons. Orthopedic surgeons did acknowledge limited knee mobility in the period from 6 weeks to 3 months to be concerning. For example, if a patient still does not achieve 90 degrees of knee flexion and has a knee extension deficit of 15–20 degrees at 3 months, referral to the surgeon may be warranted to assess whether an intervention is necessary. One surgeon emphasized the greater importance of extension deficits over flexion limitations, as activities such as walking can still be performed with 60 degrees of flexion. In the period between 9 to 12 months post-TKA, orthopedic surgeons defined delayed recovery as suboptimal progress in physical functioning and/or persistent pain. By this stage, most patients should have achieved their goals, provided that these were formulated realistically. All surgeons stressed the importance of informing patients that recovery from a TKA is a lengthy process. While many patients experience most of their improvements within a year, further progress in pain relief and function can continue between 2 and 5 years postoperatively. Topic 3: Prognostic factors for TKA rehabilitation recovery Patients Patients mentioned several prognostic factors that could positively influence recovery during TKA rehabilitation, such as adequate guidance from the physiotherapist, a supportive home environment (including social support and a well-prepared home situation), adequate (pre-operative) patient education resulting in realistic expectations for recovery, and effective (post-surgery) pain medication management. Patients also identified several prognostic factors that could impede recovery, with obesity considered to be most important, while other factors mentioned being overloading the knee too early after TKA, complications during or after surgery (such as infection), insufficient pain relief in the early postoperative phase (particularly during the first few days), mental health (i.e., anxiety and depression), and severely limited preoperative knee joint mobility. After being informed on the prognostic factors consistently associated with TKA outcomes as reported in the literature, the group discussion resulted in a consensus-based top-5 of most important prognostic factors: patient expectations (being positive but realistic, managed by preoperative patient education), physiotherapist’s guidance during rehabilitation, social support and well-prepared home environment, post-TKA pain medication and obesity. Physiotherapists According to the physiotherapists, the most important prognostic factors for recovery after TKA were (positive but realistic) patient expectations, psychological factors (such as illness or pain perception, fear of movement, anxiety), coping style, motivation and preoperative status (particularly limited knee extension and history with chronic pain or central pain mechanisms). Building trust and an active treatment strategy were also identified as important to recovery, particularly for patients with negative coping styles or low self-efficacy. Regarding patient expectations, they emphasized the need for preoperative education in which realistic expectations about the recovery process and realistic goals should be discussed to avoid disappointment and to ensure commitment to rehabilitation. Other prognostic factors that were noted included inadequate pain management, inadequate social support and insufficient physical capacity. After being informed on the prognostic factors consistently associated with TKA outcomes as reported in the literature, the group discussion resulted in a consensus-based top-4 of most important (categories of) prognostic factors: patient expectations (being positive but realistic), psychological factors (e.g., fear of movement, pain perception, coping strategies, confidence in movement, illness/pain perceptions), preoperative status (particularly limited knee extension and history of chronic (knee) pain/central pain mechanisms) and active rehabilitation approach. Orthopedic surgeons Orthopedic surgeons identified several prognostic factors that positively influence recovery during TKA rehabilitation, with positive but realistic patient expectations (and goals) as the most important one. First, they emphasized the importance of patients understanding the gradual nature of recovery, in which initial post-operative pain is normal. In addition, similar to the physiotherapists, they stressed the importance of establishing realistic goals through preoperative discussions, ensuring that patients have a clear understanding of what to expect from the procedure. Other prognostic factors that, according to orthopedic surgeons, could positively influence recovery were worse preoperative functional status, having social support (particularly the presence of a partner at home), financial stability, positive mindset, and pro-active role of the patient during rehabilitation. The following prognostic factors were identified that could impede recovery, namely unrealistic expectations, passive coping style, psychological factors (such as anxiety, depression, pain catastrophizing), low physical activity and work-related issues (such as physical labor and work conflicts). Also strength training with too much intensity too soon in the TKA-rehabilitation was mentioned as factor that could hinder recovery.After being informed on the prognostic factors consistently associated with TKA outcomes as reported in the literature, the group discussion resulted in a consensus-based top-4 of most important (categories of) prognostic factors: patient expectations (being positive but realistic), psychological factors (e.g., pain catastrophizing, fear of movement, coping strategies, motivation, anxiety, depression), preoperative status (particularly better physical functioning) and work conflict. Discussion This qualitative study on delayed recovery during the rehabilitation phase following TKA showed that patients, physiotherapists and orthopedic surgeons had different perspectives. According to physiotherapists, delayed recovery can already be identified in the first phase of rehabilitation, while patients and especially orthopedic surgeons mentioned longer periods to determine delayed recovery. Patients considered being pain free as most important outcome for recovery, physiotherapists prioritized physical functioning, whereas orthopedic surgeons patient satisfaction. Finally, despite some overlap, the stakeholder groups clearly differed in which prognostic factors for delayed recovery they perceived to be most important. The prioritization of most important outcome domains of TKA rehabilitation differed across the three stakeholder groups, with pain being prioritized by patients, physical functioning by physiotherapists and patient satisfaction by orthopedic surgeons. On the other hand, the three stakeholder groups agreed in recognizing the interconnected nature of these three outcome domains. Patients highlighted that pain relief enables them to resume daily activities, a view supported by physiotherapists, who regarded pain reduction as prerequisite for functional recovery. Similarly, while prioritizing patient satisfaction as most important, orthopedic surgeons also acknowledged the importance of pain and physical functioning. These three outcome domains – pain, physical functioning, and patient satisfaction – align with findings from other qualitative studies (Singh et al., 2021 ; Te Molder et al., 2024a ; Te Molder et al.; 2024b ) and are part of the OMERACT core domain set (Singh et al., 2017 ). Te Molder et al. ( 2024b ) suggested that patients may accept some pain if it allows them to perform valued activities, while our study found patients less willing to accept pain, prioritizing it over activities. Besides the three outcome domains, orthopedic surgeons in our study also emphasized the importance of a technically well-performed surgery, consistent with the knee specialists’ views in a previous qualitative study (Te Molder et al., 2024a ). The differences between physiotherapists on the one hand and patients and especially orthopedic surgeons on the other hand in when and how they identify delayed recovery after TKA were remarkable. Physiotherapists argued that limited knee mobility in the first 6 weeks is a sign of delayed recovery that needs direct judgement and possible intervention from the orthopedic surgeon. Orthopedic surgeons mentioned much longer periods to determine delayed recovery in general, but acknowledged that in individual cases with severe knee mobility limitations, direct intervention between 6 weeks to 3 months can be required. This statement from the orthopedic surgeons seems to be in line with Te Molder et al ( 2024a ) in which knee specialists (i.e., combination of mostly orthopedic surgeons and physiotherapists) stated that patients with limited knee mobility within 3 months post-TKA should be referred to the orthopedic surgeon as the knee could need manipulation under anesthesia to regain full range of motion. In general, the orthopedic surgeons in our focus groups stressed that recovery from a TKA is a lengthy process, in which the natural course of recovery should be allowed to proceed without intervention, and in which improvements in pain and physical function can still occur even after a year. This aligns with previous study findings that “getting used to the prosthetic knee” is part of a long process (Te Molder et al,. 2024a). Overall, there appears to be a lack of consensus in clinical practice regarding the definition and time-point of delayed recovery during TKA rehabilitation and thereby also in the indication for orthopedic surgeons to intervene in the first phase of TKA rehabilitation. Although there is considerable overlap in the prognostic factors the three stakeholder groups consider important, some interesting differences were found as well. While both physiotherapists and orthopedic surgeons primarily focused on patient-related factors (such as psychological factors and preoperative status), patients placed greater emphasis on external factors (such as social support and physiotherapist’s guidance during rehabilitation). This patient perspective is particularly interesting, as such factors have barely been included so far in prognostic studies. Most important similarity across the stakeholder groups is that patient expectations were considered to be an important prognostic factor in each group. They all mentioned that prior to surgery, the patient’s expectations of the outcome (and its course) should be positive but also realistic, with especially patients emphasizing the importance of adequate preoperative patient education to set realistic expectations. Such education is important, because patients tend to have overly high expectations going into TKA surgery (Mannion et al., 2009 ; Nilsdotter et al., 2009 ; Neuprez et al., 2016 ). Despite this consensus within clinical practice, the literature does not yet provide strong evidence for an association between patient expectations and treatment outcomes for TKA (Haanstra et al., 2012 ; Culliton et al., 2012 ). This could be attributed to various reasons, such as a lack of a clear definition of the underlying construct of patient expectations, its multifaceted and complex nature, and the varying methods used to measure it (Haanstra et al., 2012 ). Recent studies (Laferton et al., 2022 ; Blum et al., 2021 ) however suggested that patient expectations might be a prognostic factor of TKA-rehabilitation outcome. Another difference between practice-based and literature-based prognostic factors is the emphasis on postoperative factors (e.g. post-operative trajectory of pain and knee mobility, and the physiotherapist’s guidance) in the focus groups, whereas the literature mostly focused on preoperative factors (e.g., preoperative pain and function, radiographic severity). Implications for clinical practice and future research The findings of this study have several implications for clinical practice. Based on the perceived importance of patient expectations as a prognostic factor, these expectations could also be a main treatment target. Enhancing preoperative patient education may lead to more positive, yet still realistic recovery expectations and rehabilitation goals. Furthermore, the findings highlight that consensus between physiotherapists and orthopedic surgeons is needed on how and especially when they identify delayed recovery. This may prevent uncertainty in patients regarding their recovery process. Future research should focus on determining whether practice-based prognostic factors, such as patient expectations and the physiotherapist’s guidance indeed have prognostic value in the (delayed) recovery during TKA rehabilitation. More knowledge on prognostic factors could ultimately lead to an accurate clinical decision support tool in which TKA rehabilitation outcomes can be predicted early in (or even before) the rehabilitation process and could inform treatment decisions if needed. Strengths and limitations The strength of this study is its multi-stakeholder approach, which captures diverse perspectives on recovery following TKA. The use of small focus groups enabled in-depth exploration of experiences, and the modified nominal group technique facilitated consensus within stakeholder groups (Harvey et al., 2012). The study has some limitations. First, despite having used purposeful sampling, the small sample size may not fully reflect the diversity of experiences in the particular profession. Second, the orthopedic surgeon group, consisted of predominantly middle-aged men, lacked diversity, although seems to be an adequate representation of the Dutch population. Third, only one instead of multiple focus groups per stakeholder group was conducted, which may have not been sufficient to achieve saturation (Hennink et al., 2019 ). Fourth, for patients with a successful recovery, it was challenging to discuss delayed recovery, as they could not base this on their own experiences. Conclusion In conclusion, this study found similarities but mostly differences in how patients, physiotherapists, and orthopedic surgeons perceive recovery during TKA rehabilitation. Patients prioritized pain relief as most important outcome domain of TKA rehabilitation recovery, whereas physiotherapists prioritized physical function, and orthopedic surgeons patient satisfaction. Physiotherapists and orthopedic surgeons also differed on how and especially when they identify delayed recovery. All three stakeholder groups considered positive but realistic patient expectations as important prognostic factor for TKA rehabilitation recovery. In addition, physiotherapists and orthopedic surgeons considered patient-related factors as more important, whereas patients consider external factors as more important. Our findings imply that consensus is strongly needed across clinicians on how and especially when delayed recovery can be identified. Future research should confirm that patient expectations are an important prognostic factor as well as a potential treatment target in TKA rehabilitation that could result in optimization of TKA rehabilitation outcomes. Declarations Ethics approval and consent to participate The study was approved by the ethics committee of HAN University of Applied Sciences Nijmegen, Netherlands (approval number ECO 552.05/24). They considered the study not being subject to the Medical Research Involving Human Subjects Act (in Dutch: WMO). Prior to the focus group meetings, written informed consent was obtained from all participants. Consent for publication Not applicable. Competing interests The authors declare they have no competing interests. Funding The study was funded by SIA (project number KIEM.K23.01.063). The funder had no role in the design, organization and execution of the study. Author Contribution AvdB was the executive researcher of this study, and drafted the first version of the manuscript. AvdB and JK conducted the focus group meetings. JBS, MGJG, TVV and JK conceptualized the study, acquired funding, supervised AvdB and provided feedback on the manuscript. All authors contributed to this study and approved the final version of the manuscript. Acknowledgement We would like to thank all patients, physiotherapists and orthopedic surgeons who participated in the focus groups. Data Availability The data generated during these studies will not be publicly available, but will be available upon reasonable request to the corresponding author. References Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. (2012). What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ open, 2(1), e000435. 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Adapting the nominal group technique for priority setting of evidence-practice gaps in implementation science. BMC medical research methodology, 16, 1–9.. Sanchez-Santos, M. T., Garriga, C., Judge, A., Batra, R. N., Price, A. J., Liddle,A. D.,… Arden, N. K. (2018). Development and validation of a clinical prediction model for patient-reported pain and function after primary total knee replacement surgery.Scientific reports, 8(1), 3381.. Santaguida, P. L., Hawker, G. A., Hudak, P. L., Glazier, R., Mahomed, N. N., Kreder,H. J.,… Wright, J. G. (2008). Patient characteristics affecting the prognosis of total hip and knee joint arthroplasty: a systematic review. Canadian Journal of Surgery, 51(6), 428.. Singh JA, Dowsey MM, Dohm M, Goodman SM, Leong AL, Voshaar MMS, Choong PF. Achieving consensus on total joint replacement trial outcome reporting using the OMERACT filter: endorsement of the final core domain set for total hip and total knee replacement trials for endstage arthritis. J Rhuematol. 2017;44(11):1723–6. Singh JA, Mehta B, Mirza SZ, Figgie MP, Sculco P, Parks M, Goodman SM. When has a knee or hip replacement failed? A patient perspective. J Rhuematol. 2021;48(3):447–53. Sinnige A, Kittelson A, Van der Wees PJ, Teijink JA, Hoogeboom TJ. Personalised outcomes forecasts of supervised exercise therapy in intermittent claudication: an application of neighbours based prediction methods with routinely collected clinical data. Eur J Vasc Endovasc Surg. 2022;63(4):594–601. Te Molder ME, Smolders JM, Heesterbeek PJ, van den Ende CH. Definitions of poor outcome after total knee arthroplasty: an inventory review. BMC Musculoskelet Disord. 2020;21:1–6. Te Molder ME, Vriezekolk JE, van Onsem S, Smolders JM, Heesterbeek PJ, van den Ende CH. Exploration of adverse consequences of total knee arthroplasty by patients and knee specialists: a qualitative study. Rheumatol Adv Pract. 2024a;8(1):rkad111. Te Molder ME, Verhoef LM, Smolders JM, Heesterbeek PJ, van den Ende CH. 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Supplementary Files Appendix123QualitativestudyperceptionsdelayedrecoveryduringTKArehabilitation.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 18 May, 2026 Reviews received at journal 14 Apr, 2026 Reviewers agreed at journal 13 Apr, 2026 Reviewers agreed at journal 09 Apr, 2026 Reviewers invited by journal 09 Apr, 2026 Editor invited by journal 06 Apr, 2026 Editor assigned by journal 03 Apr, 2026 Submission checks completed at journal 03 Apr, 2026 First submitted to journal 01 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9291961","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":623206334,"identity":"e62eb130-2d22-47bf-a6f1-1208f8689b54","order_by":0,"name":"Anke van den Broek","email":"","orcid":"","institution":"HAN University of Applied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Anke","middleName":"van den","lastName":"Broek","suffix":""},{"id":623206335,"identity":"0d8ebe78-bd84-4c97-8876-094b082fa7e6","order_by":1,"name":"J. Bart Staal","email":"","orcid":"","institution":"HAN University of Applied Sciences","correspondingAuthor":false,"prefix":"","firstName":"J.","middleName":"Bart","lastName":"Staal","suffix":""},{"id":623206336,"identity":"5ae8b841-5f2e-4ba5-bf1b-6b3e56c1aa43","order_by":2,"name":"Maaike G.J. Gademan","email":"","orcid":"","institution":"Leiden University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Maaike","middleName":"G.J.","lastName":"Gademan","suffix":""},{"id":623206337,"identity":"9a987f5d-2838-48f8-ae4c-ce160bbe70f3","order_by":3,"name":"Thea Vliet Vlieland","email":"","orcid":"","institution":"Leiden University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Thea","middleName":"Vliet","lastName":"Vlieland","suffix":""},{"id":623206338,"identity":"61c814e3-98d3-498a-af56-73abf265226e","order_by":4,"name":"Jesper Knoop","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1klEQVRIiWNgGAWjYBACxgYIbQAmP4J5zA3Ea2Gc2YAsRgCAtTDzEqOFub392YOPexiMzdmbjz223WGXxyDdSMBhPWfMDWc8YzCz7DmWbpx7JrmYQeYgAS0zctikeQ4w2BjcyDGTzm1jTmyQSCSgZf7zZ9J/YFos2+qJ0DKDwUya4QCDGVgLY9thIrT05Jgb9hyQMDY4cyzdsLfteGIbIS2G7cefPfhxwMZww/HmYw9+tlUn9kskH8CvpYGBDUhJgNhsDAgSD5BHUkNQ8SgYBaNgFIxQAABAR0dBwfGSOAAAAABJRU5ErkJggg==","orcid":"","institution":"HAN University of Applied Sciences","correspondingAuthor":true,"prefix":"","firstName":"Jesper","middleName":"","lastName":"Knoop","suffix":""}],"badges":[],"createdAt":"2026-04-01 12:38:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9291961/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9291961/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107481948,"identity":"dfab22fd-555a-4147-94a5-963d2bb0aaed","added_by":"auto","created_at":"2026-04-22 02:21:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":393056,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9291961/v1/94c88690-f6b0-44e0-9d6a-e599a466963d.pdf"},{"id":107188051,"identity":"b9341686-5c25-4cc4-89b0-1eb54ae1e0e8","added_by":"auto","created_at":"2026-04-17 19:44:31","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":18091,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix123QualitativestudyperceptionsdelayedrecoveryduringTKArehabilitation.docx","url":"https://assets-eu.researchsquare.com/files/rs-9291961/v1/6ae7c65ee7fe61c4bf2704ab.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"How do patients, physiotherapists and orthopedic surgeons perceive delayed recovery during total knee arthroplasty rehabilitation? A qualitative study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTotal knee arthroplasty (TKA) is one of the most frequently performed surgical procedures worldwide, and its incidence is still increasing (Kurtz et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; van Veghel et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). This procedure is widely regarded as a successful and cost-effective intervention for managing advanced symptomatic knee osteoarthritis (OA) (Kamaruzaman et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). After TKA, postoperative physiotherapy in primary care for a period of 3 to 6 months is standard practice (Groot et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Jette et al, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). While many patients recover well during TKA rehabilitation, a substantial proportion (10\u0026ndash;30%) is not satisfied with their recovery (Beswick et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Bourne et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; DeFrance et al., 2023; Gunaratne et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Halawi et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Apart from the impact on the individual patients, unsuccessful TKAs lead to a significant societal and economic burden, including increased costs due to prolonged work absenteeism and at-work productivity loss (Hylkema et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Marsh et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Tilbury et al., 2015).\u003c/p\u003e \u003cp\u003eCurrently, it is challenging to predict recovery during TKA rehabilitation (Halvorson et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). This may be due to previous prognostic research (Dowsey et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Duan et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Gokhale et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Halvorson et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Harmelink et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Pua et al., 2019; Sanchez-Santos et al., 2018; Santaguida et al., 2008; Waheeb et al., 2015) predominantly focusing on acute (e.g., first week after surgery) rather than long-term outcomes, and on preoperative rather than postoperative) predictors, as well as a lack of consensus regarding the definition of delayed or unsuccessful recovery. As a result, international guidelines (e.g., Jette et al., 2022) provide limited guidance on how to predict and optimize this recovery, leading to suboptimal TKA rehabilitation. Potentially, early prediction of recovery could enable timely treatment adjustments and improve outcomes (George et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Sinnige et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Van der Groen et al., 2024). Considering the enormous and even further increasing number of TKA procedures performed annually and the substantial proportion of TKAs failing to achieve the desired outcome, it is important to gain new insights into the prediction of delayed recovery during TKA rehabilitation. Recent qualitative studies explored patients\u0026rsquo; (Singh et al, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Te Molder et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2024a\u003c/span\u003e; Te Molder et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2024b\u003c/span\u003e) and professionals\u0026rsquo; perceptions of TKA outcomes (Te Molder et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2024a\u003c/span\u003e; Te Molder et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2024b\u003c/span\u003e), with a primary focus on negative outcomes such as adverse consequences. Thus, there remains limited understanding of how (differently) patients, physiotherapists, and orthopedic surgeons perceive delayed recovery during the TKA rehabilitation process, and which prognostic factors play a role in this (delayed) recovery. Addressing these gaps would be a next step towards early prediction and optimization of TKA rehabilitation outcomes.\u003c/p\u003e \u003cp\u003eThe overall objective of this study is to explore and compare the perceptions of patients, physiotherapists, and orthopedic surgeons regarding delayed recovery during TKA rehabilitation. Specifically, the study focused on three predefined topics: (i) most important (positive and negative) outcome domains for TKA rehabilitation, (ii) how and when delayed recovery can be identified during the TKA rehabilitation process, and (iii) most important prognostic factors of (delayed) recovery during TKA rehabilitation. To facilitate the discussion of the third topic, a rapid review of reviews was performed prior to the focus group meetings, to compile a list of prognostic factors consistently associated with TKA rehabilitation recovery, as reported in recent systematic reviews.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eA qualitative study design, to gain insight into the perceptions of patients, physiotherapists, and orthopedic surgeons regarding aspects of delayed recovery during TKA rehabilitation. Reporting of the qualitative study was done according to the Consolidated Criteria for REporting Qualitative Research (COREQ) (Tong et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2007\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFocus groups\u003c/h3\u003e\n\u003cp\u003eThree online focus groups were conducted, each with a distinct stakeholder group: patients, physiotherapists, and orthopedic surgeons. Each focus group was intentionally designed to be homogenous in terms of participant type (i.e., patients, physiotherapists, or orthopedic surgeons), to create a comfortable environment where participants can speak more freely and to ensure focused discussions (Krueger, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). A maximum of six participants per focus group was chosen to ensure in-depth discussions, individual input and richer exchanges of perspectives (Smith et al., 2009). We chose online meetings to enable participation from different locations without the need for travel (Jones et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Lee et al., 2024). We applied a deductive approach (i.e., use of semi-structured interview guide with predefined topics) in combination with elements of nominal group technique to facilitate structured discussion, enhance participant engagement and achieve consensus within each stakeholder group (McMillan et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Rankin et al., 2016; Harvey et al., 2012).\u003c/p\u003e\n\u003ch3\u003eRecruitment and selection\u003c/h3\u003e\n\u003cp\u003ePurposive sampling was used to recruit participants who met the predefined inclusion criteria (Appendix 1). Patients were recruited from an ongoing multi-center, prospective cohort study (Longitudinal Leiden Orthopedics Outcomes of Osteoarthritis Study (LOAS) (Tilbury et al., 2020; Groot et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)). Since 2012, that study includes patients scheduled for primary TKA or total hip arthroplasty as a result of osteoarthritis. A research assistant from the LOAS study contacted potentially eligible participants for the current qualitative study via phone, but only if they had previously given consent for being contacted for future research. If this would not be sufficient, patients were additionally recruited from the network of the project group or via the participating physiotherapists or surgeons. Physiotherapists and orthopedic were recruited from six primary care physiotherapy practices and five hospitals, respectively, with one person per site allowed. If this would not be sufficient, additional candidates were recruited from the network of the project group.\u003c/p\u003e \u003cp\u003eFor the focus group with patients, we aimed for diversity in terms of age, gender, educational level, and whether they were satisfied or dissatisfied with their perceived recovery after TKA. For the focus group with physiotherapists and with orthopedic surgeons, diversity was sought in age, gender, and working experience in TKA rehabilitation/procedures.\u003c/p\u003e\n\u003ch3\u003eStudy procedure\u003c/h3\u003e\n\u003cp\u003e All potentially eligible participants received an information letter, outlining the study background, aims, and design, and a consent form to sign. After having provided informed consent, three focus groups were scheduled between June and September 2024.\u003c/p\u003e \u003cp\u003e One week before the focus group meeting, participants were asked to complete a brief online questionnaire via Microsoft Forms (Microsoft Corporation, Redmond, WA). Next to collecting general characteristics (for patients; age, gender, time since TKA, duration (in months and number of sessions) of physiotherapy rehabilitation, and whether they were satisfied (yes/no) with their recovery); for physiotherapists and surgeons: age, gender, profession, education, work experience, TKA rehabilitation/surgery experience), the questionnaire allowed participants to independently reflect on the three main topics by filling in four open-ended questions. This would ensure that each participant had time to carefully consider the topics before engaging in the focus group discussion.\u003c/p\u003e \u003cp\u003eA semi-structured interview guide with open-ended questions was constructed, as shown in Appendix 2. The focus groups were structured into three parts, each dedicated to one of the three main topics:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003emost important (positive and negative) outcome domains of recovery during TKA rehabilitation;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ehow and when delayed recovery during the TKA rehabilitation process can be identified;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003emost important prognostic factors of (delayed) recovery during TKA rehabilitation.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eTo facilitate the discussion of the third topic, a rapid review of reviews was performed prior to the focus group meetings. Aim of this review was to pragmatically compile a list of prognostic factors consistently associated with TKA rehabilitation recovery, as reported in the most recent systematic reviews (i.e., published since the review of Harmelink et al \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). We included systematic (umbrella) reviews reporting associations between prognostic factors and outcome domains pain and/or physical functioning, with follow-up points exceeding 6 months post-TKA. Reviews were identified through a PubMed search strategy (see Appendix 3). From the selected reviews, prognostic factors were derived if reported in at least two individual studies with consistent evidence which we defined as \u0026ge;\u0026thinsp;75% of these studies reporting a statistically significant association in the same direction). This definition is in line with the Cochrane Collaboration Back Review Group (Van Tulder et al., 2013) and used by for example Van der Worp et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2015\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe focus group meetings followed the subsequent stages of the nominal group technique: round robin, clarification, and voting (McMillan et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). The \u0026lsquo;round robin stage\u0026rsquo; involved participants sharing their ideas one at a time, with each response being recorded for further discussion. The summarized responses from the questionnaire served as the foundation for the group discussion (\u0026lsquo;silent generation of ideas\u0026rsquo;). The \u0026lsquo;clarification stage\u0026rsquo; allowed participants to expand on their responses, ask for clarification, and evaluate the importance of the ideas in the context of the study. In the \u0026lsquo;voting stage\u0026rsquo;, participants collaboratively discussed the ideas generated and came to a consensus on which answers, ideas, or themes were the most important for each main topic. When applicable, insights from previous focus group(s) were incorporated into subsequent ones. All three online focus group meetings were conducted using Microsoft Teams (Microsoft Corporation, Redmond, WA). Each focus group was led by a moderator (AvdB) and supported by an observer (JK). The moderator followed the semi-structured interview guide, encouraged active participation from all patients, and facilitated interaction among participants. Meanwhile, the observer took notes, ensured the continuity of the recordings, and assisted the moderator when needed. With permission from participants, focus group meetings were audio recorded.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe questionnaire was analyzed descriptively, using numbers and percentages (for categorical variables) and median, minimum and maximum (for continuous variables). The focus group meetings were transcribed, coded and interpreted qualitatively, using elements of thematic analysis (Braun and Clarke, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Braun and Clarke, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). After each group meeting, one researcher (AvdB) analyzed the audio recordings, cross-referenced them with the notes and verified the completeness of the data analysis. The detailed minutes of the focus group were sent to participants via email to check whether this reflected the views of participants (Morse et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2002\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eLiterature review\u003c/h2\u003e \u003cp\u003eFor the rapid review of reviews facilitating the discussion of the third topic, from a total of 18 eligible reviews published since 2017, the three most recent reviews focusing on the outcomes pain and physical function were selected. These were an umbrella review of reviews by Fernandez-de-las-Penas et al. (2023) (outcome: pain), and two systematic reviews by Olsen et al.: Olsen et al. (2022) (outcome: physical function) and Olsen et al. (2023) (outcome: pain). From these three reviews, 11 prognostic factors with consistent evidence were derived (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Factors consistently associated with more pain during/after TKA-rehabilitation were more preoperative pain (Fernandez-de-las-Penas et al. (2023); Olsen et al. (2023)), presence of chronic pain (Fernandez-de-las-Penas et al. (2023); Olsen et al. (2023)), central sensitization (Fernandez-de-las-Penas et al. (2023)), anxiety (Fernandez-de-las-Penas et al. (2023); Olsen et al. (2023)), and pain catastrophizing (Fernandez-de-las-Penas et al. (2023); Olsen et al. (2023)); factors consistently associated with less pain were higher radiological severity of knee OA (Kellgren-Lawrence (KL) grade) (Olsen et al. (2023)) and more social support (Fernandez-de-las-Penas et al. (2023); Olsen et al. (2023)). Factors consistently associated with worse physical functioning during/after TKA-rehabilitation were BMI and walking aid use; factors consistently associated with better physical functioning were better preoperative physical functioning, higher radiological severity of knee OA (KL grade), and more knee joint mobility (all reported in Olsen et al. (2022)).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrognostic factors identified in rapid review of reviews\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical function\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026bull; Preoperative pain\u003c/p\u003e \u003cp\u003e\u0026bull; Severity of osteoarthritis (KL grade)\u003c/p\u003e \u003cp\u003e\u0026bull; Chronic (knee) pain\u003c/p\u003e \u003cp\u003e\u0026bull; Central sensitization\u003c/p\u003e \u003cp\u003e\u0026bull; Anxiety\u003c/p\u003e \u003cp\u003e\u0026bull; Pain catastrophizing\u003c/p\u003e \u003cp\u003e\u0026bull; Social support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Preoperative physical function\u003c/p\u003e \u003cp\u003e\u0026bull; Preoperative knee joint mobility\u003c/p\u003e \u003cp\u003e\u0026bull; BMI\u003c/p\u003e \u003cp\u003e\u0026bull; Walking aid use\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBMI: Body Mass Index; KL: Kellgren Lawrence.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFocus group meetings\u003c/h3\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eParticipant characteristics\u003c/h2\u003e \u003cp\u003eTwelve patients were approached, of whom six participated: three from the LOAS cohort study and three via one of the researchers\u0026rsquo; (AvdB) own network. From nine invited physiotherapists, six participated. One physiotherapist did not fully meet the requirement of two years of experience, but was deemed eligible due to his/her amount of supervised TKA-rehabilitation trajectories. From ten invited orthopedic surgeons, five participated. One orthopedic surgeon did not fully meet the requirement of performing 30 TKA procedures a year, but was included for his/her extensive prior experience. Characteristics of focus group participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The focus group meetings were conducted in the following order: physiotherapists (duration 86 minutes), orthopedic surgeons (68 minutes), and patients (85 minutes).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eThematic analysis\u003c/h2\u003e \u003cp\u003eThe consensus-based results for each of the three topics are presented separately for each stakeholder group below, and summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of focus group participants*.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysiotherapists\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOrthopedic surgeons (n\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (66.7)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (50)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (20)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (50\u0026ndash;76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (23\u0026ndash;60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47 (41\u0026ndash;66)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHighest level of education\u003c/p\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003cp\u003eVocational or technical school\u003c/p\u003e \u003cp\u003eUniversity or college\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (50.0)\u003c/p\u003e \u003cp\u003e2 (33.3)\u003c/p\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime elapsed since TKA (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.25 (1\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTKA rehabilitation\u003c/p\u003e \u003cp\u003eDuration (months)\u003c/p\u003e \u003cp\u003eNumber of PT-sessions\u003c/p\u003e \u003cp\u003e3\u0026ndash;12 sessions\u003c/p\u003e \u003cp\u003e25\u0026ndash;36 sessions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (3\u0026ndash;10)\u003c/p\u003e \u003cp\u003e2 (33.3)\u003c/p\u003e \u003cp\u003e4 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSatisfied with recovery after TKA rehabilitation (yes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorking experience with TKA patients (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (2\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (10\u0026ndash;35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of TKA patients per year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (10\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e150 (15\u0026ndash;160)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Values are numbers (percentage) or median (range; i.e., min-max); PT\u0026thinsp;=\u0026thinsp;physiotherapy; TKA\u0026thinsp;=\u0026thinsp;total knee arthroplasty.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eConsensus-based results on the three topics by stakeholder group.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTopic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysiotherapists\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOrthopedic surgeons\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMost relevant outcome domains during TKA rehabilitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Being pain-free, allowing the return to activities important for the patient, such as ADL, work, hobbies, and sports\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Physical functioning in ADL, work, and sports, for which outcomes at the impairment level (e.g., pain, ROM, stability) are prerequisite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull; Meeting patient expectations and patient satisfaction\u003c/p\u003e \u003cp\u003e\u0026bull; Pain and its related physical functioning in ADL, work, and sports\u003c/p\u003e \u003cp\u003e\u0026bull; Technically well-performed surgery, with no infection occurring\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow and when to identify delayed recovery during TKA rehabilitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; If there is no improvement in recovery after 6\u0026ndash;8 months and it is still not possible to perform certain activities that are important to the patient and should be possible according to the physiotherapist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; A lack of progress in comparison to expected outcomes based on preoperative status and exercise frequency, with no improvement despite modifications to the treatment plan\u003c/p\u003e \u003cp\u003e\u0026bull; Delayed recovery could generally be identified within 6 weeks post-TKA: reduced ROM, in particular knee flexion (4\u0026ndash;6 weeks), persistent pain that does not decrease (6 weeks), wound healing (1 week), stiff gait pattern with a non-relaxed swing phase (6 weeks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull; 6 weeks to 3 months post-TKA: functional impairment in the knee, with extension deficits being considered more significant than flexion deficits\u003c/p\u003e \u003cp\u003e\u0026bull; 9 to 12 months post-TKA: pain and ADL outcomes do not reach the expected level for the patient\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMost important prognostic factors for (delayed) recovery during TKA-rehabilitation*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Positive, realistic patient expectations, managed by preoperative patient education\u003c/p\u003e \u003cp\u003e\u0026bull; Physiotherapist\u0026rsquo;s guidance during rehabilitation\u003c/p\u003e \u003cp\u003e\u0026bull; Social support and well-prepared home environment\u003c/p\u003e \u003cp\u003e\u0026bull; Post-TKA pain medication\u003c/p\u003e \u003cp\u003e\u0026bull; Obesity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Positive, realistic patient expectations\u003c/p\u003e \u003cp\u003e\u0026bull; Psychological factors (e.g., fear of movement, pain perception, coping strategies, confidence in movement, illness/pain perceptions)\u003c/p\u003e \u003cp\u003e\u0026bull; Preoperative status (particularly limited knee extension and history of chronic (knee) pain/central pain mechanisms)\u003c/p\u003e \u003cp\u003e\u0026bull; Active rehabilitation approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull; Positive, realistic patient expectations\u003c/p\u003e \u003cp\u003e\u0026bull; Psychological factors (e.g., pain catastrophizing, fear of movement, coping strategies, motivation, anxiety, depression)\u003c/p\u003e \u003cp\u003e\u0026bull; Preoperative status (particularly better physical functioning)\u003c/p\u003e \u003cp\u003e\u0026bull; Work conflict\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eADL: activities of daily living; ROM: range of motion; TKA: total knee arthroplasty.\u003c/p\u003e \u003cp\u003e*consensus for a top 3\u0026ndash;5 was attempted to reach within each focus group\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eTopic 1: Most relevant (positive and negative) outcome domains\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eAll six patients mentioned pain as the most relevant outcome domain during TKA rehabilitation. Pain relief was considered to enable better sleep, regain activities of daily living (ADL), and return to hobbies, sport, or work, and longer walking and cycling distances. Both two patients who were not satisfied with their recovery after TKA mentioned persistent pain hindering their activities as most important outcome domain.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003ePhysiotherapists\u003c/h2\u003e \u003cp\u003eThe majority of the participating physiotherapists identified physical functioning as a key outcome domain during TKA rehabilitation. They emphasized the importance of patients regaining independence in ADL and achieving functional use of the knee, including activities such as walking and cycling. Additionally, the ability to participate in sports and return to occupational activities, when applicable, was regarded as important. Outcomes such as pain reduction, knee range of motion (ROM), knee stability, and gait pattern were viewed as prerequisites for achieving the patient-specific goals.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eOrthopedic surgeons\u003c/h2\u003e \u003cp\u003eOrthopedic surgeons emphasized that patient satisfaction (by meeting the patient\u0026rsquo;s expectations) is the most relevant outcome domains during TKA rehabilitation. Orthopedic surgeons described patient satisfaction as multifaceted and sometimes unpredictable, referring to it as a black box. While a technically well-executed surgery without complications was considered a prerequisite for success, it was mentioned that a well-executed TKA was not always decisive for patient satisfaction. Pain and physical functioning, particularly in ADL, work, or sports, were also identified as important outcome domains, despite difficulties regarding their subjective nature.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eTopic 2: How and when to identify delayed recovery\u003c/h2\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eMost patients indicated that they would be concerned if there was no improvement and they were unable to perform important activities after on average 6\u0026ndash;8 months post-TKA. Two patients emphasized that understanding what to expect, especially during the first months after TKA, helped them manage their recovery process more effectively. Patients considered physical complaints during this first period (3 months) challenging but normal.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003ePhysiotherapists\u003c/h2\u003e \u003cp\u003eMost physiotherapists stated that delayed recovery could generally be identified already within 6 weeks post-TKA. They mentioned reduced knee mobility (in particular knee flexion) at 4\u0026ndash;6 weeks as a first sign of delayed recovery, and that in such cases an orthopedic surgeon or hospital-based physiotherapist may need to be consulted. While pain alone was not considered a definitive indicator of delayed recovery, physiotherapists considered pain accompanied with other issues like reduced mobility to be concerning, within the first 6 weeks. Also wound complications, such as poor closure or leakage, were flagged as signs of delayed recovery. Physiotherapists stressed the importance of prompt referral to the orthopedic surgeon within one week to prevent infection. Additionally, abnormal gait patterns, such as a stiff walk without a relaxed swing phase, were noted as contributing to delayed recovery, as they could exacerbate pain and hinder progress.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eOrthopedic surgeons\u003c/h2\u003e \u003cp\u003eOrthopedic surgeons generally believed that the 6-week period that was mentioned by the physiotherapists is too early to determine delayed recovery. They recognized that patients are often referred to them by worried physiotherapists within this early stage. Such cases usually do not require intervention rather than reassurance, as symptoms often improve over time, according to the orthopedic surgeons. Orthopedic surgeons did acknowledge limited knee mobility in the period from 6 weeks to 3 months to be concerning. For example, if a patient still does not achieve 90 degrees of knee flexion and has a knee extension deficit of 15\u0026ndash;20 degrees at 3 months, referral to the surgeon may be warranted to assess whether an intervention is necessary. One surgeon emphasized the greater importance of extension deficits over flexion limitations, as activities such as walking can still be performed with 60 degrees of flexion. In the period between 9 to 12 months post-TKA, orthopedic surgeons defined delayed recovery as suboptimal progress in physical functioning and/or persistent pain. By this stage, most patients should have achieved their goals, provided that these were formulated realistically. All surgeons stressed the importance of informing patients that recovery from a TKA is a lengthy process. While many patients experience most of their improvements within a year, further progress in pain relief and function can continue between 2 and 5 years postoperatively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eTopic 3: Prognostic factors for TKA rehabilitation recovery\u003c/h2\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003ePatients mentioned several prognostic factors that could positively influence recovery during TKA rehabilitation, such as adequate guidance from the physiotherapist, a supportive home environment (including social support and a well-prepared home situation), adequate (pre-operative) patient education resulting in realistic expectations for recovery, and effective (post-surgery) pain medication management. Patients also identified several prognostic factors that could impede recovery, with obesity considered to be most important, while other factors mentioned being overloading the knee too early after TKA, complications during or after surgery (such as infection), insufficient pain relief in the early postoperative phase (particularly during the first few days), mental health (i.e., anxiety and depression), and severely limited preoperative knee joint mobility. After being informed on the prognostic factors consistently associated with TKA outcomes as reported in the literature, the group discussion resulted in a consensus-based top-5 of most important prognostic factors: patient expectations (being positive but realistic, managed by preoperative patient education), physiotherapist\u0026rsquo;s guidance during rehabilitation, social support and well-prepared home environment, post-TKA pain medication and obesity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003ePhysiotherapists\u003c/h2\u003e \u003cp\u003eAccording to the physiotherapists, the most important prognostic factors for recovery after TKA were (positive but realistic) patient expectations, psychological factors (such as illness or pain perception, fear of movement, anxiety), coping style, motivation and preoperative status (particularly limited knee extension and history with chronic pain or central pain mechanisms). Building trust and an active treatment strategy were also identified as important to recovery, particularly for patients with negative coping styles or low self-efficacy. Regarding patient expectations, they emphasized the need for preoperative education in which realistic expectations about the recovery process and realistic goals should be discussed to avoid disappointment and to ensure commitment to rehabilitation. Other prognostic factors that were noted included inadequate pain management, inadequate social support and insufficient physical capacity. After being informed on the prognostic factors consistently associated with TKA outcomes as reported in the literature, the group discussion resulted in a consensus-based top-4 of most important (categories of) prognostic factors: patient expectations (being positive but realistic), psychological factors (e.g., fear of movement, pain perception, coping strategies, confidence in movement, illness/pain perceptions), preoperative status (particularly limited knee extension and history of chronic (knee) pain/central pain mechanisms) and active rehabilitation approach.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eOrthopedic surgeons\u003c/h2\u003e \u003cp\u003eOrthopedic surgeons identified several prognostic factors that positively influence recovery during TKA rehabilitation, with positive but realistic patient expectations (and goals) as the most important one. First, they emphasized the importance of patients understanding the gradual nature of recovery, in which initial post-operative pain is normal. In addition, similar to the physiotherapists, they stressed the importance of establishing realistic goals through preoperative discussions, ensuring that patients have a clear understanding of what to expect from the procedure. Other prognostic factors that, according to orthopedic surgeons, could positively influence recovery were worse preoperative functional status, having social support (particularly the presence of a partner at home), financial stability, positive mindset, and pro-active role of the patient during rehabilitation. The following prognostic factors were identified that could impede recovery, namely unrealistic expectations, passive coping style, psychological factors (such as anxiety, depression, pain catastrophizing), low physical activity and work-related issues (such as physical labor and work conflicts). Also strength training with too much intensity too soon in the TKA-rehabilitation was mentioned as factor that could hinder recovery.After being informed on the prognostic factors consistently associated with TKA outcomes as reported in the literature, the group discussion resulted in a consensus-based top-4 of most important (categories of) prognostic factors: patient expectations (being positive but realistic), psychological factors (e.g., pain catastrophizing, fear of movement, coping strategies, motivation, anxiety, depression), preoperative status (particularly better physical functioning) and work conflict.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis qualitative study on delayed recovery during the rehabilitation phase following TKA showed that patients, physiotherapists and orthopedic surgeons had different perspectives. According to physiotherapists, delayed recovery can already be identified in the first phase of rehabilitation, while patients and especially orthopedic surgeons mentioned longer periods to determine delayed recovery. Patients considered being pain free as most important outcome for recovery, physiotherapists prioritized physical functioning, whereas orthopedic surgeons patient satisfaction. Finally, despite some overlap, the stakeholder groups clearly differed in which prognostic factors for delayed recovery they perceived to be most important.\u003c/p\u003e \u003cp\u003eThe prioritization of most important outcome domains of TKA rehabilitation differed across the three stakeholder groups, with pain being prioritized by patients, physical functioning by physiotherapists and patient satisfaction by orthopedic surgeons. On the other hand, the three stakeholder groups agreed in recognizing the interconnected nature of these three outcome domains. Patients highlighted that pain relief enables them to resume daily activities, a view supported by physiotherapists, who regarded pain reduction as prerequisite for functional recovery. Similarly, while prioritizing patient satisfaction as most important, orthopedic surgeons also acknowledged the importance of pain and physical functioning. These three outcome domains \u0026ndash; pain, physical functioning, and patient satisfaction \u0026ndash; align with findings from other qualitative studies (Singh et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Te Molder et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2024a\u003c/span\u003e; Te Molder et al.; \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2024b\u003c/span\u003e) and are part of the OMERACT core domain set (Singh et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Te Molder et al. (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2024b\u003c/span\u003e) suggested that patients may accept some pain if it allows them to perform valued activities, while our study found patients less willing to accept pain, prioritizing it over activities. Besides the three outcome domains, orthopedic surgeons in our study also emphasized the importance of a technically well-performed surgery, consistent with the knee specialists\u0026rsquo; views in a previous qualitative study (Te Molder et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2024a\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe differences between physiotherapists on the one hand and patients and especially orthopedic surgeons on the other hand in when and how they identify delayed recovery after TKA were remarkable. Physiotherapists argued that limited knee mobility in the first 6 weeks is a sign of delayed recovery that needs direct judgement and possible intervention from the orthopedic surgeon. Orthopedic surgeons mentioned much longer periods to determine delayed recovery in general, but acknowledged that in individual cases with severe knee mobility limitations, direct intervention between 6 weeks to 3 months can be required. This statement from the orthopedic surgeons seems to be in line with Te Molder et al (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2024a\u003c/span\u003e) in which knee specialists (i.e., combination of mostly orthopedic surgeons and physiotherapists) stated that patients with limited knee mobility within 3 months post-TKA should be referred to the orthopedic surgeon as the knee could need manipulation under anesthesia to regain full range of motion. In general, the orthopedic surgeons in our focus groups stressed that recovery from a TKA is a lengthy process, in which the natural course of recovery should be allowed to proceed without intervention, and in which improvements in pain and physical function can still occur even after a year. This aligns with previous study findings that \u0026ldquo;getting used to the prosthetic knee\u0026rdquo; is part of a long process (Te Molder et al,. 2024a). Overall, there appears to be a lack of consensus in clinical practice regarding the definition and time-point of delayed recovery during TKA rehabilitation and thereby also in the indication for orthopedic surgeons to intervene in the first phase of TKA rehabilitation.\u003c/p\u003e \u003cp\u003eAlthough there is considerable overlap in the prognostic factors the three stakeholder groups consider important, some interesting differences were found as well. While both physiotherapists and orthopedic surgeons primarily focused on patient-related factors (such as psychological factors and preoperative status), patients placed greater emphasis on external factors (such as social support and physiotherapist\u0026rsquo;s guidance during rehabilitation). This patient perspective is particularly interesting, as such factors have barely been included so far in prognostic studies. Most important similarity across the stakeholder groups is that patient expectations were considered to be an important prognostic factor in each group. They all mentioned that prior to surgery, the patient\u0026rsquo;s expectations of the outcome (and its course) should be positive but also realistic, with especially patients emphasizing the importance of adequate preoperative patient education to set realistic expectations. Such education is important, because patients tend to have overly high expectations going into TKA surgery (Mannion et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Nilsdotter et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Neuprez et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Despite this consensus within clinical practice, the literature does not yet provide strong evidence for an association between patient expectations and treatment outcomes for TKA (Haanstra et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Culliton et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). This could be attributed to various reasons, such as a lack of a clear definition of the underlying construct of patient expectations, its multifaceted and complex nature, and the varying methods used to measure it (Haanstra et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Recent studies (Laferton et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Blum et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) however suggested that patient expectations might be a prognostic factor of TKA-rehabilitation outcome. Another difference between practice-based and literature-based prognostic factors is the emphasis on postoperative factors (e.g. post-operative trajectory of pain and knee mobility, and the physiotherapist\u0026rsquo;s guidance) in the focus groups, whereas the literature mostly focused on preoperative factors (e.g., preoperative pain and function, radiographic severity).\u003c/p\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003eImplications for clinical practice and future research\u003c/h2\u003e \u003cp\u003eThe findings of this study have several implications for clinical practice. Based on the perceived importance of patient expectations as a prognostic factor, these expectations could also be a main treatment target. Enhancing preoperative patient education may lead to more positive, yet still realistic recovery expectations and rehabilitation goals. Furthermore, the findings highlight that consensus between physiotherapists and orthopedic surgeons is needed on how and especially when they identify delayed recovery. This may prevent uncertainty in patients regarding their recovery process.\u003c/p\u003e \u003cp\u003eFuture research should focus on determining whether practice-based prognostic factors, such as patient expectations and the physiotherapist\u0026rsquo;s guidance indeed have prognostic value in the (delayed) recovery during TKA rehabilitation. More knowledge on prognostic factors could ultimately lead to an accurate clinical decision support tool in which TKA rehabilitation outcomes can be predicted early in (or even before) the rehabilitation process and could inform treatment decisions if needed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThe strength of this study is its multi-stakeholder approach, which captures diverse perspectives on recovery following TKA. The use of small focus groups enabled in-depth exploration of experiences, and the modified nominal group technique facilitated consensus within stakeholder groups (Harvey et al., 2012). The study has some limitations. First, despite having used purposeful sampling, the small sample size may not fully reflect the diversity of experiences in the particular profession. Second, the orthopedic surgeon group, consisted of predominantly middle-aged men, lacked diversity, although seems to be an adequate representation of the Dutch population. Third, only one instead of multiple focus groups per stakeholder group was conducted, which may have not been sufficient to achieve saturation (Hennink et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Fourth, for patients with a successful recovery, it was challenging to discuss delayed recovery, as they could not base this on their own experiences.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this study found similarities but mostly differences in how patients, physiotherapists, and orthopedic surgeons perceive recovery during TKA rehabilitation. Patients prioritized pain relief as most important outcome domain of TKA rehabilitation recovery, whereas physiotherapists prioritized physical function, and orthopedic surgeons patient satisfaction. Physiotherapists and orthopedic surgeons also differed on how and especially when they identify delayed recovery. All three stakeholder groups considered positive but realistic patient expectations as important prognostic factor for TKA rehabilitation recovery. In addition, physiotherapists and orthopedic surgeons considered patient-related factors as more important, whereas patients consider external factors as more important. Our findings imply that consensus is strongly needed across clinicians on how and especially when delayed recovery can be identified. Future research should confirm that patient expectations are an important prognostic factor as well as a potential treatment target in TKA rehabilitation that could result in optimization of TKA rehabilitation outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003e The study was approved by the ethics committee of HAN University of Applied Sciences Nijmegen, Netherlands (approval number ECO 552.05/24). They considered the study not being subject to the Medical Research Involving Human Subjects Act (in Dutch: WMO). Prior to the focus group meetings, written informed consent was obtained from all participants.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eThe authors declare they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe study was funded by SIA (project number KIEM.K23.01.063). The funder had no role in the design, organization and execution of the study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAvdB was the executive researcher of this study, and drafted the first version of the manuscript. AvdB and JK conducted the focus group meetings. JBS, MGJG, TVV and JK conceptualized the study, acquired funding, supervised AvdB and provided feedback on the manuscript. All authors contributed to this study and approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to thank all patients, physiotherapists and orthopedic surgeons who participated in the focus groups.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data generated during these studies will not be publicly available, but will be available upon reasonable request to the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBeswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. (2012). What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ open, 2(1), e000435.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlum CL, Lepkowsky E, Hussein A, Wakelin EA, Plaskos C, Koenig JA. 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In \u003cem\u003eSeminars in Arthritis and Rheumatism\u003c/em\u003e (Vol. 44, No. 4, pp. 461\u0026ndash;471).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Total knee arthroplasty, Rehabilitation, Physiotherapy, Orthopedics, Recovery, Outcome domains, Prognostic factors.","lastPublishedDoi":"10.21203/rs.3.rs-9291961/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9291961/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground. \u003c/strong\u003eAlthough total knee arthroplasty (TKA) and its physiotherapeutic rehabilitation process are among the most frequently performed medical interventions, a substantial proportion (10-30%) of patients is not satisfied with their recovery. Early identification of delayed recovery would enable timely adjustments of the rehabilitation process. This study aimed to explore and compare the perceptions of patients, physiotherapists, and orthopedic surgeons regarding delayed recovery during TKA rehabilitation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods. \u003c/strong\u003eThree focus group meetings were organized: patients (n=6), physiotherapists (n=6), and orthopedic surgeons (n=5). Focus group meetings were structured around three predefined topics regarding delayed recovery during TKA rehabilitation: (i) most important outcome domains, (ii) how and when delayed recovery can be identified, and (iii) most important prognostic factors of (delayed) recovery. To facilitate the discussion of the third topic, a rapid review of reviews was performed prior to the focus group meetings, to compile a list of prognostic factors consistently associated with TKA rehabilitation recovery, as reported in recent systematic reviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults. \u003c/strong\u003eThe focus group meetings showed that patients prioritized pain relief as most important outcome domain of TKA rehabilitation recovery, whereas physiotherapists prioritized physical function, and orthopedic surgeons patient satisfaction. According to the physiotherapists, delayed recovery can already be identified within the first six weeks after TKA, while orthopedic surgeons mentioned much longer periods before delayed recovery can be determined. All three stakeholder groups perceived patient expectations as an important prognostic factor of TKA rehabilitation recovery. Besides this factor, physiotherapists and orthopedic surgeons mostly prioritized other patient-related factors, whereas patients considered predominantly external factors as important prognostic factors of recovery during TKA rehabilitation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion. \u003c/strong\u003eThis study found similarities but mostly differences in how patients, physiotherapists and orthopedic surgeons perceive delayed recovery during TKA rehabilitation, and which prognostic factors they consider to be most important in this recovery. Our findings suggest that consensus is needed among clinicians on how and when TKA recovery should be considered as delayed. Future research should confirm that patient expectations are an important prognostic factor as well as a potential treatment target in TKA rehabilitation that could result in optimization of TKA rehabilitation outcomes.\u003c/p\u003e","manuscriptTitle":"How do patients, physiotherapists and orthopedic surgeons perceive delayed recovery during total knee arthroplasty rehabilitation? A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-17 19:44:27","doi":"10.21203/rs.3.rs-9291961/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"53685055875364852372939805626541376092","date":"2026-05-18T07:39:41+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-14T21:33:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"319257791120859931442974388825953340569","date":"2026-04-13T14:06:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"90160343049287332113467041649838596240","date":"2026-04-09T19:44:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-09T13:57:58+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-06T17:24:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-03T13:11:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-03T13:10:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2026-04-01T12:24:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5a7aeb57-e20e-4ccf-8f38-305709d9b61b","owner":[],"postedDate":"April 17th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"53685055875364852372939805626541376092","date":"2026-05-18T07:39:41+00:00","index":48,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-17T19:44:27+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-17 19:44:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9291961","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9291961","identity":"rs-9291961","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}