Development of a pre-operative education and prehabilitation digital intervention for patients awaiting total knee replacement: a Virtual Knee School

Background: Total knee replacement (TKR) is a common operation usually performed to relieve the symptoms of end-stage knee osteoarthritis. Patients often face a long wait for TKR whilst experiencing severe pain. Even after TKR, ~20% of patients continue to experience long-term pain. Providing pre-operative TKR education and prehabilitation (pre-operative health/wellbeing optimisation) support could improve pre- and post-operative outcomes. However, current pre-operative TKR services are variable, inefficient and often inadequate. A rigorously developed digital intervention could help address these problems. Aim: To develop a pre-operative TKR education and prehabilitation digital intervention, the ‘Virtual Knee School’ (VKS). Methods and findings: The VKS was developed using an evidence-, theory- and person-based approach and complex mixed methods design. A rapid review (n=52 studies) demonstrated that definitive evidence on the optimal content/delivery of pre-operative TKR interventions is lacking. A modified Delphi study (n=30 patients; n=30 professionals) enabled the development of recommendations on pre-operative TKR interventions, which support digital delivery formats. A qualitative descriptive study (n=14 patients) highlighted the VKS should account for individual differences and be tailored to the pre-operative context. Three theoretical modelling approaches helped guide the design, description and evaluation of the VKS. A VKS prototype was developed based on the preceding studies’ findings and iteratively refined through think-aloud interviews (n=9 patients). The interviews evaluated the prototype’s usability and explored patients’ perspectives of it. The findings suggest the VKS would be a valuable resource for many patients pre- and post-TKR, but the digital delivery format is unlikely to meet all patients’ individual needs. Conclusions: This project rigorously developed a novel pre-operative TKR digital intervention, which warrants further evaluation. Key implications include: comprehensive pre-operative TKR education and prehabilitation support should be rapidly accessible in digital and non-digital formats; pre-operative TKR digital interventions should employ computer- and self- tailoring to account for patients’ individual needs/preferences.